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

• Identify contraindications and adverse effects

associated with common prn medications

• Known when to evaluate the patient prior to

ordering or the nurse giving a prn medication
 Common Uses

• Sleep
• Pain
• Cardiovascular: Hypertension
• Sedatives: ETOH withdrawal, agitation
• Pulmonary: Nebulizers, Mucolytics
• GI: Bowels, Heartburn
 Case Vignette
HPI: 59 year old male admitted for chest pain
and acute ETOH intoxication. He also complains
of hematemesis during his most recent drinking
binge.

PMHx: AVNRT, Hepatitis C, insomnia, depression

and COPD

Outpatient medications: combivent inhaler bid,

ibuprofen 600mg po tid prn
 Case Vignette
• EKG on admission reveals AVNRT @111 bpm
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?

 Case Vignette
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?
 Analgesics
Oral Pain Severity SC/IM/IV Pain Severity Adverse Effects
Non- Acetaminophen Mild Ketorolac Moderate Caution in
Opiods 325-650mg 30-60mg hepatic or renal
impairment

Ibuprofen Mild PUD, GI bleed,

600-800mg renal toxicity

Opiods Tramadol Mild to

50-100mg Moderate

Tylenol w/ Mild to Morphine Moderate to Constipation,

codeine Moderate Severe Ileus, n/v,
30mg-60mg respiratory
depression,
urinary retention
Vicodin Moderate Dilaudid Severe Caution Hepatic
(5mg/500mg) or Renal
Impairment
Percocet Moderate Fentanyl (IV or Severe
(5mg/325mg) patch)
 Case Vignette
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?
 Hypertension
• Goal:
-To identify and treat the underlying cause
-Prevent end-organ damage

• Common Causes:
Rebound
Inadequate dosing
Drug Interactions
ETOH withdrawal
Hypoxemia, respiratory distress
Pain, Anxiety
Autonomic response: urinary retention, constipation, SCI
 Hypertension
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
 Hypertension
Treatment:
• Urgency (DBP >120 or SBP >180):
-gradual reduction of BP to 160/110 over 24-48 hours
-use ORAL meds

• Emergency (evidence of end-organ damage) :

• Immediate reduction of SBP by 15-20%
• Use PARENTERAL agents and transfer to ICU
 Hypertension Clinical Pearls
• Hypertensive treatment rarely requires
immediate treatment in the middle of the
night
• Avoid prn use of rapid acting agents (can
precipitate ischemic events)
• For patients with sustained HTN, primary
team should initiate treatment with long
acting regimen
 Case Vignette
• Later that night the patient requests something for sleep and
receives Benadryl 25mg po, written as qhs prn per night float.
On day three of admission he develops urinary retention with
a PVR of 300cc. A foley catheter is placed. You review his chart
and notice a prior urology note indicating the patients
prostate size on DRE is 50g.

7. What could be contributing to the urinary retention?

8. What other alternatives could have been used for his

insomnia?
 Hypnotics
Benadryl Beers high severity Anti-cholinergic effects
25mg-50mg (confusion, dry mouth,
urinary retention, wheezing;
caution in pts with glaucoma
and BPH

Temazepam Beers high severity Same AE as any benzo;

15-30mg contraindicated in glaucoma
(geriatric 7.5mg) caution in those with falls
risk, hepatic or renal
impairment
Trazodone (unlabeled use) Okay in elderly Hypotension, increased
25-50mg bleeding risk if on NSAID’s or
warfarin, priapism, serotonin
syndrome, caution post-MI or
with h/o seizures
Ambien Okay in elderly HA, dizziness, caution in
5-10mg those with respiratory
compromise, myasthenia
gravis
 Case Vignette
• He remains hospitalized due to social issues
including homelessness. On day 4 of admission
you are called by the nurse due to the patient
falling in his room. You evaluate his gait and
notice he is unsteady in addition to being more
somnolent than usual.

9. What could be contributing to the fall and gait

impairment?
 Sedatives
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)
 Case Vignette
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?

 Pulmonary
• Nebulizers:
– Albuterol (max dose 3mL q4hours): can cause
tachycardia, arrhythmia, caution in patients with
ischemia
– Atrovent: anti-cholinergic side effects; caution in
those with glaucoma, BPH
• Mucolytics:
– Mucomyst: can cause bronchospasm; use 10-20
minutes after bronchodilator administration
 Case Vignette
• The patient subsequently complains of
diarrhea the next day. Stool studies are sent,
and the intern orders lomotil prn for loose
stools.

11. Is this an appropriate order?

 Gastrointestinal
• Heartburn: Maalox (aluminum dioxide, magnesium hydroxide)
or Maalox plus (includes simethicone)
– AE: constipation, cramps, fecal discoloration; aluminum
intoxication
– Use with caution in renal impairment: hypophosphatemia or
hypermagnesemia
– long list of drug interactions
– Must be administered one hour apart from other oral meds

• Constipation: phosphate (fleets) enema

– Do not use in patients with renal impairment, ascites, heart failure, GI
obstruction or megacolon

• Diarrhea: do not use in those with c.difficile colitis

– Loperamide (Immodium): caution in hepatic impairment
– Lomotil (diphenoxylate/atropine): anti-cholinergic side effects)
 Case Vignette
• The patient subsequently does well and is discharged. Upon
discharging the patient, you order the following outpatient
medication regimen:
– Ibuprofen 600mg po tid prn
– Vicodin5/500mg 2 tabs q6hr prn
– Combivent inhaler q4hr prn
– Benadryl 25mg po qhs prn
– Librium taper
Are these appropriate orders?
 Summary
• For all PRN orders, know the correct dosage,
common adverse effects and contraindications
• Check the next day to see if your patient actually
received any of the PRN meds
• Convert frequently administered PRN meds into
standing orders
• Don’t just put in PRN orders to save night float
the “trouble” of getting called
• Evaluate underlying cause or condition requiring
use of a PRN med and treat accordingly