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

Nurses General Nursing

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The pt asked to receive 2/3 of the dose of celexa and when I asked the provider for an order he told me "the patient has the autonomy to take whatever dose if he wants too" and did not want to change the order. Just wondering if I can administer a lesser dose without an order.

Thanks

I was taught in school (in Texas) that we could always use "nursing judgemen" to decrease doses. And for PRNs, it was often encouraged that we "start low and go slow" or something like that. The nurse educator at my first job continued to reinforce this teaching.

When I moved to California and gave two milligrams of morphine instead of four (at a patient's request), everyone went absolutely insane. It's a huge NO out here and I was instructed to call the doctor for an alternate order.

I just looked on the Texas BON site and can't find a definitive answer either way, but I'm wondering if this varies from state to state if if my initial teaching was just wrong or outdated.

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Specializes in Geriatrics, Dialysis.
I was taught in school (in Texas) that we could always use "nursing judgemen" to decrease doses. And for PRNs, it was often encouraged that we "start low and go slow" or something like that. The nurse educator at my first job continued to reinforce this teaching.

When I moved to California and gave two milligrams of morphine instead of four (at a patient's request), everyone went absolutely insane. It's a huge NO out here and I was instructed to call the doctor for an alternate order.

I just looked on the Texas BON site and can't find a definitive answer either way, but I'm wondering if this varies from state to state if if my initial teaching was just wrong or outdated.

That's funny. I have to admit that I wouldn't have ever thought a nursing instructor would teach that it's OK to use nursing judgment for med dosing. Not that it doesn't ever happen, just surprised it was actually taught as a standard of nursing care by a school instructor and reinforced by a hospital nurse educator. Seems to me that dose adjustments should be outside scope of practice for nursing in any state. There are just way too many differences state to state on what constitutes acceptable nursing practice.

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That's funny. I have to admit that I wouldn't have ever thought a nursing instructor would teach that it's OK to use nursing judgment for med dosing. Seems to me that should be outside scope of practice for nursing in any state. There are just way too many differences state to state on what constitutes acceptable nursing practice.

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.

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.
Celexa only comes in doses of 10mg, 20mg or 40mg. Not sure how the pt would be able to take 2/3 of any of those doses.

1. Celexa is scorable but in half and only on some tablets with certain MG doses.

2. The patient wants 2/3 how do you know if you cut this you are giving 2/3 of the medication?

Not going to get into what this actual drug is for and how it is usually administered. Just going to comment on the math part of this.

If the dose is 30mg, and patient normally takes a 10mg and a 20mg pill to total that 30mg, you don't have to cut anything in half to get to the 2/3 dosage -- you just give the 20mg pill and omit the 10mg pill.

I have a lot of patients on 75mg of Lopressor, and our Pyxis dispenses that as a 25mg pill and a 50mg pill for a total dose of 75mg. It would be simple to cut that dose by a third.

Similarly, I've had patients get 300mg of a med that gets dispensed as two 200mg pills, with one pill cut in half to make a 100mg pill and a 200mg pill (with the other 100mg discarded). If this patient's normal dose is 15mg (one 10mg pill and half of a 10mg pill), simply giving one whole pill and omitting the half-pill will create the 2/3 dosage.

As to whether your state's laws or your facility's protocols allow you to do this is for you to figure out based on your particular setting. But the MATH part of the question isn't necessarily all that complicated, depending on what the ordered dose was and how the pills are supplied.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
I just looked on the Texas BON site and can't find a definitive answer either way, but I'm wondering if this varies from state to state if if my initial teaching was just wrong or outdated.

It's a CMS and TJC rule. So, if your hospital accepts Medicaid and/or Medicare money, then it's law, even if it's not explicitly mentioned in your Nurse Practice Act.

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It's a CMS and TJC rule. So, if your hospital accepts Medicaid and/or Medicare money, then it's law, even if it's not explicitly mentioned in your Nurse Practice Act.

Interesting. Unless that's a really new rule, it's been broken a whole heck of a lot in at least some places. It was a very common, every day sort of thing for me and everyone I worked with. I've been gone from there for about five years, though. Maybe it's changed.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
Interesting. Unless that's a really new rule, it's been broken a whole heck of a lot in at least some places. It was a very common, every day sort of thing for me and everyone I worked with. I've been gone from there for about five years, though. Maybe it's changed.

A lot changes in 5 years. Five years ago, range based dosing could be used (only ONE range, though, you couldn't have two ranges in the same order) and now it's verboten.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

No. You cannot.

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Specializes in Critical Care.
A lot changes in 5 years. Five years ago, range based dosing could be used (only ONE range, though, you couldn't have two ranges in the same order) and now it's verboten.

Neither CMS nor the Joint Commission has ever forbidden range orders. The JC has suggested in the past that the upper end of a range order not needing more than double the lower end, but it should be noted that the JC is not a regulatory agency and does not make laws

Keep in mind that as nurses we are overseen by our state nursing boards, not CMS or the JC which don't always agree with BONs. I have done regulatory compliance at a facility that got ding'd because too many of the nurses said that if the order said 4-8 mg of morphine then they couldn't give just 2. We had to submit a corrective action plan stating we would remind nurses they could give the smallest dose necessary regardless of the low end of the range in the order.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

edited

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Muno, I stand corrected on range orders. From TJC's website:

Medication Administration - Range Orders

Does The Joint Commission prohibit the use of 'range' or 'double-range' orders?

No, there are no Joint Commission standards that prohibit the use of range orders as long as such orders are permitted by the organization's medication management policy (see MM.04.01.01). In addition, range orders may be a component of other order types, such as taper orders and titration orders, unless prohibited by hospital policy.]

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.

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Specializes in Pedi.
Not going to get into what this actual drug is for and how it is usually administered. Just going to comment on the math part of this.

If the dose is 30mg, and patient normally takes a 10mg and a 20mg pill to total that 30mg, you don't have to cut anything in half to get to the 2/3 dosage -- you just give the 20mg pill and omit the 10mg pill.

I have a lot of patients on 75mg of Lopressor, and our Pyxis dispenses that as a 25mg pill and a 50mg pill for a total dose of 75mg. It would be simple to cut that dose by a third.

Similarly, I've had patients get 300mg of a med that gets dispensed as two 200mg pills, with one pill cut in half to make a 100mg pill and a 200mg pill (with the other 100mg discarded). If this patient's normal dose is 15mg (one 10mg pill and half of a 10mg pill), simply giving one whole pill and omitting the half-pill will create the 2/3 dosage.

As to whether your state's laws or your facility's protocols allow you to do this is for you to figure out based on your particular setting. But the MATH part of the question isn't necessarily all that complicated, depending on what the ordered dose was and how the pills are supplied.

This is what I was thinking the whole way through this thread. The fact that you cannot administer 2/3 of a tablet does not mean that you cannot administer 2/3 of a patient's dose.

I easily can (and occasionally DO) take 2/3 of my dose of one of my medications, which is only available in 0.1 mg and 0.2 mg tablets. My dose is 0.15 mg, so 1.5 pills and I can easily omit the 1/2 pill if I feel like I don't need it for whatever reason one day.

Giving a lower than ordered dose was something that we literally did every day when I worked in the hospital for PRNs. The normal pediatric dose for morphine is 0.05-0.1 mg/kg q 2-4 hrs PRN. The good residents wrote for 0.1 mg/kg q 2 hr PRN post-op and we often started with 0.05 mg/kg to see how the kid handled it/if it held him. If it didn't, we already had the order for 0.1 mg/kg and we gave the higher dose the next time.

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