Do separate Norco orders stand alone

Here.I.Stand, BSN, RN · May 3, 2017

The way that reads, it seems to me it's a q 4 hr order with a dose range. However if the pt's pain is not well controlled, you should contact the MD/NP for new orders. They might dc that order and write for 2 5/325s q 4 hrs prn (that would give more of the opiate AND the equivalent of a standard dose of Tylenol...not sure about others, but I never bother with 1 Tylenol). Or they might order an IV med for breakthrough pain.

What I see more often is Norco/Percocet orders which are limited by the acetaminophen content. Giving a combo drug more often could result in >4000 mg in 24 hrs. In THAT case, lots of times they add an order for plain oxycodone for breakthrough, or an IV med.

MunoRN, RN · May 3, 2017

I would argue that any provider who is ordering opiates using this dose-by-the-number formula isn't competent enough to be ordering opiates, and any facilitate that encourages this practice should be shut down, but I digress.

How dose-by-the-number orders are intended to work varies since there is no rhyme or reason to provide a common definition. But generally these are seen as two different orders based on two unrelated parameters, the same as if you gave Zofran for nausea it wouldn't prevent you from giving hydralazine for hypertension 10 minutes later. So if the patient's pain was 9 and you gave 10mg, and then 10 minutes later it's 4 then you could give 5 mg. The other problem is that these orders create the potential to exceed the daily APAP limit, and having acetaminophen in two different orders increases the chance for give too much acetaminophen.

quiltynurse56, LPN, LVN · May 3, 2017

It doesn't look like it to me. You assess the pain and give them one or the other. If they are still have pain less than the 4 hours, I would call the MD or NP for further orders.

Trauma Columnist · May 3, 2017

Moved to nursing student assistance forum

Kuriin, BSN, RN · May 3, 2017

It really depends on the facility. Our facility, you can actually link orders so that if you give the 5mg version, you CANNOT give the 10mg version until the 4 hours are up. Vice versa. However, they also do allow you to give one pain medication and then another within like an hour.

But, they really should have a medication readily available for breakthrough pain -- either sublingual or via IV.

Mavrick, BSN, RN · May 4, 2017

Hi, im a nursing student so forgive me if this question is a bit elementry.
If a patient has 2 separate orders for Norco that read:
Norco 5/325 1 tab PO Q4hr PRN Pain (4-6)
and
Norco 10/325 1 tab PO Q4hr PRN Pain (7-10)
Is it ok to give a patient a 5/325 2 hours after giving them Norco 10/325 if the patients pain is still in the (4-6) range. Do the orders stand alone or not?

You have every reason to be perplexed by these orders. They are confusing and will be interpreted differently by different nurses which makes them unacceptable.

I could easily rationalize giving Norco 5/325 then two hours later give 5mg hydrocodone (if the patient's pain had gotten worse) and "restart" the 4 hour time as if I had given the Norco 10/325.

I could also see a scenario where you assess the patient's pain every 4 hours and give one or the other Norco then wait 4 hours to assess and decide again. Thus giving the Norco 10/325 every 4 hours would result in the patient receiving 1,950mg of acetaminophen and 60 mg of oxycodone in a 24 hour period.

If these orders were to "stand alone" , the patient could receive 3,900mg of acetaminophen and 90mg of oxycodone in a 24 hour period.