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.
Hi I have been working in LTC as an LPN for almost 20 years. There are younger LPN's where I work telling me the same thing. And I say to each nurse; Each reident is different and have problems on different days. It is the nurse working that should decide if they need the PRN. We are accountable for our own actions in giving resident care. One nurse can not make the decision for another. After all You went to school & have Your license, too. :redbeathe Also this is with no disregaurd to other staff.
When I worked psych pts would request sleep meds, which they were allowed to have with an hour between pills per docs orders. They'd get the first one but refuse to lie down. After the second or third pill they'd be swaying with half open eyes, and pacing the halls. Still wouldn't lie down between pills and give the meds a chance. I wanted to hold the next pill until they spent at least 30 minutes in their room resting...THEN come back and tell me you can't sleep, and I'll give you the next drug with no issues. Unfortunately they had learned exactly how much medication they could get, and they'd hold out for the maximum high. I decided that consistency among the staff was more important than my own opinion, and gave the drugs, but I still think they got way overmedicated.
So there are situations where meds can be ordered, but not actually needed. And the judgement of a trained RN is better than the patient's
I think you answered your own question. We are not doctors but unfortunately we have to be the gatekeeper sometimes who will tell the docs to do their damn job!
I work psych every week or so and this is a tricky situation.
I've wanted to give prn meds sometimes but the CN has said no as well. I suppose they get to know the patients, and don't want to encourage their drug seeking habits. The doctors don't know the patients as well as the nurses, however, I have seen nurses go over the CNs head and speak to the doctor or just give a medication once the CN has gone home. Of course the s**t hits the fan later, but these nurses have justified their actions later.
You are an independent practitioner and must use your own judgement. I would say if this is an ongoing problem, speak to your NM or call the doctor. But the Dr isn't going to be too happy when you call him saying the other nurses won't give his med order/s. Meds ARE ordered for a reason, I suppose you just have to use your judgement that is all. Make sure you do a full assessment of the patient before giving the med so u have evidence as to why ur giving it as well.
YOU are their nurse for the shift, in the end it is your call. And when you do give a prn med for whatever reason, docuemnt everything to back yourself up.
I'm more tight-fisted with the meds, as too many of my patients just love to take any and all drugs, even if not really needed. They honestly just like the whole process of taking a pill. If they say they're puking or having diarrhea, we make them show us. We have patients say, "I'm having a lot of anxiety right now. Can I have XX?" -- VS are not elevated, no shakiness, rapid breathing, pupils normal, or or other signs of agitation -- I don't give it. One of our senior nurses says, if they can ask for an ativan by name, they generally don't need it. You learn to have a practiced eye, working in chemical detox and psych when someone is trying to pull one over on you.
I would never withold a prn med from a patient/resident if they asked and it was time for it. As you already know, it is not up to us to decide if they "really" need it. I've actually had nurses withold morphine from hospice patients because they shouldn't be taking so much. Oh please!
I'm more tight-fisted with the meds, as too many of my patients just love to take any and all drugs, even if not really needed. They honestly just like the whole process of taking a pill. If they say they're puking or having diarrhea, we make them show us. We have patients say, "I'm having a lot of anxiety right now. Can I have XX?" -- VS are not elevated, no shakiness, rapid breathing, pupils normal, or or other signs of agitation -- I don't give it. One of our senior nurses says, if they can ask for an ativan by name, they generally don't need it. You learn to have a practiced eye, working in chemical detox and psych when someone is trying to pull one over on you.
I had a shift from hell today. I'm trying to decide if I leave nursing, or move far, far away from everyone. Literally, run away! Our financial and work problems are almost overwhelming...
I could use a Xanax. Seriously. My stress has actually caused sick days. I don't take Xanax, don't have a script for it. Don't take any medications, actually. I exercise as best as I can. I do the best that I can.. life happens.
I have no elevated VS, normal breathing, normal pupils. Etc....
IMO, if thats how you judge anxiety, then it's a poor assessment technique.
If I were to be hospitalized right now, with all of our problems, and had a PRN for something that I needed, give it to me. Let me repeat, GIVE IT TO ME.
The hospital is NOT our place to judge, its our place to nurse. So be a nurse, and treat your patient.
I had a shift from hell today. I'm trying to decide if I leave nursing, or move far, far away from everyone. Literally, run away! Our financial and work problems are almost overwhelming...
I could use a Xanax. Seriously. My stress has actually caused sick days. I don't take Xanax, don't have a script for it. Don't take any medications, actually. I exercise as best as I can. I do the best that I can.. life happens.
I have no elevated VS, normal breathing, normal pupils. Etc....
IMO, if thats how you judge anxiety, then it's a poor assessment technique.
If I were to be hospitalized right now, with all of our problems, and had a PRN for something that I needed, give it to me. Let me repeat, GIVE IT TO ME.
The hospital is NOT our place to judge, its our place to nurse. So be a nurse, and treat your patient.
I obviously was just giving a quick run-down of some of the things I look for, as I'm responding to this board while running in between the problems of my kids (middle-school age and one at University). And yes, I do make judgments--nursing judgments. Working in chemical dependency detox/psych is also a different cup of tea than working med/surg. I've done both, you see. In my current unit, we're trying to get them away from the pill-popping. We use a lot of non-pharmacological nursing interventions. P.S. I've been told I'm a damn good nurse.
Additional P.S. : I think you need a hug. Sorry about all the problems that you're having.
I think if the requested prn is medically safe per assessments, it should be given. It is the responsibility of a doc to decide the appropriateness of and initiate abuse protocols and attempting to do so as a nurse bends the scope of practice. You should always speak with your team about these concerns as not to inadvertently disrupt the plan of care.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
I'm more tight-fisted with the meds, as too many of my patients just love to take any and all drugs, even if not really needed. They honestly just like the whole process of taking a pill. If they say they're puking or having diarrhea, we make them show us. We have patients say, "I'm having a lot of anxiety right now. Can I have XX?" -- VS are not elevated, no shakiness, rapid breathing, pupils normal, or or other signs of agitation -- I don't give it. One of our senior nurses says, if they can ask for an ativan by name, they generally don't need it. You learn to have a practiced eye, working in chemical detox and psych when someone is trying to pull one over on you.
I think this is where I am having problems distinguishing. Because in someone who has been dealing with mental illness for years, they may not always manifest physical signs right away. When it's someone who is detoxing, I usually have a better understanding, or judgement I guess you could say. Because I have cared for plenty of patients in DT's and such on M/S and ICU. But at the same time, like you said in your other post, psych is a lot different from the floor. Although we don't generally have admissions for just detox. They also have psych diagnoses as well.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
I would never withold a prn med from a patient/resident if they asked and it was time for it. As you already know, it is not up to us to decide if they "really" need it. I've actually had nurses withold morphine from hospice patients because they shouldn't be taking so much. Oh please!
I've heard that alot. That and because hospice patients can be on such higher doses, they believe they really don't need it. Thats sad.
I think this is where I am having problems distinguishing. Because in someone who has been dealing with mental illness for years, they may not always manifest physical signs right away. When it's someone who is detoxing, I usually have a better understanding, or judgement I guess you could say. Because I have cared for plenty of patients in DT's and such on M/S and ICU. But at the same time, like you said in your other post, psych is a lot different from the floor. Although we don't generally have admissions for just detox. They also have psych diagnoses as well.
I think your judgment sounds good, Simply Complicated. It will take a little while to get confident in your ability to distinguish the true drug-seekers vs. those that genuinely need to be medicated, but in my opinion, you have some sound reasoning ability. (Again, a bit different in psych vs. the normal floor.) In my unit they get admitted just for detox, but many are dual-diagnosis w/psych issues. Everything you're saying sounds well-thought-out to me, and I'd just take the feedback from the nurses on your floor into consideration, but go with what feels right to you.
mabs21676 LPN
2 Posts
Hi I have been working in LTC as an LPN for almost 20 years. There are younger LPN's where I work telling me the same thing. And I say to each nurse; Each reident is different and have problems on different days. It is the nurse working that should decide if they need the PRN. We are accountable for our own actions in giving resident care. One nurse can not make the decision for another.
After all You went to school & have Your license, too. :redbeathe Also this is with no disregaurd to other staff. 