Tylenol max/safe dosage

[Gabby-RN]

Let's say a 55 year old patient has an order for MS Contin every 12 hours 8am and 8pm for chronic pain. They also have an order for 2 tabs Vicodin 5/500 every four hours as needed for breakthrough pain. These orders have been in place for 10 days and the patient has been receiving the PRN Vicodin 5 times per day for all 10 days.

On Monday, the patient receives 2 tabs of Vicodin at 6am, 10am, 2pm, and 6pm. The patient requests 2 Vicodin at 10pm from the RN that just came on duty. This nurse typically works on the other side of the unit and has never cared for this patient before. The nurse reviewed the MAR and realized that administering the medication would put the Tylenol over the safe dose of 4000mg/day.

The on-call MD was notified and the nurse went over the patients allergies with him. The on-call MD ordered a lidocaine patch to be applied to the lower back. The nurse applied it, in addition to assisting the patient with other comfort measures. The patient seemed satisfied and verbalized an understanding of why the Vicodin could not be given.

The next day however, the patient complained to the regular MD when he was doing morning rounds, the MD in turn complained to the unit manager. The unit manager approached the RN (next scheduled shift) and asked why the Vicodin was not given. The nurse explained the situation, to which the Unit Manager replied that if it doesn't explicitly state on the MD orders for the patient not to exceed 4000mg/day, there is no reason to hold the dose and it was incorrect for the nurse to not give the medication.

Would you administer a medication that exceeds the safe dose? I am a fairly new nurse and did not feel comfortable giving the medication and I do not feel any better now after hearing the managers response to the situation.

Thank you in advance for any feedback :)

[kanzi monkey]

No. I would not give that dose. The manager was wrong. The Dr. agreed that the dose should not be given--however, he may have been more useful had he clarified the order (to not exceed 4g in 24h) or to make it q6, or to try a different medication.

[gentlegiver, ASN, LPN, RN]

No. I would not give that dose. The manager was wrong. The Dr. agreed that the dose should not be given--however, he may have been more useful had he clarified the order (to not exceed 4g in 24h) or to make it q6, or to try a different medication.

It was the On-Call Dr. that agreed the amount exceeded the safe max of 4000mg. The Regular DR must have know what his reasoning was for allowing this overage. He should change the order to read "Not to exceed 5000mg per day". If you run into this again request the patient's Dr clarify not the on call. In my facility our on-calls can be Dr's, PA's, or NP's. Often they tell me they don't know the patient or what the regular Dr was thinking when he made the order. If you can't get ahold of the regular DR then call the Nurse Supervisor and then document His/Her answer.

[LPNnowRN]

I would not give the dose without clarification and documentation by the MD who ordered it, along with documentation by you of your actions. Good catch! You gotta wonder why someone else didn't think of that for ten days. If the regular MD orders it and it exceeds the safe dose limit AND the patient begins to show signs of liver damage, then the documentation covers your license.

[Whispera, MSN, RN]

Knowing that such a dosage is over what's safe, I wouldn't give it no matter what the unit manager or doctor said. It is not SAFE! Who would be held responsible if the patient has liver complications? You! Who would be letting this happen? You.

Don't do things you know aren't appropriate. It's your responsibility to advocate for the patient as much as it is to give medications.

(stepping off soapbox now)

[Up2nogood RN, RN]

What you can do to be proactive is to ask the MD for a different hydrocodone formulation. I believe there are several dosages of this drug (10/325?) so the pt won't get to that tylenol limit and be allowed breakthrough pain meds.

[rn/writer, RN]

Don't forget to use pharmacy as a resource and back-up, although they should have caught this in the first place. Where I work, pharmacy flags things like this. Docs can override, but then it's their license on the line and their beef with pharmacy.

Good catch.

[sonja77]

I wouldn't have given it either!

This is the exact reason our hospital only carries Norco (which contains 325mg of Tylenol with either 5, 7.5 or 10mg of hydrocodone). All the orders we get for Lortab, Vicodin, Lorcet Plus, .... are automatically substituted for Norco.

[dblpn]

Knowing that such a dosage is over what's safe, I wouldn't give it no matter what the unit manager or doctor said. It is not SAFE! Who would be held responsible if the patient has liver complications? You! Who would be letting this happen? You.

Don't do things you know aren't appropriate. It's your responsibility to advocate for the patient as much as it is to give medications.

(stepping off soapbox now)

You are absolutely correct. Unfortunately, many nurses seem to think whatever the MD writes is ok without really looking to see if the doses are safe to give. Doctors make mistakes, and nurses are the last line of defense before that med is given to the patient. Kudos to the OP for being alert.

[caroladybelle, BSN, RN]

Why the heck are they using a med like vicodin/lortab along with MS Contin?!

MS IR is a frequent choice so that you can easily esculate the extended release if needed., I would think. But at very least they should try a noncombination med. Many pain control MDs don't like mixing multiple narcotics unless really necessary.

[NurseKatie08, MSN]

No way would I have administered a med that would put them over the max safe dosage of Tylenol/day.

That being said, this patient's pain management needs to be evaluated. Sounds to me that the MS Contin needs to be increased to maintain baseline pain control if they are requiring so many breakthrough doses per day. Also, why not just use MSIR instead of Vicodin for breakthrough?

[CoffeeRTC, BSN, RN]

Yes!!!! 10 days worth of taking the break thru meds like clock work means the long acting meds need to be titrated up.

I would have (and have had to) do the same.