How would you interpret this order for pain medication?

[I<3H2O]

Morphine 4mg IV q4h PRN pain

Lortab 7.5/500mg 1-2 tabs q4h PRN pain

Your patient calls out at 0800 with pain 8/10. You give Morphine 4mg IV as ordered which helps with their pain. Two hours later the patient calls out with pain rated 4/10 and wants something for it. Do you:

1. Give Lortab 7.5mg as the pt. has not had that since the order was written
   
2. Call the doctor and ask what they want given
   
3. Tell the pt. they have to wait as they only have pain medication ordered every 4 hours
   

Does this order mean to you that a patient can have pain medication every 4 hours only no matter if it is the Morphine or the Lortab?

Does this order mean to you that they can have Morphine q4h AND the Lortab q4h without regard to each other so long as the Morphine doses are 4 hr apart and the Lortab are 4 hr apart?

What do you think?

[malgosiaRN84]

check the pt and how he/she is tolerating the morphine i.e are they stable. respiratory system ok? BP/pulse good? pulse ox good? they arent confused or hallucinating?

then give the lortab. :)

[Queen2u]

HMMMMM.......I am used to seeing orders that specify giving one medication for pain every so many hours as needed, then the other medication for pain unrelieved by the first medication........seems like this doctor needs to learn to be more specific.

[Caffeine_IV]

I recall that you should give the smallest dose first and progress from there to see what minimum amount of medicine will help the pain.

Without knowing a diagnosis or anything else about the patient, I would give 1 lortab and repeat in 1hr if the pain isn't better. The IV morphine I would give for breakthrough pain (usually the doctor will write it that way).

We don't use lortab anymore..only stock Norco.

[morte, LPN, LVN]

It certainly is acceptable. It's the patients level of pain and nursing judgment that dictates whether 1 or 2 tabs will be given.

no, not acceptable. Need to have more definition...ie 1 tab for moderate pain, 2 tabs for severe pain.

not acceptable per JCAHO.

[GoodNP]

Overkill in my opinion.Just because the two orders are independent of each other, doesn't mean we should overload the patient with them.

What about,if an hour later, patient complains of breakthrough pain, what more do you have to give them?Another morphine or Lortab?

I would give one lortab (since the patient has not been taking any and one might work), and if that wasn't effective after an hour, I would give another lortab. The orders are independent, but I do try to space out my pain medications at least an hour apart to make sure that the patient is tolerating them well.

**To clarify, I would give the lortab anytime after one hour of the morphine being given, too.

ha!

i was thinking that there are pts who would love this nurse (steph.rn).

leslie

You bet there are. When you wake up from back surgery, tib/fib fracture, whipple, CABG, whatever...with 8/10 pain and I am there to help give you relief, you will love me too. Because I have the ability to use good nursing judgment and balance adequate pain control with patient safety. I have never over-medicated a patient, but I have also never given a patient with severe pain 1 Lortab and then waited an hour or more to see if they're still having pain, when a quick hit with morphine followed by longer-lasting analgesic would provide both immediate and lasting relief.

[leslie :-D]

You bet there are. When you wake up from back surgery, tib/fib fracture, whipple, CABG, whatever...with 8/10 pain and I am there to help give you relief, you will love me too. Because I have the ability to use good nursing judgment and balance adequate pain control with patient safety. I have never over-medicated a patient, but I have also never given a patient with severe pain 1 Lortab and then waited an hour or more to see if they're still having pain, when a quick hit with morphine followed by longer-lasting analgesic would provide both immediate and lasting relief.

i just don't see the point in giving the mso4 and lortabs together....the mso4 alone, helped this pt.

my plan, would have been to give the mso4 and then offer lortabs 1.5-2hrs later...

anticipating the mso4 wearing off, but wanting to maintain analgesia.

leslie

[Riseupandnurse]

I agree that the order is too vague. On the floor I work, we give either the morphine or the Lortabs. If the morphine doesn't do the job, then we need an increase in the morphine. On another floor of the hospital, they mix the two narcotics. Problem is, if the pulled nurse to either floor doesn't know that, he or she winds up doing something the doctors won't sanction. This is no longer a matter for nursing judgment alone; the doctors have to take some responsibility for it too. (JCAHO, yes)

[GoodNP]

The point is that if the patient was given Lortab with the morphine, then two hours later the patient would likely not have 4/10 pain. I understand it is a lot of medication at once, but 8/10 is really a lot of pain, and that's all the information we have in this scenario. Obviously good assessment skills and nursing judgment are requisite to safe patient care. Also, if you are concerned about over-medication, you could try just morphine 2mg with 1 Lortab, then supplement as needed. Either way, I was taught it is better to achieve pain control quickly, and then stay ahead of it in order to maintain comfort.

Current literature shows that patients' pain is under-treated, and this is a major issue being tackled by JCAHO. Adequate pain control leads to quicker recoveries and shorter hospital stays, as we all know.

Consider pages 2-3 of this article for nurses:

http://www.mbon.org/practice/pain_management.pdf

Unfortunately, none of the searches I did yielded specific instruction for nurses when faced with patients in pain who have these types of orders. JCAHO is tightening the requirements on how pain is measured and managed, and how orders are written and implemented. The American Pain Society has evidence-based practice guidelines for treating different types of pain, but these guidelines are directed at physicians. So maybe docs DO need to be a little more specific in their orders? Until that happens, we as nurses have to use our best judgment, or else call the doc.