range order rationale

LouisVRN, RN · Apr 5, 2011

My opinion on the matter is this. If I give one Norco at noon. Our policy dictates pain must be re-assessed around the one hour mark. If pain is controlled at that time, no further intervention. If pain is not controlled at that time, I'd give the second Norco. BTW our policy also dictates we must always start with the lowest dose of a range order. If an hour later the patient is complaining of pain again I would check to see if they have a BTP medication. If not I would call the doctor to ask for one, as well as letting the doctor know what I had already given the patient. Then I'd administer the BTP medication, or alternative methods, heating pack, ice pack, if provider does not wish to give additional pain medication then administer the two tabs next time, provided the pain is rated a similar level.

My problem with medications written like

Norco 1 tab q PO 4 prn pain 1-3

Norco 2 tab q PO 4 prn pain 4-6

Dilaudid 1 mg IV q 2 prn pain 7-10

Is that the patients wanting the pain medication pretty soon realize that their pain needs to be 7+.

I agree with the OP who said that if you are going to call a doctor to ask for an increase in amount/frequency of pain meds you had better been giving all that they previously wrote for.

MunoRN, RN · Apr 5, 2011

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

So if you had both norco and percocet available, and you choose the norco, then 1 hour later the patient still has some pain, you'd give the percocet? I think a lot of Docs would consider those two separate options and not necessarily something that could be combined without clarifying it that way. Our policy is that you can't "stack" meds unless there is a parameter to do such as morphine for "breakthrough pain" or for a dressing change.

MunoRN, RN · Apr 5, 2011

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.

My fault, I did sort of morph my question there part way through the thread which seems to have gotten lost in the responses, but it's the policies in particular that I'm asking about.

When the JC came out with their position on Range Orders each facility had two options: Establish a clear policy on range orders and ensure that they are consistently understood and implemented by the MD's, Nurses, and Pharmacy, or if for some reason your facility was unable to do that or didn't want to, then the JC recommended that you not use range orders. The issue was brought to our practice council, and to us it seemed pretty clear. It's like when your mom says you have to clean your room or you don't get dinner; even though it requires some work, you are of course going to clean your room because you really want dinner. We didn't really discuss which option we would choose so much as we spent 30 minutes trying to figure out how one would go about delivering good, safe pain control without a range order. As different groups such as the American Pain Society and the Society of Pain Management Nursing came out with their position statements in support of range orders, it seemed like there was really only one option and that the work required by the JC to continue using range orders with their blessing outweighed the negative impact on patient care of no longer using range orders.

We then took our recommendation to the pharmacotherapeutic committee as well as the policy committee, both of which spent about 30 minutes trying to figure out how there was even another option. We already had a policy, which we then made as fool proof as we could following the JC's suggestions (which was mainly to give examples), then sent out an e-mail, put up signs in the bathrooms, and brought it up at staff meetings. When the JC came through we all had the same understanding of how they were to be implemented and we had no problems in that area on our accreditation.

I was surprised in this thread by how many hospitals apparently came to a much different decision than we did when it seemed fairly obvious to us, so I'm wondering what we missed. My (current) question is how does a non-range order system work in a way that is flexible, safe, and responsive enough to effectively and consistently deal with the wide patient to patient variability in both gauging their own pain, as well as the wide variability in response to pain medications? In other words, does it work?

steelydanfan · Apr 5, 2011

??
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?

No, I was NOT joking. Read my original post as to my rationale. The pt. would have recieved 2 tablets within 4 hours, and 2 tablets within 4 hours of the first dose. The NEXT dose would have been 4 hours after the last tablet given.

This is not brain surgery, people; and interpreting a doctors orders is what nurse do ALL the time, because usually doctors are somewhat naive when it comes time to order pain meds. So; YES, if a pt. is crying in pain at 3pm or 3am , I will do the same thing: look at the doctors orders and FIGURE out what I can do. I would not exceed a specific order for "x q3hs" without a specific order, but when I can give one more tablet and be within guidelines without calling a doctor at 3 am, heck yes. If it doesn't work, then I call.

I am not interested in getting sued, and I would not put my licence on the line for ANY MD's comfort; but if I find that an order can be properly carried out to the benefit of my pt., fine. Just THINK for a minute, nurses.

steelydanfan · Apr 5, 2011

My fault, I did sort of morph my question there part way through the thread which seems to have gotten lost in the responses, but it's the policies that I'm asking about.
When the JC came out with their position on Range Orders each facility had two options: Establish a clear policy on range orders and ensure that they are consistently understood and implemented by the MD's, Nurses, and Pharmacy, or if for some reason your facility was unable to do that or didn't want to, then the JC recommended that you not use range orders. The issue was brought to our practice council, and to us it seemed pretty clear. It's like when your mom says you have to clean your room or you don't get dinner; even though it requires some work, you are of course going to clean your room because you really want dinner. We didn't really discuss which option we would choose so much as we spent 30 minutes trying to figure out how one would go about delivering good, safe pain control without a range order. As different groups such as the American Pain Society and the Society of Pain Management Nursing came out with their position statements in support of range orders, it seemed like there was really only one option and that the work required by the JC to continue using range orders with their blessing outweighed the negative impact on patient care of no longer using range orders.
We then took our recommendation to the pharmacotherapeutic committee as well as the policy committee, both of which spent about 30 minutes trying to figure out how there was even another option. We already had a policy, which we then made as fool proof as we could following the JC's suggestions (which was mainly to give examples), then sent out an e-mail, put up signs in the bathrooms, and brought it up at staff meetings. When the JC came through we all had the same understanding of how they were to be implemented and we had no problems in that area on our accreditation.
I was surprised in this thread by how many hospitals apparently came to a much different decision than we did when it seemed fairly obvious to us, so I'm wondering what we missed. My (current) question is how does a non-range order system work in a way that is flexible, safe, and responsive enough to effectively and consistently deal with the wide patient to patient variability in both gauging their own pain, as well as the wide variability in response to pain medications? In other words, does it work?

In your original post, you gave 2 sets of orders for pain meds.

This often happens, and nurses feel free to honor one or both as the pt.s condition warrants. It's perfectly legal, and I have no hesitation to use either; as the pt.s estimation of pain should be the guiding factor, according to JOINT COMMISSION STANDARDS.

MunoRN, RN · Apr 5, 2011

In your original post, you gave 2 sets of orders for pain meds.
This often happens, and nurses feel free to honor one or both as the pt.s condition warrants. It's perfectly legal, and I have no hesitation to use either; as the pt.s estimation of pain should be the guiding factor, according to JOINT COMMISSION STANDARDS.

I only gave 1 order: Norco 1-2 q4hr prn pain, were you referring to post 61? Which standard are you referring to? Is every patient's 5/10 pain controlled (but not overcontrolled) with 1 norco? Maybe I just have less predictable patients.

steelydanfan · Apr 5, 2011

I don't know how to begin to reply to this post.

MunoRN, RN · Apr 5, 2011

I don't know how to begin to reply to this post.

How about if I just limit it to asking what the two different orders were in my original post. This is the only order I see "So you've got an order for 1-2 Norco q 4hrs prn pain,".

CoffeeRTC, BSN, RN · Apr 5, 2011

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?

Everyone's pain is different. We just make them rate it in the form of the number scale so that we can try to treat it effectively. To be honest...I would try to give another prn that might not be narcotic like the ultram etc to try and stretch it. Next time I will encourage them to take the two tabs to see if it gets them more relief. We all know that uncontrolled pain takes longer to get back into a managable range. If it seem like that inbetween prn isn't going to cut it, I will try to call the doc to see if I can give a different med or give the other med early (in the 3 hr range)

A lot of the above replies are for the "perfect world" or acute setting. In LTC, we don't have alot of meds on hand in our Emergency Box or just even trying to get ahold of the doc in a timely manner isn't always happening. (think 1/2 to one hr wait time for a call back....while waiting it is often time for the next dose and I'm going to encourage the pt to try to take the two tabs) Alot of times it is left up to the nurse to use critical thinking and their experince in nursing and dealing with that specific patient in deciding what med to use, when to call the doc to advocate for a different med. The nurse should also take into consideration what type of pain the patient is having and what med might be best and also the patients experience with pain meds. The ranges or lack of ranges and standing orders are one other way to guide us or limit us in what type of meds the patient can take.

kanzi monkey · Apr 5, 2011

No, I was NOT joking. Read my original post as to my rationale. The pt. would have recieved 2 tablets within 4 hours, and 2 tablets within 4 hours of the first dose. The NEXT dose would have been 4 hours after the last tablet given.
This is not brain surgery, people; and interpreting a doctors orders is what nurse do ALL the time, because usually doctors are somewhat naive when it comes time to order pain meds. So; YES, if a pt. is crying in pain at 3pm or 3am , I will do the same thing: look at the doctors orders and FIGURE out what I can do. I would not exceed a specific order for "x q3hs" without a specific order, but when I can give one more tablet and be within guidelines without calling a doctor at 3 am, heck yes. If it doesn't work, then I call.
I am not interested in getting sued, and I would not put my licence on the line for ANY MD's comfort; but if I find that an order can be properly carried out to the benefit of my pt., fine. Just THINK for a minute, nurses.

I wasn't responding to your post--I was responding to this--

"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."

In this scenario, the patient got one tablet at 12, then got 2 tablets at 1:30--so, 3 pills in less than 2 hours, which is more than the "1-2 q4h" So, yes, in this scenario this is a med error.

I think you and I are generally in agreement, but you misunderstood my post.

Altra, BSN, RN · Apr 5, 2011

So if you had both norco and percocet available, and you choose the norco, then 1 hour later the patient still has some pain, you'd give the percocet? I think a lot of Docs would consider those two separate options and not necessarily something that could be combined without clarifying it that way. Our policy is that you can't "stack" meds unless there is a parameter to do such as morphine for "breakthrough pain" or for a dressing change.

As best I can ascertain (and I may be wrong) ... your posts seem to be stuck on how to best utilize one single order to alleviate pain. This may be your physicians'/facility's practice, for whatever reason they chose to write the policy that way.

If "stacking" meds, to use your term, is considered inappropriate at your facility, then I'm guessing that your physicians do not write multiple orders for different pain meds but instead rely on nurses' implementation of range orders, followed by requests for new orders if that proves ineffective.

Maybe I'm being obtuse ... but I don't see much difference in administering the lowest dose of a range order, followed by subsequent administration of the remaining dose of the original order (which seems to be your preference) to achieve more effective relief ... vs. implementing multiple orders to achieve the same result.

In the end ... it comes down to policy committees' interpretation of guidelines, and that will always vary.

MunoRN, RN · Apr 6, 2011

As best I can ascertain (and I may be wrong) ... your posts seem to be stuck on how to best utilize one single order to alleviate pain. This may be your physicians'/facility's practice, for whatever reason they chose to write the policy that way.
If "stacking" meds, to use your term, is considered inappropriate at your facility, then I'm guessing that your physicians do not write multiple orders for different pain meds but instead rely on nurses' implementation of range orders, followed by requests for new orders if that proves ineffective.
Maybe I'm being obtuse ... but I don't see much difference in administering the lowest dose of a range order, followed by subsequent administration of the remaining dose of the original order (which seems to be your preference) to achieve more effective relief ... vs. implementing multiple orders to achieve the same result.
In the end ... it comes down to policy committees' interpretation of guidelines, and that will always vary.

We are usually given a variety of pain med options so it's not about how to use just one order, what I'm wondering about is how a non-range order is utilized vs a range order. Our policy is that we can switch to and give another med while you are still in the time frame of the first med, but you can't exceed the opioid dose equivalency of the either medication's max order. For instance, if you give someone 1 norco for 5/10 pain, and 1 hour later their pain is only down to 4/10, it's possible but unlikely the second norco will adequately relieve the pain. If your sedation assessment allows, you can then switch to the percocet order, even though you just gave norco an hour ago, but you have to include that 1 norco in the percocet dose. If your percocet max is 2 tabs and you are using 5/325, then you've already given 2/3's of a percocet in the form of one 5/325 vicoden. So you could give up to 1 1/3 percocet and not exceed the 2 tab maximum for that timeframe.

If you give 2 percocet and that isn't sufficient, and your order says of max of 2 percocet in 4 hours, switching to and give 2 norco an hour after the percocet was given is no different than giving another percocet in terms of opiate dose.

The rationale behind being able to use multiple meds in a short time frame but not exceeding the maximum of the largest opiate equivalent dose is to ensure there is a consistently understood limit to how much opiate a patient will get in a certain time frame, as well as to define a "decision point" where the MD may need to be aware that the patient is having more pain than expected or a different pain treatment strategy may be needed.

My first impression of non-range order strategies was that it seemed inflexible, and while being allowed to use 5 different opiate orders at once definitely allows for additional pain control when the first attempt is ineffective, it seems like it would be difficult for an MD to place a consistent limit on the amount of opiate that could be given in a certain time frame. How would the MD write orders for both a variety of choice, while still ensuring that, say, you don't exceed the equivalent of 2 percocets in 4 hours?