Timing of PRN pain meds to scheduled meds

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I'm trying to find some evidence based research or some reliable resources on pain management and PRN medication administration. This is something I'm coming across at work quite frequently and just want some standards of care (not just other nurse's opinions).

If you have a scheduled pain medication given 2xs a day and then you have a few options for PRN medications based on pain scale how long do you have to wait between scheduled meds and PRN meds if they are ineffective. For example, pt has oxycodone scheduled twice a day and then they have PRN norco 1 tab q 4 hours for mild pain and PRN norco 2 tabs for moderate pain and morphine q 2 hrs for severe pain. (This is one of standard orders.) How long do you need to wait from giving the scheduled meds to giving a PRN and how long between 1 PRN and bumping to the next. If PRN one tab doesn't work can you just give the other tab an hour later or do you have to wait the full 4 hours? (That one I usually go to a different medication, but if anyone had any feedback on that I'd take an opinion.)

Me, I generally give med an hour if it's not working I give a PRN or bump to a higher PRN unless respirations are depressed or there's a physical reason not to give it. Should I be waiting longer? If so, can I get some links and info on why I should hold meds. I see a lot of my coworkers waiting longer and all I get is them looking up possible drug reactions and saying possible respiratory depression. I don't see that as a reason to not give a PRN medication. ANY dose of narcotics has a possible adverse effect of respiratory depression, if this was a reason to hold it then you'd never give narcotics. I do get peak times and maybe the dose hasn't had it's full effect so I am trying to find some info on this because I do try to stagger my meds as much as possible, but it someone is really hurting I want to do my very best to try and manage their pain. Any links, books, resources, would be helpful. I have tried to search this, but having trouble finding credible resources that give detailed information.

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Specializes in Medical-Surgical/Float Pool/Stepdown.

It would help to know whether or not the oxycodone BID is extended release or not. Really the pharmacokinetics of the meds should be weighed along with the patient's exposure and tolerance to the pain meds. (Grew up as a surgical-trauma nurse)

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It would help to know whether or not the oxycodone BID is extended release or not. Really the pharmacokinetics of the meds should be weighed along with the patient's exposure and tolerance to the pain meds. (Grew up as a surgical-trauma nurse)

Oxycodone is extended release.

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Specializes in Medical-Surgical/Float Pool/Stepdown.
Oxycodone is extended release.

Do you mean the oxycodone was extended release or that all oxycodone is extended release?

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Specializes in Med/Surg, LTACH, LTC, Home Health.
Oxycodone is extended release.

With extended release pain meds, I will give a Norco along with the scheduled meds. Extended release meds are designed for maintenance over time. The addition of PRN meds covers breakthrough pain. Every patient is different and therefore, some people are controlled with only the extended release.

Depending on the patient, if they request pain meds after receiving the scheduled dose, extended release or not, I'll give the PRN regardless of how much time has lapsed if it is indicated. But before I go pull it, I will let them know how many hours will pass before they're able to receive anything else, and I try to provide them with a 'coverage schedule' to include both meds and minimize that 12-hour BID gap, if needed. They usually agree to the plan, and this minimizes the anxiety and apprehension by knowing that there is a plan in effect that won't leave them out there suffering. Believe it or not, just the knowing decreases or delays the actual requests for pain meds, I've found, especially in psychosomatic and chronic pain sufferers.

Now, my experience in the above scenario does not include acute trauma patients in the first few days of the trauma. These patients require meds as soon as clinically possible, with the addition of phone the physician if necessary.

And my example definitely does not include the known drug seeker/addict; here, all you can do is medicate, vitals permitting, and look forward to the end of your shift.

As for looking for standards of care with pain control, given that pain is an objective symptom (patient-specific), I believe nurses opinions are going to be the standard you're looking for, as we all have had different experiences in deviating from or tweaking our approaches (using the foundation of knowledge) in order to adequately care for the patient. Critical 'thinking' to incorporate this, or that, or a little bit of both....;)

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Specializes in Acute Care, Rehab, Palliative.

I have many patients that receive the short acting along with the long acting regularly. If the scheduled ones are long acting they aren't going to have an immediate effect. I would give any PRN about an hour before using a stronger one.

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I always encourage my patients to take 2 instead of one. When you give one and another one an hour later it reads in the EMR that you are given it way too soon. Then, you will find yourself given 1 pill every 2-3 hours. So I s stick to 2 tabs q4h.

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Specializes in Medical-Surgical/Float Pool/Stepdown.

I think the issue here is not really knowing how the different meds work and therefore being anxious to appropriately medicate for pain control.

If the oxy is extended release (because not all oxy is!) then it is given for "maintanence" pain control like Lantus or long-acting insulin is given to control blood sugars. If it works by itself then that's great and all is good to go.

The norco is given for break through pain and can last around three to six plus hours depending on a persons tolerance and metabolism but the med usually takes a half hour to and hour to become effective.

The morphine is also breakthrough and has a way faster onset but usually only lasts a way shorter time. Minutes to effect and sometimes minutes before it wears off.

So if the pt has been tolerating the oxy round the clock, the norco round the clock, and is having uncontrolled pain then it can all be given at once with the nurse just checking on the pt as they normally would...as in not two plus hours later.

I personally would be giving the oxy as scheduled and the norco round the clock to try and stay on top of the pain. I would use the morphine as my back up plan but I would give them all at once initially as well depending on the pt and the situation to try and get the pain down because playing catch up with Trauma/surgical/etc pain is not only physically stressful for the pt but also tends to take longer to get the pain down to a reasonable tolerance.

As far as standards of care and EBP go, actually reading up on the meds and understanding how they work in the body while searching a library for EBP journals/papers should be up to the OP, not us (even though my opinion is based on my own educational background, research, and work experiences).

I will never understand why a nurse would administer a med or meds that they didn't understand.

I will also never understand why there is such a gap in knowledge about pain control on any spectrum whether it be a naive patient, chronic patient, or an addicted pt. If I'm ever in an MVA and my nurse is pussyfooting around with my pain meds, my opioid naive ass will be pissed!

Hopefully I don't get banned from AN for this post but pain control is such a hot button topic and maybe if we educated ourselves and treated acute and chronic pain more effectively then we could have less people with chronic pain and less people abusing or overdosing on pain meds.

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Specializes in Med/Surg, LTACH, LTC, Home Health.
With extended release pain meds, I will give a Norco along with the scheduled meds. Extended release meds are designed for maintenance over time. The addition of PRN meds covers breakthrough pain. Every patient is different and therefore, some people are controlled with only the extended release.

Depending on the patient, if they request pain meds after receiving the scheduled dose, extended release or not, I'll give the PRN regardless of how much time has lapsed if it is indicated. But before I go pull it, I will let them know how many hours will pass before they're able to receive anything else, and I try to provide them with a 'coverage schedule' to include both meds and minimize that 12-hour BID gap, if needed. They usually agree to the plan, and this minimizes the anxiety and apprehension by knowing that there is a plan in effect that won't leave them out there suffering. Believe it or not, just the knowing decreases or delays the actual requests for pain meds, I've found, especially in psychosomatic and chronic pain sufferers.

Now, my experience in the above scenario does not include acute trauma patients in the first few days of the trauma. These patients require meds as soon as clinically possible, with the addition of phone the physician if necessary.

And my example definitely does not include the known drug seeker/addict; here, all you can do is medicate, vitals permitting, and look forward to the end of your shift.

As for looking for standards of care with pain control, given that pain is an objective symptom (patient-specific), I believe nurses opinions are going to be the standard you're looking for, as we all have had different experiences in deviating from or tweaking our approaches (using the foundation of knowledge) in order to adequately care for the patient. Critical 'thinking' to incorporate this, or that, or a little bit of both....;)

I meant to say "objective at times, but primarily subjective". My thoughts were moving faster than my fingers.:blink:
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Do you mean the oxycodone was extended release or that all oxycodone is extended release?

I meant the oxycodone I was speaking of was extended release.

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Depending on the patient, if they request pain meds after receiving the scheduled dose, extended release or not, I'll give the PRN regardless of how much time has lapsed if it is indicated. But before I go pull it, I will let them know how many hours will pass before they're able to receive anything else, and I try to provide them with a 'coverage schedule' to include both meds and minimize that 12-hour BID gap, if needed. They usually agree to the plan, and this minimizes the anxiety and apprehension by knowing that there is a plan in effect that won't leave them out there suffering. Believe it or not, just the knowing decreases or delays the actual requests for pain meds, I've found, especially in psychosomatic and chronic pain sufferers.

I do exactly this. I am primarily dealing with post surgical pts. At the start of my shift I discuss when pain meds will be available. Depending on where they are rating their pain at and how well the extended release meds are covering their pain I may or may not wake them up for PRN meds.

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I think the issue here is not really knowing how the different meds work and therefore being anxious to appropriately medicate for pain control.

If the oxy is extended release (because not all oxy is!) then it is given for "maintanence" pain control like Lantus or long-acting insulin is given to control blood sugars. If it works by itself then that's great and all is good to go.

The norco is given for break through pain and can last around three to six plus hours depending on a persons tolerance and metabolism but the med usually takes a half hour to and hour to become effective.

The morphine is also breakthrough and has a way faster onset but usually only lasts a way shorter time. Minutes to effect and sometimes minutes before it wears off.

So if the pt has been tolerating the oxy round the clock, the norco round the clock, and is having uncontrolled pain then it can all be given at once with the nurse just checking on the pt as they normally would...as in not two plus hours later.

I personally would be giving the oxy as scheduled and the norco round the clock to try and stay on top of the pain. I would use the morphine as my back up plan but I would give them all at once initially as well depending on the pt and the situation to try and get the pain down because playing catch up with Trauma/surgical/etc pain is not only physically stressful for the pt but also tends to take longer to get the pain down to a reasonable tolerance.

As far as standards of care and EBP go, actually reading up on the meds and understanding how they work in the body while searching a library for EBP journals/papers should be up to the OP, not us (even though my opinion is based on my own educational background, research, and work experiences).

I will never understand why a nurse would administer a med or meds that they didn't understand.

I will also never understand why there is such a gap in knowledge about pain control on any spectrum whether it be a naive patient, chronic patient, or an addicted pt. If I'm ever in an MVA and my nurse is pussyfooting around with my pain meds, my opioid naive ass will be pissed!

Hopefully I don't get banned from AN for this post but pain control is such a hot button topic and maybe if we educated ourselves and treated acute and chronic pain more effectively then we could have less people with chronic pain and less people abusing or overdosing on pain meds.

This is one of the reasons I don't post here that much any more because so many posts are negative filled with people 2 cents and nothing more. Almost every time I ask a question I get answers like this. I have looked for EBP. I flipped through the 2 journals I subscribe to and you know what so much of nursing journals is utter BS. I mean seriously do I need to read article after article on pain is what the pt says it is. (Not saying that it isn't but it'd be nice to find an article on pain that said something besides that.)

As to the rest of your comments that was helpful. This is what I do. I was looking for EBP to print out for my coworkers because I have been a nurse 2 years and they've been nursing longer. My 2 cents doesn't way too heavy. I also have nurses that I work with that regularly flip out about giving insulin. (I have 2 diabetic children I know insulin profiles.) I give insulin when it's ordered unless there is a legitimate reason to hold it and I almost never hold Lantus. If I think the doctor has his dosage wrong then I might check sugars more frequently and chart the hell about it. Anyhow, as far as pain goes I was hoping to find something I could print out, and if I find something I will surely post it here.

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