Multiple prn pain meds requested all at the same time

  1. I have a question for ya ... been struggling with this for a bit... While working in a SNF, I have a patient who receives scheduled pain medications as follows: oxycodone 15mg q 4 hrs, gabapentin 300mg QID .. she also has a fentanyl patch 75mcg/hr. She is requesting the following prn meds to be given to her at the same time as the scheduled meds -- morphine sulfate liquid 10mg for chronic pain and fioricet for migraine. She tells me the 'squirt' medicine is to be given with the fioricet so as to give it a 'boost' to help make it work. Any PDR I've referenced advises not to give together as each one can cause respiratory depression. I'm concerned with giving them all together..."do no harm". This pt is also on hospice. I've notified the resident's PCP, asking for parameters and/or recommendations as regards the above.

    Have any of you nurses run across this type of issue and/or what are your thoughts? I appreciate your input greatly ... I have talked with my supervisor and she has given me direction as well. Thanks so much!
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  2. 4 Comments

  3. by   brownbook
    I am not clear on why you posted this in addiction nursing? A patient in a SNF and under hospice care is not considered addicted to drugs!


    Your should go by what your supervisor told you...But I am hoping, assuming, her advice was proper? Ideally you could ask your supervisor to write down her directions.

    You have to go by how the patient is reacting to the medication. Is she is sitting up, talking, easily aroused? Is her blood pressure, heart rate, and respiratory rate, within the normal parameters....or even what is normal for her (may not be what is normal for the average person)? Then she can take all these medication as ordered. Her body is used to these potent drugs.

    If you can't easily arouse her or her vital signs are poor...(do you have access to pulse oximetry?) then you can notify the PCP that such and such drug was not given due to the patient being difficult to arouse or due to such and such vital signs.

    You should re-post this question in the Hospice / Palliative Nursing specialty section. This is not my area of expertise. There you would get replies from nurses who deal with this daily.
    Last edit by brownbook on Dec 7
  4. by   vampiregirl
    I would recommend collaborating with the patient's hospice team. Agree with previous poster that addiction isn't a concern in hospice. What is a concern to me from your post would be this patient's symptom management - the different pain meds you are referring to address different types of pain (or may be attacking the pain from different directions). Sounds like some adjustments to the plan may me needed for more effective symptom management. People with chronic pain often appear to be "tolerating" the pain well but may still be very much in pain.

    Or there may be something deeper that needs to be addressed also - both related to the pain and to having a terminal diagnosis. Hospice also has other resources - chaplain, social worker to help the patient. Maybe a volunteer would be helpful to spend time with the patient - sometimes a diversion and support will help a patient feel more relaxed which contributes to pain control.

    The previous poster gave you great considerations for patient assessment which will help you gauge the effectiveness of an intervention as well as monitor for side effects. Often times hospice orders are not what is typically seen in a LTC. Good for you checking into the PDR - we don't disregard that info just because it's a hospice patient.
  5. by   hppygr8ful
    Quote from vampiregirl
    I would recommend collaborating with the patient's hospice team. Agree with previous poster that addiction isn't a concern in hospice. What is a concern to me from your post would be this patient's symptom management - the different pain meds you are referring to address different types of pain (or may be attacking the pain from different directions). Sounds like some adjustments to the plan may me needed for more effective symptom management. People with chronic pain often appear to be "tolerating" the pain well but may still be very much in pain.

    Or there may be something deeper that needs to be addressed also - both related to the pain and to having a terminal diagnosis. Hospice also has other resources - chaplain, social worker to help the patient. Maybe a volunteer would be helpful to spend time with the patient - sometimes a diversion and support will help a patient feel more relaxed which contributes to pain control.

    The previous poster gave you great considerations for patient assessment which will help you gauge the effectiveness of an intervention as well as monitor for side effects. Often times hospice orders are not what is typically seen in a LTC. Good for you checking into the PDR - we don't disregard that info just because it's a hospice patient.
    I might also add from my own experience with a father dying of Bone Cancer. There comes a point when even the strongest pain medicines have little or no effect. Towards the end we were giving with Physician and Hospice blessing Morphine every hour. He would go down and relax for about 15 minutes before the pain overwhelmed him. Hospice is about keeping the patient comfortable and providing a death with dignity not excruciating pain. I agree OP needs to seek out hospice care forum rather than addictions.

    Hppy
  6. by   lots2care4
    Thank you ladies so much for your words of advice. This resident is in a LTC facility and is on Hospice; however, she continues with all her regularly scheduled meds along with the prns. I was not comfortable giving what she was asking for and I believe she is in pain but, she wanted them all at once and wanted to argue about it. Numerous attempts I made to have the resident understand my concerns went unnoticed; I notified her PCP who wrote an order for parameters and distinct orders, 'do not give prn morphine with fioricet, oxycodone or gabapentin'. This has helped immensely. I agree she should discuss her concerns with the Hospice RN and go off a lot of the 'non-essential' meds and stick to bringing her pain under control. I have worked for Hospice and love the concept.

    Again, I thank you ladies greatly! Have a great holiday!

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