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Written Up

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by medteleER medteleER (New Member) New Member

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Meriwhen is a ASN, BSN, RN and specializes in Psych ICU, addictions.

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IMO, the orders are clear.  

But I wouldn't have thrown both doses at the patient at one time...not because I'd be worried about overdose (while I'm not writing off overdose concerns, a 1 mg dose of Xanax is fairly common), but because if the patient was either anxious or awake later on in the night, she doesn't have a PRN left to take.  I would have given the sleep PRN dose first since--in my facility anyway--we have a cutoff time for giving sleep medications.  Then if necessary, the anxiety PRN dose could be used.  

If the patient is still anxious--and therefore still awake--despite getting both doses, then the PCP should be notified because they may need to adjust the dosing and/or change the medication.

I also think writing-up the OP was a bit extreme.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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7 hours ago, medteleER said:

all i wanted to do was help my patient sleep and not wig out.  the patient told me "the MD ordered 1mg of xanax for me", but the orders didn't reflect this.  so i took their word for it and got creative.  i figured 0.5mg+0.5mg = 1mg, so let's try that.  since 1 was for sleep, and 1 was for anxiety, it would be OK, i thought. i did take into consideration 1mg of xanax isn't going to kill the person. but now i'm not so sure.  i actually feel bad about this.

1). Nurse R.V. also just wanted to help her patient, as did all others who participate in the case. All of them had only good intentions, yet the patient died. 

2). If a patient will tell you that he always gets dilaudid 4 mg IV every 2 hours, phenergan IV every time he is nauseated and Xanax 1 mg every 2 hours, would you believe him as well? 

3). Your job is not to "justfollowtheorders", and not to "get creative" in how to satisfy patient's whims and wantings. Your job is to think and analyze clinical situation and act consciously within your scope of practice. That order was unclear, sorry for that. It was also borderline inappropriate (Xanax is not indicated for insomnia). It was your job to clarify it and administer what the ordering provider deemed as safe one time dose, not double. Or request alternative med. 

4). Yes, under certain circumstances 1 mg of Xanax can add to development  pathologic avalanche which will eventually kill someone. 

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morelostthanfound has 27 years experience as a BSN and specializes in CVOR, General/Trauma Surgery.

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15 minutes ago, KatieMI said:

1). Nurse R.V. also just wanted to help her patient, as did all others who participate in the case. All of them had only good intentions, yet the patient died. 

2). If a patient will tell you that he always gets dilaudid 4 mg IV every 2 hours, phenergan IV every time he is nauseated and Xanax 1 mg every 2 hours, would you believe him as well? 

3). Your job is not to "justfollowtheorders", and not to "get creative" in how to satisfy patient's whims and wantings. Your job is to think and analyze clinical situation and act consciously within your scope of practice. That order was unclear, sorry for that. It was also borderline inappropriate (Xanax is not indicated for insomnia). It was your job to clarify it and administer what the ordering provider deemed as safe one time dose, not double. Or request alternative med. 

4). Yes, under certain circumstances 1 mg of Xanax can add to development  pathologic avalanche which will eventually kill someone. 

Wow...really?  

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8 hours ago, RNNPICU said:

Technically yes, you did double dose the patient if you gave both at the same time.  The order should have been clarified as was the sleep dose only at night?  Likely they need both orders for daytime and night time.  The medication is the same regardless.  

I would have questioned the order.  Even if I gave the patient a dose at let's say the dose for sleep was due at 8pm.  I gave a patient a dose for anxiety at 6pm.  Since this med needs 8 hours spaced apart, I would question the MD.  

 

A quick search online reveals that a single dose is 0.25 - 0.5mg Q 8, you gave your patient 1mg in a single dose.

1 mg PO, *gasp!  What would Dr. Google say?

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54 minutes ago, KatieMI said:

4). Yes, under certain circumstances 1 mg of Xanax can add to development  pathologic avalanche which will eventually kill someone. 

You had me at pathologic avalanche...

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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28 minutes ago, murseman24 said:

 

You had me at pathologic avalanche...

Well, the same case I described before (without HIPAA details):

Patient was started oral amio load while Cardizem drip was still running. Was also on IV opioid d/t NPO. Not opioid naive, but not high dose either. Liked it very much, so dose was increased. Then he was complaining on anxiety before EP lab, so was given one dose of Xanax and that pain shot plus phenergan for nausea. 

It was his luck that he was in ICU already because at one beautiful moment he just stopped breathing, but survived. Woke up right after Narcan + Romazicon. The two possible explanations were either synergetic actions of opioid, phenergan and benzo on respiratory center, or at large suppressed CYP3A4 by high loading doses of amio and diltiazem, adding to the benzo action. 

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25 minutes ago, KatieMI said:

Well, the same case I described before (without HIPAA details):

Patient was started oral amio load while Cardizem drip was still running. Was also on IV opioid d/t NPO. Not opioid naive, but not high dose either. Liked it very much, so dose was increased. Then he was complaining on anxiety before EP lab, so was given one dose of Xanax and that pain shot plus phenergan for nausea. 

It was his luck that he was in ICU already because at one beautiful moment he just stopped breathing, but survived. Woke up right after Narcan + Romazicon. The two possible explanations were either synergetic actions of opioid, phenergan and benzo on respiratory center, or at large suppressed CYP3A4 by high loading doses of amio and diltiazem, adding to the benzo action. 

Yep.  CNS depressant, benzo, opioid all together create a synergistic "avalanche" that can culminate in a stormy blizzard of respiratory depression. 1 mg PO Xanax (an appropriate dose) is not in and of itself a problem.

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No write-up from me.  But I would talk to you about not giving them both.

And the doctor is wrong for writing such unclear orders.  Orders should have said "Xanax 0.5 po for  anxiety q 8 h PRN, Xanax 0.5 mg. po for sleep HS PRN.  Do not give more than 0.5 mg. in an 8 hour time span".  Or something like that.  I would be talking to him/her, too.

Did you sign the orders off or was it another nurse or who? 

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2 hours ago, KatieMI said:

Well, the same case I described before (without HIPAA details):

Patient was started oral amio load while Cardizem drip was still running. Was also on IV opioid d/t NPO. Not opioid naive, but not high dose either. Liked it very much, so dose was increased. Then he was complaining on anxiety before EP lab, so was given one dose of Xanax and that pain shot plus phenergan for nausea. 

It was his luck that he was in ICU already because at one beautiful moment he just stopped breathing, but survived. Woke up right after Narcan + Romazicon. The two possible explanations were either synergetic actions of opioid, phenergan and benzo on respiratory center, or at large suppressed CYP3A4 by high loading doses of amio and diltiazem, adding to the benzo action. 

how exactly would you approach this?  i am asking, not being contentious.    we care of patients like these frequently, with "patient advocates" who somehow manipulate (maybe that isn't the correct word) the MDs into prescribing meds like dilaudid, benedryl, trazodone, xanax, ativan, librium, phenergan, seroquel, gabapentin, amitriptyline, restoril in 1 sitting. most are scheduled and cleverly labeled PRN.  

i once questioned some orders being "not safe" and was grilled by the an MD and charge nurse. roughly, "if the vitals are stable, you have no reason to deny a patient their medication."   even if i spread medication out an hour apart, some do not metabolize out in an 1 hour.  and i'll get terminated for time management issues.  any ideas?

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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5 hours ago, medteleER said:

how exactly would you approach this?  i am asking, not being contentious.    we care of patients like these frequently, with "patient advocates" who somehow manipulate (maybe that isn't the correct word) the MDs into prescribing meds like dilaudid, benedryl, trazodone, xanax, ativan, librium, phenergan, seroquel, gabapentin, amitriptyline, restoril in 1 sitting. most are scheduled and cleverly labeled PRN.  

i once questioned some orders being "not safe" and was grilled by the an MD and charge nurse. roughly, "if the vitals are stable, you have no reason to deny a patient their medication."   even if i spread medication out an hour apart, some do not metabolize out in an 1 hour.  and i'll get terminated for time management issues.  any ideas?

I would do whatever I can to use non-pharmacologic methods to comfort the patient and help him sleep

I would explain him that what he was taking home may or may not be safe for him right now. He is in hospital because he is sick, isn't he? He takes many other meds now for that reason. Now, ALL meds are working in the same human body at once. Some of them work together, and it can be good or not. Some counteract each other, same story. I am a nurse, I cannot determine if that 1 mg of Xanax safe right now. Doctor can, would you like me to call? 

If I call, I will start from fresh set of vitals taken by me personally. And I will tell the whole story, not only "hi, this is KatieMI from X, about your patient ftom 1234, can he get something for sleep?". In the case I described sbove, I would sure mention loading amio, drip and quickly escalating opioids. 

I would not tell about "home dose Xanax for sleep" at all, unless it was verified or I can verify the dose. Most conscientious providers would not order it "for sleep" anyway. 

If a provider will indeed order Xanax or something equally borderline (say, Versed - I had such orders in ICU), I would politely doubt it right then and there. I would mention my discomfort re. possibility of respiratory depression and then "just suggest" Valium, low dose Restoril, eszopiclone, Remeron or Benadryl. 

If the provider still wants Xanax, I would call to whoever manages the amiodarone and cardizem and ask that person directly if they think it would be okay. Cardiologists are usually better verced in complicated pharmacology of their own drugs.

I have strong pharmacology background, so doctors usually listened to what I said.

About "1 hour apart" rule: 

For example, you work with IV dilaudid to be given q2h. 

1) check renal and liver functions.

2) if they are more or less normal, proceed on your own; if clearly not, call pharmacy and speak with PharmD, not tech

3) go Google and search for "dilaudid half life". Or use free app like Epocrates or drugbook. 

You do not need a peer-reviewed article. The first link Goodle has is from something named "therecoveryvillage.com". It is good enough, as the number will be the same everywhere. 

Dilaudid half life is about 2 hours. So, if you gave dose at 10 AM and the next at 12, your dose #2 will be "catching tail" of the first one as 1/2 of #1 will still be there. After #3 at 2 PM, you will have 1/4 of #1, 1/2 of #2 and whole #3. After #4, you will be close to "doubling" (draw it if it is difficult to understand). Which can be fine if you treat acute postop pain or cancer pain, but not for chronic.

Usually showing Higher Ups that you understand that works. But I must tell you - it sucks to be more than average intelligent person in general, and especially if you are a nurse. 

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Emergent has 25 years experience.

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21 minutes ago, KatieMI said:

 

Usually showing Higher Ups that you understand that works. But I must tell you - it sucks to be more than average intelligent person in general, and especially if you are a nurse

I find my vastly superior intelligence a useful asset 🤓

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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22 minutes ago, Emergent said:

I find my vastly superior intelligence a useful asset 🤓

I do too. But, what I went through before that got clear enough to others, including the management...

Edited by KatieMI

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