Use of PRN/NOW Psychoactive Medications

Introduction

Date of Last Review: 02/25/2011
SME: Chief Nursing Officer

UTHCPC has developed guidelines for PRN/NOW Psychoactive Medication usage.

Crisis intervention for the agitated patient

When a patient is agitated, staff:

Use less intrusive treatment Example: Verbal redirection as taught in SAMA training.

If less intrusive treatment is not effective, administer PRN/NOW psychoactive medication as indicated.

Agitated patient treatment

If no contraindications for psychoactive medication use exist, the physician does the following when treating a patient with the medication:

Consider giving the patient benzodiazepine (even for substance abuse patients)

If the benzodiazepine does not help or is not indicated consider giving the patient a second dose of benzodiazepine, a dose of an antipsychotic, or a combination of a benzodiazepine and an antipsychotic

	For severe agitation, a combination of benzodiazepine and an antipsychotic may be the first line of medication choice. Example: Patient throwing chairs
	Indication for any PRN should be specified and should not duplicate the indication for another medication written as a PRN.

Consent

The patient must consent to the administration of PRN psychoactive medications.

Exception: NOW orders, see below.

NOW orders

The physician may issue a "NOW" order to administer psychoactive medication without the patient's consent in an emergency as follows:

See Consent to Treatment with Psychoactive Medication for an explanation of what constitutes an emergency

The physician documents the order on the following form NOW Order for Involuntary Emergency Administration of Psychoactive Medication within 1 hour

Algorithm for managing agitated patient

This table describes how the patient's agitation can progress and how nursing staff responds:

Stage	Description
1	The patient is visibly emotionally or subjectively distressed. Signs and symptoms may include but not limited to the following: Staring, tone of voice (i.e., threats, yelling, swearing, etc) anxiety (i.e., clutching body, grimacing, clinching fist, tense posture, etc.) mumbling pacing sleep disturbance self report of agitation
2	Assess the reason for distress and treat appropriately or with other nursing (non-pharmacologic) least restrictive interventions. Interventions may include but not be limited to: Assess cause of agitation and anxiety Move patient to quiet area Reduce milieu noise/activity level as possible (i.e. television/radio volume, etc.) Remove objects that can be used as weapons Attend to concern supportively without delay Verbal de-escalation in a calm manner with a non-threatening stance Acknowledge behavior and/or level of stress and discomfort Maintain a safe distance
3	Does the patient respond and become less distressed and agitated? If yes, the process ends. If no, s/he becomes visibly agitated Response: Utilize less intrusive interventions Example: Ask the patient to go to a room for a more focused period of rest/relaxation, and offer PO PRN lorazepam or other non-neuroleptic antianxiety agent.
4	Does the patient respond and become less agitated? If yes, the process ends. If no, s/he becomes severely agitated and verbally abusive or threatening Response: Give verbal redirection and offer the patient PRN (PO/IM) lorazepam or other benzodiazepine and the process continues to stage 5.
5	Does the patient respond and become less agitated? If yes, the process ends. If no, s/he becomes severely agitated and his/her action begins to escalate to physical aggression toward property or staff Response: Call a special team Request a physician consider a "NOW" order. If needed, seclude and/or restrain the patient

PRN order

The physician may consider a PRN order for an antiparkisonian agent or give a "NOW" dose of one with the IM (intramuscular) injections of lorazepam and haloperidol. S/he should consider using the same IM neuroleptic as the scheduled one where possible.

General suggestion

Staff should note that the preceding information is a general suggestion. Not all patients follow this progression and may require significant interventions earlier. Staff and physicians must use their clinical judgment.

Related standards

Related to regulatory standards

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