Pain meds that can be given together?

[Plantladynurse, BSN]

Worried new nurse here,

I have been a nurse for about a month at my job. I took care of an elderly patient yesterday who has been in severe knee and generalized pain. This patient had an order for PRN Tramadol and IV morphine 1mg. I administered the Tramadol, checked on pain an hour later and my patient was still screaming out requesting something else. I readjusted them, and went to grab ice packs since that worked before.

My preceptor asked how the patient was doing and once I explained it was suggested to me to administer the PRN morphine. I explained that I just gave Tramadol an hour ago and if that would be contraindicated?

My preceptor and another nurse agreed it was acceptable. I ask my preceptor to come with me - patients vital signs were within normal limits. I administered the morphine. I check back 15 minutes later - my patient is awake and sitting up but appears spacey and "high". I gave report to the oncoming nurse, my shift is almost over and we discover the blood pressure is 99/60, respiration's are normal. I know this reading is not incredibly low, but it was the lowest reading I've had from this patient.

I do not feel that I used my better judgment. No one else seemed to be alarmed by the BP besides the CNA that took the vitals. I feel I made a major mistake. Why on earth would I believe giving two narcotics so closely together is acceptable? Is Tramadol and Morphine combined therapeutic? My gut tells me no, and I am so worried today. I have the day off and have no idea how my patient is doing. I feel that I failed my patient. I wanted them to be comfortable, and I did everything I could to provide that. I love my job. I would never want to put someone in harm but I feel I did not use good judgment.

I expressed my concern to my preceptor after this and she guaranteed she will be fine. However, I am not only extremely worried sick but also confused about combining these drugs. Is this common?

[Okey Foley, BSN, RN]

I work on acute surgical floor and depending on the pt and MD having a few pain med orders is not unusual. Tramadol with IV morphine PRN for unrelieved severe pain I personally think is safe as long as her pressure is high enough. 99/60 is lower end, but with SBP >90 I wouldn't be concerned. Want to see what others say too, but this is my experience. I think it's more important pain is managed and you also tried nonpharm modalities too.

[toxicodendron25]

if CNA gives vitals, I always recheck myself, sometimes they use wrong size cuff, or put on wrong, or they are in too big a hurry to leave the pulse ox on long enough to get above 90

giving 2 pain Meds at the same time is common

1mg of morphine is low dose, I would give with tramadol with BP 99/60 (map is73) especially if patient is yelling ( she is not obtunded if she is yelling)

Whether to give or hold a narcotic/ sedative is a judgment call that you will be more confident with time, it depends on the patient; do they have a high tolerance; been on narcs for years? There are some patients I will give IV dilaudid, Benadryl and Ativan to at the same time, and some I won’t,

If SBP less than 100 maybe hold IV morphine but call doc and ask for PO pain med and recheck BP in an hour, Hold if they are obtunded,

Read your med order closely, sometimes docs write “give morphine if tramadol not effective” so you gotta give tramadol first and wait...

never be afraid to ask charge nurse for second opinion, or call doc and tell them BP low but patient has pain 10/10, they may tell you to give pain med anyway

just make sure patient has good IV and you know where the narcan and crash cart are

Lori B

med/surg nurse