Multiple prn pain meds requested all at the same time

  1. I have a question for ya ... been struggling with this for a bit... While working in a SNF, I have a patient who receives scheduled pain medications as follows: oxycodone 15mg q 4 hrs, gabapentin 300mg QID .. she also has a fentanyl patch 75mcg/hr. She is requesting the following prn meds to be given to her at the same time as the scheduled meds -- morphine sulfate liquid 10mg for chronic pain and fioricet for migraine. She tells me the 'squirt' medicine is to be given with the fioricet so as to give it a 'boost' to help make it work. Any PDR I've referenced advises not to give together as each one can cause respiratory depression. I'm concerned with giving them all together..."do no harm". This pt is also on hospice. I've notified the resident's PCP, asking for parameters and/or recommendations as regards the above.

    Have any of you nurses run across this type of issue and/or what are your thoughts? I appreciate your input greatly ... I have talked with my supervisor and she has given me direction as well. Thanks so much!
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    About lots2care4, LPN

    Joined: Jun '08; Posts: 18; Likes: 14

    10 Comments

  3. by   brownbook
    I am not clear on why you posted this in addiction nursing? A patient in a SNF and under hospice care is not considered addicted to drugs!


    Your should go by what your supervisor told you...But I am hoping, assuming, her advice was proper? Ideally you could ask your supervisor to write down her directions.

    You have to go by how the patient is reacting to the medication. Is she is sitting up, talking, easily aroused? Is her blood pressure, heart rate, and respiratory rate, within the normal parameters....or even what is normal for her (may not be what is normal for the average person)? Then she can take all these medication as ordered. Her body is used to these potent drugs.

    If you can't easily arouse her or her vital signs are poor...(do you have access to pulse oximetry?) then you can notify the PCP that such and such drug was not given due to the patient being difficult to arouse or due to such and such vital signs.

    You should re-post this question in the Hospice / Palliative Nursing specialty section. This is not my area of expertise. There you would get replies from nurses who deal with this daily.
    Last edit by brownbook on Dec 7, '17
  4. by   vampiregirl
    I would recommend collaborating with the patient's hospice team. Agree with previous poster that addiction isn't a concern in hospice. What is a concern to me from your post would be this patient's symptom management - the different pain meds you are referring to address different types of pain (or may be attacking the pain from different directions). Sounds like some adjustments to the plan may me needed for more effective symptom management. People with chronic pain often appear to be "tolerating" the pain well but may still be very much in pain.

    Or there may be something deeper that needs to be addressed also - both related to the pain and to having a terminal diagnosis. Hospice also has other resources - chaplain, social worker to help the patient. Maybe a volunteer would be helpful to spend time with the patient - sometimes a diversion and support will help a patient feel more relaxed which contributes to pain control.

    The previous poster gave you great considerations for patient assessment which will help you gauge the effectiveness of an intervention as well as monitor for side effects. Often times hospice orders are not what is typically seen in a LTC. Good for you checking into the PDR - we don't disregard that info just because it's a hospice patient.
  5. by   hppygr8ful
    Quote from vampiregirl
    I would recommend collaborating with the patient's hospice team. Agree with previous poster that addiction isn't a concern in hospice. What is a concern to me from your post would be this patient's symptom management - the different pain meds you are referring to address different types of pain (or may be attacking the pain from different directions). Sounds like some adjustments to the plan may me needed for more effective symptom management. People with chronic pain often appear to be "tolerating" the pain well but may still be very much in pain.

    Or there may be something deeper that needs to be addressed also - both related to the pain and to having a terminal diagnosis. Hospice also has other resources - chaplain, social worker to help the patient. Maybe a volunteer would be helpful to spend time with the patient - sometimes a diversion and support will help a patient feel more relaxed which contributes to pain control.

    The previous poster gave you great considerations for patient assessment which will help you gauge the effectiveness of an intervention as well as monitor for side effects. Often times hospice orders are not what is typically seen in a LTC. Good for you checking into the PDR - we don't disregard that info just because it's a hospice patient.
    I might also add from my own experience with a father dying of Bone Cancer. There comes a point when even the strongest pain medicines have little or no effect. Towards the end we were giving with Physician and Hospice blessing Morphine every hour. He would go down and relax for about 15 minutes before the pain overwhelmed him. Hospice is about keeping the patient comfortable and providing a death with dignity not excruciating pain. I agree OP needs to seek out hospice care forum rather than addictions.

    Hppy
  6. by   lots2care4
    Thank you ladies so much for your words of advice. This resident is in a LTC facility and is on Hospice; however, she continues with all her regularly scheduled meds along with the prns. I was not comfortable giving what she was asking for and I believe she is in pain but, she wanted them all at once and wanted to argue about it. Numerous attempts I made to have the resident understand my concerns went unnoticed; I notified her PCP who wrote an order for parameters and distinct orders, 'do not give prn morphine with fioricet, oxycodone or gabapentin'. This has helped immensely. I agree she should discuss her concerns with the Hospice RN and go off a lot of the 'non-essential' meds and stick to bringing her pain under control. I have worked for Hospice and love the concept.

    Again, I thank you ladies greatly! Have a great holiday!
  7. by   candacern59217
    I would check the back charting. If this is how it's been administered before and the patient is clearly tolerating it then I would administer it that way per patient request.

    They're on hospice. I don't withhold meds from hospice patients.
  8. by   hrnurse
    The PCP wrote an order for parameters . Hospice or not , nurses can question parameters and prn meds . Better to clarify than blindly accept what the pt reports .
  9. by   MunoRN
    Quote from lots2care4
    Thank you ladies so much for your words of advice. This resident is in a LTC facility and is on Hospice; however, she continues with all her regularly scheduled meds along with the prns. I was not comfortable giving what she was asking for and I believe she is in pain but, she wanted them all at once and wanted to argue about it. Numerous attempts I made to have the resident understand my concerns went unnoticed; I notified her PCP who wrote an order for parameters and distinct orders, 'do not give prn morphine with fioricet, oxycodone or gabapentin'. This has helped immensely. I agree she should discuss her concerns with the Hospice RN and go off a lot of the 'non-essential' meds and stick to bringing her pain under control. I have worked for Hospice and love the concept.

    Again, I thank you ladies greatly! Have a great holiday!
    That doesn't make any sense. The gabapentin for instance is always active in their system when taking it as scheduled, so by that logic they can never have any prn morphine.
  10. by   chare
    Quote from lots2care4
    ...oxycodone 15mg q 4 hrs, gabapentin 300mg QID .. she also has a fentanyl patch 75mcg/hr. She is requesting the following prn meds to be given to her at the same time as the scheduled meds -- morphine sulfate liquid 10mg for chronic pain and fioricet for migraine. She tells me the 'squirt' medicine is to be given with the fioricet so as to give it a 'boost' to help make it work...
    [...]
    With what she scheduled, I think I would have given her what she wanted, particularly if she was awake and in no respiratory depression.
    Quote from lots2care4
    ...Any PDR I've referenced advises not to give together as each one can cause respiratory depression. I'm concerned with giving them all together..."do no harm"...
    [...]
    These recommendations typically refer to patients that are narcotic naïve, which this patient definitely wasn't. She has probably been receiving these medications in the manner requested for some time.
    Quote from lots2care4
    ...This pt is also on hospice. I've notified the resident's PCP, asking for parameters and/or recommendations as regards the above.
    [...]
    The fact that she is hospice is all the more reason that she should have received the requested medications.
    Quote from lots2care4
    Thank you ladies so much for your words of advice. This resident is in a LTC facility and is on Hospice; however, she continues with all her regularly scheduled meds along with the prns...
    [...]
    With the modification and parameters that you requested. How long ago did all of this transpire? Is the patient's pain under control? If the pain regimen that concerned you was working, noe that you've had it modified her pain might no longer be controlled.
    Quote from lots2care4
    ...I was not comfortable giving what she was asking for and I believe she is in pain but, she wanted them all at once and wanted to argue about it.
    [...]
    I can't understand this, you state that you believed her complaint of pain, but yet you wouldn't give her the requested medications. If she had been on narcotics long enough to have a 75 mcg/hour fentanyl patch, it is highly unlikely that 10 mg oral morphine sulfate and one Fioricet were going to cause any respiratory depression.
    Quote from lots2care4
    Numerous attempts I made to have the resident understand my concerns went unnoticed; I notified her PCP who wrote an order for parameters and distinct orders, 'do not give prn morphine with fioricet, oxycodone or gabapentin'. This has helped immensely.
    [...]
    Helped who? You? Or the patient? And why didn't you contact hospice if you had a concern with her pain medication treatment plan?
    Quote from lots2care4
    ...I agree she should discuss her concerns with the Hospice RN and go off a lot of the 'non-essential' meds and stick to bringing her pain under control...
    [...]
    What "non-essential" medications do you believe her to be on? Don't you think it would be appropriate to voice your concerns to hospice, as you seem to be the one with the most?
  11. by   cayenne06
    Quote from lots2care4
    This resident is in a LTC facility and is on Hospice; however, she continues with all her regularly scheduled meds along with the prns. I was not comfortable giving what she was asking for and I believe she is in pain but, she wanted them all at once and wanted to argue about it.
    What made you uncomfortable about the situation? Are you concerned that she might be seeking a high, as opposed to pain relief? If so, who cares?! She can get high, she's in HOSPICE for goodness sake. I mean really.

    In terms of resp depression, I would imagine she has requested and received this cocktail regularly, so you could look back at her chart to make sure she has been tolerating it.


    If you are concerned that her current treatment plan is not addressing her underlying pain, then continue the PRNs as she desires and work with the doc to make a better plan that she is comfortable with.
  12. by   Tenebrae
    I've nursed a hospice patient who 600mcg of fentanyl in a syringe driver running over 24 hours.


    Mum recently died of lung cancer. Prior to going into hospice she was on 140mg long acting morphine with 10-40mg of short acting morphine for break through pain. She would periodically overdose herself but because she was on such high doses of morphine, all it made her do was sleep for hours

    When my mum was dying she had 140mg morphine in her pump, she was also getting 10-20mg morphine Q3

    The questions I would have
    - Is your patients pain being adequately managed?
    - Does your patient show any signs of respiratory depression on the current pain regime.

    If your patient is on hospice, they are dying. Your focus as a nurse should be on making sure they are as peaceful and relaxed as possible

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