The US Food and Drug Administration recently requested that practitioners stop prescribing combination prescription pain medications that have more than 325 mg of acetaminophen per tablet, capsule, etc., due to the risk of liver damage. This is a good thing.
AMDA’s Pain Management in the Long-Term Care Setting clinical practice guideline recommends limiting the total daily dose of acetaminophen to 3,000 mg for most elderly patients and 2,000 mg for elderly patients with renal or hepatic insufficiency.
What about anticholinergic loads? Again, according to AMDA’s guidance (in its medication manual) serum anticholinergic levels in people, especially those with dementia, have been shown to have adverse effects on cognition and ability to perform activities of daily living. Anticholinergic load is cumulative so that when a patient is taking several medications, his or her cumulative anticholinergic load may be considerable, despite the fact that taken individually, each medication’s level of anticholinergenicity may be low.
Since we can have different doctors prescribing different medications for one resident, what the heck can we as nurses do to keep the “load” down?
Well, there are actually several things we can do. As DONs, (or DNSs, or whatever we call ourselves), we can work with our totally awesome medical directors and make this a quality improvement project and then partner with our totally awesome pharmacy consultants and have them check for “loads” reaching maximum capacity. And, if they tell us the load is high, we can then ask for recommendations to give the attendings on what can be titrated down, substituted or maybe even eliminated.
Then we “suck it up” and make those calls (because we don’t really like having to do this!) and communicate those recommendations. And if we get “politely” blown off, we just give the job over to our totally awesome medically directors who by virtue of F-tag 501 can pull rank and get the job done. (Despite how scary we nurses can be sometimes —think the non-real “Nurse Jackie” — F-tags are a lot scarier!)
So consider the loads (not the workloads, I need to write a book for that!) and make it lighter!
Just keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.