Guidelines for the prescribing and administration of prn psychotropic medication

Guidelines for the prescribing and administration of PRN psychotropic
medication

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Title
administration of PRN psychotropic medication.

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Guidelines For The Prescribing and Administration of PRN (Pro Re Nata)
Psychotropic Medication

1.0 Background
The use of PRN psychotropic medication, such as haloperidol and lorazepam, during All Trust inpatient charts have the facility to prescribe these drugs for rapid tranquillisation PRN. Nursing staff are then able to administer these drugs to patients PRN prescribing is clearly a valuable facility, particularly in those with acute, fluctuating conditions. Nonetheless, it is open to misuse and PRN prescribing may be unnecessary or inappropriate. PRN prescribing undoubtedly increases the risk of patients being given above maximum doses. Indeed, findings from the recent POM UK audit of high dose and combination antipsychotics prescribing (2006) confirm that the prescribing of PRN antipsychotics is an apparent major contributor to combined and high dose antipsychotic medication. Hence, the routine and common practice of prescribing PRN antipsychotic medication needs to be addressed. These guidelines should be read in conjunction with the Trust’s High-dose Antipsychotic and Rapid Tranquillisation Guidelines. (ELCMHT intranet / Policies Aim of guidelines
The aim of these guidelines is to help change the culture of prescribing PRN antipsychotic medication. That is, to discourage routine prescribing, to ensure safe, effective and appropriate prescribing and to encourage regular review of PRN Recommendation For Prescribing PRN Psychotropics:
Choice of Drug
• Where sedation or tranquillisation is required, benzodiazepines, such as lorazepam are preferred, at least initially. Promethazine may also be used. In most patients, antipsychotics should be used second line. • For agitation, if the intention is to improve the symptoms of a psychosis, then the evidence is strong that antipsychotic medication is beneficial for reducing agitation in both schizophrenia-like psychoses and in mania. Additional medication with benzodiazepines can be used to augment the effect of the antipsychotic in reducing agitation. • When prescribing or administering “prn” antipsychotics one should consider antipsychotics prescribed regularly and take the percentage maximum dose of regular and PRN antipsychotics into account Avoid Routine Prescribing of PRN
• In general, all PRN prescriptions should be individualised in the same way that regular prescriptions are written for individual patients. PRN medication should not routinely be prescribed in advance. If it is prescribed in advance then the rationale for doing so should be clearly documented in • Should nursing staff assess a patient to be in need of PRN psychotropic medication, a doctor, who is available 24 hours a day, should first assess the patients mental state and then prescribe PRN medication accordingly. Specifics of the Prescription
• All PRN prescriptions should specify dose (not a range of doses), frequency, maximum daily dose and the precise circumstances for which the drug is to be given. A time period for the prescription must also be • Medicines for rapid tranquillisation must be prescribed in the Rapid Tranquillisation section of the prescription chart. Review of PRN Medication
• All PRN prescriptions should be reviewed at least once a week by the multidisciplinary team and if the drug is no longer required the prescription • Should there be a need for the repeated administration of PRN psychotropics, consider prescribing them regularly and discontinuing the Documentation of Administered PRN Medication
• All PRN medication administered should be documented in the clinical notes with details of the name of drug administered, date and time administered, name and dose of drug, the specific symptoms and conditions which resulted in the drug being administered and a description of the patients response to the medication. • All actions and interventions taken to prevent PRN psychotropics being administered should also be documented in the clinical notes. • After the event the patient should be offered the opportunity to write an account of their experience of receiving PRN medication and this should be kept in the medical notes. (NICE guidance for schizophrenia, 2006). • The reason for administering the drug should also be documented in the appropriate section of the prescription chart. Night Sedation
• Those patients who require night sedation should be prescribed and administered licensed hypnotics rather than antipsychotics or short-acting • When treating people with a diagnosis of depressive illness, mania or paranoid psychosis (including schizophrenia) it is preferable to use a sedative antidepressant or antipsychotic, rather than to use a benzodiazepine or similar sedative-hypnotic. This is because benzodiazepines do not improve depression or psychosis and may lead • If a hypnotic is prescribed it should not be continued for longer than four weeks (preferably one week) according to BNF recommendations. When using a non-sedative antidepressant a benzodiazepine may be used briefly to avoid the initial increase in agitation. Medicines Committee
March 2007

Source: http://elcmht.nhs.uk/uploads/documents/prn_guidelines.pdf