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.

[McGyverRN]

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.

JCAHO just surveyed my hospital and they absolutely demanded that we eliminate range order dosing. Perhaps the surveyors who came to your facility did not, but ours did. So yes, I do have a basis for what I believe.....experience.

[MunoRN, RN]

JCAHO just surveyed my hospital and they absolutely demanded that we eliminate range order dosing. Perhaps the surveyors who came to your facility did not, but ours did. So yes, I do have a basis for what I believe.....experience.

Hospitals often get rid of range orders and claim they had no choice from the Joint Commission, although the Joint Commission has been clear that range orders are still an option if used consistently, even if a hospital fails to meet the recommendations of the JC, the JC is not a regulatory agency so the JC doesn't have the power to ban range orders even if they set out to do so. The JC would insist that a facility avoid range orders if the facility refuses or is unsuccessful in establishing an adequate policy or educating staff on it's use, but the JC does not prohibit the use of range orders as an absolute.

As an example, if a nurse is found to be diverting narcotics the BON may state that RN can no longer administer narcotics, but that doesn't mean the BON no longer allows nurses in general to administer narcotics, just those that can't meet the requirements for doing so.

The accreditation binder is pretty clear on this (mm.3.20), as are the numerous articles that discuss the issue, such as this one:

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

and this one:

http://forums.pharmacyonesource.com/t5/Surveys-and-Safety-Strategies/Range-Orders-Myths-Facts-and-How-to-Handle-Them/ba-p/382

Hospitals often find it easier to do away with range orders thinking that you can achieve the same level of care without them, although as the American Pain Society and the Society of Pain Management Nursing both point out this is not the case:

http://www.aspmn.org/pdfs/As%20Needed%20Range%20Orders.pdf

Based on this I'm surprised how easily Nursing seems to have allowed administrators to do away with an evidence based best practice for the purpose of avoiding the hassle of updating a policy or clarifying it's use in order to make a JC visit easier.

[Altra, BSN, RN]

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?

This seems unnecessarily snarky.

I've been a nurse long enough to have worked with range orders and then subsequently had them eliminated from the hospitals in which I have worked. Rather than get worked up about this limiting my nursing judgement, I have instead appreciated ordering systems which provide for more than one analgesic for different levels of pain. If the first that I choose is insufficient, then I can implement a different order.

[MunoRN, RN]

This seems unnecessarily snarky.

I've been a nurse long enough to have worked with range orders and then subsequently had them eliminated from the hospitals in which I have worked. Rather than get worked up about this limiting my nursing judgement, I have instead appreciated ordering systems which provide for more than one analgesic for different levels of pain. If the first that I choose is insufficient, then I can implement a different order.

No snarkiness intended, I really am curious how this works. Do you have to wait until the time frame for the medication initially given is over to implement a different order, or can you address unresolved pain prior to waiting until the 4 or 6hr timeframe is over? I'm not sure why you wouldn't be able to have different analgesic options with a range order system, we use range orders and often have tylenol, tramadol, norco, percocet, and morphine available based on our assessment and the patient's response to previous interventions.

[Altra, BSN, RN]

I utilize a different med/order as soon as it becomes apparent that the first was ineffective.

[CCL RN, RN]

JCAHO just surveyed my hospital and they absolutely demanded that we eliminate range order dosing. Perhaps the surveyors who came to your facility did not, but ours did. So yes, I do have a basis for what I believe.....experience.

I actually *heard* the JCAHO surveyor make a nasty comment about range orders a few years back, was involved in the meetings about the results, and witnessed our policy change because of it.

[reggae55]

The nursing student questions the need to check placement of the ng tube.what is the rationale for doing so?

[CCL RN, RN]

The nursing student questions the need to check placement of the ng tube.what is the rationale for doing so?

This has nothing to do with this thread at all. This thread is about medication range orders. You'll need to start your own thread to find this info although you should either know how to answer this or know where in your book to find it.

[steelydanfan]

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.

If any nurse I ever worked with considered giving 3 tablets in 4 hours under these circumstances a med error, I would do my best to have them put under remedial training.

[highlandlass1592, BSN, RN]

No snarkiness intended, I really am curious how this works. Do you have to wait until the time frame for the medication initially given is over to implement a different order, or can you address unresolved pain prior to waiting until the 4 or 6hr timeframe is over? I'm not sure why you wouldn't be able to have different analgesic options with a range order system, we use range orders and often have tylenol, tramadol, norco, percocet, and morphine available based on our assessment and the patient's response to previous interventions.

Not really sure where you're going with this thread. Seems to me plenty of people have given you their input regarding what they would do. At all the hospitals I've been at, this really comes down to hospital policy.

[steelydanfan]

Not really sure where you're going with this thread. Seems to me plenty of people have given you their input regarding what they would do. At all the hospitals I've been at, this really comes down to hospital policy.

Actually, most hospital policies do not address this, and what the OP was looking for was experienced nurse's take on a gray area.

We gave her that. What a new grad might think is VERY different from a nurse with 20 years experience might think.

And it is good to give our new nurses any input that we can. THIS is the kind of stuff that they SHOULD have in clinical, but sadly never get anymore, for myriad reasons.

[kanzi monkey]

If any nurse I ever worked with considered giving 3 tablets in 4 hours under these circumstances a med error, I would do my best to have them put under remedial training.

??

But...

it's...a med error...

If the patient NEEDED 3 tablets in a 4 hour period, then yes, a page to the on-call is warranted for an increase in medication. You are joking maybe?

I also get pages all the time a la "the dose you have ordered is NOT going to cut it, 0.2 of dilaudid will not TOUCH this patient." So I increase the dose--no biggie, I don't doubt that a nurse can anticipate that a patient will have a high medication tolerance, and why go through the suffering of the "slow and safe" titration when you know that the patient can tolerate his pain meds (ie, he was admitted last month and only the ketamine gtt held him over). But in the example, 1-2 tablets q4h, two tablets may be given. Not 3. If 3 are given and no order is changed, it's a med error.

You were joking, right?