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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?
Depending on the med, it could matter quite a bit.
Can you elaborate? New RN and I am trying to use this as a learning experience. We also had a pt that had an order for 3 mg dilaudid Q 6H. The report I was given from the previous RN was that the pt had requested to get 1 mg Q2H and that is what she had been doing for him. I can't remember what the pt's dx/condition was but the previous RN had no problem dividing up his pain meds that way.
Also, the pharmacists are usually aware of the P&P involved in med administration. It's likely that this pharmacist is familiar with the P&P (written or unwritten) at this particular facility. If there is a written policy that the pharmacist referred to in answering your question, then you need to be familiar with it too. If there is no written policy, but there is a general agreement between physicians, pharmacy, and nursing, as to how to interpret such orders, then you need to find out what it is from your supervisor.
The supervisor didn't know either. She was the one that called pharmacy to find out. I do not know if the pharmacist referred to a written policy or not but I do think we need to be more aware of what the policy is. I just can't believe it never has come up before when it's something we do all the time.
There's no state or federal regulatory group that doesn't allow Nurses to follow range orders. Hospital policies though might place tighter restrictions on their use.
It sounds like you are talking about two different orders, not a single range order. Multiple pain med orders is usually how hospitals that ban range orders replace those range orders, usually with different indications for each order: 1mg q4 for pain level 1-5, 2mg q4 for pain 6-10, etc. We may also have multiple morphine orders for different indications such as 4mg q4 for pain, and 2mg q4 for dyspnea.
If you have 2 morphine orders that both just say "prn pain", we usually go with the most recently written order and D/C the order.
Where I work you would be allowed to give a 3mg q 6hr dilaudid dose in divided doses of 1mg every 2 hours, which is actually a much more effective and safer way to administer 3mg of dilaudid, which is a whopping dilaudid dose.
If you give 1mg of xyz med at 1200, then another 1mg at 1400, and start your 4 hour window at 1200, then you give another 2mg at 1600, then the patient has actually had 3mg within a 2 hour time frame (1mg at 1400, 2mg at 1600). Depending upon the half life of the medication as well as variance from patient to patient in metabolizing medications, if you continue to do this, then the medication can accumulate in the bloodstream to dangerous levels, slowly over time, eventually causing adverse effects such as respiratory depression.
We also had a pt that had an order for 3 mg dilaudid Q 6H. The report I was given from the previous RN was that the pt had requested to get 1 mg Q2H and that is what she had been doing for him. I can't remember what the pt's dx/condition was but the previous RN had no problem dividing up his pain meds that way.
At my facility, you would have to get a new order for 1mg q2h. I can't imagine any physician having a problem with that.
If you give 1mg of xyz med at 1200, then another 1mg at 1400, and start your 4 hour window at 1200, then you give another 2mg at 1600, then the patient has actually had 3mg within a 2 hour time frame (1mg at 1400, 2mg at 1600). Depending upon the half life of the medication as well as variance from patient to patient in metabolizing medications, if you continue to do this, then the medication can accumulate in the bloodstream to dangerous levels, slowly over time, eventually causing adverse effects such as respiratory depression.
The time frame is always based off of the current time. If it's 1600 and you're considering giving pain medication, you would need to look at the amount given over the past 4 hours, if you're limited to 2 mg every 4 hours and you gave 1 mg 2 hours ago, then you can only give 1 mg right now.
Dividing does not result in a cumulative build-up of the medication or it's active metabolites. It is true that if you given 1mg every hour over a 4 hour period, the patient will have more medication effect at hour 3 than at hour 1 (which is good) just as giving it all at once will result in more effect at hour 1 than at hour 3.
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.[/quoteGuess the sarcasm r/t the pharmacist giving meds went right over your head. Read the arguments on this thread closely. The reason for clear med orders is r/t the fact that each nurse may interpret the order differently, which can lead to potentially fatal med errors. You state, "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." I thought you were an RN who is "trained...and qualified to administer meds and use our critical thinking skills and judgment." Gues that doesn't really matter a ton
The time frame is always based off of the current time. If it's 1600 and you're considering giving pain medication, you would need to look at the amount given over the past 4 hours, if you're limited to 2 mg every 4 hours and you gave 1 mg 2 hours ago, then you can only give 1 mg right now.
My post was in response to the OP asking for an example of how it could matter at what time you start your four hour window. It was an example of how if you start it with the first dose, as the OP stated that they would, this could lead to overdosing.
Dividing does not result in a cumulative build-up of the medication or it's active metabolites. It is true that if you given 1mg every hour over a 4 hour period, the patient will have more medication effect at hour 3 than at hour 1 (which is good) just as giving it all at once will result in more effect at hour 1 than at hour 3.
Dividing doses, no....I don't recall suggesting that it would. But misinterpreting range orders...absolutely, yes, it can result in a cumulative build-up, which is why it is so important to either have a written policy on how range orders are to be interpreted, or a clear understanding of such (but written policy is much easier to look up and refer to when one has questions).
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.[/quoteGuess the sarcasm r/t the pharmacist giving meds went right over your head. Read the arguments on this thread closely. The reason for clear med orders is r/t the fact that each nurse may interpret the order differently, which can lead to potentially fatal med errors. You state, "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." I thought you were an RN who is "trained...and qualified to administer meds and use our critical thinking skills and judgment." Gues that doesn't really matter a ton
No need to be nasty. I did get the sarcasm, however, when that is the only resource one has on a pm shift what else is one supposed to do? What nurse has the time (and even knows how) to search through manuals for policies, if there even is one??? Not that I am opposed to doing so but when a pt is in pain I have to use the resources I have readily available. ALl of the nurses agreed that it was okay to give the med that way.
I should also say that after I posted before I forgot to say that let's say I gave 1 mg at 1200 and 1 mg at 1400 to divide the dose for longer, more effective pain relief. At 1600 if the pt requests more pain meds I would not give a 2 mg dose because then the pt will have had over 2 mg in the 4 hour time frame. I AM careful and don't think there is any reason to be so snarky when I was just asking how others would interpret this.
Anna Flaxis, BSN, RN
1 Article; 2,816 Posts
Also, the pharmacists are usually aware of the P&P involved in med administration. It's likely that this pharmacist is familiar with the P&P (written or unwritten) at this particular facility. If there is a written policy that the pharmacist referred to in answering your question, then you need to be familiar with it too. If there is no written policy, but there is a general agreement between physicians, pharmacy, and nursing, as to how to interpret such orders, then you need to find out what it is from your supervisor.