Charting PRN requests

[vintagemother, BSN, CNA, LVN, RN]

Im a new grad LVN on an inpatient psych unit incl forensic cases.

When a resident specifically requests PRN Haldol (or Thorazine, Ativan, etcetera), how do you question them to ascertain the reason so you can chart the reason.

I know certain meds are for, say psychosis. I can read that.

But I'd like to be able to be specific, such as "c/o internal stimuli" or "states hearing voices" rather than just writing "psychosis"

I've asked clients, "how are you feeling?" And they usually just say "agitated" or "my head hurts"

In my mind, I don't see how to equate those types of complaints to a valid reason for giving a PRN meant for psychosis or some other reason.

I'd like an example of how to best question clients on their PRN needs. Perhaps I'm feeling a little shy about asking "are you hearing voices?" It seems rude or intrusive, to me.

Thank you in advance!

[Davey Do]

Good Question, VM.

Patients who have a history of letting Professionals know that they have experienced Auditory Hallucinations are usually relatively open to admitting an exacerbation of that particular Symptom. And a Symptom is all Auditory Hallucinations are; certain symptoms make up certain Diagnoses.

Objective Reporting of a Behavior can be a Reason for administering a PRN Antipsychotic. For example, "Patient stares off into space and self talks". Or the Subjective Statement of the Patient: "I hear the voice of my dead Mother telling me that I will see her soon".

In addition to documenting the administration of the PRN, the documentation of Reality Orientation, Support and Reassurance are also Sound Interventions.

Sometimes we need to be Creative with the Documentation of our Interventions. For Example, I have often administered a PRN Antipsychotic for Restlessness or Racing Thoughts, even though Psychosis is the Rubber-Stamped Reason for its Indicated Use.

Often times, a Physician will Prescribe a mild Antipsychotic, along with an Antidepressant, for a Diagnosis of MDD, since the Antipsychotic helps with the Relentless Racing Thoughts Majorly Depressed Patients often Experience.

So, all-in-all, Psychosis can be a Matter of Interpretation. I've not received any Flack for my Interventions and Documentation, if that Helps at all.

The Best to you, VM. Keep On Keeping On

[nurse lala, BSN, RN]

I applaud your sensitivity Vintagemother, it will serve you well as a professional nurse.

It is neither rude not intrusive to ask about the symptoms for which a client is seeking medications. If the person is on a MH unit, it is acceptable to talk about the sx that got s/he there into treatment. Anericans are known to somaticize feelings. We need help teasing thoughts from feelings. A good follow up question to how are you feeling is to ask what triggered the feelings. This gives you an opportunity to explore the triggers and if indicated alternative or supplementary interventions to the medication. For example, if the individual wants ativan because s/he just had a fight, talking and processing and problem solving may be a better intervention. The person learns coping skills and decreases dependency of medications to treat feelings.

By shying away from asking crucial questions you may be reinforcing the negative stigma of mental illness. The psych unit is the safest plaace to be candid about those symptoms.

[Davey Do]

By shying away from asking crucial questions you may be reinforcing the negative stigma of mental illness. The psych unit is the safest place to be candid about those symptoms.

Well said!

[vintagemother, BSN, CNA, LVN, RN]

Nurse Lala and Davey Do...thank you for your thoughtful detailed responses. I feel a little more comfortable with questioning and documentation regarding PRNs.

[Meriwhen, ASN, BSN, MSN, RN]

I agree, it's not rude to ask about their symptoms: after all, those symptoms are exactly what we are trying to treat.

I try to dig deeper if I can--and if they'll let me. Let's take AH: Are you hearing voices? When did they start? What are the voices saying? Are they telling you to hurt yourself? Do they make you feel unsafe? What have you done to cope with the voices? Have you tried X, Y, Z? Do you want one of your PRNs?

If they can't/don't want to talk, then I'll observe. Are they cocking their head or focusing hard as though they're listening to something/someone not there? Talking to themselves? Facial expressions or laughter present that isn't congruent to their situation?

Then I'll summarize and chart their responses--though I will quote the patient when possible--and my observations, any suggested interventions and PRNs given.

That usually explains the PRN much better than that statement "Haldol 5mg PO given for psychosis." Though it's better to chart that than to not chart anything at all.

Hope this helps.