Can you give a lesser dose than prescribed without an order?

MunoRN, RN · May 22, 2018

Muno, I stand corrected on range orders. From TJC's website:
You know, I've questioned other things they've said to us, and have shown proof that my assertion is correct. I'm not sure why I didn't do it in this case. G-d, I hate TJC.

It's a very commonly held belief, it seems to come from facilities that tell their staff they are getting rid of range orders because the JC doesn't allow them, rather than admitting they are too lazy to do what CMS does require which is that everyone interprets them the same same way.

And yes, the JC is pretty horrible at what they do, which is why DNV is quickly taking over their market.

guest769224 · May 22, 2018

Even our EMAR was set up for it. When a partial dose was given, a reason had to be selected. "Patient request" was one reason. "Nursing judgement" was another.

That's how the MAR at my current hospital is. Most of the hospitals in my city allow for partial dose given by nursing and then RN indicates the reason.

osceteacher · May 22, 2018

I'm always baffled by the total lack of autonomy nurses in other countries get. Here in the UK you can do this and then just document and discuss with a doctor, you can't go OVER a prescribed dose but thats about it. We regularly have Filipino and Indian nurses and when you tell them what their role is they look completely shocked that a nurse can be so autonomous. You want to catheterise someone, go do it, don't badger a doctor. My friend in Australia works in ED and they have some really strict rules in place too.

I don't understand it, most junior doctors are blagging it anyway and just come and ask the nurses what to do, especially the first 3 or so months.

There's plenty of evidence to suggest nurse autonomy = lower mortality and better job satisfaction, I cant fathom why America, Australia etc still trudge on with backward philosophy on medicine and the roles within.

Greater nurse autonomy associated with lower mortality and failure to rescue rates | Evidence-Based Nursing

Nurses' autonomy: influence of nurse managers' actions. - PubMed - NCBI

Daisy Joyce · May 22, 2018

If I understand the question correctly, you have to offer the med, but the resident can take or refuse as they prefer.

So, if I bring in the three pills, and they only take two, I can't force the third one down their throat, but I have to chart how many pills they actually took, and if they continue to refuse, I would contact the doctor about it.

inthecosmos, BSN, MSN, RN, APRN · May 22, 2018

I'm always baffled by the total lack of autonomy nurses in other countries get. Here in the UK you can do this and then just document and discuss with a doctor, you can't go OVER a prescribed dose but thats about it. We regularly have Filipino and Indian nurses and when you tell them what their role is they look completely shocked that a nurse can be so autonomous. You want to catheterise someone, go do it, don't badger a doctor. My friend in Australia works in ED and they have some really strict rules in place too.
I don't understand it, most junior doctors are blagging it anyway and just come and ask the nurses what to do, especially the first 3 or so months.
There's plenty of evidence to suggest nurse autonomy = lower mortality and better job satisfaction, I cant fathom why America, Australia etc still trudge on with backward philosophy on medicine and the roles within.
Greater nurse autonomy associated with lower mortality and failure to rescue rates | Evidence-Based Nursing
Nurses' autonomy: influence of nurse managers' actions. - PubMed - NCBI

Folks 'round here have no issue in suing someone. Regulatory boards make it clear what our roles and scopes are. Not that I wouldn't mind being more autonomous.

JKL33 · May 22, 2018

There is misunderstanding about a lot of things like this because TJC may say one thing and then top leadership decides they don't want to deal with it and simply professes that something is a certain way (which is their way of handling it) and mentions TJC in the same sentence allowing everyone to simply assume it's actually a TJC rule.

People have many similar misunderstandings about what HIPAA is and isn't, because hospitals are careful to conflate their own privacy practices with HIPAA.

TJC does have commentary about related standards, but not this issue in particular (that I can find). I can't find evidence that it's acceptable to give a lesser dose that isn't part of an originally-ordered range, though - not saying it doesn't exist somewhere. This is all I can find right now:

Loosely-related issues here

(Scroll down to: "Medication Administration - Incorporating Patient Preference Into Medication Administration Practices" and "Medication Administration - Range Orders")

**

If anyone out there can find something that addresses this issue specifically (like along the lines of information Sour Lemon was given) I'd love to read it. My guess is it's acceptable as long as an evidence- or high-level recommendation-based policy (?)

KalipsoRed21, BSN, RN · May 22, 2018

This nitpicky, time wasting BS is one of many reasons that I want out of nursing. My advice is as follows:

PRN medications I am always willing to give less of at a reasonable request. 2/3 a dose is not reasonable as it is not possible to accurately give 2/3 a pill. The order for PRN meds are written in a manner that this is possible if I am the one to write it: Morphine, up to 8mg, every 6 hours, as needed for pain.

If I didn't write the order and it is written: Norco 1-2 tabs every 4 hours as needed for pain. I will still give a smaller dose if requested by patient. And document that the patient requested 1 and 1/2 tablets. If I were in California and other were flipping out that I did it that way, well to bad take my license.

For non PRN medicines there are only 2 options for you as a nurse: the patient takes it as ordered or refuses it and you tell the doctor. Nothing in between. And when a doctor tells you something asinine like "the patient can choose to take 2/3 a pill" you say "at home maybe, but here I have the two above options and no I cannot write an order for an unquantifiable amount of a pill whole or half pills only, thanks."

Sour Lemon · May 22, 2018

If I didn't write the order and it is written: Norco 1-2 tabs every 4 hours as needed for pain. I will still give a smaller dose if requested by patient. And document that the patient requested 1 and 1/2 tablets. If I were in California and other were flipping out that I did it that way, well to bad take my license.

It gets even trickier, because we cannot document that we gave a partial dose (at least at the two jobs I've been at in CA). You have to document the four mg, even if you gave two mg. The computer will not accept anything else. You also have narcotics to waste with a witness, but there's no way to do it properly because the computer says the waste does not exist. So you either have to call for a different order or lie about how much of a narcotic you gave and do "something" improper with the remainder.

chacha82, ADN, BSN · May 22, 2018

So you give the patient the medicine. If the patient says, "I'm taking 1 of this pill but not the other" you take the other pill back, waste in front of another RN, notify the physician, and document.

Tenebrae, BSN, RN · May 22, 2018

It gets even trickier, because we cannot document that we gave a partial dose (at least at the two jobs I've been at in CA). You have to document the four mg, even if you gave two mg. The computer will not accept anything else. You also have narcotics to waste with a witness, but there's no way to do it properly because the computer says the waste does not exist. So you either have to call for a different order or lie about how much of a narcotic you gave and do "something" improper with the remainder.

Our system doesnt allow us to give less than the prescribed dose, however there is an option to put a comment such as I did 'Eg patient X refused to take charted dose of Xmg, but accepting of 1/2 dose"

Like I said, wrote it up, talked to the doctor who was happy with that.

If its a regular med, and patient declines it, or refuses to take the full dose, I attempt to find out why, provide education where possible and if patient still refuses to take the full dose. I give the patient all the meds and they choose what they take.

I then document, advise the doctor who chooses whether to keep the medication at the same level or to reduce the dose and gives us instructions as to what to do if patient continues to decline

We are fortunate to not live in such a litigious society as you folks in the US, not that means we get to run amok with medications at all. We have a-lot more autonomy and dont need to have an MDs order for every single little thing.

cleback · May 22, 2018

I'm sure there is an official answer but I think a little nursing judgment is in order. If you call the oncall for a half Tylenol or miralax dose, you'd probably get a reputation pretty fast. For med that it isn't crucial to get the full dose (and I'd phone a friend in pharmacy to check if I was not sure), I'd give the lower dose and let the rounding docs address the order in the morning.

kbrn2002, ADN, RN · May 23, 2018

I'm sure there is an official answer but I think a little nursing judgment is in order. If you call the oncall for a half Tylenol or miralax dose, you'd probably get a reputation pretty fast. For med that it isn't crucial to get the full dose (and I'd phone a friend in pharmacy to check if I was not sure), I'd give the lower dose and let the rounding docs address the order in the morning.

This is exactly the type of situation I was thinking of when I wrote in an earlier post that "nursing judgement" doses do happen. I work in a SNF, we don't have providers in the building and there is no way I am calling the primary MD or an on call every time a resident refuses a dose of stool softener or a Tylenol even though technically I am supposed to. Prescription meds are another matter though, any refusal or adjustment in dose does need the providers input.