Medication question

[MPM2]

have a hypothetical question about breakthrough medication: New orders for a patient read 'Morphine 10mg IM/sc/po q4hours ATC' in addition to '2.5-5mg IM/sc/po q1hour prn for Breakthrough Pain'. The first routine dose of 10mg sc was given at 2000hbut ½ hour later the patient still complains of severe pain. Since the onset of sc Morphine may not have occurred yet should the nurse wait until 2100h to safely administer 5 mg sc prn? When is the earliest that the prn dose can be initiated in this case?

[BluegrassRN]

What does ATC mean?

If the first order is scheduled, and the next order is prn, to me, it'd depend upon what the pt has been needing. If this really is the first dose of pain medication, I'd wait 45-60 minutes before giving the prn dose. If the pt has been receiving pain medications and we're still having problems controlling pain, I'd go ahead and give the prn dose after half an hour or so.

[MPM2]

thank you for your input. ATC means around the clock - routine, scheduled.

[wooh, BSN, RN]

I'd go ahead and give it. And put an IV in so they don't have to constantly be stuck.

[morte, LPN, LVN]

First off, i would never have accepted the first order...MS given in different routes is going to have different peaks, onsets etc

all one route is needed

[MPM2]

Morte: I completely agree with you about the order - I think it's unacceptable as well. The patient was also NPO so I question the experience of the dr. Also, I think I would wait an hour and then even then start with the lower dose of 2.5mg sc then reassess. thanks for your input. Wooh: The patient had an IV but because this is a ward situation, IV Morphine administration is not allowed. Anyway, thank you for you input. Regards.

[morte, LPN, LVN]

I could see were a doc might write for sc, "until taking fluids by mouth", even then they would have to work out pharmaco equal dosing.....

Morte: I completely agree with you about the order - I think it's unacceptable as well. The patient was also NPO so I question the experience of the dr. Also, I think I would wait an hour and then even then start with the lower dose of 2.5mg sc then reassess. thanks for your input. Wooh: The patient had an IV but because this is a ward situation, IV Morphine administration is not allowed. Anyway, thank you for you input. Regards.

[Double-Helix, BSN, RN]

Actually, neither order is acceptable. The MD cannot write multiple route on a single order. Only one route is permissible. The MD also cannot write range orders. 2.5mg-5mg is not acceptable. The MD must specify either 2.5mg or 5mg.

That being said, you know the initial dose was given SC. What do you know about the onset, peak and duration of SC morphine? (Hint, find your drug book and look it up.) Is half an hour an adequate amount of time to allow the morphine to take effect? How long should you allow for the initial dose to take effect before giving the PRN?