Percocet PRN

MunoRN, RN · Jul 10, 2011

to 1 tab q3 PRN as the patient requested

You already have an order that includes the ability to give 1 q3hrs. So lets say you call in the evening to get the order changed, then at midnight the patient now wants 2 pills q 6hrs so they don't have to wake up in 3 hours to take another pill, are you going to call again? Then again in the morning to get it changed back to q3? How is that any different? (Other than being really annoying to the MD).

MunoRN, RN · Jul 10, 2011

Your policy cannot alter a phsyician order. If it says '2 q 6' PRN, and you give '1 q 3' PRN, you are practicing medicine wihout a license, administering medication against the order on the label, and other violations that might include narcotic charges. You cannot be too careful. Get the order changed to read '1 q 3' PRN, or better yet '1 or 2', q whatever hour (s) based on a standard pain scale of 1-10 (or whatever your employer uses), and document the pain scale on the med sheet as well the dose you gave. That leaves nothing to misinterpretation.

Following a range order is not practicing medicine without a license. Writing a range order with any direction from an MD would be. Range orders are not only legal for a nurse to follow, but are considered best practice for pain control:

http://forums.pharmacyonesource.com/t5/Surveys-and-Safety-Strategies/Range-Orders-Myths-Facts-and-How-to-Handle-Them/ba-p/382

http://www.ampainsoc.org/advocacy/pdf/range.pdf

We use range orders where I work which allow for 1tab q 3hr in this situation if that provides the best pain control, and recently had visits from the JC, DOH, and DEA and had no problems. Physicians are required to follow DEA and guidelines for prescribing when writing prescriptions for home use of narcotics, my wife has a bottle of Norco sitting here that says 1-2 q4hrs, should I call the cops on her because she has narcotics without valid prescription? Is she practicing medicine by following this range order?

The method of ordering pain meds based on a pain scale is has the advantage of being more rigid, although that's not really much of an advantage in pain control because it assumes that patient's perception of pain, as well their response to pain medication is the same from one patient to another. It's quite possible that one patient's 4/10 pain may require a reasonable sized dilaudid dose to treat, while another patient's 8/10 may be fully treated with 1 tylenol. Without titrating pain medication and adjusting dosing within Physican ordered parameters, you'll often either be giving more pain med than needed or not enough, either of which is poor Nursing care.

MunoRN, RN · Jul 11, 2011

Well, you have some good points here. The problem is we are talking about narcotics. I know that we have such strict parameters at my facility because of past incidences of drug diverting by RNs. The orders are not too complex, they just leave room for someone to get in trouble in the worst case scenario.
As far as the numerical pain rating system, we find out what our patient's tolerable level is and go from there. This way we can get a personal baseline which may vary from "0 pain" or "6/10 pain" as being tolerable. We have to have some way of knowing where our patient's personal pain tolerance lies and then issue meds accordingly.
A prescription of 1-2 tablets would not fly in a hospital situation. It all boils down to covering butts. What people do at home with their own bottles is different. Technically, your wife could take six pills if she wanted because she is self administering. In a hospital, the RN is administering and it needs to be documented and orders followed.

"1-2 tabs" is acceptable in a hospital situation, that's what a range order is and range orders are allowed in hospital settings. There are rules set by the Joint Commission on Range Orders which allows them but you just need to have a policy that defines how they are used so they are interpreted consistently. Following a range order is following the order, the order is a range order and yes you would still document accordingly.

SNIXRN · Jul 31, 2011

Our physicians write orders like, "5mg percocet Q4H. May repeat x1 during dosing interval". That way if one pill isn't adequately alleviating the pain, the patient could receive another pill. So, if we give 1 percocet at 0800 then one at 0900, they cannot receive another one until 1200, then the next at 1300. If their pain is managed better with 2 pills at a time, we can give one, then technically another one min later.

#1ME · Aug 7, 2011

HIPPO

You must certainly can give only, it is best to start off with the minimum dose, you can assess if it is sufficient, if it is not, you could give the second tab within the hr (as long as you don't give more than two within the 6 hrs. Document on the MARs that one was given, ex (1). I would have to know the electronic system to find out how to record it there

Catch22Personified · Sep 5, 2011

Our facility says to follow the order to the letter: I don't know why but there is a nurse on our floor that just hunts for these kind of med errors. I catch about 2-3 med errors last month on our floor, she has caught 8 of them in a single month.

xtxrn, ASN, RN · Sep 8, 2011

If a doctor has ordered 2 percocets q6h prn for pain, can it be given 1 percocet q3h instead (not to exceed 2 tablets in 6h?)

As it's written there, no. Decreasing the dose is beyond the scope of practice for nurses. It's going to get hairy if the doc writes for both:

Percocet ii tabs po q6h prn pain OR Percocet i tab q3h, not to exceed ii tablets in any 6 hour period.... where are you going to document to be sure that nurse A doesn't give the 2 tabs at 12pm, and nurse B shows up at 6pm, gives i tablet...that adds up to 3 tablets in 6 hours. It makes it more complicated than needed.

If a patient is having breakthrough pain with the 2 tabs q6h, maybe ask for something like tramadol for that...less risk of CNS depression as well. jmo :)

Aeterna, BSN, RN · Sep 11, 2011

Decreasing the dose is beyond the scope of practice for nurses.

Really? Maybe it's different where you are, but I was always told that it's ok to go below what the doc has ordered if you feel it is necessary (although, I can and will call the doctor if it's a scheduled medication; it just depends, but this mostly applies to narcs and benzos, sometimes insulin but that's a whole other story). After all, patients can technically refuse, so if I go in with 2 Percocet tabs, the patient can refuse one tab if they want.

It's all critical thinking and communication with your patient, right? If they feel like the dose they've been ordered is too sedating or something, I have no issue with giving them a smaller dose to see if it works better and then leaving a note for the doctor to address the next time they round. And, of course, I document that I've discussed the matter of pain control with the patient, what the patient decided/requested, what I gave, and that I have left a note for the doctor (at our hospital, they seem to prefer these if the issue is minor rather than harassing them with pages/calls for every little thing).

joycelorelle · Sep 26, 2011

"Give 2 tabs q 6hours" is not a range order. It is an explicit order. A range order would be 1-2 tabs q 4-6 hours prn. In that instance, you would most likely need clarification (ie when to give 1 tab? when to give 2? NTE what dose in a 24 hour period?). The clarification isn't because the nurse is stupid -- it's to protect him/her in the instance that there was an error or an issue. It's also to protect the patient from an accidental overdose, or different interpretation by 2 nurses caring for the same patient.

PsychNurseWannaBe, BSN, RN · Oct 27, 2011

We are not suppose to take range orders anymore.

Percocet 5/325 one tablet by mouth for mild to moderate pain

Percocet 5/325 two tablets by mouth for severe pain.

I would not split a 2 tab q 6 hours order. The order for the 2 tablets to be taken every 6 hours, not 1 tablet in 3 hours and 1 in another 3. The problem might be the 6 hours. Kinda seems long for pain pills.

CharmedJ7 · Oct 29, 2011

Pharmacologically it is safe to give 1 then the second at 3 hrs vs 2 together. The only risk I see potentially is if at 6 hrs from the first you give another 2 more than the patient has 3 in their system for a time.

It's a little scary that anyone would give a high dose of narcotic vs. a smaller one simply because they feel the need to follow the order to the letter. I can't imagine telling a patient, "no sorry, the doc ordered 2 percocet, it's 2 or nothing". Of course we can call the docs and get sliding orders put in or alter the order, which is maybe fine if responsiveness is good, but it's kind of a waste of time as a general policy. I had a patient worried that 2mg dilaudid would be too much for her since she's often sensitive to narcotics - I said "let's try one" and when she said that worked I approached the doc to change up the order. Changing it before would have limited me if it had ended up 2 was better for her in the end, and it would have involved several more phone calls. What's the point?

One of our new nurses had an anxious patient and asked the new resident for ativan. The doc ordered 2mg ativan IVP for an itty bitty old lady (!). The nurse was skeptical and chose to give 0.75mg instead to see how she tolerated it, and even with that the woman was zonked and difficult to arouse for the next 12 hrs. Docs, esp new ones, are not infallible, and it's safer to add more of a potentially sedating agent then to try to reverse an overdose. I often give 1 instead of 2 percocet, any prn I think can always be titrated down and if you need an official 'excuse' "pt refused full dose".

It's sort of a tricky topic. I'm in favor of more sliding and standing orders for pain management since seeing how a patient responds to and tolerates pain medicine is the duty of the nurse already, and it seems safer to leave some control in their hands vs. the voice on the other end of the phone who's not able to keep a close eye and isn't familiar with the patients hourly fluctuations. Just my :twocents: