Psych Meds

pinkiepie_RN · Jan 19, 2010

Most of our patients have standard PRN orders, with Ativan for anxiety/agitation and Zyprexa for severe agitation/aggression. I can't imagine patients having that many separate PRN orders but it helps to know what each drug does and what indications are that a patient might need it.

Whispera, MSN, RN · Jan 19, 2010

Are you saying that all patients have all those meds ordered prn? Or that the Kardex is pre-printed and the doctor picks his choices for individual patients when he writes orders? Usually doctors have preferences.

If you have to pick from all those each and every time, here's my experience:

Ativan: to help with anxiety, works rather quickly

Klonopin: for anxiety, lasts longer than Ativan

Haldol: for anxiety, restlessness, and psychosis (hallucinations, delusion, paranoia), works quickly, has big side effects, inexpensive

Seroquel: same as Haldol except fewer side effects and more expensive

Chloral Hydrate: for sleep, very inexpensive

Meriwhen, ASN, BSN, MSN, RN · Jan 19, 2010

When writing PRNs, most doctors will indicate what each drug should be used for. This is the guideline I follow, which pretty much mirrors most of the doctors' preferences:

Benzos if it's mostly anxiety or agitation. Usually it's Ativan.
Antipsychotics if it's psychosis. Usually it's Haldol, sometimes it's Geodon or Zyprexa if the patient has allergies or a bad reaction to haloperidol.
Both the benzo and the antipsychotic if both anxiety/agitation and psychosis are present, and/or the patient is aggressive and escalating.
Vistaril/Benadryl if it's mild anxiety. If I think they mostly fine and just need something to take the edge off their mood or are med-seeking, I'll give them Vistaril instead of a benzo...because sometimes just giving them a pill is as effective at calming them down as the medication itself (the good old placebo effect). Besides, I could always give the benzo later if necessary.
Trazodone/Seroquel for sleep. The MDs at my place don't prescribe benzos or barbituates as PRN sleep aids. Everyone gets Trazodone to start with.

Very few of our MDs will write "multiple-choice" PRNs...for example, I've never seen someone with both Ativan and Klonopin as PRNs for anxiety: it's either one or the other. They may write Ativan and Vistaril PRN for anxiety though (as Vistaril's an antihistamine, not a benzo).

Same thing with the antipsychotics: it's usually just Haldol PRN, or possibly Haldol or Geodon PRN, but there is never a list of three or four antipsychotics to choose from.

If I did have more than one anxiolytic/benzo/antipsychotic to choose from, I'd only use one at a time unless ordered otherwise by the MD. And if one medication wasn't effective, I'd let the doctor and other staff know so they know to try another one first next time.