Doctors orders

[new_worker]

Hello all i have a question regarding new orders. Say you have a patient with a pain and the regular standing orders are Tylenol 250 mg P.O q6h PRN. if you give them the pill and they are still in pain within one hour. What i would do is message doctor saying:

"MR. Smith complained about pain 4/10 in left upper quadrant, given Tylenol 250mg as per standing orders and it was ineffective, patient is still in pain 4/10. Any suggestions?"

and doctor replies, " Tylenol 500mg P0 B.I.D"

So i would chart in Nursing notes about the patients pain, sent doctor a fax about it and next send pharmacy the copy of the doctors orders. then begin with the pain med when appropriate correct. I have to contact family or not

So i have questions:

1) Am i missing anything??

2) Its not necessary to contact family is it? just double checking? or would you make them aware of it but it might go away but since its doctors orders maybe just update them on the situation??

Thanks all

[LPNweezy]

Is there anyone at your place of employment who can help you with this? i think your boss may have the best advice for you on the policy of your facility. :)

[Forever Sunshine, ASN, RN]

Well it would depend as per your facilities policy. But its not something I would notify the family for. If it was a serious change in the residents condition and you were contemplating sending them to the hospital or having diagnostics done such as an x-ray or ultrasound...then I'd call the family.

[Kooky Korky, BSN, RN]

250 is an odd dose. I've never seen it. Maybe in Peds?

Usual is 325 or 650. I know that was not your question.

No I would not call family about it unless it was policy.

An hour isn't really long enough for the action to peak, I don't think. Perhaps by another 30-60 minutes it should be peaking and your pt should be getting relief.

You can, of course, offer other comfort measures. Talk with her, distract her, try a little pressure from a pillow against the sore area. Reposition her, things like that. It's amazing how positively react when we take the time to speak with them, hold their hands, adjust their pillow or blanket, offer a little sip of warm milk, get them to talk about their kids or pets, etc.

I think your other question was when to start it. How long to wait after you already gave a dose. Well, this new order is BID, not PRN. So you'd have to go by whatever BID is at your facility. Often 0800 or 0900 and 2000 or 2100.

that could mean a very long wait to give another dose.

I think you should ask a charge nurse or supervisor for a little help. If your pt had had only 250, I'd be tempted to give another 250 to = the 500 and look upon it as the first dose of BID dosing.

[Isabelle49]

Does tylenol even come in a 250 mg dose? Depending on the cause of pain, what has been prescribed seems least effective for relief.

[agldragonRN]

i would not contact the family for this unless it is a policy in your facility. yeah i have not seen a 250 mg dose for tylenol and you gave only one tab of this? maybe that is why it was ineffective. the usual dose in my facility is 650 mg q 4 hrs prn.

you can try many non-pharmacological interventions for pain and one of the poster's above suggested many of them. i would just add that you can also reposition patient, offer distractions such as turning on the tv or music to their favorite channel, offer to fix their bed linens, fluff the pillow, offer back massage, etc..

[LPNweezy]

Does tylenol even come in a 250 mg dose? Depending on the cause of pain, what has been prescribed seems least effective for relief.

Maybe the person has a liver issue and they are using only half of the 500mg tablet.

[loriangel14, RN]

Oh dear, if I had to call the family every time a med was changed I would be on the phone a lot.

[P_RN, ADN, RN]

Check with your pharmacy to see if 0.80 ml is equal to 80 mg in a liquid is available to use. Then calibrate the liquid Tylenol.Then 1 ml would equal 100 mg etc.

Frankly I wouldn't worry. I'd give what would bring it you to the new order as soon as possible then the new 500 mg the next time. It will probably have to be from a liquid source and calibrated well.

[tyvin, BSN, RN]

I wouldn't say "any suggestions". As an RN you should have an idea of what you want for the patient. The patient could be allergic or have a bad reaction to certain meds that's in the chart or admission notes or your pharmacy might not carry certain meds etc... so it's a good idea to have specifics at the ready.

I always know what I'm going to ask for before I contact a doc. Docs want to hear specifics not questions. And know your docs on what they'll give and not give; it saves a lot of time. Don't contact the family for; medication changes unless it's Abx, the doc tells you to, or it's something specific that the family requested to be contacted about concerning the meds.

Good Luck

[new_worker]

thanks for all replies :)

Sorry to confuse everyone with the dosages. i just made up that Tylenol 250mg question. this is not a true scenario i just wanted to see how you would go through it and if there is something further needed to be done that others would that I would of forgotten to do.

So thanks again

[CoffeeRTC, BSN, RN]

Oh dear, if I had to call the family every time a med was changed I would be on the phone a lot.

I try to call the family with med changes. (yes, some people have tons of them too). Normally, I will let them know if it is a new order because it is a new problem. Infections/ antibiotics...Psych meds..esp those that will sedate or take a while to adjust. There is nothing worse than having a family member (or being that family member) come into the facility and find out that mom or dad is on a ton of different meds that they really didn't need in the first place and the nurse never really questioned the doc.

I've had some people started on expensive appetite stimulants when all they really needed was a dietary consult or asking the family about food issues.

Or...starting a resident on a narcotic and finding out the hard way that they go bezerk or that "Mom eats them like candy"

The tylenol issue in this senario..probably not calling about that one unless again...there is an uderlying issue.