Knowing when to medicate/give a prn

[Guest321574]

I'm a new nurse, and just off a very short orientation. I feel confident in handling the routine stuff, paperwork/admissions/med pass, etc. However, actually managing my patients isn't coming as easily. I work nights, and last night we had 2 patients/roomates that were refusing to sleep or at least remain in their room. They were in and out of the room, singing, RIS, or rambling to the staff incoherently. I didn't feel they were disruptive to the other pts, no one else woke during the night, but they were disruptive to us as we had 2 admissions and routine paperwork to complete. Considering that they weren't bothering the other pts, I was reluctant to give a prn, and felt redirection was more appropriate. However, when one of the women began walking in the hall topless, I had to draw the line, so I gave a prn haldol - she was cooperative - and that seemed to be effective for a time (it was about 4:30am at this point, and she did go to bed, however when she woke at 630 for vitals her behavior was unchanged).

This brings me to another question. How to select the appropriate prn, when more than one is ordered for the same sx. Most often the prns that we have ordered are Haldol/Benadryl and Ativan, both for anxiety/agitation, sometimes I'll see Seroquel too. This pt had Haldol and Ativan order, and I was inclined to give the haldol, because the ativan is controlled, but wasn't sure if that was the proper choice.

If I didn't mention, I am the only nurse on my unit overnight with 2 techs. So I didn't have someone to turn to right there, though there is a nurse sup in the building at night also. I will definitely be questioning my co-workers when I go to work next, however, I am hoping for some "outside" opinions as I sometimes think maybe my facility "overmedicates." But that could just be my naive opinion, which is why I'm asking you all!

So to summarize (sorry for being long winded):

1) How does one know when medicating a pt is appropriate or if redirection is a better choice?

2) How to decide between PRN's ordered for the same symptoms?

[Jules A, MSN]

Hi and congrats on your new job!

1) How does one know when medicating a pt is appropriate or if redirection is a better choice? I'd guess that many of us thought there was too much medication flowing when we first started but with experience it has become my opinion that nipping this stuff in the bud is important. I'd agree that not disrupting the unit buys them a bit of time but when it is overnight my concern, in addition to the inevitable escalation that you saw where the patient's privacy and dignity were compromised by her behavior, would be that if they aren't sleeping at night they will be irritable and drowsy during the day, made worse if you wait until the wee hours to start passing the prns.

2) How to decide between PRN's ordered for the same symptoms? In my experience different doctors, nurses and facillities in general have favorites as well as the fact that some patients react better to certain meds. I'd definitely look at what other nurses are giving specific patients and use that information. If you have frequent flyers or long term patients you will get a good feel for what to give and when. For new patients that I don't know I like a Haldol/Benadryl combo if they are agitated. If you get drug addicts they are a whole different topic and you will need to become familiar with your detox protocol. Good luck!

[elkpark]

You can always offer a prn in the scenario you describe, as early in the "process" as you like, and let the client choose. (You can't justify medicating them against their will in the situation you describe, so it's going to be up to them to accept or decline the medication, anyway.) I would approach it in terms of offering something to help her/him relax and get some sleep.

When it comes to choosing a prn, I always start with the more benign medication and "work up" if necessary. Ativan has fewer side effects and risks than Haldol (I try to avoid Haldol as much as possible, because of that, unless there's no other reasonable option). I would also give Seroquel before Haldol, outside of a violent, emergency situation (i.e., for sleep or "ordinary" anxiety/agitation). Again, you can always discuss it with the client (outside of an emergency, that is) and let them choose from the available choices.

[Jules A, MSN]

When it comes to choosing a prn, I always start with the more benign medication and "work up" if necessary. Ativan has fewer side effects and risks than Haldol (I try to avoid Haldol as much as possible, because of that, unless there's no other reasonable option). I would also give Seroquel before Haldol, outside of a violent, emergency situation (i.e., for sleep or "ordinary" anxiety/agitation). Again, you can always discuss it with the client (outside of an emergency, that is) and let them choose from the available choices.

Great advice and I wanted to add that my patients are acutely ill and aggressive so imo the Haldol is often necessary. I'd agree that Ativan is better for someone that is simply anxious although I use it with caution due to how attached people become to it.

[cocoon2butterfly]

Personally, I would have given the Ativan...reasoning being that as someone said, I like to nip things in the bud as well, and also, because of the fact that there was only you and 2 techs present, I would have been concerned about the safety issue if that patient had become out of control...

Just my two cents...

[Guest321574]

Thank you, you've all given me good insight and things to consider in adjusting my approach. I think I was hoping for confirmation that it's not horrible to give out PRN's for behavior that isn't highly disruptive or overtly aggressive.

Cocoon, may I ask why you would have selected Ativan over Haldol? for the same reason that elkpark mentioned?

These two ladies (and really it was mainly the one that ended up going topless, her roommate was just kind of along for the ride) are "pleasantly psychotic" if that means anything. I never saw or read of any signs of aggressiveness from either of them, so I wouldn't think safety was an issue. At least not that I anticipated (I guess you never know for certain).

I think of Ativan for sedating and Haldol for controlling psychotic sx (although I know it is sedating) but 5mg isn't all that much right? I guess I also felt that her psychosis was the real issue hence my selecting Haldol. I guess I'm wondering, are there specific behaviors that go better with Ativan or Haldol? Or do they both have essentially the same effect? Or is it really just pt dependent as was mentioned above?

This actually was a trying night for me as a new nurse, though I have a feeling it is not out of the norm. My night looked like this: at 11p we had a code situation, where a pt was acting out over the outgoing RN whom he had been coming on to, and of course she made it clear that wasn't going to happen. So as she was about to leave, he flipped out, and we were on the verge of putting him in restraints, but (again my reluctance to take it there) I tried to calm him by making it clear that "she is gone now", and "it seems like you are very upset" and "would you like something to relax?" which he agreed to and after he got a PO Ativan, he went to bed without complaint. So that behind me, I settled in to get my admissions done for the night, and then trying to deal with the ladies all night. Finally when I got that resolved, I managed to get all my admission paperwork done, accuchecks, etc. THEN while I'm counting the narcs with the relieving RN, a pt had a seizure...all this on my second shift as an RN ever.

[cocoon2butterfly]

LovenandjRN--

I would have picked the Ativan over the Haldol (in this case) because of the sedating effect of the Ativan - I'm not one for "drugging" the patients, but if I were in that situation where it was just myself and 2 techs on the night shift, I would have wanted to make sure that the patient would be calm...because I feel that should that patient have acted out, it could have stirred up the rest of the unit and gotten out of hand (other patients waking up, etc.)

Again - NOT with the intention of "drugging" them up (usually, I am for giving the patient a chance), but to assure that the unit stays calm...in the daytime, for the patient and symptoms you're describing, I would have gone for the Haldol...

And I totally understand what you mean by "pleasantly psychotic", hehe...have a few of those myself, and I have to say, they always make my day a little more interesting... :)

[Orca, ADN, ASN, RN]

They were in and out of the room, singing, RIS, or rambling to the staff incoherently. I didn't feel they were disruptive to the other pts, no one else woke during the night, but they were disruptive to us as we had 2 admissions and routine paperwork to complete. Considering that they weren't bothering the other pts, I was reluctant to give a prn, and felt redirection was more appropriate.

Right off the bat, I would have medicated these patients. The fact that they were wandering around the unit and being noisy during the night would have been enough. Also, just because you didn't see anyone up doesn't mean that they weren't disturbing other patients. The fact that they were "rambling incoherently" tells me that there was active psychosis going on - which you aren't going to fix with simple redirection. I might try to redirect once, maybe even twice, but if it becomes a continuing issue it's time to stop it.

This brings me to another question. How to select the appropriate prn, when more than one is ordered for the same sx.

Generally speaking I avoid using antipsychotics unless there is psychotic behavior evident. I used a lot of Ativan in situations like the ones you described.

And I totally understand what you mean by "pleasantly psychotic", hehe...have a few of those myself, and I have to say, they always make my day a little more interesting...

Those were among my favorite patients.