Practice Expectation Spotlight: Should you get a benzodiazepine order?

Consider this example of putting evidence-informed practice into action to assist a client restore optimal health.

elderly man squeezing his temples with his hands

A client, 69 years-old, admitted post-surgery who is becoming increasingly upset as the evening progresses into night because he cannot sleep.  His behaviours include picking at his IV and pulling at the various wires/tubes attached to him, blaming others for turning on the lights, and noisily pacing the hallway. The post-op admission assessment revealed nothing untoward, and the last set of vital signs were within expected limits. 

Should you call the on-call staff for lorazepam?

You may be considering that he needs to sleep to aid in the healing processes. His loud behaviour is also disruptive to others on this ward, so sleep may offer some much-needed relief.

But a benzodiazepine may not be the best option. While there are other medication options, such as trazadone or z-drugs, each of these medications carry concerns that also can outweigh their short-term benefits. For example, there is an increased risk of falls, fractures, and hospital readmission with sedative hypnotic drugs. Sedative-hypnotic drugs also are associated with memory loss, cognitive decline, daytime sedation, orthostatic hypotension, even at low doses. Initiation of sedative-hypnotic drugs in the hospital setting can lead to continued use after discharge where the long-term benefits can be minimal.

However, there is the question how to assist your client in a manner that facilitates his post-op recovery. Possibly the client’s pain may not be adequately managed yet, or he may already be experiencing the beginning of post-op delirium, for which adding a medication could contribute to worsening of his condition.

A more fulsome assessment is required to determine root-causes and a plan of action. Practice expectations include use of the nursing process including steps to planning for the needs of your client, including assessment, diagnosis or determination, planning, implementation and evaluation.

So how might you assist to promote sleep for this patient?

There are nonpharmacological interventions such as sleep education, limiting external stimuli, reducing noise or the perception of noise, maintaining circadian alignment and relaxation therapies that can support in-hospital sleep. Reducing the number of times that the client’s room needs to be entered can also assist. Additionally, re-orientation to time and place, cognitive stimulation and sleep hygiene can reduce the risk of delirium. Attention to nutrition and hydration, oxygenation, medication review, and bowel/bladder care may also help. Resources such a cognitive behaviour therapy are another option. Supporting the client towards recovery so he can return home to his own bed as soon as possible is another important option.

You may also want to review evidence-based resources such as Choosing Wisely Canada’s which endorses not using of benzodiazepines to treat delirium, among many other recommendations.

Supporting your client’s well-being and recovery, through the application of current evidence in practice is continually challenging. We need to look for alternatives to some of the most difficult and most important aspects for the lives of the people we care for. The need for recovery and sleep are aspects of recovery that we all can identify with.

References

Choosing Wisely. Nursing – Choosing Wisely Canada

CRNM Practice Expectations for RN, RN (AP) and RN(NP):

Burton, J. et al. (2021). Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews, 7.

Chan, M. P. et al. (2022). Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. Journal of the American Medical Association Internal Medicine, 182(9).

Davidson J et al. (2019). Cognitive-behavioural treatment of insomnia in primary care: A systematic review of sleep outcomes. British Journal of General Practice, 69 (686): e657-e664.

Heinemann, S. & Neukirchen, F. et al. (2019). Patient‐reported factors associated with the desire to continue taking sleep‐inducing drugs after hospital discharge: A survey of older adults. Pharmacoepidemiology Drug Safety, 28, 1014–1022.

Najafi et al. (2021). Effectiveness of an Analytics-Based Intervention for Reducing Sleep Interruption in Hospitalized Patients A Randomized Clinical Trial. Journal of the American Medical Association Internal Medicine, 182(2), 172-177.

Neville, H. et al. (2020). Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients. Canadian Journal Hospital Pharmacy, 73(3), 193-201.