How early is too early to give a PRN med?

PediLove2147, BSN, RN · Mar 20, 2012

We have to give a reason why we are giving a PRN medication early so by doing so it would require you to admit you are not following the doctor's order or not documenting that you are giving something. The only time I give something early is if it is due in 10 minutes and I have something to do so by not giving it early would require them to wait.

sharpeimom · Mar 20, 2012

as a former psych nurse, i gave prn meds no more than about 10 minutes early. if someone went off the deep end and a staff member yelled something like, "i need ____ for ___stat!" then i got and gave it after assessment.

as the wife of a type-1 diabetic who took excellent care of himself for decades, annd despite that, developed several venous stasis ulcers on his right leg, i want him to be given his scheduled meds on time plus any ordered prn meds that he requests (though rarely) so he won't be miserable during and after debridement and pt sessions. when he's at home and taking his own meds, he doesn't abuse them and while he's in inpatient wound care rehab, i expect that his scheduled pain meds and his prn meds be given in a timely manner and as requested, after assessment (for prns.) to the few mostly older nurses who decide without bothering to assess his pain level,

resps., how he looks, go get updated!

BostonTerrierLover, BSN, RN · Mar 23, 2012

When dealing with Narcotics, always follow the book. I wouldn't do anything with them you couldn't flip open your Policy and Procedure Manual for your facility out and point to the line that will save your license. Pharmacies now have automated systems that run audits to see if Nurses are:

1. Giving more PRN Narcotics than their Colleagues.

2. Giving Narcotics more Frequently than Collegues.

3. Wasting according to Policy and Procedure.

4. Using the smallest Mg Vial for the Mg Dose (Wasting More than Colleagues).

5. Even Recieving Orders (VO, PO) for Stronger PRN Narcotic Analgesics.

6. Moving back to IM, or IV after a PO has been ordered.

7. Not even administering a PO if available and Ok(not NPO) before administering IV and IM Pain Meds (Narcs)

8. Off Counts on more than one occasion on a certain nurse(the same two nurses always count in my last contract facility)

You don't even have to be doing anything illicit to get redflagged, You may just be the nurse on shift who always gets the higher acuities for trade-offs, example IV nurse, PO med nurse, and Patient care nurses who take a load. One of our Pharmacists said that 95% of their RED FLAGs were cleared without any wrong doing.

It was a real eye opener.

luckynurse_1234 · Apr 2, 2012

Scary. Although I do notice the same nurses get tagged in discrepancies over and over again in my facility. Not that I think they're drug-using, but they tend to be the ones that get in a hurry and take 2 doses when they put they're taking out 1 (or vice versa) and/or forget to document.

txredheadnurse, BSN, RN · Apr 3, 2012

I would give it a little early. I do have a question...is it ok to give a prn Lortab 10 one hour before a scheduled Lortab 10? I had a resident request one and told him to wait until his routine was due. My boss said it is ok to give him the prn right before the routine since he asked for it. Seems like that is doubling up his meds. He is actually a fall risk, and addicted to them.

Personally I wouldn't be comfortable doing this. I have always been told by the pharmacy consultants that PRNs need to be time specific ie. q4 hours, q6hours and not BID, TID to help avoid this specific issue of a resident basically getting a doubled dose. This way if a resident gets a routine dose at 9 AM and 5 PM say & the PRN specifies q6 hours then doses can't be given any closer than 6 hours apart. Make sense?

In addition if you feel this resident is a fall risk but he has also developed a high tolerance to his Lortab I would suggest his pain control needs be reassessed by the prescribing medical provider.

Reese0608 · Jun 7, 2012

thank you everyone for the question and replies! helpful

JBGill15 · Apr 25, 2015

Hello, Luckynurse 1234!

Since your post is now about 3 years ago, how would you answer your question?

Is giving prn meds for pain early would be going against doctor's orders as it would have parameters like max every 4- 6 hours? Would it be safer to call the doctor first before you give it early like 15-30 mins so you can document it as appropriate? Does 10 mins early warrant not calling at all?

How can you tell a needy patient? Would it be not judgmental or biased with patients with history of abuse or as perceived by outgoing nurse on report off? Would you not assess for yourself to validate reported baseline before you set your mind that patient is just needy? As prn was made available to be given within safe time frame, does that not supersede the "needy" bias?

What about if its almost change of shift which happens to be in time prn time is within safe administration? Would you try to give it per reassessment before getting into the focus of turnover report or let patient go through the pain while patient wait for incoming nurse to give it when that nurse have settled?

What is really the aim of prn? Is it proactive or reactive?

Do we wait for them to feel full blown pain before we give one? Then how does that affect our goal of helping or supporting patients on their better response to treatment or helping them cope during treatment?

What is your perception of pain complaint of a patient? Do you treat each patient differently depending on the handoff report?

I saw this great site for a wristwatch with 6 alarms that can be favorable for our maximum 5 patients per shift on the medsurg floor. I was wondering of setting them 15-30 mins before the max 4 hours due for prn so I can proactively assess my patient related to their pain despite craziness on the floor. Its how I feel I would want myself to feel cared for when I am a patient of chronic pain. Pain for me serves as obstacle for patient conditioning to be compliant with care plan. Being proactive with pain management for me would help with targets for good patient experience and continued relations even referrals. I believe its a first line conditioning for their trust in our patient advocacy and sincere interest towards their better response to treatment. I would even write the clock times targets on their bedboards and will go to extent to ask them to call me ahead of time for their pain med when its safe to re-administer so we ( me and patient) can both assess on the effectiveness of the pain med and update the doctor. For this, I would definitely set condition for sincerity to be mutual for this day plan to work. I would even ask the tech on the floor to keep notifying me for any expressed patient discomfort related to pain or potential side effects. It would be my opportunity to teach techs on relationship of particular meds and side effects so they can better work with me more effectively rather not conveniently. I know there would be techs who may react to this negatively as everyone has too much to do as perceived but I have good faith that setting example or initiating this concern would hopefully land a good fertile ground in one's heart. It takes initiation and consistency.

Vibrating Alarm Watch 6 Alarm Non-Digital

Any health team member reading this, I would truly appreciate if you please reply your valuable thoughts and teach me. I am still a student on my clinical.

canned_bread · May 6, 2015

Depends on the drug and the potential for side effects. If its an anti-emetic, then sure, maybe up to 30 minutes early. Low side effects risk for most patients. If it's pain I evaluate why are they having "break through" pain? I may give it to the patient a little early (15 minutes), but if it's intense or doesn't seem enough for them, I will also call for a medication review.

After you have developed some skills in medication administration, in judging patients, in knowing when a patient is drug-demanding, and what things can go wrong with what meds etc, you can then use your own judgement. But until then, as a new grad, if the med is due every 4 hours PRN then give it right then at that 4 hours :)

heron, ASN, RN · May 6, 2015

My main experience has been with pain control and psychoactive prns for anxiety or agitation. I generally go by the one hour window ... I might give up to a half an hour early, for a number of reasons. For one thing, there's a normal variation in response to pain meds, especially opioids and other controlleds. A rational prn order should take that into consideration when specifying an interval. If the prescribed interval is too long to allow symptoms to be treated timely, then the order should get modified if at all possible.

I don't play chicken with pain or anxiety and that half-hour wiggle room makes it more likely that I can catch a pain problem early, before it turns into major torture for the patient and a time suck for me. When I know there's a problem and the patient is somewhat cognitively intact, I make sure to tell the patient to call me early and explain why. When this isn't possible, I use non-verbal cues like irritability, body language and so on.

I follow this policy even with patients known to play a lot of games with meds. If the request comes more than 30 minutes ahead of time, then it's time for reassessment and a call to the doc. People having symptoms need to be assessed and treated. Personality-disordered or demented people need limits set on behaviors that get them in trouble. It can get challenging to do both at the same time.

Dranger · May 6, 2015

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