Pain med admin

[kimdav]

At the hospital I work at there has been some discussion regarding the appropriate admin of pain meds. Doctor ordered pain meds for mild Q8 hours, mod Q8 hours, severe Q6 hours.There was no order for breakthru pain or unrelieved pain. Pt received pain meds for severe pain at 0230, then at 0445 received pain meds for mod pain. Is this proper admin?

My understanding of pain med admin is (in this example) the pt should NOT have received the 0445 dose as it is too early, next dosing of any med in this case should have been 0830. At 0445 when pt still had pain the nurse should have called the doctor for a one-time or breakthru/unrelieved med order.

[RN403, BSN, RN]

What type of pain medication are we talking about here? We often have oral pain medication (Vicodin or Percocet) at a lower dose and then a higher dose. There is also usually an order for IV Dilaudid or Morphine for more severe pain.

If a patient had IV pain medication for severe pain at 0230 and then their pain level came down but was still "moderate" according to the pain scale, then it would be appropriate to give the PO pain medication at 0445.

If if two oral narcotic pain medications such as hydrocodone or oxycodone were given within two hours of each other that would be more concerning. Again, it depends on the type of pain medication you are referring to and the route...

Always call a pharmacist or clarify with the physician when in doubt.

[SarahMaria, MSN, RN]

That sounds like a poorly written order.

[ixchel]

That sounds like a poorly written order.

Agreed.

Is it one written order by itself? Or is it three separate orders? If they are separate, I guess technically it might be okay. If it is one order, there needed to be at least 6 hours between them. In this case, I would contact the MD for something different or a one-time order.

[kimdav]

sorry - let me add some details: iv 1mg morphine for severe, po norco 5/325 (1) tab for mod, po tylenol 650mg for mild

[kimdav]

what do you mean by one order or separate orders?

[RainMom]

sorry - let me add some details: iv 1mg morphine for severe, po norco 5/325 (1) tab for mod, po tylenol 650mg for mild

So in the op, the pt received morphine at 2:30, continued to have pain & received a norco at 4:45. That's completely appropriate. If the pt had wanted another dose of morphine, then no, because it needs to be at least 6 hrs. The q6 or q8 only refers to the specific med in the order, not all pain meds ordered. In some scenarios, it wouldn't be unusual to give the norco & morphine simultaneously. Then it would be 6 hr wait for the next dose of morphine but an 8 hr wait for the norco.

[KatieMI, BSN, MSN, RN]

sorry - let me add some details: iv 1mg morphine for severe, po norco 5/325 (1) tab for mod, po tylenol 650mg for mild

Absolutely appropriate order set, IMHO. As well as absolute appropriate utilization as long as patient's vital signs are OK. Only one thing to watch out is excess of acetaminophen.

If patient had incomplete pain relief after morphine and doesn't breathe 8/min, it is ok to give norco po even if only one hour late. If the combination gives full/acceptable relief, it would be totally OK. If the relief is null (10/10 before, 9/10 after morphine), then we are possibly playing with something else and need to call the doc.

The thing is, ideas about "full relief, right away" is what gives start to unnecessary escalation of opioid dosing in acute care. 1 mg morphine iv and 1, even 7.5/325 norco po is less than 2 mg morphine iv in equianalgetic dosing, plus norco has some acetaminophen with nice added pain relief by another mechanism. By bumping morphine up to 2 mg, relief may be better immediately but last no so long due to acting m-opi vs. k-opi vs. l-opi receptors plus no acetaminophen to add to it all (for details, please see any good pharm textbook of your choice). Plus, we add side effects quite significantly, respiratory supression being first.

[ixchel]

sorry - let me add some details: iv 1mg morphine for severe, po norco 5/325 (1) tab for mod, po tylenol 650mg for mild

This example would be separate med orders. They are completely appropriate and the administration times were valid and acceptable.

[MunoRN, RN]

This is one reason why I find these pain scale based orders moronic. Other than the odd belief that people's description of their pain is a standardized measurement that have established correlating medications, I also don't get how you don't often end up giving patients every medication order as their pain level increases and decreasing as the medications you've given kick in and wear off?

[KatieMI, BSN, MSN, RN]

I also don't get how you don't often end up giving patients every medication order as their pain level increases and decreasing as the medications you've given kick in and wear off?

Because some of us know the true and secret meaning of "RN", which is "Refusing Nonsense":up:

[Thessaly36]

Interesting, when I had my 2nd child I was Rx ibu and norco because they potentials each other. I often get an order for ibuprofen for my patients with their opioids because I know it's super effective when just the opioid alone isn't working to full effect.