Prn meds - can they over-lap?

[sunnysandiego]

Ok, well to let you know - I am a new grad in orientation at my hospital. This is my question:

Your patient has an order for PRN pain med:

1-2 mg Morph IV Q4H

1-2 tab Norco Q6H

They have had no previous med, and for the sake of argument lets say they can tolerate the full dose of both with no probs.

I give my patient:

8:00 am 1mg morph- still in pain 8 out of 10

8:45 am 1mg morph - still in pain 7 out of 10

Come 9:30 would you administer the Norco? Or would you wait until 6 hours from the time you first (or last) administered the Morphine?

AND IF

you do administer the Norco at 9:30. Would you base your administration of the next Morphine on the 8:45 morph or the 9:30 Norco?

Thanks for any feedback - I am getting a LARGE VARIENCE on how our nurses are handleing this and my hospital policy and procedure do not address it. I will not just take your answers and go do it that way- so don't worry! I am looking for info!

Thankyou Thankyou Thankyou!!!

[whipping girl in 07, RN]

Honestly, I would call the MD to get an order for a higher morphine dose before moving to a PO pain med. But each med stands alone as far as timing. Morphine has a shorter onset of action and duration. I probably would have given the Norco first, given it 45 min to an hour to work, if it didn't try the morphine and if that didn't work call the doctor. If you are giving more than one narcotic you have to be aware that the patient could become too sedated or develop respiratory depression. Also remember other nursing interventions...positioning, distraction/diversion, imagery, massage.

[kanzi monkey]

I'd give the Norco first--since the patient can't go home with IV meds and PO provides longer coverage. If pt is in pain before the time for the next dose, I'd give the morphine (for "breakthrough"). If the pt requires morphine between each dose of Narco, I'd ask the MD to increase the dose or frequency of the PO med.

[jnrsmommy]

I think that I would have to disagree. Considering that the pain was so high to begin w/, I would've started w/ the higher dose of Morphine, then worked back from there. Playing catch-up on pain control is a frustration the pt and I can do w/o. This is based on the acute pt recently admitted. Someone going to be d/c in the next day or two, you're getting the PO.

I do agree w/ whipping girl, though. Each med has it's own timing. Even though you gave 1mg of Morphine separately in two instances, the 4 hr window starts again w/ the second dose. Same thing w/ the Norco. This is going to become something to pay close attention to, especially when you get the pt that wants any and all their scheduled and prn meds.

[ChristyRN2009]

If I have a patient who can have morphine IV q4h, and PO pain med q6h, I will tell you what I do ideally. Ideally, I give the percocet, because they won't go home on IV meds. And then if after 30 min the pain is still bad or they still request the morphine, I give it. Lets say the time is 0800 for the pill, and I give them the Morphine at 0830. They can have the morphine again at 1230, or the pill at 1400. Regardless of when you gave the last pain med, whatever the time parameters for the med you are wanting to give are what you follow. I hope Im making myself clear. I said ideally because there are patients who might need or want and can tolerate both at the same time. So lets say I give IV Morphine and PO pain med to that patient both at 0800. They can have the Morphine again at 1200 or the pill at 1400. Or if 1400 rolls around and they request pain meds, I give them the choice with the encouragment of pills over IV. Hope I understood your question and that answered it for you.

Oh, and as far as 1-2 mg of morphine question, in my hospital at least it is policy to give one or the other. So if I give 1mg of Morphine and an hour they request pain meds, I call the doc or try other tactics/meds to get them through until its time for the next dose, and likely I will give them 2mg of morphine and pass on to the next shift that that seems to work best for them. There is a little leeway and judgement needed here, because lets say I give morphine 1mg at 0800, and by 0815 the patient is in need of more, I will give the extra 1mg and use the 0800 time to schedule the next dose.

[sunnysandiego]

Thanks for your feedback! I appreciate it!

[AllSmiles225]

I have a patient on subacute rehab who has extreme pain r/t PVD, a leg with gangrene (probably needs an amputation), COPD, lobectomy you know the whole deal and the MD orders Percocet 5/325 PO q4h PRN for pain & then orders Oramorph 60 mg PO q4h for pain.. Well needless to say the nurses layer those meds meaning that if they give the Percocet at 10 am, they will give the Oramorph at 12 pm, then the Percocet at 2 pm and so on and so forth--Apparently it's the only way to control her pain so I guess layering them would be okay if there is extreme pain. Of course I would try typical nursing interventions. I would also notify the MD of your concern with IV pain management if this lady is going to go home.