Pain control via PRN narcotics

  1. 0 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 often order analgesics like this:

    Morphine 2.5-5 mg IV PRN

    My question is - how would you administer this to effectively control pain safely? I come from an oncology frame of mind where, if the patient is still breathing and has an adequate GCS, RR, and BP, they can be safely dosed. If the patient is in severe pain, I will normally give the max dose and give the lesser dose on follow up Q15 min (if they are coming under decent pain control - otherwise I'll repeat the high end).

    Other nurses tend to be a lot more cautious and will often see how they do on the lower end (2.5) and give the PRN less frequently (heard the other day: "Well, it's only been 35 min..")

    I know that the research suggests that patients' pain is typically undermanaged in the ED.

    When you have someone come in under these criteria, how do you approach pain control? Ultimately I want to give my patients as much pain control as is safe, but I'm not sure if my approach is the most effective.

    Thanks for your thoughts, and bestowing your knowledge upon me
  2. Visit  flyingchange profile page

    About flyingchange

    flyingchange has '2+' year(s) of experience and specializes in 'MPH Student Fall/14, Emergency, Research'. From 'Canada'; Joined Nov '08; Posts: 309; Likes: 417.

    16 Comments so far...

  3. Visit  lilarox profile page
    2
    Don't know if this helps, but I am a new graduate and in orientation we had the pharmacist as one of the speakers. She said
    in situations where there is a range it is best to administer the minimum/most frequent. For example using your morphine question:
    Morphine 2.5-5 mg IV PRN (have to add frequency here) so PRN 4-6 hours, so you would give 2.5 mg q4hrs. Assuming of course that the pt maintains stable vitals and needs it.
    flyingchange and geminiBSN75 like this.
  4. Visit  flyingchange profile page
    0
    Thanks for that advice! Nice to hear it from pharmacy.

    The problem I am running into is that the orders are written with no frequency. The docs are leaving it up to nursing judgement to manage pain. I feel like it is important to aggressively manage pain under these parameters but how to do so safely?

    I appreciate that old and frail pts require more careful dosing. I am more thinking of the 35 yo healthy pt in severe pain?
  5. Visit  iluvivt profile page
    1
    Pain Treatment Guidelines - Descriptions


    This may provide some help but that is NOT a complete order. It legally needs to have a frequency otherwise you are practicing medicine. Once you have a frequency on the order it will be much easier for you to select a dose within the range b/c you will know when you can administer another dose if needed. Yes I am aware that many pain protocols will state to start within the low range but of key importance is to determine if the pt is opioid naive or not. I can tell you from personal experience that if you have been on narcotics when you experience acute pain it takes a definite increase to get pain relief. I had to wait 8 mos for surgery one time and was taking a po narcotics to manage the pain..I was shocked when the MS did not enough touch the post op pain I had! Interested to see the other opinions as well!
    Last edit by iluvivt on Nov 4, '12
    flyingchange likes this.
  6. Visit  sapphire18 profile page
    1
    Yes, the order needs a frequency, even if it's something like "Q5min." If the pt is in severe pain, I would dose with the higher dose; minimal pain gets the lower dose, and for moderate pain I would take other factors into account like age/size, opioid-naive or not, current VS, etc.
    flyingchange likes this.
  7. Visit  hiddencatRN profile page
    1
    I will dose higher when given the option. And sometimes when I'm not given the option I'll go to the doctor and say "hey, this 4 year old with the bony deformity screaming in pain probably can handle 2 mg of morphine rather than the 1 mg ordered." Docs I've worked with like to start conservatively with narcotics, but I've yet to be in a situation where a patient in severe pain gets snowed in 1 dose.
    flyingchange likes this.
  8. Visit  hherrn profile page
    1
    Quote from equestriRN
    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 often order analgesics like this:

    Morphine 2.5-5 mg IV PRN

    My question is - how would you administer this to effectively control pain safely? I come from an oncology frame of mind where, if the patient is still breathing and has an adequate GCS, RR, and BP, they can be safely dosed. If the patient is in severe pain, I will normally give the max dose and give the lesser dose on follow up Q15 min (if they are coming under decent pain control - otherwise I'll repeat the high end).

    Other nurses tend to be a lot more cautious and will often see how they do on the lower end (2.5) and give the PRN less frequently (heard the other day: "Well, it's only been 35 min..")

    I know that the research suggests that patients' pain is typically undermanaged in the ED.

    When you have someone come in under these criteria, how do you approach pain control? Ultimately I want to give my patients as much pain control as is safe, but I'm not sure if my approach is the most effective.

    Thanks for your thoughts, and bestowing your knowledge upon me
    There is no good answer to your question. Your order essentially says: " Give this patient as much morphine as you like, just don't push more than 5 mg in one dose".

    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.

    The LOL who thinks of tylenol as a dangerous narcotic and is in mild pain, is going to get 2 mg, and re-assesed in 20 minutes.

    The 30 year old who is on 200 mg of Kadian daily and has an open femur is going to get 2 back to back 5 mg doses, re assesed in 10 minutes, and probably be given another 10 mg (in 2 back to back doses).

    Assuming:
    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

    You are going to need guidance. I would suggest seeking out somebody whose judgement you trust, and ask for guidance, as well as their rationale for their decision making.

    If you work in an environment too hectic for another nurse to help, this will be a challenge.

    Where I work, we respect nurses who acknowlege their weak areas, and seek guidance. We don't expect a nurse new to ER to autimatically and magically have ER skills. We are far more concerned when a nurse has limitations, but does not acknowlege them.

    Your workplace may have a different culture.

    Good luck.
    flyingchange likes this.
  9. Visit  nurse2033 profile page
    0
    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. If a doctor ordered 2.5 I'd think s/he was a little cracked. We use much more effective narcs like dilaudid and fentanyl for acute pain. You have to evaluate the patient's response before giving them the max dose. You can always repeat a lower dose, but if you have to reverse it with narcan because you gave too much it doesn't do much good for the patient.
  10. Visit  hiddencatRN profile page
    1
    .....you can't figure out how to give 2.5 mg of a medication that comes in a known concentration in liquid form?
    LEVELoneRN likes this.
  11. Visit  ecerrn profile page
    1
    That was something I thought as well..please order the dose as what is supplied in the ampule so I don't have to waste it...time consuming. Also, please add a frequency....and a cap...you just can't give narcs ad lib and ad infinitum in the er, not legally anyway. 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.
    flyingchange likes this.
  12. Visit  KellyBrackett profile page
    2
    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...).

    Brooks
    flyingchange and Medic2RN like this.
  13. Visit  ~Mi Vida Loca~RN profile page
    0
    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.
  14. Visit  flyingchange profile page
    0
    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.

    Assuming...

    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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