Help with PRN medications

[belle005]

I need some guidance on PRN pain medications. How do you decide what to give, when to give it, and what you can overlap? I get confused if they have several pain medications ordered as to what to offer them and when to do this. Coworkers all seem to do it very differently. One nurse told me she will not overlap any PRN med because it will put her license in jeopardy - so if she gives one PRN pain medication that is q4-6h, then she will not give any other PRN pain med until the 4-6h on the first one are up. She feels if they were meant to overlap, they'd be scheduled. Is that correct? I'm very new, and I admit I'm itimidated by the PRN med list. I am self-conscious because I have heard nurses make negative comments about the previous nurse's use of PRNs. Any advice would be helpful.

For example, hypothetically, let's say this is your PRN list below and every time you enter the room, your patient reports 9/10 neck and back pain and wants whatever medication you are willing to give them. When you check the previous shifts, what this patient has received varies widely depending on the nurse assigned. The patient is a chronic pain patient and is used to heavy doses of pain medications. In addition to the PRNs, there are scheduled medications too. Where do you start? How do you know what to give?

Oxycodone 10mg PO q4h PRN for severe pain

Oxycodone 5mg PO q4h PRN for moderate pain

Norco 5/325 1 tablet PO PRN q6h for pain

Flexeril 10mg PO TID PRN for pain

Tramadol (don't recall dose) IV PRN for pain - stop after 3 days

Morphine 1-2mg IV q4-6h PRN for pain

Acetaminophen 325mg 2 tablets PO PRN for pain or elevated temp

Thank you for the help!

[KBRN413]

My facility now has strict orders that basicall read:

percocet 2 tab q4hrs prn for pain 1-4

hydromorphone 0.5mg q4hrs prn for pain 5-7

hydromorphone 1mg q4hrs prn for pain 8-10.

That way we are not prescribing a medication. It is there for us to use as a guide. I work on an post op abdominal surgical floor, so everyone is usually on a PCA with toradol. But after the PCA is discontinued, we have that scale to go by.

[KBRN413]

That is just an example, not an actual order!

[Lev, MSN, RN, NP]

I'm a student but Ill give my (unprofessional) opinon anyway.

A couple thoughts

The oxycodone should be reserved for moderate or severe; it's addictive. I think norco is a combo of oxycodone and aceteminophine which can be used if the pain is really bad.

The IV meds will work quickly - if your patient is screaming in pain try one of those.

[Hospice Nurse LPN, BSN, RN]

If your pt has chronic pain, what is he on for long-acting pain relief? If he is asking for pain meds Q time you enter the room, I'm guessing his pain is never relieved.

[SneakySnake]

Great question! I am interested to see the responses :)

[rn/writer, RN]

Very good questions.

JCHAO is now getting after docs to number the meds in the order they want them used and list parameters for adding a second or third option.

Example: Ibuprofen 600 mg PO q 6 hours for moderate pain. If no relief after 1 hour, Percocet 1-2 tabs PO q 4 hours for moderate to severe pain. Oxycodone 5 mg PO q 4 hours for breakthrough pain.

One nurse told me she will not overlap any PRN med because it will put her license in jeopardy - so if she gives one PRN pain medication that is q4-6h, then she will not give any other PRN pain med until the 4-6h on the first one are up. She feels if they were meant to overlap, they'd be scheduled. Is that correct?

No, that is not correct. In the example above, the patient could theoretically have all three meds mentioned within the six hour period after the ibuprofen was given. Why? Because she needs all three to get and keep her pain under control.

Many experienced nurses would employ this kind of dosing in their own heads (if all three meds were ordered), but JCHAO is now asking docs to spell it out formally so that patients can actually have what they need and not suffer in pain because an overly cautious nurse doesn't understand the concept of combining meds to get the desired result.

I work postpartum, and it is commonplace to give both ibuprofen and Tylenol. They have different actions and together are able to cover our patients' discomfort.

When we get c-section patients, they usually come to the floor with a dilaudid (hydromorphone) PCA AND IV push toradol. If they're not on a PCA, they have Duramorph and toradol.

Combining meds is not only not wrong, it's completely acceptable and highly recommended in many cases.

You do want to make sure that you give the first med time to work. But if you assess your patient and her pain is still 6/10, it's time to look at the list and see what else she can have.

If you are combining or increasing narcs, of course, you have to keep tabs on sedation and respiratory symptoms, but if you are having problems in those areas, you need to let the doc know so something else can be prescribed.

One of my daughters was on a morphine PCA post-appendectomy. She was in agony. They upped the dosage until her respirations had dropped to eight and she was still in far too much pain. Finally, they changed the PCA to dilaudid and she got almost instant relief. She's one of the folks for whom morphine does not get the job done.

That's one more reason to do timely assessments. If you've tried all the tricks in your bag and there is still significant pain, you and the doc need to talk and come up with a different plan.

It's sad that your co-worker doesn't understand the idea of combining meds. It's great to be protective of your license, but not unnecessarily so and not at the expense of your patients.

Thanks for asking some really good questions.

[Tait, MSN, RN]

Good question, and you will find a very wide array of answers to this one.

Some of the things I take into consideration in this hypothetical scenario would be:

1. Chronic pain: Ask the patient what works for them at home and try to get them as close to that regiment as possible.
   
2. Nausea: Preferrably if a patient is nauseous/vomiting I will try and manage pain IV, monitoring sedation.
   
3. Sedation: If the patient recieved 10mg PO Oxy and is still complaining of 9/10 pain, yet is fully alert I might supplement with the morphine, or try the Toradol (neck/cervical pain might be related to inflammation therefore the Toradol should help more than the Morphine.) Generally I would give the PO around an hour to work before supplementing.
   
4. Strength: If a patient is 9/10 I wouldn't bother with the lesser pain meds, Tramadol/Tylenol. I would save those for when pain is minimal, but aggravating (2-3 on the pain scale).
   
5. Vital Signs: Respirations/BP. As always avoiding oversedation/respiratory suppression.
   

Honestly if I had a patient who was still 9/10 with Oxy and Morphine I would request a pain management consult and let them hash out the details of controlling it.

It takes practice to figure out what works for patients. Look back at notes if they have been there for awhile and see if anything in the past 24 hours or so has worked better than your current course. If the patient is fresh to the floor, don't panic if they are in pain, just remember it takes time to get pain under control in some people. If they start to fight with you, remind them to breathe, and that you are working to get their pain under control but protecting their safety as well by being careful.

And always remember where the Narcan is :)

Best of luck,

Tait

[belle005]

Thanks for the info! If anyone else has any other opinions, I'd love to hear how you handle PRNs. I get competely different responses from all my coworkers who all seem to have their own unique understanding of PRN medication administration. I wish now I would have asked more questions of my nursing instructors about this!

I'd love to have the orders read - give this first, then that second, etc. Unfortunately, that's not the case where I work. And the PRN lists can be long!

It's just very confusing to me. If the patient got the oxycodone 10mg at 6am, I walk in at 8am and their pain is 9/10, where do I even begin? Do I start with IV morphine? Or would it be better to give maybe the norco and the flexeril together, and reassess in 90 minutes?

Everyone says too that giving on a schedule is better than sporatically. That said, should I be trying to give these meds consistently through the day, or just when asked?

[belle005]

Thank you Tait, that was a very helpful response!

[diva rn, BSN, RN]

i'm a student but ill give my (unprofessional) opinon anyway.

a couple thoughts

the oxycodone should be reserved for moderate or severe; it's addictive. i think norco is a combo of oxycodone and aceteminophine which can be used if the pain is really bad.nope

the iv meds will work quickly - if your patient is screaming in pain try one of those.

norco is a combo of hydrocodone and acetaminophen...it is also addictive but not quite as strong as oxycodone..but in the same family.

and yes, it's perfectly acceptable to combine prn pain meds as long as you keep within the parameters of dose and time. most of the time it's the only way you will achieve pain control initially. the clue is to figure out what worked and then use that formula.

[lorilvnb]

i am no expert, but i will give it a try. in my experience people have many pain medications because they are having pain that is unrelieved much of the time. one sure way not to have an error, call the md and clarify your orders. most docs are very willing to discuss with you parameters and scheduloing conflict when it comes to medication administration, I hope this helped!