Friday, 4 April 2008

PRN medication

It's not uncommon for folks to be prescribed medication to take when it's needed, rather than regularly at the same time each day.

Such medicine is prescribed with the accepted abbreviation PRN (pro re nata), i.e. when required.

Doesn't this get you thinking?

If I prescribe a drug PRN for one of my in-patients, it's not there to be used regularly (or I'd write it up regularly, at specified times). It's then wholly up to the nurse to decide if or when it's given.

Usually if I want a nurse to decide if the patient has a particular problem, then formulate presentations to conclude that pharmacological treatment is indicated, then determine that a drug I've suggested is the right drug for that patient with that problem at that time, then ensure my patient gets that drug, the nurse is a Supplementary Prescriber. She's done courses on therapeutics, pharacokinetics and dynamics and (critically) has ongoing teaching and ongoing individual supervision with me and mandatory attendance at our ongoing training programme and attendance at our non-medical prescribing forum.

Thus, for an experienced band 7 community to think, yes, this psychotic patient who is believing that "they are out to get me" and is 'phoning police a dozen times a day and daren't leave the house really could use some additional medication (that a Consultant has written in a Clinical Management Plan with the nurse) to de-escalate their distress and help them cope, they have a rigorous training and ongoing development programme.

For a less experienced band 5 ward nurse to think, yes, this psychotic patient is agitated and I'll settle them down with some additional medication (that a Consultant has written on a drug card with a nurse at the MDT), they have no scrutiny or guidance or support or supervision or review of their practice.

This seems odd.

Is it just in my corner that life's like this?


marcella said...

for a patient in the community it may be their carer who probably hasn't had a minutes training in anything relevant at all who gets to make the decision, at least on a day to day basis

Elaine said...

Ummm, this is a difficult one. Perhaps in the absence of nursing staff with the appropriate training it might be better to write it up for routine administration.

But then the patient's condition probably fluctuates (or you wouldn't have prescribed it prm), and in that case giving the drug routinely could be harmful.

This a conundrum.

Dragonfly said...

I would be willing to bet that band 7s are scarce. What about band 6s?

Tainted_Halo said...

Use of PRN medication is a traditional nursing competence. It happens routinely in every in-patient setting and many places now include nurse prescribing for 'household remedies' such as Paracetamol or Ibuprofen.

I was disappointed when this happened as ringing the Consultant at 4am for pain relief for a toothache was one of my sadistic pleasures in work.

I am unsure as to how/why this Band7 nurse is required to undergo such rigorous extended skills training for a job s/he ought have been competent in anyhow. Conversely I do not agree that the band5 nurse will have no support, scrutiny or supervision. It is part (or should be) of the unit regime to monitor PRN use for all patients and to also evaluate any increased useage (times, places, people). Decision to give or not to give PRN has always been a nursing prerogative.

I understand the argument, and in fact agree that where I work wioth a mix og generically trained RNs and RMNs with specific mental health training, the tendency is for RNs to go with the medication first - and then both barrels at once. Usually 100mg CPZ and 10mg Diaz.

Adding more to the argument: I once worked in a residential community home as a manager. Nursing was not a requirement of the job but my skill set suited. The 4 learning disabilty residents were on medications that were supplied by Boots chemists in blister packs that carers 'assisted' residents to take. They were also allowed to 'assist' residents to take PRN that may have been supplied in a separate bottle. (kept in a drawer - as the regs are not so strict in a residential home as in hospital).

The odd thing was - I wasn't allowed to 'assist' with the medication (8yrs post-RMN) as I hadn't attended the Boots half day course. This included PRN medication that was being administered.. sorry, assisted by unlicensed workers.

I did do the course eventually tho... it went something like:
"Now the ones in the PINK blister pack of for morning because this is like sunrise. The YELLOW ones are like the mid day sun so give those at lunch. ORANGE is for the sunset and BLUE is for the dark night."
I was then a certified dispenser.

Oh wait.. the PRN ...
"Sometimes the resident might need some extra stuff if they're unsettled. Then they can have a P - R - N tablet from the little bottle."

Now what's really interesting is... It used to be the case under Drug Administration law that only nurses and pharmacists could dispense medication. The law made no provisions for doctors to actually administer medication - only prescribe - and I once had to advise a doctor (to his pleasure) that he was not permitted to give a patient medication (no idea how the occasion arose alas).

Shrink Wrapped said...

As a trainee psychologist I find PRN can be very tricky, especially in inpatient settings.

On the one hand, it can be very useful to the patient and essential to have PRN medication for when they are very distressed...

On the otherhand, I notice that when the staff are more stressed generally, the PRN comes out much more frequently. It can become about the staff's stress and tolerance levels. You get PRN when you cause a problem to other people, not necessarily when you are at your most distressed (although, mercifully, I think there is usually a correlation.)

I think it is a real challenge for staff, especially those who are in constant contact with the patient (e.g. those working inpatient units who have to be with patients every minute of their working day - I say that with respect, I know I would find that very exhausting and I wouldn't be able to be as present, thoughtful and productive in that setting as I am when I see 3 or 4 people in a day for one hour each).

It might be interesting to help people reflect on when they use PRN, what the effect is on them and when they are more and less likely to use it, and also to think about other more effective and long-term coping strategies.

More generally, I am tetchy about the use of PRNs like lorazepam for when people have acute anxiety attacks. It only reinforces the idea that anxiety is dangerous and they can't possibly cope with it. It becomes, in cognitive therapy terms, a safety behaviour.

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