Routine Tylenol #3 and PRN administration

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A patient is ordered Tylenol #3 1 tab, po, TID. and 1 tab Q 4-6h PRN

I know I should know this. I am ashamed for even asking but,

If the patient gets one Tylenol #3 at 0600, 1200 and 1700. The patient wakes up in horrible pain at 0600 and is asking for another tab of Tylenol #3 at 0600 on top of his routine Tylenol #3.

What could I suggest to him?

Could I give him another PRN Tylenol #3 at 0600 in addition to his "routine" dose?

I read in the MAR on one shift I happened to be filling in for another nurse, he had received a PRN Tylenol #3 one day at 1200 in addition to his 1200 routine dose. On another shift, he received a PRN Tylenol #3 at 1700 in addition to his 1700 routine dose. He had also received a PRN Tylenol #3 in addition to his 0600 routine dose.

So, one morning, I gave him another Tylenol #3 in addition to his 0600. I was the one and only one who was written up for a medication error. 

I haven't filled in the med error incident report yet. I don't know what to write in. Did I make a mistake in medication administration? I feel stupid for following suit like a lemming. The patient said he was in horrible pain at six in the morning and the other nurses were giving him two Tylenol #3's at a time. Should I also be asking if the other nurses will be written up for the same med errors?

I have officially decided that it is not in my best interest to take any extra shifts at this nursing home. I'm not well liked by the day shift staff (three full time RPN's) and the Director of Resident Care. They all hang out together and are personal friends. They gossip openly about me for the residents and staff to hear. I work very well with the staff and the residents really like me. I have been the subject of workplace harrassment and bullying and I'm currently in touch with the union head office because our union steward is one who is involved in bullying me.

I am trying to think of myself here. There are plenty of nursing homes around in my area and I could easily get another job. But, I know that the day staff are gathering every little piece of evidence to make me look incompetent. I can't even ask for any reasonable amount of help for fear of being ridiculed and the RPN's and the DOC voicing how incompetent I am. I haven't taken a break in four days so that I ensure that I do not miss anything. If I don't stalk the med cart, they complain and tell the PSW's that I don't pull my weight. I was threatened physical harm by a resident and those day shift Registered staff openly voiced to the staff and residents that I brought that on myself.

Anyway, I have to head to work now. I'm scared of going to work because I am under the microscope. I want to call in sick because I'm having these bad anxiety attacks and I'm finishing up ten shifts in a row to cover another RN's holiday. No one else likes taking the night shift.

I'm so stressed out. I can't stop crying and I want them all to just stop and leave me be to just do my job.

Your help with how to deal with the medication error situation would be immensly appreciated.

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I don't think I would give him his PRN along with his scheduled. Let the scheduled have a chance to relieve his pain, then reassess and see. Having said that, I don't think it's a med error to give him the PRN with the scheduled. It sounds like his pain isn't being controlled and his physician should address the issue. What's his pain like between 1700 and 0600?

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Specializes in Pysch, SN, Med-Surg.
I don't think I would give him his PRN along with his scheduled. Let the scheduled have a chance to relieve his pain, then reassess and see. Having said that, I don't think it's a med error to give him the PRN with the scheduled. It sounds like his pain isn't being controlled and his physician should address the issue. What's his pain like between 1700 and 0600?

I agree, and if there is still confusion clarify it with the ordering physician or you can even call up the pharmacist you guys go through and ask them. I'm truly sorry to hear this story. Is this your first year? just stay strong and positive until something else comes through.

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Specializes in CAMHS, acute psych,.

You poor thing. Get out now - before your rep is damaged by gossip and before you break down. Good luck and best wishes

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Specializes in CAMHS, acute psych,.
littlenursemom said:
I agree, and if there is still confusion clarify it with the ordering physician or you can even call up the pharmacist you guys go through and ask them. I'm truly sorry to hear this story. Is this your first year? just stay strong and positive until something else comes through.

Sounds good to me - PRN means pro re nata - when the patient requires. The way you describe the med order it sounds like he can have up to 4 PRN doses per day. It doesn't say he can't have them at the same time as his scheduled doses.

Agree about getting his pain reviewed by MO - breakthrough pain is one thing; constant pain is inadequate pain meds scripting.

If you want to know more about breakthrough pain there's a great free CE training module on Medscape.

Stay strong - get out - look after yourself FIRST (remember DRABC? What does 'D' stand for?)

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Specializes in NICU, Post-partum.

Think it through.

PRN is "as needed" and used when scheduled meds have been given and the patient is still in need.

When it was time for the scheduled med to be given...a need for the PRN was not yet determined because the scheduled dose had not been given. It's not really justifyable to double the dose when there is no documentation that the scheduled med didn't work.

If he/she was still in pain at 7 or 8...then yes, you would have been justified in administering an additional dose...PRN.

It was a valid med error.

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Specializes in PCU, cardiology, oncology.
Quote
I'm scared of going to work because I am under the microscope. I want to call in sick because I'm having these bad anxiety attacks and I'm finishing up ten shifts in a row to cover holiday

You need to take a breather. You're getting way overworked, and that's when mistakes happen. You made a very minor med error, not a huge deal, no one got hurt, you learn from it... You need to take care of yourself. If you don't have to work in that negative environment then don't, move on to another place where you can do your job without petty cliques and politics. Good luck.

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BabyLady said:
Think it through.

PRN is "as needed" and used when scheduled meds have been given and the patient is still in need.

When it was time for the scheduled med to be given...a need for the PRN was not yet determined because the scheduled dose had not been given. It's not really justifyable to double the dose when there is no documentation that the scheduled med didn't work.

If he/she was still in pain at 7 or 8...then yes, you would have been justified in administering an additional dose...PRN.

It was a valid med error.

If the PRN order read "give 1 tab PRN q 4-6 for pain" then it was NOT a med error. If it read "give 1 tab PRN q 4-6 for breakthrough pain or do not give with scheduled dose, then yes, it would've been an error. The dose wasn't doubled, he got a double dose at that time. There's a difference.

If the clocks says the patient may have a PRN and he's asking for it (again, unless there are parameters rather than simply "PRN pain"), we are obligated to give it. And I'd still like to know how often the patient was asking for his PRN dose at the same time as his scheduled and how was his pain controlled from 1700 to 0600. Given the info in the OP, I get the impression his pain isn't controlled.

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Specializes in ..

Im only a student and we haven't covered pain yet (that's later this semester!) but...

Pain, from my understanding, is subjective to the patient. If the pt says that their pain is 10/10, who is to argue with them? & if the pt knows that they have PRN pain relief to take "as needed" at anytime, why it is a med error that the nurse administered the scheduled dose and the PRN at the same time if the pt requested it. The nurse could hardly have deined a PRN if the pt insisted on it - that's not "legal" either, is it?

Perhaps the error is with how the medication chart is written?

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Specializes in MPCU.

Really seems like the MD was trying to get around the pharm guidelines that say you can't prescribe 1 to 2 tabs. So it was 1 tab atc and then the prn. Doesn't exceed the 4 grams in 24 hours and sounds like good critical thinking.

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Specializes in Mostly LTC, some acute and some ER,.

I have seen orders like this. I would give the routine dose, and tell the patient to "give this one a chance to work, if it doesn't then I will give you another." I would definantly talk to the physician. maybe he just needs something a little stronger than the T3's. I am sorry that you were the chosen one to get in trouble for this.

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Specializes in Trauma & Emergency.

IF the order read the way that you described I do think that it would be an extremely MINOR med error. The order says q4-6h PRN so to me that would mean that one dose would have to pass for four hours before I could give another pill. I would have given the first one and went back to reassess in 1 hour.. if the patient still had no releif I would notify the MD, ask if it was okay to give another and then document the conversation with the doctor.

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