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.
My son, 23 years old is Schizo affective with Bipolar tendencies. His Psychiatrist was telling me that often times, patients use aggression, threats to commit suicide and posturing behavior to manipulate the nurse/parent/caregiver into doing what they want.
When viewing my son's extensive record of psych hospital stays and ER visits, an acknowledging smile crept across my son's psychiatrist's face. He recognized at least a quarter visits were possibly manipulated by son's desire to seek attention when he didn't get what he wanted from me.
My son often uses aggression and threats of severe violence to "persuade" me to take him somewhere or buy him things, even to the point of hurting himself. When I stick to my guns and refuse to give in, suddenly son becomes very ill or will collapse in public at the worst time to cause the paramedics to be called. The payback is the attention. To deal with this, I simply stopped taking him out until his behavior leveled.
My point though is that the psychiatrist having extensive experience in urgent psychiatric unit care has noticed that my son does use his aggressive and impulsive behavior to manipulate staff and me to do what he wants.
The psychiatrist further explained (and I have seen this with my son) such patients lie through their teeth about how they feel and give not only lip service but demonstrate appropriate behavior in urgent inpatient psych wards to get released ONLY to resume the aggression and/or destructive behavior once released causing this cycle of aggression/manipulation to occur. Some visits caused by medication issues are legit visits and stays, some are not.
When I asked the psychiatrist HOW one can tell the difference between manipulation (to get released or what is wanted) and TRUE aggression needing intervention, he stressed that gut intuition was the number 1 line of defense (for lack of a better way of wording this) against being manipulated into calling the EMT's for attention sake (for example) or by being in total denial when confronted with obvious warning signs of relapse or noncompliance with medication or participation in therapy. Of course this denial isn't the type that is legit and caused by the mental illness BUT the type used to give the staff/docs what they want to hear so that he'll be released.
Specializes in PICU, NICU, L&D, Public Health, Hospice.
If, in your professional judgement the patient needs the med then give it. If not, then don't. If you are unsure, collaborate first with your charge nurse and then (if still unsure) with the prescriber.
When I have worked with nurses who like to play the power trip thing--and I have seen it both in psych and detox-- I have gone to the doc. They are ordering the meds and expect that they are being given as appropriate. When this is not happening the doc needs to know. I have seen most of the time that this works. The doc will usually look at the nursing notes, review their own notes, talk to the nurses about what their rationalization is and usually do a little re-education if need be. That has usually solved the problem for the most part. Yeah it isn't perfect and you will still get the nurse on the power trip who is clueless.....but it helps. Good luck!
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
So the same patient who I used as an example, I worked the same unit again. Another nurse went as far as telling him all his PRN's had been discontinued, which was a flat out lie. The man is going to rehab in the next couple days.
I just don't get it. You're not going to cure the patient of his addictions. Even if he is done with the withdrawl symptoms themselves, he is now sober, which he is not used to. Is it really that surprising that he may be having some anxiety or agitation.
So why make him angry, by refusing to give him his meds? What is that going to accomplish. It's not like it's making the nurses job easier. It's just going to cause more problems, because you are now causing a patient to become angry.. which is a perfect way to escalate the problem.
I always assess for need in all those ways we're all taught, of course.
I also judge how much autonomy to grant each patient, based on my sense of their judgement and on the likelihood of harm if they make a bad decision. Often enough, they seem reasonably able to judge their needs, OR the stakes are low enough that I feel no need to impose my own judgement.
I also look at all the other ways I can help the patient cope and learn and grow BESIDES the meds - people get angry, frustrated, upset, etc., and sometimes clarification, education, reassurance, problem-solving (even as to what Rx, if any, to take) or even help e.g. with making a phone call or the like can make all the difference, build trust and rapport and so on.
I see at least as many patients who AVOID meds (or avoid the kinds of meds that would most help them) as seek them - I try to help them come to a beneficial, prudent decision as to their treatment.
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.
I agree wholeheartedly - I look at all the evidence, and make a decision based on words but also paraverbals, affect, behavior, vital signs, physical evidence like tremors or nystagmus, etc.
PRN is Latin - Pro Res Nata - basically for things that come up - often patients see the need first, often I do. Then we come to an agreement as to how to proceed - I tend to defer to patients unless I see a relatively strong reason otherwise - it builds trust and rapport, so that patients defer to my judgement better when the need arises, e.g. in emergencies.
If I feel a patient is abusing medications, I also aim my efforts at the physician, to cut back on those orders, and/or to seek more useful alternatives.
This has been a helpful thread for me, a new nurse who is about to start working at a psych hospital. In school I did my immersion on a trauma floor and was exposed to many dual diagnosis pts. I encountered many nurses who wrote off complaints as "drug-seeking" and was told more than once that the MAR is not an "open drug buffet" for us to dole out to the pt. While I understand the sentiment there, I think it would have been helpful for other nurses to have reminded me the importance of assessing the pt and using nursing judgment when giving PRN meds.
I'm so worried about making a mistake...but this is a good reminder to assess, assess, assess and trust in my developing nursing judgment. And to ask for help!
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.
How do the patients behave after the other nurses do not give PRN's that they have asked for?
If my assessment is incongruent with the pt's complaint and prn request, I process with the pt and offer alternatives. I discuss the triggering event with the pt, and help them identify and implement coping mechanisms. If the pt is not receptive, or if they are but still want the prn, I give it. Can't say I didn't try, lol..
I feel that if the prn is ordered and the patient asks for it like for anxiety or pain that it is my job to give it. If the doctor does not want the patient to have it they should dc it. The nurse should use good judgement in administration of prn medications not withhold the meds because they don't want to give it.
caregiver_deborah
3 Posts
My son, 23 years old is Schizo affective with Bipolar tendencies. His Psychiatrist was telling me that often times, patients use aggression, threats to commit suicide and posturing behavior to manipulate the nurse/parent/caregiver into doing what they want.
When viewing my son's extensive record of psych hospital stays and ER visits, an acknowledging smile crept across my son's psychiatrist's face. He recognized at least a quarter visits were possibly manipulated by son's desire to seek attention when he didn't get what he wanted from me.
My son often uses aggression and threats of severe violence to "persuade" me to take him somewhere or buy him things, even to the point of hurting himself. When I stick to my guns and refuse to give in, suddenly son becomes very ill or will collapse in public at the worst time to cause the paramedics to be called. The payback is the attention. To deal with this, I simply stopped taking him out until his behavior leveled.
My point though is that the psychiatrist having extensive experience in urgent psychiatric unit care has noticed that my son does use his aggressive and impulsive behavior to manipulate staff and me to do what he wants.
The psychiatrist further explained (and I have seen this with my son) such patients lie through their teeth about how they feel and give not only lip service but demonstrate appropriate behavior in urgent inpatient psych wards to get released ONLY to resume the aggression and/or destructive behavior once released causing this cycle of aggression/manipulation to occur. Some visits caused by medication issues are legit visits and stays, some are not.
When I asked the psychiatrist HOW one can tell the difference between manipulation (to get released or what is wanted) and TRUE aggression needing intervention, he stressed that gut intuition was the number 1 line of defense (for lack of a better way of wording this) against being manipulated into calling the EMT's for attention sake (for example) or by being in total denial when confronted with obvious warning signs of relapse or noncompliance with medication or participation in therapy. Of course this denial isn't the type that is legit and caused by the mental illness BUT the type used to give the staff/docs what they want to hear so that he'll be released.