scheduled meds with prns

[sassyann85]

Hi everyone:

So I often have patients on scheduled antipsychotics like risperdal or abilify and then they have PRN antipsychotics ordered. How do you know if these can be given together or how long you have to wait between meds? IE- a patient on scheduled PO risperdal comes and taken their med and then reports they are really agitated and wants their PRN IM Geodon? Or a patient on scheduled risperdal PO takes their med and then requests their PRN PO Haldol because they are starting to feel really agitated?

[elkpark]

I would check your facility policy and/or clarify with the ordering physician/provider.

[ThymeRN]

If they are asking for PRNs often, maybe talk to the doctor to get the order changed. In the short term, until you learn the particulars of each med, pharmacy is your friend.

[Jules A, MSN]

I would check your facility policy and/or clarify with the ordering physician/provider.

Excellent suggestion.

As a general rule of thumb unless a patient was floridly psychotic, and in those cases they rarely ask for PRNs, I would request the patient consider allowing the standing order medications time to kick in before adding another antipsychotic or perhaps offer something complimentary from a different class like Benadryl.

[greenbeanio]

So much depends on the individual patient, and what their body can handle. Some of them can have enough antipsychotics to slay a horse and still be walking around quite calmly. Some of them need it to stay in control. And then again, some are med-seekers and totally dependent on popping pills. What you do depends on who you have.

Here's how I would proceed:

1) Like Jules A said, ask the patient to give the previous meds a chance to start working, and offer support/distraction in the meantime.

2) If it's a patient well known to the unit, check with the other nurses who have been there longer to see if they know this patient's pattern.

3) Like Elkpark said, check with the doctor who wrote the orders, if they are available.

4) If that MD is not available, check with the on-call doctor.

5) If there is some reason you can't reach the on-call doctor, then like ThymeRN said, check with pharmacy.

6) If all else fails, check with the Nursing Supervisor.

7) If nothing else works, and you have checked with everyone available, you can give the medication as ordered. After all, it is ordered and the attending doc is the one responsible for being aware of the patients meds including PRNs and it is up to them to write in clear parameters.

OR

If you have a strong gut instinct about it and your nursing judgment says not to give it, then don't give it and start preparing for a code. (Which may not happen but its good for the unit to have a heads up.)

8) Document everything, including everyone consulted and rationale for your decision to medicate or not medicate.

[TCASII, ADN]

double post...delete

[TCASII, ADN]

I can tell you that 99% of the time there is no problem with adding other antipsychotics on top of another drug. I've given Zyprexa, Risperdal and Haldol at the same time. I've given injections to individuals already on a load of meds; More than I can count.

You run more risk of inducing akathisia than anything. Nurses need to understand that most patients are on such low doses of these meds anyhow. Back in the day they use to given up to 20 MG of Risperdal a day. Haldol can be dosed up to 100 MG. I've seen Geodon given as twice the daily max dose and all they did was sleep good.

I'm not saying to play fast and loose, but aside from prolonging QT and inducing EPS side effects, it's pretty safe.

I've even given the ole nasty Thorazine to patients on 20 of Zyprexa and 100 mg of Benadryl.

Working crisis kinda gave me a clue as to how many meds people can tolerate. Sometimes you feel that the whole pharmacy wouldn't touch them. If they're new to the meds then obviously their tolerance and potential reactions are higher.

As posted above, a lot of them are addicted to the pills and want everything to feel drugged.

[vintagemother, BSN, CNA, LVN, RN]

I had this same question when I first started working in psych. I wondered, can i actually safely give both of these meds (the prn and the scheduled) so close together?

I ended up calling the psychiatrist to ask. I was always told, "It's fine. I don't prescribe meds that contradict with the prn meds I've prescribed"

I felt better after that.

As another poster said, I also learned to ask the other nurses who knew the PTs better, "can I safely give these to him/her?" This info told me which pt was likely to get snowed if you gave them the requested prns and which PTs routinely took multiple meds with no adverse effects.

[Elladora]

Your facility should have a developed protocol for this. Where I work clients have to wait an hour after scheduled meds to receive a prn that is in the same classification. We encourage clients to use coping skills during that hour. About 50% of the time the coping skills keep the edge off until the original (scheduled) med kicks in.

[banana, MD]

agree with a lot of the above and that antipsychotics are generally safe and many of them used to be used in much higher doses. Of the few contraindicated combinations that exist, one is the administration of the IM formulations of Ativan and zyprexa within 3 hours of each other.

Also, just always consider the possibility of akathisia, as this can be mistaken for agitation (and can only be diagnosed unless asked about) and result in further administration of more antipsychotics which just worsens things for the pt

[nickfitz1969]

Banana, MD, who told you that psychoactive medication is generally safe; the pharmaceutical companies!! That is a really irresponsible statement to make. Have you never read any research that counter-argues against the data spouted by pharmaceutical companies in their compromised/ inaccurate research.

I would imagine you don't take psychoactive medication, as you will be fully aware of the metabolic syndrome caused by this treatment. The very same industry that has promoted the chemical imbalance for years, which people were led to believe as true and accurate! And the great Thomas Insell who promoted the DSM-5 as the greatest thing since sliced bread, and then states that it is invalid and unreliable!!

[MMC.RN]

I get these types of requests a lot. If they just took their scheduled antipsychotics I follow the rule of thumb and wait about an hour. I very rarely administer scheduled and PRN meds simultaneously unless it's obvious that the patient needs it. Although if they are requesting it, I generally find that they can wait. I always offer options and encourage them to utilize coping techniques. If they have something like Benadryl or another class of meds I will offer that in lieu of an antipsychotic as well. I know that the doc will most likely not prescribe things that can't be administered together and he has said that much, but I attempt to avoid snowing my patients and making them zombies.