Betsy@ asked
I am a R.N. working in a long term facility in the state of Florida. I have a patient that is on Narcotics ordered every 4 hrs. p.r.n.. He often seeks these meds at 3- 3 1/2 after the previous dose was given. I have asked him every time if the narcotic was effective and he always gives a follow-up pain rating of 2-3. I am concerned for his safety and for my license because he has been seeking these meds around the clock. Recently he stated to me that he can have them 1 hr. before they are ordered (q4hrs.prn). I can not find anything that tells me that administering any narcotic that early is safe or legal. This pt. is A/O x 3 and is good at manipulation. I want to do what is right for him and for me. Can you help me?
Answer
You certainly are in a tough situation based on the needs of your patient! We will try and offer as much help as we can. Firstly, if his medications are ordered every four hours as needed by his practitioner, it is important for you legally to assess the validity of your patients remark stating that he can have them one hour before they are ordered. That order, true or not, cannot come from the patient. Be sure to check with the prescriber to make sure that is accurate. Often times many pain medications such as morphine or oxycodone CAN be dosed every 2 to 3 hours, so that is certainly not out of the ordinary. You are fine legally as long as you are following prescribers orders and to your knowledge that order is medically acceptable. The fact that the medication prescribed is as needed and not specifically noted as around the clock is of some concern. Typically if a patient is taking medication at every opportunity, they need to be re-evaluated for something more than just a PRN medication.
In terms of you wondering if the medication is safe, it's probably safe to assume that it is. I'm guessing the medication the patient is getting is an opioid medication. Opiods are obviously dangerous when they are overdosed, but the real danger is for people that are over dosed that aren't used to such high doses. There is no ceiling dose on opioid medications because patients soon become tolerant to them and their side effects. If you or I were to take a dose of opioid medication someone has been taking for years with no issues, we would have some major problems. Most everyone that dies on opioid medications dies for one reason, respiratory depression. Respiratory depression happens at high doses of opioids and it happens quickly. If you aren't noticing shallow or labored breathing in your patient, chances are they are OK. The only concern is they might not be getting effective pain relief or they are trying to abuse the medication.
The type of facility you are practicing at typically has some sort of guidelines on how to deal with pain control. Hospice locations typically only go with immediate release pain control, while longer term nursing facilities tend to have much broader guidelines on how to treat patients. Have you or the prescriber ever considered an extended release controlling pain medication? It all depends on your location if you use them or not, but if a patient has chronic pain, sometimes a 12-24 hour extended release medication along with an immediate release medication for breakthrough pain makes more sense and cuts down on the total doses a patient needs.
It is important to find out why he is asking for more medication early. Is the pain coming back that quickly after dosing? Is the patient experiencing any sort of withdrawal symptoms after being without medication for a few hours? Has the patient had chronic pain issues for some time or is this an acute injury? It certainly seems as though he needs to be re-evaluated for pain control based on what you mentioned in your question but some more information is needed.
Again, as you state in your question, the two most important things are your license and the patients health. As long as you are following the prescribers dosing instructions and they are medically acceptable, you are fine. I would not dose the patient more than the every 4 hours prescribed however. If that is not adequate, the patient needs to be re-evaluated for a possible controller medication or something else all together.
