Hypothetical Question re: prn meds - page 2

I don't know how the subject came up but here's the scenario: Dr. orders 1-2 mg. Dilaudid IV q4h. Pt doesn't usually ask for pain meds, rates pain low. You give 1 mg. In only one hour, Pt... Read More

  1. by   Sleepyeyes
    Thanks very much, all! That helped me.
  2. by   Tweety
    What they said. I wouldn't wait an hour to assess paint. If after 15 to 30 minutes they reported no relief I would give the second mg. But not after an hour. After an hour I probably would call the MD for an extra dose if the hour was decent. That's a toughie, but definately assess sooner than an hour.
  3. by   BadBird
    I agree, give the other 1mg and assess in 15 minutes. If within a hour or so the patient is still complaining of pain then call the Dr. and get new orders.
  4. by   duckie
    Our facility will not accept an order like that. It must state specifically, X mg. q 4hr PRN pain. That stops confusion. And if that doseage is not affective, we get the med increased. Orders such as pt. may have 1 or 2 tabs PRN pain cause confusion and increase possibilites of med errors or drug diversion, also meds given but not charted or charted but not given. Just my 2 cents.
  5. by   fab4fan
    My facility wouldn't accept an order like that either; felt it put the nurse in the role of "prescribing."

    Why isn't this pt on a PCA; instead of having to depend on staff for pain relief, he could self dose as needed, with appropriate lockouts.
  6. by   KC CHICK
    PCA's aren't appropriate for EVERY pain pt, IMO.
    I don't see a prob with the order...we get those ALL the time.
    Just use good judgement and you'll be fine.
  7. by   Sleepyeyes
    Originally posted by fab4fan
    My facility wouldn't accept an order like that either; felt it put the nurse in the role of "prescribing."

    Why isn't this pt on a PCA; instead of having to depend on staff for pain relief, he could self dose as needed, with appropriate lockouts.
    Further details I didn't feel relevant at the time:

    This was not a surgical pt. Pt had chronic, low-level pain. Pt initially reported "it helped some" & rated pain after 15 minutes of 5/10 rather than 9/10.

    Pt had also had an oral prn pain med that was still in effect at time of IV dosage. Pt normally didn't have that level of pain, and consistently rated 4/10 as "tolerable" and has refused meds rated as such.
  8. by   fab4fan
    Well, having gotten deeply involved in pain mgmt., I can tell you that the majority of pain mgmt. authorities will say that if the pt is competent and capable of self dosing with the PCA, then PCA should be used. Since the pt has a patent IV, it seems like this would be approp. (of course, there may be other issues preventing PCA that can't be revealed here...I'm just saying what the standard of care is in general).

    Again, depending on a nurse to bring a pain med puts the pt in the position of having to wait...possibly a long time, to get relief. What if the nurse can't get to the pt quickly? Pain can escalate to the point that the prn dose is ineffective. Then, too, there are nurses who are very judgemental about giving pain meds (and I am NOT saying this is the case, just a general obs.), and will say they don't think the pt really has that much pain, thus putting their own feelings in place of the pt's assessment of pain.

    Check the AHCPR guidelines on pain mgmt; research by McCaffery et al, just for examples...

    Remember, once the pt goes home, he will be resp. for his pain mgmt. What better place than while he is in the hosp to start learning when and how to medicate for pain.
  9. by   Sleepyeyes
    Thanks, fab4fan, for your input. I respect your insight.
  10. by   AmAnRN
    One thing i often think about is- you sometimes cant take away all thier pain, but you can lessen it!
  11. by   Spidey's mom
    I go ahead a give the additional dose that is prescribed in that 4 hour period and then give the next dose, if needed, 4 hours from the first dose. I've asked the docs about this and they agree. I don't remember reading a protocol though . . .better go look it up.

    If you assess the pain quicker, you can feel more comfortable giving the drug as above. It wouldn't work if you gave the first dose and then the second 1/2 before the next prn dose was due.

    Good question . .
  12. by   P_RN
    If 1-2 mg q 4his ordered....and I agree that's not an appropriate way to write it.....
    If I gave 1mg at 2pm the second 1mg at ___whatever time...

    .then the next dose would be given 4 hours from the FIRST 1 mg and I would then give 2 as the dose.

    Otherwise you are making the patient wait an extra hour.....or you end up going in there q 2h and playing catch-up.
  13. by   liberalrn
    What is not figure out here? Give the med as written--1-2mg q 4 hr. prn. I prefer this type of order--gives me a little wiggle room so that I can scale up for pain management w/o tracking down a doc. I also prefer having oral/iv choices for analgesia--maybe pt has deep wound that requires a heavy hitter analgesia for the dressing change, but then only needs maintenance oral drub for pain relief. I would assess this pt's pain level and vitals and maybe give the 2mg right off the bat. Dilaudid is potent, but we usually way undermedicate for pain.......But if only 1mg was warranted, and then no relief, I would give the additional 1mg, and time 2nd "full" dose off the initial 1mg. If that's clear.

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