any suggestions for handling PRN

wellseasoned · Feb 15, 2009

:prdnrs:Where I work we try to have both nurses at the desk while meds are being pulled, or at least another staff. This way attention, assessment and education can be provided without potentially error producing distraction. A reasonable time frame is given to pt on when to expect the medication, IF it's actually indicated. Many times it isn't, and pt's use other means (positive behaviors) If the issue is pain that is not moderate to severe, most are willing to wait. We also try to have activities at difficult times such as shift change /before and after visiting. I hope this was helpful!

nana23 · Feb 15, 2009

Thank you your reply . We are finding PRNs are at times becoming really scheduled meds by some pts. We are moving towards making patients more accountable for working their program, not relying on meds at first sign of anxiety or craving. It is just so time consuming ,and pts just seem like they are entitled to PRNs just because they know they are available. THinking of using the pain scale, and having them have to work a work sheet after receving PRN, as to what other coping skills they can use, as med issues and dependency are main reason so many are there! ughhhhhh so frustrating. The patients in pain and really withdrawing get lost in the shuffle. Maybe if we attach work to the PRNs, it will deter some. Thoughts??

wellseasoned · Feb 16, 2009

I don't hesitate to let a pt's psychiatrist know that prn's are being sought around the clock. Some doc's are more concerned about that issue than others, but many times adjustments are made. Also, I'm much more straight-forward with the medseekers than I used to be, and at least part of the time, it pays off-for them.They may be able to see it is their interests we're looking out for, not our own. If nothing else, it may plant a seed. Also, we will not hesitate to treat our pts as in a "triage" setting. , again, having those that are waiting treated with respect and compassion, knowing they were heard and have suggestions for self care. I use run-ins with med seeking as an opportunity for education. Yes , it IS frustrating. Thank goodness your pts have someone who is thinking how best to help them, not someone who just hands out pills.

Mr Ian · Feb 16, 2009

Depends a lot on which sort of PRN you're talking about.

The simplest way is to get the prescribing pdoc to take responsibility as they should.

If a patient is requesting max/high frequency PRN - the pdoc needs to review them to make a decision.

They can either increase regular dose or decide the pt is over-seeking PRN and reduce available doses.

I'd flag anyone who had presented for or required PRN more than 4 times in a week (usually on the 4th presentation - unless there was a particular reason; eg crisis or evidence of EPSEs). I would also have a 1:1 with the patient to discuss it and try to discover any pattern or reason for it before flagging it. Document the conversation for the pdoc review.

Or you can get your staff to use nursing assessment skills to verify the need for PRN rather than simply rely on the patients' requests. Dishing out PRN on request is nice and all - but it doesn't encourage the pt to attempt other ways.

However, there are those who will require increased PRN use for genuine reason and sometimes it's difficult to discern who is and who isn't genuinely 'suffering' as oppposed to 'bored' or simply seeking a hit.

When pts are presenting at meds rounds for PRN - I always check and see what else they are on as often there is a similar drug already ordered - eg Seeking Benzos for 'agitation' but getting a Olanzapine - this may help settle the pt and I tell them to come back in half hour if the problem persists; then get someone to work with them in that period to discover and deal with the issues.

If a pt presents just before meds round for PRN I'll often ask them to wait. Or I will bring forward the 'best' drug from the next round if there's one due if they say they "cant' wait til then".

There's one final group and those are the ones who genuinely need PRN relief. Judging this comes down to knowing your patients well enough to work out who is actively acutely ill.

inthesky · Feb 17, 2009

four times a week? I work 8 hour shifts and see about half my patients 3 x a shift for PRNs! The doctors and patients get angry if we don't give available PRNs. I do my best to find other alternatives, but in the end, I'm just a med nurse =(. I walked into the day room today for a scheduled med and I got jumped by 3 patients for PRN ativan >_<. they were sitting around relaxed and talking before i arrived. src="%7B___base_url___%7D/uploads/emoticons/banghead.png.efe82398e89c00d042ae4e4f63b11321.png" alt=":banghead:">

wellseasoned · Feb 18, 2009

:redlight:Wow, that's a tough and exhausting culture to work in. Can you involve your nurse manager? The unit I formerly worked on is similar, and the above suggestions effecitve at least to a degree. Like you said,some doctors don't like dealing with angry pts and take the path of least resistance,or won't listen ,which is not helpful, obviously. The pts I work with now are primarily psychotic and involuntary, with alot less med seeking, not agreeing to take meds is the issue. I hope you make progress with this issue-whatever happens, keep us posted!:caduceus:

Whispera, MSN, RN · Feb 19, 2009

I have to take exception to all of this. I hate the words "med-seeking," because they imply a negative personality trait. Please consider that if a person is trying to get medications, they have a need for them. Maybe we can help them without medication--in fact that's the choice, but maybe they need to just get their prns! Also, if a patient is sitting and talking and when you come into the room he is clamoring for medication, that doesn't mean he didn't need the medication before. It could be that he was distracted some and then he remembered on seeing you, or it could be he's needed the meds for such a long time in his life that he doesn't "show" the need in an objective way. I'd like to say that anxiety is what the patient says it is, just as we say pain is what the patient says it is. Surely if someone has a choice he wouldn't want to be taking medications--he'd rather be well!

aloevera · Feb 19, 2009

I have to take exception to all of this. I hate the words "med-seeking," because they imply a negative personality trait. Please consider that if a person is trying to get medications, they have a need for them. Maybe we can help them without medication--in fact that's the choice, but maybe they need to just get their prns! Also, if a patient is sitting and talking and when you come into the room he is clamoring for medication, that doesn't mean he didn't need the medication before. It could be that he was distracted some and then he remembered on seeing you, or it could be he's needed the meds for such a long time in his life that he doesn't "show" the need in an objective way. I'd like to say that anxiety is what the patient says it is, just as we say pain is what the patient says it is. Surely if someone has a choice he wouldn't want to be taking medications--he'd rather be well!

Believe me, when you work on an addiction unit, 1/2 of the pts. ARE med seeking...I have seen them jump up and down to get their pulse up so they can have an ativan...

They are so used to taking meds that even tho they are detoxing, they still have the habit...

Yes, many do need their PRN's .... that is why it is so crucial to assess them accurately to see if they really do need a PRN....H/A's, sure give them their PRN's....no doubt....nausea? sure, give them their vistaril...

but something like ativan, klonipin, we must assess and see if they trully need it....

Whispera, MSN, RN · Feb 19, 2009

I worked an addictions unit for over a decade....and of COURSE I assess to see if they really need it...

wellseasoned · Feb 19, 2009

:prdnrs: I for one have not always been correct in my original assumption re: pts described as medseeking prior to actual assessment -it IS an emotionally loaded term- that's why I should never assume, but assess for myself. The term medseeking is actually on our required q24h nursing assessments. I think we agree using our skills as nurses, we should have some idea if there is an abuse issue, or lack of education issue, or whatever-and proceed in the manner that's best for the pt using our best judgement and skills . I don't withhold prns unless it's medically neccessary, such as someone obviously sedated insisting they get it (happens )and then I get a doc to back me up. People with addiction don't feel they have a choice, or the word choice may not even be in their radar. it's natural to medicate and unnatural not to. We can begin the process for positive change, not just for them, but for all our pts. when we help them realize they do have choices.:cookies:

aloevera · Feb 19, 2009

I never doubted that you didn't assess the pts...I was replying to your dislike of the term "med seekers".....I don't like it either, but they are there. Just because they ask for something, doesn't always mean that they should get it.