The use of PRN medication orders will differ depending on the facility (ie low-care versus high-care facility, availability of registered nurses [or enrolled nurses who are medication endorsed]) to administer medication and/or injections.
Examples of conditions where pre-planning (ie PRN medication orders, supplies of medicines) for specific residents can assist in optimal management include:
- allergic reaction and anaphylaxis
- asthma and COPD
- management of changed behaviour
- palliative and end-of-life care
- nausea and vomiting
- urinary tract infections.
Allergic reaction and anaphylaxis
Severe allergic reaction after drug administration is defined as urticaria, angioedema or anaphylaxis, and occurs most commonly after the first or second dose of an antibiotic. Severe allergic reactions may also occur after vaccination and to those with anticipated anaphylactic reactions (eg peanuts, monosodium glutamate [MSG], bull ants, wasps, bees). Usual products required include:
- EpiPen autoinjector
- adrenaline 1:1000 ampoules.
In some cases antihistamine orders may be required.8
Ensure residents have PRN orders for sublingual, short-acting nitrates (eg glyceryl trinitrate) available for breakthrough angina. Regular checks on dating are essential, as glyceryl trinitrate sublingual tablets have an expiry of 90 days after opening, while the glyceryl trinitrate sublingual concentrate spray has a longer dating.
Asthma and chronic obstructive pulmonary disease
Ensure residents with asthma have PRN orders for salbutamol metered dose inhaler (MDI) plus a spacer for emergency use. Residents using budesonide/formoterol (two lowest doses) products may use this for their action plan.9
Residents with COPD may have initial treatment with salbutamol or ipratropium MDIs. Nebulisers using salbutamol, terbutaline or ipratropium may be required by some residents for asthma or COPD.10
Regular aperients should be ordered when opioid medications are prescribed to older people. Bowel management plans should be put into place to avoid severe impaction. The resident should have PRN orders for appropriate preparations (eg enema, suppositories, docusate and senna tablets) and a care plan outlining when such preparations should be administered.
Residents with diabetes require a care plan outlining action to take in the event of hypoglycaemia or hyperglycaemia. Orders should be written for glucagon or short-acting insulin. A suggested protocol is:
When BGL falls below: … mmol/L give … glucose tablets or glucose gel
… mmol/L give glucagon injection
When BGL is above … mmol/L give … units insulin
Specify instances when the RACF should notify the prescriber.11
More information on the early identification and optimal management of people with type 2 diabetes is available in the RACGP’s General practice management of type 2 diabetes.
The use of oral rehydration solutions may be included in nurse-initiated medicines (NIMs) at some RACFs. If the resident’s requirement for such preparations is predictable, they should be included on PRN orders, and used prior to intravenous (IV) or subcutaneous hydration.
PRN orders for seizure management should be developed for individual residents at risk of seizure. It is important to note that the absorption of intramuscular (IM) diazepam is erratic. Options may be intrarectal diazepam or midazolam IM.
Medical examination will be required in most cases of falls. Protocols for prevention should be reviewed following a resident’s fall (eg medication review, physical restraints, use of hip protectors).
Management of changed behaviours
Residents displaying behavioural and psychological symptoms of dementia (BPSD; eg physical aggression, risk of harm to self or others, severe agitation, hallucinations, paranoia delusions) require regular review by their GP (refer to Part A. Behavioural and psychological symptoms of dementia).
An individualised care plan should be established, including appropriate person-centred non-pharmacological strategies to manage concerning behaviour with behaviour charting. If medication is prescribed PRN as a chemical restraint, the decision should be documented in the progress notes. The resident and/or family should be informed.12,13 The appropriate PRN medication orders should be provided by the GP, together with instructions on when, why, maximum doses per 24 hours and when the GP should be contacted. A three-monthly GP review should be scheduled and, where possible, the medication ceased.
Anticipate additional pain needs with PRN orders; it is important to include guidance for RACF and nursing staff as to mild, moderate or severe pain requirements (refer to Part A. Pain). Specify the maximum doses per 24 hours, and take into account regular doses. All residents on regular analgesics should have a PRN analgesic for incident pain.
Palliative and end-of-life care
GPs, RACF staff and nursing staff should work in collaboration to ensure the resident remains pain free and comfortable. The use of protocols to assist in maintaining comfort may improve end-of-life care and quality of dying (refer to Part A. Palliative and end-of-life care).
Nausea and vomiting
When predicted, PRN protocols should be clearly stated, including the maximum number of domperidone, metoclopramide and prochlorperazine to be used before calling a prescriber.
Urinary tract infections
If the patient frequently encounters urinary tract infections, consider preventive strategies such as increase fluid, prophylactic antimicrobial use, oestrogen creams, frequent changing of pads, hygiene, and catheter care (refer to Part A. Infection and sepsis).