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To medicate or not to medicate

Posted

So I generally work 3p-11p. I always scope out the PRN's to see if my patients like to take sleeping meds or anxiety before bed and always ask if they want them. I otherwise use my best judgement if I feel they need or don't need them. Basically I don't like to just give everything to get them to bed. It never fails though, as I am giving report to the next shift, I get chewed out for not giving all that is possible! I don't understand why you would just give everything possible...even if not needed. I like to always have something on hand if necessary and leave something available for the next nurse. I get told I should have already gave it or "wouldn't you rather them have a good-nights sleep?". I can recognize when someone needs it, I just don't like to over medicate. Am I wrong in this thinking?

odaat

Specializes in ER, Med/Surg, Telemetry, Dialysis. Has 4 years experience.

It sounds like they may just be trying to medicate their way into a smoother shift. PRNs are as needed for a reason and it sounds like you are being entirely appropriate and correct in your administration of them.

Dogen

Specializes in Behavioral Health. Has 1 years experience.

The answer is in the order: if a med is ordered PRN, and you don't need it, then don't give it. If the prescriber wanted them to get all of them every night they'd order it scheduled.

On top of that, think twice about the use of benzos to induce sleep. We do it all the time - I do it all the time - but research shows that benzos alter sleep architecture (reduces delta or slow wave sleep), which is why they increase the risk of ICU delirium. Altered sleep is better than no sleep, so if your patient can't sleep because they have worries, racing thoughts, anxiety, or some other indication for benzos, then by all means give it. But if they can make it through the night without meds, then it's generally better for them to not have them. A lot of sleep aids are habit forming (benzos and sedative-hypnotics), and so using them chronically can make falling asleep harder.

Always use your best judgment, and hang whatever the next nurse says. If they're giving PRNs just because they can that sounds like no judgment at all.

loriangel14, RN

Specializes in Acute Care, Rehab, Palliative.

But if you are working nights and you have a patient that is awake all night because they didn't get their pain meds and/or sedation then yeah, I would be chewing out that nurse too. The meds are ordered for a reason, why wouldn't you give it? mY patients will tell you they don't need anything and then you end up spending all ight trying to get them to settle. My patients aren't able to make that call. They get whatever is ordered. ( I am amazed at the amount of meds it takes to settle some people. I would sleep for a week on what they take).

macawake, MSN

Has 13 years experience.

I can recognize when someone needs it, I just don't like to over medicate. Am I wrong in this thinking?

Well, I guess that the answer to that question depends on how adept you are at judging if someone needs their meds and if you base your decisions on the correct things instead of your own biases. I don't know you so I'm not saying that you are biased or that you let your own opinions of the meds affect how you administer them, the only reason I mention it is that I've met several nurses who let their own personal ideas about medications like anxiolytics, hypnotics and (opioid) analgesics affect the clinical decisions they make.

I like to always have something on hand if necessary and leave something available for the next nurse.

As long as you don't refrain from giving all meds just so that you won't use up all the available PRN's allowed at that time, despite the patient needing them. If that is the case then in my opinion the patient's medical provider needs to be contacted so that the prescription can be changed and the problem solved.

I always scope out the PRN's to see if my patients like to take sleeping meds or anxiety before bed and always ask if they want them. I otherwise use my best judgement if I feel they need or don't need them.

If you ask your patients if they want their PRN's and they decline I don't see a problem. I assume that you give the patient the meds if they ask for them and their vital signs permit administration?

I get chewed out for not giving all that is possible! I don't understand why you would just give everything possible...even if not needed. I get told I should have already gave it or "wouldn't you rather them have a good-nights sleep?"

How do your patients normally sleep after you've worked the evening shift? It is possible like oddat suggests that night shift are looking for "an easy shift" but it's also possible that you undermedicate your patients.

The trauma of surgery or stress of illness takes sleep to facilitate recovery and healing. It's vital that patients get the rest that they need. While medication might not always be the best long-term solution for sleep problems (ay least not as mono-therapy), I think that they definitely have a place in the stressful acute care setting.

Dogen

Specializes in Behavioral Health. Has 1 years experience.

But if you are working nights and you have a patient that is awake all night because they didn't get their pain meds and/or sedation then yeah, I would be chewing out that nurse too. The meds are ordered for a reason, why wouldn't you give it? mY patients will tell you they don't need anything and then you end up spending all ight trying to get them to settle. My patients aren't able to make that call. They get whatever is ordered. ( I am amazed at the amount of meds it takes to settle some people. I would sleep for a week on what they take).

If the prescriber wanted them to have all the meds ordered, then they wouldn't be PRN, right?

Now, all of this depends on the context. If it's my third night and I know X doesn't fall asleep without PRNs, then sure, you make sure they get sleep. But if it's my first night with a patient then I'm looking for the need before I give an "as needed" med.

Dogen

Specializes in Behavioral Health. Has 1 years experience.

How do your patients normally sleep after you've worked the evening shift? It is possible like oddat suggests that night shift are looking for "an easy shift" but it's also possible that you undermedicate your patients.

This seems like the $20,000 question. :)

~PedsRN~, BSN, RN

Specializes in Acute Care Pediatrics. Has 4 years experience.

The way I look at it is this - if the patient needs them at 2200 to sleep every night, then it should be a scheduled medication and not a PRN. I am not going to forcefully medicate a patient. Just as I would not force them to take a pain medication. It is their right of refusal, ESPECIALLY with a PRN medication. If you ask the patient if they need them, the patient knows they are available to them - then you have done your job. You are not withholding medication, you are simply not giving a med that is on the mar PRN.

If the nurses behind you have issue with this, if the patient is climbing the walls and refusing a PRN medication for sleep, then they need to consult with the physician and this med needs to become a scheduled night time med.

~PedsRN~, BSN, RN

Specializes in Acute Care Pediatrics. Has 4 years experience.

And you leave at 11. It's not like you are leaving at 3am. Can they not give a needed dose of PRN at 11 if the patient is having issues sleeping? I'm confused. LOL!

loriangel14, RN

Specializes in Acute Care, Rehab, Palliative.

The way I look at it is this - if the patient needs them at 2200 to sleep every night, then it should be a scheduled medication and not a PRN. I am not going to forcefully medicate a patient. Just as I would not force them to take a pain medication. It is their right of refusal, ESPECIALLY with a PRN medication. If you ask the patient if they need them, the patient knows they are available to them - then you have done your job. You are not withholding medication, you are simply not giving a med that is on the mar PRN.

If the nurses behind you have issue with this, if the patient is climbing the walls and refusing a PRN medication for sleep, then they need to consult with the physician and this med needs to become a scheduled night time med.

I would not let them refuse if it means they are going to awake and /or yelling/ climbing out of bed all night.

loriangel14, RN

Specializes in Acute Care, Rehab, Palliative.

I usually know what my patient usually takes and give it. I am not going to wait until 3 am to think " oh maybe I should have given them something."

~PedsRN~, BSN, RN

Specializes in Acute Care Pediatrics. Has 4 years experience.

I would not let them refuse if it means they are going to awake and /or yelling/ climbing out of bed all night.

So are you going to pin them down and force them to take the medication?

We can explain why they need it, we can offer it, we can educate -

We can not forcefully medicate a patient.

Dogen

Specializes in Behavioral Health. Has 1 years experience.

I usually know what my patient usually takes and give it. I am not going to wait until 3 am to think " oh maybe I should have given them something."

It seems like there's probably a middle ground between "throw the kitchen sink at them," and "wait until they've missed half the night to intervene."

macawake, MSN

Has 13 years experience.

I would not let them refuse if it means they are going to awake and /or yelling/ climbing out of bed all night.

How about the Afib patient who refuses to take their anticoagulant or the patient with a bp of 200/110 who refuses their antihypertensives? Aren't they allowed to refuse either?

Patients have a right to make stupid decisions for themselves. Legally or ethically, we don't have a right to force-feed our patients their medications. Not even when we know that the patient would benefit from said medication.

loriangel14, RN

Specializes in Acute Care, Rehab, Palliative.

How do you educate a demented patient that is eating the contents of their brief that they need to take something ?

Dogen

Specializes in Behavioral Health. Has 1 years experience.

How do you educate a demented patient that is eating the contents of their brief that they need to take something ?

It's possible to construct scenarios in which it's okay to give a patient medications without educating or asking them, but it seems like the OP was more general, and not specifically about patients who lack the capacity to make decisions.

How did this devolve into forcing demented patients to take benzos?

Take a step back and cool down, please, and come on back to Rational Land.

I think two things about the scenario the OP posted:

1) You are giving too much information in report. Why does day shift need to know you didn't give your patient a PRN? They don't. Tell them that it is available Q whatever hours for whatever indication and leave it at that. I agree with Dogen, if the patient needs it daily, day shift can address it with the provider and get it scheduled.

2) Make sure the patient is asleep by midnight or so. If they aren't, then they need it. Check to make sure they aren't/weren't a noc worker, though, that changes things. These patients sleep better in the afternoon.

If your patients are asleep by midnight-ish, you have done your job and you can tell day shift to worry about what happens during their shift and to leave you alone.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

How do you educate a demented patient that is eating the contents of their brief that they need to take something ?

Maybe it's different in Canada, but in the US there is a legal process for medicating someone against their refusal, and just having dementia doesn't automatically allow us to medicate someone despite their refusal.