PRN med order question

[sassyann85]

Hi everyone!

So here is my question. I might be overthinking, but a couple nurses told me a couple different things...

Say a patient has an order "Ativan 1 mg q 4 hours max 6 times in 24 hours." And they requested their PRN Ativan yesterday at 7am, 11am, 4pm, and 9pm. So, if the doctor comes in today at 10am and changes the order to "Ativan 1 mg q 4 hours please do not give more than 2 mg in a 24 hour period) and the pt requests a dose at noon, would you be able to give it then? As in, would you consider the milligrams and timing the patient got of the previous PRN Ativan order? If so, and you give the PRN Ativan 1 mg at noon, then technically (taking into consideration the PRN Ativan they got from the discontinued order) they will have gotten 3 mg in 24 hours. Or is the new Ativan order an entirely separate entity unto itself, and you just cant give more than 2 mg of Ativan in 24 hours of the new order of Ativan.

Hope this is clear. Thanks so much for any input!

[BSNbeauty, BSN, RN]

I would clarify with the doc to see if the new dose should be given now.

[KelRN215, BSN, RN]

This order doesn't make any sense. The patient can get Ativan 1 mg q 4hrs but he can't because he can only get 2 doses in a 24 hour period. And he required 4 doses yesterday? I'm not understanding the rationale for the change.

[nrsang97, BSN, RN]

I am confused as well. Why did they change it to po q 4 hours with only two doses in 24 hours? Why not just order the ativan 1 mg po 2 x daily? I would have been calling for clarification.

[firstinfamily, RN]

It sounds like the MD is trying to wean the pt from the ativan. I would also call to clarify and ask if the PRN dose could be reduced to 0.5mg instead of 1mg. If the goal is to wean the pt, then they should be getting a smaller dose. To answer your question about when to start the new order. Lets say the pt received 1mg at 11:00 from the old order, and the MD came in re-wrote the order for no more than 2 mg in 24 hr period. That order is now the active order, so if the pt gets another 1mg at 3:00 pm then that is all pt can have for that day. Most likely that pt would be coming off the wall around 8:00 pm and would not be able to have another dose. I have seen orders similiar to this where the MD does not want the pt to receive as much as initially ordered, however to make the dose 1 mg and no more than 2 mg in 24 hours does not make much sense. The nurse should call to clarify the order with the MD and even possibly suggest the dose be reduced. This way the pt is actually being weaned from the ativan. This pt is most likely going to have some symptoms of withdrawal from this medication with the way it is limited to 2 mg in a 24 hour period when the initial total dose was about double this. Possible need for psych consult!!!

[KelRN215, BSN, RN]

I don't think I've ever seen ativan weans done with PRN dosing. Every patient I've ever weaned from narcs or benzos had standing doses ordered and the doses decreased/times spaced until they were weaned.

If he wants to wean, it would make more sense to space it q 6hr then q 8hr then q 12hr while also decreasing the dose...

[TheCommuter, BSN, RN]

So, if the doctor comes in today at 10am and changes the order to "Ativan 1 mg q 4 hours please do not give more than 2 mg in a 24 hour period) and the pt requests a dose at noon, would you be able to give it then?

You are over-thinking it. This scenario would not happen in real life. If the doctor orders Ativan Q4hours PRN with a limit of 2mg over a 24 hour period, I can guarantee you that each dose is going to be 0.5mg or less Q4hours PRN, and not 1mg.

[heron, ASN, RN]

Sounds to me that the resident was inadvertently over-sedated. That doesn't address OP's question - just a comment.

[Karou]

What a messy order. The physician should be called to clarify.

1mg q4hr with max of 2mg in 24 hours is weird because that really means the patient can only get it twice in a 24 hr period. Ordering it twice daily as needed would make more sense to me. Either that or possibly the physician did not intend on 1mg as the dose and meant to do 0.5mg or 0.25mg.

Until clarified I would not give the Ativan, because that would mean the patient would receive more than 2mg in a 24 hour period (since noon the day before). Needs clarification.