Pain control via PRN narcotics - page 2

Hi everyone, I have a general question regarding how you dose your patients with narcotics. Frequently we'll get patients in acute severe pain (kidney stones, dislocations, low speed MVCs) in our Level V ED, and the docs... Read More

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    Real interesting topic!

    First off, MDs (I'm an MD) should, of course, write complete orders. But more than that, they should also be written clearly, and be capable of achieving the desired goal. Some studies have shown that, give a range of doses and times, PRN orders will generally result in fewer & lower doses.

    So, if the MD is actually trying to control the pain of an acute problem with severe pain, they should be very clear about the dosing and timing, and be appropriately proactive. For example, initial doses for morphine IV should be on the order of 0.1 mg/kg for most folks, and titration should occur q 15', or sooner. 2.5 mg for a bad burn is fine - for a 7 year-old.

    But this sort of dosing may still seem aggressive to some RNs, so it should fall to the MD to write clear & complete orders. You shouldn't have to feel like you are shouldering the "risk" of choosing the shorter frequency/higher dose end of the range!

    For my sickle-cell patients, the doses get crazy. I ordered 8 mg of IV hydromorphone last week on one patient. Brought the pain down to "8." For an aortic dissection, we gave a total 65 mg of morphine over the course of 2 hours (pt was still in severe pain...).

    flyingchange and Medic2RN like this.

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    I have never seen a range dose for a pain med in my ER for any of my patients. Our docs have always just written a set dose. The only thing I see ranges on is when titrating and that's more so just titrating to the parameters like on a cardizem drip. In my ER we have 2,4 and 10 mg Morphine vials and 1, 2 mg hydromorphone vials. But the 2.5 really isn't an issue, we have to use math all the time in the ER.

    I can never find any rhyme or reason though with some of our docs med orders. Can have a pt. come in with a kidney stone and the doc orders 2 of morphine. Another patient comes in with generalized abdominal pain with no found cause and the same doc orders them 1mg of hydromophone. :|

    But I will say, most of our docs I have a great relationship and often times I have been told. "Just give them whatever you want and put the order in" Of course I wouldn't go and give 10 of ativan, but it's nice to have those relationships.
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    Quote from hherrn
    There is no good answer to your question... The only way to safely utilize that order is to have an experience base on which to base your decisions, which you don't have.


    You can't change the culture that allows illegal orders
    You want to stay in this position
    You don't want to kill anybody
    You want to effectively manage pain
    Thank you for this post. There was a lot of food for thought here, and yes, since the culture is quite embedded with these orders (which I never realized were illegal) I think that I will need to be a lot more forward in seeking guidance from colleagues. I will get advice from them, but I'm not sure it will be best practice advice (many nurses are under-dosing IMO), so maybe I will approach some of the more approachable docs too. And your four points describe exactly where I'm coming from

    Quote from ecerrn
    Also, ask the doc to explain it...just say, I'm new and still learning, will you teach me the parameters on this medication? The oath taken promises to teach others, so Dr don't mind ....or he/she shouldn't anyway. Ha. Some oldtimers like to trust the nurse to figure it out and not keep bugging them on writing additional orders for pain meds....sadly, it is no longer legal.
    That's exactly what I'm going to do. Thanks for your advice
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    Quote from nurse2033
    Depends on nursing judgement. BTW not to be too picky but I've never seen MS packaged in 2.5mg. It comes in 2mg or 10mg.
    Quote from ~Mi Vida Loca~RN
    In my ER we have 2,4 and 10 mg Morphine vials.
    We stock 10 and 15 mg/mL vials of morph. I don't know why the docs are so in love with 2.5 mg and multiples of same (5, 7.5 mg). The 10 mg/mL math is straight forward though.

    I have literally never pulled a 15 mg vial because typically if the patient needed 15 mg in one dose we'd be going to something stronger.
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    Something else to think about: the typical PCA dose for morphine is 1-3 mg Q8 minutes. Until your docs start writing correct orders, that can provide a starting point for administration. Of course that assumes patients are being monitored appropriately.
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    OP, it sounds to me like your ED does not have a pain protocol, is that right? A standardized protocol developed in tandem betweeen your pharmacists and your medical director might be useful. It could just be a check box on the order sheet the doctor can check. For patients whose pain control needs are outside of the scope of the protocol, for example, someone who has been on opioids for ten years and has a very high tolerance, then the physician can write an order outside the protocol. It might be something you can suggest at an opportune time.

    Edited to add: I think it's safer to give the lower end of the dose since you don't really know these people that you're seeing in the ED. It's not like on an oncology floor where you get to know your patients over the course of hours, days, and maybe even weeks. Also, your doctor's order is incomplete. They need to give a range of time, such as Q15-20 minutes, and the reason for the PRN, such as "for pain". There should also be a maximum cumulative dose, so that if you have given the max, and the pain is still unrelieved, you check back in with the doc.
    Last edit by ~*Stargazer*~ on Nov 16, '12
    DC Collins likes this.
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    The first time in the ED that you have an otherwise healthy pt, who just happens to have a painful situation going on, and you snow them to the point where you have to bag them or place an oral or nasal airway, or worse, they have to be tubed, you will never start on the high end again unless you are very familiar with that patient (frequent flier).

    On the other hand, if you have someone in that much obvious pain, and you are giving IV narcotics, plan on checking on them in 15 minutes. That way, if their pain is still not well managed, you can give more. 35 minutes is unreasonable as a way of thinking. Obviously its and ED and something can come up that will delay you, but at least Try to get there and check on them quickly.

    Also as has been suggested above, do Not be afraid of asking the doc to put times down. If you feel comfortable with choosing the dose out of a range go for it. If not, ask that as well. A good doc will understand you have the patient's best at heart, especially knowing you are newer in the ED. A bad doc, who complains, his/her opinion of you doesn't matter.

    DC :-)

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