Legal ? re: med timing

[NightOwlNurse]

In nursing school 2 of my instructors forcefully stated that if we had an order such as

" Morphine IV 1-10 mg every 4 hours prn" we absolutely were not allowed to give, for instance, 1 mg of IV morphine, then an hour later, 2 mg of IV morphine, than another hour later, 3 mg of IV morphine.

This question is meant to focus specifically on the legal issues regarding a ranged timed medication order, and how we are legally able to time the meds we give, not any other aspect of this scenario.

Legally speaking, my nursing instructors said as RNs we were to make a choice from dose amounts from those available in the order (say, 1 mg), and then until the time frame listed (4 hours in my example) passed, our hands were tied and we were not allowed o give any more of that medication. At the end of the time frame (the 4 hours) we were then free to choose to give a higher amount in the range, say, 2 mg IV, then we would again need to wait 4 hours to medicate.

This issue has become a challenge in one hospital I work in. The unit I started in was in agreement with what my nursing instructors had said. In fact, the manager of our floor disciplined some of my coworkers who had given multiple doses within one order's time (for example, one had an order to give morphine IV 1-4 mg every 4 hours prn, and had given 2 mg IV to start, and 2 hours later given another 2 mg IV).

Now I've moved to a different floor, and I am getting great pressure to give my patients multiple doses within one orders time frame (example, when I had an order for 2-4 tabs Percocet PO every 4 hours prn, and I gave one tab, and the patient asked for another tablet of Percocet after 2 hours, my fellow nurses expected me to give my patient "the second" Percocet even though it had not been 4 hours since the first).

Obviously I don't want my patients to suffer, but equally obviously I don't wish to endanger my license by not respecting the time frame of the order. I know enough to ask other nurses, but the problem is that I get different interpretations from different nurses, and different pharmacists. One of my charge nurses actually told me "Don't think so much!" when I asked her about the situation.

How can I find out what the law requires of me, and what I am allowed to do, with certainty, in this situation?

Thanks.

[MouseMichelle]

This is me...if it says 1-2 PCT q4hours PRN then if I give one and two hours later they want another one I say it's not time. Then I look to see if I can give an alternative pain pill in the meantime such as Tylenol or Ibuprofen. If I gave one and it's two hours later and the patient is in agony then I call the doctor and tell the doc what is going on and get an order for 1pct NOW, then I learn from it and give that patient 2 pcts depending on his/her pain level.

I always ask for pain levels when giving it if it's 1-2 prn, and they say their pain is 8 I give two if it's a 4 I give one.

Just my opinion.

Mouse.

[MunoRN, RN]

Of all the myths we deal with, this one is by far the most aggravating to deal with.

The dosage range for a prn specifies the maximum amount of medication that can be given in a specified time frame. There are regulatory interpretations that you must give at least the minimum dose (you have to give at least 1mg of morphine if it is ordered as 1-4mg), but that is a whole different argument. If the order is for 1-4mg q 4hours Morphine you absolutely can give 1 mg, then give another dose (3mg or less) if that is ineffective. The thing to keep in mind is that 4mg limit over 4 hours is defined by when each dose is given; if you give 2mg at 0800, then 2mg at 1000, you would only be able to give 2mg at 1200 since they have already had 2mg in the past 4 hours.

What really drives me nuts about this myth is that it encourages bad pain control techniques. The basic premise of pain control, particularly when using opiates, is to use the minimum dose required to adequately treat the pain. If nurses feel that they have to guess right with the initial dose and then won't have anything they can give for 4 hours, they may be encouraged to give a larger dose than necessary, if they guess low and feel they can't give any more for 4 hours, even though it's ordered, then the patient suffers for no reason.

The American Pain Society's recommendations for pain treatment is to give the low end dose initially, unless you have knowledge that the patient needs more based on Hx, then re-evaluate when you have reached the time-to-effect for that med (don't wait until the prn timeframe has ended), re-medicate if pain level is not at goal staying within the dosage limit for that time frame. The next time the patient has a similar pain level, give the amount of medication that was required to relieve the pain initially.

[LPN_FTW]

MunoRN said it perfectly.

You can adequately perform your 8/9/10 medication rights on the order examples you have provided. Right drug through the right route at the right time in the right dose, and ordered for the right patient.