Dose ranges on prn med orders

MissBell · Mar 31, 2011

We actually have a journal article thumbtacked to our nurse's station about this very topic. While the name escapes me, the gist is this:

Using your example of 1-2 tabs q4h, you give 1 tab at 8am. This does not alleviate the pain, so at 10am you can give the second tab, however, this restarts the clock, and you cannot give any more meds for the full 4 hours. I can write down the journal article next time I work if you would like to look it up yourself. Hope this helps!

MissBell RN

simplvbl · Apr 1, 2011

We actually have a journal article thumbtacked to our nurse's station about this very topic. While the name escapes me, the gist is this:
Using your example of 1-2 tabs q4h, you give 1 tab at 8am. This does not alleviate the pain, so at 10am you can give the second tab, however, this restarts the clock, and you cannot give any more meds for the full 4 hours. I can write down the journal article next time I work if you would like to look it up yourself. Hope this helps!
MissBell RN

I agree with MissBell! When you give 1 tab at 8am you have to wait until times hits 10am before you can give another dose. This is also the reason why you have to asses how much pain the patient has prior to deciding how much to give, whether 1 or 2...because of the frequency of the order. If just in case you only gave 1 tab but should've been 2 tabs, just give whatever other pain medication is available until the med is due again (just keeping in mind about the max per day of APAP if you're giving APAP-containing meds). You're DON is so wrong! Besides, that order is to be read as "1-2 tabs EVERY 4hrs PRN" instead of "1-2 tabs WITHIN 4hrs PRN." Tricky, huh! Well, I don't have any proof or article to share here, but I worked as a pharm tech for an LTC pharm for almost 8yrs, so I know what I'm talking about.

MunoRN, RN · Apr 1, 2011

If the patient is still in pain at 1000 then you not only can give the second tab, but you should, assuming there are no significant adverse effects that would prevent you from doing so. There are no laws or regulatory rules that prevent this.

Range orders have been a hot topic lately due to the Joint Commission recommendations which have been controversial, but don't include any recommendations that range ordered medications can only be administered once during the specified time frame. The only JC recommendation that would effect this is that they require that each institution establish a policy on range orders to ensure consistent interpretation of the order. So if your institution says you can give a 1-2 tab q4hr as 1 tab q2, then you can. You can google "medication range order policy" and you'll find quite a few institutional policies, none of them say you only get once chance to administer the medication in the given time frame, just that you can't exceed the ordered limit in any given time frame; so if you give 1 tab at 0800, another at 1000, you could give 1 tab at 1200 or wait until 1400 and give 2.

I know the myth exists that the order is to be interpreted as only being able to administer once per 4 hours, even if less than the max was given, but what I don't understand is the rationale behind the myth. The purpose of the max per timeframe in a range order is to ensure that the patient doesn't have more than a certain level of drug acting at any given time. Spreading out doses is a hassle, but provides more consistent pain control with less severe side effects, so why would we assume that is wrong? Particularly with nothing to base it on?

The closest thing you could get to a law would be a statement from your state's BON. Most states including my own make no specific recommendations on this, although here is the Arizona BON's response to this question:

"QUESTION: If the health care provider gives an order for a range dose, such as "morphine 4-8 mg IV every 4 hours PRN, is it within the nurses scope of practice to administer an initial dose, i.e. 4 mg and then give an additional 4 mg if the patient's pain persists, as long as the maximum range (8 mg) is not exceeded within any 4-hour time frame?

ANSWER: The patient will be assessed by the nurse to determine their level of pain. After

giving the "initially selected dose," the patient is reassessed to determine if additional medication is needed. If the patient's pain is not controlled, and the maximum dose was not initially selected and given, additional medication may be given (within time frame stated in the order) until the maximum amount ordered by the health care provider is administered."

http://www.azbn.gov/documents/advisory_opinion/FAQs/FAQ%20REGARDING%20RANGE%20ORDERS%203-18-05.pdf

Havin' A Party!, ASN, RN · Apr 3, 2011

Great answer by Muno.

Nevertheless, many facilities (particularly LTCs) interpret range scripts as "one-dose per period" orders... allowing only one med administration for the duration of the stated frequency.