A Question for Night shift Psych Nurses - Do you limit PRNs?

[greenbeanio]

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?

[greenbeanio]

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.

[Liddle Noodnik]

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.

It's a tough call. I agree w/ using other measures but there is not always the time and, as you said, can make for a lot of disruption.

Are these issues dealt w/ in a group setting during the day? Good education groups would be: sleep hygiene, relaxation therapy, non-medication measures for sleep/relaxation. That way you're just backing up what the staff is working together to accomplish!

[nicholaa2]

You make a lot of wonderful points, but what we have to remember as nurses is that we are not the prescribers, not the doctors responsible for deciding what prn medications to order/give and our patients typically know exactly what meds they have available and how they are able to manipulate the staff to get their meds (acting out, threatening, other personality II responses, etc.)

Quite often these patients are also somaticizing so much that they really have created legitimate pain and anxiety from getting themselves all worked up and yes, often it would take a prn that we know will not officially "fix" their complaints, but rather fix their somatic symptoms.

My issue... see a post I am about to write - is that I am getting so frustrated with acute inpatient facilities rushing to over-medicate or over-treat the mentally ill patient (such as jumping right to ECT), especially on patients that clearly need therapy more than anything else. I mean really, can a borderline personality patient be fixed by giving them bi-lateral ECT 20 times? Hardly... Yet, I am seeing this more and more - guessing since ECT is such a $$ making venture.

It really is a pick your battles scenario, especially if you don't have the support from the rest of the staff at setting limits and/or the options for secluding/stopping a patient that is willing to pretty much do anything to get the meds they're seeking.

[adgesmeraldiamond]

I too believed in limiting PRN use. However, the director of nursing in my facility (A psych NP) provided research articles and education on the effectiveness of PRNs. I can't recall what articles he provided but the gist was, There's a time and place for everything but that PRNs are actually underutilized and result in poorer pt outcomes when not given. While you might want to encourage other methods instead of medication, it needs to be taught and practiced BEFORE a person is agitated and wants a PRN. If they're able to ask, you're in the early stages of an outburst. However, deny them long enough and you'll have a very messy situation on your hands that may result in a) more medication b) restraints c) injury to pt or others. There is a certain amount of judgment, You know the pt and their history, You've established rapport with them, etc. For those that I feel are abusing the PRN system or who don't know me I do a quick bit about education... if you use it now it won't be available for when you REALLY need it.... or I try to put them off. If my first subtle attempts to deny do not succeed and they are adamant then I provide the medication. I also speak with the Drs about PRN use. If someone is using a PRN too frequently their scheduled medications need to be addressed. If I feel the pt is only switching from one chemical dependance to another (alcohol to benzos) I ask for changes to something less potent (IM benadryl?). Either way I definitely have that ongoing conversation with the psychiatrist to sort out better care for the patient.

[greenbeanio]

I think what I am most uncomfortable with is giving out benzo-antipsychotic combinations just to help someone sleep. I'd much rather give out antihistamines for sleep, like Benadryl or Vistaril, rather than Haldol&Benadryl or Risperdal&Ativan. The PRN parameters say things like for extreme agitation, but there I am forced to give to someone who isn't agitated at all, just used to taking sleep meds every night.

[TerpGal02, ASN]

I wish we had a med nurse on nights! As it is we have 2 nurses for capacity of 46 pts. If we were doing PMR and other interventions, while great, it would be impossible to get through admissions ic it happened to be a busy night. I agree that sleep hygiene is important, but if someone is used to a cocktail of meds to sleep, likely they just won't sleep without them at best, or cause a discontinuation syndrome at worst. It sucks that we just throw a ton of meds at these pts, especially those who axis II is their biggest problem. Unfortunately the way insurance is is that they want the pts medicated and out the door. With the short stays for psych nowadays, there's really no room to make any decent headway with therapy when they are inpt.

[morecoffeepls, BSN, RN]

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