PRN vs routine pain meds

Been there,done that, ASN, RN · Aug 4, 2016

"I have questioned my staff about wether or not the patient is actually asking for the prn or if it is given out of habit". What is the answer to that? Either way she is getting the breakthrough dose.

The prescriber (haha) calls the shots. They are attempting to minimize opioid use.. that is a good thing. What other pain management techniques have been tried?

nutella, MSN, RN · Aug 4, 2016

I work in a SNF and have a patient who is on long acting pain meds as well as prn narcs which she asks for at routine times. I have asked her doc several times to make these prns routine since her breakthrough prns are "routinely" given (since she reuests them) at regular intervals for break through. This has been happening for 6+ months but her doc refuses to make them routine and claims she's drug seeking. I use pain scales to asses and follow protocol for my facility. I'm not sure what else I can do. I have listened to the patient and spoken to the doc on multiple occasions. He continues to refill a prn script regardless of the consistency of the use. Times down to the minute. I have questioned my staff about wether or not the patient is actually asking for the prn or if it is given out of habit. I suppose my question is what can I do about the situation. I'm a new RN and I feel as though more should be done but I'm hitting a brick wall here. am I going about this wrong? Am I naive? What can I do?

Of course the MD may not share your view and may not prescribe medication in a different way. There is much more focus on narcotics and drug seeking behavior so it can be hard for MDs as well especially when the patient has multiple issues.

The thing with narcotics is that if somebody is on them longterm, they develop some tolerance and many patients do not feel the same effect after some while. Or an illness that is progressing and causing more pain is not covered by the chronic pain medication regimen and now it is acute on chronic pain or just worsening chronic pain.

Or the "pain" is approached in a way that does not make much sense because narcotics do not work best for all pains and all patients.

Generally speaking - when a patient has legitimate pain concerns that are addressed with narcotics, and uses long acting as well as breakthrough meds, there usually comes the point when the long acting medication needs to be increased once a person takes so and so much breakthrough pain meds. Theoretically, that will cut back on breakthrough doses as the patient has overall better coverage.

In practice it is not always the case though because not all physicians are comfortable with the conversion of medications/narcotics.

You can suggest a referral to the pain clinic to the MD. A lot of patients do not seem to like their approach as they are not gung ho on narcotics for everybody and often suggest something else or in combination that makes sense but the patient does not want to give up narcotics or does not want to try other meds.

As a nurse in palliative care I do in depth assessments and ask specifics about how the pain feels, how it impacts functional status, how they take it at home and I have them repeat in their own words their understanding of how the medication works or what their expectation is. It is also important why a patient has pain as the reason for pain often points to why a medication does or does not work. Plus the expectations - if somebody comes in and says 10/10 pain and they get a pain medication it is now 7/10 that is a good amount of relief at that point because we do not just look at the number but the difference and how it changes the functional status as well.

Patient education is important. It is not uncommon for patients to ask for a prn narcotic because they want to sleep at night and it makes them sleep through. And of course by now most patients know that if they say their pain is 10/10 the nurse will hurry up while otherwise it may take some time.

If you are a new RN I would encourage you to reach out to a RN that has been there for some time and who seems to be approachable and has good knowledge and ask her to give you her view on the situation. Especially as a newer nurse it is important to have a mentor or colleague you can ask for a "consult" to discuss problems like that because it is often a learning experience.

I have been a nurse for 20+ years and still ask other RNs for their opinion when it is a strange case or complex and I want some input.

As a new nurse you probably want to make sure the patient is comfortable and cared for but in the real world there are other factors that influence that and of course you can suggest something to the MD but the prescriber may not take your advice based on their preference or understanding of the situation. Generally speaking, it is best to avoid heads on collisions with MDs about stuff like that. Instead, you can say something like "I have noted that the patient is asking for pain medications consistently every x hours without fail - I wonder what your thoughts are on scheduling those medications instead of prn / pain consult/ pain management." That leaves room for the MD to tell you what their rationale is and may be more beneficial than saying "I think it should be scheduled".

TheCommuter, BSN, RN · Aug 4, 2016

Moved to the Nursing & Patient Medications forum for more responses.

loriangel14, RN · Aug 4, 2016

What difference does it make? Either way she's getting the meds PRN or routine

toomuchbaloney · Aug 6, 2016

There is not enough information...

what sort of pain, how long has patient had this pain, is the type of pain consistent, are there other therapies in place to assist with pain control, etc.

I have seen too many elderly patients suffer long term in pain with little relief because their provider refuses to treat their pain adequately.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Aug 6, 2016

What difference does it make? Either way she's getting the meds PRN or routine

I think the difference is in the documentation. Inside a skilled nursing facility, follow-up documentation is not required on routinely-scheduled pain medication like it is with PRN pain meds. There are just too many residents-to-one-nurse for that amount of documentation, especially when a lot of those residents have been on some of these controlled meds for years.

...just my opinion regarding the OP's concern based on my experience during my LPN nursing home years and my more recent regulatory experience....

dishes, BSN, RN · Aug 6, 2016

I think the difference is in the documentation. Inside a skilled nursing facility, follow-up documentation is not required on routinely-scheduled pain medication like it is with PRN pain meds. There are just too many residents-to-one-nurse for that amount of documentation, especially when a lot of those residents have been on some of these controlled meds for years.
...just my opinion regarding the OP's concern based on my experience during my LPN nursing home years and my more recent regulatory experience....

Inadequate staffing is an employment problem, from a patient safety point of view, the solution isn't have the physicians write scheduled pain medication orders for the convenience of the nursing staff. The solution is have employers held accountable to hire adequate numbers of staff.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Aug 6, 2016

I agree. However, when looking over the required nursing hours in LTC facilities, these places staff with the minimum amount of staff as required according to regulations. Barring any increase in patient injuries and/or elopements, they cannot be forced to hire additional staff.

That being said, the physician knows these patients are taking PRN meds on a regular schedule (the nurse has informed him/her). It is my opinion that the physician will not modify the order in anticipation of plausible deniability. In the event of an adverse outcome related to narcotic consumption, the fault will be placed on the nurse for administering the medication on a routine basis, even though it was administered according to specified time frames and patient/resident need or request.

So, there will be no solutions to this problem if it is left up to the physician. Nor will staffing be increased for this stable population in the absence of serious injuries, lawsuits, or fines. My previous post was that I believed the issue was in the area of documentation...not saying that this was the solution. But documentation, or lack thereof, is a problem when it comes to time management. In the hospital, it has been partially addressed by the induction of the EHR. But we still have to go back and assess medication effectiveness on 5-7 patients. Imagine having to do this regularly on twice as many residents, if not more, and having to handwrite the follow-up in those enormously thick MAR books, instead of simply clicking a pre-populated drop-down box, then having to sign, date, and time each entry on ALL of those PRNs. That's what these nurses have to go through in SNF if there is no EHR/EMAR at the facility. That is extremely time-consuming. The little things we take for granted tend to have enormous impact on others.

When I worked LTC, the ADON tried to alleviate some of the charting by attempting to get the physician to modify those regularly administered PRNs; he would not budge. The patients/residents knew they had it ordered and they wanted it. What just kills me is when the physician tells them it is on board, and then comes to the nurse and says to give this but not that, yet refuse to discontinue the 'that'. At the end of the day, point towards the primary nurse as the villain.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Aug 7, 2016

^^^^The last sentence should have read "all arrows" point to the nurse. :blink:

BeenThere2012, ASN, RN · Aug 10, 2016

Of course the MD may not share your view and may not prescribe medication in a different way. There is much more focus on narcotics and drug seeking behavior so it can be hard for MDs as well especially when the patient has multiple issues.
The thing with narcotics is that if somebody is on them longterm, they develop some tolerance and many patients do not feel the same effect after some while. Or an illness that is progressing and causing more pain is not covered by the chronic pain medication regimen and now it is acute on chronic pain or just worsening chronic pain.
Or the "pain" is approached in a way that does not make much sense because narcotics do not work best for all pains and all patients.
Generally speaking - when a patient has legitimate pain concerns that are addressed with narcotics, and uses long acting as well as breakthrough meds, there usually comes the point when the long acting medication needs to be increased once a person takes so and so much breakthrough pain meds. Theoretically, that will cut back on breakthrough doses as the patient has overall better coverage.
In practice it is not always the case though because not all physicians are comfortable with the conversion of medications/narcotics.
You can suggest a referral to the pain clinic to the MD. A lot of patients do not seem to like their approach as they are not gung ho on narcotics for everybody and often suggest something else or in combination that makes sense but the patient does not want to give up narcotics or does not want to try other meds.
As a nurse in palliative care I do in depth assessments and ask specifics about how the pain feels, how it impacts functional status, how they take it at home and I have them repeat in their own words their understanding of how the medication works or what their expectation is. It is also important why a patient has pain as the reason for pain often points to why a medication does or does not work. Plus the expectations - if somebody comes in and says 10/10 pain and they get a pain medication it is now 7/10 that is a good amount of relief at that point because we do not just look at the number but the difference and how it changes the functional status as well.
Patient education is important. It is not uncommon for patients to ask for a prn narcotic because they want to sleep at night and it makes them sleep through. And of course by now most patients know that if they say their pain is 10/10 the nurse will hurry up while otherwise it may take some time.
If you are a new RN I would encourage you to reach out to a RN that has been there for some time and who seems to be approachable and has good knowledge and ask her to give you her view on the situation. Especially as a newer nurse it is important to have a mentor or colleague you can ask for a "consult" to discuss problems like that because it is often a learning experience.
I have been a nurse for 20+ years and still ask other RNs for their opinion when it is a strange case or complex and I want some input.
As a new nurse you probably want to make sure the patient is comfortable and cared for but in the real world there are other factors that influence that and of course you can suggest something to the MD but the prescriber may not take your advice based on their preference or understanding of the situation. Generally speaking, it is best to avoid heads on collisions with MDs about stuff like that. Instead, you can say something like "I have noted that the patient is asking for pain medications consistently every x hours without fail - I wonder what your thoughts are on scheduling those medications instead of prn / pain consult/ pain management." That leaves room for the MD to tell you what their rationale is and may be more beneficial than saying "I think it should be scheduled".

This is everything I would say to this situation.