Stacking PRN pain med orders?

[guest1143647]

So my patient has an order for Oxycodone 5 mg po every four hours for severe pain. They also have an order for  tramadol 50mg po every four hours for moderate pain. I gave the oxy at 0300 for a pain level of 8. I went on break at 0330. When I came back at 0415, she said the patient was still in pain so she gave the tramadol at 0350. 
 

There is no order to stack pain meds that way. She stated it was OK to give. Who is right?

 

In home care we had to have an order to do it that way. For example,a nurse  I worked with gave ibuprofen 1000mg at 2pm and then turned around and gave tylenol 500mg at 3pm for pain. (Pt had orders for both, for pain) The homecare supervisor stated it was a med error because we don’t have an order to stack pain meds that way. She said the nurse should have waited the 4 hours and then gave Tylenol or called the doctor.

[Nursingmypride]

What do you mean there is no order to stack pain meds that way? If the pt has both meds ordered then they are fine to give as long as you are not giving the tramadol and oxy together, wait at least an hr in between since they are both narcs. I agree with the nurse who gave the Motrin and then the Tylenol after an hour. If the pt has no relief from the Motrin then the Tylenol was also ordered for pain. The only reason you would wait 4 hours after giving the Motrin to give the Tylenol is if the Tylenol was also an NSAID which it is not. So therefore it is OK to give. We do it this way all the time at my hospital. If the pt has both orders they were meant to be stacked IMO otherwise the provider wouldn’t have put both orders in. 

[JBMmom, MSN, NP]

Not really knowing all of the background I would say that administering the tramadol one hour after the oxycodone was ineffective is appropriate. We also have orders for breakthrough pain administrations of medications. If both orders are active, and not be administered recklessly, it's acceptable. 

[Mr. Murse]

In 10 years+ of nursing I've never seen orders specifically stating to stack pain meds, or to not stack them. It's really a nursing judgement call, as most PRN meds are. There are a number of factors to consider. As a general rule I try to space narcs at least an hour or more apart, but I have given them together before for specific reasons including things like what procedures the patient had done and their history of tolerance for the medications.

So to answer your question: you're both right.......depending on the situation.

If there is no written order to space different meds out then it is a nursing judgement call based on the individual situation. There may come a time when giving two meds at once or shortly after one another may be appropriate, and legalistically sticking to a "never stack meds" mentality without assessing the situation could be a bad call. Just like giving two meds at once just because a patient says they're in pain could be a bad call too, depending on all the details of the situation.