range order rationale

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Specializes in Critical Care.

So you've got an order for 1-2 Norco q 4hrs prn pain, you give 1 at 1200 for 6/10 pain. At 1330 their pain is still 4/10, does you interpretation of the order allow you to give the second or do you have to wait until 1600? How would you interpret this and more specifically why?

I know there have been other threads on the subject of range orders but what I haven't been able to find is rationale for different views that exist on these threads. I'm having a hard time understanding why so many nurses believe a medication ordered as a range order can only be administered once during the timeframe rather than titrated to effect, please enlighten me.

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Specializes in Med surg, LTC, Administration.

Because you were to give one or two every four hours, then you need to wait the full 4 hours before you can administer again, unless you have a doctors order to give another one or two, sooner. Why, because that is what the order said. You gave the one. Now you will assess it's effect for the next four hours. You may then decide to give two or continue on with the one. PRN meds have to be given as written, or at the end of 24 hours, you would have given an extra dose.

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Specializes in Cath Lab/ ICU.

Range orders are not allowed at my facility. It would be more like:

1tab q4 PRN for pain 1-6

2 tabs q4 PRN for pain 7-10.

So I'd give one tab and wait 4 hrs to give the other.

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IMO, you give another one. The order is written that way on purpose so you have some flexibility to correctly manage pain. The way I see it, the Dr. "allows" for 12 Norcs per day, so the total dose allowed per day will be the same if you give 2 norcs Q 4hrs, OR 1 norc Q 2hrs.

I have not had this situation arise, and am curious if my thinking is right???

Actually, after reading the previous posts, i see that I am incorrect. Gotta give it the way it was written.

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Specializes in Cardiac, ER.

I think this would depend on what kind of pain the pt is having, how big they are, are they used to taking narcotics? This is where your nursing judgement comes in,..but I would do just as you say,..give one, if in an hour and a half the pt is still in pain and requesting more meds I would give the second one.

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Specializes in Critical Care.
Because you were to give one or two every four hours, then you need to wait the full 4 hours before you can administer again, unless you have a doctors order to give another one or two, sooner. Why, because that is what the order said. You gave the one. Now you will assess it's effect for the next four hours. You may then decide to give two or continue on with the one. PRN meds have to be given as written, or at the end of 24 hours, you would have given an extra dose.

Norco peaks at 40-60 after ingestion, so at 90 minutes you've already seen most effect it will have, so I'm not sure why you would continue to assess for improving pain control after peak concentration has already passed.

The order does say you can give another (1-2 tabs) and that you can't exceed 2 tabs in any 4 hour period, so where would the extra dose come from?

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Specializes in Cardiac, ER.
IMO, you give another one. The order is written that way on purpose so you have some flexibility to correctly manage pain. The way I see it, the Dr. "allows" for 12 Norcs per day, so the total dose allowed per day will be the same if you give 2 norcs Q 4hrs, OR 1 norc Q 2hrs.

I have not had this situation arise, and am curious if my thinking is right???

Actually, after reading the previous posts, i see that I am incorrect. Gotta give it the way it was written.

I agree with you. As long as you don't exceed the 12 doses in 24 hours I would give the second tablet. For those of you who wouldn't give the second one, what would you do in an hour and a half when the pt is still in pain and asking for meds?

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Specializes in Critical Care.
Range orders are not allowed at my facility. It would be more like:

1tab q4 PRN for pain 1-6

2 tabs q4 PRN for pain 7-10.

So I'd give one tab and wait 4 hrs to give the other.

Do you know the reasoning for not allowing range orders?

The examples you give seem odd to me, since every patient's pain scale is different and how they respond to pain treatment varies widely. One person's 3/10 may require two norco to relieve and another's 10/10 may be fully relieved with only a tylenol.

Wouldn't the fact that the 1 tab only brought the patient's pain level down from a 6 to a 4 prove that the one size fits all prn order doesn't work for this patient? Would the next step then be to call to Doc to change the order or is it 1 tab for 1/10-6/10 for every patient as a standard rule?

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Specializes in Med surg, LTC, Administration.
IMO, you give another one. The order is written that way on purpose so you have some flexibility to correctly manage pain. The way I see it, the Dr. "allows" for 12 Norcs per day, so the total dose allowed per day will be the same if you give 2 norcs Q 4hrs, OR 1 norc Q 2hrs.

I have not had this situation arise, and am curious if my thinking is right???

No, I don't believe this is correct at all. The order does not say one tab every two hours. It says every four. If you do it your way, you are prescribing meds. But say you gave 1 at 12, then 2 at 1:30, 2 at 5:30' 2 9:30, 2 at 130 and 2 at 5:30 and 2at 9:30. That would be 13, not 12 in 24 hours.

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Specializes in Med surg, LTC, Administration.
I agree with you. As long as you don't exceed the 12 doses in 24 hours I would give the second tablet. For those of you who wouldn't give the second one, what would you do in an hour and a half when the pt is still in pain and asking for meds?

Call and ask for a new or stat order. Nurses are not allowed to prescribe meds.

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Specializes in Critical Care.
No, I don't believe this is correct at all. The order does not say one tab every two hours. It says every four. If you donitnyour way, you are prescribing meds. But say you gave 1 at 12, then 2 at 1:30, 2 at 5:30' 2 9:30, 2 at 130 and 2 at 5:30 and 2at 9:30. That would be 13, not 12 in 24 hours.

You couldn't give 2 at 1:30, you could only give 1 since you gave 1 at 12:00, so no it wouldn't be 13 in 24 hours.

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Specializes in Critical Care.
Call and ask for a new or stat order. Nurses are not allowed to prescribe meds.

You already have a prescription; 1-2 tabs q 4hrs. Titrating within ordered parameters is not prescribing.

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