Confusion over pain med administration

[HarmonyStewart]

I am orientating to a new hospital and while orientating on the floor, pain management was brought up between my orientator and me. My patient had an order for Norco 1-2 tabs every 6 hours. At the bottom of the order it also said "give one and if pain not controlled after an hour, give another." My patient received one tab and approximately 5 hours later was having more pain. I brought up to the RN working with me that she can have another Norco because the order was 1-2 within 6 hrs. She had only received one. She told me I can't do that. If they only take one and don't take the second within an hour they can't have another tab for 6 hours. What? I argued with her and she said I'd have to call the doctor to get an order to give a second tab early. This just seemed bizarre to me. Seems like she would not be properly controlling the patients pain by this method.

[chare]

As I interpret the order, your preceptor is correct.

[HarmonyStewart]

So it is specifically because of the "give one tab then hour later give second tab" that makes the patient unable to have a second tab say 3 hours later rather than one hour? I guess I've just never seen a pain order written like that.

[MunoRN, RN]

There is no set definition to this sort of thing, the requirement is that the ordering provider and the person interpreting the order have a common understanding of how the order is to be followed. If there are uncertainties, they should be clarified. I generally though wouldn't assume that the ordering provider didn't intend for the patient to get up to 2 tabs in a 6 hour period if indicated, since the order clearly includes that is allowed by the order. The added instruction to that range, to reassess the patient's pain 1 hour after the initial dose to see if the other dose is needed doesn't appear to mean that this is only time the patient can receive the remainder of the range ordered.

[NutmeggeRN, BSN]

We cannot have a mixed order anymore in my LTC facility. It has to be one tab for one pain level, and another order that says 2 tabs for a different or higher level. Paremeters determined by MD. Goes for narcs as well as OTC analgesics. The pain is one or the other and the PRN is given accordingly.

[Have Nurse, ADN, RN]

If there is no specificity as to when you may give the 2nd tablet, you can give it at the 5th hour, just understand that it will be another 6 hours before they are due again. Not sure why this is an issue though, as in the hospital setting, you can give a med 30 minute earlier than it's due, or 30 minute later.

Was there anything you could have given in between that wasn't a narcotic? Sometimes that can help the pain med work better and longer.

[djmatte, ADN, MSN, RN, NP]

The order itself is faulty and can be problematic for the patient. If you gave a single dose now and gave the second dose 5 hours later, there is confusion as to when the next dose is given. Technically the next round is an hour after the second dose. You are running into a situation where in theory that patient could receive 3 doses in very short succession. You also could run into a situation where pain is not well controlled if you go by the last dose given.

Another thought on it is what is clearly stated here is that the follow-up dose should/should not be given in 1 hour. It doesn't establish further intervals or state that the nurse has a 6 hour window to give whenever he/she chooses.

[MunoRN, RN]

The order itself is faulty and can be problematic for the patient. If you gave a single dose now and gave the second dose 5 hours later, there is confusion as to when the next dose is given. Technically the next round is an hour after the second dose. You are running into a situation where in theory that patient could receive 3 doses in very short succession. You also could run into a situation where pain is not well controlled if you go by the last dose given.

Another thought on it is what is clearly stated here is that the follow-up dose should/should not be given in 1 hour. It doesn't establish further intervals or state that the nurse has a 6 hour window to give whenever he/she chooses.

The order states "1-2 q 6hrs" so I'm not sure what's unclear about that, the patient can have up to 2 tabs in any 6 hour period of time.

I agree there's the potential for under controlled pain since Norco lasts for about 3-4 hours and the doc should be questioned on the interval.

[djmatte, ADN, MSN, RN, NP]

The order states "1-2 q 6hrs" so I'm not sure what's unclear about that, the patient can have up to 2 tabs in any 6 hour period of time.

I agree there's the potential for under controlled pain since Norco lasts for about 3-4 hours and the doc should be questioned on the interval.

The order later clarifies the exact interval I when to give the second dose. It literally means you can only give one dose (regardless of pain score) and the second dose needs to be given one hour later if needed.

[MunoRN, RN]

The order later clarifies the exact interval I when to give the second dose. It literally means you can only give one dose (regardless of pain score) and the second dose needs to be given one hour later if needed.

I'm not sure how you're getting that from the order. The MD wants the pain reassessed an hour after giving the initial dose, but does not prohibit given the second half of the range at a time other than one hour after the initial dose, the range limits the dose that can be given in a 6 hour period to 2 tabs, but doesn't say you can't complete the available range in hours 2-5.

[djmatte, ADN, MSN, RN, NP]

Just because it doesn't prohibit doesn't mean the nurse gets permission. It says how frequent the med is allotted (every 6 hours) and a clear instruction on when to give the second dose. Give it outside that that a lawyer would be all over you. We also went through this exact scenario with the joint commission a year ago.

[MunoRN, RN]

Just because it doesn't prohibit doesn't mean the nurse gets permission. It says how frequent the med is allotted (every 6 hours) and a clear instruction on when to give the second dose. Give it outside that that a lawyer would be all over you. We also went through this exact scenario with the joint commission a year ago.

It asks that the patient be reassessed at one hour and the second tab be given if needed, it doesn't state that this is the only time the second tab can be given, I'm not sure where you are getting that from.

The legal standards for range orders as well as regulatory standards are well established, there is no standard prohibition for giving the remainder of a range order within the ordered timeframe.