Not giving PRN's even though they are ordered?

[Simply Complicated]

Even though this is regarding psych nursing, I'm posting it in general as it can apply to any type of nursing, and others may still have some good insight, opinions, or advice.

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.

[Nurse_Candice]

I think these problem crosses into all specialties I know Ive seen it in rehab, memory care, LTC and AL settings. I personaly have felt that some res' have become accustomed to receiving prns and will request or expect them all the time when there pain scale numbers show they don't quite need them,(a hydro/apap 10/325 for pain of 2/10) so I will give an alternative first, Tylenol or tramadol etc. Ive seen co workers who over admin the prns and those who hold them so its a problem on both ends of the spectrum, my advise is do what you feel is right. I always state my opinion when faced with nurses who tell me how to give it,(respectfully but confidently), and found they no longer do that. I also make sure to discus it in report as this helps to give some nurses another's perspective and may have them think twice but some are still going to do it there way.

[Zookeeper3]

I'm going to give you two different thoughts about this so take from them what you will...

1. I worked a very, very short year in geriatric psyc many years ago... disclaimer:rolleyes: even though geriatric... the nurses communicated whom they thought was med seeking. This changed the plan of care after being discussed with the doc. We aired our concerns and let the psyc. decide if they needed to be dc'd and if not, the PRN's were to be given at the patient request. So we maybe had a 24 hour window where we'd watch and nurses made uncomfortable independent decisions, usually to medicate until we could meet with the doc and discuss. My thoughts at that time were... if he/she was comfortable with ordering it, knowing the patient would possibly get every possible PRN dose that was deemed safe, I was good giving it until I could discuss "other, abuse" concerns with them... that was I was sure my patient was safely medicated and their needs were met... one shift didn't compromise my morals.

2. Now I'm in an acute ICU setting... other than our weekly DKA admits seeking dilaudid.. "pushed fast"... I've realized that the ICU is not the place to try to fix a drug habit.

So I've learned that there are many ways to address addiction and drug seeking and it may not be on my shift tonight, but I will get it done.

I hope that helps.

[Altra, BSN, RN]

Just my ...

Working in the ER, we are the point of entry for many psych admissions. Over the last couple of years I have seen a definite shift toward lessening the use of meds during what is generally a brief inpatient admission, so that the 48-96 hour hospital stay is not spent with the patient zonked.

Five years ago, an admitting psych RN would flat out say to me to please medicate the patient before they went upstairs to "ease the transition" to the inpatient unit. I haven't heard that in the last couple of years.

[classicdame, MSN, EdD]

behavior modification takes longer than one shift and requires more than a nurse alone can provide. Give the med

[bjaeram]

You are the nurse at the time. You make a judgement call based on what you are seeing. The shift before you may have seen different behaviors. If you feel the paitent could use it give it!

[INLPN93]

Give the med as ordered.

If the patient doesn't need it, document it.

After a period of time, the PRN can be dc'd for non-use.

Not giving a PRN based on YOUR view is a no-no.

Psych drugs are being classified as a chemical restraint now days, but if you have the request and an assessment for need documented you are covered. Good, clear documentation will always have your back. Always.

And definitely more so than the nurse you are working with's advice.

[highlandlass1592, BSN, RN]

To me, your reasoning appears sound, your assessment of your patient sounds correct. PRN meds are ordered for a reason, if they are not needed an MD will usually d/c. I also agree with your statement that I'd give a po before an IM/IV unless I was in an acute situation. My reasoning is the pt isn't going to go home on IV/IM, so if we need to give prn po's, that can be calculated into the d/c plan and accomodated.

I work in critical care where most of my prn's are based upon a physical, not psychological condition. However, I have had some psych patients come into my area due to needing surgery. If they have prn's ordered for psych issues and it appears they need them, they get them. I"m not here to fix addiction issues nor to force them to have a psychotic break due to stress. I try to keep ahead of the curve by using po meds but if needed, I have no problem giving IV. IM"s are interesting, working in the ICU I have maybe given 4 IM injections over the past 5 years....but I still remember how.

As to what other nurses are telling you to do, I wouldn't discount their input. But ultimately, YOU are assigned to care for that patient, you have a license, you do what YOU feel you need to do. Always document the reason for a prn (just like a pain assessment) and make a follow-up assessment. That way, anyone who comes after you, be it MD or RN, will know why you did what you did.

[MrChicagoRN, RN]

We posess both personal & professional judgement.

My personal judgement may be that the person is drug seeking in general, but my professional judgement is that it is needed.

It's important to be sure it is your professional judgement you are listening to. If they don't need it, they don't need it, but it needs to be more than just an off the cuff decision.

But is there something else going on with the patient? Is the patient misreading his/her symptoms (i.e. akathesia vs anxiety)? Is their only coping mechanism asking for meds?

This is the opportunity to say, "let's try something else first and see how this works first..."

[Simply Complicated]

It's very interesting to hear everyone else's thoughts. I transferred from ICU so I am still learning how to handle the manipulative patients. I'm definetly not just handing the meds out like candy, I just don't feel it is my place to judge. I will suggest alternatives if they don't appear to be really needing it. But just like pain, not everyone will physically show their symptoms as obvious as another. Yes there are signs of anxiety but some ask for the medication before it gets horrible. Doesn't mean they don't need it. I know some are obviously taking advantage, I guess I am just not as cynical. I hope I never get as bad as I see some others.

[canesdukegirl, BSN, RN]

This is exactly the type of scenario where you must rely on your own critical thinking skills. If the pt is asking for PRN meds and they are walking around with clenched fists, slightly diaphoretic and you see signs of escalating anxiety, GIVE THE MED! You must be confident in your own assessment in order to give a med that you deem appropriate for your pt at the time, no matter what the other nurse said to you.

If the pt went into an acute episode because you withheld meds because the other nurse told you that "he didn't need it", do you think she would have your back?

[evolvingrn, BSN, RN]

It's very interesting to hear everyone else's thoughts. I transferred from ICU so I am still learning how to handle the manipulative patients. I'm definetly not just handing the meds out like candy, I just don't feel it is my place to judge. I will suggest alternatives if they don't appear to be really needing it. But just like pain, not everyone will physically show their symptoms as obvious as another. Yes there are signs of anxiety but some ask for the medication before it gets horrible. Doesn't mean they don't need it. I know some are obviously taking advantage, I guess I am just not as cynical. I hope I never get as bad as I see some others.

Actually it is your place to make a nursing judgement....our prns are standing orders for every pt

I have heavy duty drugs on that list haldol,loraz,morphine ect......so that may morph my perception but if the symptoms don't match I don't give it. The other day my patient for a prn of iv dilaudid.... Denying pain and shortness of breath just wanting to help her ambien work. I said no but did give her some later when she began having restless legs.I know now that she does have more disomfort at night and will give it now , but I got important info by waiting to give it appropriately