Advice w/ administering meds

Specialties Med-Surg

Published

I'm a new grad RN & will be off orientation in a couple of weeks......& I'm just not comfortable with administering meds to certain patients.

Actually, I'm nervous about administering meds period...lol. But, I'm more nervous about narcotics/benzos/etc. Sometimes I have patients who are on multiple narcotics & benzos & I feel so uncomfortable administering all of them. They say they're in pain & are requesting the meds as soon as they're due & even before. I had one patient with a pretty extensive wound who I knew was definitely in pain, but the thought of all that I was giving her just made me nervous.

I had another patient who had a procedure that could have been done in a MD's office but was hospitalized with a PCA & taking benzos, muscle relaxants, etc. She was very lethargic & I couldn't even get her to be alert enough to take her other scheduled meds. This particular patient takes these meds (benzos, muscle relaxants, etc.) at home so these are her home meds I'm giving her. Needless to say, I still felt uncomfortable giving her meds that she regularly takes at home!! She also tried to get me to give her boluses off her PCA for her pain of 10 but I told her she was too sedated for the bolus & she fell asleep as I was telling her this.

I know pain is what the patient says it is but we can't just give them all the pain meds they want right? I guess what I mean is that there has to be a point where you just know it's not safe to administer them. I know you can look at VS & make sure the BP isn't too low & their respirations are WNL but anyone have anything else to add??

I know nursing judgement comes with time.....that's what's so scary for us new grads!!! We don't have that experience yet. I get so nervous anytime I have to administer a med I've never given before.

Any advice or words of encouragement are welcome :redbeathe

Ayvah, RN

722 Posts

Specializes in Med Surg, Specialty.

Think of alcoholics - these people can ingest a tremendous amount of alcohol and still be 'sober', whereas a fraction of what they took could cause another person to pass out. Many people have been taking narcotics in increasing strengths over time at home, and their body is used to it. A good phrase to remember in the hospital setting is "even drug addicts need pain relief". People can become very 'tolerant' to narcotics just like they can to alcohol. If the doctor has ordered the drugs and the vitals are fine and they aren't about to pass out like your patient you mentioned, then yes, you can keep giving these people the meds that are on their MAR. Of course a big stopping point is the tylenol hidden in many narcotics since you shouldn't go over 4g of that.

Remember, the goal is for short term pain relief, not to fix their drug problems, and if they are awake and coherent and vitals stable they are likely ok for more. If worse comes to worse, then there is narcan, but I think the biggest potential problem for harm actually comes from well-meaning family who hits the pca button of their family member every time it is available! I know of a few instances of that happening - so be sure to educate those with pca's that only they (or the nurse) should be hitting that button!

Specializes in M/S, Tele, Sub (stepdown), Hospice.

Thanks Ayvah!

Hmmm...another Q - why do the MD's order narcotics (ex. Darvocet 1-2 tabs Q4h) like that when the acetaminophin will be well over 4g/day?? I think 1 tab of Darvocet has 650mg/acetaminophen so if the patient was taking 2 Darvocet tabs Q4h - that would be 7800mg/day!!

Ayvah, RN

722 Posts

Specializes in Med Surg, Specialty.

You're welcome! Some docs who write that order will include "do not surpass 4g tylenol" but not all will. Oftentimes the doc will order "1-2 tabs q 4 hours" because while hopefully 1 tablet will take care of their pain, sometimes 2 are needed for breakthrough pain, i.e. at the time of a dressing change or when the patient is getting physical therapy. Now you and I both know there's a lot of patients who want 2 tablets every time ;) This is where it can get tricky. Many times a doc will also put in morphine prn, or an additional type of narcotics with less tylenol in them, and then its just 'experiment till you find what works'. Always have the nurse who is giving you report run down the patient's pain and how it was managed throughout their shift so you have an idea of what is to come. Ask how effective each pain med has been for the patient so you can plan ahead.

Then (if the patient is with it/rational)talk with the patient about the plan of care for pain as soon as you can, tell them about the tylenol limit if you are concerned they will hit it, and see if they will try one of the narcotics with less tylenol in it, or an iv push med if they haven't before, so you can assess the pain relief. If it is good, then you can alternate between the iv med and the tablets. Even if that gives you an hour of pain relief that buffer can add up over time and take care of your tylenol limit issue. If this is not working, then you should call the doctor right away for non-apap pain relief measures, whether that include a lidoderm patch or neurontin or addition of a pca. Since it can take a while to get a med entered into the system, and pharmacy to stock it, its good to do this as early as possible before you even need it. [or alternatively, if you notice this issue right away and you know the doc usually rounds an hour into your shift, put a note in the chart to alert the doc to the issue (such as 'pt routinely using 2 tabs percocet q4h and will hit tylenol limit at the end of the shift, can she have an additional pain med to get her through?) and hopefully by the time you are done with your med pass you'll have an answer and save yourself a phone call. ]

Pain control can get tricky, that's why its important to plan ahead (and see, you are doing that already - you'll do great! :) )

bear_mom

24 Posts

Thanks Ayvah!

Hmmm...another Q - why do the MD's order narcotics (ex. Darvocet 1-2 tabs Q4h) like that when the acetaminophin will be well over 4g/day?? I think 1 tab of Darvocet has 650mg/acetaminophen so if the patient was taking 2 Darvocet tabs Q4h - that would be 7800mg/day!!

Doctors can't write an order like that anymore at our facility, the order would be like this: Darvocet N-100, 1 Q4 hours for pain 1-3, 2 Q6 hours for pain 4-10. When we are discharging patients on Vicodin or Darvocet, then we write out their discharge instructions the same way.

Prior to that, it was up to us as nurses to ensure that the patient wasn't exceeding the max allowed to Tylenol.

Also, we recently switched to norco in the hospital to help with the acetominophen problem. (doesn't help with the Darvocet, but we don't use it too often on the surgical floor anyway)

Emily

creo

26 Posts

I am just going to add: do frequent assessments (BP, resp, level of consciuosness, O2 sat...) and have Oxygen and reversal agents ready (Narcan, Anexate)

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