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

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    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 legaly (I'm in Ohio) once you have chosen the 4mg dose, don't you have to wait until the next dose window-in this case 2hrs- before you can give an 8mg dose, or can you give an additional 4mg within the 2hr window to add up to the maximum ordered dose?
    If you can give an additional dose- where do you begin the 2hr window- from when you started giving the 8mgs with the first 4mg, or from the 2nd 4mg where you finished giving the 8mg dose?
    If anyone has a definitive legal answer to this question please let me know, and where you got this answer. We are in quite a discussion at work.
  2. 23 Comments so far...

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    Titrate the morphine to 1mg/ml, administer 4mg, wait for ten minutes, then ask the patient if there's any relief. If not, or if there's only partial relief, you may then administer a further 1-2mg, wait another 10 minutes and reassess. That's how it works in PACU, and I presume that's the meaning of the script you describe. Just don't exceed the maximum dose.
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    Where I work you would be able to give the additional 4mg within the 2 hour window.
    LTCangel, Nurse_Diane, and Ashley_RN like this.
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    Where I work you can give the additional 4mg and count the 2 hour window from the 2nd dose given. I have no idea about the laws in Ohio though- sorry.

    But best stick with the patient or follow up within 10 minutes to see if your medication resulted in the desired pain relieve. If not give the 2nd 4mg then and don't let the poor patient suffer for another 20 minutes. IV morph is fast acting - you shouldn't need to wait 30 min to reassess.
    Ashley_RN likes this.
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    We have been having issues with this at our hospital lately, in particular with the new barcoding system. Technically, and per our policy, we are not allowed to give an extra dose after the first one has been given (and the computer causes quite a fuss if we try to scan again). Does this mean it doesn't happen? No. If I have a fresh post-op and I am trying to get them caught up, but not oversedate them I will sometimes give a little more later. If I do, then I time from the second dose. If that still doesn't make them comfortable I call the MD and try to find another way to manage pain control. Thankfully this doesn't happen very often.
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    I'm in Ohio as well, and when I was doing bedside nursing I would give the 4mg, reassess in 10min (for an IV med 30-45 for PO) and if needed give more. If I gave the second dose within an hr from the first I wouldn't restart my timing, just use the first dose as my guide. Now, if the order was Percocet 1-2 tabs q4 hrs PRN pain and I gave 1 tab at 12 and then at 1330 gave the second, I would tell the patient that their next dose was available after 1730.
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    Quote from GHGoonette
    Titrate the morphine to 1mg/ml, administer 4mg, wait for ten minutes, then ask the patient if there's any relief. If not, or if there's only partial relief, you may then administer a further 1-2mg, wait another 10 minutes and reassess. That's how it works in PACU, and I presume that's the meaning of the script you describe. Just don't exceed the maximum dose.
    THis is how we did it in PICU. You are still within the limits of the order. Then go from the second dose when you time it again and use the higher dose.
    Our orders were frequently written as: morphine .1mg/kg q15min or 30min so you didn't have to wait so long to assess or readminister.

    I think you are w/in the scope of practice to give another dose.
    Esme12 likes this.
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    PICU/PACU/ICU all differ a lot from the floor. I think the main question here might be "what area do you work in?".
    Esme12 likes this.
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    This is very true-but the order does say IVP...I didn't do a lot of med surg, are there many IV push orders for morphine given on the general floors?
    I am just curious.
  11. 0
    Quote from Tait
    PICU/PACU/ICU all differ a lot from the floor. I think the main question here might be "what area do you work in?".
    OP states it's a hypothetical situation.


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