meds--are we supposed to know EVERYTHING??

  1. Ok for whatever reason, my pt has vicoden instead of percocet ordered. Q4h prn pain. So she wanted it round the clock since yesterday. I got her today. I got the first dose about five hours after her last dose, and another nurse gave her the next dose 4h later at my request since I was admitting another patient at the time.
    So the nurse coming on after me tells me that there is too much tylenol in Vicoden to give q4 and that it should be q6h.
    I am new enough to not have known. And I was told by the previous nurse (who is also an upper level nurse) that she wants it q4 and to give it that way. (Pt kept track and asked for meds, didn't automatically bring them in)
    So what the heck...the order was over a day old, and no one said anything about too much tylenol before this. I am GLAD the nurse mentioned this, as I did not know it. I know that vicodin has tylenol, but I never dreamed that it was too much.
    I am having trouble knowing what I should know, and not knowing htat I should know something that I don't know! Do I have to look up EVERY medication that is ordered? I always look up the ones I don't know, but the problem is that I thought I knew vicodin.
    I didn't think to question the order because I didn't know I should question it.
    I *thought* I knew vicoden, I was wrong I guess.
    I call the pharmacy at the drop of a hat, with any medicine question, its not like I don't pay attention. I just plain didn't know.
    I know I am at fault for not knowing and for not looking it up--but if I don't know, how do I know to look it up?
    I am thinking of requesting that there be a protocol that ALL vicoden orders be standard at q6 unless there are special circumstances, or that each vicoden order clearly states the max dose.
    anyway, I hate leaving work with that as the last thing done.
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  2. 31 Comments

  3. by   SportyNurse
    Standard protocols really do help. Our docs will write out "not to exceed blah blah blah" at the end of the order. There is also a new protocol that doesn't allow orders to say "vicodin 1-2 tabs q4-6h prn mod to severe pain". They have to be separated... "vicodin 1tab q6h for mod pain, and vicodin 2tab q6h for severe pain, not to exceed x number of tabs per day".It's impossible to know everything, however I bet you'll never forget that there is a lot of tylenol in vicodin ever again. : )
  4. by   catlady
    Don't be so hard on yourself. Vicodin comes in several different strengths, both of the hydrocodone and of the APAP. And you might be giving one or two tabs, depending on the order. So there's no hard-and-fast rule that you can't ever give it q4h. Giving a safe dose doesn't just fall on you. It's also the doctor's responsibility to order the right medication, and pharmacy's job to monitor the prescriptions.

    Our Pyxis and our computer-generated MARs break out combination drugs to remind us of the components of what we're giving. Anything with APAP in it also has a NTE warning.
  5. by   MIA-RN1
    Quote from catlady
    Don't be so hard on yourself. Vicodin comes in several different strengths, both of the hydrocodone and of the APAP. And you might be giving one or two tabs, depending on the order. So there's no hard-and-fast rule that you can't ever give it q4h. Giving a safe dose doesn't just fall on you. It's also the doctor's responsibility to order the right medication, and pharmacy's job to monitor the prescriptions.

    Our Pyxis and our computer-generated MARs break out combination drugs to remind us of the components of what we're giving. Anything with APAP in it also has a NTE warning.
    whats an NTE warning?
  6. by   MIA-RN1
    Quote from SportyNurse
    Standard protocols really do help. Our docs will write out "not to exceed blah blah blah" at the end of the order. There is also a new protocol that doesn't allow orders to say "vicodin 1-2 tabs q4-6h prn mod to severe pain". They have to be separated... "vicodin 1tab q6h for mod pain, and vicodin 2tab q6h for severe pain, not to exceed x number of tabs per day".It's impossible to know everything, however I bet you'll never forget that there is a lot of tylenol in vicodin ever again. : )
    yes we can't use orders with ranges in them.. such as 1-2 tabs or q4-6 hours...But I wish that we had the 'do not exceed' part on ours.
  7. by   catlady
    Quote from CoopergrrlRN
    whats an NTE warning?
    NTE = Not To Exceed
  8. by   MIA-RN1
    Quote from catlady
    NTE = Not To Exceed
    LOL One MORE thing I didn't know.
  9. by   BGgirl
    You should also remember that percocet also contains acetaminophen. Ususally our oders for percocet or vicodin state that you shouldn't exceed X amt of acetaminophen in a 24 hour period.
  10. by   RobCPhT
    just as a heads up vicodin has 500mg of apap per tablet you can max out at 4000mg or 4g daily so you can actually give it every 4 hours because then it would be passed 6 times in 24 hours and would be at 3000mg. when dosing recommendations are followed, the risk of hepatotoxicity is rather low. check this book out for helpful tips.




  11. by   morte
    NTE 4000 mg in 24', look further, and the literature from the manufacturer says NOT MORE THAN TWO DAYS .....NTE 2000 mg daily NTE 10 DAYS......
  12. by   traumamomtx
    it's very difficult to monitor vicodon over a 24/hr basis to determine if every nurse was giving it q4 or q6 hrs for 24 hrs. it is even more difficult to tell a pt they can't have it every 4 hrs if they have been getting it every 4 hrs; tends to piss pts off!!!!! We hand it out like candy on our floor. I try and offer 1 tab sometimes instead of 2 if I think the pt can handle it or offer something else 1 time out of my shift like a little morphine. Although, when a dr. orders it to take home with them on DC you know those pts are taking it every 4 hrs sometimes even sooner. I would just offer a lesser dose once during your shift or an alternate to see if the morphine or demerol or dilaudid will help the vicodin last longer 1 time during your shift. P.S. you can't know everything and you will never know everything; this is a constant learning job.
  13. by   Laurie Kay
    I had a patient last evening, who, when I came on duty was nauseous, had been all day, and now could not keep down her liquid tray. She had an abdominal hysterectomy, so I was looking for a possible bowel issue. However, after looking over her meds, I saw she hs a vicodin allergy. The previos nurse had been giving her percocet for pain. I knew that they were closely related meds, so there in I found my nausea culprit. I verified with pharmacy about the issue and he said yes indeed that could be the problem. In the mean time I gave her tyl. # 3, which is a codiene base and there were no problems after that.
    The rule of thumb for tylenol useage is not to exceede 4000 mg per 24 hours.
    PLEASE dont be upset about not knowing. The nurse who gave the percocet was a 35 year veteran RN who did not realize percocet would be an issue. NOT TO MENTION the doctor ordered it AND pharmacy never questioned it either.
  14. by   ICRN2008
    Quote from robcpht
    just as a heads up vicodin has 500mg of apap per tablet you can max out at 4000mg or 4g daily so you can actually give it every 4 hours because then it would be passed 6 times in 24 hours and would be at 3000mg. when dosing recommendations are followed, the risk of hepatotoxicity is rather low. check this book out for helpful tips.



    actually, if you give 2 tablets q4h and there are 500mg of apap per tablet:

    12 tablets x 500 mg = 6g of apap

    most orders say not to exceed 4g of tylenol per 24h

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