Loading ...
- why won’t professionals answer patients’ questions
- Ask the mentalists – Boundaries
- Ask the Mentalists – Artificial Language Barriers
- Ask the Mentalists – Charting
- Ask the Mentalists – PRN Lorazepam
- Question for MN
- Newbie Questions
- What happens to well-meaning professionals?
- What if your patients are smart?
- A question regarding suicide
Just wondering if other RMN’S out there ever feel pressured by in-patient service users..fellow nurses and medics to dish out prn* Lorazepam…(on a daily basis.) How long does it take to become addicted to Lorazepam? And surely there is the possibility that by not administering PRN lorazepam (indicated for agitation) you may be unwittingly sending the service user into a benzo withdrawal. Any views appreciated.
*Editorial note: PRN = medic-speak for “as and when required”
Pro re nata is banned as it is Latin (banned in England anyway by some councils). PRN daily is no longer PRN, seriously.
The Cockroach Catcher
Oh! Didn’t you know; it was in The Telegraph.
Good read!
The Cockroach Catcher
Councils might be banning it, but personally I haven’t seen any sign of the NHS following suit.
That said, I can think of a good case for abandoning the use of Latin in healthcare in favour of plain English. It would certainly make patient records more understandable to the patients themselves.
Mental Nurse to explode into pro- and anti-Latin factions in 10…9….8…
Yes, and it particularly frustrating if you are dealing with someone who has a history of addiction or who is increasingly requesting it, especially as when it is written up as PRN they begin to expect to receive it when requested – explaining that there is a limit to how much they can have, and that other forms of relaxation should be used as an initial approach can be met with various responses, my [least] favourite being “but the Doctor said…”.
Quick query – what is the differences/advantages of Lorazepam over Diazepam? Having used Diazepam 2mg for anxiety in the past, I find myself studying service uses who are on these medications and trying to differentiate them. Also, is Lorazepam less addictive? I’ve been getting mixed responses!
GG
x
All the benzo’s are essentially the same. Lorazepam is a slightly stronger version – ie can potentiate more and can last longer in the system (half life stuff). Loraz has half life of 12 hours or so – Diazepam is about 4 hours I think.
Addiction in a physical sense can happen over weeks rather than months or years – but depends on amount taken. The body generates more tolerance the more it has – thus leading to increased need and then needing it to stave off the withdrawals
As for the PRN stuff – I suggest alternative interventions in a very non-pushy way…
“Let me know what’s wrong and I can see if there’s other things we can do to help” … if the response is favourable then I make suggestions.
Sometimes the pt ‘thinks’ they have to jump the hoops and respond in a positive way or I’m going to say “No” for not trying my ways – that’s not the case but there’s no way to avoid it – institutionalisational behaviour I’m afraid.
If they’re reluctant to try other things there can be a number of reasons – usually they know themselves that’s what they want – else why ask?
So I give it.
PRN is recorded and a weekly review will tell you if the pt is needing lots of it.
I’ve given up arguing – I went thru that stage of course… “You don’t look like you need it to me….” – which regularly turned into the pt needing it – not only was the challenge most often futile – I realised it to be unecessarily controlling someone. Controls and monitors ( checks and balances) are there after the event and provide for multi-person review – ward rounds; nursing handovers; etc to review PRN use – so it doesn’t have to be a battle there and then.
So if the doc prescribed it – the pt requests it – then I generally give it.
I’ve heard of some places where they have to meet certain physical thresh holds to get PRN benzo – eg heart rate <100 or BP (systolic) <140 or something etc.
Lorazepam has a shorter half life than diazepam. Dependence and withdrawal effects can occur after about 7 days regular use.
Nah you made me check – you’re very right on the half life stuff.
My benzo knowledge is patently shit.
No one ever ask me for advice or opinion on medication ever again.
Or better still – I’ll just not offer any.
Good simple tabular reference here:
http://www.benzo.org.uk/bzequiv.htm
I’ve been told by a patient that PRN stands for Pleasure Right Now.
But frankly, why worry about it if a druggie wants to get medication that they’re prescribed. They’ll get hold of some kind of drug/substance anyway as soon as they’re discharged.
You could keep track of how much the patient is asking for and point it out to the prescribing doctor if it seems excessive. If the doctor wants to overprescribe and if the patient wants to over imbibe it’s not your problem. You’re not responsible for other people’s stupidity.
The pressure is entirely the opposite. Don`t administer benzos. That`s fair enough in a way but it`s entirely lacking in context. An outsider would be forgiven for thinking anti – psychotics, mood stabilisers and anti – depressants were wholly benign and entirely wholesome. The demonisation of benzos seems only to be happening in countries where the legal profession and compensation culture are out of control i.e here and the USA. In the remainder of the first world ( obviously, I`m not including Australia in this ) benzos are used as they ever were to good effect. We have to restore some balance. Continuing dismissal of benzos as a legitimate prescribing option will lead to the over prescribing of cheap old rubbish when the credit crunch impacts on drug budgets.
The point is to use them appropriately and they’re an excellent medication if used so. It’s complicated by the fact that people find them pleasant to use. They induce dependence and have unpleasant and dangerous withdrawal effects. It can be tempting for some people to use benzos to take away the symptoms of a problem without then going on to address the underlying problem in a constructive and lasting way. I agree that they can provide excellent symptom relief for a few weeks until other therapies can start to take effect. Like any medication, they have to be used correctly with due regard for their dangers.
Pleasant???? I had 80mg of librium daily shovelled into me on one 4-month admission and I did not enjoy it. Mind you, I was a banshee from hell even when on this much of it, so maybe there was a reason….
If you were given that much for that long it may have been the Librium that made you a banshee from hell.
Considering subsequent events…. no, it wasn’t. I was having a major mixed depressive episode, but bonehead consultant didn’t see it, just filled me full of tranquiliers to “calm me down”.
If you have the staff and the time, I think offering alternative anxiety management is appreciated by most people. The as required medication can then be used if this has not helped sufficiently.
Giving out pills can be a “quick fix” that may be seen as dismissive of the real difficulties that patient is having. It is very “medical model” and may reinforce institutionalisation and decrease the persons own ability to contirbute to their recovery. Inadequate staffing levels and a manic “fire fighting” ward environment aside, I would most times want to be able to spend time with a person requesting PRN medication (particularly of the bezo variety) even when it is clear that their distress is such that I give the pill first.
I must disagree with Celtic that it is not a nurses problem if a doctor over prescribes and a patient over imbibes. We are responsible for administration of these medications and could be called upon to give a rationale for our part in, say, creating a benzo dependency. Sadly nurses are more easily blamed, suspended and less well defended than medics.
Finally, a huzzah! for at last remembering my password, and being able to participate as well as observing this corner of the net.
Lorazepam is used in the general wards as part of a rapid tranquilization policy. As far as I am aware it is not used as a PRN. I don’t honestly know about the psychiatric wards but will find out.
Ayrshire. Scotland
My hospital use lorazepam, but not excessively in my opinion.
We would discuss it with the patient first and suggest alternatives (most staff would anyway).
We keep a close eye on the regularity of use.
There are staff who will just give it out when asked with minimal observations but there are also patients that know how to act if they are encouraged to try something else first and are adamant that they ‘need’ the lorazepam. Sometimes it’s a tough one.
Oh, and we use the term “as required” not PRN.
There should be a built-in cut off point into every prescription of PRN loraz, after which it should be reviewed for its necessity. This should be a matter of prescribing policy.
Committee on Safety in Medicines advice (from BNF):-
Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness.
The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate and unsuitable.
Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme distress.