Do you limit PRNs to what they are prescribed for or do you give patients what they are asking for as long as it's safe to do so?
I am a fairly new nurse (a little over a year) and I am the med nurse on the night shift on an adult inpatient psych unit. In terms of medical ethics, I am uncomfortable encouraging the rampant overuse of and dependence on PRNs for everything, (especially anxiety, insomnia, and to a lesser extent, pain), that I see in many of our "frequent flyers".
For instance, many of our patients have an antipsychotic-benzo combination ordered as a PRN for "extreme agitation and aggression", and many of these patients keep coming and requesting this combo to help them sleep. "I want something to knock me out" they say.
If they are open to it, I usually spend time with them discussing sleep hygiene, suggesting a hot shower, a cup of warm milk or chamomile tea (which I then make for them), and sometimes leading them through some progressive muscle relaxation. Sometimes all it takes is for someone to sit with them and let them talk or to just have a light low-key conversation about nothing in particular, and they relax and pretty soon they're smiling and yawning and heading off to bed. All this takes a good deal of time, and I'm usually left scrambling to catch up with charting, checks and all the other stuff our nights are usually filled with, and sometimes this means my teammates ending up picking up my slack, but still, I feel committed to offering non-pharmacological alternatives.
Some of the patients however, are very fixated on getting meds to help them with all of their discomforts and refuse to try anything else. If they feel that you are even trying to suggest non-pharmacological alternatives, they start subtly (or not so subtly) threatening to lose it, and actually start displaying "extreme agitation and aggression".
So lately I find I've been just going ahead and giving them what they are asking for, particularly if they are habituated. I find myself giving out Risperdal for sleep, Haldol for anxiety, and ... believe it or not, 0.5 mg Klonopin "for back pain" and Tylenol "for a stomach ache"! Not because I believe they will work but because I don't want the patient ramping up and starting a big noisy disturbance that will wake other patients up and wreck everybody's night, especially since we are not very generously staffed at night. I feel held hostage by these patients because it's like "give me the meds I want or else I'm going to yell and throw things and wake everyone up", but I feel like this is what I'm encouraged to do by coworkers (in an unspoken way), in the spirit of "picking my battles", where the main goal is to have an uneventful night regardless of the means to get there.
So I guess my question is - do you all do this too, just to keep the peace at night? Or do you only give out PRNs if they are well justified?
Mar 5, '13
And in case you're wondering what my objections are to handing patients whatever PRNs they request, it's really not about being controlling or anything like that. I am uncomfortable with it because polypharmacy can be dangerous, physically harmful, and have increased side effects. Tolerance can develop and the medication loses effectiveness and doesn't work when it's most needed, and they are not doing themselves any favors by developing a disempowering and unhealthy psychological dependence on drugs. I really do want to help people get better, not enable them to harm themselves further.
Also, I tend to just go ahead and medicate for pain. As long as the pt is not in danger of ODing, I'd rather err on the side of enabling drug-seekers than under-medicate pain.
Last edit by greenbeanio on Mar 5, '13
Apr 8, '13
I am the lone night nurse on a small community hospital acute inpatient psychiatric unit. I agree with several salient points made by the OP & commenters. I value an "uneventful" night (no string of admissions, no one actively psychotic or suicidal, no falls, etc.) as much as the next nurse with three kids and a second job; however, when it is slow and a patient is having issues, I feel very fortunate to have the time to spend with that person. In fact, I sometimes feel these exchanges have been the only genuinely important moments of my nursing career so far. Med-seeking, whether by habit or a deficiency in coping skills, and somatic complaints are often regarded with contention or indifference by some of my co-workers. I am neither naive nor a pushover, but I have a hard time being overly annoyed by needy, manipulative, or borderline behaviors. For the most part.
I also have a hard time giving a prn for reasons other than their indications. There are obviously exceptions - like a Neurontin for pain if other prns are exhausted and it's neurogenic. Your concern with giving prns that are not as innocuous is a really valid one. We're not pill-pushers, and of course alternative therapies in addition to - as opposed to in lieu of - appropriate administration of prns are essential. Teaching moments (med education, coping skills, whatever) are invaluable if you can get through before an eruption or someone shuts down. I have many advantages working nights on this small unit, including a certain level of autonomy being alone and having a brilliant psychiatrist that keeps bizarre hours and is accessible to me in person. If he's not here, I don't hesitate to page the on-call if I need something. We are fairly liberal when it comes to passing prns (as someone commented, there is an evidence base to support the practice); however, unless it's appropriate, I can't give something like a Haldol/Ativan/Benadryl cocktail. Also, how do you document this?
As one astute commenter stated - we are not the prescribers. We are, however, responsible when it comes to safe and appropriate administration of medication, regardless of the culture or environment in which we practice. Just be careful & who cares what your co-workers think, say, or do if it makes you uneasy ... CYA
Last edit by morecoffeepls on Apr 8, '13