General and Ped Questions- pls help

ParkerBC,MSN,RN, PhD, RN · Nov 25, 2010

1. Since Garvol is not a controlled substance, you can put it back in the cart for multi-dose. If it is reconstituted, you will want to put your initials and date on the vial. If you are drawing up a controlled substance and are not going to use it all, you have to waste it with a witness (another nurses) who will sign as the witness.

2. What medication are you diluting? If you are reconstituting the medication, it is done in the vial. If you talking about pain medication and diluting it to decrease the burning sensation the client will feel when giving it IV, draw your NS first, then morphine. I have seen and used different size syringes. For my special patients, those who are “frequent flyers” although I ignore the term, I use a larger syringe as it give the appearance they are getting more.

3. 5 mg is the maximum that can be given in a 3 hour time frame. Start small and work your way up if needed. Some hospitals have policy as to what drug and amount based upon the pain score. Anyways…let’s say you gave 2 mg at 0730 and the client is at a 7/10 at 0930. You can give another 2mg dose. Then at 1100 perhaps the client is a 4/10, then give the other 1mg. I have let the clients know the maximum amount within the time frame and asked how they would like for me to handle their pain management. For example, you have 5mg over 3 hours. I can do 1.6 mg every hour or 2mg, 2mg, and 1mg. Also, there is generally a PRN given for breakthrough pain.

4. Yes

decembergrad2011, BSN, RN · Nov 25, 2010

3. 5 mg is the maximum that can be given in a 3 hour time frame. Start small and work your way up if needed. Some hospitals have policy as to what drug and amount based upon the pain score. Anyways...let's say you gave 2 mg at 0730 and the client is at a 7/10 at 0930. You can give another 2mg dose. Then at 1100 perhaps the client is a 4/10, then give the other 1mg. I have let the clients know the maximum amount within the time frame and asked how they would like for me to handle their pain management. For example, you have 5mg over 3 hours. I can do 1.6 mg every hour or 2mg, 2mg, and 1mg. Also, there is generally a PRN given for breakthrough pain.

This isn't my knowledge of medication administration. To the best of my knowledge, PRN medications are written to give some amount of leeway in dosage and time administered, but not in amount of doses or time between doses. You should not be splitting up a standard written order into smaller amounts to give over time. And even with PRN medication, it's my understanding that you choose to give an amount at Point A, and cannot give more even if you have not exceeded the max dose until the window open up for Point B.

Order: Percocet 1-2 Tab PRN pain Q6 hours

Example: Patient states they are in 5/10 pain at 4:45 am, you give 1 tab at 5:00 am. You cannot give another tab until at least 11:00 (or some hospitals are okay with giving it within an hour window, so 10:30-11:30) would be within the hour of 11:00. What that order is saying is to make a choice with your nursing judgment: Does your patient need 1 or 2 tablets based on the amount of pain they are in?

This situation is often why more than one pain medication is prescribed for breakthrough pain. If you could break up the dosage within a certain timeframe, the order would be written that way.

glovedgoddess · Nov 26, 2010

These two replies are the exact reason as to why I am confused about pain managment! My instructor mentioned to me that the way the RN had administered the morphine was acutally the more effective way giving small amounts of morphine more often (why havent doctors caught on to this and written the order this way?? Because nurses dont have time to run around giving pts morphine every hour?. Because IV morphine has a such a short half life, if 2 mg is given at 0730 and the patient has that 7/10 pain at 0930 (^sorry I just realized I had put 1115, wow could my math be any more off?) than really how is that pain supposed to be managed until 1030? The only other pain meds that were ordered for this patient were tylenol and advil. Ideally should PO morphine have been ordered for maintenance and IV for breakthru??

If I ever question this in the future, should I phone the doctor to inquire about having the order written as q2h or q1h so that I am not administering the morphine as I please q couple hours while keeping until the maximum dose?

ParkerBC,MSN,RN, PhD, RN · Nov 26, 2010

i am sorry my response was confusing. the other poster did a good job of providing an example of how to administer a prn along with the morphine.

your instructor is correct. give less more often is how i learned to better manage my client’s pain. why don’t doctors simply write an order stating such? you know as well as i do that everyone tolerates pain differently. some may need the medication spread out (for a total of 5mg) while others may only need a 2mg bolus at the beginning of the 3 hours and are fine. i think this is why doctors write the orders the way they do. i am surprised to hear your patient had advil and tylenol as prn pain medications for breakthrough pain.

often times in addition to the morphine, the client has a prn order for let’s say percocet. give 1-2 tabs every 6 hours prn for pain. so, if your client is still experiencing pain after a 2mg bolus of morphine, it can be suggested to the client that another kind of pain medication is available. i know some facilities have policies as to the number of tabs to give based upon the pain level. you will have to check with your clinical instructor about those policies.

you bring up a good point. it is difficult to stop in the client’s room every hour for pain management, but i would much rather do that than allowing their pain to reach a 7 or above. besides, if the client is in a lot of pain, they are on the call light the entire time.

how i manage my client’s pain is this. i let him/her know the orders including the prn. i want him/her to know that there are medications at his/her disposal. i explain how we can administer the morphine and what typically works best (less more often). we develop a plan together and move forward. of course that plan is subject to change based upon the client’s needs. after the first few hours, my client begin seeing that i am in their room every hour to help manage their pain and to get him/her what they need. they tend not to use the call light as often, seem to not be so anxious, and tend to have lesser pain.

if the orders you have for pain management are not effective, try other alternatives such as music. if that doesn’t work, get a hold of the md and ask for a change in the orders. i have had to do that once. after telling the md the different techniques i tried (non-pharmacological) and asking if the orders could be changed from 2-5mg of morphine q4h to 2-5mg or morphine q3h and have the prn changed to q4h. the md made the change. it worked.

i hope this helps. if you have any other questions, i will be more than happy to discuss them with you.

glovedgoddess · Nov 26, 2010

Thank you so much for your consideration and taking the time to write a reply parkerbeancurd! I am slowly getting clarity.

Thanks again to all