Scheduled and PRN Doses

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Specializes in LTC.

Hello!

I'm wondering if anyone can please answer this question I have about scheduled and PRN doses... But first I will give some background:

We had a lady who had been pacing.. Like really pacing... Around the unit. This lady is on scheduled hydromorphone. The other nurse working with this lady gave her the scheduled hydromorphone along with her scheduled medications to help her sleep. Shortly after, I could hear from the other side of the unit a lady calling out for help... Sure enough, it was the lady who had been apparently been pacing. So this lady usually has no problems with her scheduled night meds. Had always received them and never fell until tonight.

When she was on the floor, she was still restless and wanting to get off the floor. So we get her up off the floor and got her to sit in a wheelchair and at this point, still restless. She wants to get up. So she gets up and we take her to her room. Other nurse is trying to check her BP and she's wanting to get up after we sit her down on the bed.

Before this last had her fall, she was apparently pushing another resident around in their wheelchair.

I take her to my side of the unit. While we're walking, I ask her if she has any pain and she confirms that she does. Once we're there, the CNAs get her to sit down for a glass of juice and a sandwich.

At this point, I decide in addition to her scheduled dose of hydromorphone, I give her a PRN dose as she was complaining of pain post fall. Shortly after the CNAs give this lady a glass of juice and a sandwich, she starts pushing her table towards the unit entrance doors. Only has a few sips of juice. Too restless to eat. The CNAs manage to sit her down once more and spend some time talking with her, then decide to take her to her room. The talking was effective for time until the lady wanted to get up again.

I tell the other nurse that I gave the lady a PRN dose of hydromorphone due to complaints of pain post fall.

So my question is, should I not have given the extra PRN dose if the lady already had a scheduled dose before her fall?

She was VERY restless before her fall and I honestly didn't think that her other scheduled dose was cutting it. I just thought that giving a PRN dose post fall would help to settle this resident?

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Specializes in Progressive Care, Sub-Acute, Hospice, Geriatrics.

What is the PRN order? A PRN order should have Q4h or Q6h, once daily, BID, etc

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Specializes in Med-Surg, Geriatrics, Wound Care.

It also depends a bit on the time. I would wait to give the pain medication a chance to kick in before adding to it (like 45 mins for tabs or something). But, if she is restless and pacing, she may need something more than pain medication. Her docs should find out some other things, sometimes antidepressants help with pain, anti anxiety meds for the pacing. Something else. But, assuming you can give the PRN , no reason not to.

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Specializes in Emergency Department.

Restlessness usually isn't a pain issue. It's more of a psych issue or it can be a reaction to a medication. It can be an expression of agitation.

As for following a PRN dose after a scheduled dose, give the scheduled dose sufficient time to take effect before you administer a PRN. The reason for the PRN is to allow you to administer a medication in addition to what's scheduled. You should also be judicious in administering PRNs and wait for those doses to become effective before you administer additional PRN meds for the same reason. For instance, I'll look at recent NSAID or acetaminophen-containing doses before administering a PRN for pain if the ordered meds contain an NSAID or acetaminophen. How much and when was "it" given previously?

If my patient is complaining of moderate to severe pain, I'm not likely to give a PRN pain med for "mild pain" before advancing to a "moderate to severe" pain med. If the order is for 1-2 doses as a PRN, I'll give a first dose, reassess for effectiveness and give 2nd dose if needed and consider it as following a single PRN order, of course documenting 2nd dose as such.

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Specializes in Progressive Care, Sub-Acute, Hospice, Geriatrics.
15 hours ago, CalicoKitty said:

It also depends a bit on the time. I would wait to give the pain medication a chance to kick in before adding to it (like 45 mins for tabs or something). But, if she is restless and pacing, she may need something more than pain medication. Her docs should find out some other things, sometimes antidepressants help with pain, anti anxiety meds for the pacing. Something else. But, assuming you can give the PRN , no reason not to.

This too. I would request for a psych consult for this patient

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I disagree with the restlessness. It can definately be a pain issue but does this resident have a hx of restlessness? How long has she been on that medication? The medication can cause restlessneses. There is nothing wrong with giving a PRN dose if its been adequate time for the routine one to work. I have given scheduled and Prn together for my hospice patients. The PRN is considered break thru. The routine isn't working. It may need to be increased or even have a time change. There are a few things to look into for your answer.

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Specializes in retired LTC.

The fact that this pt is wheeling another pt around the unit sends up a red flag to me. Like she's trying some diversionary activity? Like WHY???

I have other questions but if it's legit pain (without my suspicions & red flags), the other approaches mentioned prev are fine.

You used your judgment for timing and cumulative dosing. And communicating with others.

Just what you're supposed.

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A medication can only be given safely every so many hours. For example if someone gave a resident Tylenol for a fever then one hour later the resident complained of a headache you cannot safely administer that prn does because it is not within a safe time frame of 4 hours. When in doubt call the MD who ordered the medication for clarification.

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Specializes in LTC.
On 1/7/2020 at 7:30 PM, Dani_Mila said:

What is the PRN order? A PRN order should have Q4h or Q6h, once daily, BID, etc

I think the prn order was for hydromorphone 0.5 to 1mg q 2 h

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Specializes in LTC.
On 1/7/2020 at 8:24 PM, CalicoKitty said:

It also depends a bit on the time. I would wait to give the pain medication a chance to kick in before adding to it (like 45 mins for tabs or something). But, if she is restless and pacing, she may need something more than pain medication. Her docs should find out some other things, sometimes antidepressants help with pain, anti anxiety meds for the pacing. Something else. But, assuming you can give the PRN , no reason not to.

She's on anti anxiety meds but I can't remember what else she's on

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Specializes in LTC.
On 1/8/2020 at 11:40 AM, Dani_Mila said:

This too. I would request for a psych consult for this patient

She's in the special care unit, if that counts? I don't think she is being seen by the geri-psych doc. I can't remember is she is but I'm pretty sure she isn't

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Specializes in LTC.
On 3/4/2020 at 2:10 PM, amoLucia said:

The fact that this pt is wheeling another pt around the unit sends up a red flag to me. Like she's trying some diversionary activity? Like WHY???

I have other questions but if it's legit pain (without my suspicions & red flags), the other approaches mentioned prev are fine.

You used your judgment for timing and cumulative dosing. And communicating with others.

Just what you're supposed.

This is just what I heard from the cna's as I was not this lady's primary nurse. The unit is separated into 2 sides so the doors were closed when she fell and I didn't know what had happened until I opened them to the other side of the unit. The other nurse had her hands full that evening.

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