multiple dosing times

JRD2002 · Apr 8, 2008

I would say give the scheduled dose and if pain does not subside give the prn breakthrough dose. Then the scheduled dose again. At this point if the pain is being controlled then only go with the scheduled doses. If not, give another breakthrough and repeat the cycle until the pain levels start to get under control.

I would only give the breakthrough dose if the scheduled lortab was not helping at all or very little.

nursemike, ASN, RN · Apr 8, 2008

Hello, being new to nursing I have a question for the more experienced staff. I was taking care of a hospice pt getting lortab q4h while awake and also had a breakthrough order of the same med at q4h intervals. Am I restricted to keeping a q4h dosing regiment or can I use the breakthrough order to keep the pt medicated every couple hours?

This is a pretty easy mistake to make. I've occassionally seen nurses giving Percocet q4h alternating with, say, Tylenol 3 q4h, so the pt ends up getting pain meds q2h. I even once had a pt whose Percocet was holding him just fine, except it wore off after about 3 hours. So I called the (new) resident and got an order for Percocet (2 tabs) q3h. Immediately got a call from Pharmacy that that was too much acetaminophen to be giving. The narcotic component isn't the problem, it's the potential for liver damage from overdosing the Tylenol. So I might be willing to chance one extra dose of Lortab, one time, but if the problem is recurring, the order needs to be adjusted. If the Lortab isn't holding them most of the time, they need something stronger. If the lortab is working, but they regularly need a breakthrough dose--before a regular dressing change, say--it should be something without the acetaminophen, like oxycodone IR, for example. Of course, if IV access is available, that's probably going to be the fastest acting route for true breakthrough pain.

Er--I was just looking to verify the maximum allowable dose of acetaminophen (4g/24hrs) and realized I'd read Loracet for Lortab. Actually, I think I've seen hydromorphone/acetaminophen prescribed as "Lortab." If what you are giving is straight hydromorphone, without the acetaminophen, then you wouldn't need to worry about overdosing the acetaminophen that you aren't giving. So I'll revise my position to say that if they are needing pain meds q2h as a matter of routine, it should be ordered that way, or better, they should have something more effective for q4h dosing. In fact, if they are getting hydromorphone alone and can tolerate acetaminophen as well, that combo tends to last longer than the hydromorphone alone. But a hospice patient might well have impaired liver function and not be able to take any Tylenol at all, or less than an otherwise healthy adult could.

GeminiTwinRN, BSN · Apr 8, 2008

Er--I was just looking to verify the maximum allowable dose of acetaminophen (4g/24hrs) and realized I'd read Loracet for Lortab. Actually, I think I've seen hydromorphone/acetaminophen prescribed as "Lortab." If what you are giving is straight hydromorphone, without the acetaminophen, then you wouldn't need to worry about overdosing the acetaminophen that you aren't giving. So I'll revise my position to say that if they are needing pain meds q2h as a matter of routine, it should be ordered that way, or better, they should have something more effective for q4h dosing. In fact, if they are getting hydromorphone alone and can tolerate acetaminophen as well, that combo tends to last longer than the hydromorphone alone. But a hospice patient might well have impaired liver function and not be able to take any Tylenol at all, or less than an otherwise healthy adult could.

I agree that the problem with this dosing schedule (depending on the number of pills at any given administration time) is the acetaminophen dose. Lortabs contain 500mg of tylenol in each pill. I think NurseMike was confused (it was early, lol) about hydromorphone vs. hydrocodone as well. Lortab contains hydrocodone, not hydromorphone (which is dilaudid). Anyway, it's all sort of strange in that the scheduled lortab is also the breakthrough drug 2 hours later. I'd request a change if s/he is asking for breakthrough meds often.

HTH. :)

nursemike, ASN, RN · Apr 9, 2008

I agree that the problem with this dosing schedule (depending on the number of pills at any given administration time) is the acetaminophen dose. Lortabs contain 500mg of tylenol in each pill. I think NurseMike was confused (it was early, lol) about hydromorphone vs. hydrocodone as well. Lortab contains hydrocodone, not hydromorphone (which is dilaudid). Anyway, it's all sort of strange in that the scheduled lortab is also the breakthrough drug 2 hours later. I'd request a change if s/he is asking for breakthrough meds often.
HTH. :)

Eh--hydrocodone, hydromorphone, hydralazine...it's all pretty much the same thing, right? (Just kidding!!!) Anyway, I can remember like it was just a couple of years ago, being so impressed with the narcotic component that I didn't even consider the dangers of acetaminophen. But, yes, now that my GCS is back in double digits, thanks for the correction.

(Usually, at 0700, I'm either preparing to drag my weary butt home from night shift, or sleeping away my days off. Getting up early to go birdwatching on such a gorgeous day seemed like a good idea, and after a little allnurses fix, some coffee, a short nap, some breakfast, and another short nap, I was out in the field by the crack of noon--my customary hour for rising.)