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.

[Young_Torso]

2 minutes ago, Sour Lemon said:

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

Unless I'm reading what you wrote incorrectly, you're stating the average acute care patient gets the same scrutiny of their orders that the average LTC resident does. Every subsequent sentence I wrote was to show how that claim isn't true.

[Sour Lemon]

5 minutes ago, Young_Torso said:

Unless I'm reading what you wrote incorrectly, you're stating the average acute care patient gets the same scrutiny of their orders that the average LTC resident does. Every subsequent sentence I wrote was to show how that claim isn't true.

OK, in that case we do disagree.
I also have no idea what SAR means.

[Young_Torso]

2 minutes ago, Sour Lemon said:

OK, in that case we do disagree.
I also have no idea what SAR means.

Sub-acute rehab.

[MunoRN, RN]

It doesn't seem particularly confusing, leaving aside the issue of whether this is an appropriate way to prescribe and use benzos (it's not), the only thing that matters is how the prescriber intended for the order to be interpreted, which in this case sounds like is was a continuation of a home med.

The most likely way it was meant to be interpreted would appear to be that the patient takes Xanax 0.5mg throughout the day, then takes an additional 0.5mg at hs, which would mean you interpreted the order correctly.

Would it make more sense to people if it was written "0.5mg q hrs, MRx1 at HS" or "0.5-1mg q 8hrs". I think people are getting into the weeds with the semantics of the orders and missing the intent of the order(s).

[MunoRN, RN]

22 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.

Of course two meds that both impact BP are given at the same time or in the same duration of action, the number of different orders that are being utilized aren't what determines if a med isn't going to safely tolerated by a patient, a since med from a single order may be excessive, and 5 different meds given from 5 different orders may be insufficient.

I'm curious about how you define 'stacking'? Why wouldn't you give ibuprofen and an opiate "at the same time"?

[Jory, MSN, APRN, CNM]

15 hours ago, kbrn2002 said:

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.

Can you copy and paste where I said LTC is EQUAL to "crappy nursing".

Oh that's right...gosh, I never said that did I? Seems like you have a literacy issue if you didn't catch that I was SPECIFICALLY referencing a particular practice that I am sorry...still amounts to crappy nursing.

Do you have any acute care experience? I'm getting the vibe you don't or your experience is very limited. You seem to think that acute care isn't regulated at all. This isn't true.

Guess what? Some drugs <shock> do two things at once. If someone was opiate naive and you gave them a Percocet at night ordered PRN for pain. would you also give them a Valium at the same time that had also been ordered PRN for sleep? Or would you put your critical thinking cap on and figure the Percocet is going to most likely knock them out anyway and you don't need to combine the two?

A prudent nurse would give only the Percocet before you ended up with a non-responsive patient. If you think you should give both meds because "one was ordered for sleep" and the "other was ordered for pain", then I would highly suggest a pharmacology refresher. Sorry of that offends you--but this is a huge issue in nursing right now.

That kind of ranks up there with your acute renal failure being prescribed vancomycin. Would you just give it because, "Well, it was ordered" or question it?

[Jory, MSN, APRN, CNM]

9 hours ago, MunoRN said:

Of course two meds that both impact BP are given at the same time or in the same duration of action, the number of different orders that are being utilized aren't what determines if a med isn't going to safely tolerated by a patient, a since med from a single order may be excessive, and 5 different meds given from 5 different orders may be insufficient.

I'm curious about how you define 'stacking'? Why wouldn't you give ibuprofen and an opiate "at the same time"?

We have patients admitted to the hospital every day that forget they have already taken their BP meds, take another dose, and bottom out. So yes, the duration of action and drug class absolutely matters because you have a combined effect.

I'm not completely disagreeing with you that the patient the OP described may have needed a second dose...but you don't double up for a single administration just because the same drug or drug class is ordered for two different indications.

You can give beta-blockers for anxiety as well as blood pressure. So if someone's blood pressure was 100/70, was feeling anxious, and it was time for their BP meds, you would just double the dose if it was ordered? Not unless you want to code your patient.

In terms of what I define as stacking, depends on the indication. In our hospital, unless someone is immediate post-op, we prefer the nurse give the ibuprofen, wait an hour, then give the opiate unless the pain level is really high, then we prefer the opiate be given and then give ibuprofen on an alternating schedule.

[peachtreednurse, RN]

I find it disheartening that so little emphasis be on the nurse not having to handle clarification of the Physician's or P.A 's orders. That, except for the most extreme circumstances everyone from the ordering physician to the nurse administering the medication be exacting during the process; that each phase align to each persons level of expertise, and that rarely if ever should any expectation be that someone else remedy any deviation from their own lapse in performing to the standard of care

[kbrn2002, ADN, RN]

On 3/19/2019 at 4:27 PM, 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.

I understand what you are saying here. Same thing in the SNF I work at. We have to have a supporting diagnosis or get the med discontinued, even if it's a med that resident has been on for awhile and even if it was originally prescribed for an off label diagnosis. Heck I was recently asked by management to have a compazine order for a recently admitted resident either discontinued or changed to something else as that med requires signed consents where other anti-emetics do not.

[kbrn2002, ADN, RN]

On 3/20/2019 at 3:25 AM, Jory said:

Can you copy and paste where I said LTC is EQUAL to "crappy nursing".

Oh that's right...gosh, I never said that did I? Seems like you have a literacy issue if you didn't catch that I was SPECIFICALLY referencing a particular practice that I am sorry...still amounts to crappy nursing.

Do you have any acute care experience? I'm getting the vibe you don't or your experience is very limited. You seem to think that acute care isn't regulated at all. This isn't true.

Guess what? Some drugs <shock> do two things at once. If someone was opiate naive and you gave them a Percocet at night ordered PRN for pain. would you also give them a Valium at the same time that had also been ordered PRN for sleep? Or would you put your critical thinking cap on and figure the Percocet is going to most likely knock them out anyway and you don't need to combine the two?

A prudent nurse would give only the Percocet before you ended up with a non-responsive patient. If you think you should give both meds because "one was ordered for sleep" and the "other was ordered for pain", then I would highly suggest a pharmacology refresher. Sorry of that offends you--but this is a huge issue in nursing right now.

That kind of ranks up there with your acute renal failure being prescribed vancomycin. Would you just give it because, "Well, it was ordered" or question it?

OK. Here it is: 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.

Now how else should I interpret that except crappy nursing is rampant in LTC??

As far as my experience it's certainly not limited despite my choice to work in an environment other than an acute care setting. As far as my literacy issues, well maybe I'll concede that as words that would not violate TOS are failing me at the moment.

[traumaRUs, MSN, APRN]

STAFF NOTE - Per our terms of service, we encourage lively debate but please lets not get personal. Carry on....this is an interesting debate.

[GadgetRN71, ASN, RN]

On 3/16/2019 at 8:25 AM, Sour Lemon said:

That explains a lot. Evil goes where a daisy award goes. They’re practically like pink slips. Accept one and you’ll be fired very soon.

Not true. ?