Pain Med Administration

allthesmallthings · Sep 7, 2012

You may want to check w/ your pharmacy, the MD, or your charge nurse, or the other nurses, to see what the hospital rule is, or the "floor culture" is, to make sure you're not flying rogue unknowingly - but, personally

1) if a Pt has been having trouble w/ pain, I use what I have to steady out his pain. So if pain is 8/10, I'll go w/ dilaudid, and then in an hour, when the dilaudid has brought the pain to a more manageable level, I may give the oxycodone or percocet to keep the pain from shooting back up again. This can lower the number of times that he may need IV dilaudid.

**Of course, you want to make sure to assess the Pt's LOC, how well he's breathing, possibly O2 sat, etc., to make sure it's safe to give another pain med after the first one** although if it's been an hour, the dilaudid has peaked

2) sometimes I'll give an oral med (oxycodone or percocet) when the pain is moderate to try to keep it from going high to the point that the Pt needs IV med. But if the oral med doesn't work, and the pain is climbing, then I may follow with IV narcotic - again, after checking LOC, responsiveness, etc.

**Caution: the oral med takes longer to kick in and also longer to get out of the Pt's system, so if you follow it w/ an IV med (as opposed to giving an IV med and then thirty minutes/sixty minutes later an oral med), you do risk the IV med hitting the Pt at the same time that the oral med is becoming effective. So I warn the Pt of this, make sure that they don't get up w/out calling for help after taking narcotics, and monitor him. I take baby steps w/ giving 2 meds in succession if I haven't had the Pt before and don't know his ability to tolerate narcotics and/or if other shifts haven't been giving meds this way w/ the Pt tolerating it. That is to say, go w/ a smaller dose at first and monitor the Pt! Explaining what you're doing and the different time frames for effectiveness/peak/duration of IV vs PO meds also helps the Pt understand, and participate in the plan of care, and to help you make things safe.

And don't forget that you can contact the MD - either to get an order (at least a "Yeah, that's okay" which I can chart) that meds can be given successively (this covers your butt), or to let him know pain meds aren't working, so he can dose pain meds appropriately.

Aeterna, BSN, RN · Sep 12, 2012

Generally, we try not to have two types of prn narcotics ordered so we don't accidentally "double up" on them and overly sedate our patients. If two different types of narcotics are ordered, our general practice is to get the older one D/C'd and/or clarify with the MD.

For example, a patient's pain is being managed by prn Dilaudid. The doctor comes along and orders prn morphine. I'd contact the doctor and ask which ones he/she wants the patient to be on.

There are rare occasions where the doctor wants a patient to be on two types of narcotics (i.e. Percocet and morphine), but in these instances the doctor sometimes writes instructions (i.e. "Give Percocet for moderate pain and morphine if pain is severe"). If the doctor doesn't leave us instructions, we go with the least potent first and if that doesn't work, we move on to the stronger one, and once we start giving one, we don't really bounce back and forth between the two. For example, the patient is in pain so we give Percocet. It's not very effective, so the next time we can give them analgesia, we'll give the Dilaudid. If it's effective, we keep going with the Dilaudid. If that's not effective, then I'd call the doctor for another order. We wouldn't give Percocet, then the next time give Dilaudid, and then the next time give Percocet.

Regarding the timing of administration of different prn narcs, as allthesmallthings noted, it's important to know when a medication will take effect and for about how long. Where I work, we never give narcs intravenously. However, we give a lot of SQ and PO narcs. SQ meds take effect faster but last for shorter amounts of time. PO meds take longer to take effect but last longer than SQ. It also depends on the individual patient. For one patient, 2 mg of PO Dilaudid will be enough for half the day, but for another, 4 mg of PO Dilaudid will only last maybe two hours. Also be aware that different meds are metabolized in the body differently. I've had renal failure patients get overly sedated from narcs/benzos because their bodies can't clear the drugs fast enough from their bodies.

rnwings · Sep 12, 2012

Yes, be sure you know the peak times of each med as well as the route. I would definately start with the smaller dose first and move my way up the chain. And assess assess, assesss. I know being on a busy med surge floor sometimes that is hard to do. And most times you don't know the pts well enough. Explain the med to the pts, the effects of the meds and make sure they understand to ask for help when when getting up. And the 2nd thing is to chart, chart, chart. So you can COVER YOUR BUTT. If you EVER have questions or are in doubt contact your supervisor, pharmacist, or better yet the doc.

RheatherN, ASN, RN, EMT-P · Sep 18, 2012

i cant say we dont have several meds ordered for many of our pts due to the surgerys that we do and the random admits that we get. i feel i really know my docs well, w/ the exception of the random dang hospitalists and the frustrating teaching services that decide to come thru and order whatever their student hearts desire b/c they can. (can you tell interns and residents and med students drive me a littllllleee crazy?) we dont have a written standard of what we do, but we do have "unwritten" rules on what to follow.

i know that doesnt help, but its a lot of trust and nursing judgement as well.

sorry i cant be more help!