Confusion over pain med administration

Specialties Pain

Published

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.

You have a policy says pain reassessments can only be done at 1 hour? A common time to reassess pain aside from when you would expect it to take effect is when you would expect it to no longer be effective, why would you limit nurses to reassessing only the initial effect?

No later than one hour after administration of any pain med. Nursing judgment based on onset of action. Also during normal vitals.

Up Vote Up Vote ×

At the end of the day, it comes down to practice standards of the hospital. If the op can identify what the in house rules are through their safety rep, then that's how they should approach the subject. I wouldn't correct the other RN unless I had something concrete.

Up Vote Up Vote ×
Specializes in Critical Care.
No later than one hour after administration of any pain med. Nursing judgment based on onset of action. Also during normal vitals.

Proper nursing judgement according to professional practice recommendation is to base the timing of reassessments on both the onset and the duration of action. And while the JC used to recommend reassessing PO pain medication "within one hour", they dropped that recommendation in 2003 after it was discovered that 'recommendation' actually came from a faux-practice organization called the American Pain Foundation, which it turned out was a front group for a number of opiate manufacturers with the intention of encouraging overuse of opiate medications. (Dosing by pain score and 'pain is the fifth vital sign' also came from this group).

The current JC standard on pain reassessment is that "the hospital reassesses and responds to the patient's pain based on it's reassessment criteria". The hospital is only required to follow whatever criteria the hospital chooses. Requiring that pain must be reassessed and re-medicated "no later than one hour after" the initial dose is bad practice. The full effect of a PO opiate can take a full hour to occur, in most care environments, it's unlikely that a nurse can predictably be assessing at 59 minute mark, and if their reassessment must occur in less than one hour, then it's quite possible it's going to have to occur 15 minutes after it was given since there may not be another opportunity until 1 hour and 5 minutes after it was given. It's far more appropriate to reassess at 65 minutes than at 15 minutes and an effective an safe policy would have to reflect that. It's also unlikely that any physician actually intends that reassessments can't be done based on the known characteristics of the medication, so this would violate JC standards.

Up Vote Up Vote ×

Our policy is to reassess for medication side effects and pain response... not redosing. An hour is appropriate for noisy PO opiates and much sooner for iv push meds. But I'm not here to discuss the rights of wrongs of our hospitals medication administration guidelines. Joint commission had no problem with them as written.

Up Vote Up Vote ×

The order is poorly written. First it says give 1 or 2. Then it says give 1 and then a 2nd one in an hour if pain is still bad. So really there isn't an order to ever give 2 at once. And do the 6 hours start over after the 2nd tab?

An order that causes so much confusion just needs to be written over.

Up Vote Up Vote ×
On 2/23/2018 at 4:26 AM, Have Nurse said:

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.

According to your reply - "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", could you please let us know how did you calculate the duration of 6 hours?

Did you calculate from the 5th hour giving the 2nd tablet which is a partial dose of PRN range analgesia during the first 6 hours to the 11th hour of the second 6 hours?

In other words, did you calculate the duration of the second 6 hours from the time point of the last partial dose of PRN range analgesia during the first 6 hours to the 11th hour of the second 6 hours?

If so, does it mean the patient can only take a potential third due dose of PRN analgesia as early as the 11th hour?

If the patient still has pain at another time point after the 5th hour and before the 11th hour, according to your reply, "just understand that it will be another 6 hours before they are due again", as it is not at the 11th hour yet.

Could you please provide literature to support your judgement?

Up Vote Up Vote ×
Specializes in Transitional Nursing.

If you give the 2nd med at hour 5 you'd have to wait another 6 hours to administer another dose. Wouldn't it be better to wait the hour and administer two tabs?

Up Vote Up Vote ×
Specializes in Transitional Nursing.
On 4/9/2019 at 8:29 AM, Nursing Au said:

According to your reply - "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", could you please let us know how did you calculate the duration of 6 hours?

Did you calculate from the 5th hour giving the 2nd tablet which is a partial dose of PRN range analgesia during the first 6 hours to the 11th hour of the second 6 hours?

In other words, did you calculate the duration of the second 6 hours from the time point of the last partial dose of PRN range analgesia during the first 6 hours to the 11th hour of the second 6 hours?

If so, does it mean the patient can only take a potential third due dose of PRN analgesia as early as the 11th hour?

If the patient still has pain at another time point after the 5th hour and before the 11th hour, according to your reply, "just understand that it will be another 6 hours before they are due again", as it is not at the 11th hour yet.

Could you please provide literature to support your judgement?

Whaaa.....what?

Up Vote Up Vote ×
+ Add a Comment