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Discussion

weird PRN orders

Hey everyone,

So we have patients that are ordered to be on the WAS (withdrawal scale for alcohol or benzo withdrawal). It usually goes that they will get their vitals every 2-4 hours depending on their score, and be medicated with ordered Ativan 1-2 mg PO q 2 or q 4 hours based on their scores. Since the WAS is a little subjective (patients who constantly say they are super anxious can continue to score high enough to get a PRN even if their VS are stabilized) after a few days, our docs like to start cutting them down on the amount/frequency of Ativan they can get per day. I've even seen it go down to an order for Ativan 1 mg PO q 12 hours PRN withdrawal after the patient had been in the facility for about a week. My question is, if the patient only has an order for PRN Ativan 1 mg q 12 for withdrawal, isn't it more of a tapering process then an actual withdrawal assessment process? If someone is only requiring up to 2 mg of Ativan in a 24 hour period a week after they were admitted, to me, they are no longerbeing monitored on the WAS (since the policy states VS q 2-4 hours with meds q 2-4 hours as needed) maybe getting the med more for anxiety at that point. But the docs never change the PRN indication to anxiety, they leave it as withdrawal. I guess my point is, it just seems silly to leave a PRN Ativan 1 mg q 12 hr order for the indication of "withdrawal".....does anyone see/agree with my point? How does your facility handle this?

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    I don't know why they don't just dc the etoh wd order. My nurses wouldn't allow me to get away with that. :) I like to document the actual withdrawal process clearly for my notes also so I wouldn't leave it as if the patient was continuing to get meds for wd. Then again my patients with substance abuse rarely get benzodiazepines from me unless they are being treated for withdrawal from alcohol or benzodiazepines so the Ativan would be long gone.

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    Our protocols have a specific timeframe, so after a week it ends, the Ativan is slowly tapered down from 3 times a day initially then to 2 days then on the final day it's only once then they are done. We usually do clonidine, vistaril, benadryl etc for anxiety PRN's.

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    The benzos are being used to help prevent withdrawal complication (i.e., delirium tremens, seizures). These are most likely to occur in the 72-96 hours after the patient's BAL hits zero. After that period, they aren't needed and should be d/c, and any remaining withdrawl symptoms managed by non-benzo medications.

    Benzos should not be given as anxiety PRNs for the detoxing patient. There's a risk of cross-addiction since benzos and ETOH are both CNS depressants and produce that lovely numb/mellow feeling that these addicts seek. And the last thing you want to do is replace one addiction (ETOH) with a new one (benzo). A non-benzo should be used for managing anxiety: Vistaril is one of the usual standbys, but there's also buspirone, Seroquel, risperidone, gabapentin (the last three in low-doses).

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    The benzos are being used to help prevent withdrawal complication (i.e., delirium tremens, seizures). These are most likely to occur in the 72-96 hours after the patient's BAL hits zero. After that period, they aren't needed and should be d/c, and any remaining withdrawl symptoms managed by non-benzo medications.

    Benzos should not be given as anxiety PRNs for the detoxing patient. There's a risk of cross-addiction since benzos and ETOH are both CNS depressants and produce that lovely numb/mellow feeling that these addicts seek. And the last thing you want to do is replace one addiction (ETOH) with a new one (benzo). A non-benzo should be used for managing anxiety: Vistaril is one of the usual standbys, but there's also buspirone, Seroquel, risperidone, gabapentin (the last three in low-doses).

    So, using psychoactive medications (Quetiapine and Risperidone) off-label are used to manage anxiety, or are Quetiapine and Risperidone labelled in the USA to manage anxiety? There are other non-psychoactive ways to support a patient to manage their anxiety! I thought short-term use of benzo's is safe and does not increase addiction? What's the % risk of cross-addiction and what does the research say? The risk of the patient experiencing metabolic disturbance and iatrogenic harm is more likely than cross-addiction! Also, if off-label psychoactive drugs are used to manage anxiety, then surely this is not evidenced-based practice?

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