Med order question -giving Roxanol to someone who is dying

tothepointeLVN, LVN · May 21, 2012

Without seeing the full order I would say the routine RTC is Q8 for pain management and the Q4 is for break through pain. I would think if you needed to give the PRN within a short time after the routine that would be ok since they are two separate orders. Is this for hospice?

Double-Helix, BSN, RN · May 21, 2012

You can give the PRN at any time, but you cannot give the PRN more frequently than every 4 hours.

Using your nursing judgement, you should not give the PRN before the standing dose has had a chance to take affect. So if you give the standing at 6a, you shouldn't give the PRN at 6:30a before the standing dose has reached it's full effect. Likewise, if it's 1330 and your standing dose is due at 1400, it wouldn't make sense to give the PRN at 1330 and then the standing half an hour later.

But you could, potentially, give the standing at 6a, the PRN at 8a, the PRN again at 12p and the standing at 2p and still be within the range of the order.

However, if the patient is requiring the PRN that frequently, it would be best to contact the doctor to get an order to increase the standing dose.

Need2Care · May 22, 2012

Yes for a hospice patient. The patient was actively dieing and respirations became rapid and shallow and clearly needed the prn. The scheduled dose was given as ordered and I gave the prn 1.5 hours later additionally knowing I could not give another dose for at least 4 hours (my thought process). However, after the fact a new order was received from the MD okay to give Q1 hour.

Where I work doesn't see it as you both do (and as I was taught previously at a different facility). I was written up for a med error for it being given too soon and before the new order came in. They say they've been cited before from state for having done this in the past so it is a rule/law to not do it this way. I explained that the previous employer I worked for gave prn's on top of sceduled dose in this 180 bed facility which is where I learned this and thought it was okay to do and so I was told that's too bad that I learned the wrong way and now have a concern about me that I just don't get it.

It was lectured to me the nicest possible way (I think) but it still hurts.

I wish I knew what the right way is. Is it per facility policy or is it a state guideline? How could it be okay for the other place I worked at 15 miles away to do in such a large facility but yet not at this place that is 1/4 the patient capacity? I guess I don't "get it".

tothepointeLVN, LVN · May 22, 2012

Yeah for an actively dying patient Q4 is too skimpy depending on doseage. Sometimes I've had orders for PRN Q15. The above is a reason sometimes some hospices will send nurses out to do 24/7 even if the patient is in a nursing home because they can do the medicating if the hospice provides the meds. The further complications come however when the LTC want everything to go through their nurses still which defeats the point of having cc coverage if it takes 30mins to track one down to explain what needs to be given and why and then debate back and forward with them when the patient needs an intervention now. Have also had a lot of hospice patients that are expected to transition transferred back to home out of the LTC which gives a lot more control to the hospice nurses.

Your visiting hospice nurse will be your best resource in getting this clarified and making sure the facility understands.

The main confusing one I run into is say 5-20mg Q4 which I interupt as being able to give UP TO 20mg every 4 hours meaning I can give 5mg every hour if needed. Other nurses say once you've given the first dose regardless of the strength you can't give another for 4 hours. I try and do whats best for the patient and will call if I need the order changed.

lumbarpain, ADN, RN · May 26, 2012

Depends on the breakthrough discomfort/pain. If the standard order was given at 6am and the patient asks for it again at 7am, then you can give it......but if he asks again for it at 8am.....the doc would have to be notified. The next time you are allowed to give it would be at 11am. I would alert the Nurse manager and make her aware of the patients request for more pain relief, also if the patient is asking for more pain medication than the orders call for. If he continues to ask every hour after the pain med was just given, I would call the doc on that one.

Need2Care · May 30, 2012

I definitely agree with that. The patient has since passed away however she wasn't verbally asking for the med. She was given it at 1:30pm as a scheduled dose then I observed her breathing rapid and shallow, struggling for air so I decided to put the prn dose into action at 3pm. I was written up for a med error because sheduled dosed and prn dose of the same med cannot be given that close together.

I'm just so mad about this, I didn't need to be written up.

lumbarpain, ADN, RN · May 30, 2012

I am perplexed that you were written up for this. Objectively you observed the patient in distress and keeping her pain free is the goal here if she is hospice. If I were written up for this, I would say then WHY is there a prn ordered, Did the PRN STATE NOT TO GIVE within a certain space of the standard order???? If the standard dose was given at 1;30, and she gets this standard dose every 8 hours......then obviously she was crashing and needed that prn for comfort measures. Like I said, its always good to get the DON or ADONs advice when you are questioning yourself first or if that doesnt satisfy you get a separate order from the MD for a one time dose only if you must give it much sooner.

Need2Care · May 31, 2012

I didn't think to question it because I thought just as you did *lumbarpain and gave the med. To my utter shock I was reported to the DON for this and the DON herself said this was wrong and that there's something wrong with me for not knowing this. The PRN simply stated can give Q4 hours for pain or discomfort. And I was supposed to have used my nursing judgement and known that meant not to give it within 4 hours of the standard Q8 order.

I too am perplexed. I'm glad that so far all the feedback I've gotten is inline that what I did seems to have been correct but yet still leaves me ... confused.

Idk, I have many years ahead of me to gain more experience and I know this is just the beginning and I will learn so much more from many more nurses who will be as supportive to me as I feel when I come here.

SuesquatchRN, BSN, RN · Jun 17, 2012

You were written up for not followng the facility's policy, not any actual med error. If anything, your judgment was spot on.

DookieMeisterRN · Jun 17, 2012

The DON of this facility obviously needs a current course in hospice and what the hospice orders mean.

What you did is what I presume to be common nursing practice. Unless it specifically stated do not give prn dose within a certain time frame of the standing order than I see nothing wrong except for the DON.

In the future if the visiting hospice nurse could write an ORDER stating the MD okays the PRN dose to be given within say 1 hour of scheduled doses it would make the DON happy?

DYLANB · Jun 18, 2012

Is the strength of the prn dose the same as that of the scheduled dose? If so, it seems to me that by giving a q8h order the ordering MD intended for the patient to receive a minimum of 3 doses within a 24 hour period and by leaving a q4h prn order the MD intended for the pt to receive the medication a maximum of 6 doses within a 24 hour period. To give the medication more frequently than q4hs, in my opinion would be wrong. Say the pt has a scheduled dose at 1000, the prn dose is then given two hours later at 1200 then again at 1600 followed by the scheduled dose at 1800. This means the pt is receiving the medication in 2 and 4 hour intervals when the order calls for 4 and 8 hour intervals. This also means the pt could potentially receive a total of 8 doses in a 24hr period. Two more doses than what then original order implies. After reading the comments posted I feel as if many nurses responding to this post feel like because there are two seperate orders here (scheduled and prn) you can give the prn whenever the nurse deams necessary using "nursing judgement" disreagrading the amount of time that has passed between doses. If you follow that logic you have essentially changed the intention of the original order. If the pt is requiring more medication for greater pain control the MD needs to be called and the prn medication frequency needs to be changed to ,for example, q2h. Still the pt should not receive doses more frequently than what is allowed by the prn order. So to answer your question if the "Q8 is being given at 6a, 2p and 10p. Does that mean I can only give the prn at at 10a, 6p and 2a?" I believe yes, the medication should only be given in 4 hour intervals. To solve this dilema in future situations you may ask the MD for a maximum dose allowed/per 24 hour period. This would prevent you from having this problem again.