[GradRNKylie]

Hi, Wondering when giving pain medication is it best to give the lower dose first then titrate up if pain is not relieved?

[Runningnurse]

The fast answer would be "yes, in most circumstances". But I think the better question is...why are your orders unclear enough that you need to ask? The MD or ordering provider should provide clear guidelines as to how much pain medication you should give and when.

For example, we will often have 5mg oxycodone ordered if the patient states pain 3-5/10 and 10mg if pain is 6-10/10. The hospital actually just made a rule that each has to be a separate order, because having the dosage as "5-10 mg (see words)" was too confusing.

We have the same issue with narcotic drips for end of life care and patient-controlled analgesia. The orders will clearly state that if pain stays above a certain level for a certain time, the nurse can increase the dosage by a set amount. If pain remains unresolved, the orders state that the MD must be called.

So I'd encourage you to clarify orders with whoever wrote them and see what they want for that particular patient.

[Daytonite]

In the places that I have been working in the last few years, the doctors have been discouraged and sometimes prohibited from writing pain medication orders in the way I think you are describing. We were instructed to call the doctor back and get definitive orders with a specifically stated dose and specified time interval, or else the pharmacist did it. It is for the very reason you are asking. Too many possible interpretations of the order. Each nurses interpretation is totally subjective. Perhaps some of the other licensed nurses reading this will have some perspectives on this to share with you if this practice is still allowed where they are doing their nursing.

[chenoaspirit]

Where I work, we get orders like that frequently. An example would be: Morphine IV 2-4 mg q 2 hours PRN. I can give either 2, 3, or 4 mg, depending on my judgement. Another example would be percocet 5 mg 1-2 tabs q 6 hr PRN for pain. I usually give the minimum dose first, then if it didnt help I give the maximum dose the next time. If the patient is moaning with facial grimaces and rating pain a 10, I would probably go ahead and give the maximum dose in the beginning. The physician should never give a maximum dose that is too much or dangerous for the patient. The nurse should have the critical thinking skills to determine which dose is needed, but still have the guidance of the doctor's order (safe doses). Some hospitals may discourage such orders, but we find it very helpful. I hope this helps you.

[chenoaspirit]

But I agree with the other posters, if you are questioning the order, call and get clarification. If in doubt, its better to be safe than sorry.

[TallGirlAni]

Also, consider the age and prior history of use of the narcotic for the patient. What is his pattern while he has been staying at the hospital? What are his vitals? What does the patient say works for him? If this is his or her first administration of the drug, and the pain is between a 4 and 7, I usually give a the lower dose, monitoring the patient for a reaction and change in respirations and perhaps b/p. Then, as you start to know the patient, you will feel more comfortable with a pain regimen. Remember that pain is what the patient says it is, and that it is important to make sure that the patient gets meds for painful things like dressing changes, ambulation, physical therapy, etc.

Like the other posters write, if there are no parameters, like 1-2 tabs q4h prn, use 1 tab for moderate pain of 4-7, and 2 tabs for severe pain of > 10, then I would call the MD for clarification.

[Sabrina's Mommy]

Originally Posted by SN_2B_RN

Hi, Wondering when giving pain medication is it best to give the lower dose first then titrate up if pain is not relieved?

I remember learning about the WHO pain ladder. Here is a link for more information. This is for cancer pain.

http://www.who.int/cancer/palliative/painladder/en/

[GradRNKylie]

Thank you heaps to all who responded. I appreciate your guidance and knowledge on this topic, Thank you