Not giving PRN's even though they are ordered?

[Simply Complicated]

I'm hoping I can get some insight into this. What is your opinion or experience with this? First let me specify I work in an acute hospital psychiatric setting, not long term.

Ok, I can understand when the plan is for a patient to be going home in the next couple days, and you want them off the PRN benzo's and what not, since they need to be able to function without, since they won't be going home on them.

But I am frequently seeing where the doctor has PRN's ordered, the patient asks for them, but nurses are always saying not to give them. They don't need them, etc. Comments that they are just drug seeking, they like there narcs, etc. My thought is, we are not the doctors. It is not up to us to decide if they "really" need that medication. If the doctor doesn't want them to have it, then they need to discontinue it, or change the frequency if they feel they are abusing it. We can tell the doc we feel they are abusing it, not really needing it. But to me, it's like pain. If they say they are having it, we need to treat it. Regardless of our "opinion"

Now I can see not giving them an IM, when they have a po. Or offering a medication that is not as strong first, before going to the stronger if that doesn't help.

For example, we have a patient on one of the units now, who does have a DX of polysubstance. He had a PRN ordered for PO/IM zyprexa, as well as IM Geodon. I was flat out told by one of the longer standing nurses DO NOT give him the IM geodon, he doesn't need it. I did give it to him on my shift, because the zyprexa didn't work. He was pacing, fists clenching, slightly diaphoretic, just showing signs of escalating agitation. I'm not going to hold a med I have available, simply because someone else has deemed he "doesn't need it", because he is "drug seeking." Then end up having a take down, because I ignored the signs.

Now I am a new psych nurse. So maybe there is something I just don't understand yet. I'm not in any way trying to be hypocritcal, and judge the longer standing nurses. I am still learning, so I am trying to understand how to distinguish this.

Any insight is greatly appreciated.

[Whispera, MSN, RN]

What are the Geodon and Zyprexa ordered for? Are they intended to substitute for a benzo?Pacing, clenching, diaphoresis and escalation, to me, are signs of withdrawal, but not psychosis. Was the patient hallucinating? Geodon and Zyprexa are anti-psychotics. While they can de-escalate a patient, that's not their usual usage. Maybe that's why your co-workers said the patient didn't need them. Maybe they meant he needed something else, but just didn't say what.

The symptoms you describe call for a benzo in a withdrawing patient. Do the patients have benzos ordered? If their addiction isn't to benzos, then it's appropriate to give the benzos until discharge, and even to give a Rx for at home. Sometimes withdrawal can last for weeks. The time in the hospital might not be enough. Weaning off is a good thing, but it shouldn't be done prematurely.

Pacing, clenching, diaphoresis and agitation are more likely to be signs of withdrawal than of "med-seeking." Take vital signs!

[Meriwhen, ASN, BSN, MSN, RN]

First of all, you need to assess your patient, not the other nurse. If you feel that the patient warrants a PRN then you should give it. Keep in mind that with some detoxes, particularly benzos, there are a lot of symptoms that aren't necessarily physical, such as agitation and the feeling of jumping out of one's skin. Plus, a lot of withdrawals are not the three-day variety, but can take weeks or even months for the patient to get through them. A lot of the time, when they're asking for the PRN med they really do need it...

That being said, the reality is that in addictions nursing you do have to deal with the beast known as the med-seeking patient. Some patients want medications because they want the buzz they can get off of them. Or they believe the answer is a pill (albeit another pill from the one they're coming off of), instead of learning coping skills.

It' s up to you to assess your patient. You need assess their vitals, S & Sx, history and behavior, as well as find out from your techs how the patient is behaving when they're NOT in front of you. You'd be surprised at how many patients' conditions (tremors, pain, etc.) seem to drastically improve when they're no longer in the nurse's line of sight. If in doubt, IMO it's better to give the PRN...however document your assessment and let the MD know.

As far as your polysubstance patient, I'm also surprised at the Geodon and Zyprexa orders, unless the patient has a history of psychosis. Most detoxing benzo patients I've seen are on some sort of benzo or barbituate taper...and I would have rather have given the benzo/barb than an antipsychotic.

[Simply Complicated]

What are the Geodon and Zyprexa ordered for? Are they intended to substitute for a benzo?Pacing, clenching, diaphoresis and escalation, to me, are signs of withdrawal, but not psychosis. Was the patient hallucinating? Geodon and Zyprexa are anti-psychotics. While they can de-escalate a patient, that's not their usual usage. Maybe that's why your co-workers said the patient didn't need them. Maybe they meant he needed something else, but just didn't say what.

The symptoms you describe call for a benzo in a withdrawing patient. Do the patients have benzos ordered? If their addiction isn't to benzos, then it's appropriate to give the benzos until discharge, and even to give a Rx for at home. Sometimes withdrawal can last for weeks. The time in the hospital might not be enough. Weaning off is a good thing, but it shouldn't be done prematurely.

Pacing, clenching, diaphoresis and agitation are more likely to be signs of withdrawal than of "med-seeking." Take vital signs!

The doctor did not want to order him benzo's. Zprexa and Geodon is what was ordered to give him for "agitation" I figured the diaphoresis was withdrawl, although he was at the end of it. He's been in for a week now. VS were fine, I did check those. He was also saying her "felt like he was going to blow"

She was also specific saying he did not need them, because he was drug seeking. I was only using that as an example though. I'm just looking for advice on a general level, because this is a common thing I see.

[Simply Complicated]

First of all, you need to assess your patient, not the other nurse. If you feel that the patient warrants a PRN then you should give it. Keep in mind that with some detoxes, particularly benzos, there are a lot of symptoms that aren't necessarily physical, such as agitation and the feeling of jumping out of one's skin. Plus, a lot of withdrawals are not the three-day variety, but can take weeks or even months for the patient to get through them. A lot of the time, when they're asking for the PRN med they really do need it...

That being said, the reality is that in addictions nursing you do have to deal with the beast known as the med-seeking patient. Some patients want medications because they want the buzz they can get off of them. Or they believe the answer is a pill (albeit another pill from the one they're coming off of), instead of learning coping skills.

It' s up to you to assess your patient. You need assess their vitals, S & Sx, history and behavior, as well as find out from your techs how the patient is behaving when they're NOT in front of you. You'd be surprised at how many patients' conditions (tremors, pain, etc.) seem to drastically improve when they're no longer in the nurse's line of sight. If in doubt, IMO it's better to give the PRN...however document your assessment and let the MD know.

As far as your polysubstance patient, I'm also surprised at the Geodon and Zyprexa orders, unless the patient has a history of psychosis. Most detoxing benzo patients I've seen are on some sort of benzo or barbituate taper...and I would have rather have given the benzo/barb than an antipsychotic.

Thank you for the description of how to asses. I did talk with the supporting staff to check that he was in fact exhibiting these signs, not just in front of me. The doctor who ordered these meds commonly orders meds like this, as he will not normally give benzo's for patients of polysubstance.

Just to clarify, I'm not saying to just hand the meds out like candy just because they ask, without assessing first. I have just seen some people who have the attitude of don't give it, they don't need it. They blow them off, without bothering to check if it's really necessary. Expecially if it is a frequent flier. To me, even if they are abusers, people who come in and out, doesn't mean they don't really need the med.

[Meriwhen, ASN, BSN, MSN, RN]

Thank you for the description of how to asses. I did talk with the supporting staff to check that he was in fact exhibiting these signs, not just in front of me. The doctor who ordered these meds commonly orders meds like this, as he will not normally give benzo's for patients of polysubstance.

Just to clarify, I'm not saying to just hand the meds out like candy just because they ask, without assessing first. I have just seen some people who have the attitude of don't give it, they don't need it. They blow them off, without bothering to check if it's really necessary. Expecially if it is a frequent flier. To me, even if they are abusers, people who come in and out, doesn't mean they don't really need the med.

There's other drugs that aren't benzos (Vistaril, Buspar, Neurontin), that they could use to help a detox patient with agitation. I do think that running for Zyprexa and Geodon for withdrawal symptoms is extreme, but that's my opinion...and I'm also not a doctor.

I encounter the "he/she doesn't need it" attitude a lot from the older nurses too...and sometimes they're right.

However I can only control what I do, and that's based on what I assess...so I will usually give the PRN unless I have a very good reason not to. And for those good reasons not to give it, I'll usually call the MD to bounce it off of them and see what they want me to do.

[Simply Complicated]

There's other drugs that aren't benzos (Vistaril, Buspar, Neurontin), that they could use to help a detox patient with agitation. I do think that running for Zyprexa and Geodon for withdrawal symptoms is extreme, but that's my opinion...and I'm also not a doctor.

I encounter the "he/she doesn't need it" attitude a lot from the older nurses too...and sometimes they're right.

However I can only control what I do, and that's based on what I assess...so I will usually give the PRN unless I have a very good reason not to. And for those good reasons not to give it, I'll usually call the MD to bounce it off of them and see what they want me to do.

Yeah, Vistaril is one of our most common orders. He had been on it, but it was discontinued the day before. I am a float nurse, and had not been on that unit in a while, so I wasn't familiar with him. My guess is the doc thought he was done with withdrawls. The Geodon did calm him down though. Whether it was because he was getting mad that he had been told he couldn't have it, and calmed down when I gave it to him, or because he was actually agitated I'm not sure. He did have other issues besides just the polysub. I can't remember exactly what all it was, it was a very busy shift, so I didn't really have time to sit and read.

After talking with the other nurse I was working with, who was also a newer psych nurse, although not as new as me, she felt the same way. I did document all his symptoms as well.

Thank you, I am starting to get a better understanding. I think it's just as the new kid on the block, you tend to listen to the more experienced nurses. In this case, and others I have used my own judgement and did what I fel was right. I was just wanting to gain a better understanding of what to consider when making that decision.

[chevyv, BSN, RN]

Pt states he felt like he was going to blow. This is a sure statement that he needed a prn. I'm a newer nurse as well and I would have given the geodon. I'm learning to take some of my patients at their word. Many times I've seen nurses ignore the pacing and the statements that are telling us this patient is going to lose it big time. This is the safety of the pt, other pts as well as staff. I've tried to let some ride it out, but more often than not, I end up calling security. After I saw a pt assault another pt, I've learned that I really need to have faith in my own assessments and my gut.

[Whispera, MSN, RN]

When a patient tells you he's going to blow, believe him. He wouldn't be saying it if he felt he had control over his behavior.

[Simply Complicated]

That is my thought, to listen to those statements. Other nurses would take that and say they just know what to say to get their meds. I think from now on I am just going to do my best to not let them make me feel I don't know or to make me feel intimidated, and just do what I think is right. Bottom line is I am not doing something wrong my giving an ordered medication.

[Meriwhen, ASN, BSN, MSN, RN]

That is my thought, to listen to those statements. Other nurses would take that and say they just know what to say to get their meds.

That's why you also look at what the patient is not saying, i.e., their non-verbal behavior, just as much as what they are saying.

And don't just rely on their word: I've had patients tell me they were fine and their non-verbals say otherwise; to them I'm going to suggest a PRN instead of waiting for them to come to me to ask for it. After all, if they don't want it they can always refuse.

Yes, there are some patients that know what to say for their meds (or to not get their meds)...and that's why you have to assess the whole picture when dealing with them.

[Meriwhen, ASN, BSN, MSN, RN]

Pt states he felt like he was going to blow. This is a sure statement that he needed a prn. I'm a newer nurse as well and I would have given the geodon. I'm learning to take some of my patients at their word. Many times I've seen nurses ignore the pacing and the statements that are telling us this patient is going to lose it big time. This is the safety of the pt, other pts as well as staff. I've tried to let some ride it out, but more often than not, I end up calling security. After I saw a pt assault another pt, I've learned that I really need to have faith in my own assessments and my gut.

I would have given it too. Geodon or Zyprexa are not my first choices in this case, but IMO better to prevent a situation from escalating, for the patient's safety as well as for those around him.

Never underestimate the power of the gut.