meds--are we supposed to know EVERYTHING??

[MIA-RN1]

Ok for whatever reason, my pt has vicoden instead of percocet ordered. Q4h prn pain. So she wanted it round the clock since yesterday. I got her today. I got the first dose about five hours after her last dose, and another nurse gave her the next dose 4h later at my request since I was admitting another patient at the time.

So the nurse coming on after me tells me that there is too much tylenol in Vicoden to give q4 and that it should be q6h.

I am new enough to not have known. And I was told by the previous nurse (who is also an upper level nurse) that she wants it q4 and to give it that way. (Pt kept track and asked for meds, didn't automatically bring them in)

So what the heck...the order was over a day old, and no one said anything about too much tylenol before this. I am GLAD the nurse mentioned this, as I did not know it. I know that vicodin has tylenol, but I never dreamed that it was too much.

I am having trouble knowing what I should know, and not knowing htat I should know something that I don't know! Do I have to look up EVERY medication that is ordered? I always look up the ones I don't know, but the problem is that I thought I knew vicodin.

I didn't think to question the order because I didn't know I should question it.

I *thought* I knew vicoden, I was wrong I guess.

I call the pharmacy at the drop of a hat, with any medicine question, its not like I don't pay attention. I just plain didn't know.

I know I am at fault for not knowing and for not looking it up--but if I don't know, how do I know to look it up?

I am thinking of requesting that there be a protocol that ALL vicoden orders be standard at q6 unless there are special circumstances, or that each vicoden order clearly states the max dose.

anyway, I hate leaving work with that as the last thing done.

[ICRN2008, BSN, RN]

just as a heads up vicodin has 500mg of apap per tablet you can max out at 4000mg or 4g daily so you can actually give it every 4 hours because then it would be passed 6 times in 24 hours and would be at 3000mg. when dosing recommendations are followed, the risk of hepatotoxicity is rather low. check this book out for helpful tips.

actually, if you give 2 tablets q4h and there are 500mg of apap per tablet:

12 tablets x 500 mg = 6g of apap

most orders say not to exceed 4g of tylenol per 24h

[wooh, BSN, RN]

This is when it's good to alternate meds. Depending on the reason for the pain meds, maybe an order for Toradol or Ibuprofen to alternate with would be in order. Or I had an older lady that Darvocet seemed to be the only thing that worked for her pain. We got it changed to Darvon instead so we didn't have the risk of going over on the Tylenol, and that worked great for her. And keep in mind, if it's your typical post-op pain, once they start recovering, the need for pain meds should decrease, so even if the first 12 hours you're giving 2 q 4, once they're up moving around and recovering a bit, that should stretch out a bit time-wise, so even if it seems destined to go over the limit, it should balance out towards the end of that 24 hour period.

[MIA-RN1, RN]

just as a heads up vicodin has 500mg of apap per tablet you can max out at 4000mg or 4g daily so you can actually give it every 4 hours because then it would be passed 6 times in 24 hours and would be at 3000mg. when dosing recommendations are followed, the risk of hepatotoxicity is rather low. check this book out for helpful tips.

hang on i cant get that math straight.

12am 1000mg

4am 1000 mg

8am 1000 mg

12pm 1000 mg

the order was for two tabs, so after 12h the dose is maxed, isn't it?

[leaflet]

I've always learned NTE 4 g of acetominaphen in 24 hours, no matter what med it is mixed with

[MIA-RN1, RN]

it's very difficult to monitor vicodon over a 24/hr basis to determine if every nurse was giving it q4 or q6 hrs for 24 hrs. it is even more difficult to tell a pt they can't have it every 4 hrs if they have been getting it every 4 hrs; tends to piss pts off!!!!! We hand it out like candy on our floor. I try and offer 1 tab sometimes instead of 2 if I think the pt can handle it or offer something else 1 time out of my shift like a little morphine. Although, when a dr. orders it to take home with them on DC you know those pts are taking it every 4 hrs sometimes even sooner. I would just offer a lesser dose once during your shift or an alternate to see if the morphine or demerol or dilaudid will help the vicodin last longer 1 time during your shift. P.S. you can't know everything and you will never know everything; this is a constant learning job.

I was giving ibuprofen q6 and I did suggest to pt lets see how the ibuprofen does, maybe you won't need so much vicodin but then at four hours, pain is rated 6 and what could I do? I hardly even see morphine, demerol or dilaudid on our floor, so it didn't occur to me to think of that either!

I am glad I have today off becuase I don't feel like a very good nurse today.

[catlady, BSN, RN]

I am glad I have today off becuase I don't feel like a very good nurse today.

You mean you're not a perfect nurse today? That line forms over here. Right here, behind me. No pushing in the back of the line, kids.

[HappyNurse2005, RN]

Well, here's some good math

1 tab q4h=6 tabs per day

500mg tylenol per vicodin tab x 6 pills per day=3000mg tylenol per day, not exceeding max dose. Our Lortab orders always say not to exceed 4g per day tylenol.

Our pt's all get Lortab as a discharge med. (post surgery). I always write on the bottom to not take other Tylenol products while taking Lortab, and not to take more than 8 Lortab per day.

[MIA-RN1, RN]

Well, here's some good math

1 tab q4h=6 tabs per day

500mg tylenol per vicodin tab x 6 pills per day=3000mg tylenol per day, not exceeding max dose. Our Lortab orders always say not to exceed 4g per day tylenol.

Our pt's all get Lortab as a discharge med. (post surgery). I always write on the bottom to not take other Tylenol products while taking Lortab, and not to take more than 8 Lortab per day.

yep but the dose was 2 tabs so it 1000mg q4h so it was like 6000 mgs if she got it all. LIke I said, I spaced one out accidentally but I'm glad I did. I hope the other nurses today stayed on top of it.

[rehab nurse]

another great (sarcasm) thing about vicodin/lortab/norco (all those hydrocodone/acetaminophen combos) is this. if a pt has been taking 2 vicodin 5/500 pills every 4 hours (for whatever reason), you can always call the doc and maybe get just ONE lortab 10/500 one PO q 4. that happens a lot where we work. or even lortab 7.5/500. that way your pt is getting the hydrocodone in the same amount of 2 regular vicodins but a lesser dose of acetaminophen. not so hard on the liver.

i remember it this way:

vicodin=acetamin dose always increases with strength...i.e. 5/500, 7.5/750

lortab=is always over 500mg of tylenol. i.e. 5/500, 7.5/500,10/500

norco=always over 325mg of tylenol. i.e. 5/325, 7.5/325, 10/325

so if your pt gets adequate pain relief from two regular vicodins, but needs them every 4 hours to maintain relief, maybe doc will switch it to the 10/500 or 10/325 (norco) so your pt is getting good pain relief with less chance for hepatotoxicity.

hope this helps. i know a lot of nurses, even one of our physiatrists doesn't remember all the doses. they always refer everyone to me, the unofficial, uncertified "pain control" nurse. it's embarassing.

good luck!

one more thing. a lot of our pt's don't get demerol, dilaudid, or morphine. vicodin hands down is the number one. however, if pt's will be on long term meds, sometimes we start them on duragesic as well. though sometimes the elderly don't handle it well. if they start on 25mcg, or even the new 12.5 mcg patch, you might be able to cut down the vicodin usage in a day or two when the fentanyl kicks in. and then the vicodin would only be needed for b/t use.

just wanted to offer that as well. it all depends on how long the pt is to be expected to be in pain, if they have other disease processes that contraindicate, if they have other chronic pain issues, etc. it's all very individualized.

when i started out too, i had a hard time remembering all the combo meds. i actually looked up the common ones, typed them out and made a page of it for my clipboard at work. if a new one came up, i added it. before i knew it, i know most by heart. don't beat yourself up over it. you learned now. i know some nurses who have been nurses since i was born and they don't know. heck, like i said above, docs will ask me as well sometimes. you'll have them down pat before you know it.

i'll shut up now.

[MIA-RN1, RN]

thanks rehab nurse! Want to come work with me? LOL

[P_RN, ADN, RN]

To the OP's initial question: No you are not supposed to know everything, but you are supposed to know where to find the correct answer.

Our pharmacy refused to stock various strengths of Vicoden etc. They even got a waiver to make percocet/tylox equivalent (though they aren't) depending on which provider gave the lowest price.

What we were able to obtain were orders for the narcotic alone or with apap so that the apap wouldn't exceed 4k a day.

The pharmacy put out a formulary that listed what they carried. If a doc ordered something not there, then the PharmD would contact the doc with requests for what was IN formulary.

[rehab nurse]

thanks rehab nurse! Want to come work with me? LOL

if that's a job offer, i'm there! lol....i need a different job. need to get far away from job. i'm on medical leave now because it got to me so bad. i'll be the first one to vouch that stress does make everything worse.

would love to move to NY...my brother is there. *sniff*

hope i helped a little bit :)