Med order question -giving Roxanol to someone who is dying

DYLANB · Jun 18, 2012

5-20mg q4 is considered an incomplete/incorrect order. When ever an MD writes an order for a medication the order must have the name of the medication, the dose, the route and the frequency. Pain medications must have an accompanying pain scale. ie.

Roxanol 5mg IV push q4h/prn for mild pain

Roxanol 10 mg IV push q4h/prn for moderate pain

Roxanol 15 mg Iv push q4h/prn for moderate to severe pain

Roxanol 20 mg Iv push q4h/prn for severe pain.

Drips, IV pushes or medications expected to exact a somewhat immediate change should have a similar accompanying scale. ie.

Tylenol 650 mg PO q6h/prn for temp > 101.0F

Cardizem IV drip titrate to keep heart rate less than 110 bpm.

IV bolus of 0.25mg/kg over 2 minutes

Follow with 5mg/hr IV drip and titrate increase by 5mg/hr q30min with a maximum dose of 15mg/hr.

MD's assume that facilities have protocols in place (usually they do) for titration of meds and they neglect to write complete orders which puts us nurses in a tight spot. All you can really do in these situations is call the MD and ask him to clarify and hope he/she is not in a bad mood.

tothepointeLVN, LVN · 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.

I disagree with this. With the hospice companies I staff for you would get in trouble for messing around and waiting 4 hours before giving the patient the prn and letting them suffer with the pain.

The above logic suggests that the two orders are tied together which they are not unless they specifically say they are. Sometimes the orders will say give xyz if the routine dose is not effective within x # hours.

Now I should clarify that Roxanol /MS is SL but essentially you have to view these orders the same way you do with a CAD pump. You have a basal/routine dose and a bolus/prn dose. The PRN's are written so you can change the frequency of the pain medication without having to immediately call the MD. If it seems after administering a few PRN doses that the routine dose is no longer maintaining comfort you call to get the order changed. That's nursing judgement.

To the OP I would suggest talking to the visiting hospice nurse and explain the situation. They would have no problem clarifying the order and intervening on your behalf. Education is a BIG part of the job.

tothepointeLVN, LVN · Jun 18, 2012

5-20mg q4 is considered an incomplete/incorrect order. When ever an MD writes an order for a medication the order must have the name of the medication, the dose, the route and the frequency. Pain medications must have an accompanying pain scale. ie.
Roxanol 5mg IV push q4h/prn for mild pain
Roxanol 10 mg IV push q4h/prn for moderate pain
Roxanol 15 mg Iv push q4h/prn for moderate to severe pain
Roxanol 20 mg Iv push q4h/prn for severe pain.

Well the complication part is the official order on the chart is a complete order as above but that's back at the office. The little folder for the family has abbreviated orders for simplicity which is what the 24/7 nurses have to work with. If the patients live long enough printed orders come out but usually not.

Also the above order in order to be correct for the abbreviated order I mentioned would have to have a modifier stating no more than 20mg every 4 hours.

BTW Roxanol is never IV only SL and sometimes rectal.

DYLANB · Jun 19, 2012

I have never used or even heard of Roxanol before reading this post. I breifly looked it up and I found it was morphine sulfate. I assumed it was an injectable form not realizing it was strictly an oral/sublingual form of morphine. I should have looked through the med info more carefully before posting. How embarassing. After speaking with my facilites pharmacist he stated that because they are two separate orders and they have no set maximum dose to be received within a time frame the scheduled and prn can be given without regard to the amount of time passed between the last dose given. As long as the meds are given with regard to the time frames established within their respective orders. Although I still feel that my original post has some merit, I was wrong. If only the MD would write a max dose to be given within a set time frame the order would not be up for interpritation.

PS: I do advicate for my pts. I would never have allowed a pt to writhe in agony for 4 hrs because the next dose wasn't due. I would have called the MD without hesitation to increase the frequency of the dose or add an additional med for pain relief to the pts MAR.