Vol. 7 Issue 9
To Give or Not to Give
Challenging the use of prn medication for pain and behaviors in long-term care
Mary Jones is a psychiatric nurse consultant in a long-term care setting. She receives a consult stating "patient tried to elope, hit nurse with her cane, was assaultive and verbally abusive. Staff requests an inpatient admission to a psychiatric unit." They note increasing aggression and combativeness during the preceding month. These incidents are well documented in the nursing notes.
The patient, Mrs. D, an 80-year-old female with severe dementia, does not respond well to redirection due to her cognitive deficit and paranoid delusions. The consultant reviews the chart and notes Mrs. D is on a standing medication for psychosis and also has a prn available for agitation.
The consultant then makes a somewhat puzzling discovery: There were 14 episodes similar to the one above in a 4-week period, and the patient never received a prn. She asks various staff about this and receives many different thoughts on why it was not used, including they didn't think it would work since they tried with another patient and it didn't help him, and they didn't know it was available.
Literature is scarce regarding the use of prn medications in long-term care settings. One study points out, "according to the literature, this important aspect of nursing practice has been poorly explored and studies that have been undertaken demonstrate that nursing documentation of prn medication administration is often inadequate."1 Another study notes, "the inadequacy of existing research for the purposes of evidence-based prn medication practice in psychiatric settings" and notes the absence of relevant evidence-based clinical practice guidelines and policies, both nationally and internationally.2
What research or clinical practice is available to support or dispute reasons given by nurses, like those above, to not give prn medications? Let's explore these in the context of statements made below.
"We didn't think it would work" and "Another patient had been on it and it didn't help him."
A recent study published in the Australian and New Zealand Journal of Psychiatry on prn use would dispute this attitude. For agitation, 56 percent and 86 percent respectively viewed benzodiazepines and antipsychotics as effective, while 60 percent preferred an antipsychotic. For acute control of psychotic symptoms, the following percentage of nurses thought these drugs were effective: antipsychotics, 99 percent; benzodiazepines, 58 percent, and antipsychotics, 87 percent.3
Nurses must guard against their own faulty thinking patterns. Predicting something without evidence won't help, or comparing one patient's response to another's is a type of a distorted thinking pattern. Knowing medications, what they can and can't do, and frequent review of the medical literature are musts.4
"They may have given it but forgot to chart it."
A descriptive study examining the administration of prn psychotropic medication was conducted at a secure acute inpatient mental health unit attached to a regional hospital in Australia. The findings of inadequate or no documentation regarding prn administration is a major concern. In 41 percent of cases, the results of the prn administration were not documented in the nursing progress notes; in 38.6 percent of entries, it was impossible to identify who initiated the request for medication; in 9.1 percent of cases, no reason was given for the administration of prn medication.2
In a review of multiple healthcare facilities and nursing school protocols, all stated prn medications are to be charted with time, initials and response or nonresponse to the medication. Reasons for not charting the medication on the med sheet may range from simply forgetting to drug diversion. Failing to document prn medication is a medication error, which can be corrected with education, auditing of records and corrective action.
"I didn't know she had one."
A recent study publicized by ABC News showed nurse staffing levels contribute to 19 percent of medication errors.5 Multiple studies have documented the effect of the nursing shortage on patient care and medication errors. With nurses floating from other units or units being staffed by agency or floating nurses, there often is little time to familiarize oneself with every aspect of a patient's care. However, that does not negate the duty of nurses to care safely for the patient, and will not legally protect nurses. Failing to prevent an assault toward another resident by recognizing agitation and addressing it with a prn could be seen as negligence.
The solution is to practice within accepted nursing guidelines: Review the patient's medication sheet as a beginning guide to all medications available to use if needed.
"We can't under OBRA. It's chemical restraint."
Part of the Omnibus Budget Reconciliation Act (OBRA) of 1987 was developed to prevent the misuse of powerful psychotropic drugs in elderly populations.
The prevalence of side effects, use of meds for the "convenience of the staff," and the risk of injuries due to falls all are valid reasons for its implementation. The law is specifically designed to protect patients with dementia, and when properly followed the guidelines can enhance and improve the quality of life for nursing home residents.
Important points to know concerning the use of prns in long-term care regarding OBRA include:
1. OBRA restricts the use of antipsychotic drugs only in patients with dementia. None of the OBRA dosage restrictions or monitoring requirements apply in patients with psychotic disorders or mood disorders (e.g., mania).
2. Sedative-hypnotics can be used as prns. Staff must document the reason for use, any side effects and the outcome (was it effective?).These agents are mainly used to facilitate sleep. Many current practices may go against OBRA guidelines in this area, as drugs from other classes such as the antipsychotic Seroquel (quetiapine fumarate) are increasingly used for their sedative effect. Antipsychotics are not indicated for sleep.
3. Antianxiety drugs can be used as prns. Behavioral interventions such as counseling, reassurance and breathing techniques should be tried first. Again, document medication given, time, initials, for what behavior and outcome.
4. Antipsychotic drugs are the medications most monitored by OBRA. Chris Caronna, RPh, FASCP, a member of the American Society of Consultant Pharmacists, recommends they not be used prn unless used in conjunction with a scheduled dose of the same, or a similar, medication.6 Seroquel 50 mg po tid and 25 mg po bid prn agitation is an example. Using the same medication can give a better idea of what the standing antipsychotic order should be and the prn can be eliminated. For example, if the patient receives Seroquel 50 mg po tid and receives the two 25 mg prns daily also to control behavior, you can suggest the Seroquel order be changed to 100 mg bid and eliminate the need for a prn.6
AIMS testing (Abnormal Involuntary Movement Scale) must be done on all patients receiving antipsychotics.7
"He was too sedated and may have fallen."
Studies have shown psychotropic drugs can lead to falls, over-sedation and other unwanted consequences.8 The decision to use a prn medication often is based on which is the most desirable action, and finding a balance may be difficult.
Once all nonmedication and behavioral means have been exhausted, the nurse must evaluate which is worse: the risk of potential side effects versus threatening behavior toward others, or the patient being aggressive toward others or being sedated. Of course, if the patient is sedated, medication can be adjusted to find the right dose that controls behavior with the least sedation. And the lower the dose, the less chance side effects will occur.
A study by Liao and Weissman points out there is a critical shortage of RNs in nursing homes and pain medication often is managed by those with lesser assessment skills.9 Patients with dementia and mental illness may not ask for pain medication but exhibit their need by withdrawal or agitation. Patients with chronic medical illnesses require complete pain assessments on a regular basis by an RN to ensure pain is adequately addressed.
Staff must view pain as the fifth vital sign and use the entire gamut of tools available. Most important is the subjective experience of the patient. Faulty thinking patterns must be addressed. Labeling a patient as a "drug seeker" or believing the patient should not receive pain medication because he doesn't look like he's in pain is not based on good scientific nursing practice.
"We should be able to manage without prn medication."
Managing behavior without the use of medication always should be a priority. A study by Thapa, et al. showed the practice of writing prn orders may expose psychiatric inpatients to unnecessary psychotropic medications.10 The researchers of this study also were unable to find any study supporting the assumption that nurses would not be able to maintain a safe unit without the use of prn medications.
However, many nursing homes lack training programs in behavioral management, and many nursing assistants note there are not enough direct care staff to care for residents with time-consuming psychiatric disorders.11 I support this assertion based on my observations.
There are many reasons prn medications are not always given to patients when available. These can include issues such as the large amount of documentation required, staffing, lack of RNs in long-term settings and the attitudes of the nurse regarding how behaviors and pain should be managed. More research is needed in this diverse area of nursing practice. The best result for the patient will always be the defining goal in any prn protocol.
1. Curtis, J., & Capp, K. (2003). Administration of 'as needed' psychotropic medication: A retrospective study. International Journal of Mental Health Nursing, 12(3), 229-234.
2. Usher, K., et al. (2003). PRN psychotropic medications: The need for nursing research. Contemporary Nurse, 14(3), 248-257.
3. Geffen, J., et al. (2002). Pro re nata medication for psychoses: The knowledge and beliefs of doctors and nurses. Australian and New Zealand Journal of Psychiatry, 36(5), 642-648.
4. LaFerney, M. (2001). Boosting morale: Changing negative thought patterns can improve team spirit. Advance for Nurses, 1(10), 11.
5. Pozniak, A. (2004, Aug. 7). Nurses wanted: Data highlights problem of nursing shortage. ABC News. Retrieved Oct. 7, 2004 from the World Wide Web: http://www.abcnews.go.com/sections/living/DailyNews/nursingshortage020807.html
6. Caronna, C. Consultant/Forum: Monitoring tips for psychotropic drug classes. The Consultant Pharmacist. Retrieved Web Oct. 7, 2004 from the World Wide: http://www.ascp.com/public/pubs/tcp/1997/feb/consultforum.html
7. Gardos, G. (2003). Tardive dyskinesia: How to prevent and treat a lingering nemesis. Current Psychiatry Online, 2(10). Retrieved Oct. 7, 2004 from the World Wide Web: http://www.currentpsychiatry.com/article_pages.asp?AID=684&UID=8119
8. Kasckow, J.W., et al. (2004). Using antipsychotics in patients with dementia. Current Psychiatry Online, 3(2). Retrieved Oct. 7, 2004 from the World Wide Web: http://www.currentpsychiatry.com/article_pages.asp?AID=720&UID=8119
9. Liao, S., & Weissman, D. (2003, May). Fast fact and concept #89: Pain management in nursing homes: Analgesic prescribing tips. Retrieved Oct. 7, 2004 from the World Wide Web: http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff89.html
10. Thapa, P., et al. (2003). PRN orders and exposure of psychiatric inpatients to unnecessary psychotropic medications. Psychiatry Services, 54, 1282-1286. Retrieved Oct. 7, 2004, from the World Wide Web: http://www.ps.psychiatryonline.org/cgi/content/abstract/54/9/1282
11. U.S. Department of Health and Human Services Office of the Inspector General. (2001, November). Psychotropic drug use in nursing homes: Supplemental information, 10 case studies. Retrieved Oct. 9, 2004 from the World Wide Web: http://www.oig.hhs.gov/oei/reports/oei-02-00-00491.pdf
Michael C. LaFerney is employed by Arbour SeniorCare, Rockland, MA.