range order rationale

Nurses General Nursing

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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.

Specializes in Infusion, Med/Surg/Tele, Outpatient.

Myself, I'd give the second at 1330 and that'll be all until 1730; the pt had all the dose at 1330.

Now my work has been improving range orders. Norco X/325 1-2 tabs q4-6prn and morphine 2-4 mg IVP q 4-6h prn comes on our MARs:

Norco 1 tab PO q 4h for pain 1-3

Norco 2 tab po q 6 h for pain 3-5

Morphine 2 mg IV q 4 h for pain 5-7

Morphine 4 mg IV q 6 h for pain 8-10

Which is nice because it means that pts have standardized dosing for set pain parameters regardless of which nurse is working. But, I argue, what about giving morphine 3 mg IV or norco 1 1/2 tabs? [clearly allowed in the written range order ;)]

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Specializes in Developmental Disabilites,.

I take that order to mean in a 4hr period I can give 1-2 pills. So if in 45mins they need that second norco they are going to get it. I do not see it as practicing medicine but rather using nursing judgement.

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Specializes in Med surg, LTC, Administration.
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?

That is not what the order says. It says, give 1 or 2 every 4 hours PRN. It does not say, give 1 or 2 whenever you feel like it. Sorry, but this is a simple order. It would have been written, 1-2 every 2-4 hours PRN for pain or 1 every 1-2 and 2 every 2-4. You have to do PRN as written, or you will give an extra dose. Really. We can't prescribe meds. If the pain is still severe, let the MD know.

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Specializes in Med surg, LTC, Administration.
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.

No, you would not give any at 1:30. You would wait until four. Period. Or call for a stat order. Think through what you just said and see if it makes sense, 1 doesn't work at 12, so one more at 1:30 and then he has to wait another four hours till he gets two? Or does he ever get two?

Or you keep prescribing one every two hours, bogus. That is not what is written.

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Specializes in Med surg, LTC, Administration.
I take that order to mean in a 4hr period I can give 1-2 pills. So if in 45mins they need that second norco they are going to get it. I do not see it as practicing medicine but rather using nursing judgement.

Well, that nursing judgement will get you written up. Peace!

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Specializes in Critical Care.
No, you would not give any at 1:30. You would wait until four. Period. Or call for a stat order. Think through what you just said and see if it makes sense, 1 doesn't work at 12, so one more at 1:30 and then he has to wait another four hours till he gets two? Or does he ever get two?

Or you keep prescribing one every two hours, bogus. That is not what is written.

According to my facility's protocols the patient can have an additional at 1:30 (or any time during the 4 hour period until they reach the max for the ordered timeframe), which would mean they could have 1 tab at 4:00 or 2 at 5:30. Can you clarify what doesn't make sense about that scenario?

Again, titrating within prescribed parameters is not prescribing, patient often go home with similar parameters, that does not mean they are prescribing their own meds.

If you have any evidence that this is not acceptable as an absolute rule I'd be interested to see it. Everything I can find says it is OK to give additional doses within the timeframe as long as you don't exceed the maximum for any ordered timeframe.

So what's the rationale as to why this is better? In terms of whether or not it is acceptable to give that second norco if the pain isn't well controlled the answer seems quite clear; as long as you facility policy doesn't exclude it then it is acceptable, what I'm interested in is the rationale for not following this interpretation; how is that better for the patient.

A couple of examples: "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."

-Arizona Board of Nursing

"Example B: The following is ordered for opioid-naïve

patient: Morphine sulfate 2 mg to 6 mg IV every 2 hours as needed for

pain. An initial dose of 2 mg is given. The assessment at 15 minutes

after the dose indicates the patient is tolerating the medication but is still

in severe pain. Additional medication, up to 4 mg may be given to

control the pain. No more than 6 mg may be given during the 2-hour

interval period."

http://67.132.127.103/Policy/17/pdf/9-204%20Medication%20Range%20Orders%20Procedure.pdf

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Specializes in Critical Care.
Well, that nursing judgement will get you written up. Peace!

Why would that get written up?

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Specializes in Critical Care.
That is not what the order says. It says, give 1 or 2 every 4 hours PRN. It does not say, give 1 or 2 whenever you feel like it. Sorry, but this is a simple order. It would have been written, 1-2 every 2-4 hours PRN for pain or 1 every 1-2 and 2 every 2-4. You have to do PRN as written, or you will give an extra dose. Really. We can't prescribe meds. If the pain is still severe, let the MD know.

Can you provide an example of how that would result in extra medication over time?

1-2 every 2-4 hours is called a "double range order" and where I work is automatically changed to a single variable range order. 1-2 every 2-4 hours prn is very different than 1-2 q 4 hours since under that order the patient could get 2 tabs every 2 hours, twice the dose of 1-2 q4hr.

If we are to take prn orders that literally, then if I give a dose at 1200 and the patient is having no pain at 4:00, does that mean I have to wait until 8:00 to give a dose or can at 6:00?

If you have given the pain meds ordered and the patient is still in pain then you should notify the MD. But if you've only given one and the MD has already told you the patient can have up to two in 4 hour period why do you need to call? Let's say they give you a one time order for a single tab that you give at 3:30, could you give another 2 at 4:00?

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It is written as 1 - 2 q4 not 1 or 2 so you can give up to 2 tabs. We start with the lower dose, reassess within 30 min- 1hr and determine.to.give the 2nd tab or not. That is what our hospital practices.

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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.

I would give the 2nd dose after 1 hour, and then wait the 4 hours before giving 2 again. You already know 1 pill did not do the trick, why make the pt. suffer for another 3 hours when you have a second order? You know he won't overdose with 2 pills, so what is the harm here? THIS is what nursing judgement implies.

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And we wonder why our skills are not acknowledged and respected by physicians ??

This whole order is written in a way to allow for use of our assessment and critical thinking skills but no.......can't do that.

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No, you would not give any at 1:30. You would wait until four. Period. Or call for a stat order. Think through what you just said and see if it makes sense, 1 doesn't work at 12, so one more at 1:30 and then he has to wait another four hours till he gets two? Or does he ever get two?

Or you keep prescribing one every two hours, bogus. That is not what is written.

RN: Hello Dr. I know it's 230am, but I'm calling about patient M who is c/o 8 of 10 pain. You did order 1-2 Norco prn Q4H. I gave 1 about an hour ago, and it isn't enough. Could I have a STAT order for another one.

MD: Didn't you just say you gave 1, but the order is for 1 to 2?

RN: Yes, that is correct.

CLICK

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