My place of work has a MSDS nurse who tries to instruct us on the use of PRN medications. We have a certain resident who has in the past had psychotic episodes, and we have IM ativan to give and once, when the patient was throwing themself on the floor, IM haldol. Other than that, the POA isn't very cooperative and has blocked efforts of routine benzodiazepine and /or antipsychotic administration. Said patient has suspected BPD, but was only on an antidepressant and that didnt manage the mania of course. Well, until recently we got an antipsychotic commonly used to treat BPD and now that it's been a few weeks, the effect is kicking in and things have been going great. Has some bouts of agitaton, and I give prn po ativan to this person and it has worked fine if I catch it soon. My problem is that now the MSDS nurse has given us direct care nurses a side note to give PRN norco to this patient 2x a day. I assess pain in this patient by asking "do you have any pain?" And get a yes or no answer. No probs. Other nurses where I work will just give the med, no question. So by the time I have a shift, said resident will be physically dependent, even if she has no pain. What would you do?? Please note this resident has dementia and can't advocate for self.
Specializes in Gerontology, Med surg, Home Health.
The nurse who assesses the resident is the one who should medicate or not based on their assessment. That is my point...whether too much medication or not enough.
The nurse who assesses the resident is the one who should medicate or not based on their assessment. That is my point...whether too much medication or not enough.
I understood what you were saying. I actually spoke with my facility's DON about the pressure I/we was/were getting from third shift and even the MDS nurse about the PRN meds and she did clarify for me that whomever assesses should give the med or not per their assessment. I am pretty sure that she was aware of what was going on with the MDS nurse leaving her notes to those of us in direct patient care, but since I rather directly asked for a clarification, there hasn't been any more pressure yet and I'm glad about that. I just give them...as needed and things are going great so far:up:
And I knew their unwritten policy was wrong, I just wanted to know if anybody outside of the facility I work at has heard of such a practice. This is my second job in LTC.
There is a sheet which is off the chart, but where the nurses can see: "Give prn norco to x resident @0800 and 2000 every day". This is what they do at this place for some reason...
Just so you know, over medicating patients has drawbacks as well. If you see my OP, I was trying to get seasoned nursing professionals opinions on what may well be perceived as the use of "chemical restraints" which is something instructors touch on, among many other things during the course of our nursing education.
Talk to the MD who actually ordered this medication. Does he/she have a belief that this patient's episodes are related to pain? Could be the reason for the Norco order. Also, talk with the MD about your observations that pt symptoms/QOL improve with just the anti-psychotics, and go from there.
I have worked at several LTC facilities with programs for reducing unnecessary psychotropic medications. There is lots of research andI have witnessed many times personally how a resident who wasn't showing typical signs of pain but was medicated for behaviors were treated for pain and their behaviors decreased enough to be able to eliminate their psyc meds.
That being said, we were working closely with the psychiatrist and primary MD and were giving the meds as ordered by the MD, not necessarily a "note" next to the PRN sheet.
i was amazed at how well so many of our residents responded to pain management and we were able to reduce a lot of psyc meds.
Perhaps your MDS nurse has read a lot of similar research or perhaps her pain scores have been showing pain in that resident.
Are you able to ask her what the pain section of the MDS is showing? Why does she feel that pain management should be increased?
I agree that a PRN medication should not be given without an assessment and following the MD orders, but think that the research is amazing in this area, and we all have lots to learn to keep our residents able to live the best life they are able.
I have worked at several LTC facilities with programs for reducing unnecessary psychotropic medications. There is lots of research andI have witnessed many times personally how a resident who wasn't showing typical signs of pain but was medicated for behaviors were treated for pain and their behaviors decreased enough to be able to eliminate their psyc meds.
That being said, we were working closely with the psychiatrist and primary MD and were giving the meds as ordered by the MD, not necessarily a "note" next to the PRN sheet.
i was amazed at how well so many of our residents responded to pain management and we were able to reduce a lot of psyc meds.
Perhaps your MDS nurse has read a lot of similar research or perhaps her pain scores have been showing pain in that resident.
Are you able to ask her what the pain section of the MDS is showing? Why does she feel that pain management should be increased?
I agree that a PRN medication should not be given without an assessment and following the MD orders, but think that the research is amazing in this area, and we all have lots to learn to keep our residents able to live the best life they are able.
Thanks for your comment. If you could post a link supporting your claims, I'd appreciate that. As other posters have mentioned, there should be a prescription stating to give this on a regular bid basis, especially when pain has not been assessed by way of sliding scale, guarding, grimacing, etc. Not saying it's nonexistent in this case. I am usually willing to consider new possibilities. You have no idea, but the MDS nurse at our facility is new to her position, and has been leaving notes without explanation for long before she took that position. She is somewhat of a newer nurse too. interestingly, she rarely gives even a half decent report when she has "signed off" from working a direct patient care shift. So I think that in this case, which is quite complex, the information you divulged may well not apply. Please post that link when you get a chance. Thanks!
I see that actually everyone agrees with each other...patients need to be carefully assessed before the use of medication as a form of chemical restraint or behavior modification.
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
And I knew their unwritten policy was wrong, I just wanted to know if anybody outside of the facility I work at has heard of such a practice. This is my second job in LTC.
Pre-emtive meds can serve good use. They help prevent problems before they start.
I understand your moral dilemma, though. If you can document/justify your assessment and rationale for not giving the meds, you are good.... As far as your license goes. Remaining employed... That may be difficult if you go against informal policy.
I've found that in a lot of geriatric patient's pain can manifest as agitation. A lot of these patient's don't need hard hitting medications for pain control 650mg of tylenol or 25mg or tramadol can go a long way. People with dementia can't always put the right words or body language to what they are feeling. When I worked nights I found that sometimes a couple of tylenol could really calm someone down and curb behaviors.
Again however, this MDS nurse shouldn't be leaving notes, she should be working with floor staff, nurse managers and contacting MDs and getting orders to schedule medications.
I would politely take the note back to the MDSC and inform her, based your nursing judgment and assessment, you do not feel there is a need for the resident to have this PRN drug. Inform your supervisor as well. Continue to advocate for your resident!
CapeCodMermaid, RN
6,092 Posts
The nurse who assesses the resident is the one who should medicate or not based on their assessment. That is my point...whether too much medication or not enough.