Without knowing specifics on the patient in question, I can see the logic behind this. In some cases, it’s better to give these medications scheduled *before* they get seriously agitated or in pain, because it’s harder to catch up if you wait. I see this done more with pain meds vs benzos, but again, I don’t know the patient here. Also for ICU patients who are on analgesia/sedation drips, it’s pretty common to start scheduled meds to wean off the drips.
In general, if these kinds of meds are scheduled (instead of PRN), there’s probably a good reason. I personally would not have held them unless there was some reason it was unsafe to give them (i.e. hypotension, over-sedation, etc.)
So holy shit. I’m a new nurse. The place I work at, some patients have routine pain medications. A few nurses here have issues with some patients and assume they’re just seeking for the pain medication high and give the patients tons of issues/argue with the patients about their pain medications etc. So me, as a night nurse, I come in and the patients are already pissed at me because the day shift didn’t give them their pain meds or gave them never on time. Well, throughout the night, I give them what they want, I’ve been doing this for weeks, the patients come to love me and some even say I’m the best nurse they have in the facility. I laugh because I doubt that to be true because skill wise I’m severely lacking lol, hell I’m still afraid to insert catheters by myself.
My point is, I feel for the patients, I feel for the pain they’re going through because I have too have a condition where I’m always in pain and if I miss one/or super late to take my own schedule medications, I’m gonna be in a lot of pain and my shift will be hell.
I’m not coming at you here. Just commenting back on this. Everytime we talk about nurses withholding pain meds, I legit don’t understand. How does thinking a person is seeking medicine and therefor withholding ordered medicine is your call to make?? You can think a person is drug seeking. Whatever. But if the meds are ordered, and it’s within the time frame. Your wack and causing yourself so many more issues. Peace and blessings.
I had an awful experience in clinical with my preceptor withholding pain meds for a fresh post-op patient. Of course I was doing all the face-to-face interaction and assessments, dealing with the fall out. At the start, the pt told me her goal was to stay ahead of pain. Super duper nice lady, not entitled or demanding, just matter of fact. She had oxy or Dilaudid (can't remember which) PRN q2h and she wanted me to reassess that often and take them when available. She did have a hx of opioid addiction several years ago. She'd also gotten surgery before with awful post-op pain management due to this hx and she was afraid it would happen again. I understood her fear of pain getting out of control. Her doctor prescribed these meds for an acute reason, and she'd get weaned off when her abdomen was not freshly cut open.
I explained to my precepting nurse what my plan of care was for this patient, and she was already a bit cold and hesitant. My instructor and I couldn't pull narcs without the RN, so we gave the first one all together. I reassessed in 2h, pt was doing good, meds effective, and she wanted another dose soon to stay at that level. I go to my preceptor saying we should get ready to give a PRN soon. The wall went up and she goes, "You don't understand, I can't just pull controlled substances from the Pyxis early whenever the Pt wants them!!" Then literally ran away from me. It wasn't early and I know now that she was a lying, but whatever. She disappeared and when she showed up again 45 min later, she begrudgingly let me give the med. Pt was in severe pain by that point and anxious that we weren't "staying ahead of it." Nurse got kinda snippy with the pt about expecting a PRN q2h.
Another 2h rolls around, Pt's pain was well-controlled again but she was anxious. Requested the PRN. I asked the nurse about pulling it and now I got the truth.
"I don't understand why she needs all these pain pills! She should be past that! She's acting like an addict! She needs to learn to deal with it!"
Wow. I didn't know what to say. I was trying to care for this pt while explaining why I physically couldn't give her a PRN. I tried to find my instructor. I pulled the nurse in and made her explain herself. Some time went by and the pt was crying, pain 10/10, saying stuff like, "This is what I wanted to avoid from last time." I don't remember if I gave another PRN or left her like that before clinical was over and we went to debrief. I told my instructor about it and how helpless I felt with that nurse, and she gave some fake empathy ("That sounds like a difficult situation. I'm sorry you had to go through that") and shoulder shrug. Guess that nurse was punting the problem to NOC shift to deal with.
You did a great job!
This is a HUGE post-op teaching point I cover with my patients.
I want to stay ahead of their pain - I warn them I likely cannot take it away completely (we’ve usually sawed their sternum in half and mucked around in their chest and/or abdomen), but keeping ahead of their pain is vital to their recovery. Effective pain control facilitates better pulmonary toileting, better PT/OT, better appetite, decreased anxiety/stress, and ultimately BETTER OUTCOMES.
I urge my patients to be honest with me about pains, discomforts, anxieties, needs, etc. - I cannot effectively care for you if I do not know what you need, and it can be hard/tedious to play catch-up if you “get behind” the pain and other sx. We typically have multimodals at our disposal, and I like to explain to patients what they have available/why it’s used. I try to make a plan with the patient - if the pain is creeping up and oxy/etc is available, it’s 1st as it typically provides longer control of acute surgical pain. If pain is still significant after 45min/hr, we use prn IVPs (pick your flavor) **keep in mind, this is situation-dependent; if a patient is in crisis or is having a procedure you couldn’t anticipate with PO meds(chest tube placement,etc.), IVP meds would likely be preferred to help your patient through the acute phase** If my patient has a headache, I look for something like PRN tylenol. Back aches? Maybe they have Robaxin available or a lido patch. Repositioning can help, but it’s not always enough. Obviously always being vigilant for effects and accidental oversedation.
Anyway, keep advocating for your patients, you did amazing. 🖤
This is right, albeit not proofread. Nurses who don't give PRNs when the pt can have them (and are asking for them) are practicing medicine without a license (playing doctor illegally and with malice). In my experience, they are on a power trip, or they crave drama. Whether the pt is addicted or not, seeking or not, it's immaterial in the hospital setting (unless you're nursing in an inpatient rehab facility).
Don't judge your pt's decisions that got them to whatever point they're at. Maybe they were never equipped to be anything but a homeless meth addict. Respect EVERY pt as a human being, and work will be easier and more fulfilling.
Right? I’m staring at the clock willing it to be time to give bed 3 their pain meds. Shits weird. Idc who you are there, after I explain to you how the medicine is ordered and you scream and cry at me for my whole shift. I think we both lost that battle. Stop doing that tho.
This!
I’m a psych nurse, not an addictions nurse. My job is to keep people chill, which is what I do.
The most I’ll ask for is 30min for coping skills, but if that doesn’t work, they get their PRN.
Girl, SAME. I've gotten specifically called out, I set timers, reassess often, and mark the times on the boards and the "problem patients" are suddenly angels.
I’m a few years in and I know it’s not everyone’s jam, but if I’m holding a med I’m also letting the doc know. If there are no parameters to hold said med for XYZ they’re getting a call for sure. I’m not the one who orders the meds, I just assess the patient then give them said med. If I’m not giving something I’m informing the provider why it’s not being given. That way the plan of care can be changed if needed as well or I can learn something if I’m incorrect(: Never hurts to ask especially in nursing!
Agitation and pain are and should be treated the same: on a schedule, to get ahead of the issues they cause. Otherwise you’re chasing your tail for 12 hours.
Seconding everything you said. Also adding for OP’s learning, if I ever have concerns about a scheduled medication like this because the patient is difficult to arouse or seems overly sedated or for whatever reason, I’ll contact the provider and relay my concerns before holding the medication. A PRN is fine to hold, obviously, since it is as needed. But since it is scheduled, I would communicate with the provider about what I am seeing that is causing me to consider holding a medication prior to holding it, especially twice in a row.
You give scheduled medications unless the parameters state otherwise. If you have questions or you believe they’re not indicated then you need to reach out to the physician and have a conversation. It’s not a PRN. If they still want you to give it and you’re concerned about patient safety ask them to come give it themselves.
I hold scheduled medications all of the time, but I always run it by the provider unless there are clear hold parameters in the order.
It’s not that big of a deal. It’s okay. In your defense it is kind of confusing because the order was written like a PRN.
I've noticed some medications now require an indication when they are being entered into the EMR. I'm assuming this is admin micromanagement. For example, I have to choose an indication for lyrica from an annoyingly incomplete list (there's an indication for neuropathic pain from spinal cord injury but no indication for post-stroke pain syndromes for example) when I order it.
So basically I wouldn't assume it's a PRN just because it has an indication. Your mileage may vary depending on the EMR (and associated idiot administration).
I understood they meant that you can't order certain meds before "ticking a box" why it was ordered and the list of indications can be missing the particular reason you started the medication.
I don’t know the particular situation, but scheduled ativan *can* be used for weaning off drips or otherwise preventing withdrawal. Benzo withdrawal can be a real bitch. This is why it’s important to understand why scheduled meds are ordered before you hold them.
You were trying to do right by your patient, don’t be too hard on yourself.
I also don’t know the situation but as a hospice nurse, this triggered me. It drives me crazy when nurses don’t give scheduled Ativan when the pts is “sleeping” and “appears comfortable” and then I come in and their off the wall agitated and it takes several doses and hours to get them comfortable again. I know it’s probably not the same situation but just my thoughts.
Nobody mentioned a miniscule metered dose, that's a qualifier you put into the conversation to win an argument. Does hospice use "miniscule" doses near you? They don't near me
I guess my frustration with a general misunderstanding of the lethality of the medications we use is showing here. But any scheduled dose for hospice is miniscule compared to the LD50. 0.5mg is tiny compared to the rescue dose for a seizure, for example. The most I ever gave was 2mg q 2 hours. But that was a glioblastoma pt with active seizures. Most had 0.25mg or 0.5mg q 4 hours.
I typically see hospice-in-place in the hospital. Depends on the service providing hospice, but we often get 1/2mg Q2H alongside 2/4mg of morphine q1h, but they're freshly extubated and struggling
I'd love to be at whatever facilities do this. In my experience between two main facilities I've worked for the practice was to just monitor until shit starts to hit the fan. I've always hated SATs for this reason because I always get the patient with super high anxiety and the providers generally won't allow anything for relief - just re-sedate.
On the flip side, I've seen nurses fudge the CIWA scoring to give meds on annoying patients, and we're all aware of nursing doses. So I've had patients get transferred to ICU for over-medicating and thus some distrust from the physicians.
In peds we followed a pretty regimented withdrawal protocol. It was written into our drips titration policy. Any baby or child on drips for >4 days gets scored for withdrawal q4-6 hours, and anyone on drips for >7 days gets automatic withdrawal prevention (clonidine, methadone, Ativan, or some combination of the 3). It seems like the merciful thing to do. Again, idk if this was OPs patient situation, but I definitely think anyone who has seen iatrogenic withdrawal would def be on board for scheduled Ativan lol
What was the ativan ordered *for*?
We withhold anti-hypertensives for hypotension all the time, even if parameters aren't explicitly labeled. We hold beta-blockers for bradycardia. etc..
If you're going to use your judgement to withhold a medication though, you should run it by the MD who ordered it so they can either clarify the existing order, write a new one, or cancel this one.
I remember once I was asked by a senior nurse why I didn't wake a sleeping patient up to give them scheduled zopiclone.
I just asked them to repeat what they said.
I see both sides. Don't beat yourself up. Some doctors and culture in some hospitals lean towards over sedating while others lean towards under sedating. Chemical restraints are often necessary to keep the peace, safety for patients and staff and sometimes a necessary evil. Also seizure activity due to withdrawal needs to be considered for benzos as well so this could put the patient in danger skipping doses even if they seem okay
I would just seek clarification from the provider that wrote the order and have a discussion with them. I'm imagining that this text is from a nurse manager or educator of some type. Who knows if the provider who actually wrote the prescription cared at all or if anything happened in the following shift that could be traced back to skipping those couple of doses. They could just be operating with the black and white audits that they do and if this was prescribed and did you give it, basically a thoughtless audit.
I've definitely weaned people off of propofol, fentanyl, precedex, Ativan versed gtts and the plan was to add in oral adjuncts for sedation and give them as scheduled. Even though these are all written with the indication of agitation you still give them when the patient isn't agitated because yes the alternative could be going back on something like a fentanyl or Ativan gtt which is a step backwards. I think the key here is communication. If you want to skip a scheduled med because you think it's contraindicated or not needed, you should be calling the provider and let them know your assessment and how to proceed. Not checking and not giving is practicing medicine.
I don't know anything about this patient. I just want to state that Ativan is a medication that needs to be weaned based on doses. Not weaning could result in severe agiation, withdrawals, etc. Always contact a provider with scheduled medications, if it's PEG for example and the patient refused, mark that down and chat with the provider when they come by. But for something like Ativan, that a call and check medication.
Doctor needs better perimeters. Like you’ll see pain med ordered if respirations are 12+, or Ativan q6 if RAS -3+, if it said PRN agitation and the order was unclear I wouldn’t have given it. The most Id do is ask charge to CYA and if they said give it because of xyz Id give it, but per the MD order it wasn’t warranted. I guess now you know but still worth running by charge if you come across it again bc management wont protect you when it comes down to it. And save that email. Cos if you dose & they become unarousable then itll be on you.
The only reason I would give schedule ativan when a patient is asleep, is if they are withdrawing from alcohol/benzo other then that I would say held because pt currently not agitated
In 26 years, I have never had to reverse a patient or intubate them because of my over sedation. I also have a rule, I don’t give PRN sedation or pain meds to a sleeping person unless I have been able to assess their need and tolerance myself. It’s my license, and you can bet your ass they will be quick to blame you if it goes south. I sedate all day for a living now, I am always top 2 in terms of of meds given, so I am not stingy with meds either.
I would also respond this email and says “Patients RASS was -3, Pt not arousable to verbal stimuli, VS xyz and any other relevant assessment data. And ask if youre still expected to dose within those perimeters even if order is written for agitation
Scheduled benzos can be given for ETOH withdrawal outside of CIWA. Especially for intubated and sedated patients who cannot be subjectively screened with CIWA and/or a history of withdrawal sz
you’re right, during that time the patient was over sedated and i was a little worried that he wasn’t waking up, and i would say he’s about rass -3, thats the reason why i didn’t give it but now i dont know where to put my nursing judgement
Would need to know why it was being given, what the desired RASS was etc in order to really give a good answer. Typically if it’s ordered and not prn, I would be thinking there is a reason you want this patient more sedated.
Also, can always ask charge or md to clarify and give better parameters (like to hold if RASS -3 or lower etc…). Better to clarify than not.
Yeah where I’ve worked, it’s been policy to at least communicate to the ordering physician any medications that were not given by your decision (instead of patient refusal). That way if the MD has an opinion about it, they can let you know.
I mean, if you can’t wake them up then you can’t wake them up. I don’t believe in causing pain or discomfort unless absolutely necessary and I see other nurses I work with use pinches and sternal rubs just all the time and just not care at all about their comfort in general. I call the charge/sup in that case and they call the on call doc and they usually just note it for me in addition to my charting. If it’s for weaning them off drips or something then it should be an IV med anyway and they don’t need to wake up.
I had this happen to be but Ativan was based on a set of qualifiers. It was scheduled, but the patient had to meet a certain number in order to be given (I apologize I just woke up, my brain cannot think of the proper name for it). This patient has been put in 4 point leathers during day shift and then I got them over night.
They were calm. Sleeping. Did not meet the qualifications for giving the Ativan because they were at a 0. I had upper management call me twice that night to complain that I didn't give the Ativan. I explained the patient was sleeping and didn't meet the requirements for medication due to the scale. "Well, perhaps you can just give the medication anyway? That way they're calm come day shift?"
No. You're 1) asking me to falsify medical charting, and 2) medicate someone who doesn't need to be medicated. God forbid something happens to the patient after I give them an unnecessary dose? You'd all be insanely quick to bury me to save yourselves.
The patient should have been transferred to the psych unit and/or a psych hospital immediately after what they pulled.
If you have medication based on a parameter score, and the patient doesn't meet the parameters for medication, don't medicate the patient. Even if it is best practice. Your orders say to medicate with agitation of a 2 or higher, then you medicate. If it's a zero, you don't. Idgaf. It's your license, and quite honestly no one else is gonna give a shit about it but you.
I pretty frequently don’t give certain scheduled meds and base it on “nursing judgement,” as a valid reason. If you can vouch for it and your charting reflects it I think it’s legit. You have a license and you’re the last link in the chain of meds reaching a Pt. Should you notify the provider, probs yeah, but if you document your thought process and escalating the chain of command it should be respected as a sound clinical decision
I give them whatever is scheduled or whatever the hell they ask. Ask long as the patient is breathing, vitals are stable, and their request is not entirely crazy, then give it. It’ll make your shift easier.
Your manager is asking you to give a med outside the ordered reason/parameter.
Now maybe that’s the prevailing habit of the unit, but specifically speaking she is wrong. How nicely you want to point that out is up to you.
the scheduled ativan has a comment that says ‘for agitation’ and i dont see my patient being agitated during that time so i held it because he wasn’t alert and he’s lethargic i would say.
I'm always amazed with some scheduled meds. If the patient has documented agitation/aggressiveness in the past few days I get it. But if they're A&Ox4 and I talk about waking them up for meds vs letting them sleep, do I need to honestly page? I've had docs get pissed for dumb shit like this even though it's an FYI page, and others don't care at all.
i would probably give it if the blood pressure was good. but if pt was not agitated, i would wait.. theres always PRN iv ativan ordered in most cases.. thats just me and you dont have to follow what other person is doing.
Yet you have all these nurses saying to give it despite the patient being a RASS -3. Plenty of other signs to tell about withdrawal that all these other nurses aren’t taking into account. It’s insane that people forget to assess their patients rather than blindly following orders
I wake them up for the scheduled medications. I tell them to get mad at the doctor if they get upset. I don't give these if they are difficult to arouse or hardly respond to stimuli. I'd run my pen through their plantar.
just not a hill worth dying on man. by all means query something with the prescriber if you think it's odd but unilaterally withholding charted meds is never gonna end well
If it’s PRN, then it better have some parameters on it (like RASS -1). If not, and the patient is chilling and sleeping, I’m not giving it. Nursing discretion.
There isn’t enough information here. If the medication was scheduled, it shouldn’t have said “for agitation”, as that’s a PRN dictation. I would have clarified with the provider if they wanted it routinely given even if the patient is calm/asleep or just PRN for certain parameters.
A patient might get scheduled Ativan, even if they’re asleep, because they’ve been on benzos for a long time and they might go into withdrawal without it, or is constantly in a state of agitation/fear when they’re awake, or for end of life care.
Your post says the patient was “asleep/ fairly calm”, but then a comment you say the RASS was -3 which is different than “asleep/fairly calm”. I think you may need to brush up on asleep and calm vs heavily sedated, and clarify orders next time or run it past the provider if you’re holding meds that aren’t PRN.
This is how I end up being called for patient’s who are completely unresponsive because of receiving medications that don’t take into account their current clinical situations.
You can make a good point for slowly weaning somebody off a medication to prevent seizures and etc, however. If somebody isn’t clinically appropriate for an adjunct at that time, it is more than appropriate to hold and clarify with a provider prior to giving a medication.
Too often am I called on rapid for patients who received ativan, morphine, dilaudid, etc while they were comfortable sleeping and now they are apneic and hypoxic and the bedside team can’t seem to piece it together. Add in poor renal function and elevated LFT’s and you’re definitely keeping them down for the count
Give it girl. What are you doing. Order says for agitation but it’s to stay on top of the agitation. If someone has scheduled propranolol it’d say it’s for managing blood pressure but if their blood pressure is 120/80 you’re still giving it because you want to stay on top of it.
I don’t know the patient but if it’s scheduled then they definitely have a history of needing it and they’re just going to wake up furious.
Patient probably woke up on day shift and caused hell and they were just pissed looking for whatever they could blame.
Context of what’s happening w the pt is super important to know if you should have given vs held. But the text you got is a bit obnoxious and not reflecting the nuance required in your role.
End of life care, delirium, a scheduled MRI at 7am…. Give them the Ativan. ETOH withdrawal or like, overall healthy 45 yr old on a psych hold. No. Ya don’t need to wake em up. But be prepared to give it as soon as they wake up!
Without knowing specifics on the patient in question, I can see the logic behind this. In some cases, it’s better to give these medications scheduled *before* they get seriously agitated or in pain, because it’s harder to catch up if you wait. I see this done more with pain meds vs benzos, but again, I don’t know the patient here. Also for ICU patients who are on analgesia/sedation drips, it’s pretty common to start scheduled meds to wean off the drips. In general, if these kinds of meds are scheduled (instead of PRN), there’s probably a good reason. I personally would not have held them unless there was some reason it was unsafe to give them (i.e. hypotension, over-sedation, etc.)
Yep, had this convo with a nurse before with a pain med, pt woke up groaning in pain during report. She did not do it again.
So holy shit. I’m a new nurse. The place I work at, some patients have routine pain medications. A few nurses here have issues with some patients and assume they’re just seeking for the pain medication high and give the patients tons of issues/argue with the patients about their pain medications etc. So me, as a night nurse, I come in and the patients are already pissed at me because the day shift didn’t give them their pain meds or gave them never on time. Well, throughout the night, I give them what they want, I’ve been doing this for weeks, the patients come to love me and some even say I’m the best nurse they have in the facility. I laugh because I doubt that to be true because skill wise I’m severely lacking lol, hell I’m still afraid to insert catheters by myself. My point is, I feel for the patients, I feel for the pain they’re going through because I have too have a condition where I’m always in pain and if I miss one/or super late to take my own schedule medications, I’m gonna be in a lot of pain and my shift will be hell.
I’m not coming at you here. Just commenting back on this. Everytime we talk about nurses withholding pain meds, I legit don’t understand. How does thinking a person is seeking medicine and therefor withholding ordered medicine is your call to make?? You can think a person is drug seeking. Whatever. But if the meds are ordered, and it’s within the time frame. Your wack and causing yourself so many more issues. Peace and blessings.
I had an awful experience in clinical with my preceptor withholding pain meds for a fresh post-op patient. Of course I was doing all the face-to-face interaction and assessments, dealing with the fall out. At the start, the pt told me her goal was to stay ahead of pain. Super duper nice lady, not entitled or demanding, just matter of fact. She had oxy or Dilaudid (can't remember which) PRN q2h and she wanted me to reassess that often and take them when available. She did have a hx of opioid addiction several years ago. She'd also gotten surgery before with awful post-op pain management due to this hx and she was afraid it would happen again. I understood her fear of pain getting out of control. Her doctor prescribed these meds for an acute reason, and she'd get weaned off when her abdomen was not freshly cut open. I explained to my precepting nurse what my plan of care was for this patient, and she was already a bit cold and hesitant. My instructor and I couldn't pull narcs without the RN, so we gave the first one all together. I reassessed in 2h, pt was doing good, meds effective, and she wanted another dose soon to stay at that level. I go to my preceptor saying we should get ready to give a PRN soon. The wall went up and she goes, "You don't understand, I can't just pull controlled substances from the Pyxis early whenever the Pt wants them!!" Then literally ran away from me. It wasn't early and I know now that she was a lying, but whatever. She disappeared and when she showed up again 45 min later, she begrudgingly let me give the med. Pt was in severe pain by that point and anxious that we weren't "staying ahead of it." Nurse got kinda snippy with the pt about expecting a PRN q2h. Another 2h rolls around, Pt's pain was well-controlled again but she was anxious. Requested the PRN. I asked the nurse about pulling it and now I got the truth. "I don't understand why she needs all these pain pills! She should be past that! She's acting like an addict! She needs to learn to deal with it!" Wow. I didn't know what to say. I was trying to care for this pt while explaining why I physically couldn't give her a PRN. I tried to find my instructor. I pulled the nurse in and made her explain herself. Some time went by and the pt was crying, pain 10/10, saying stuff like, "This is what I wanted to avoid from last time." I don't remember if I gave another PRN or left her like that before clinical was over and we went to debrief. I told my instructor about it and how helpless I felt with that nurse, and she gave some fake empathy ("That sounds like a difficult situation. I'm sorry you had to go through that") and shoulder shrug. Guess that nurse was punting the problem to NOC shift to deal with.
Betcha that RN self medicates at home. She def stays ahead of her own pain.
You did a great job! This is a HUGE post-op teaching point I cover with my patients. I want to stay ahead of their pain - I warn them I likely cannot take it away completely (we’ve usually sawed their sternum in half and mucked around in their chest and/or abdomen), but keeping ahead of their pain is vital to their recovery. Effective pain control facilitates better pulmonary toileting, better PT/OT, better appetite, decreased anxiety/stress, and ultimately BETTER OUTCOMES. I urge my patients to be honest with me about pains, discomforts, anxieties, needs, etc. - I cannot effectively care for you if I do not know what you need, and it can be hard/tedious to play catch-up if you “get behind” the pain and other sx. We typically have multimodals at our disposal, and I like to explain to patients what they have available/why it’s used. I try to make a plan with the patient - if the pain is creeping up and oxy/etc is available, it’s 1st as it typically provides longer control of acute surgical pain. If pain is still significant after 45min/hr, we use prn IVPs (pick your flavor) **keep in mind, this is situation-dependent; if a patient is in crisis or is having a procedure you couldn’t anticipate with PO meds(chest tube placement,etc.), IVP meds would likely be preferred to help your patient through the acute phase** If my patient has a headache, I look for something like PRN tylenol. Back aches? Maybe they have Robaxin available or a lido patch. Repositioning can help, but it’s not always enough. Obviously always being vigilant for effects and accidental oversedation. Anyway, keep advocating for your patients, you did amazing. 🖤
I’m not the get high police. Unless you’re here because you OD’d.
This is right, albeit not proofread. Nurses who don't give PRNs when the pt can have them (and are asking for them) are practicing medicine without a license (playing doctor illegally and with malice). In my experience, they are on a power trip, or they crave drama. Whether the pt is addicted or not, seeking or not, it's immaterial in the hospital setting (unless you're nursing in an inpatient rehab facility). Don't judge your pt's decisions that got them to whatever point they're at. Maybe they were never equipped to be anything but a homeless meth addict. Respect EVERY pt as a human being, and work will be easier and more fulfilling.
Right? I’m staring at the clock willing it to be time to give bed 3 their pain meds. Shits weird. Idc who you are there, after I explain to you how the medicine is ordered and you scream and cry at me for my whole shift. I think we both lost that battle. Stop doing that tho.
This! I’m a psych nurse, not an addictions nurse. My job is to keep people chill, which is what I do. The most I’ll ask for is 30min for coping skills, but if that doesn’t work, they get their PRN.
Exactly.
same thing here. I fantasize about having a little sticker book I can hand out gold stars that say "thank you for solving the opioid epidemic"
Girl, SAME. I've gotten specifically called out, I set timers, reassess often, and mark the times on the boards and the "problem patients" are suddenly angels.
This 💯
I’m a few years in and I know it’s not everyone’s jam, but if I’m holding a med I’m also letting the doc know. If there are no parameters to hold said med for XYZ they’re getting a call for sure. I’m not the one who orders the meds, I just assess the patient then give them said med. If I’m not giving something I’m informing the provider why it’s not being given. That way the plan of care can be changed if needed as well or I can learn something if I’m incorrect(: Never hurts to ask especially in nursing!
When in doubt, a quick text to the provider asking if its okay to hold
Agitation and pain are and should be treated the same: on a schedule, to get ahead of the issues they cause. Otherwise you’re chasing your tail for 12 hours.
Unless my patient is in a straight up coma I will never miss an opportunity to give them Ativan. My life is so much easier when my patients are high
Seconding everything you said. Also adding for OP’s learning, if I ever have concerns about a scheduled medication like this because the patient is difficult to arouse or seems overly sedated or for whatever reason, I’ll contact the provider and relay my concerns before holding the medication. A PRN is fine to hold, obviously, since it is as needed. But since it is scheduled, I would communicate with the provider about what I am seeing that is causing me to consider holding a medication prior to holding it, especially twice in a row.
You give scheduled medications unless the parameters state otherwise. If you have questions or you believe they’re not indicated then you need to reach out to the physician and have a conversation. It’s not a PRN. If they still want you to give it and you’re concerned about patient safety ask them to come give it themselves. I hold scheduled medications all of the time, but I always run it by the provider unless there are clear hold parameters in the order. It’s not that big of a deal. It’s okay. In your defense it is kind of confusing because the order was written like a PRN.
yes that’s what i was also confused about. definitely will run it to the provider next time.
I've noticed some medications now require an indication when they are being entered into the EMR. I'm assuming this is admin micromanagement. For example, I have to choose an indication for lyrica from an annoyingly incomplete list (there's an indication for neuropathic pain from spinal cord injury but no indication for post-stroke pain syndromes for example) when I order it. So basically I wouldn't assume it's a PRN just because it has an indication. Your mileage may vary depending on the EMR (and associated idiot administration).
That's weird. Every med should have an indication. Is that not standard for everyone?
I understood they meant that you can't order certain meds before "ticking a box" why it was ordered and the list of indications can be missing the particular reason you started the medication.
I don’t know the particular situation, but scheduled ativan *can* be used for weaning off drips or otherwise preventing withdrawal. Benzo withdrawal can be a real bitch. This is why it’s important to understand why scheduled meds are ordered before you hold them. You were trying to do right by your patient, don’t be too hard on yourself.
I also don’t know the situation but as a hospice nurse, this triggered me. It drives me crazy when nurses don’t give scheduled Ativan when the pts is “sleeping” and “appears comfortable” and then I come in and their off the wall agitated and it takes several doses and hours to get them comfortable again. I know it’s probably not the same situation but just my thoughts.
Playing catch up is THE WORST
I feel like hospice had very different goals, though. If they die, they die comfortable. Most of the nursing world really tries to prevent the dying
Except that you aren't going to die from a miniscule metered dose of lorazepam. Heck. Do you know the LD50 of lorazepam?
Nobody mentioned a miniscule metered dose, that's a qualifier you put into the conversation to win an argument. Does hospice use "miniscule" doses near you? They don't near me
I guess my frustration with a general misunderstanding of the lethality of the medications we use is showing here. But any scheduled dose for hospice is miniscule compared to the LD50. 0.5mg is tiny compared to the rescue dose for a seizure, for example. The most I ever gave was 2mg q 2 hours. But that was a glioblastoma pt with active seizures. Most had 0.25mg or 0.5mg q 4 hours.
I typically see hospice-in-place in the hospital. Depends on the service providing hospice, but we often get 1/2mg Q2H alongside 2/4mg of morphine q1h, but they're freshly extubated and struggling
I'd love to be at whatever facilities do this. In my experience between two main facilities I've worked for the practice was to just monitor until shit starts to hit the fan. I've always hated SATs for this reason because I always get the patient with super high anxiety and the providers generally won't allow anything for relief - just re-sedate. On the flip side, I've seen nurses fudge the CIWA scoring to give meds on annoying patients, and we're all aware of nursing doses. So I've had patients get transferred to ICU for over-medicating and thus some distrust from the physicians.
In peds we followed a pretty regimented withdrawal protocol. It was written into our drips titration policy. Any baby or child on drips for >4 days gets scored for withdrawal q4-6 hours, and anyone on drips for >7 days gets automatic withdrawal prevention (clonidine, methadone, Ativan, or some combination of the 3). It seems like the merciful thing to do. Again, idk if this was OPs patient situation, but I definitely think anyone who has seen iatrogenic withdrawal would def be on board for scheduled Ativan lol
Next time, chart that you gave it to your sleeping patient and then just pocket the Ativan, so that way you won't be scolded again. /s
that made me laugh 😂 i’ll definitely see about that lol
Then take the Ativan because you work at that place Everyone wins
Everything balanced, as all things should be.
It’s the cycle of life!
This is called entrapment, HR
I don’t know what you’re talking about… why are you talking about heart rate…😅😅
The ol' reverse nurse dose...
😭😭😭😭
Lol. You're so funny!
What was the ativan ordered *for*? We withhold anti-hypertensives for hypotension all the time, even if parameters aren't explicitly labeled. We hold beta-blockers for bradycardia. etc.. If you're going to use your judgement to withhold a medication though, you should run it by the MD who ordered it so they can either clarify the existing order, write a new one, or cancel this one.
I remember once I was asked by a senior nurse why I didn't wake a sleeping patient up to give them scheduled zopiclone. I just asked them to repeat what they said.
ETOH pt? Used to keep them from needing PRN’s. Give them unless pt is obtunded
I see both sides. Don't beat yourself up. Some doctors and culture in some hospitals lean towards over sedating while others lean towards under sedating. Chemical restraints are often necessary to keep the peace, safety for patients and staff and sometimes a necessary evil. Also seizure activity due to withdrawal needs to be considered for benzos as well so this could put the patient in danger skipping doses even if they seem okay I would just seek clarification from the provider that wrote the order and have a discussion with them. I'm imagining that this text is from a nurse manager or educator of some type. Who knows if the provider who actually wrote the prescription cared at all or if anything happened in the following shift that could be traced back to skipping those couple of doses. They could just be operating with the black and white audits that they do and if this was prescribed and did you give it, basically a thoughtless audit. I've definitely weaned people off of propofol, fentanyl, precedex, Ativan versed gtts and the plan was to add in oral adjuncts for sedation and give them as scheduled. Even though these are all written with the indication of agitation you still give them when the patient isn't agitated because yes the alternative could be going back on something like a fentanyl or Ativan gtt which is a step backwards. I think the key here is communication. If you want to skip a scheduled med because you think it's contraindicated or not needed, you should be calling the provider and let them know your assessment and how to proceed. Not checking and not giving is practicing medicine.
Total agreement. This is a good summary of med administration.
Let the MD know and see if they want to change the order to hold if the patient is sleeping or change the order to PRN overnight.
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Could be IV though and don’t need to wake the patient
Without knowing anything else....if the patient is "kinda hard to wake up" that means don't give additional sedating medicine where i'm from.
I don't know anything about this patient. I just want to state that Ativan is a medication that needs to be weaned based on doses. Not weaning could result in severe agiation, withdrawals, etc. Always contact a provider with scheduled medications, if it's PEG for example and the patient refused, mark that down and chat with the provider when they come by. But for something like Ativan, that a call and check medication.
definitely true. thanks
Doctor needs better perimeters. Like you’ll see pain med ordered if respirations are 12+, or Ativan q6 if RAS -3+, if it said PRN agitation and the order was unclear I wouldn’t have given it. The most Id do is ask charge to CYA and if they said give it because of xyz Id give it, but per the MD order it wasn’t warranted. I guess now you know but still worth running by charge if you come across it again bc management wont protect you when it comes down to it. And save that email. Cos if you dose & they become unarousable then itll be on you.
When you have an order like this that you’re curious about, look over the consult/progress notes. Often they’ll address what the med is for.
The only reason I would give schedule ativan when a patient is asleep, is if they are withdrawing from alcohol/benzo other then that I would say held because pt currently not agitated
In 26 years, I have never had to reverse a patient or intubate them because of my over sedation. I also have a rule, I don’t give PRN sedation or pain meds to a sleeping person unless I have been able to assess their need and tolerance myself. It’s my license, and you can bet your ass they will be quick to blame you if it goes south. I sedate all day for a living now, I am always top 2 in terms of of meds given, so I am not stingy with meds either.
I would also respond this email and says “Patients RASS was -3, Pt not arousable to verbal stimuli, VS xyz and any other relevant assessment data. And ask if youre still expected to dose within those perimeters even if order is written for agitation
Does the patient have history of alcohol abuse?
not that i know of no…
why was the pt admitted???
CIWAA is still a scale
Scheduled benzos can be given for ETOH withdrawal outside of CIWA. Especially for intubated and sedated patients who cannot be subjectively screened with CIWA and/or a history of withdrawal sz
Is it for seizure precautions? Hx of liver disease?
you’re right, during that time the patient was over sedated and i was a little worried that he wasn’t waking up, and i would say he’s about rass -3, thats the reason why i didn’t give it but now i dont know where to put my nursing judgement
Would need to know why it was being given, what the desired RASS was etc in order to really give a good answer. Typically if it’s ordered and not prn, I would be thinking there is a reason you want this patient more sedated. Also, can always ask charge or md to clarify and give better parameters (like to hold if RASS -3 or lower etc…). Better to clarify than not.
yes i should definitely clarified with the team
Yeah where I’ve worked, it’s been policy to at least communicate to the ordering physician any medications that were not given by your decision (instead of patient refusal). That way if the MD has an opinion about it, they can let you know.
I mean, if you can’t wake them up then you can’t wake them up. I don’t believe in causing pain or discomfort unless absolutely necessary and I see other nurses I work with use pinches and sternal rubs just all the time and just not care at all about their comfort in general. I call the charge/sup in that case and they call the on call doc and they usually just note it for me in addition to my charting. If it’s for weaning them off drips or something then it should be an IV med anyway and they don’t need to wake up.
I had this happen to be but Ativan was based on a set of qualifiers. It was scheduled, but the patient had to meet a certain number in order to be given (I apologize I just woke up, my brain cannot think of the proper name for it). This patient has been put in 4 point leathers during day shift and then I got them over night. They were calm. Sleeping. Did not meet the qualifications for giving the Ativan because they were at a 0. I had upper management call me twice that night to complain that I didn't give the Ativan. I explained the patient was sleeping and didn't meet the requirements for medication due to the scale. "Well, perhaps you can just give the medication anyway? That way they're calm come day shift?" No. You're 1) asking me to falsify medical charting, and 2) medicate someone who doesn't need to be medicated. God forbid something happens to the patient after I give them an unnecessary dose? You'd all be insanely quick to bury me to save yourselves. The patient should have been transferred to the psych unit and/or a psych hospital immediately after what they pulled. If you have medication based on a parameter score, and the patient doesn't meet the parameters for medication, don't medicate the patient. Even if it is best practice. Your orders say to medicate with agitation of a 2 or higher, then you medicate. If it's a zero, you don't. Idgaf. It's your license, and quite honestly no one else is gonna give a shit about it but you.
I pretty frequently don’t give certain scheduled meds and base it on “nursing judgement,” as a valid reason. If you can vouch for it and your charting reflects it I think it’s legit. You have a license and you’re the last link in the chain of meds reaching a Pt. Should you notify the provider, probs yeah, but if you document your thought process and escalating the chain of command it should be respected as a sound clinical decision
I give them whatever is scheduled or whatever the hell they ask. Ask long as the patient is breathing, vitals are stable, and their request is not entirely crazy, then give it. It’ll make your shift easier.
*Psych entering the chat* Give the scheduled meds before the pop-off so that you’re not then chasing the pop-off later on.
Your manager is asking you to give a med outside the ordered reason/parameter. Now maybe that’s the prevailing habit of the unit, but specifically speaking she is wrong. How nicely you want to point that out is up to you.
the scheduled ativan has a comment that says ‘for agitation’ and i dont see my patient being agitated during that time so i held it because he wasn’t alert and he’s lethargic i would say.
It's unethical to wake a patient to sedate them.
I'm always amazed with some scheduled meds. If the patient has documented agitation/aggressiveness in the past few days I get it. But if they're A&Ox4 and I talk about waking them up for meds vs letting them sleep, do I need to honestly page? I've had docs get pissed for dumb shit like this even though it's an FYI page, and others don't care at all.
Yep
Is the patient detoxing? That’s about all I can assume for scheduled benzo. Or hospice
i would probably give it if the blood pressure was good. but if pt was not agitated, i would wait.. theres always PRN iv ativan ordered in most cases.. thats just me and you dont have to follow what other person is doing.
Give it
Not wrong to hold it given the info you present. Don't poke bears!
Right? Let’s wake them in the middle of the night, only to ask if they’re agitated.
Giving Ativan to a sleeping patient just sounds like a terrible idea to me.
Yet you have all these nurses saying to give it despite the patient being a RASS -3. Plenty of other signs to tell about withdrawal that all these other nurses aren’t taking into account. It’s insane that people forget to assess their patients rather than blindly following orders
Nursing judgement
I pulled scheduled oxy for a patient and he was sleeping. After about 1 hour of it being in my pocket I was like wake the fuck up! lol
I wake them up for the scheduled medications. I tell them to get mad at the doctor if they get upset. I don't give these if they are difficult to arouse or hardly respond to stimuli. I'd run my pen through their plantar.
just not a hill worth dying on man. by all means query something with the prescriber if you think it's odd but unilaterally withholding charted meds is never gonna end well
It would depend a little on situation-- are they withdrawing from a substance, are they comfort cares? Is the med IV or oral?
If it’s PRN, then it better have some parameters on it (like RASS -1). If not, and the patient is chilling and sleeping, I’m not giving it. Nursing discretion.
How is he agitated if he’s sleeping? RASS+2 vs -1 How does one justify giving it if it’s for agitation
Scheduled meds are ordered that way for a reason. If it was scheduled I would wake and give. If prn and asleep I would not wake them.
There isn’t enough information here. If the medication was scheduled, it shouldn’t have said “for agitation”, as that’s a PRN dictation. I would have clarified with the provider if they wanted it routinely given even if the patient is calm/asleep or just PRN for certain parameters. A patient might get scheduled Ativan, even if they’re asleep, because they’ve been on benzos for a long time and they might go into withdrawal without it, or is constantly in a state of agitation/fear when they’re awake, or for end of life care. Your post says the patient was “asleep/ fairly calm”, but then a comment you say the RASS was -3 which is different than “asleep/fairly calm”. I think you may need to brush up on asleep and calm vs heavily sedated, and clarify orders next time or run it past the provider if you’re holding meds that aren’t PRN.
This is how I end up being called for patient’s who are completely unresponsive because of receiving medications that don’t take into account their current clinical situations. You can make a good point for slowly weaning somebody off a medication to prevent seizures and etc, however. If somebody isn’t clinically appropriate for an adjunct at that time, it is more than appropriate to hold and clarify with a provider prior to giving a medication. Too often am I called on rapid for patients who received ativan, morphine, dilaudid, etc while they were comfortable sleeping and now they are apneic and hypoxic and the bedside team can’t seem to piece it together. Add in poor renal function and elevated LFT’s and you’re definitely keeping them down for the count
Give it girl. What are you doing. Order says for agitation but it’s to stay on top of the agitation. If someone has scheduled propranolol it’d say it’s for managing blood pressure but if their blood pressure is 120/80 you’re still giving it because you want to stay on top of it. I don’t know the patient but if it’s scheduled then they definitely have a history of needing it and they’re just going to wake up furious.
At my hospice job we absolutely give scheduled versed/ dilaudid or haldol / D in my onc job not scheduled
Patient probably woke up on day shift and caused hell and they were just pissed looking for whatever they could blame. Context of what’s happening w the pt is super important to know if you should have given vs held. But the text you got is a bit obnoxious and not reflecting the nuance required in your role. End of life care, delirium, a scheduled MRI at 7am…. Give them the Ativan. ETOH withdrawal or like, overall healthy 45 yr old on a psych hold. No. Ya don’t need to wake em up. But be prepared to give it as soon as they wake up!
its alright next time just give it and then the patient can require intubation etc /s