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.
I worked in LTC years ago. There was an agency nurse who had steady work at our facility. She felt that one of our extremely alert patients was a drug seeker and didn't need so many pain pills. She told the patient that she didn't need so many pain pills and was very slow in giving the patient her prn pain meds. The alert patient reported that nurse and the LTC got rid of that agency nurse. I give prn meds. I don't care if so and so nurse complains that I gave it.
The biggest problem I've seen in med-surg with nurses not giving PRN's is when they have a pt with a history of drug abuse that is post op and asking for pain meds. I had one nurse refuse to give the pt anything for pain because he claimed the pt was "drug seeking" even though the pt wasn't even 12 hrs post-op!! Any other pt would have been asking for narcotics in that time frame, so it was not fair of him to choose to "punish" the pt.
I think (my opinion) that some of the posts are going a bit off-topic. The OP is a psych nurse talking about her experiences in an acute psych unit--not pain management, etc on a typical floor, LTC, or hospice. I think that that's a completely different issue.
Like the others I agree you shouldn't be trying to fix a "drug" problem unless that is what a patient is there to do!
PRN meds are ordered as needed for a reason....if a patient frequently uses these meds at their discretion at home THEY ARE NEEDED IF REQUESTED and should be given.
I take flexeril pre emptively for back spasms.....a few a year, but when I need them...I NEED THEM. For the days I didn't have them, I was basically screwed!
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
I think (my opinion) that some of the posts are going a bit off-topic. The OP is a psych nurse talking about her experiences in an acute psych unit--not pain management, etc on a typical floor, LTC, or hospice. I think that that's a completely different issue.
I don't mind. I posted in the psych specific thread as well. While it's not the same, I was still wanting to get ideas on others thought process and opinion, even if they are not psych related.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
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.
Thank you! I had an 8 week orientation, and have only been off for a couple of weeks. Everyone says I am doing an excellent job. It's just hard going from something you understood and were very competent in, to having to start from the bottom. I already can see how much I have learned and grown in just a month, so I know it will get easier.
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.
Thank you. I do need a hug...
Sorry for the attack, but I'm sure as a psych nurse, you are familiar with those who strike out when they are hurting.
I meant to add this is a problem in psych as in many other wards, because quite often doctors over-prescribe for patients and turn them drug-dependent. Then the patients end up with more problems than they had before.
I think patients get too many meds sometimes, that they do not need. Doctors should be UNDER-prescribing instead of writing up too many prn meds, OR adding that prn meds must only be given with certain signs & symptoms.
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 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.
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 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.
It sounds to me that the nurse that lied is not using her critical thinking skills (by escalating the patient's anxiety/agitation through withholding meds.) Definitely not the smartest of moves.
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
just a thought here, i understand the rationale behind knowing more about a patients condition and connecting this with our practice, but do you realise that you denied the patient the relief they needed and potentially caused her to suffer an increase in discomfort (aka pain?) as a direct result? the two things that stand out in this particular process are the ignoring of the fact that part of the treating team believed this prn was necessary or it wouldn't have been charted and also the suggestion that you know her physical condition better than she does... how do you know that she hadn't already discussed this with the treating doctor and this was why it was charted in the first place? do patients have to experience more pain and discomfort before we help them? "an ounce of prevention is worth a pound of cure" develops and enhances the trusting relationship - and to believe that someone may be drug-seeking and being "manipulative" (not words you used, i realise) is a judgemental stand... there's a lot of literature about patients' perceptions of pain - and although it's more complicated, drug seeking behaviour is of a very similar nature... sorry if i missed anything in your description of the situation... not meaning to be criticial...
i meant to add this is a problem in psych as in many other wards, because quite often doctors over-prescribe for patients and turn them drug-dependent. then the patients end up with more problems than they had before.
i think patients get too many meds sometimes, that they do not need. doctors should be under-prescribing instead of writing up too many prn meds, or adding that prn meds must only be given with certain signs & symptoms.
not sure how it works where you are but here in our psych ward prn medications can only be given if the prescribing clinician has completed the "indications" section of the med. chart - - in other words, if they have detailed the specific conditions that must be present for the prn to be utilised... - if this section of the chart is incomplete, it is considered a medication error to administer this medication and the nurse administering the prn will get support and instruction on how and when to withhold meds and address the issue with the medical officer (or immediately with any medical officer if the patient is suffering)!
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Blackcat99
2,836 Posts
I worked in LTC years ago. There was an agency nurse who had steady work at our facility. She felt that one of our extremely alert patients was a drug seeker and didn't need so many pain pills. She told the patient that she didn't need so many pain pills and was very slow in giving the patient her prn pain meds. The alert patient reported that nurse and the LTC got rid of that agency nurse. I give prn meds. I don't care if so and so nurse complains that I gave it.