Vicodin and Percocet

flightnurse2b, LPN · Jan 21, 2009

that's an awful lot of tylenol.

if she's on vicodin q6 thats 500 x 4... so we're at 2,000mg

then percocet q8 thats 325 x 3... so 975 mg

then if she gets her prn's she would be up close by or over the maximum per day dose of 4,000mg.

if she's been getting this much for a while, she may have gotten acetaminophen toxic. plus, since she has COPD, that much tylenol is not a good choice since she has decreased lung functions already.

GrumpyRN63, ADN, RN · Jan 21, 2009

It makes no sense to have an order for both Vicodin and Percocet. She should be ordered one or the other. Vicodin Q X hrs 1-2 prn, if the pt takes 2 Vicodin with no or minimal relief, it could be upped or changed to Percocet. She could take motrin simultaneously for better effect with either one, OR tylenol for mild pain.

If she is sent home on both tylenol and any opiod containing tylenol, she should be instructed in the potential danger of too much tylenol with either. If this pt was inpt, I would hope the nurses would know better than to give Vicodin and percocet and Tylenol, it's pretty basic, and one narc should be dc'd. High K levels may certaintly cause dysrhythmias (as well as low), but that's not related to the narc issue.

Seishiro · Jan 21, 2009

I would definitely bring this up with your supervisor or the physician responsible for prescribing the orders.

Blee O'Myacin, BSN, RN · Jan 21, 2009

How about having the order changed to vicuprophen? But they are both short acting pain meds. If the patient needs long term pain managment, how about a oxycodone ER with a perc or an oxy IR rescue dose? Or morphine IR? Definately sounds like pain manangement needs to be consulted.

Blee

nghtfltguy, BSN, RN · Jan 21, 2009

yeah... i have to agree w/ the above.... that is WAY too much tylenlol... i have seen vicodin and percocet given @ the same time.. but not w/ a prn tylenol order... that could shut down her liver and we don't want that!!

and yeah...hi levels of K or low levels of K is very problematic w/ heart probs....

does she live in an LTC? or home?... either way... does she take lasix or some diuretic that would make her K levels low? did she have chest pain that you know of before she became non responsive?.. and her allergies.... is she allergic to anything that ya know of... and was she given anything new???

were her lungs clear? was she having any S.O.B?.... when was her eye surgery?.. today?.. did these symptoms happen right after she got back or a few days later.... im sure the doc w/ check her lytes and stuff... if her K was a panic high then you need not admister any k-dur or whatever she might be on until further orders.... sorry... im rambling... lol...

but yes... elevated K can cause ekg abnormalities.... what did her ekg look like? were there any ST elevations? or a block of some sort?

:cool:

kmoonshine, RN · Jan 21, 2009

Is it appropriate for a client to have and order for Vicodin q 6 hrs and an order for Percocet q 8 hrs and concurrent orders for prn motrin and tylenol prn. The client just had eye surgery for cataracts and she has a history of CHF and COPD, In any event, she became non responsive and her face became swollen and was subsequently hospitalized. She said the doctor told her her potassium levels were high!!! Does this make sense? I read that high potassium levels are associated with dysrhythmias!!!

It is not appropriate to have both vicodin and percocet ordered concurrently. It would be appropriate for orders to give tylenol every 6 hrs for mild pain, OR vicodin every 6 hrs for moderate pain, OR percocet every 8 hours for severe pain (never heard of dosing every 8hrs for percocet, its generally every 4-6 hrs). Ibuprofen can be given concurrently with tylenol, vicodin, or percocet if the pts condition permits.

Tylenol is usually 500mg-1000mg per dose. Vicodin usually is 5/500mg, and 2 pills equal 1000mg of tylenol. Percocet is usually 5/325 and 2 pills add up to 650mg of tylenol. If you gave all of that at the same time, that's well over 2000mg of tylenol combined in one dose! BAD BAD BAD!

Potassium is associated with dysrhythmias. But, vicodin, tylenol, and percocet would have little/no effect on potassium levels. I guess excessive ibuprofen could cause kidney problems if the doses were too high, and kidney problems would increase one's potassium levels. However, I'm not positive on this so who knows.

I wonder what the pts LFT's were like, since tylenol is harmful to the liver in excessive amounts.

Since the pt has CHF: if the pt is on diuretics, it can screw up their potassium levels (diuretics usually cause low potassium, but if the pt has been taking too much potassium, if they stopped their diuretic prior to surgery, or if they switched to a potassium-sparing diuretic its possible their potassium levels may be elevated). Usually high potassium levels are seen in end-stage renal disease, massive burn/crush injury patients, metabolic acidosis, and other conditions.

Virgo_RN, BSN, RN · Jan 21, 2009

Sounds like possible angioedema related to ACE-I use, which can also elevate serum K+.

As far as the pain meds, we commonly have patients with orders for APAP, hydrocodone/APAP, oxycodone/APAP, oxycodone, and morphine concurrently. Typically, they're all PRN, though, and the nurse uses nursing judgment in combination with collaboration with the patient to find the best medication to address their pain issue. Currently, we have no way to be alerted if the patient hits their 4g limit of APAP. We have to be aware of what they have had in the preceding 24 hour period, and make decisions accordingly.