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

  1. 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
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    Joined: May '18; Posts: 1; Likes: 1
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    58 Comments

  3. by   caliotter3
    I would write up what the doctor said in "order-ese", and send it to him for signature.
  4. by   klone
    No, you cannot. That is not legally in an RN's scope of practice.
  5. by   CharleeFoxtrot
    Quote from klone
    No, you cannot. That is not legally in an RN's scope of practice.
    Yes indeedy. I'd write it up as follows:

    TVO Dr. Yuve Gottobekidding Date and Time. (insert 2/3 dose of whatever) PRN for (whatever issue), and hold patient's regularly scheduled dose (inset 100% dose of whatever).
    Send to Doc for signature.
  6. by   Here.I.Stand
    If it's a prn, something like an order for 2 Percocet or 8 mg Zofran I might administer the lower dose and note "per pt request/refused full dose." If the smaller dose is effective I'd have the dr write an order for the smaller dose or a dose range.

    For something like a scheduled med with the effects being expected over time -- and especially one that I can't accurately give (such as 2/3 of a tablet) -- I would hold the med, call the dr, and notify him/her what pt requesting. They can then use their prescriptive authority to order it, or to explain to the pt why they don't think a lower dose is safe.
  7. by   HeySis
    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. Besides it's important that pts take their antidepressants as ordered and not change the dosage themselves. It's not like taking one Tylenol instead of two. Changes in the doses should be a conversation between the pt and their provider. I would not administer a 2/3 dose.

    First I would do talk to the patient to find out why they want a lesser dose. Is it the side effects? Are they trying to wean themselves off? Then some education about the importance of not suddenly changing doses and the reality that this medication doesn't come in the wanted dose amount. If no answer is apparent with those steps, I would speak to the doctor again, explain the pharmacy doesn't stock a 6.33mg, 14.33mg or 16.33 mg tablet to be able to do that and you need to know the amount they want ordered. The patient then can take that dosage or refuse. If the pt refuses the MD needs to be notified each and every time.
  8. by   Tenebrae
    I had this come up the other day with a PRN medication. Patient was prescribed 8mg of ondansetron, didnt want to take the full 8mg but was agreeable to taking half the dose.

    I documented it in emeds, patient declined to take full dose and why and advised the doctor who was happy for the patient to take the half dose.

    If patient refuses to take the full dose, they have the right to choose, important to find out if there is a reason, provide education ir possible. And if patient still declines to take the full dose, document and advise the MD asap

    I look at it as a nurse I am not choosing what the patient has, the patient is making an informed decison as to what they are willing to take
  9. by   klone
    Yes, the patient has the right to say "I don't want 8mg, I want 4mg." And in that case, you need to call the physician and see if you can get an order for 4. You can't just give the patient 4mg and document that and go on your way, because you are in fact practicing medicine without a license if you do that. TJC and CMS would come down on you on a hot second (and, even range doses "1-2 tabs q4h" are a big no-no).
  10. by   ruby_jane
    Quote from klone
    Yes, the patient has the right to say "I don't want 8mg, I want 4mg." And in that case, you need to call the physician and see if you can get an order for 4. You can't just give the patient 4mg and document that and go on your way, because you are in fact practicing medicine without a license if you do that. TJC and CMS would come down on you on a hot second (and, even range doses "1-2 tabs q4h" are a big no-no).
    ^That^

    Also consider what Celexa is, and how it works. Is it a new RX? An increase? Was the pt just put on the med? Does he/she know how it works and why taking less may not be the best? Is it making him/her nauseous? Can s/he take it at bedtime instead of AM??

    I have too many questions.
  11. by   HeySis
    Quote from Tenebrae
    I had this come up the other day with a PRN medication. Patient was prescribed 8mg of ondansetron, didnt want to take the full 8mg but was agreeable to taking half the dose.
    I do think this comes up with PRN's all the time. And I had a doc tell me he always prescribes the larger dose (8mg of zofran, 650mg/1000mg tylenol, 50mg benadryl) knowing the patient can refuse and take just one instead of two... it's the work around now that dose ranges are a no-no.... we can give half the dose and inform provider, rather then delay because we have to get a new order.


    But this medication is not a PRN medication. and she's not asking for half the dose, but 2/3, which is not easily done. Also the nature of this medication can make it dangerous to shift doses. I think these are important considerations that are not present with a PRN drug. Because of that I would not give any dose other then the one prescribed by her physician. Educate and then one of three things happen.. she takes it as prescribed, she refuses and you inform the MD or the MD changes the dose to what she wants to take.
    Last edit by HeySis on May 21 : Reason: typo
  12. by   Neats
    Never should you give a lesser does.

    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?
    3. If the provider wishes to rewrite the order for not greater than 10 mg over a 24 hour time period then I would be OK with this if I had 10 mg tabs on hand...and the patient was asking for half, but I still would have a hard time with 2/3 requested. It is impossible to give this dose without a pharmacist careful skill to ensure you have 2/3 tabs on hand. I just would not do this.

    I would communicate with the patient, doctor and pharmacist with defined orders, do not get sucked up in this drama it is your license and when or if there are issues you will be hard pressed to defend your self.
  13. by   kbrn2002
    As long as the patient has received education on the medication and the reason that particular dose of the medication was ordered there isn't a lot you can do except what you are already doing. If the patient doesn't want to take the full ordered dose continue to do exactly what you did and contact the provider for instructions. If the provider doesn't want to change the order continue to call said provider every single time the patient refuses the full dose despite education provided and ask for instructions. Either the provider will continue to write one time orders every time the full dose is refused or the provider will eventually change the order to the requested dose.
  14. by   Sour Lemon
    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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