How would you interpret this order for pain medication?

Nurses General Nursing

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Morphine 4mg IV q4h PRN pain

Lortab 7.5/500mg 1-2 tabs q4h PRN pain

Your patient calls out at 0800 with pain 8/10. You give Morphine 4mg IV as ordered which helps with their pain. Two hours later the patient calls out with pain rated 4/10 and wants something for it. Do you:

  1. Give Lortab 7.5mg as the pt. has not had that since the order was written
  2. Call the doctor and ask what they want given
  3. Tell the pt. they have to wait as they only have pain medication ordered every 4 hours

Does this order mean to you that a patient can have pain medication every 4 hours only no matter if it is the Morphine or the Lortab?

Does this order mean to you that they can have Morphine q4h AND the Lortab q4h without regard to each other so long as the Morphine doses are 4 hr apart and the Lortab are 4 hr apart?

What do you think?

Specializes in TELEMETRY.
Overkill in my opinion.Just because the two orders are independent of each other, doesn't mean we should overload the patient with them.

What about,if an hour later, patient complains of breakthrough pain, what more do you have to give them?Another morphine or Lortab?

True Katie.... but I work with pts with so much pain and if they have already developed a tolerance then even these pain meds wont touch thier pain.... Chronic pain is another issue if the pt has a hx of chronic pain giving both of these med ATC wont do anything.... I'm just saying...

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Specializes in Med/Surg.

I work on a med/surg unit and we are supposed to have the patient stick to one pain medicine or another, not alternate them. We may try the morphine first and if it doesnt last long enough, give them the lortab and if it works then stick with the lortab. If it doesnt control their pain well enough then I would call the MD and get the morphine more frequent or get something else ordered.

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Specializes in Psych ICU, addictions.
Morphine 4mg IV q4h PRN pain

Lortab 7.5/500mg 1-2 tabs q4h PRN pain

Your patient calls out at 0800 with pain 8/10. You give Morphine 4mg IV as ordered which helps with their pain. Two hours later the patient calls out with pain rated 4/10 and wants something for it. Do you:

  1. Give Lortab 7.5mg as the pt. has not had that since the order was written
  2. Call the doctor and ask what they want given
  3. Tell the pt. they have to wait as they only have pain medication ordered every 4 hours

Does this order mean to you that a patient can have pain medication every 4 hours only no matter if it is the Morphine or the Lortab?

Does this order mean to you that they can have Morphine q4h AND the Lortab q4h without regard to each other so long as the Morphine doses are 4 hr apart and the Lortab are 4 hr apart?

What do you think?

The order means that I can give either or depending on the patient's condition, and if one isn't working I can augment it with the other. In this case, since the morphine isn't quite doing it, then it'd be OK for me to give the Lortab. They are independent orders of each other.

Now, while I technically could give both PRN morphine and PRN Lortab together at, say, 10am, I would not d/t the risk of oversedating the patient...plus the fact that if there were breakthrough pain, I'd have nothing left in my PRN orificenal to give them until the 4 hours have elapsed. So I'd try one PRN first depending on the severity of the pain and if necessary, try the other PRN in 2 hours. If the patient's pain still isn't being relieved after that, I'll bring it to the doctor's attention to see if he/she wants to make any changes to the orders.

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I work on a med/surg unit and we are supposed to have the patient stick to one pain medicine or another, not alternate them. We may try the morphine first and if it doesnt last long enough, give them the lortab and if it works then stick with the lortab. If it doesnt control their pain well enough then I would call the MD and get the morphine more frequent or get something else ordered.

Why are you supposed to have a patient stick to one pain medication or another and not alternate them? Depending on the reason for the pain and the patient's history with pain medications it might not be appropriate at all to give just one kind of pain medication.

I interpret the order as meaning give lortab first as it is a longer acting medication, then give morphine for breakthrough as needed. If you 'run' out of PRN (say the patient gets pain in one hour after administering the morphine) it's an indication that the dosing of morphine needs to be adjusted to increase dosage or frequency, so a call to MD is warranted.

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Specializes in Medical Surgical Orthopedic.

I would give one lortab (since the patient has not been taking any and one might work), and if that wasn't effective after an hour, I would give another lortab. The orders are independent, but I do try to space out my pain medications at least an hour apart to make sure that the patient is tolerating them well.

**To clarify, I would give the lortab anytime after one hour of the morphine being given, too.

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Specializes in Cardiology.
First of all, the order for Lortab 1-2 tabs every4 hours prn isn't acceptable. We would need parameters

It certainly is acceptable. It's the patients level of pain and nursing judgment that dictates whether 1 or 2 tabs will be given.

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Overkill in my opinion.Just because the two orders are independent of each other, doesn't mean we should overload the patient with them.

ha!

i was thinking that there are pts who would love this nurse (steph.rn).

leslie

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Specializes in ER, Med/surg, LTC, and correctional nurse.

If this is an exam question for NCLEX, do not call the doctor. NCLEX wants to know what you will do, not what the doctor will do (Kaplan 2009), if this is an exam question, please let us know which answer was the best answer :)

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Specializes in Med/Surg.

we are only allowed to alternate the pain medications if the doctor orders one of them "for breakthrough pain." thats the way we've done it for as long as I've been there (6 years) and it works. I dont know if its policy or what but of the 21 RN's on my floor none of us alternate meds. The pt has to stick to one or another. If the morphine is ordered Q4H and the percocet is ordered Q4H we cant alternate them so the patient is always getting something Q2H. That just seems like an awful lot of medication to me. And our patients rarely complain that their pain is not controlled.

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Specializes in future OB/L&D nurse(I hope) or hospice.

I am not a nurse yet, but I take care of a partner with chronic pain and have been for over 10 years. So while this question may have an approriate answer for the general person, someone with chronic pain would need either both of these and possibly even more morphine. At one point my partner was taking 240mg oxycontin, 10mg lorcet, 10mg valium AT THE SAME TIME (of course the oxy was q8h and valium and lorcet q6h) and was still in pain. Needless to say we have changed doctors in hopes of finding another method for pain control. The weaned off the oxy and just started on methadone. So....it depends on the person and their history.

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You will see this type of order all the time, especially on the med surg floors. You can give each independent of the other, per the order. However, the more important question is what does an RN do? What makes an RN an RN is the assessment. If your patient is having c/o pain, two or less hours after he is given the Morphine, what is the appropriate action? Is he A&O x 4 or does he appear to be slurring his words. Is he asleep until you walk into the room, or is he wide awake and obviously uncomfortable? What are his respirations? We all know the clock watcher, the drug seeker, the give-me-all-the-narc's-you-can type. This is where the rubber meets the road, and an RN is an RN. If your assessment of this patient tells you he really needs this drug, than give it. But if he appears under the influence, maybe you need to wait.

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Specializes in Critical Care.
we are only allowed to alternate the pain medications if the doctor orders one of them "for breakthrough pain." thats the way we've done it for as long as I've been there (6 years) and it works. I dont know if its policy or what but of the 21 RN's on my floor none of us alternate meds. The pt has to stick to one or another. If the morphine is ordered Q4H and the percocet is ordered Q4H we cant alternate them so the patient is always getting something Q2H. That just seems like an awful lot of medication to me. And our patients rarely complain that their pain is not controlled.

There isn't really any single definition for "an awful lot of medication" and the belief that there is why many patients end up under-medicated for pain. 2mg Morphine and 2 lortab q 4hr might me pushing it for one patient, but only a small fraction of what might be reasonable for another.

An appropriate amount of narcotics should be based on the patient's pain related to their comfort and activity goals, balanced with signs of adverse effects such as sedation scale, VS, and ETCO2 which is the gold standard for noninvasive assessment respiratory depression.

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