medication doses

[MIA-RN1, RN]

Here is the scenario--a patient had two percocet ordered q4 hours prn pain. So at 2000 she decides she wants to take it but only wants one. Fine, its entered on the MAR as just one tab given. Then at 2200 she feels her pain is not well controlled and asked me for the other pill. To give or not to give?

I asked several nurses, the pharmacist and a doctor. They all said the same thing--as long as the second pill will not put her over 4gm/24h it is perfectly okay to give it to her. The order does not need to be changed or rewritten to do this.

I did but I kept thinking something was wrong. The order was written two pills every four hours, not one pill every two hours. Which I guess, she could safely do, but it wasn't written that way.

Because I am new enough to follow orders directly as written or seek clarification, it felt weird to me to give her the second pill two hours after the first. She was not drug-seeking etc. Just had increased pain and wanted to control it better. Only took one pill at first because she didn't like the way the perc made her feel and was trying to balance pain relief with not feeling too loopy.

So was what I did right? When I gave the second pill, I told her that she'd have to wait four hours til the next dose of perc. THe nurse I reported off to also seemed to feel this was okay to do and usually if I do something wrong, I find out when I report off.

???

[KMSRN]

According to the way range orders are interpreted at our facility, you did the right thing. If the lowest dose is not sufficient, the remainder of the full dose can be given but then the 4 hours starts at the time the remainder was administered.

[BrnEyedGirl, BSN, MSN, RN, APRN]

Hi,..I frequently give one pain med q 2hrs if the order is for 2 q 4hrs,..for the very same reason,.some pts seem to tol it better,..makes more work on my part,.but some pts have better pain control this way,...would it make you feel better if the order read "percocet 1 or 2 q 4hrs prn"? Im sure the dr wouldn't have a problem w/that.

[MIA-RN1, RN]

our orders aren't written as ranges tho. They have to be either q4H or q6H, not q4-6h. The pills too, have to be either one pill or two pills. We get around it because the patient can refuse the second pill, as they can refuse any med. But the time is definitely specific and not written as a range.

I know that it makes logical sense that I gave her the med okay but I just keep wondering if it was right legally?

[AuntieRN]

I too wondered that CoopergrrlRN. My preceptor explained it to me the same way people are explaining it here. Our orders also are written 1-2 tabs q4h prn. It is confusing to me. I guess this is one of those...Welcome to the real world things....

[rita359]

Here is the scenario--a patient had two percocet ordered q4 hours prn pain. So at 2000 she decides she wants to take it but only wants one. Fine, its entered on the MAR as just one tab given. Then at 2200 she feels her pain is not well controlled and asked me for the other pill. To give or not to give?

I asked several nurses, the pharmacist and a doctor. They all said the same thing--as long as the second pill will not put her over 4gm/24h it is perfectly okay to give it to her. The order does not need to be changed or rewritten to do this.

I did but I kept thinking something was wrong. The order was written two pills every four hours, not one pill every two hours. Which I guess, she could safely do, but it wasn't written that way.

Because I am new enough to follow orders directly as written or seek clarification, it felt weird to me to give her the second pill two hours after the first. She was not drug-seeking etc. Just had increased pain and wanted to control it better. Only took one pill at first because she didn't like the way the perc made her feel and was trying to balance pain relief with not feeling too loopy.

So was what I did right? When I gave the second pill, I told her that she'd have to wait four hours til the next dose of perc. THe nurse I reported off to also seemed to feel this was okay to do and usually if I do something wrong, I find out when I report off.

???

I think you did the right thing. In my own practice I wouldn't make someone wait 4 hours after the second of the original order was given. My theory is the original dose could have been 2 pills. Now 2 pills have been given. My timing would start from the time the first pill was given. I suppose if it would make you feel better you could call the physician and get a specific order.

[MIA-RN1, RN]

I think you did the right thing. In my own practice I wouldn't make someone wait 4 hours after the second of the original order was given. My theory is the original dose could have been 2 pills. Now 2 pills have been given. My timing would start from the time the first pill was given. I suppose if it would make you feel better you could call the physician and get a specific order.

I thought of that, giving the next 2 pills in two hours, but then I thought she'd have three percs floating around in her for that 2 hour overlap, and was getting close to the max dose of acetaminophen since she'd taken tylenol earlier, and I wasnt sure about the rest of the drug either, worried it might be too much of a sedative effect.

[Larry77, RN]

I worked on a very busy surgical floor before I transfered to ED and the only potential problem I see from your scenario would be having a group of 7 patients who all need their pills every two hours (along with drsg changes, assessments charted, ABO's hung, and any tx's that are ordered).

Only thing I would have done a little different is possibly ask the doctor for some added med (ie Toradol) to possibly increase the pain management for your patient.