combining PRNS

Granted Fal · Dec 17, 2014

Good question. You mentioned several antipsychotics and the benzo ativan. My suggestion is that you put the free ePocrates app on your phone and it has a good interaction checker. YOu can also check interactions on Drugs.com and on drugdigest.com also. Most med interactions come from meds sharing the same enzyme system in the liver that processes them, some inhibit some induce and this can offset other meds unpredictably and sometimes dangerously depending on the medication. Sure, ativan interacts with all of those in terms of sedation but not so much by the enzyme component. The additive effect with sedation is really related to the antipsychotics antihistamine and anticholinergic side effects and the ativan is a CNS depressant. So, that can make you droggy.

Hope that helps,

RFal

vintagemother, BSN, CNA, LVN, RN · Dec 20, 2014

When I first started working, nearly a year ago, I was worried about combining PRN meds, also. I asked the psychiatrists about it as well as the nurses. The simple answer I was given is that the psychiatrists will not prescribe meds that are contraindicated (in most cases).

Now that we use electronic mars, the computer tells us which meds shouldn't be given together.

I try not to give 2 meds with the same effect, such as I'll give an antipsychotic non narcotic such as haldol with an anti anxiety med such as Ativan. But I won't do that unless I know the Pts tolerance/typical response. I probably wouldn't give Ativan and klonopin together because they're both narcotics and wouldnt combine a narcotic anti anxiety med close to a narcotic sleep aid. But some nurses do.

When our mds give orders, they first find out which meds the pt is already on.

Over time, I've learned which meds tend to over sedate when given together. I've also learned that for some Pts, a certain combo that sedated another pt will not sedate them.

Jules A, MSN · Dec 24, 2014

I'm more of a fan of doing an antipsychotic with an anticholinergic such as benadryl or vistaril which gives you double coverage for eps prophylaxis as well as additional sedation. I rarely use benzodiazepines with antipsychotics due to the remote chance of inhibiting respirations and concern of possibly resulting in disinhibition or delirium. The exception of course would be an extremely aggressive psychotic patient who gets the B52 but again I don't like the overload of ativan as often happens in the ED.

Gooselady, BSN, RN · Dec 24, 2014

When I did psych, what meds we gave in emergent situations were 'preferred' cocktails entered into the MAR. The med nurse didn't have to make an independent decision, and mostly conferred with the charge or the doc if they were on site.

So the issue of what PRNs to combine together was a decision made by the team.

We used to use Droperidol, Benadryl and Ativan (we unkindly called it 'Dropping' the patient), as it sure kicked in fast. Patients were closely monitored every fifteen minutes thereafter. This was always for emergent out of control behavior. But if you are trying to just help a patient get back in control, combining PRNs, whichever ones, is a bit of an overkill unless the patient is very tolerant to Ativan, for instance. Some patients can't get it together without Haldol and Ativan, and have received in together often, so you have a history of them tolerating it without complications.

I don't remember ever having to make a decision like that on my own, though. We need to think for ourselves, of course. But I don't think I was ever 'responsible' to make such a decision on my own. It was either already on the MAR or it came straight from the doc, who generally know what they are doing.

califoRNia. · Dec 25, 2014

When I was a new psych nurse I worried about over sedation of the patients. For someone extremely agitated I wouldn't worry about giving a benzos with routine meds etc. It will take a lot to calm someone down who is very agitated. I would worry if they were elderly, or had low BP. Some med combinations I have learned about. Do not give valium w/ suboxone - a man at our hospital almost died from respiratory depression. If someone has tachycardia do not give benadryl or other anticholinergics because it can increase their heart rate further. I learned this from our internist after I gave an anxious pt with a HR of 120 some benadryl to 'calm them down.' Most likely they will want you to give them clonidine for anxiety combined with elevated HR.

MDMBSNRN · Dec 30, 2014

Standing orders for agitation in my department are 20 mg Geodon and 2 mg Ativan given together (either IM or PO). If this fails, we generally move on to the B52 (50 mg Benadryl, 2 mg Ativan, and 5 mg Haldol given IM). If that fails, our last resort is usually TLC (Thorazine, Ativan, and Cogentin in some combination, depending on patient weight, tolerance, etc). We can also give IM Zyprexa, 10 mg Zyprexa Zydis, 50 mg PO Vistaril, 100-200 mg PO Trazodone, as well as other medications.

Just the other day, I administered 40 mg Geodon, 4 mg Ativan, 100 mg Vistaril, and 200 mg Trazodone, and the patient was still raging like I had thrown water on them.

psychnursie · Dec 31, 2014

we frequently give all of those meds together. we also combine them with seroquel and or zyprexa, they all have different actions.

Jules A, MSN · Jan 1, 2015

Standing orders for agitation in my department are 20 mg Geodon and 2 mg Ativan given together (either IM or PO). If this fails, we generally move on to the B52 (50 mg Benadryl, 2 mg Ativan, and 5 mg Haldol given IM). If that fails, our last resort is usually TLC (Thorazine, Ativan, and Cogentin in some combination, depending on patient weight, tolerance, etc). We can also give IM Zyprexa, 10 mg Zyprexa Zydis, 50 mg PO Vistaril, 100-200 mg PO Trazodone, as well as other medications.
Just the other day, I administered 40 mg Geodon, 4 mg Ativan, 100 mg Vistaril, and 200 mg Trazodone, and the patient was still raging like I had thrown water on them.

I was never a fan of Geodon for emergency administration. Does it still come in a white powder that takes what feels 4 hours to reconstitute while your staff is getting their brains beaten in?

Crazed · Jan 1, 2015

We do a good deal of zyprexa/Ativan in medically stable patients. I like to lead with zyprexa and see if they calm down and then follow with Ativan.

Jules A, MSN · Jan 1, 2015

We do a good deal of zyprexa/Ativan in medically stable patients. I like to lead with zyprexa and see if they calm down and then follow with Ativan.

When I order them as PRNs I stipulate they need to be separated by 1 hour. There have been instances of patient death when the two were administered together, by IM I think.

Crazed · Jan 2, 2015

We don't have those parameters, I just do it because I'm not a fan of piling meds. Controlled not unconscious is what I aim for.