Rule Book On Narcotic Pain Medication

Kymmi · Sep 20, 2007

I see you have three posts so far on this same subject so it is very difficult to follow this along as a thread with three separate posts to look at but anyway.......I do believe that q 4 hours prn on a narcotic pain med means just that.......every 4 hours---not every 3 1/2 hours because patient requested....if thats the case we'd have patients requesting every 3.5 hours and in the course of 24 hours you'd end up giving an extra dose. I guess it would all depend on what your hospital's policy is however I would not give it any sooner than every 4 hours if thats the way it is ordered.

The difference between scheduled meds that are ordered every 4 or 6 or 8 hours are they are scheduled and if they are given 30 minutes early or late the patient will still not receive a extra dose in the 24 hour period.

catlynLPN · Sep 20, 2007

If it's ordered like q6hr, I might give something a few minutes early,

but for q4hr I usually try to stick closer to the 4 hours. If they're not getting any relief on their ordered schedule, then the doctor needs to be called.

But a nurse has to be careful. You wouldn't want to give something 15-30 minutes late and the next nurse give it 30 minutes early. That's getting too close. Right? Patients can be tricky, some of them. I give narcotic pain med to a patient now, and she will do everything she can to get me to give it early. One night she swore to me that she had not had her last pain pill. It was signed out, documented on the MAR, but she sure tried every trick to try to make me believe she didn't get it.

Of Course, I didn't give until scheduled time several hours later. I knew she had rec'd her pain pill. She just didn't remember, or didn't want to remember.

I'm rambling, back to your original question.

MustangSallie1997 · Sep 20, 2007

I have this in 3 different areas because I wanted to get the most input. I am new to this site, and still trying to figure things out. Sorry for any confusion.

agent66 · Sep 20, 2007

I stick to the 4 hour rule as well and if they are showing a pattern of continually asking for it before the four hours is up then they need either A) a breakthrough dose of the same drug or B) a different drug . A call to the doc of course for someone not responding well to narcotics.

woody62, RN · Sep 20, 2007

I'm going to swim against the tide but I have always understood it was permissible to give a pain medication up to thirty minutes before it was due, if one had determined it was necessary. To avoid any conflict, I would ask doctors to write the medication for every three of four hours. Rarely did a patient ask for it three and half hours before it was due. This focusing on waiting exactly four hours, is in my opinion, silly. We will not make a patient and addict by giving him/her their medication a half an hour early. In fact, it is really better management of their pain and it doesn't increase their pain level and agitation, like strictly adhering to 'every four hours only, to the minute'.

Woody:balloons:

Zookeeper3 · Sep 20, 2007

Our POLICY is that we have a 30 minute window with narcotics to give early or held late. If a patient needs it before that I simply call the doc. I've honestly never said it's not time yet, you'll have to wait.

Now I've called and said the patients objective signs do not reflect the amount of pain they are reporting and said the opposite when true, so the doc has the knowledge to choose the right med and dose. I usually call for a one dose break through, unless I am sure I need to increase the frequency then I ask for a break through PRN.

We have orders that vary from Q1 hr to Q6 hr, so I don't have any hourly rule that I go by and I've seen such a varying need for pain meds over the years that I don't impose an arbiturary time frame.

hope this helps

Kymmi · Sep 20, 2007

Zookeeper---I understand what you are saying and I agree with the fact that if they are needing the med more often than every 4 hours it is time for the MD to be made aware of the level of pain with no relief. I wasnt implying in my post that I'd ignore the c/o pain but the point I was getting at was 4 hours for a prn is just that....4 hours and not 3 and 1/2 hours...at least that is our policy and I suppose every hospital is different but the point I was trying to make is we all know of the patients that are constantly in need of a narcotic pain med so therefore they'd be requesting every 3.5 hours so in the course of 24 hours if the drug was given every 4 hours you'd have given 6 doses however if given every 3.5 hours then 7 doses could be given...I understand that pain is an objective symptom and I dont want to make this a post about pain relief all I wanted to do was point out that by giving the dose 30 minutes early it could potentially lead to extra medications that were not really ordered.

Zookeeper3 · Sep 20, 2007

umn, sorry, did not mean to offend or get preachy, I initially didn't look at you're experience level and wanted to be thorough in case this was a new outlook for you. does that make sense?

sorry, but your second post was much clearer to me, Coming from a cardiac unit as well. Lets say the dose was Q6 hrs, (on the 6-12 schedule) if I give it 30 minutes prior per policy for the 6pm dose 17:30 then I cannot give it until 23:30 which does not add the dose over 24, just gives me the 30 minute window for each dose. This keeps the order from the MD as ordered.

again, I'm sorry, should have read your experience. I've just tried to be thorough in my responses so they're not read wrong, I guess it came out wrong anyway:trout:

We use a MAK computerized system that will prevent us from administering even a minute before that 30 minute window, perhaps you or someone can head up a policy change to address your concern because if I read you right, your patients can and are getting an extra dose that is not covered by the order.

Because I can't give the extra dose, I read your post in a totally different light, head is fully under the chair, thanks for the understading

cmo421 · Sep 20, 2007

I could be way out of the ball park here, but I am betting that most of us have given a narcotic early at some point. I agree with the post that the half hour rule covers regular schduled meds only. If you asked a pharmacist, I think they would make you wait til the last second!..lol I wonder why a facility would fire you over one incident. Ususally a reprimand or reminder unless policy was continuously broken. You might benifit from some legal advice if you do not have a union. Good luck!

Kymmi · Sep 20, 2007

Ok Zookeeper.....I understand still what you are saying and I agree that if its a regularly scheduled med for instance q 6 hours then our policy is actually a hour either way and I realize that no extra dose would be given in that instance because it is a regular dose...but lets look at PRN meds....lets say it is q 4 hours and its given at 6am...then each dose thereafter is given every 3 1/2 hours.....it would be 930 instead of 10....then 1 pm instead of 2 then 430 instead of 6...so there in less than 12 hours you are off by 1.5 hours.....follow that thought thru for a whole 24 hours and you'll see where the extra dose comes from. I know my logic seems like a very little error and I will be the first one to admit that if the OP was fired and reported to the board of nursing that I find that totally crazy because looking at the big picture it is a very little problem however I was just attempting to point out what the hospital will probably say in order to justify why they fired the OP.......and btw.......I did not find your post offensive at all and was just attempting to explain my thoughts better.

Kymmi · Sep 20, 2007

Let me clarify---- I am not saying I agree with the OP being fired....I am not saying that I agree with the strict rule for prn meds or that I have never given a med prn or otherwise early......if we're honest we'll admit we do things that arent always "by the book".....what I am doing is trying to point out where the hospital will attempt to come from in this instance and I could easily see where they could say medication was dispensed without a MD order for the mere fact that a extra dose could be given over a 24 hour period....does it happen often?? I would say not but you know the reality of nursing and the way we do things compared to the actual rules that the hospital or BON could imply if they wanted to are entirely different.

I think we all do what is best for our patients but if we're honest with each other and ourselves we'd all admit that in some situations things could be done by us one way but viewed by others differently.

All I am saying is that if you look at things from a legal issue the potential is there for someone to say that the judgement made was outside the scope of nursing because it involved a medication which needs to be ordered by the MD and followed per instructions...do I agree or am I critizing the OP....NO I am not...just pointing out the way things are compared to the way they are done.