PRN Medications Indications & Use. Inpatient Medicine Core Curriculum Bindu Swaroop , MD VA Long Beach Health Care System. Objectives. Identify which prn medications are appropriate for inclusion in admission orders
Inpatient Medicine Core Curriculum
VA Long Beach Health Care System
HPI: 59 year old male admitted for chest pain
and acute ETOH intoxication. He also complains
of hematemesis during his most recent drinking
PMHx: AVNRT, Hepatitis C, insomnia, depression
Outpatient medications: combivent inhaler bid,
ibuprofen 600mg po tid prn
He is admitted to the medicine service with the following prn orders:
-Ativan 2mg IVP q5min prn seizures
-Ativan 2mg po q4hr prn withdrawal
-Albuterol neb q6h prn, Atrovent neb q6hr prn
-Acetaminophen 650mg q4hr prn pain
-Ibuprofen 600mg po tid prn pain
Do you see any problems with these orders?
That night the patient subsequently requests pain medication for
his chest pain. It is determined by the night float that there is no
evidence of ACS. Since ibuprofen is ordered prn the night float
instructs the nurse to give this to the patient. The patient still
complains of pain later that night, and the night float writes an
order for Morphine sulfate 2mg IVP q4hr prn pain.
2. Are these appropriate meds to give to the patient?
3. What other alternatives could have been given?
The next day his BP has risen to 170/105. He is given hydralazine
10mg IVP by the team with a drop in his BP to 125/78.
3. What is likely contributing to the rise in BP?
4. What side effects could occur from lowering the BP too much?
5. How else could this patient have been treated?
-To identify and treat the underlying cause
-Prevent end-organ damage
Hypoxemia, respiratory distress
Autonomic response: urinary retention, constipation, SCI
Approach to evaluating the patient:
-Determine patient’s baseline
-Confirm accuracy, both arms, cuff size
-Screen for underlying cause
-Determine if hypertensive emergency or urgency is present
-gradual reduction of BP to 160/110 over 24-48 hours
-use ORAL meds
7. What could be contributing to the urinary retention?
8. What other alternatives could have been used for his insomnia?
9. What could be contributing to the fall and gait impairment?
Ativan: common use in ETOH withdrawal
-AE include sedation, respiratory depression
-Caution in those with acute angle glaucoma, sleep apnea, respiratory issues, hepatic/renal impairment, h/o drug abuse or falls risk
-Geriatric patients no more than 3mg/day
Anti-psychotics: Haldol (Typical), Atypical Antipsychotics (seroquel, risperidone)
-anti-cholinergic side effects, QT prolongation
-Not for use in dementia related psychosis (increased risk of death compared to placebo)
A review of BCMA indicates the patient has continued to receive
ativan despite no further evidence of withdrawal due to
complaints of anxiety and insomnia. A review of his chart reveals
he was previously on mirtazapine but this medication had not
been continued on admission.
On review of vital signs during rounds, it is noted that the
tachycardia noted on admission is persistent despite
administration of ativan.
10. What else could be contributing to the tachycardia?
11. Is this an appropriate order?
Are these appropriate orders?