any suggestions for handling PRN

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hi, we are having a very difficult managing our time pulling scheduled meds due to constant interruptions from the "needy" PRN seekers. And, then the true patients in need of meds get lost in this mix. We are trying to find a way to somehow contain this, and was wondering how you all handle this, or have any suggestions. We have tried to have in our first group to have pts that think they need PRns between that group and dinner see the charge nurse(ME), and I make a list and submit to LPN, thus a t least one long interruption. And also making a daily accountability check list for meeting daily goals, which include weaning oneself from the every four hour PRN request. Any other ideas??

Specializes in psych, addictions, hospice, education.

:yeahthat"

what she said...

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Specializes in behavioral health.

I just get frustrated when a patient approaches me and says "I want my PRN now" "i need ativan" "I am having a family meeting soon so i need ativan" "I just had a rough phone call so I need ativan". I try and talk to the patient and I get "I don't want to talk about it, just give me an ativan". It has been especially bad the last couple of days so I'm feeling irritable; it isn't always like this. I had that ativan, addiction, coping mechanisms, replacing addictions with 6 patients the last two days.

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Specializes in behavioral health.

When I assess that the patient really does not need an ativan, they often get themselves so angry that they do :trout: At my facility, we technically do have to give any PRN requested unless they are truly sedated.

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Specializes in telemetry, med-surg, home health, psych.
When I assess that the patient really does not need an ativan, they often get themselves so angry that they do :trout: At my facility, we technically do have to give any PRN requested unless they are truly sedated.

At my facility ativan PRN is usually given for factors > 100.....so when one has BP WNL and HR of 80, I really cannot give it no matter how hard they try.....now if they are close.....> 95 I usually go ahead and give it to make both my life and pts. easier.... ;)

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Specializes in behavioral health.

When I'm at work, my HR is easily 110 =P Is there also a "probability of chair thrown at door if ativan denied" factor? :chuckle We had a patient yesterday who threatened restraints if he didn't get his PRNs...:confused: That is dedication.

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Specializes in mental health; hangover remedies.
I have to take exception to all of this. I hate the words "med-seeking,"

Stop attention seeking. ;)

Sorry... you know I can't resist. Of course I agree with you - the dismissive attitude of psychiatry that almost routinely dismisses and invalidates peoples' experiences annoys me, to put it mildly.

But there are two sides to this - and there is a non-dismissive solution.

I just get frustrated when a patient approaches me and says "I want my PRN now" "i need ativan" "I am having a family meeting soon so i need ativan" "I just had a rough phone call so I need ativan". I try and talk to the patient and I get "I don't want to talk about it, just give me an ativan". It has been especially bad the last couple of days so I'm feeling irritable; it isn't always like this. I had that ativan, addiction, coping mechanisms, replacing addictions with 6 patients the last two days.

I know exactly the ones you mean and I've struggled with the same issues. My end result of considered options:

1. The doc prescribed it that much - so they accept it that much. If the pt runs out for the day, that's that.

2. The pt is there for addictive behaviours so it's likely to happen. Never be surprised or shocked that it does.

3. The meds serve a clinical purpose - even if they don't look agitated - document this; it indicates willingness to change (or not) and informs future team decisions. Part of addiciton is not just the physical need - but the psychological dependence. It's not about 'med seeking' for the "hit" but because that's been their coping mechanism for some time.

4. Review the PRN use at a time when the pt isn't clambering for it. Get some quiet time to go thru the PRN use with the patient and involve them in the debate. Point out your observations about increased use or not looking agitated so why do you need it? Let them know their answers won't change anything but will help you to help them - if they want to (most will tell you whatevere they think you want to hear tho - but at least you've done your part)

5. Work with them - "I am having a family meeting soon so i need ativan" is not a completely invalid reason. But incorporate it into the care plan - "Anxiety over meeting with family".

At the end - if the pt is taking too much of an addictive drug then it's down to the medical team to address that with the MDT and with the pt; not for the nurses alone.

So I resolved to simply give the PRN (following the normal Q+A with the pt) and record it and discuss at the next clinical meeting. If the doc had no problem with it - I simply carried on whether I agreed with it or not.

IMO PRN addictive drugs on an addictions unit should be available no more than b.d.

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Specializes in telemetry, med-surg, home health, psych.
When I'm at work, my HR is easily 110 =P Is there also a "probability of chair thrown at door if ativan denied" factor? :chuckle We had a patient yesterday who threatened restraints if he didn't get his PRNs...:confused: That is dedication.

It is different on the addiction unit,,,,if one does any "threatening" he has a great chance of being transferred to the psych unit !!!!! :bugeyes: Yes, I have been in those frightening situations on the psych unit, we are taught not to give in to their requests for meds, but I take each case individually.....If I can find a valid reason to calm one down, go for it....but some of our docs really do not want anything given....that is why we have "codes" :angryfire :down:

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Specializes in behavioral health.

The variation in facilities is so interesting! My unit mixes psych and addiction. Showing the PRN log is a good idea. Sometimes I really can get through to the patient. Sometimes they are brick walls. I rarely ever stop the conversation no matter how futile-appearing, as to me that would equal giving up on someone. Like you said, this works best when the whole team is involved such as the doctor, nurses, therapists, techs, and the patients (of course!). It is really difficult to get an audience with the doctors. I have painfully discovered that my opinion is not important or valid and I cannot question any order. Part of my problem is that I am 25, but can pass for under 20 while everyone else there is over 40. Thus, if I think I know anything, I am arrogant and 'dangerous'. I talked to our therapist yesterday about the PRN problem as last week was the worst I have seen in months. She took that to heart (I felt so good about this) and did a group about PRNs and coping.

I have seen this working. We once had a patient in which the whole team came together and heavily encouraged a patient to not rely on PRNs on top of her opiate detox and continued to decrease the doses. It was rough. There was a lot of crying and pleading, but she did it. and she was able to later analyze the addictive behavior. She was the one who eventually made the decision to DC the ativan and did so full of pride. Before DC, she gave us the opiates she had come in with (rx bottles) and called her PCP and told him that she was abusing them and not to give her any more of them. She was here for a full week during Christmas time and our insanely low census and everyone had tons of time to help her. It was truly glorious. Even one of the docs said that we did really good work with her. I think all this collaberation (and of course the strength and perseverence of the patient) is the difference between her making it or not.

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Specializes in mental health; hangover remedies.
It is really difficult to get an audience with the doctors. I have painfully discovered that my opinion is not important or valid and I cannot question any order.

Then I'd exert my energies into something else. No point flogging a dead horse.

Your point is valid - you are absolutely right - now forget about it and do something that'll get a positive outcome.

[Harsh - but realistic. I've had to do this for myself so many times over the years. Choose your battles carefully.]

Kudos to the therapist for taking the impetus with the PRN use group. (S/He may be a useful ally and voice your concerns to the group - but I'd let him/her choose their own battles)

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Specializes in Psychiatric Nursing.

On the units I have been assigned to we have quite a few patients receiving meds all at once. To decrease a bit of the commotion our wonderful PNAs are kind enough to stand outside the window and help the patients to line up to receive meds. Calling up anyone who forgets to come and helps to maintain a safe enviorment for whoever is up at the window at that moment. If someone wants a PRN we allow them to get in line just as if they were there for a scheduled med and as soon as they make it to the med window we assess and adminster. The line can get a little long at times but our PNAs are wonderful about interacting with the patients (which allows them a little 1 on 1 time to chart on later) and cuts down on the hecticness that can sometimes result during the med pass. Good Luck hope you find a system that fits your unit

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