prn question

The way I understand what you wrote is:

The order is:

Tylenol #3 0600-1200-1800-2400 -- a scheduled med

Tylenol Plain Q6 hours PRN

You gave a PRN Tylenol at 0300.

Am I correct so far?

If so, the answer is yes. The scheduled 0600 Tylenol #3 should be given.

I would guess this is for pain control. And the Plain Tylenol is for minor breakthrough discomfort?

The next time you could give a PRN Tylenol in this scenario is at 0900. And then, yes, you would give the 1200 scheduled dose of Tylenol #3.

You usually have another nurse to consult with until you are comfortable and gain more experience and confidence.. Also, in the hospital, there is usually a pharmacist to ask his opinion. And lastly, you can always call & ask the doctor...... (I wouldn't do it in the middle of the night).

The doc likes to see his scheduled meds given as he ordered them. If there is doubt, hold on the PRN and give the scheduled. As far as Tylenol is concerned, it is a handy thing to know the maximum mg. a person should take a day, so you don't exceed it. Tylenol is liver toxic. Many docs with toddlers and young children say they won't even have it in their house....if I didn't get the scenario correct, repost it, and I will re-reply. :) Hang in there.............

we frequently have confusing orders like this. maybe the order is for routine meds of xanax .5 at 8 am 4pm and 8pm plus prn every 8 hrs, the same pt has routine ms 30mg every 8am, 4pm amd 12 midnight and percocet every 4 hrs prn, plus the same pt. has ultram prn every 6 hrs, and soma every 8 hrs prn, plus tyl # 3 every 6 hrs. diferrent docs order different things and never look back to see what the pt is already on. some nurses refuse to give the meds too close together(no matter if the med function is different) and some give everything all at once if the specified time has passed in between doses. good question to bring up.

Thankyou for the input and yes I do realize how toxic tylenol is on the liver, so I am always cautious when following orders. I do work the graveyard shift sooooooo, not to many people to confer with. I do like that I can come to this site and get some advice from you wonderful nurses. Thanyou.

A lot of our prn pain meds are ordered Q3-4hr prn. Sometimes a physician will order Tylenol gr10 or gr 15 "now" if the pt has a HA or elevated temp. I always make sure the physician knows if it is less than 3 hrs since the last dose of a pain med that had acetaminophen as an ingredient. This is usally a one time order and our patients (post-partum) are usually only in the hospital for 2-4 days after delivery. When I review discharge meds with a pt I always point out the fact that their prescrition pain med contains Tylenol and that they should not be taking Tylenol at home unless they are substituting Tylenol for a script pain med dose unless they discuss it with their OB first.

When I was in nursing school, one of my pts was a very young women who took more than double the labeled dose of Extra Strength Tylenol for several days for stress-related HA's prior to a big event in her life. She went into liver failure and had already had two liver transplants by the time I cared for her. She was in her mid-twenties. She spent over a year in ICU and was a frequent re-admit after that. I have taken Tylenol very seriously ever since then.

The general rule w/Tylenol is no more than 4000 mg / 24 hours for an average size adult w/normal liver function. I don't know how many mg that your were giving w/each dose, but it doesn't take many tabs plus a few combo drugs to hit the limit .

I'm surprised that the pharmacy computer didn't flag it.

Tylenol#3 has 300 or 325 mg acetaminophen in it. Giving Tylenol#3 1 q6hr= 1300mg acetaminophen in 24 hr (figuring the 325 mg amount). One plain tylenol has 325 mg also. Your PRN tylenol is also ordered 1 Q6Hr; which would also give you 1300mg/24 hr. So, if you were giving the MAXIMUM dose of PRN tylenol on top of the scheduled dose, the MAXIMUM amount of acetaminophen the pt. would receive is 2400mg(or 2.4gm)/ 24 hr; which is well below the recommended 4 GM/ 24hr for adults with normal liver function.

Because of allergies to NSAIDs, Extra Strength Tylenol is the only med I can take for pain and I often need to take 4-5 Gm/day to deal with my hip pain and be able to work. I do not condone that high of a dose for anyone else; but I am overly sensitive to narcotics and this is the only way I can do something I love (and earn my living too). My MD is fully aware of my tylenol use, and we monitor my liver function as needed.

On the 4000mg/day max. Elderly residents almost always have decreased liver function d/t age. I wouldn't go up to 4000/day without some liver function tests. Also, on PRNs, even though a patient asks for something, it is still within your rights to use your judgment about whether or not to give. Also remember that it is part of the Standards of Care to contact a physician about ANY order that you feel is questionable or inappropriate. Ultimately, no matter what an order(s) say, the nurse is legally responsible for administering it.

Personally, I would contact the MD the next day during business hours and ask for something like Ultram, expecially if this patient frequently has breakthrough. Another option would be to go to a Duragesic patch to control chronic pain, it doesn't have some of the side effects of codeine and more effective in controlling chronic pain. Get the order changed. :)

Back in the olden days when I did adult nursing, we used to get orders like this so that we could give a Tylenol plain with a Tylenol #3 instead of giving 2 Tylenol #3 when one wasn't enough. Something about the full dose of Tylenol potentiating the Codiene...

Thankyou for all your knowledge guys, I feel more confident about my prn,s.