range order rationale

rnccf2007, BSN, RN · Apr 3, 2011

At both of the hospitals that I have worked, range orders are not allowed. I never gave this much thought, but after reading these posts, I now see that these orders can be interpreted differently. Instead of range orders, our prn orders must read like this (just an example):

morphine 2 mg IV q4h prn for mild pain

morphine 3 mg IV q4h prn for moderate pain

morphine 4 mg IV q4h prn for severe pain

MunoRN, RN · Apr 3, 2011

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.

As I've pointed out a few times some facility policies no longer allow range orders, and if that is the case then that is what you need to follow. Although outside of facility policies there is nothing that prohibits it according to numerous sources I've cited, yet the opposite has been asserted in this thread without any supporting evidence.

If your facility no longer uses range orders, what is the rationale? Does a set algorithm without titration seem to work better? How does it ensure adequate pain control without overmedicating? Is it better at pain control but just as safe or less safe? Or vice versa? How flexible is it?

linearthinker, DNP, RN · Apr 3, 2011

I didn't read past the first 2 or 3 posts, so this may have been covered already. An appropriate "range" order has a max dose/per x hours. If the 2nd tab wasn't going to exceed max dose, I'd give it in the instance described in the OP.

kanzi monkey · Apr 3, 2011

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.

Sure, if your facility policy specifically states that you need a new order once you've given the smaller portion of a range dose, then get the new order. If you're at my hospital, which doesn't have this rule, asking for a new order is inappropriate.

I could care less whether or not you are concerned about me just as I never blame nurses for how busy I am--it's my job. I deal. However, I hope that my colleagues have a modicum of understanding and respect for the needs of my other patients who may have actual concerns that need tending to. Just as I understand that the nurses who take off orders that I write are also quite busy *taking care of patients*. I would rather that they use good clinical judgement in giving narcotics to patients in pain and start with a smaller dose without having to worry that their patient will have to wait for a new order if the small dose doesn't cut it (and their other patients have to wait for whatever they need while the nurse is paging me and checking to see that I've followed up).

I imagine that in a facility that has such rules, the higher dose is often given initially to avoid having to get a new order while a patient suffers, but clearly this is not the safest route. I hope you don't need an order to get Narcan out of the Pyxis as well...

RescueNinja · Apr 3, 2011

The order says 1 to 2 (1-2) not 1 OR 2. I would give a second, but I would wait a full 4 hrs after the 2nd pill before giving another.

If my pt needed more during that period I'd call the doc because there is a reason this pt is having pain that is not controlled with narcotics and the doc should know as it may need to be investigated.

Chin up · Apr 4, 2011

Great thread, no one got nasty, will agree to disagee. But love a lively debate! Peace!

MunoRN, RN · Apr 4, 2011

Aside from how facilities may have come to decide to do-away with range orders, do those of you not using range orders find that you are able to provide better care as a result of not having range ordrers?

CoffeeRTC, BSN, RN · Apr 4, 2011

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.

In LTC we are not permitted range orders either and clarify the orders to be like the above. I would see if they had any other orders for tylenol, motrin or ultram and see if one of them can be given. at the next dose, I would give the two tabs or if it was really severe, I would call the doc to see if it could be given early and change the orders.

Even tho I stated that I was in LTC, we are more of a rehab and get alot of hips, knees and other post ops around day two or three and have a good bit of pain issues to deal with.

MunoRN, RN · Apr 4, 2011

In LTC we are not permitted range orders either and clarify the orders to be like the above. I would see if they had any other orders for tylenol, motrin or ultram and see if one of them can be given. at the next dose, I would give the two tabs or if it was really severe, I would call the doc to see if it could be given early and change the orders.
Even tho I stated that I was in LTC, we are more of a rehab and get alot of hips, knees and other post ops around day two or three and have a good bit of pain issues to deal with.

So if you discovered that 1 tab was not sufficient for 6/10 pain you could give 2 the next time? Or would you have to call the Doc only to supplement the current dose? Would you educate the patient the they were wrong, their 6/10 pain was obviously 7/10 since 1 norco wasn't sufficient and we all know that 1 norco is sufficient for everyone's 6/10 pain?

McGyverRN · Apr 4, 2011

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.

Don't worry, range orders are becoming a thing of the past. JCAHO is cracking down on them. My hospital has completely eliminated them.

MunoRN, RN · Apr 4, 2011

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.

So how do you determine to give 1 or 2? If you guess wrong why should the patient have to suffer? How would you prefer that the order be written so that it would allow you to give the 2nd while still assessing for the effectiveness of 1 tab first? What's the rationale in terms of better patient care?

MunoRN, RN · Apr 4, 2011

Don't worry, range orders are becoming a thing of the past. JCAHO is cracking down on them. My hospital has completely eliminated them.

JC isn't "cracking down" them in terms no longer allowing their use. All they have done is to push for consistent implementation of them. There are plenty of sources explaining this if you read back through the thread.

I'm beginning to wonder if their is any basis to really anything Nurses believe to be true.