Written Up

[medteleER]

The oncoming shift charge nurse got on me about "double dosing" a patient. MD had (2) specific orders PRN:

1) xanax 0.5 mg for sleep

2) xanax 0.5 mg q8h for anxiety

I gave BOTH of them because the patient claimed being anxious and wanted something to sleep. My charge nurse pulled me to the side afterward and stated she was going to write it up. The patient was VSS in the morning. I'm not sure how I should be feeling about this.

[Sour Lemon]

2 hours ago, NuGuyNurse2b said:

I wouldn't have given both doses. We just had this exact situation with morphine for a pt. One of the other nurses asked me to cover her pt, there's an order for Morphine 2mg stat, and then for morphine 2mg Q4hrs (standing, not prn). Well the brilliant system allowed the stat order to be entered into the MAR at the same time to start with the Q4 standing dose. So I'm staring at two tasks for morphine to be given, 4mgs total. I bounced it back to the primary nurse to handle her pt, I wasn't about to get caught up in that one. I don't know whatever came of it, there's no doubt in my mind the Q4 hr standing was to be started 4hrs after the initial dose, but since the MD ordered both at the same time, the system automatically kicked it in like that.

In one place I worked, the "STAT" order would have allowed an override and immediate administration. Our pharmacy could take 4-6 hours (or longer) to profile routine medication orders.
I would have passed it back to the primary nurse, too.
I think your order actually is confusing ....the OP's, IMO, was not.

[Jory, MSN, APRN, CNM]

10 hours ago, kbrn2002 said:

I'm surprised at how many people here are questioning OP's judgement like this was some major error. I'm guessing not many of you work in LTC. Orders like this is where I work are not that uncommon and yes, I would have given both doses concurrently as ordered.

Would you have given two meds that impacted blood pressure? No, you would not because you don't want your patient to bottom out.

It may be "common" in long term care, but it's called crappy nursing and why so many seniors are over-medicated for staff convenience.

I write for scheduled pain meds and PRN meds all the time after deliveries. I count on the nurse's critical thinking skills not to stack meds inappropriately. RNs should not need a baby sitter. I don't mind stacking ibuprofen with an opiate for better pain control, , but you don't give them at the same time and you don't stack opiates with other sedating drugs such as Ativan, etc.

[Kooky Korky, BSN, RN]

On 3/15/2019 at 1:12 PM, lokipr said:

I highly doubt there was an adverse reaction. Its just 1mg of Xanax.

For a very ill or very tiny Pt, 1 mg. could be problematic.

[Katie Slayton]

I would’ve given one dose. Waited about 45 minutes to an hour. And if the patient was still anxious or sleepIess I would give another one. I wouldn’t give them both at the same time though.

[Sour Lemon]

2 hours ago, Jory said:

Would you have given two meds that impacted blood pressure?

I don't mind stacking ibuprofen with an opiate for better pain control, but you don't give them at the same time and you don't stack opiates with other sedating drugs such as Ativan, etc.

I do all of these things, at times. My doctor also gave opiates and ibuprofen together every six hours after both of my deliveries. I don't think it's "crappy nursing" at all and I've never worked in long term care.

[Katie Slayton]

You could also talk to the physician who wrote these orders. Honestly my guess is that the physician wouldn’t have minded you doing that. If this patient needed PRN and Xanax to sleep they are probably an anxious patient. If anyone does question you I would just tell them that you had a good faith believe that you were following the doctor‘s orders. Also 1 mg of Xanax is not an unreasonable dose. It’s not like you gave two doses of 2 mg. My guess is that the doctor would’ve allowed some nursing discretion on this one

[Katie Slayton]

Also it’s reasonable to assume that given the orders the doctor was allowing you to go up to 2 mg a day

[umbdude, MSN, APRN]

I think it's petty to write someone up for this unless there's clear policy or the OP has been told specifically not to do something like this in the past. Prescribers and RN mgr cannot assume that every RN on the unit will act with the same logic, and it's their responsibility that something like this doesn't occur.

I would've said "the 0.5 mg should take care of both anxiety and sleep." If patient insists, per how the order is written, the patient is entitled to both doses. I would call the MD if I feel that it's highly unsafe.

[kbrn2002, ADN, RN]

15 hours ago, Jory said:

Would you have given two meds that impacted blood pressure? No, you would not because you don't want your patient to bottom out.

It may be "common" in long term care, but it's called crappy nursing and why so many seniors are over-medicated for staff convenience.

I write for scheduled pain meds and PRN meds all the time after deliveries. I count on the nurse's critical thinking skills not to stack meds inappropriately. RNs should not need a baby sitter. I don't mind stacking ibuprofen with an opiate for better pain control, , but you don't give them at the same time and you don't stack opiates with other sedating drugs such as Ativan, etc.

Yes I would and I do give multiple meds that impact BP concurrently. If that's the med cocktail that has proven to work for that resident you bet I give them. Stacking meds is not always inappropriate, sometimes that is what works for that individual.

Our residents are certainly not over-medicated for staff convenience. We perform monthly order audits on every resident by pharmacy in conjunction with the primary provider and the RN to ensure all orders remain appropriate. We are required to attempt med reductions of psychotropics, benzo's and opiates on a regular schedule. LTC is one of the highest if not the highest regulated field of medicine there is. I doubt the average acute care patient gets the kind of scrutiny of their orders that our residents do.

I am greatly offended that you assume LTC is equal to "crappy nursing." RN's certainly shouldn't need a babysitter, but they also certainly don't need your condescending attitude and insults toward an entire specialty.

[Sour Lemon]

18 minutes ago, kbrn2002 said:

I doubt the average acute care patient gets the kind of scrutiny of their orders that our residents do.

They do. I agree with the rest of your rant, though.

[Young_Torso]

4 hours ago, Sour Lemon said:

They do. I agree with the rest of your rant, though.

Disagree. I've worked LTC/SAR and currently work in acute care and it's a different ballgame now. Haldol and seroquel are routinely used for agitation in the hospital (along with benzos). At my SAR job we were told to instruct the attendings to d/c the antipsychotics when doing med reviews for new admits coming from the hospital unless they had a diagnosis of schizophrenia, Tourette's, or Huntington's. If a doctor was resistant to stop the meds we were instructed to call the medical director to get the d/c order, or an order for a psych consult at the very least. Same thing if a patient came in with a benzo order without a diagnosis of an anxiety disorder.

[Sour Lemon]

7 minutes ago, Young_Torso said:

Disagree. I've worked LTC/SAR and currently work in acute care and it's a different ballgame now. Haldol and seroquel are routinely used for agitation in the hospital (along with benzos). At my SAR job we were told to instruct the attendings to d/c the antipsychotics when doing med reviews for new admits coming from the hospital unless they had a diagnosis of schizophrenia, Tourette's, or Huntington's. If a doctor was resistant to stop the meds we were instructed to call the medical director to get the d/c order, or an order for a psych consult at the very least. Same thing if a patient came in with a benzo order without a diagnosis of an anxiety disorder.

Are you disagreeing with my disagreement? ...because it sounds like you actually do agree from everything you wrote after that first sentence.