Multiple prn pain meds requested all at the same time

[lots2care4]

0I have a question for ya ... been struggling with this for a bit... While working in a SNF, I have a patient who receives scheduled pain medications as follows: oxycodone 15mg q 4 hrs, gabapentin 300mg QID .. she also has a fentanyl patch 75mcg/hr. She is requesting the following prn meds to be given to her at the same time as the scheduled meds -- morphine sulfate liquid 10mg for chronic pain and fioricet for migraine. She tells me the 'squirt' medicine is to be given with the fioricet so as to give it a 'boost' to help make it work. Any PDR I've referenced advises not to give together as each one can cause respiratory depression. I'm concerned with giving them all together..."do no harm". This pt is also on hospice. I've notified the resident's PCP, asking for parameters and/or recommendations as regards the above.

Have any of you nurses run across this type of issue and/or what are your thoughts? I appreciate your input greatly ... I have talked with my supervisor and she has given me direction as well. Thanks so much!

UPDATE: we received parameters from this patient's PCP ... all is good.

[4boysmama]

I would need more info on this before offering an opinion. There are folks tat I would have no problems doing the meds you listed all together, and there are ones I wouldn't - it all depends on their opiate exposure/tolerance, disease process, etc. One thing, however, that stands out is if she is needing oxycodone 15mg every 4 hours scheduled on top of the fentanyl - why hasn't the PCP d/c'd the oxy and gone to a higher dose on the patch? the 75 is clearly not effective. Even with my hospice folks, I don't like to have that many different opiates in the rotation. I would want to d/c oxy, go higher ont he fentanyl, and use the roxinol for breakthrough (with or without the fioricet, though I'm not really a fan of fioricet in general.)

[Munch]

Definitely depends on her tolerance..how often she has been on those meds. I have had patients on long and short acting narcotics, fioricet, lyrica, ativan and Ambien and given them all at the same time(obviously Ambien is only HS). Some of them even had muscle relaxers on board as well and they were awake and alert!

Also like 4boysmama pointed out with the fentanyl patch not only is their room to increase the dose but if its if changed every 72 hours for a lot of patients it doesn't last that long and changing it every 48 hours can help and decrease the need for BT meds..just a thought.