TJC and prn analgesics - How are your orders?

Nurses General Nursing

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It's almost time for TJC to come by and I'm wondering how your organization places prn orders for analgesics. Right now I'm hearing things that make nursing judgement obsolete because it may appear to TJC nurses are "prescribing" medication in certain situations. How does your organization deal with such issues:

Currently we need to have prn analgesic orders with a pain rating, such as "Tylenol 650mg Q4H PO prn for mild pain; Norco 5-325mg Q4H PO prn for moderate pain."

We technically cannot give Tylenol if a pt rates their pain 5/10, but they ask for the Tylenol and states Tylenol works really well for their pain.

We must call the provider, ask to change the verbiage in the order, and then it's okay. This sounds totally like a waste of time and undermines nursing judgement.

Another example is we have a lethargic pt post-op and is NPO and requiring morphine IVP and the order states 4mg morphine IVP q3H for moderate or severe pain. The nurse only wants to give 2mg morphine IVP d/t the lethargy, but that may be seen as "prescribing."

I'm not sure how we will deal with prophylactic analgesics, such as before physical therapy or major dressing changes. Maybe there needs to be something that states "for mild pain or prior to PT" in the order.

We need the whole organization on the same page and I'm just wondering if there are any organizations with a good system right now.

It's almost time for TJC to come by and I'm wondering how your organization places prn orders for analgesics. Right now I'm hearing things that make nursing judgement obsolete because it may appear to TJC nurses are "prescribing" medication in certain situations. How does your organization deal with such issues:

Currently we need to have prn analgesic orders with a pain rating, such as "Tylenol 650mg Q4H PO prn for mild pain; Norco 5-325mg Q4H PO prn for moderate pain."

We technically cannot give Tylenol if a pt rates their pain 5/10, but they ask for the Tylenol and states Tylenol works really well for their pain.

We must call the provider, ask to change the verbiage in the order, and then it's okay. This sounds totally like a waste of time and undermines nursing judgement.

Another example is we have a lethargic pt post-op and is NPO and requiring morphine IVP and the order states 4mg morphine IVP q3H for moderate or severe pain. The nurse only wants to give 2mg morphine IVP d/t the lethargy, but that may be seen as "prescribing."

I'm not sure how we will deal with prophylactic analgesics, such as before physical therapy or major dressing changes. Maybe there needs to be something that states "for mild pain or prior to PT" in the order.

We need the whole organization on the same page and I'm just wondering if there are any organizations with a good system right now.

The Joint Commission gives examples on their webpage:

https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1518&StandardsFAQChapterId=27&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=

read especially those points:

"7. The medical record must accurately reflect that the lesser potent medication was administered based on patient preference (RC.02.01.01 EP 2). It is NEVER acceptable to administer a medication of stronger potency based on patient preference.

8. Each organization is responsible for determining how such orders are to be entered into the medical record. However, the following is an example for consideration:

Acetaminophen 325 mg 2 tablets po every 4 hours prn mild pain.

Hydromorphone 2 mg 1 tablet po every 4 hours prn moderate pain. May administer less potent prescribed medication based on patient request per the organization's medication management policy (MM.04.01.01).

The policy must be explicit in that such an order is ONLY for administration of a different (lesser) agent, not changing the dosage ordered of the same medication. If the policy allows a lower dose of the same medication than ordered, it would not be accepted as compliant."

It pretty clear outlines what the expectations are, what needs to be considered when ordering and administering and what needs to be reflected in the documentation.

If your providers do not order medication in that format or do not order medication in a manner that supports the safe administration as well as considering patient choices it would be helpful to bring that up to whoever deals in your workplace with pain medication orders and providers/standards.

I also find it helpful to have index cards with commonly used orders etc. to have the language at hand when I have to talk to a provider. Many have a hard time with keeping up to date on what is acceptable as this changes periodically - they might appreciate suggestions on how to write orders - make sure to discuss this with your educator / manager as well.

I found that standard order sets can help for populations that have similar needs - in those cases, the work place might consider to add or modify existing order sets to include frequently used restrictions or conditions.

It is essential that your documentation reflects what is going on.

Example: A nurse complained that the patient is experiencing severe pain not relieved by medication ordered BUT the pain documented was consistently "0" or low numbers. There was no description of pain or pain quality and the medication was only given two times in that shift but ordered prn q 4 hours.

In those cases I just wonder....

Your policies need to be evaluated to see whether they meet TJC standards.

We had a several-pages long thread here just days ago that touched on some of the topics you're concerned about.

I posted this link within that thread, which gives some insight - you'll have to scroll down to the MM (medication management) sections.

It was an interesting discussion. I don't know about everyone else but the overall conclusion I came to is that there may be some variety in practice that is acceptable from institution to institution, but each one must have policies in place that meet TJC standards and the practice at each institution must be in accordance with their own policies on the related matters.

So...I don't think your question can be "what should we do in all of these various situations when it's time for our survey visit?" but rather, "What are our current policies, do they meet the standards, and is our practice in line with our policies?"

Good luck ~

Thank you, I think the first bullet answered a lot of the question:

1. That the medication order is written in a manner that supports deferring to patient preference when:

a. Requesting a lesser potent medication. (Potency should be established with an evidence based tool i.e. morphine equivalents).

b. Requesting a lesser prescribed dose in a range order.

c. Requesting a less intrusive route of administration if both routes are prescribed by the provider.

I guess it is ok to administer a lesser dose (if in a range order) or less potent medication if needed. Nursing judgement will come into play and they may question if nurses are "prescribing" rather than using judgement.

I'm not sure why TJC is cracking down on the verbiage, but it seems just like busy work rather than anything evidence-based to back up this crackdown on prn analgesics. Our practice will not really change, but only the way the order is written.

I'm going to be brutally honest here and I'm sure I'll see some backlash, but if somebody can't figure out how to go around that, then how can they claim nursing judgement goes out the window?

Can you not a put a note in? It's very rare for me anyway that a patient rates their pain as a legit 8 and only want Tylenol. It's happened but I can count on both hands the number of times. At that point, a note is in the MAR as to why I gave them Tylenol. This is to try and cover my butt when they then fill out a survey and say their pain isn't adequately treated.

The point the TJC is for nurses to not giving dilaudid when their pain is only a one or a two and could be treated with maybe Ice packs or Tylenol.

People make it harder than it has to be.

I'm going to be brutally honest here and I'm sure I'll see some backlash, but if somebody can't figure out how to go around that, then how can they claim nursing judgement goes out the window?

There are many ways to get around this nursing-wise, however it does not meet TJC rules. I'm not sure you understand the scope of the situation or understand the question. Nurses can work around many things, but it seems to now be undermining nursing judgement and making physician's go through busy work.

If a nurse puts a note in but doesn't give the medication exactly as ordered, then the nurse may be "prescribing," such as giving 2mg morphine when ordered is 4mg. I think you are looking at things from a staff nurse position, but TJC will look at things from an organizational position.

The point of TJC is not what you mention. I'm not sure what nurse gives dilaudid for 1-2/10 pain, but no nurse that I know does that. If that is the point for TJC, then that would be scary and I would throw nursing judgement out the window as well. TJC is trying to make things with less errors, but I think it undermines nursing judgement and assessment.

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