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Discussion

confused about PRN use

Hi everyone,

So I am a little confused about the use of different PRNS in different scenarios, after talking to different nurses I work with.

For example, if a pt has PRN Ativan and PRN Haldol ordered, and they come up to you and they do not seem overly agitated, just a little anxious, and report anxiety d/t "hearing voices"--would you give the PRN Haldol ordered for psychotic agitation AND PRN Ativan ordered for psychotic agitation together? The reason I get confused it b/c if you give this to them, it's likely going to put them to sleep. And PRN Ativan AND Haldol is always what we give someone who is VERY agitated to calm them down. it doesn't seem right to give the same combo of meds to a patient who is more calmly reporting some lower level agitation and voices vs someone who is ready to "go off." I thought giving EITHER the prn Haldol OR Ativan might be a good option in scenario one, but a few nurses had said that the Ativan and Haldol PRN shouldn't be split up and should be given together. In the first scenario the pt just requested the PRN ativan and it worked for them in the past.....would you have told them they need to take the haldol as well?

I guess my point is, should you pretty much always give both the PRN Ativan for psychotic agitation and PRN Haldol for psychotic agitation together when they are both ordered? Note-it doesn't implicitly say the the order they have to be given together. thank you all so much for any insights!

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    • Featured Replies

    If the pt is reporting anxiety in addition to hearing voices, haldol and Ativan should be given together. Ativan is for anxiety and haldol is an antipsychotic, the pt will probably fall asleep but the haldol will help them wake up with a clear mind.

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    Well, I personally would probably give haldol first and if their anxiety still continues give Ativan. If they're hearing voices that would probably give them anxiety and if we resolve that the anxiety may go away.

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    If the patients is calm like you described, I like to ask the patient what works best for them.. (they usually know) And explain the difference between the Haldol and Ativan if they didn't. We can always reassure our patient if one doesn't work there are additional options... I (like you), don't want to put my patients too sleep, just help them as best I can. Options are always nice. And the order doesn't state they absolutely have to be given together.

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    • Expert

    This is one of the times you can use your nursing judgment. If they seem reasonably calm about things, go with just the Haldol. If they verbalize severe anxiety--or if say they're fine but YOU see signs that they are anxious--go ahead and offer/give the Ativan with it. And as others have said, you can always ask what they'd prefer.

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    • Author

    thanks for the response! i had a long-time psych nurse told me they HAD to be administered together and that didn't seem right to me, I'd rather actually look at their presentation :)

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    • Author

    oh one more thing...if they requested just the ativan because they said that helped (and didn't want the haldol despite saying they hear voices), would you give just that? I guess I get worried about pts becoming "hooked" on benzos but really, if they are in a locked inpatient facility and only requesting it every so often, it seems like the compassionate thing to go.

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    • Expert
    oh one more thing...if they requested just the ativan because they said that helped (and didn't want the haldol despite saying they hear voices), would you give just that? I guess I get worried about pts becoming "hooked" on benzos but really, if they are in a locked inpatient facility and only requesting it every so often, it seems like the compassionate thing to go.

    Depends on how the patient presents. If they don't appear to be responding (head cocking, inappropriate laughter/grimacing, talking back to them), I may consider it. But the fact that they reported voices would make me try to sell them on the Haldol as well, and explain that the Haldol is by far the better medication of the two for hallucinations.

    Developing a physiological dependence on a benzo during a short-term stay is highly unlikely. They might develop a psychological dependence, i.e., they really like that numb and fuzzy feeling that a dose of Ativan can give them and prefer that instead of dealing with the discomforts of their own emotions. But even so, it's not as though they have unlimited access to the benzos--they can get them when you give it to them, and if they can't get them when they want, they're going to have to develop some coping skills to deal.

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    Hearing voices isn't always a terrible thing. Sometimes the voices are comforting or not bothersome, just there. It's important to ask what the voices are saying. You wrote that your patient was anxious d/t hearing voices. Still, assess what the voices are saying.

    If the voices are the root of the anxiety, then get to the root and give the Haldol.

    Another thing to consider is that Haldol has some pretty big side effects (extrapyramidal symptoms, etc.) in addition to its sedation side effects...

    Consider the size of the dosage too.

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