prn medications

Doey, BSN, RN · Nov 27, 2000

I have always been taught that with prn meds such as ativan etc., the nurse may give less than the amount ordered. I just document why I gave less and let the MD know so that the order may be changed to include the original dose as well as the lesser dose. I've never had any problems with docs over this, nor have my co-workers. You can always give more if needed but you can't take away what's already been given. Now technically I don't really know if this consitutes practicing medicine or nursing judgement. It would be interesting to know as this is a not an unusual occurrence. But most of the time the situation I run into is that the order for prns; pain meds, anit-anxiety etc. is not enough.

Miss Mollie · Nov 27, 2000

I agree with Doey. Seems it is ok to give less, but not to give more. In essence you are "holding" some of the dose. Completely holding a dose would be appropriate. Our MAR's come up with the dose written say 2 mg, underneath it it says the amounts we can give. it will say whatever,and then underneath it will say dose is 1-4mg. Maybe you can get them to write that if it is becoming an issue or problem. But I do that all the time, especially because in our neuro population, MD's get sort of irritated if you have "knocked" out the pts neuro exam.

mustangsheba · Nov 27, 2000

You're probably not going to get into trouble for giving a lower dose and documenting the reason. However, sometime during office hours, I would request from the MD a new order with a range, i.e., 1-2mg. q. whatever so you're covered without question. Picture yourself defending your decision. It's so much easier and safer if the order covers that decision.

Jenny P · Nov 27, 2000

I don't think it's wrong to give less than the ordered amount of most PRN drugs which can affect either mentation or consciousness in certain patients or at certain times as long as you document your reasoning about the dose reduction. I certainly wouldn't give 2 mg Ativan to an 85 y/o who had had MSO4 20 minutes ago and needs to go to physical therapy soon; even if she told me she was anxious! I don't think that is practicing medicine; that would be exercising good nursing judgment to give less than the ordered amount. But documentation is the key here, and I would ask the doctor to change his order to include the lower dosage if it seems that the lower dose is indicated for more than a one time occurrence. (I would give half of the ordered dose of a pain med for a first dose on an elderly pt. just waking from anesthesia, but wouldn't ask for the order change if he tolerated that dose or it didn't affect him).

lesliee · Nov 28, 2000

Good question. I was always taught to follow the order. What if, in your judgement, you felt that 1 mg. was appropriate and 1 hr. after giving it, you discover that it was ineffective? You can always give the other 1 mg., but then do you wait 4 hrs. since giving the last dosage, when, technically, by the time 4 hrs. is up they don't have a full dosage in their system? It seems to me to be safer to follow the written order - or place a call in to the on-call doc to get the okay for a change, before altering the order. Just my opinion...