PR N SE Q U E NC I N G: 1 , 2 , 3

SI M P L E A S D O R E M I ?
A SUPPIN GER, P HARMD
CHELSE
TABLE OF CONTENTS

• OBJECTIVES
• BACKGROUND INFORMATION: WHY IS THIS IMPORTANT?
• COMMON CLASSES OF PRN MEDICATIONS
• POLICIES RELATED TO PRN SEQUENCING
• EXAMPLES
OBJECTIVES

• EXPLAIN THE IMPORTANCE OF PRN SEQUENCING

• IDENTIFY MEDICATION ORDERS THAT NEED SEQUENCED
• DETERMINE WHETHER TO SEQUENCE BASED ON PROTOCOL OR TO CONTACT PROVIDERS FIRST
• CREATE APPROPRIATELY SEQUENCED PRN ORDERS
BACKGROUND INFORMATION: WHY IS
PRN SEQUENCING IMPORTANT?
 PROS
Definition: medications
whose administration should
be based on patients’
Pro re nata” (PRN)
immediate needs rather than
at predetermined
administration times

Allows quick response and Studies have shown several

flexibility benefits of prn orders

Vaismoradi M, Jordan S, Vizcaya-Moreno F, Friedl I, Glarcher M. PRN Medicines

Optimization and Nurse Education. Pharmacy (Basel). 2020 Oct 26;8(4):201.
 CONS PRN medicines form a significant
proportion of medication errors

Between 9–40% in intensive

care units
Studies have shown
differences in provider
intention and nurse
interpretation
When to contact
provider

When to administer

Oh SH, Woo JE, Lee DW, Choi WC, Yoon JL, Kim MY. Pro Re Nata Prescription and Perception
Difference between Doctors and Nurses. Korean J Fam Med. 2014 Jul;35(4):199-206.
 JOINT COMMISSION STANDARDS
The Joint Commission has medication
management standards

MM.04.01.01: Medication orders are

clear and accurate

MM.06.01.01: The hospital safely

administers medications

The Joint commission issues citations

for not having prn orders sequenced
2021 Comprehensive Accreditation Manuals [Internet]. The Joint Commission Standards. The Joint
Commission; 2020 [cited 2021Oct28]. Available from: https://www.jointcommission.org/standards/
 MEDICATION CLASSES COMMONLY USED PRN
Analgesics Antihistamines
• “pain/pain and fever” • “itching/itching and pruritus”

psychotropics Antiemetics
• “agitation or anxiety” • “nausea/nausea and vomiting”

Sedatives Laxatives
• “sleep/insomnia” • “constipation”

Antihypertensives Antacids
• “blood pressure” • “indigestion/dyspepsia/heartburn”
WHEN TO SEQUENCE
 WHEN DO WE NEED TO SEQUENCE?
Medications: Orders with Range Doses and Therapeutic Duplication Policy

• For medications ordered under the same PRN reason, that

may be considered therapeutic duplication, please see “PRN
Medication Classification and Sequencing” policy.

• Exact duplicate medication orders (exact medication, dose,

frequency, route, timing, PRN reason and comments) should
be discontinued upon verification.

Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
 SEQUENCE WHEN:
More than
one Hydromorphone prn severe pain
medication and fentanyl prn severe pain
per prn need sequenced
indication
and
severity Acetaminophen prn mild pain
and fentanyl prn severe pain do
not need sequenced

Same
location/ Hydromorphone ordered as prn
time severe pain PACU order only and
morphine prn severe pain do not
need sequenced
MORE THAN ONE SIMILAR PRN INDICATION
Sleep/insomnia

Heartburn/indigestion/dyspepsia

Nausea/nausea and vomiting

Itching/itching and pruritus

Pain/pain and temperature/fever

Wheezing/sob and wheezing

DO THESE ORDERS NEED SEQUENCED?

• TYLENOL 1,000 MG PO Q6H PRN PAIN

• TRAMADOL 50 MG PO Q6H PRN MODERATE PAIN
DO THESE ORDERS NEED SEQUENCED?
Fentanyl injection 50 mcg IV push as
ordered prn severe pain, order comments
“PACU order only”

Morphine injection 2 mg IV push q4h prn

severe pain
 DO THESE ORDERS NEED SEQUENCED?
Benadryl capsules 25 mg po
qhs prn insomnia
Melatonin tablet 3 mg po qhs
prn sleep
PRN MEDICATION CLASSIFICATION
AND SEQUENCING POLICY
 1. Medication classes
specifically addressed in
the appendices

2. Medication classes
not addressed
3. Medications with both IV
and PO orders
4. Post op anesthesia and Intranet  Memorial  General Info  Policies and
surgeon’s orders Procedures  9.0 Medications and IVs
 1. MEDICATION CLASSES
ADDRESSED IN APPENDICES

Analgesics

Laxatives/stool
softeners

Antiemetics

Anxiolytics

Agitation

Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
HOW WOULD YOU SEQUENCE THESE ORDERS?

• TYLENOL 1,000 MG PO Q6H PRN

PAIN Morphine
prn severe
• TRAMADOL 50 MG PO Q6H PRN Tramadol pain
PAIN prn
Tylenol moderate
• MORPHINE INJECTION 2 MG IV prn mild
pain
pain
PUSH Q4H PRN PAIN
Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
HOW WOULD YOU SEQUENCE THESE?
• LORAZEPAM 0.5 MG INJECTION IVHydroxyzine: use first
PUSH Q2H PRN ANXIETY

• DIAZEPAM 5 MG TABLET PO TID Lorazepam PO: use second

PRN ANXIETY

• LORAZEPAM 0.5 MG TABLET PO Diazepam: use third

BID PRN ANXIETY

Lorazepam inj: please administer this
• HYDROXYZINE 25 MG CAPSULE medication if unable to administer PO med for
anxiety
PO Q6H PRN ANXIETY
Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
 2. MEDICATION
CLASSES NOT
SPECIFICALLY
ADDRESSED

Sedatives
Antihypertensives
Antihistamines
Antacids
Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
 3. MEDICATIONS WITH
BOTH IV AND PO ORDERS
EXAMPLE:

• Zofran 4mg tablet PO

Order
q4h prn nausea and
1
vomiting

• Zofran 4mg injection

Order
IV push q6h prn
2
nausea and vomiting

Intranet  Memorial  General Info  Policies and Procedures  9.0 Medications and IVs
HOW WOULD YOU SEQUENCE THESE?
Ondansetron
inj PACU
• ONDANSETRON 4 MG INJECTION IV PUSH Q4H Zofran PO: only: use
PRN NAUSEA use first first

• ONDANSETRON 4 MG INJECTION IV PUSH AS

ORDERED PRN NAUSEA/VOMITING, PACU Promethazin
ORDER ONLY Promethazine e inj PACU
only: use
• ZOFRAN 4 MG TABLET PO Q6H PRN PO: use
second second
NAUSEA/VOMITING

• PROMETHAZINE 25 MG TABLET PO Q6H PRN

NAUSEA/VOMITING Ondansetron
inj: use if
• PROMETHAZINE 6.25 MG IV PUSH AS ORDERED unable to give
PRN NAUSEA/VOMITING, PACU ORDER ONLY po medication
CHECK
COMMUNICATION
ORDERS FOR
PATIENTS WITH
ORDERS/POWERPLANS
BY
ANESTHESIOLOGISTS
AND SURGEONS
Medications
in these
powerplans
do not need
to be
sequenced
with each
other
 MEDICATIONS TO BE ADMINISTERED BY PROVIDER

Do not need
sequenced
QUESTIONS?
REFERENCES
• VAISMORADI M, JORDAN S, VIZCAYA-MORENO F, FRIEDL I, GLARCHER M. PRN MEDICINES OPTIMIZATION
AND NURSE EDUCATION. PHARMACY (BASEL). 2020 OCT 26;8(4):201.

• OH SH, WOO JE, LEE DW, CHOI WC, YOON JL, KIM MY. PRO RE NATA PRESCRIPTION AND PERCEPTION
DIFFERENCE BETWEEN DOCTORS AND NURSES. KOREAN J FAM MED. 2014 JUL;35(4):199-206.

• 2021 COMPREHENSIVE ACCREDITATION MANUALS [INTERNET]. THE JOINT COMMISSION STANDARDS.

THE JOINT COMMISSION; 2020 [CITED 2021OCT28]. AVAILABLE FROM:
HTTPS://WWW.JOINTCOMMISSION.ORG/STANDARDS/
PR N SE Q U E NC I N G: 1 , 2 , 3
SI M P L E A S D O R E M I ?
A SUPPIN GER, P HARMD
CHELSE