Asking all nurses...need a consensus!

  1. Ok, here we go...just think, this COULD be fun!! :0)

    As a 15 year-practicing, highly experienced RN, with a background in a multitude of specialty areas, I have come across a nurse manager who has a belief about PRN order interpretation, which is well, interesting to say the least.

    Believe it or not, the Nurse Practice Act in my state, nor the BRN, are able to give me a satisfactory answer on this. Despite having graduated from an accredited school of nursing, with a BSN, I DID graduate 15 YEARS ago...thus, my textbooks (all of which I HAVE KEPT) ARE somewhat outdated, so I am looking for a current answer re: this question (which I do PROMISE TO GET TO), eventually! (ha). Sorry! ; 0)

    Ok, here is THE Queston: Please explain your understanding of the acronym "T.I.D." when used in a PRN order, VERSUS, "Q8h" when used in a PRN order...why are they the same/why/how do they differ?

    Let me begin by saying this:

    1) My understanding is that there are TWO OPTIONS (T.I.D. & Q8h) for a REASON. In other words...if they meant the SAME THING, the two DIFFERENT WAYS OF PRESCRIBING WOULD NOT EXIST.

    2) I was taught and have always followed (remember, only in the case of PRNs!) the concept that T.I.D. = "three times daily" & is generally the order of choice for specific cases where meds which cannot harm if given on a non-timed/ non-"well-spaced" time frame.
    Example? Tums. Silly example, but it works for illustrative purposes. (& for the sake of the example, because we are nurses and I just know someone will bring this up...this is a healthy, non cardiac, non-hypercalcemic, 20 year-old who gets occasional heartburn due to overeating a bit too often)...

    How I would handle this dosing with a "T.I.D" order?: GIVE ONE @ initial request. Second assessment after one hour, client states some, but minimal, response and tells me, "@ home, I usually take three or for before it works", and I WILL give the other two.
    Now, this client has had three Tums in two hours, is feeling fine, and even if she wasn't, would get no further Tums for 24 hours. Instead, I'd call and get an order for something else if my assessment didn't show other untoward signs requiring further testing/etc... client/new scenario:

    3) "Q8h"...Ativan 2Mg PO. Client can get dose #1 @ initial request at 0500. Then, they want another dose at 1500. Great. Give's been greater than 8 hours and thus, is allowed. Next, they ask for Ativan at 2100. Answer is, "Sorry Mr.'ve only had your last dose six hours ago, so it's a bit too soon. I will check with you at 11 pm (2300), & if you are still anxious, I'll be happy to give it to you then!

    4) The order is WRITTEN Q8h BECAUSE we don't KNOW WHEN MR. JONES is going to become anxious, but we DO KNOW (by the way he's written the order) that our MD does not feel comfortable giving him his Benzo closer than every EIGHT HOURS.

    Now give me all of your opinions/scenarios, or straight up bottom line answers! I can WAIT TO SEE what other RNs and LPNs think! Have at it'll help my unit out a lot to see where the CONSENSUS lies.
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    About EquestrianRN

    Joined: Jan '13; Posts: 23; Likes: 25


  3. by   Hygiene Queen
    I have seen Ativan ordered just TID PRN.
    I still try to space them appropriately.
    If the pt takes 1mg and then wants another just an hour later, I encourage other coping skills until I clarify with the doc.
    I can see this type of order being used for Tums but I dislike when I see it for something like Ativan.
    I just try to use some common sense but I have gotten this changed before especially when pts want it too close together.
    I mean, as written it sounds like you could give them 3mg in 3 hours... though I don't know anyone who would do that.
    I agree with you, OP.
  4. by   EquestrianRN
    Quote from Hygiene Queen
    I have seen Ativan ordered just TID PRN.
    I still try to space them appropriately.
    If the pt takes 1mg and then wants another just an hour later, I encourage other coping skills until I clarify with the doc.
    I can see this type of order being used for Tums but I dislike when I see it for something like Ativan.
    I just try to use some common sense but I have gotten this changed before especially when pts want it too close together.
    I mean, as written it sounds like you could give them 3mg in 3 hours... though I don't know anyone who would do that.
    I agree with you, OP.
    First, I adore your "handle"...Hygeine Queen totally rocks! :0) Second, thank you for your input-very much appreciated!

    This is how I see a T.I.D order as well; "technically", & probably legally, (as long as the client is not sedated, has appropriate vital signs and SaO2, & you document as much...INCLUDING THE REASON for needing SO MUCH Ativan SO CLOSE together--a client experiencing extreme agitation/anxiety attack, with corresponding VS & client statements/actions documented to prove such), you probably COULD GIVE three doses of Ativan in three hours and be covered, as long as you gave NO MORE until 21 hours later!

    Hopefully, in a client that acutely anxious or agitated, an RN/LONG would have a physician involved long before dose #3 of 2Mg Ativan was considered; & would be suggesting alternative meds, such as IM Geodon, or perhaps ODT Zydis, etc...but, we're talking legalities and "what ifs" here, not perfect or even best example...

    Of course we all know that this would not, except perhaps in EXTREMELY rare cases, be the "reasonable and prudent nurse's course of action", but still...

    I completely agree with you; IF such a PRN order was used with Ativan or other sedating med, it would be risky, and I too would first off get an order rewrite/clarification, and change it to at the very least contain written PARAMETERS!

    Now, in the case of the Tums (my original T.I.D order example) I feel it WOULD be appropriate....that's the thing with T.I.D vs. Q8h...they each have a "place"in PRN order writing, from a physician-standpoint, and order following, from a nursing standpoint, and I do NOT BELIEVE THEY ARE interchangeable, to a great degree, as they do not mean the same thing!

    Anyhow, again, I very much appreciate your input! Anyone else like to share their perspective?
  5. by   SaoirseRN
    I was taught as you were and this is how I practice.

    I have had doctors who think the other way, and in those cases I have asked them to change their orders to read Q8h instead of TID.
  6. by   MunoRN
    To be exact there is no answer that is absolute, facility policies will largely determine what's right and wrong, but in general:
    TID is used for a scheduled medication, and most facilities have set times when TID medications are given (ie 0800 1200 and 2000). Facilities also have timespans in which scheduled medications can be given. So if you are giving one dose at 0800, and another at 1000 when you are allowed a 1 hour leeway, then you haven't followed the order.

    The Joint Commission doesn't make specific requirements about prn orders, but they do require that the person making the order and the person utilizing the order both interpret the order exactly the same. So if the MD wrote TID thinking it was synonymous with q 8hrs then you'd also be practicing incorrectly. Our facility (more specifically the pharmacists) automatically change "TID" terminology to "q8hrs" on prn orders. TID and other frequencies intended for scheduled administration really make no sense with prn medications and will almost always lead to varying interpretations. If the MD is writing "TID" to express that he is OK with a med being given as frequently as needed, but does not want more than 3 doses given per day, then it makes more sense to write it that way (Tums 1-3 tabs q 24 hours). Or that a certain number of doses can be given close to together (Ativan 2mg q 2hours, not to exceed 4mg per 8 hours or 6mg per 24 hours).
  7. by   PediLove2147
    At my hospital they mean the same thing. Our computer system only allows you to scan a TID med Q8H. I agree with you though.
  8. by   eatmysoxRN
    At my facility a med ordered TID can be given close together. Pain pills come to mind. I have given a percocet @ 0100 and when they want another at 0500, I remind them that they will only be able to have one more that whole day. Assuming vitals/LOC permit, I will give it though. If the patient requires more later, I'd call the doc and let them know.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
  9. by   lumbarpain
    I have been out of practice for a couple of years, but I remember the doc specifying the number of hours for any prn order. I dont remember ever seeing TID for a prn was tylenol 1 325mg tab po q4h for pain.....this was written as a prn but the hours to give it were always written.
  10. by   M/B-RN
    I agree with what you have said OP. That is my understanding of it.

    At our facility if the doctor writes TID or BID, then pharmacy will schedule it automatically. If the docotor writes a PRN order they usually specify how many hours apart it can be given, for example Q6H PRN. I had an order before that was BID PRN and for that one pharmacy did not schedule it, but the computer would warn me that it had "been given recently" even though it was more than 8 hours ago.
  11. by   EquestrianRN
    The consensus thus far, as I see it, is that for OBVIOUS REASONS, TID is not often, or ever really, anymore, used for PRNs! And as a few have stated, computerized MARs are written by pharmacists to take any potential "guesswork" out of the times to administer when MDs still choose to utilize acronyms rather than exact times for PRNs ...

    Interestingly, my hospital is a stand-alone facility where the RNs still transcribe ALL THE ORDERS! Up until recently, RNs also filled all the meds from "stock psych meds"which were kept on cards in our own "pharmacy"!...

    Our entire process is very archaic, I realize...moreso even now as the trend towards computerization of MARs is enormous and has swept nursing especially in the mere five years I've been HERE...We have ONLY RECENTLY stopped stocking our own RXs!

    Great info..thanks again all! :0)
  12. by   queenjulie
    I'm still a fairly new RN, but I don't think I've ever seen a PRN scheduled as BID or TID for exactly this reason--they are always Q8H or Q12H or whatever, so there is no question about the spacing required. If I gave a PRN Ativan and needed more right away, I would need to page the physician and make them aware that there is some kind of special circumstance going on.
  13. by   liveyourlife747
    We get some TID and BID PRN medications on our floor. But the Pyxis flags us if we try to pull a controlled med before the 8-12 hr time that needs to be between them. Other PRNs that's aren't a controlled med that are TID or BID PRN don't have a warning. I agree MDs should specify times because someone can get too much Meds in too little time if it gets into the wrong persons hands.
  14. by   EquestrianRN
    Very good points, QueenJulie and Liveyourlife! We obviously have some excellent "critically thinking" nurses out there...

    I have often wondered these days, when, of the "new grads" coming through my facility; one-third are PHENOMENAL and they absolutely blow me away with their intelligence, attention to detail, and ability to critically think through any problem put before them...

    However, the other two-thirds really have given me pause and I felt, cause for concern, in terms of the depth and breadth of things they absolutely do not understand...

    Clearly, ESPECIALLY regarding those graduated and working nurses on this site (but certainly not ONLY, so please do not misunderstand! I'm absolutely NOT SAYING that students don't have these same's just easier to SEE IN the graduated/working population), there are some AMAZINGLY INTELLIGENT AND BROAD-THINKING minds in nursing today...this thoroughly impressed me when I first began "stalking" around 'AN' prior to joining; reading through the topics and what not...

    These factors are not only evident when nurses are discussing the biggest issues relevant to our carers, but also the smaller points, which people in the field for any length of time obviously grasp exactly in the manner which they should. This gives me great hope for the future of nursing! :0)