How much pain medication is "too much pain medication"?

[Phillygryl]

I work in an assisted living facility! A client there who needs knee surgery but is refusing it has Hepatitis C.

A chronic user of pain medication and a former IV drug abuser gets 500 mg of Tylenol and 50 mg of Trammadol q 6 hrs. She also has prn order for (2) 325 mg of tylenol also q 6 hrs additionally, she has an order for 1 mg of Ativan q 6 hrs. Everyone administers it she even complains that at night she is given 1000 mg of tylenol!!! Is Tylenol contraindicated for people with Hepatitis C or not???

[BradleyRN]

I don't think she's taking too much pain medication.

That's a pretty low dose of tylenol.

If the regimen is actually controlling her pain, then she sounds fine.

Her orders exceed the limit by 600mg/day, adding up to 4600mg/day. (That does not include her getting 1000mg HS, since under the current orders, there is no way to give 1000mg.) Change her PRN dose to q8h or TID, and she will be within the limit. Her doctor will thank you for pointing out this discrepancy. :)

[november17, ASN, RN]

Her orders exceed the limit by 600mg/day, adding up to 4600mg/day. (That does not include her getting 1000mg HS, since under the current orders, there is no way to give 1000mg.)

That's why you use nursing judgement to delay a dose or wait until the twenty four hours is up. I can do math - I'm assuming everyone here can but thanks for pointing that out. I'm sure the doctor will be impressed by the ingenious math skills displayed when this is pointed out. And she theoretically could get >1000mg if someone is giving her a prn dose on top of a scheduled dose. I still don't think 4g / 24 is a large dose but whatever!

[makes needs known]

Is everyone adding up the mg's of tylenol to make sure she is not getting more than 4gm's by the end of the day? If her pain is not under control and she only has tylenol for breakthrough pain I think there is a potential to overdose. She's already got a compromised liver, so why doesn't she have something more effective for pain?

[kmoonshine, RN]

...I hear you! I work on a surgical floor but we seem to get all the back patients regardless of whether or not they will have surgery. They know the magic words -BACK PAIN- and are often frequent flyers. These are the pts that ring 30 minutes before their meds are due just to make sure you remember that they're due in 30 minutes. I had one pt getting 3mg dilaudid IVP Q3h and another 2 mg dilaudid po Q3h for breakthrough pain. All while walking around, talking on his phone, playing cards, etc. I'm sorry, but I think that's too much pain medication.

The hospital I work at is REALLY big on pain control in the ED. I almost always get orders for morphine 4mg IVP up to 12mg total if needed, and I also frequently have orders for dilaudid 1mg IVP up to 3mg if needed. The other night I pushed 10mg of morphine on some guy whose foley was occluded and irrigating the cath was causing EXTREME pain (it had been placed by a urologist earlier that day in the ED because the nurses couldn't pass a 16Fr, coude, or a 3-way cath). BTW, I think the catheter the guy had in was a 22Fr - the morphine slightly eased the pain while the ER doc blasted out a huge blood clot; the pt was in so much pain that I refused to continue to try and irrigate the catheter, since 10mL of saline caused him extreme pain.

I'm often amazed at how much pain meds I push on a daily basis. But let me tell ya, if I was in pain I'd want to be at my place of work - at least I'd be treated appropriately! I've never "snowed" anyone badly; I always start low and go slow with opiates, even if it means pushing 2mg of morphine every 10 minutes or so until the pts pain has improved. My previous workplace used morphine 2mg only, and sickle-cell pts would get dilaudid - and no one had good pain control. At the hospital I'm at now, its so nice to help people feel better quickly since pain is usually what finally drags people to see us. And I could care less if I'm giving pain meds to a "drug seeker"; addiction is an illness and we can't fix it in the ED, but we can work on treating their withdrawl while coordinating services...

I've pushed narcan on people who OD out of the hospital; I've never had to push narcan on a pt in the ED due to the nurses administering too much pain meds.

[tripp3horn]

It's regular-strength Tylenol. Here's what you do: Get her to open her mouth, take a handful, and throw it at her. Whatever sticks, that's the correct dosage.

OMG! Thanks for the laugh!:chuckle

[hypocaffeinemia, BSN, RN]

OMG! Thanks for the laugh!:chuckle

I failed to acknowledge it was delivered by the wonderful Dr. Cox in the pilot episode of Scrubs.

[dorianna]

"At the hospital I'm at now, its so nice to help people feel better quickly since pain is usually what finally drags people to see us. And I could care less if I'm giving pain meds to a "drug seeker"; addiction is an illness and we can't fix it in the ED, but we can work on treating their withdrawl while coordinating services... "

I so agree with you. People who are or who have been drug seekers should not be denied adequate pain control. There are many worse things in life than being addicted to pain medication. I'm certainly not promoting pushing narcs but, darn it, I wish people in health care would stop being so judgmental. Tylenol is not the drug of choice for people with compromised livers. If someone is admitted who is obese, do we put them on a water diet!? I do advocate the idea of coordinating services.

[cherrybreeze, ADN, RN]

People with liver disease should not be given excess amounts of Tylenol since it is processed by the liver. People with Hep C can get Tylenol, but personally I would question the doc about ordering so much. In my hospital people with liver disease (including Hep C)usually have Tylenol ordered PRN for fever, not for pain relief ATC in addition to another 4 PRN doses, as other NSAIDS can be used that will not affect the liver.

I hear you! I work on a surgical floor but we seem to get all the back patients regardless of whether or not they will have surgery. They know the magic words -BACK PAIN- and are often frequent flyers. These are the pts that ring 30 minutes before their meds are due just to make sure you remember that they're due in 30 minutes. I had one pt getting 3mg dilaudid IVP Q3h and another 2 mg dilaudid po Q3h for breakthrough pain. All while walking around, talking on his phone, playing cards, etc. I'm sorry, but I think that's too much pain medication.

This is a little off the OP:

Statements like this are why nurses need more education on pain management with medication. The BODY gets tolerant to meds, even in the absence of psychological dependence. I am chronically on pain meds for medical conditions that have no *real* treatments, and no cure. I can take a lot more medication than the normal person, and function fine....in fact, I CAN'T function if I DON'T take them, due to pain. Most nurses would probably hesitate to give me the meds I normally take, or refuse to give them at all. That isn't right. I know what my body can handle, and what it needs.

Pain patients do have fear that they won't get their meds, because of statements like this (and I'm not just aiming that at this poster, you hear this from a LOT of nurses). And I WILL concede that there ARE a lot of patients that abuse even the meds they're prescribed, and are preoccupied with. But with narcotics, there is no ceiling. With a gradual taper up, the body can tolerate anything, negating the "too much" theory in those patients. Now, in an opioid-naive patient, that's another story....

[heron, ASN, RN]

I think the OP is right to be a bit leery of giving so much Tylenol to that pt. I have seen a pt (with Hep B) slide right into liver failure on technically correct dosages of tylenol. If the pt herself is questioning the amount, then I'd definitely approach the doc with these concerns. Perhaps tylenol atc and an NSAID prn if she's not having any difficulty with bleeding or gi issues. At the very least, maybe the doc would be willing to check LFTs on a regular basis so you can keep an eye on the trend.

Meanwhile, it can't hurt to keep an eye out for jaundice, drowsiness, confusion and ataxia.

[heron, ASN, RN]

BTW, "Extra Strength Tylenol" is 500 mg. If she gets all scheduled doses and maxes out on her prn, her total daily dosage would be 4500mg ... over the limit even for a healthy liver. Talk to the doc.

[traumaRUs, MSN, APRN]

This tylenol doseage is excessive for a hep C patient. And...if they are taking so much tylenol, I would question if their pain is really controlled...IMHO, they need narcotics. From Medicine Net:

"For the average healthy adult, the recommended maximum dose of acetaminophen over a 24 hour period is four grams (4000 mg) or eight extra-strength pills. (Each extra-strength pill contains 500 mg and each regular strength pill contains 325 mg.) A person who drinks more than two alcoholic beverages per day, however, should not take more than two grams of acetaminophen over 24 hours, as discussed below. "

http://www.medicinenet.com/tylenol_liver_damage/page3.htm

[Sunflowerinsc, ADN, RN]

I thought by now all nurses knew that pain is what the person says it is and "too much pain medication" is not our call. When a person says that their pain is relieved ,that is enough pain medication, not too much. Of course you have to use good nursing judgment and vital signs and assessments.

Seems like Tylenol that is being given routine and prn at top doses may not be effective any more for the pt. Time to reassess?