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!

[Tait, MSN, RN]

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? depends on the meds. one i wouldn't give them together until i had an idea of what was working with these two. norco is going to be like a normal narcotic and block pain, flexeril tends to be more for muscle spams and helping to relax the offending muscle. however i have seen patients on flexeril have dramatic changes in their bp because of it, so i would make sure i wasn't giving it unless the patient was having spasms.

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? i think once you get a regiment down that works you should try and help the patient stick with it. let them know when the next med is available, pass it on to the next shift, and make sure the patient understands they still have to ask for it, it isn't going to be automatic. empower them to understand the routine, and to understand each nurse and shift is different, but that they will be aware of what has worked for this shift. (don't ever assume responsibility for how the next nurse will manage the situation, as you can see many opinions on pain control vary). in the acute care setting i generally don't start talking about tapering until close to discharge. the day before i usually address limiting iv meds since patients can't go home on them. when i discharge patients i alert them to the addictive behavior of narcs and teach them to assess their pain, then treat accordingly. the less med the better if all is well. chronic pain is different, but most of those people will go back to their regular routine.

best of luck! it really is all about practice and assuring patients you will help them get things under control.

[ktliz]

Tait--

I enjoyed reading your reply, and I like how you intersperse your remarks in with the OPs questions. However, the combo of red and italics was pretty hard on my eyes. Maybe you can de-italicize (if that's even a word, lol) your response next time? Just an idea. Do with it as you wish.

[eslvn]

Someone else mentioned something about this nurse that said if she overlapps PRN's her lisence is in jeopardy. I would like to know who told her this crap! THis is why we go back and make sure the pain meds are working, so we can do something different if it doesnt work. It is your job as a nurse to control your patients pain. For oral meds I check within an hour, if its not working, and repositioning etc doesnt work then you give them something else. Personally I think if this person is constantly in pain you need to notify the doc so he/she can try something else. For example, some people do not find releif from morphine, but dilaudid does it. I have a hospice patient who morphine doesnt touch, but norco just a 5/325 works like a charm. Everyone is different. Looking at this persons meds is a bit confusing. I would ask the doc to schedule something, to try to control the pain. Also if your nervous about all those meds (and there is quite a variety) you can get clarification, the doctor might not even be aware that they have all those, and they might have no clue as to the amount of pain they are in.

[ZippyGBR, BSN, RN]

WHO analgesia ladder anyone ?

also multiple different prescriptions of the plain med and compounds containing them is not really good practice ...

in the scenario posted above

instead of huge numbers of PRNs , how about following the WHO analgesic ladder

as a baseline that means regular Paracetamol (Acetaminophen) and being of a right-pondian persuasion that means 1 g 4-6 hourly (max 4 g in 24 hrs ) for someone with no reasons why not.

adjunct analgesia ? is there any prescribed - would a NSAID be of benefit / are there any contraindications for this patient

Flexiril i'm not familiar with but looking it up says it's a muscle relaxant - should this be a regular med if the patient is complaining of so much pain

the morphine dose is homeopathic unless the patient is a small child ...

if you use 0.1 mg /kg 2-4 hourly as many Uk texts recommend 70kg * 0.1mg/kg = 7mg which fits with the usual ranged PRN doses in UK practice of 5-10 mg

this patient also needs to be on MR morphine or oxycontin based on their daily use of the PRNs and have appropriate breakthrough doses prescribed - 1/6th of the daily dose or the MR drug given 4 hourly prn

[nurseprnRN, BSN, RN]

also, for whoever said don't give opioid meds unless for moderate or severe pain "because they are addictive," please do your patients a favor and look up the difference between addiction, tolerance, and habituation. the literature is full of resources to clear up your misconceptions of these. margo mccaffrey is an excellent place to start.

you're not alone in this, i grant you, but we try to do the best we can to clarify these for people who think all opioids are bad, all people who take a lot of them chronically are addicts, and opioids are the only things that work for pain (or, all different kinds of pain medicines work the same). all false.

[DLS_PMHNP, MSN, RN, NP]

the oxycodone should be reserved for moderate or severe; it's addictive. (my comments are in red)

oxycodone is only addictive is used for long periods of time and abused. it is very effective, especially for cancer pain, and sob. just because an effective pain medication is "addictive" there is no reason to withhold it, especially when it benefits the pt.

i think norco is a combo of oxycodone and aceteminophine which can be used if the pain is really bad.

nope, norco is hydrocodone and acetaminophen. big difference. oxydone is a class ii control, hydrocodone is a class iii contolled medication. hydrocodone is the main ingredient in vicodin, norco, and lortab. oxycodone and acetaminophen make up the drug, percocet.

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

usually, the po route is preferred. unless of course someone is in misery. i'm a hospice rn and can only count on the one times i had patients actually screaming with pain. iv meds are usually reserved for pts who are not responding to po meds.

also, the who pain ladder will give you a wealth of info. it's really important to understand these meds.

all the best,

diane, rn

[Flo., BSN, RN]

Always try to keep on a schedule with a chronic pain pt and depending on your specialty all your pts. I work ortho and try to get everyone to take some thing q4-6hrs otherwise the pain can out of control real fast.

On my floor it is interesting with IV pain meds. The docs keep it on the pts mars for emergencies but get upset if you give it to them past pod 0 without trying all PO meds first. With the exception being toradol. That stuff is great!

[rockinRN04]

In my practice, i look at their diagnosis, try to assess the cause of the pain, is it muscle pain, neuropathy, deep surgical pain? think about your choices for meds and what their actions are, then start as low as possible (narco before oxy). keep in mind a patient's pain is what they say it is. nonmed interventions can also be very effective, are they 80 years old and lonely, would a 15min neck rub and some attention work just as well?

[morte, LPN, LVN]

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!

1) Flexeril is not for pain but spasm, if you get that corrected perhaps your med shy coworker would give that

with one of the others

2) Tramadol isnt IV that would be toradol which is a NSAID....which acts differently than the opiates, and on a

chronic pain patient, unless they have new pathology, may not be indicated.

3) Tylenol could be given with all but the norco

4) I think you need to "get with" the doc and have him make some adustments and the order of use. And have

him/her write as was suggested earlier, that if one doesnt work, go to the next, not waiting for the time be-

tween doses.

5) In the case of a chronic pain patient....ask the patient what they took at home, they are going to need that

much at least, and if they have new pathology, they will need more.

[NRSKarenRN, BSN, RN]

great resources found in our pain management nursing forum.

start here: pain management resources lists pain scales, medication mangement based on type of pain: acute vs chronic and palliative care pain mgmt.

[Lev, MSN, RN, NP]

Ok, Ok cut me some slack...I'm a student giving my "unprofessional opinon"

But thanks for explaining it. I'll let my pharm teacher know :)

[belle005]

Thanks everyone! Great responses. I got some good leads for more information too. I feel bad to say this, but I never heard of the WHO pain ladder. I will look it up and do some reasearch.

Someone corrected me that it is toradol, not tramadol that's IV. You're right! I was trying to remember the med list from memory and I got that one mixed up. Thanks a lot. That one said to stop after 3 days in the order. Anyone know why? What would be the main worry administering longer than 3 days?

Thanks again! I feel like I can do a better job now helping my patient's with their pain.