When do you need an order to increase dosage of med?

Specialties Hospice

Published

Greetings, I have a question about the concentration and prn dosage of a medication. At work tonight, I have a Hospice patient who was on Diladud 5 mg/hr via CADD pump with breakthrough pain boluses of 1.5 mg. every 10 minutes prn for pain. My patient needed quite a few doses on the first half of the shift but as he progressed, I didn't have to dose him as much. For the 4- 12 shift, I had to give him 15 doses. The night nurse who came after me said that I gave him too many prn doses and that I should have called Triage for an order to increase the regular dose. But I kept him comfortable with the prn dosing. Should I have called to increase the regular dose or was I able to keep him as comfortable as I believed I did? He is actively dying and by 10:30, he appeared to be calm, comfortable & relaxed except for repositioning, for which I gave him the prn dose. He has Ativan 1 mg Q 4 hours and 1 mg.,Q 4 hours prn for anxiety. I only had to give him 1 prn dose. I would like to learn more about those nuances of med dosages. Thanks!

Up Vote Up Vote ×
Specializes in Oncology/Haemetology/HIV.

I would have probably called after about 4-6 doses in 2-3 hours to increase the basal rate. Especially going into a night shift. Main reason, is when the patient falls asleep, s/he will not be pushing the button....and may wakeup or have disturbed sleep from having to wake up to bolus themselves/have you bolus them several times to get comfortable again. And it is better to get a steady level of comfort before they/the world is sleeping and you would have to wake someone for a change.

Up Vote Up Vote ×
Specializes in Critical Care, Cardiothoracics, VADs.

If I had to give that many PRN doses, I'd probably get a higher base order. However, you were there, and you know your patient and if he was comfortable, and you practised safely within the law, so don't worry about it! Everyone does things differently. Perhaps you can ask the doc next time.

Up Vote Up Vote ×

Thank you. My patient was totally unresponsive so I was dosing him. Is there a good source for protocals for dosing medications in these instances? Most certainly, if he was responsive and not kept comfortable, I would have called. But I was able to keep him comfortable. They had already up the dosage that afternoon but I want to become more proficient in good dosing protocals.

Up Vote Up Vote ×
Specializes in Palliative Care, NICU/NNP.

Libralady, What type of facility do you work in that you're using a CADD pump? Just curious not critical. You kept your pt comfortable but if I had given 3-4 BTP (break through pain) doses I would have increased the basal dose every few hours if I was still giving that much prn. When I get to that many doses I'd ask for a range to titrate up. I guess since I usually have 4 other acute patients I wouldn't have time possibly to reply on giving prn doses that frequently. The one reason to have an adequate basal rate is so the pt. isn't having pain spikes. Best wishes.

Up Vote Up Vote ×

Ginger, I was in a private home. In my previous Hospice job, we almost never used IV meds, only sublingual, patches or suppositories. This is a new Hospice job and some of the other nurses are saying that this hospice job is starting to use CADD pumps more and more. My day nurse also gave around 12 - 15 doses, then the Hospice doctor came around 2:00 p.m. and increased the basal dose at that time. I had hoped that it was sufficent. I want to increase my learning curve on using the CADD pumps since I am somewhat distressed at myself over last night. I want to ask my superiors for more learning opportunities without jepordizing my job. As much as I love Hospice nursing from my previous job, I will need to make changes to adapt to this new position and hope that they will understand and help me to learn their protocals without it appearing that I am not up for the job. There weren't any protocals discussed in orientation so I am "learning on the job". I hope to find the resources that I need. But then, I found this site and I am delighted. I would welcome any leads and advice. I want to become the very best Hospice nurse that I can be. Thanks so much!

Up Vote Up Vote ×
Specializes in Med-Surg, Rehab, MRDD, Home Health.
Ginger, I was in a private home. In my previous Hospice job, we almost never used IV meds, only sublingual, patches or suppositories. This is a new Hospice job and some of the other nurses are saying that this hospice job is starting to use CADD pumps more and more. My day nurse also gave around 12 - 15 doses, then the Hospice doctor came around 2:00 p.m. and increased the basal dose at that time. I had hoped that it was sufficent. I want to increase my learning curve on using the CADD pumps since I am somewhat distressed at myself over last night. I want to ask my superiors for more learning opportunities without jepordizing my job. As much as I love Hospice nursing from my previous job, I will need to make changes to adapt to this new position and hope that they will understand and help me to learn their protocals without it appearing that I am not up for the job. There weren't any protocals discussed in orientation so I am "learning on the job". I hope to find the resources that I need. But then, I found this site and I am delighted. I would welcome any leads and advice. I want to become the very best Hospice nurse that I can be. Thanks so much!

Don't be so hard on yourself, it appears to me that you did an excellent job,

you kept your patient comfortable and that's what matters. Most of the time

the hospice physicians that I've dealt with require at least a 24 hour period of

prn medications before titrating the scheduled dose.

If your patient is still not comfortable, you may wish to ask your doc about

increasing dosage/frequency of Ativan SL and adding morphine concentrate

SL prn. You present yourself as very competent and compassionate, God bless you!

Up Vote Up Vote ×

I agree - don't be hard on yourself. You did everything to keep the patient comfortable (and he was comfortable.) As Emptytheboat said, most docs want to hear about how much someone had over the last 24 hours so you can get an average. On an actively dying patient, you could call after a few hours (say 6) and average out how much you had given extra in that amount of time to an hourly dose and then call the doc and ask if you can turn the pump up that much more per hour. It's all a learning experience. If there was nothing to learn, the job would be boring.

Up Vote Up Vote ×

Thanks so much! Before I left, my patient's face changed dramaticly. Before, there were some grimmaces and furrowing of the brow which decreased when I dosed him. But 1 1/2 hours before I left, his face became very relaxed. Believe it or not, though he was very, very pale, he began to appear 10 years younger. It was as if he accepted things and was ready for his journey. I brought in the family and explained it to them and they saw it. They were comforted by this very calm appearence. He passed at 3:30 the next morning. Thank you all for your kindness. I believe I have found a new home with other nurses. I am thrilled that I found this site! Cheers ~:studyowl:

Up Vote Up Vote ×
Specializes in Palliative Care, NICU/NNP.

Libralady, I think that you will become the best hospice nurse you can be. All this has a learning curve to it and I think you're up for it. Your patients are lucky to have you. Best wishes in your career. I find end of life nursing so rewarding.

Up Vote Up Vote ×

Thank you Ginger! You are most kind. I love Hospice Nursing but I still have much to learn.

Up Vote Up Vote ×
+ Add a Comment