Can I refuse to give PRN medications

[guest1113379]

Long story short, I work in an LTC home and one resident has multiple PRN laxative orders - PEG 17g once daily prn, bisacodyl 10mg PO BID PRN, and bisacodyl 10mg supp once daily PRN. If the patient received a supp and then has an XL BM and is then requesting bisacodyl and PEG together, am I within my rights as the nurse to tell this resident no as 2 further doses of laxative aren’t indicated following an XL BM (and frequent BMs over previous days). Also, if they request 3-4 doses of laxative within 3-4 hours, are you as the nurse able to say they need to allow the medication time to work before taking more? Im worried about diarrhea and possible dehydration as the patients fluid intake is not great, but don’t want to be getting myself in trouble as technically the medications are ordered. Furthermore this residents cognitive state has been declining and they believe they haven’t had a BM for approx. a week when charting Indicates this isn’t the case. My thought process is that I wouldn’t give a patient 4 different types of pain medication at once without allowed previous doses an appropriate amount of time to work so I’m not sure why this would be different but I wanted to get more opinions.

[JKL33]

PRN (pro re nata) = as the occasion arises = as needed.

Your post includes the rationales for your decision-making. Document those accordingly, including documenting interventions that are appropriate under the circumstances, such as educating, reminding, reorienting.

Make sure you are also covering your bases (assessment and documentation-wise) with regard to the patient's concern with this beyond the forgetfulness. What I mean by that is, is there a physical sensation that is contributing to the patient's concern, and is if so, is that something that needs further investigation? Or, is there another cognitive or psychiatric condition contributing to this (beyond forgetfulness) and if so does that require further evaluation?

Does this patient have any planned interventions that support bowel health/regularity, such as a plan that supports adequate baseline hydration? That will surely affect his bowel functioning separate from any meds to encourage bowel movements.

I know what you mean when you say, "within my rights as a nurse" but I would encourage you to think beyond that: The nurse's role is to develop (or contribute to) a plan of care that involves thorough assessment of the patient's situation and when these types of situations (like your OP) arise, you use the nursing process for decision-making:

Assessment: Patient requesting PRN laxatives/stool softeners. Patient denies discomfort [include other physical assessment findings] and has had a XL BM this morning. Verbalizes concern about not having a BM in over a week.

NDx: Impaired memory/Disturbed thought process

Plan: Patient will be aware of circumstances as able

Intervention: Reorient/remind/educate, etc.

Eval: obvious.

***

Does this help?

?

[guest1113379]

Thanks for your reply. The patient in question has advanced ms and is on a lot of regularly scheduled opioids, both of which contribute to constipation. We do have hydration plans in place however this resident is very specific and isn’t willing to do a lot of things we recommend for his health.

Basically my concern is that if we provide every laxative that is ordered and he ends up with diarrhea, he in the past has gotten angry with us for overloading him on laxatives, even though it was what he requested.

He basically believes that if it’s ordered we have to give it, and I just wanted to know if I was in the wrong for not providing it even when they’re not indicated.

[ruby_jane, BSN, RN]

On 3/22/2019 at 5:29 PM, NurseCR said:

Thanks for your reply. The patient in question has advanced ms and is on a lot of regularly scheduled opioids, both of which contribute to constipation. We do have hydration plans in place however this resident is very specific and isn’t willing to do a lot of things we recommend for his health.

Basically my concern is that if we provide every laxative that is ordered and he ends up with diarrhea, he in the past has gotten angry with us for overloading him on laxatives, even though it was what he requested.

You're right. However in people who are opioid dependent....the fear of not being able to poop r/t impaction is exceptionally real. One good impaction will scare someone....I was going to say poop-less but you get the idea.

Is there anything else you can do for this patient as an adjunct to what is prescribed and what is PRN?

[Kallie3006, ADN]

You also have to think of what the patient has been taking. Some people think they have to have a BM 1 or 2 times a day and if they don't they are constipated. They then use all kinds of stuff to accomplish what they think they need which could make the body reliant on medication to achieve the goal. Are there parameters set for the meds ordered such as give if no BM in the past 48 hours? This may help you advocate for your patient and not create a crap storm either way ?

[nlb0101]

Agreed with the above posts. I see this topic is a few days old, but as this is LTC, this will probably be an ongoing issue. One thing I didn't see anyone address was mentioning the consistency of said XL BM. If the patient is having ongoing complaints of needing laxes, I would especially monitor and document the specifics. Was it watery, color, etc. You want to make sure the patient isn't having liquid stool coming around an impation. When defending your rationale for not administering the PRN, I would also note an assessment of bowel sounds, distension, etc.

Also, does the patient have hemorrhoids? I've had dementia patients with bad hemorrhoids who constantly felt like they needed to have a BM because of their hemorrhoids.

I would also note this for the provider to check into the next time the patient is seen because there are lots of different laxes, stool softeners, etc to choose from. Perhaps the patient would benefit from a different type of medication.

[Glycerine82, LPN]

The reason nurses give meds (among other things) is because we learned when it is appropriate to give a medication and when to hold a medication. Just because a patient requests a PRN medication doesn't mean you have to give it if it isn't indicated or is going to cause harm. You would be wrong to give it in this circumstance, to be honest.