range order rationale - page 5

So you've got an order for 1-2 Norco q 4hrs prn pain, you give 1 at 1200 for 6/10 pain. At 1330 their pain is still 4/10, does you interpretation of the order allow you to give the second or do you... Read More

  1. Visit  Altra profile page
    2
    I utilize a different med/order as soon as it becomes apparent that the first was ineffective.
    CCL RN and Chin up like this.
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  3. Visit  CCL RN profile page
    0
    Quote from McGyverRN
    JCAHO just surveyed my hospital and they absolutely demanded that we eliminate range order dosing. Perhaps the surveyors who came to your facility did not, but ours did. So yes, I do have a basis for what I believe.....experience.
    I actually *heard* the JCAHO surveyor make a nasty comment about range orders a few years back, was involved in the meetings about the results, and witnessed our policy change because of it.
  4. Visit  reggae55 profile page
    0
    The nursing student questions the need to check placement of the ng tube.what is the rationale for doing so?
  5. Visit  CCL RN profile page
    0
    Quote from reggae55
    The nursing student questions the need to check placement of the ng tube.what is the rationale for doing so?
    This has nothing to do with this thread at all. This thread is about medication range orders. You'll need to start your own thread to find this info although you should either know how to answer this or know where in your book to find it.
  6. Visit  steelydanfan profile page
    0
    Quote from kanzi monkey
    it's "1-2 tabs q4h"; so you give 1 tablet, and then in two hours your patient is still in pain. So, you give another tablet--that is technically correct. You gave 2 tablets in a 4 hour time period. Once the 4 hours is up and the patient has 1-2 tabs available again, you might consider giving 2 at the same time since the 1 didn't hold the patient over.
    In your scenario, the nurse gave 3 tablets within 4 hours, which is a med error.

    I have been paged by nurses to "increase" dose or frequency of pain medication, or to write a "times one"--if I see that the patient hasn't actually even received what I ordered initially, I get a little annoyed. Partly because of the unnecessary page, but mostly because I am being told I need to intervene where a patient's pain isn't controlled, when it's the nurse that hasn't exercised all of the options yet, not that the patient is actually having an issue.

    This is common sense. It's not that a nurse is "prescribing"--s/he is merely being flexible when trying to manage a patient's pain with medications that can be harmful if over used and is getting a sense of what the patient needs or will tolerate. I expect that nurses will do this.
    If any nurse I ever worked with considered giving 3 tablets in 4 hours under these circumstances a med error, I would do my best to have them put under remedial training.
  7. Visit  highlandlass1592 profile page
    2
    Quote from MunoRN
    No snarkiness intended, I really am curious how this works. Do you have to wait until the time frame for the medication initially given is over to implement a different order, or can you address unresolved pain prior to waiting until the 4 or 6hr timeframe is over? I'm not sure why you wouldn't be able to have different analgesic options with a range order system, we use range orders and often have tylenol, tramadol, norco, percocet, and morphine available based on our assessment and the patient's response to previous interventions.
    Not really sure where you're going with this thread. Seems to me plenty of people have given you their input regarding what they would do. At all the hospitals I've been at, this really comes down to hospital policy.
    kanzi monkey and CCL RN like this.
  8. Visit  steelydanfan profile page
    0
    Quote from highlandlass1592
    Not really sure where you're going with this thread. Seems to me plenty of people have given you their input regarding what they would do. At all the hospitals I've been at, this really comes down to hospital policy.
    Actually, most hospital policies do not address this, and what the OP was looking for was experienced nurse's take on a gray area.

    We gave her that. What a new grad might think is VERY different from a nurse with 20 years experience might think.

    And it is good to give our new nurses any input that we can. THIS is the kind of stuff that they SHOULD have in clinical, but sadly never get anymore, for myriad reasons.
  9. Visit  kanzi monkey profile page
    0
    Quote from steelydanfan
    If any nurse I ever worked with considered giving 3 tablets in 4 hours under these circumstances a med error, I would do my best to have them put under remedial training.
    ??
    But...
    it's...a med error...

    If the patient NEEDED 3 tablets in a 4 hour period, then yes, a page to the on-call is warranted for an increase in medication. You are joking maybe?

    I also get pages all the time a la "the dose you have ordered is NOT going to cut it, 0.2 of dilaudid will not TOUCH this patient." So I increase the dose--no biggie, I don't doubt that a nurse can anticipate that a patient will have a high medication tolerance, and why go through the suffering of the "slow and safe" titration when you know that the patient can tolerate his pain meds (ie, he was admitted last month and only the ketamine gtt held him over). But in the example, 1-2 tablets q4h, two tablets may be given. Not 3. If 3 are given and no order is changed, it's a med error.

    You were joking, right?
  10. Visit  LouisVRN profile page
    0
    My opinion on the matter is this. If I give one Norco at noon. Our policy dictates pain must be re-assessed around the one hour mark. If pain is controlled at that time, no further intervention. If pain is not controlled at that time, I'd give the second Norco. BTW our policy also dictates we must always start with the lowest dose of a range order. If an hour later the patient is complaining of pain again I would check to see if they have a BTP medication. If not I would call the doctor to ask for one, as well as letting the doctor know what I had already given the patient. Then I'd administer the BTP medication, or alternative methods, heating pack, ice pack, if provider does not wish to give additional pain medication then administer the two tabs next time, provided the pain is rated a similar level.

    My problem with medications written like
    Norco 1 tab q PO 4 prn pain 1-3
    Norco 2 tab q PO 4 prn pain 4-6
    Dilaudid 1 mg IV q 2 prn pain 7-10
    Is that the patients wanting the pain medication pretty soon realize that their pain needs to be 7+.

    I agree with the OP who said that if you are going to call a doctor to ask for an increase in amount/frequency of pain meds you had better been giving all that they previously wrote for.
  11. Visit  MunoRN profile page
    0
    Quote from Altra
    I utilize a different med/order as soon as it becomes apparent that the first was ineffective.
    So if you had both norco and percocet available, and you choose the norco, then 1 hour later the patient still has some pain, you'd give the percocet? I think a lot of Docs would consider those two separate options and not necessarily something that could be combined without clarifying it that way. Our policy is that you can't "stack" meds unless there is a parameter to do such as morphine for "breakthrough pain" or for a dressing change.
    Last edit by MunoRN on Apr 5, '11
  12. Visit  MunoRN profile page
    0
    Quote from highlandlass1592
    Not really sure where you're going with this thread. Seems to me plenty of people have given you their input regarding what they would do. At all the hospitals I've been at, this really comes down to hospital policy.
    My fault, I did sort of morph my question there part way through the thread which seems to have gotten lost in the responses, but it's the policies in particular that I'm asking about.

    When the JC came out with their position on Range Orders each facility had two options: Establish a clear policy on range orders and ensure that they are consistently understood and implemented by the MD's, Nurses, and Pharmacy, or if for some reason your facility was unable to do that or didn't want to, then the JC recommended that you not use range orders. The issue was brought to our practice council, and to us it seemed pretty clear. It's like when your mom says you have to clean your room or you don't get dinner; even though it requires some work, you are of course going to clean your room because you really want dinner. We didn't really discuss which option we would choose so much as we spent 30 minutes trying to figure out how one would go about delivering good, safe pain control without a range order. As different groups such as the American Pain Society and the Society of Pain Management Nursing came out with their position statements in support of range orders, it seemed like there was really only one option and that the work required by the JC to continue using range orders with their blessing outweighed the negative impact on patient care of no longer using range orders.

    We then took our recommendation to the pharmacotherapeutic committee as well as the policy committee, both of which spent about 30 minutes trying to figure out how there was even another option. We already had a policy, which we then made as fool proof as we could following the JC's suggestions (which was mainly to give examples), then sent out an e-mail, put up signs in the bathrooms, and brought it up at staff meetings. When the JC came through we all had the same understanding of how they were to be implemented and we had no problems in that area on our accreditation.

    I was surprised in this thread by how many hospitals apparently came to a much different decision than we did when it seemed fairly obvious to us, so I'm wondering what we missed. My (current) question is how does a non-range order system work in a way that is flexible, safe, and responsive enough to effectively and consistently deal with the wide patient to patient variability in both gauging their own pain, as well as the wide variability in response to pain medications? In other words, does it work?
    Last edit by MunoRN on Apr 5, '11
  13. Visit  steelydanfan profile page
    1
    Quote from kanzi monkey
    ??
    But...
    it's...a med error...

    If the patient NEEDED 3 tablets in a 4 hour period, then yes, a page to the on-call is warranted for an increase in medication. You are joking maybe?

    I also get pages all the time a la "the dose you have ordered is NOT going to cut it, 0.2 of dilaudid will not TOUCH this patient." So I increase the dose--no biggie, I don't doubt that a nurse can anticipate that a patient will have a high medication tolerance, and why go through the suffering of the "slow and safe" titration when you know that the patient can tolerate his pain meds (ie, he was admitted last month and only the ketamine gtt held him over). But in the example, 1-2 tablets q4h, two tablets may be given. Not 3. If 3 are given and no order is changed, it's a med error.

    You were joking, right?

    No, I was NOT joking. Read my original post as to my rationale. The pt. would have recieved 2 tablets within 4 hours, and 2 tablets within 4 hours of the first dose. The NEXT dose would have been 4 hours after the last tablet given.

    This is not brain surgery, people; and interpreting a doctors orders is what nurse do ALL the time, because usually doctors are somewhat naive when it comes time to order pain meds. So; YES, if a pt. is crying in pain at 3pm or 3am , I will do the same thing: look at the doctors orders and FIGURE out what I can do. I would not exceed a specific order for "x q3hs" without a specific order, but when I can give one more tablet and be within guidelines without calling a doctor at 3 am, heck yes. If it doesn't work, then I call.

    I am not interested in getting sued, and I would not put my licence on the line for ANY MD's comfort; but if I find that an order can be properly carried out to the benefit of my pt., fine. Just THINK for a minute, nurses.
    glutton4punishment likes this.
  14. Visit  steelydanfan profile page
    0
    Quote from MunoRN
    My fault, I did sort of morph my question there part way through the thread which seems to have gotten lost in the responses, but it's the policies that I'm asking about.

    When the JC came out with their position on Range Orders each facility had two options: Establish a clear policy on range orders and ensure that they are consistently understood and implemented by the MD's, Nurses, and Pharmacy, or if for some reason your facility was unable to do that or didn't want to, then the JC recommended that you not use range orders. The issue was brought to our practice council, and to us it seemed pretty clear. It's like when your mom says you have to clean your room or you don't get dinner; even though it requires some work, you are of course going to clean your room because you really want dinner. We didn't really discuss which option we would choose so much as we spent 30 minutes trying to figure out how one would go about delivering good, safe pain control without a range order. As different groups such as the American Pain Society and the Society of Pain Management Nursing came out with their position statements in support of range orders, it seemed like there was really only one option and that the work required by the JC to continue using range orders with their blessing outweighed the negative impact on patient care of no longer using range orders.

    We then took our recommendation to the pharmacotherapeutic committee as well as the policy committee, both of which spent about 30 minutes trying to figure out how there was even another option. We already had a policy, which we then made as fool proof as we could following the JC's suggestions (which was mainly to give examples), then sent out an e-mail, put up signs in the bathrooms, and brought it up at staff meetings. When the JC came through we all had the same understanding of how they were to be implemented and we had no problems in that area on our accreditation.

    I was surprised in this thread by how many hospitals apparently came to a much different decision than we did when it seemed fairly obvious to us, so I'm wondering what we missed. My (current) question is how does a non-range order system work in a way that is flexible, safe, and responsive enough to effectively and consistently deal with the wide patient to patient variability in both gauging their own pain, as well as the wide variability in response to pain medications? In other words, does it work?
    In your original post, you gave 2 sets of orders for pain meds.

    This often happens, and nurses feel free to honor one or both as the pt.s condition warrants. It's perfectly legal, and I have no hesitation to use either; as the pt.s estimation of pain should be the guiding factor, according to JOINT COMMISSION STANDARDS.


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