Routine Tylenol #3 and PRN administration

[nurse_clown]

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.

[cjcsoon2bnp, MSN, RN, NP]

I'm just a nursing student so I don't know if what I think would be right for this situation but this is what I would do. So lets say I came to give the Tylenol #3 at 1200 as I was giving it I would tell the patient that they need to give the medication a little time to work and I would come back later to check if their pain level had gone down. I would check back at 1300 and if the patient reported that they did not achieve any pain relief I would call the physician and ask if I could administer another Tylenol #3 from the PRN order.

!Chris

[nurse_clown]

Thanks for the input. I have known the resident does have pain control issues and it is constantly a struggle for me to get people's pain under control. Especially, in a long term care setting. But, I believe I am right in giving the dosage I did. I also started a 7 day pain monitoring assessment form and of course time will tell. In nursing homes, it takes almost eons to help someone with pain or anything for that matter. I report nausea and vomiting to the next shift and they'll say something like "oh she's like that." and do nothing. Or it someone is hallucinating, they'll say "he does that." and end of story.

[nurse_clown]

I've also decided to ask for an "inservice" or education session on pain managment. It's always been a sore spot for me because I hear a lot of excuses for the other nurses not to give pain medication. I argue a lot with them. One other nurse has the gall to say that "oh it's a behaviour" when the patient screams in pain when being tansferred or when the wound care nurse changes a dressing.

[rachelgeorgina]

^ Good on you for being proactive.

[P_RN, ADN, RN]

I'd give it with the scheduled T3, Provided he had not received the additional one at the prior scheduled time. Otherwise soon you are going to be playing the game "but the other nurse did, or end up with the every two hour pstient prescribed game.. Just keep an eye out for the amount of tylenol as the FDA is recommending a much lower than the 3000 a day we all learned.

[MoopleRN]

AllSmiles225 said:

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.

Why would you notify the doctor the patient was requesting his PRN and ask if you could give a PRN that was ordered? If the clock says he can have his PRN and he's asking for it, why are you calling? I don't understand....???

[litbitblack, ASN, RN]

To me, a scheduled med is a scheduled med. Obviously he needed a prn as the scheduled one wasn't working. It also sounds like you need to bring up all the other times that it was given like that so that the others may also recieve a med error if that is what your boss wants to do. I would also contact the doc as the scheduled are obviously not working and they may need something else. One persons perception of an order may not be anothers.

[BabyLady, BSN, RN]

MoopleRN said:

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.

That wasn't the problem the OP had nor the order.

The OP stated that the patient woke up at 0600 in horrible pain...the pain meds were due at 0600.

The patient ASKED for the dose to be doubled..

The pain medication was on a schedule, along with additional doses PRN.

The OP gave the patient a double dose of the pain meds at the scheduled time, which was 0600.

That is a med error.

You cannot justify that the pain was not controlled, when you have not given the scheduled pain med and then assessed the pain before and after the administration of the scheduled dose.

If the action of the drug was 30 minutes, an hour, whenever...and the patient was still in pain, then YES...she could have administered additional doses PRN, and it would have been entirely justified.

Now, if the patient had woke up at 0500 in pain....Yes, she could have given THAT does PRN and then the scheduled dose at 0600...that action would have been justified as well, as you could have rationalized that the pain was not controlled.

She also would have had ammunition, based on assessment, administration, and response, to the physician to either increase the pain medication dosage, a shorter interval between dosages, or something stronger.

[MedSurgeMess]

The only thing I question is that the others who did the same thing and didn't get written up for a med error.

I wouldn't stick around for them to trash my reputation either. Go somewhere else, and make a fresh start

[nursecassia]

if he is needing a prn with a scheduled I would just get the doc to increase the dosing of the scheduled..It isnt uncommon for us to give 2 t3s regularly, plus give things like hydromorph or morphine prn on top of it..I wouldnt think this as a med error at all.

[MoopleRN]

The OP stated that the patient woke up at 0600 in horrible pain...the pain meds were due at 0600.

The patient ASKED for the dose to be doubled..

Correct. He was asking for his PRN along with his scheduled. He was asking for his PRN even before the scheduled had a chance to work. If the clock said he could have his PRN, he was entitled to it and covered by the PRN unless the PRN order had some kind of parameters which I've already mentioned.

The pain medication was on a schedule, along with additional doses PRN.

The OP gave the patient a double dose of the pain meds at the scheduled time, which was 0600.

That is a med error.

She did give a double dose at 0600 but it's NOT a med error if the clock says he could've have his PRN/he was asking for it/the PRN order didn't have parameters.

You cannot justify that the pain was not controlled, when you have not given the scheduled pain med and then assessed the pain before and after the administration of the scheduled dose.

Pain is subjective as you well know. Again, it was PRN (without parameters) and if the clock said ok, then she was covered, obligated/justified even, to give that PRN because the patient requested it. As I said in my original post in this thread, I would've encouraged the scheduled to have a chance to work and then reassess his pain. I agree with you on that. I don't agree that it was a med error, however, for the reasons I've stated.

She also would have had ammunition, based on assessment, administration, and response, to the physician to either increase the pain medication dosage, a shorter interval between dosages, or something stronger.

She still had that "ammunition" based on assessment/response even though she gave the PRN he was entitled to have along with his scheduled. It was getting documented how often he was getting his PRN along with his scheduled. Hopefully, a subjective/objective assessment of his pain (as well as a f/u) was documented as well. There was no med error that I can see based on the information given. What there appears to be is a failure to inform the doctor of the pain issue.

I totally see your point that the scheduled should've had a chance to work before giving the PRN but again, if the clock said he could have it, he was asking for it, there weren't any parameters on the PRN order, she was totally covered/"justified" in giving that PRN.

[KAYBDT6, BSN, RN]

If a nurse missed a schedule dose of Tylenol for a pt, Is that count as a med error?