Scenario - input, please!

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  1. Would you give the 2nd pill?

    • 2
      Yes, I see the norco and tylenol as separate orders.
    • 6
      Yes, the amount of tylenol is not a concern at that level.
    • 1
      No, Norco contains tylenol, it would be against doctor's orders.
    • 0
      No, the nurse should've just given one or the other.
    • 11
      Maybe, depends on their 24 hour total tylenol intake.

20 members have participated

Ok. Let's talk scenarios, please.

Let's say you have a new patient, one that has an acute condition that could reasonably require pain medication, and also a psychiatric disorder which has the tendency to cause anxiety and sudden mood swings.

You initially do not have the narcotic (Norco) that the MD prescribed as the pharmacy is running late, but you do have an order for acetaminophen 500-1000mg Q6H PRN and your patient insists at first that they will be fine with Tylenol.

Not knowing how they respond to Tylenol, other than that there is no allergy, you initially offer your patient 1 500mg tablet as they have insisted repeatedly that they are not in much pain and do not need anything strong. Your patient accepts it without complaint. It is 12 pm.

At 2 pm, you finally receive the narcotic. The patient states that they 'would like one of those' as their pain is back. Your order for the Norco is Q4-6H, 1-2 tablets, 7.5/325mg. Knowing that the acetaminophen you gave earlier could've been given in a 1000mg dose, let's go ahead and assume you were comfortable giving your patient 1 tablet of Norco.

In your patient's body is now 825mg of acetaminophen. 15 minutes later, you get a call from the patient. They are very agitated and accuse you of not doing your job because they are still in pain. They demand another norco tablet from you, though they did not protest earlier about the given dose.

Did you give the 2nd pill? Why / Why not? Do you give acetaminophen to your patients in between norco / percocet / ultracet doses, even though those medications contain acetaminophen? Why / why not?

Is there something you would've done differently than the nurse in the example did? If yes, what and why?

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Specializes in LTC,Hospice/palliative care,acute care.

what's the maximum recommended amount of Tylenol per 24 hours? That's the answer.We have had a number of patients prescribed drugs with acetaminophen in them ATC with plain acetaminophen for break through pain.And they are usually people with psych issues who are very focused on their meds.

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what's the maximum recommended amount of Tylenol per 24 hours? That's the answer.We have had a number of patients prescribed drugs with acetaminophen in them ATC with plain acetaminophen for break through pain.And they are usually people with psych issues who are very focused on their meds.

3 grams, but ... that's not quite as clear an answer as I hoped for. Still, I assume you're saying you see the orders as separate unless the tylenol dosage reaches / exceeds the RDD.

(edit: ah, oops, just realized ... forgot to put that the norco is also PRN.)

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Specializes in EDUCATION;HOMECARE;MATERNAL-CHILD; PSYCH.

Pain is subjective. So I will get the prescriber involved at this point because it looks like the pain management regimen is not effective. Since the RDD for Tylenol is 3g, I am willing to give the second dosage since that means the patient will have 1150mg of Tylenol in his/her system (with a notice to the prescriber, of course).

Additionally, I will encourage the patient to increase fluid intake (if there are no restrictions). Again, my action is based on the theory that pain is subjective.

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Specializes in LTC, assisted living, med-surg, psych.

This is about the time I'd be calling to ask the prescriber to switch the narcotic to oxycodone (assuming there's no allergy) so there's little chance of overdoing it on the acetaminophen.

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There are separate orders... though the Tylenol order is incomplete (PRN for what?)... Still, so long as you don't exceed the safe APAP limits, there's no problem.

In-house, we do not use APAP for pain control... if it's OTC, it's ibuprofen... otherwise, ketorolac, hydrocodone, oxycondone, hydromorphone, morphine, etc.

We use APAP only to treat fevers.

Pharmacy and the provider are dropping the ball if they have parallel PRN Norco and APAP orders that can result in the patient being overdosed with APAP.

Regarding the patient's development of agitation and the accusatory (hostile?) demeanor, treat it as appropriate... that is, Zyprexa, Valium, Ativan, Haldol, etc... PO/IM/IV as appropriate.

And I don't generally respond to patients who "demand" much of anything...

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Specializes in LTC, assisted living, med-surg, psych.

A reminder.....not every patient with mental health issues is demanding or hostile, nor does the response to agitation necessarily require heavy-duty psych meds.

Just sayin'.

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Specializes in Pediatrics, Emergency, Trauma.
A reminder.....not every patient with mental health issues is demanding or hostile, nor does the response to agitation necessarily require heavy-duty psych meds.

Just sayin'.

Agreed. :yes:

I have found "demanding" and "mood swings" in pts without a documented mental health issue. :blink:

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Honestly I don't see what the patients mental health had to do with this scenario. I think examining one's feelings about patients with mental health histories may be in order. Patients who are in pain tend to be agitated and verbally aggressive. I know I am not in the best frame of mind when I am in pain.

To the apap issue call provider for a change.

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Specializes in SICU, trauma, neuro.

I will under no circumstances exceed maximum limits for APAP. Of course I will explain to the pt that Norco/Vicodin/Percocet contain "tylenol," so to avoid toxicity to their liver they will need to wait the full four hours in between doses and not take more than 4 gm "tylenol" per day. I don't just tell them they're SOL. ;) But like Music In My Heart, I don't just comply with pt demands, esp. if they are unsafe.

When I worked SNF (the only place where we've had to wait for a pharmacy courier to deliver meds), I would give the pt their options: 1) take APAP now, which means that they will have to wait a minimum of 4 hours to take Norco (since I generally don't give 1 tab of APAP. Kind of seems like using a squirt gun to put out a fire to me)...or 2) they can try to tough it out for a while, and then they can have Norco the second I sign for it.

In the hospital where we have the drugs available as soon as the PharmD verifies them, I will call the provider for an order for plain narcotic vs. plain APAP. The pt's tolerance dictates the upper limit for narcotics, while APAP has a set upper limit in milligrams.

This is what I do regardless of the pt's mental health issues or lack thereof. :yes:

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Specializes in Emergency Department.

As I see it, those are two separate orders and since the APAP (only) order is incomplete, I can't give it because I have no idea why it's being prescribed specifically for that patient. I'd have to first clarify the APAP (only) order because it can be used for pain or fever. As to the Norco 7.5/325 order, that's also not a complete order, that order must be clarified too. Since both are probably options for pain control, you'll have to be very, very careful about APAP daily limits. That's when it's a good idea to have a pain option that's APAP-free so that you can administer that if the APAP (only) doses aren't effective. Of course, since you've got the doc on the phone for order clarifications for both APAP-containing meds, that would be a great time to ask for a non-APAP pain control med because the 3gm limit would be very easy to reach with q4 hour Norco dosing... after all, 650mg APAP q 4 hrs = 3900mg APAP in 24 hours.

ETA: given the current "mood" of the patient, I would expect that the patient would keep their eyes on the clock and suddenly become demanding of pain control every 4-6 hours, needing the 2 Norcos even though the meds are PRN.

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A reminder.....not every patient with mental health issues is demanding or hostile, nor does the response to agitation necessarily require heavy-duty psych meds.

Just sayin'.

Who are you reminding?
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