Range orders

  1. We would all agree that with an order that reads: Percocet 2 tabs po q 4 hours, that giving 3 tabs is considered prescribing...

    What if the nurse decides to give 1 tab (based on the pt only wanting 1 tab)

    I personally think this is also considered prescribing.

    Thoughts?

    I would get an order.
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    About hogan4736

    Joined: Dec '01; Posts: 781; Likes: 121
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    Specialty: 13 year(s) of experience

    15 Comments

  3. by   luvschoolnursing
    I would give 1 tab, chart that it was patient's choice to only take one and let the physician know as soon as possible (i.e. I wouldn't call him to clarify this in the middle of the night)
  4. by   HM2VikingRN
    My clinical instructor last quarter had a slightly difference perspective. If the order read 1-2 tabs hydrocodone/4-6 hours for pain he suggested offering 1 tab because if it did not work then you still had room to try another dose if the patient did not receive adequate relief of symptoms.
  5. by   meandragonbrett
    I would give the patient one percocet and document that patient requested one and not two.
  6. by   Larry77
    In our facility we are allowed to give less pain medication if either the vitals warrant it or the patient requests it, but never more than what's ordered.

    Also on the floors those "range" orders are not allowed anymore they have to read something like this:

    "Percocet 5/325 1 tab po for pain scale 1-5 or Percocet 5/325 2 tabs po for pain scale 6-10"

    But in the ED where I work we often follow orders simply stating "Morphine 4mg IVP titrate"...this is not exactly allowed but is later changed by the doctor to fill in the amount needed. There is a great trusting relationship between the doc and nurses in the ED so we are given a lot more freedom (besides the fact that they are right there if we need them).
  7. by   Mommy TeleRN
    I just found out in my new position this week that if the doc orders 1-2 we are to give 1 for pain up to 5 and 2 for pain >5. So my question was if the pt says a 5, you give one pill, and the pain isn't relieved what do you do? Well according to policy you can only give 1, to give the other you'd have to call the doc. Now I can just see calling the doc and asking "Can I give the 2nd pill?" when he's prescribed up to 2! esp working nocs lol. Yea that is really gonna fly. But that is the way the policy is currently written. The hospital instructor recommended putting a suggestion in the sugg. box that the policy be modified. As it stands according to policy if I gave the 2nd for a rating of 5 it'd be prescribing. Seems weird to me. Therefore the doctors are encouraged to not write range orders.
  8. by   miko014
    We are not allowed range orders for anything. Even if they say, "phenergan 12.5mg IV q4-6 prn" we have to call and get them clarified - or if pharmacy sees the order first, they will default to the least amount prescribled - in this case 12.5 mg Q6.

    I have no problem giving less pain meds than ordered. If someone is ordered a miligram of dilaudid and says that they don't want to take all of it b/c it makes them sleepy or whatever, I discuss it with them and see what they want to do. Often it's that they just want half the dose. So I would give half a miligram and chart that pt requested half dose of pain meds d/t "it makes me feel dizzy if I take all of it" or whatever. I would get it out the same way I would had 0.5mg been the prescribed dose - I'd have a witness since I gave less than a full miligram, I would put in pyxis that I only intended to give half a miligram, etc. The docs can look at my charting, either in the computer or on the flowsheet (we're halfway through going paperless) and see what's going on. There is no reason to call a doc because the pt wants LESS pain meds - and that is considered acceptable at my facility.

    Now if a pt has a BP of 190/100 and says they only want half of their lopressor, that would be a different story all together....
  9. by   hogan4736
    Quote from miko014
    Now if a pt has a BP of 190/100 and says they only want half of their lopressor, that would be a different story all together....
    You can't have it both ways...

    In every scenario, you have to call the doc...

    Please don't expect docs to glean info from your charting...

    Won't happen

    Check your policy

    Check w/ your BON...
  10. by   Kymmi
    Miko014--I agree with you 100%. Patients have the right to refuse any meds or treatments that they wish to refuse. I also would only give 1/2 the dose ordered if that is what the patients requests and then I would chart it as patient refused entire dose for whatever reason. Pain medications are a prn order so therefore it is different then the Lopressor order you referred to that hogan disagreed with. I would find out why the patient was refusing the lopressor or requesting only 1/2 the dose and explain to the patient the risks behind the refusal and then I would notify the doctor that patient refused because some other treatment might be needed to manage the B/P however if the patient requests only 1/2 the amount of pain med and that controls the pain then no harm done.
  11. by   P_RN
    The problem with splitting numbers like that you end up with 1 tab every 2 hours. That may keep the levels better but it's prescribing if you do it over once. I believe JCAHO strongly objected to "range" orders such as 1-2 Q 3-6 hours. Doc needs to be apprised of what's not working.
  12. by   hogan4736
    Quote from Kymmi
    ...Pain medications are a prn order so therefore it is different then the Lopressor order you referred to that hogan disagreed with. I would find out why the patient was refusing the lopressor or requesting only 1/2 the dose and explain to the patient the risks behind the refusal and then I would notify the doctor that patient refused because some other treatment might be needed to manage the B/P however if the patient requests only 1/2 the amount of pain med and that controls the pain then no harm done.
    Pain meds are frequently BID, or as I've seen on occasion "A.T.C." around the clock...

    Let me be clear. I would give 1/2 the pain med per pt request.

    An order should still be obtained.
  13. by   ElvishDNP
    Where I am, Percocet is always ordered 1-2 tabs anyway. (Or if it is another pain med that can be taken as 1 or 2 tabs, it is written 1-2 tabs, not just 2). So we are covered either way.

    However, JCAHO expects us to start with the lowest dosage first, then if that doesn't work the next dose can be 2. If we give 2 tabs to start out with we have to document why. (can be anything from pt requests 2 tabs, pain is 9/10 , pt is transitioning from epidural fentanyl, 2 tabs is pt's home dose, etc.)

    The lowest dosage goes for all meds. The other night I really wanted to give a lady 10mg of Ambien cause she is a pretty big lady, but JCAHO rules being what they are I gave her I gave her 5, as the order was written Ambien 5-10mg qhs prn, since that was the 1st dose. Wouldn't you know it worked beautifully.
  14. by   miko014
    Why, thank you Kymmi. For a second there, I thought I must be an idiot! Glad someone agrees with me .

    Hogan - yes I can have it both ways. Lopressor is a scheduled BP med that the pt needs. If they say they are not going to take it, or not going to take all of it, and their BP/HR is high, I am calling the doc. If their pressure is 104/62 HR 68 and they say that they don't take it at home when their pressure is like that, I chart "refused" and in the comments state why. If they do that more than once, doc gets a note on the chart about it. We have a dropdown menu in med admin for reasons why we didn't give a med, and "refused" is an acceptable choice. After all, the pt has the right to refuse any treatment that they don't want. PRN pain meds are different. If the pt doesn't take them at all, should I call the doc and tell him that??

    And the docs don't "glean" anything from my charting. They sign onto their computer program and read it. There is no difference between them looking at the pt's VS and labs vs. them looking at the MAR. And they do look, especially at pain meds.

    I do not HAVE to call the doc because the pt wants only one perc instead of 2. That's ridiculous. No wonder docs get annoyed with nurses if you are going to call them for every little thing.

    I work palliative care. I give a LOT of pain meds. The pts have choices. If they have scheduled pain meds, they get them ATC. That happens quite frequently where I work. The people who have ATC pain meds usually need them. That's different from someone who had surgery a couple of days ago and has percs ordered prn.

    I would never suggest that a pt take anything different from what is prescribed, and I would never give more than what was prescribed, even if they ask for it. That's when I would call the doc. But if taking fewer pain meds is effective, good for them. I hate the way perc makes me feel, and I can totally understand why someone would only want the minimun necessary to control their pain.

    Say the order is for 10 mg oxycodone Q4 prn. If the pt asks for just 5mg, you can give 5mg, but if they want more before the 4 hours is up, then you have to call. The order is for 10 q4, not 5 Q2. As I said, that is considered normal procedure for us.

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