IV med dosing question

regularRN · Aug 18, 2011

this is a situation in which you call the attending md and clarify the order. however the order states 1 or 2 mg q4, not 1mg q2...

klone, MSN, RN · Aug 18, 2011

If you have two different contradictory orders, you call the physician and clarify, in order to d/c one of the orders.

I would not give the 2nd dose of the medication before clarifying.

rnccf2007, BSN, RN · Aug 18, 2011

You have 2 orders for an IV pain med. One is for 1 mg Q4. The other is for 2 mg Q4. 1 mg is given and 2 hours later another 1 mg is given. Is this within the parameters for the dosing. The CNS wasn't sure and thought that it may be prescribing. How do you interpret it?

Have had similar discussions with other nurses regarding such orders. Don't think that this is within the parameters for dosing. The order clearly states 1 mg q4 or 2 mg q4, not give 1 mg q2 and you can give the other 1 mg 2 hours later if you feel it is within nursing judgment, afterall, 2+2=4. But, this is not a q2h order. I would clarifiy the order and be leary about about doing the 1 mg and then the other mg 2 hours later, because it is not within the nursing scope of practice to prescribe meds. Could lead to trouble. Not sure, just my interpretation. Similarly, why most hospitals will no longer allow such orders such as give 1-3 mg q6 for pain.

luv2b_a_nurs · Aug 18, 2011

Pharmacy was called and agreed that the 2nd mg can be given within the 4 hours. I would rather start a pt on 1 mg and give another later if necessary instead of going for 2 right away. We do it a lot for pills as well if 1 doesn't cut it. Does anyone have any rationale or policy on this?

rnccf2007, BSN, RN · Aug 18, 2011

Technically, I would say yes. But then again, aren't you practicing outside of your scope? You are saying that you would start the patient on 1 mg and give another if necessary. That is prescribing medications, unless you have specific orders. If pharmacy agrees, then I would let the pharmacist give the second mg personally until clarified, CYA.

AUicuRN · Aug 18, 2011

This is a tough situation. I found myself wondering this same thing recently. I could give a small dose of a narcotic or a bigger dose. I told the family, "we should try the smaller dose now and we can always give it again and make it the bigger dose if it doesn't work." I think it was morphine 1mg or 2 mg q2h prn for pain. I don't know the right thing but I was willing to try the smaller dose and not wait out the 2 hours to give more.

luv2b_a_nurs · Aug 18, 2011

Technically, I would say yes. But then again, aren't you practicing outside of your scope? You are saying that you would start the patient on 1 mg and give another if necessary. That is prescribing medications, unless you have specific orders. If pharmacy agrees, then I would let the pharmacist give the second mg personally until clarified, CYA.

Well that's what I don't understand. How is it prescribing if you have an order for either and use your nursing judgement to medicate the pt effectively? The dose has already been prescribed by the Dr and the total amt of the med is given within the stated time frame.

Anna Flaxis, BSN, RN · Aug 18, 2011

You have 2 orders for an IV pain med. One is for 1 mg Q4. The other is for 2 mg Q4. 1 mg is given and 2 hours later another 1 mg is given. Is this within the parameters for the dosing. The CNS wasn't sure and thought that it may be prescribing. How do you interpret it?

Am I correct in understanding that this is not a range order (xyz med 1-2mg IV q4hr prn pain), but rather, that there are two distinct orders for this medication?

Generally, in the case of a range order, one starts with the lowest dose and the shortest time frame in the order (i.e. for an order that states 1-2mg q4-6hr, you would start with 1mg, and if that did not have the intended effect, you would have to wait until the next 4 hour time window to then give 2mg. If giving the 2mg did not cause any adverse reaction, from there on out, 2mg q4hr could be given).

However, with two distinct orders for the same medication, things get a little fuzzier. If you go by the 2mg q4hr order, then giving a second dose of 1mg within the four hour time frame would be acceptable, but when does the next 4 hour time frame start? From the time the first dose was given, or the time when the second dose was given?

My understanding is that the JC does not require facilities to have written policies on how to interpret these types of med orders, but that if you ask two nurses and get two different answers, then this is a red flag that maybe there should be a written policy, or at the very least, better staff education so that there is an understanding among nursing staff and between physicians and nurses on how these orders are to be carried out.

The fact that you and your CNS aren't really on the same page about how these orders are to be interpreted tells me that you need to find out if there is a written policy, and if so, follow it. If not, then you need to find out what the unwritten expectation is. Your nursing supervisor is supposed to know this stuff, and if s/he doesn't, then they need to find out and share the information with staff.

I don't think this is prescribing or practicing outside your scope. You have the order. It's more a matter of unclear P&P at your facility, and if you have any doubts at all about how to interpret any order, you have an obligation to get clarification (Nursing 101 here).

I could be way off base here, but I'm sure someone will correct me if I am.

luv2b_a_nurs · Aug 18, 2011

However, with two distinct orders for the same medication, things get a little fuzzier. If you go by the 2mg q4hr order, then giving a second dose of 1mg within the four hour time frame would be acceptable, but when does the next 4 hour time frame start? From the time the first dose was given, or the time when the second dose was given?

Well, I don't know that it *really* matters a ton when the next time frame starts as long as one does not give a total of more than 2 mg in 4 hours but I would go 4 hours from the time of the first dose.

Anna Flaxis, BSN, RN · Aug 18, 2011

Well, I don't know that it *really* matters a ton when the next time frame starts as long as one does not give a total of more than 2 mg in 4 hours but I would go 4 hours from the time of the first dose.

Depending on the med, it could matter quite a bit.

luv2b_a_nurs · Aug 18, 2011

Technically, I would say yes. But then again, aren't you practicing outside of your scope? You are saying that you would start the patient on 1 mg and give another if necessary. That is prescribing medications, unless you have specific orders. If pharmacy agrees, then I would let the pharmacist give the second mg personally until clarified, CYA.

I don't believe so but having the pharmacist give the 2nd mg would be outside of THEIR scope! We as RNs are trained and are qualified to administer meds and use our critical thinking skills and judgement.