Thoughts on pain med with a range

trinitymaster · Aug 26, 2015

I say that you need to find out what your facility says about this. At mine, which is LTC), we can do what you are saying.
So, my resident is complaining of pain and she has an order of 1 - 2 pills q 6 hours PRN. Depending on the amount of pain, we can give one and then if she is in pain up to that 6 hour period, we can give her the second one. Now, if we give her both pills, we have to wait the 6 hours. We find her pain is controlled better by giving one at 3 hour intervals or there about.

If this is found out, then your Board may charge you with diversion of narcotics, negligence, and willfully acting in a manner inconsistent with the practice of nursing. If you give it a little early, then you have made a med error- Not that big of a deal. If you consistently and willfully give it every three hours, then you are in BIG trouble. Not only are you putting your license at risk, but you also run the chance of getting to wear bracelets when the Gold Badge patrol rolls in.

calivianya, BSN, RN · Aug 26, 2015

Our MAR will tell us if we try to administer a dose too close to another dose. If you try to do so, it makes you give a reason. One of the perfectly legit reasons on our MAR is "Previous partial dose." If "previous partial dose" is a perfectly legit reason to give a med before the time frame is up (i.e. you could have given 10mg of something q4h but you only gave 5mg instead) I fail to see why giving the rest of the dose is a problem.

We don't run into this problem much at my workplace (we have a really good pain management protocol that involves q15 minute dosing, so there's no reason to ever give something more often than it's ordered), but I would feel perfectly comfortable giving 5mg every two hours if the order was for 10mg every four. I would give it as the patient requested until I could snag a physician to correct the order for me or to add something else into the regimen to give the patient better control. I agree that q2h dosing for pills is just ridiculous.

OCNRN63, RN · Aug 26, 2015

I work Onc/Palliative. I have pt who have sickle cell, glio's (two with stage 4 at this moment), lung, liver, and pancreatic CA's with and without mets. I have pt who are actively dying. I have seen ranges of Q15min (20mg Roxanol) to Q8 for 10mg Norco (or Percocet). And everything in between. My sickle cellers (well know to us, well loved and nearing the end of their lives) will have 2mg Dilauded q2H at admission and eventually work down to 2mg Q4h.
Sometimes a pt needs the pain meds very frequently (my dying pt who has Lung CA with liver, bone and brain mets, or my sickle cellers) and I have pts begin weaned off the IV morphine getting it Q8H. It depends on the situation. A blanket statement of "It makes no sense to..." doesn't make sense to me.

It makes no sense with patients who are not actively dying. That's not what the OP said.

I worked in hospice for several years, was a certified hospice and palliative nurse, and was a manager. In those cases, with patients who are actively dying, yes, then it does make sense.

Here.I.Stand, BSN, RN · Aug 26, 2015

5 mg Q2H is not the same as 10 mg Q4H. I work on an ortho unit and it is very clear in our policy about meds. If a pt has 5-15 mg Q3H, we dose based on their pain score. And they do have to wait 3 hours for next dose unless there is an order for IV break through meds.

This policy is basically going to encourage people to request the max, needed or not, if there is no other option for 4 more hours. Keep in mind that not every condition is going to warrant an IV for breakthrough -- my personal example is lady partsl deliveries. My CNMs ordered 1-2 Percocet q 4 hrs prn, and ibuprofen 600 mg q 6 hrs prn. Nobody is going to order IV meds for breakthrough, or a long acting narcotic for post lady partsl delivery. It's not bone mets, flail chest, sickle cell crises...but it can be very painful esp. if you've had several babies like I have. For the first dose, I've said I'd try one percocet, and if that didn't work I'd ask them to bring the 2nd. Had the nurse not given me the option -- planned to withhold the 2nd, really -- I promise, I would be asking for 2 every single time to avoid the risk of suffering needlessly.

For RNs whose facility -- or rigid understanding -- dictates that the entire time frame must pass between the smallest dose in a range... I hope for your pts' sake that you are calling their providers and asking the order be amended. So in the case of the 5-15 mg oxygen q 3 hrs, in order to assure your pt can always get their fully ordered prns, you should be asking the MD change the order to 5-15 mg q 1-3 hrs prn.

OCNRN63, RN · Aug 26, 2015

Oxygen?

calivianya, BSN, RN · Aug 26, 2015

So in the case of the 5-15 mg oxygen q 3 hrs, in order to assure your pt can always get their fully ordered prns, you should be asking the MD change the order to 5-15 mg q 1-3 hrs prn.

I don't know that this is the answer. Maybe three separate orders - oxycodone 5mg q1h PRN OR oxycodone 15mg q3h PRN, with the stipulation that they are linked orders and you can only administer under one of the orders. I can't imagine how this would work on paper charting, but it works quite nicely on an EMAR. All "linked" orders for the same medication are timed as given when one of them is - they just have a placeholder that says "See Alt," so it would be impossible to dose under different orders without being aware of it.

The way you phrased it would give someone really good pain control with that potential for 15mg q1h. :)

Jensmom7, BSN, RN · Aug 26, 2015

Wouldn't it seem prudent to actually know things about the patient and situation before making a blanket statement about their pain medication regimen?

Not if you know anything about pain management. The goal is to move the patient to a long acting med that they take twice a day, and use the short acting med for breakthrough, so they aren't needing to medicate q2 hours and have a more stable level of relief.

That's why we monitor how much breakthrough med is needed in 24 hours-the solution is to increase the long acting med to comfort, so the short acting med is needed less often.

ButtaflyRN · Aug 26, 2015

From the American Society for Pain Management Nursing / American Pain Society position statement on this specific question:
http://americanpainsociety.org/uploads/about/position-statements/ps-opioid-dosage.pdf

I agree with that, in the sense that if you give the 5mg first, then find that it doesnt work you given the 2nd 5mg, but from there on out you should give 10mg q4h. By giving 5mg every 2 hours you are acknowledging that 5mg does not work so you are in essence not controlling your pts pain.

BecomingNursey · Aug 26, 2015

Or you could just call the physician and ask him to change the order to 5mg Q2H PRN.

Sitch321 · Aug 26, 2015

So in this case you do not consider 5mg a partial dose? Obviously it would be a med error to give 10mg q2h. But I can give up to 10mg in a 4 hour period. If in "every 4 hours" of the day they never got more than 10mg, I don't see how that is wrong. If the patient wanted 2.5mg would you not give that?

MendedHeart · Aug 26, 2015

It is practicing outside of your scope of practice (inconsistent).
The med is to be given the way the doctor ordered it.
I can't think of anything to say except that you really need to invest in some liability insurance.

No, we follow orders. These are Linked on the MAR. So our facility policy in regards to linked orders is same as OP

You are not correct.

Morphine 1-2mg q4 prn pain (7-10)

2000: 1mg of Morphine pain 10 of 10

2100: 1mg of Morphine pain 7 of 10

Cannot have anymore Morphine until 0000.

Here.I.Stand, BSN, RN · Aug 26, 2015

The way you phrased it would give someone really good pain control with that potential for 15mg q1h.

Ack, you're right!! :facepalm: I do think just reading it as up to 15 mg in a 3 hr period is the best way to adequately treat -- not under or over.