What Would You Do?

I just want opinion.. I came on duty and Dr. wrote order for pt. to get Ativan 1mg. po q 1 hr. around the clock. for Mania / insomnia/ NOT prn .

You need to call the doctor first before just saying "I refuse to give it." It certainly sounds like the pt. does not need the ativan and it could be quite harmful. Call the doctor tell him/her what you are observing. If he/she does not change the order, the you can/should hold it based on your nursing judgement. Your charge nurse is wrong here--just because it is ordered this does not mean you must give it not matter what. If you give it and something bad happens to the pt, it will be your rear on the line, not hers--even if you were "just following orders."

Wouldn't that be classified as a chemical restraint?

"A chemical restraint is a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient or in some cases to sedate a patient. These are used in emergency, acute, and psychiatric settings to control unruly patients who are interfering with their care or who are otherwise harmful to themselves or others in their vicinity."

"In the United States, no drugs are presently approved by the U.S. Food and Drug Administration (FDA) for use as chemical restraints.^[4] According to OBRA 1987 (Federal Nursing Home Reform Act), individuals have the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms"

I just want opinion.. I came on duty and Dr. wrote order for pt. to get Ativan 1mg. po q 1 hr. around the clock. for Mania / insomnia/ NOT prn . Pt. slept through till 3AM. then back and forth to room and bed. pt. was redirectible and coooerative. I refused to give This medication as pt. was not Manic and I could not justify to give A sleep med. at 0600. My charge said pt. was taking her clothes off in her room at 0500. However, she was in and out of bed. Pt. was clearly calm , gait unsteady, and walking talking with eyes closed but appropriate verbally and physically. As order was written , pt. was to get 8mg. just on my shift . Also an hour prior to my shift pt. received Ativan 2 mg. ( why she was asleep till 3) . But I told my charge " I cannot justify giving this med" she said. " the dr. ordered it every hour. you're supposed to give it. " I again refused and told my charge " If you want her to have it, then you can give it , but Im not ." This was at the last hour of shift and I did not give. AND my charge also did not give. .. I'm asking for feed back.. I guess I will hear about this Im sure.. but giving a pt. this dosage around the clock just does not sound correct. I charted in my notes.. and in communication dr.s book. and off to next shift.

You need to clarify the order with the doctor before saying that you're not going to give it. It's like due diligence. Just because the order is wrong doesn't mean you just don't give it. You have to ensure its wrong with the prescriber(if he's not available then with another doctor), because they might not realize they left something out. They might change the order after realizing it's wrong and patient Will then get the right medication.

If the doctor refuses to acknowledge it's wrong then either go get a second opinion or don't give it because it's your license. But you have to cover all your bases.

Let's give a hypothetical situation that is extreme. If the diabetic patient has an extremely high blood glucose level, doctor offers insulin but have the wrong order. You don't just go it's wrong I'm not giving it, cuz then that endangers patient safety and hampers patient care. You would go clarify the order because it is the ethically and legally right thing to do.

Don, you are correct, if you give a sedating medication around the clock, with no endpoint or parameters, that would be a chemical restraint. I'm not sure how current your definition is. There are CMS & TJC definitions and standards that really discourage any use of chemical restraints.

If a medication is given for it's intended purpose in response to the persons medical/psychiatric condition that is a therapeutic action, not a restraint. Giving Ativan to help a person sleep, decreasing agition/allowing the person to feel more in control; all therapeutic. Patient taking off her clothes vs creating a safety risk (unsteady gait)? That sounds like sedation for staff convenience, not therapeutics. Giving a sedating medication around the clock without reassessing the patient's condition or need, really sounds like "snowing" the patient, and may be hard to justify.

Wouldn't that be classified as a chemical restraint?

"A chemical restraint is a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient or in some cases to sedate a patient. These are used in emergency, acute, and psychiatric settings to control unruly patients who are interfering with their care or who are otherwise harmful to themselves or others in their vicinity."

"In the United States, no drugs are presently approved by the U.S. Food and Drug Administration (FDA) for use as chemical restraints.^[4] According to OBRA 1987 (Federal Nursing Home Reform Act), individuals have the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms"

If it's used for the purposes of discipline or for staff convenience it's a chemical restraint, if it's used to treat a medical condition or symptoms, including anxiety, mania, etc, then it's not a chemical restraint even if it causes sedation.

It is up to you as to whether or not you think it's appropriate to give the patient the med, although you generally should inform the MD of your decision. In general I would think being up and somewhat hyperactive at 3 AM would be deserving of some sort of intervention unless they slept all day the day before in which case the issue is more of re-establishing a day-night sleep-wake cycle.

The poll should have another choice-"call the MD,clarify the order"

I didn't respond to the poll because I didn't like any of your options. Why not just communicate with the provider who ordered the medication and get it changed to a PRN dose? I certainly would not hold several doses without communicating with the provider.

I might hold 1 dose and see if the behavior changed but after that definetly call the doc .

It sounds like your charge just wasn't willing to call for whatever reason ie she's already called this guy 3 times during the night ect. But regardless this order need clarifying . And also remember the patient can refuse if they're alert and oriented

I would have called the doctor, with no regrets. There's no sense in waking someone up to give them ativan every hour. The doc deserves to get woken up to clarify that one!

I mean, isn't this basic stuff? You have a concern, so you have to voice it to someone who can do something about it. Which would mean that you call the doc and clarify the order. It really doesn't matter that you are waking the doc up. I'm HIGHLY doubtful that this would be the first occurrence of them being woken up over a question (I mean why not - it's okay for you to wake a patient but not a physician?).