Medication Range Doses-What if Patient Wants Less?

Kittypower123, BSN, RN · Jul 25, 2012

You can only give what you have an order for. Since you are not a doctor, you cannot "order" a lower dose. You need to call the MD/NP and get a new order for the lower dose.

Unique X · Jul 29, 2012

You cannot adjust the dose because that medication is ordered by a physician. We as nurse are not allowed to change doses in that manner. If a patient wants a lower dose, consult physician and act as the patient advocate... Ie maybe the client wanted a lower dose because of side effects. Even though your facility does not have or care for dosage adjustment, go with the more stringent choice, contacting physician. At the end of the day always try and err on the side of caution otherwise, your license is up for grabs.

iluvivt, BSN, RN · Jul 29, 2012

This is simply a matter of law and following the nurse practice act. Unless you have prescribing capabilities or a standardized procedure (if you work in the US and in a decision tree state ) to cover you ..you would be practicing medicine

Double-Helix, BSN, RN · Jul 30, 2012

Furthermore, dose ranges are no longer approved by the Joint Commission. If you encounter an order that gives you are range of 0.5-1mg, you must call the doctor and get the order clarified to read either one dose or the other.

And I agree with the other posters. You cannot give half a dose, or twice the dose, or any other dose than what you have an order for. If the patient wants less you need to call the doctor to get a new order.

MunoRN, RN · Jul 30, 2012

First off, obviously follow your policies and the views of your particular states BON.

The Joint Commission does not currently, nor have they ever, forbid range orders. Their standard on medication administration only requires that facilities ensure that everyone has the same understanding of how they are to be used, which caused many facilities to just do away with them all together rather than clarify their use to avoid having to meet that standard all together (essentially, they were too lazy to deal with it). This is unfortunate since both the American Society of Pain Management Nursing and the American Pain Society advocate that range order be used in pain control since it provides for both better pain control without excessive administration of pain medications.

My current facility's policy, which is legal and meets all regulatory requirements, does allow for a lower dose to be given. The lower dose on our range orders does not define the smallest amount that can be given, any "measurable" dose can be given with a range order so long as it does not exceed the maximum of the range and so long as the prescriber as not specifically written to give a minimum. What the lower amount in our range order indicates is the maximum amount that can be given as the initial dose, you can then up-titrate (or down-titrate) from there.

At my previous facility, this came up on Health Dept/BON/DEA visit. They didn't care as long we weren't exceeding the dose, they didn't see it as prescribing since you have an order for whatever amount you are giving less than the maximum (the order for 1mg Morphine exists within a 2-4mg order, 5mg does not and would be giving without an order). Obviously not all surveyors will hold the same view, but it's not nearly the absolute rule it's being described as.

loriangel14, RN · Jul 30, 2012

It depends maybe on where you work.Where i work we can give less if the patients asks for it.

jadelpn, LPN, EMT-B · Jul 31, 2012

Where I work, you can not have a double range order--meaning both dose and time 0.5 to 1 mg q 4-6 hours. That is what my understaning of what the joint commission doesn't like.

But to your questgion, no you can not give less, as then you can get yourself into a situation where they say THAT did not work, can I have some more if I can have up to 0.5? If the patient feels as if they are overmedicated, then it is up to you to call the doc and tell him/her that. And see if the order can be clarified to be "0.25 for mild pain (2-4 on pain scale), 0.5 for moderate pain(5-7 on pain scale), 1mg for severe pain (8-10 on pain scale)"

KelRN215, BSN, RN · Aug 4, 2012

First off, obviously follow your policies and the views of your particular states BON.
The Joint Commission does not currently, nor have they ever, forbid range orders. Their standard on medication administration only requires that facilities ensure that everyone has the same understanding of how they are to be used, which caused many facilities to just do away with them all together rather than clarify their use to avoid having to meet that standard all together (essentially, they were too lazy to deal with it). This is unfortunate since both the American Society of Pain Management Nursing and the American Pain Society advocate that range order be used in pain control since it provides for both better pain control without excessive administration of pain medications.
My current facility's policy, which is legal and meets all regulatory requirements, does allow for a lower dose to be given. The lower dose on our range orders does not define the smallest amount that can be given, any "measurable" dose can be given with a range order so long as it does not exceed the maximum of the range and so long as the prescriber as not specifically written to give a minimum. What the lower amount in our range order indicates is the maximum amount that can be given as the initial dose, you can then up-titrate (or down-titrate) from there.
At my previous facility, this came up on Health Dept/BON/DEA visit. They didn't care as long we weren't exceeding the dose, they didn't see it as prescribing since you have an order for whatever amount you are giving less than the maximum (the order for 1mg Morphine exists within a 2-4mg order, 5mg does not and would be giving without an order). Obviously not all surveyors will hold the same view, but it's not nearly the absolute rule it's being described as.

When I worked in the hospital, our practice was similar to what this poster describes. Say someone had an order for Morphine 2 mg q 4 hr. That was often given as 1 mg q 2hr. If someone was ordered for 5 mg of morphine but their pain wasn't so severe, nurses would often given 2 or 3 mg instead and then give the remainder if the pain didn't resolve before the next dose was due.

Then we also had the issue where, as this was pediatrics and doses were based exclusively on weight, we'd get orders for 0.98732671262167 mg of Morphine which is impossible to draw up, so yeah that would turn into 1 mg. Or 347.34838721873287 mg of Tylenol on a child who could swallow pills. They would be given 325 mg and no one- nursing, pharmacy or physician alike, minded. It was just how things were done. No one ever questioned whether or not it was technically "right".

RainMom · Aug 25, 2012

Say someone had an order for Morphine 2 mg q 4 hr. That was often given as 1 mg q 2hr.

Um, no I don't think so. Who's to say that shouldn't be 0.5 mg qh? That's turning it into a completely different order. If it's written 2 mg q4h, then it's 2mg q4h. However, they can write the order as 1-2 mg q4h & then you could start with the 1 mg. My understanding is that if that is not effective, the 2nd mg can be given, but the 4 hrs starts with the 2nd mg, not the first. I try to follow up quickly with the pts on pain relief so that if the additional dose is necessary, it is given about 30-45 minutes after the first. This doesn't happen often though. Usually, its a pt who thought 1 Norco would be all they would need to get through the CPM session but realize once it starts that their knee was quite a bit more sore than they realized. We usually have protocol orders for 1-2 Norco q4h.

KelRN215, BSN, RN · Aug 25, 2012

Um, no I don't think so. Who's to say that shouldn't be 0.5 mg qh? That's turning it into a completely different order. If it's written 2 mg q4h, then it's 2mg q4h. However, they can write the order as 1-2 mg q4h & then you could start with the 1 mg. My understanding is that if that is not effective, the 2nd mg can be given, but the 4 hrs starts with the 2nd mg, not the first. I try to follow up quickly with the pts on pain relief so that if the additional dose is necessary, it is given about 30-45 minutes after the first. This doesn't happen often though. Usually, its a pt who thought 1 Norco would be all they would need to get through the CPM session but realize once it starts that their knee was quite a bit more sore than they realized. We usually have protocol orders for 1-2 Norco q4h.

You can not think so but that's how things worked in my hospital. We gave half doses or 3/4 doses all the time and as long as the maximum wasn't exceeded in the ordered time range, no one seemed to care. See the post I was responding to. Every facility is different in their policies/procedures.

BrandonLPN, LPN · Aug 31, 2012

I have a dumb question. What is the point of ordering a PRN med q 4-6 hours? You might as well just write q4 hours. The "to six" part of "every 4 to six hours" seems unnecessary and pointless. The q4 part is all that really matters.