correct way to administer synergistic medications:

[antimafia]

patients are in pain. they "tell you" they itch when they receive pain medication. they also say, whatever they are receiving isn't providing relief. they want the "for breakthrough pain" medication too.

for example, 1mg dilaudid IV, 25mg benadryl IV/PO, (2) norco 10/325

do you administer simultaneously? or hour(s) apart?

i transferred from a telemetry unit to a med/surg floor. and "their practice" is to give them each an hour apart. when i was a telemetry nurse, i dumped all of this into a patient.

how do you approach this?

some of the veteran nurses told me to give partial doses of the IV medications (dilaudid/benadryl) and diluate in a saline flush. i'm not sure this is good/legal practice.

[Okami_CCRN, BSN, RN]

If a patient states that hydromorphone causes itchiness, then I pre-medicate with diphenhydramine as ordered. I usually administer diphenhydramne IVP over 2-4 minutes. I wait about 15 minutes and then I come back with the hydromorphone and administer that IVP over the same amount of time, with a flush at about the same rate.

If the patient continues to c/o of pain then I would administer their breakthrough medication 30-45 minutes after the administration of their PRN hydromorphone.

Diphenhydramine does not cause respiratory depression, but may cause drowsiness, the main concern with hydromorphone is respiratory depression that can result in inadequate ventilation/oxygenation. It is important to administer it slowly and monitor opiate naive patients closely. Patients on narcotics in the hospital should have nalaxone ordered PRN or at least be an over-rideable med in the Omnicell/Pyxis.

[NurseGirl525, ASN, RN]

Here is what I do.

i would administer one of the norcos. I wait 30 minutes. If they are still in pain, I administer the second. Usually that works, PO meds yes take longer to take affect, but last way longer than the dilaudid abd that is how I explain it to patients. 95% of the time that works. If there is itching, I give the Benadryl first then the hydromorphone.

I find the right group of meds to give to get the pain under control, then go with that, but it is trial and error for me and I start out with the lowest dose and go from there.

There is no need to dilute hydromorphone. If you push the flush behind it slowly, they don't get that huge rush, that apparently some nurses think they are preventing by diluting. There's too much of a chance for an error by trying to dilute on your own. If it actually was an issue, pharmacy would send it that way to you, or, you would have an order on how to dilute it. You only need to dilute vesicants.

Start out low, then go up to get the pain under control. Some people need all of that pain medication, some do not. Everybody is different. But you shouldn't just automatically give that much.

[Here.I.Stand, BSN, RN]

Like the above posters, I give one pain med and reassess.

Itching is a known side effect of opioids, and if the pt is known to experience it I premedicate with the Benadryl. Making the pt wait an hour for itch relief is just plain cruel. Itching could almost be an enhanced interrogation technique.

Giving partial doses, no. If the ordered dose is 0.5-1 mg, no you can't give 0.2 mg. That is an intentional med error and practicing medicine.

I dilute vescicants only. Dilaudid, fentanyl, and morphine are not vescicants.