To medicate or not to medicate

odaat · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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 · Jul 26, 2015

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.