Can you give additional doses of a PRN to increase an already given dose to a range? - page 3

Hypothetical situation: Your patient is ordered 4 to 8 mg of Morphine IVP for pain>4 on 1-10 scale, Q2 hrs PRN. The first dose you give is 4mg, but 30min later he states his pain is unrelieved. I know what I "would" do, but... Read More

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    So here is JCAHO Range order recommendations: "Range orders Range orders may be written when the patient’s condition is unstable, or changing,
    and should include assessment parameters, whenever appropriate. Adjustments within
    the dose range are based on:
    • Patient assessment
    • Prior dose administered
    • Time interval between doses, and
    • Effectiveness of prior doses
    • Policy requires that the RN start with the lowest possible dose and increase if
    necessary by patient response"

    So if one starts with the lowest possible dose, they aren't very clear here on how to proceed with the next dose.

    Now I know we can no longer have two "variables" in the order. For example we can't have Morphine IV 2-4mg Q2-4 hours PRN pain.

    To me it really looks like one needs to follow their specific hospital/area protocol. If you have the flexibility to administer meds until "comfortable" then I would personally time from the most effective dose and then continue with that dose for the next administration if the patient was A&O and comfortable. So if I gave 4mg at noon and 4 additional mgs at 1230 I would time the dose from 1230.

    Unfortunately at our hospital they have taken the right away from us to start with the recommended JCAHO lowest dose. Perhaps there is an increase in patient oversedation related to this since the new system was implemented, due to nurses pulling larger doses in anticipation, since they know they can't go back in and scan an additional dose? Might have to ask a few questions at work when I get back!

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    When the JC recommendations came out and some hospitals were starting to just do away with range orders, the increased potential for over-medication and oversedation was one concern, but the potential for under-treatment of pain was as well. Our risk management dept. was concerned that if there was no flexibility and ability to adjust parameters to pt specific pain scales and responses to pain, then MD might be more likely to write for a high enough dose to cover the majority of pain which may result in unnecessarily high doses of opiates and then result in more over-sedation- which is a popular reason to sue.

    From a practice standpoint, we were also concerned that with less flexibility in treating pain that there may be lapses in pain control. Poorly controlled pain is associated poorer outcomes.
  3. 0
    Quote from Tait
    Well then they need to hypothetically tell us where it is happening as this will affect the responses.
    It was an hypothetical situation so we would be able to understand the question better and answer better
  4. 0
    Quote from suanna
    I'm all for pain control as well, but I'm mostly looking for any information about what the Joint Commission or BON, or pharm regulations say on the issue.
    Joint Commission? They don't really have a rule except that the hospital have a policy and that policy be followed.

    Pharm regulations? That's basically just going to make sure we aren't diverting, so keep up with what you do give so it doesn't look like you took it home.

    Boards of Nursing? Most aren't going to have a hard and fast rule either.

    Point being, it's up to your hospital policy. But this situation is why I tend to give the higher dose in the range if the patient's history suggests they can tolerate it. I also like PCAs and transitioning to PO asap so I don't have sudden "loss" of pain control.
    Last edit by wooh on Jun 19, '11

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