range order rationale

[MunoRN]

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.

[cabanaboy]

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.

It's 1 TO 2, not 1 OR 2.

Rather then titrating the dose to give the desired effect, wouldn't this encourage the RN to more often then not give the max dose, knowing they won't be able to give more for another 4 hours?

[traumalover, RN]

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

Click if you're lucky. If he's still on the phone after that you better hold that baby away from your ear about a foot.

[cardiacmadeline, RN]

If I was a doctor and received a phone call from a nurse asking to give a second norco to a patient still in pain after receiving one pill and there is an order that says you can give 2 pills, I would not be very happy and I would question the critical thinking skill of the nurses taking care of my patients.

You have an order Norco 1-2 tabs every 4 hours prn

The patient wants to start with one Norco and see if that works. That is administered at 0800. One hour later, he is still in pain so you administer the second one, AS the order states. After that he wants to take two norco every four hours. Since you administered the last one at 0900, he can start taking two pills at 1300. So 1 tab at 0800, 1 tab at 0900, 2 tabs at 1300, 1700, 2100, 0100, 0500 = 12 tabs in a 24 hour period.

It is a simple order, shouldn't be that hard to follow. If I am ever in the hospital and need pain meds, I hope I have a nurse who can understand my orders and medicate me appropriately.

[CCL RN, RN]

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?

We are told specifically that range orders are practicing medicine without a license. It is simply not allowed. If a range order is on my orders, I must have it clarified. Pharmacy will not fill it.

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

It would where I work...

[MunoRN, RN]

We are told specifically that range orders are practicing medicine without a license. It is simply not allowed. If a range order is on my orders, I must have it clarified. Pharmacy will not fill it.

A few years ago the Joint Commission came out with recommendations on range orders, although the only recommendation they actually look for in accreditation is that each facility have a policy that clearly states how range orders are to be interpreted since (as you can see from this thread) we aren't all on the same page. This somehow got interpreted as "JC no longer allows range orders". I know there was talk of many facilities just doing away with range orders to avoid trying to create a common understanding of how they are to be used, but I had the impression that range orders won out after arguments from the American Pain Society and the American Society for Pain Management Nursing. http://www.aspmn.org/pdfs/As%20Needed%20Range%20Orders.pdf

Here is an article on the myth that range orders have been banned: http://forums.pharmacyonesource.com/t5/Surveys-and-Safety-Strategies/Range-Orders-Myths-Facts-and-How-to-Handle-Them/ba-p/382

All the JC wants to see is consistency and while they do make recommendations that double variable range orders not be used (both time and dose range), they are not a regulatory agency. My facility does automatically change double range orders to single variable range orders with only a dose range and use the lowest timing range ordered, but we still use range orders and recently went through a JC visit with no lost points for how we use range orders (or that we use them).

Here is an excerpt from the article below that summarizes the whole cluster.... created by the JC (or more accurately how we incorrectly interpreted the JC)

"There is no change in 2004 with regard to range orders with one exception; we now require organizations to have a policy on what are the required elements (e.g. drug name, dose, route) for all medication orders, based on law and regulation. In addition, for range orders, the organization needs to specify any special requirements they wish with regards to how orders are written. For example, the dose or dosage interval can vary but not both in the same order, or the maximum allowable difference between the high and low dose is four times the lowest dose. This standard (MM.3.20) is directly related to physician order writing and not nursing. In addition, we only require that the policy exist—the content of the policy is strictly up tothe organization (Rich, 2003)."

http://www.medscape.com/viewarticle/480067_2

[kanzi monkey]

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.

it's "1-2 tabs q4h"; so you give 1 tablet, and then in two hours your patient is still in pain. So, you give another tablet--that is technically correct. You gave 2 tablets in a 4 hour time period. Once the 4 hours is up and the patient has 1-2 tabs available again, you might consider giving 2 at the same time since the 1 didn't hold the patient over.

In your scenario, the nurse gave 3 tablets within 4 hours, which is a med error.

I have been paged by nurses to "increase" dose or frequency of pain medication, or to write a "times one"--if I see that the patient hasn't actually even received what I ordered initially, I get a little annoyed. Partly because of the unnecessary page, but mostly because I am being told I need to intervene where a patient's pain isn't controlled, when it's the nurse that hasn't exercised all of the options yet, not that the patient is actually having an issue.

This is common sense. It's not that a nurse is "prescribing"--s/he is merely being flexible when trying to manage a patient's pain with medications that can be harmful if over used and is getting a sense of what the patient needs or will tolerate. I expect that nurses will do this.

[kanzi monkey]

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.

I'm sorry but this doesn't make any sense. You are right, it IS a simple order. But not the way you're interpreting it. Think of it this way--the patient may have a max dose of 2 tablets of norco in a 4 hour period. The rest is nursing judgement, and in general I think nurses do a pretty darn good job with this one.

When I have a list of 30 patients, getting a page for a pain medication that is ALREADY AVAILABLE can really throw me off. Please don't do this!

[Chin up]

I'm sorry but this doesn't make any sense. You are right, it IS a simple order. But not the way you're interpreting it. Think of it this way--the patient may have a max dose of 2 tablets of norco in a 4 hour period. The rest is nursing judgement, and in general I think nurses do a pretty darn good job with this one.

When I have a list of 30 patients, getting a page for a pain medication that is ALREADY AVAILABLE can really throw me off. Please don't do this!

You are so not my concern, facility policy and the BON is. I would write up as a med error in a heart beat, if i saw one signed out at 12am and then another one signed out at 1:30am without a further order. Your patient load has nothing to do with PRN narcotic rules. Peace.

[MunoRN, RN]

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 ]

I'm curious how this works and if it seems to result in better patient care, the rationale behind range orders makes sense in that it provides for both adequate pain control and safety by allowing for the minimum effective dose to be given. Whereas this system seems less flexible in addressing variations in both patient specific pain interpretation and response to pain intervention, yet less able to ensure that patients are getting more opiates than the minimum necessary.

Is it a standard algorithm for every patient? If you give 1 tab for pain of 3/10 and their pain stays at 3/10 for the next 4 hours, can you give more the next time their pain is 3/10 since it wasn't sufficient last time? If you give 2mg morphine for 7/10 pain and an hour later their pain is still 5/10 can you give the norco or does the morphine block everything out for 4 hours? The timing seems odd, Morphine has a half life of 2 hours, so if you give 4mg for 10/10 pain then are unable to give anything else for 6 hours, they will only have about 1mg working for hours 5 and 6 which wouldn't seem sufficient for someone with 10/10 pain. How do you determine the minimum amount required to treat a certain level of pain for a specific patient with this system? How does the plan change when the standard algorithm isn't sufficiently controlling pain?

[MunoRN, RN]

You are so not my concern, facility policy and the BON is. I would write up as a med error in a heart beat, if i saw one signed out at 12am and then another one signed out at 1:30am without a further order. Your patient load has nothing to do with PRN narcotic rules. Peace.

What "PRN narcotic rules" are you referring to? Can you cite anything?

[Chin up]

It's 1 TO 2, not 1 OR 2.

Rather then titrating the dose to give the desired effect, wouldn't this encourage the RN to more often then not give the max dose, knowing they won't be able to give more for another 4 hours?

It's is not about the 1-2 or 1 or 2. It is about once the dose is given at 12, the order was fulfilled. An hour and a half later does not make up for the one not given at 12. It starts a new order. By calling for a stat order, you are able to give one at 1:30 and STILL give 1 or 2 at 4:00 and not have to wait till 5:30.

[CCL RN, RN]

]

Here is an article on the myth that range orders have been banned: http://forums.pharmacyonesource.com/t5/Surveys-and-Safety-Strategies/Range-Orders-Myths-Facts-and-How-to-Handle-Them/ba-p/382

That's great. However, a ban of range orders is *not* a myth, it's policy at my hospital. Policy. I cannot allow it on my order form. The pharmacy will not fill it. And if I allow the order to written as a range, and over-ride the Pyxis, and give one med tab now and another in an hour, I can expect to get a big fat write up (and probably fired with my luck).

I think we all know that P&P is what we have to follow.