I'm curious to see what the feedback will be to this question. I've had some agree and some disagree.
Scenario: I have a patient who can get 5-10mg oxycodone q4h. Can I give her 5mg of oxycodone every 2h? She doesn't like to take the 10 all at once and her pain was very well controlled with 5mg every 2-3h. The oncoming nurse said we couldn't do that. But it's not overdosing. So long as she only gets 10mg total in a 4 hour period its all the same thing, is it not? I just make sure there's at least 4 hours between every other dose. So if she gets 5mg at 10 am and then works with PT and wants the other 5 at 11am, I now will until at least 2pm to give another 5. The daily max is the same: 24h/4 =6, and 6x10mg= 60mg/day. 24/2=12, and 12/5= 60mg.
Specializes in RETIRED Cath Lab/Cardiology/Radiology.
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I used to do what you are doing OP for post-op pts especially. Now, however, in my facility you need a frequency range (q 2-4 hours) to administer the med in that manner. Administration has declared that you only get to give the med once for every time period, I now notice a lot more IV meds being given on the off hours.
Now, I thought that the joint commission DID frown upon ranges for frequencies. As in, 5-10mg range is okay, but not a q2-4 hours range.
Like an order for 2mg q2-4 hours wouldnt be ok - it should just be q2 prn. The frequency needed to be specific.
But maybe that was a facility thing and I just thought it was JC.
Quite often a physician (in pediatrics) might order 0.05mg/kg morphine Q4H PRN, or perhaps 0.1mg/kg.
If this child has never have morphine before and I know they are opiate naive...must I give them the full 0.1mg/kg, or is it within my nursing judgement to give a half dose and see how they tolerate it? Or am I required to give either the full dose or none at all? What if it over-sedates them? I imagine that answers will differ on this.
Personally, all I can say is that I think that it SHOULD be within the nurses judgement to give a half dose. I have a brain, let me use those assessment skills that I went to school for!
OP- no matter what the Nurse Gods tell you.....you can not give a dose every two hours. Using your logic, you could give 2.5 mg every hour, or 1.25 mg every 30 minutes, or just shave a little off every 5 minutes and give it to the patient.
BTW-Position statements do not carry the weight of law.
Exaggeration much! I'm talking about a range order of 5-10 q4h. And the policy at my facility allows it. They refer to q4h as the dosing interval and on any range order I'm allowed to give up to the max dose within the dosing interval.
Specializes in Med-Surg, OB, ICU, Public Health Nursing.
There is clearly no agreement amoung the nurses here. That leads me to believe that there could be confusion amoung nurses on different shifts and the patient could be receiving conflicting information. Therefore, why not call and discuss with MD (not at 2 am)? Then if MD agrees have the order re-written for clarity so everyone is on the same page? For example, may give 5 mg q 2 hours during the day and 10 mg at HS?
Specializes in Mental Health, Gerontology, Palliative.
Well don't I have the best luck that I can learn about pain management from someone as knowledgable as yourself.
So please enlighten me, oh wise one, from where you received your pain management certification. I am assuming a cracker jack box since I can't think of a single respected pain management certification or plan that doesn't have assessment of the patient as the first step.
I dont understand the snotty tone
For that matter can you name a single medical intervention that should begin without assessing the patient?
I can't wait to hear about your extensive pain management education and experience that has taught you that it is not necessary to know anything about the patient before prescribing a pain management protocol.
That way I will know to avoid wherever you learned this knowledge like the plague so that I can continue on with actually assessing patients and treating their pain appropriately for THEM.
Argoff & Silvershein Mayo Clinic Proceedings 2009
I dont see this person not advocating for ongoing nursing assessment.
I've done alot of work in community palliative care and we often would use a syringe driver if someone was in end stage and unable to take oral analgesia.
Most doctors would chart a range of analgesia in the pump, eg 10-30mg morphine Q24 in a syringe driver. why? Because many of them have a busy GP practice and as much as they would like they are unable to get out to their community palliative patients everyday.
When we refill the driver, how much short acting anaglesia a patient has had within a 24 hour period is one of the things we base our decision on how much analgesia to put into the new syringe. If patient B has 2-3 doses of analgesia for break through pain, on top of whats in the syringe, you can bet your bottom dollar I'll be considering whether the syringe driver needs to be increased. I also talk to the patient, I also observe them while drawing up the new meds, it becomes fairly easy to assess whether the current analgesia is adequate. If the patient is unconscious as well as direct patient observation I talk to the NOK.
I'd suggest if you have the opportunity to spend time with your local palliative care nurses do it. They are very knowledgeable about what they do, as another poster said doctors are often the ones asking for their recomendations re pain and symptom management
Our EMR actually does not allow us to do this. Last night for example, I wanted my patient (and my patient agreed) to take one 10 mg pill and wait about 1 to 1.5 hours to see if it helped enough before giving a second pill. In the EMR system, the order appears like this:
Box 1: take 10 mg every 4 hours as needed...
Box 2: take 20 mg every 4 hours as needed...
The EMR would not let me click box 1 for take one pill, and then click box 1 again 2 hours later for take 1 pill (to equal giving 2 pills.) So unfortunately, I have to actually falsely document how I gave it. In this scenario the patient did end up wanting the 2nd pill. So I had to click box 2: take 2 pills every 4 hours as needed. But if one were to look at the computer documentation, it would appear that I gave 2 pills at 2100 instead of one pill at 2100 and one at 2230. Other times though, the 1 pill would ultimately be effective, and I avoid giving 2 pills instead of one.
I will say however, that although it adds up the same mathematically, the onset peak and duration are going to be different. Depending on the goal, this can be a good or bad thing. It's not a good thing if your goal is to deter abuse. They basically get one long high instead of going through one single onset peak and duration time. We have a patient that has an ER that specifically states in the system, "abuse deterrent."
Specializes in orthopedic/trauma, Informatics, diabetes.
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.
So that would allow 15 mg Q1H??? No. We are very well versed in pain management. Of course if we need more, or an additional dose, we can ask for it, but we have follow orders. We have a pain team that assists in difficult to manage pts. And another poster implied that I would get fussed at for calling to ask for a one-time dose after I gave 5 mg and needed more. NOT. Our are very understanding and are open to it. We have a lot of older pts (hip fx) and we have to be very careful with narcotics.
Narcotic administration can be tricky-it can stack like insulin depending on kidney function and post anesthesia metabolism. I would rather give the lower dose and have to ask for more than have to pull out the Narcan. Our surgeons/pain team recs have led to using a lot more regional blocks to lessen the amount of narcotics needed.
We have to follow up all our entries with "effective" or "ineffective." We have a pt who routinely asks for his oxy at say 1500, then wants his q4 Norco at 1600 (last dose 12:00.) He is very drug seeking. But I don't know what to do with him. Other nurses just ignore it, but I personally hate clicking "effective" for the oxy when at the same time I'm giving Norco. Because if I click "effective" for the oxy, I have no justification for giving the Norco. I can't simply click ineffective either. If we document ineffective, then there is no justification to continue to give the oxy. I very very rarely question a person's pain level because I myself live in chronic pain, but you'd never know it. But with this patient, it's coming down to having to falsify documentation. At the exact same time I'm clicking that the oxy is effective, I'm also clicking a pain level of 8 (per patient) for the Norco. I'm considering calling the doctor and laying out the scenario exactly as I just described. That way if the doctor doesn't change the orders, I can at least document that md was notified and cover my butt. I don't care what I give this guy. I'm just sick of the game we have to play.
But with this patient, it's coming down to having to falsify documentation. At the exact same time I'm clicking that the oxy is effective, I'm also clicking a pain level of 8 (per patient) for the Norco.
What is prompting you to chart that the oxy is effective if the patient is stating that his pain is an 8? Is the patient also telling you that his pain was previously higher and that the oxy helped? I think perhaps to cover yourself you could write a note explaining why you are charting "effective"?
Our providers are not allowed to write range orders. They order by pain scale.
For example,
A patient with pain 1-3 receives Lortab.
A patient with pain 4-6 receives Dilaudid
A patient with pain 7-10 receives MS IV
They can add a break through medication also
It works pretty well
I've never understood why this supposedly makes sense, is there any evidence that someone's subjective pain scale is standardized enough, and that their response is standardized enough for this to work properly?
I tend to agree with the American Pain Society on this one:
"Prescribing a speciï¬c dose, based solely on a unimo- dal pain intensity rating, is not appropriate or safe.
A subjective pain intensity score is just one of several
dianah, ASN
8 Articles; 4,736 Posts
Thanks to the members who continue to post addressing the subject of the thread, WITHOUT posting personal attacks and/or resorting to name-calling, both violations of the Terms of Service.
Please continue to post as if you were addressing a room of professionals.