Range orders

luvschoolnursing, LPN · May 13, 2007

I would give 1 tab, chart that it was patient's choice to only take one and let the physician know as soon as possible (i.e. I wouldn't call him to clarify this in the middle of the night)

HM2VikingRN, RN · May 13, 2007

My clinical instructor last quarter had a slightly difference perspective. If the order read 1-2 tabs hydrocodone/4-6 hours for pain he suggested offering 1 tab because if it did not work then you still had room to try another dose if the patient did not receive adequate relief of symptoms.

meandragonbrett · May 14, 2007

I would give the patient one percocet and document that patient requested one and not two.

Larry77, RN · May 14, 2007

In our facility we are allowed to give less pain medication if either the vitals warrant it or the patient requests it, but never more than what's ordered.

Also on the floors those "range" orders are not allowed anymore they have to read something like this:

"Percocet 5/325 1 tab po for pain scale 1-5 or Percocet 5/325 2 tabs po for pain scale 6-10"

But in the ED where I work we often follow orders simply stating "Morphine 4mg IVP titrate"...this is not exactly allowed but is later changed by the doctor to fill in the amount needed. There is a great trusting relationship between the doc and nurses in the ED so we are given a lot more freedom (besides the fact that they are right there if we need them).

Mommy TeleRN, RN · May 14, 2007

I just found out in my new position this week that if the doc orders 1-2 we are to give 1 for pain up to 5 and 2 for pain >5. So my question was if the pt says a 5, you give one pill, and the pain isn't relieved what do you do? Well according to policy you can only give 1, to give the other you'd have to call the doc. Now I can just see calling the doc and asking "Can I give the 2nd pill?" when he's prescribed up to 2! esp working nocs lol. Yea that is really gonna fly. But that is the way the policy is currently written. The hospital instructor recommended putting a suggestion in the sugg. box that the policy be modified. As it stands according to policy if I gave the 2nd for a rating of 5 it'd be prescribing. Seems weird to me. Therefore the doctors are encouraged to not write range orders.

miko014 · May 14, 2007

We are not allowed range orders for anything. Even if they say, "phenergan 12.5mg IV q4-6 prn" we have to call and get them clarified - or if pharmacy sees the order first, they will default to the least amount prescribled - in this case 12.5 mg Q6.

I have no problem giving less pain meds than ordered. If someone is ordered a miligram of dilaudid and says that they don't want to take all of it b/c it makes them sleepy or whatever, I discuss it with them and see what they want to do. Often it's that they just want half the dose. So I would give half a miligram and chart that pt requested half dose of pain meds d/t "it makes me feel dizzy if I take all of it" or whatever. I would get it out the same way I would had 0.5mg been the prescribed dose - I'd have a witness since I gave less than a full miligram, I would put in pyxis that I only intended to give half a miligram, etc. The docs can look at my charting, either in the computer or on the flowsheet (we're halfway through going paperless) and see what's going on. There is no reason to call a doc because the pt wants LESS pain meds - and that is considered acceptable at my facility.

Now if a pt has a BP of 190/100 and says they only want half of their lopressor, that would be a different story all together....

hogan4736, BSN, RN · May 14, 2007

Now if a pt has a BP of 190/100 and says they only want half of their lopressor, that would be a different story all together....

You can't have it both ways...

In every scenario, you have to call the doc...

Please don't expect docs to glean info from your charting...

Won't happen

Check your policy

Check w/ your BON...

Kymmi · May 14, 2007

Miko014--I agree with you 100%. Patients have the right to refuse any meds or treatments that they wish to refuse. I also would only give 1/2 the dose ordered if that is what the patients requests and then I would chart it as patient refused entire dose for whatever reason. Pain medications are a prn order so therefore it is different then the Lopressor order you referred to that hogan disagreed with. I would find out why the patient was refusing the lopressor or requesting only 1/2 the dose and explain to the patient the risks behind the refusal and then I would notify the doctor that patient refused because some other treatment might be needed to manage the B/P however if the patient requests only 1/2 the amount of pain med and that controls the pain then no harm done.

P_RN, ADN, RN · May 14, 2007

The problem with splitting numbers like that you end up with 1 tab every 2 hours. That may keep the levels better but it's prescribing if you do it over once. I believe JCAHO strongly objected to "range" orders such as 1-2 Q 3-6 hours. Doc needs to be apprised of what's not working.

hogan4736, BSN, RN · May 14, 2007

...Pain medications are a prn order so therefore it is different then the Lopressor order you referred to that hogan disagreed with. I would find out why the patient was refusing the lopressor or requesting only 1/2 the dose and explain to the patient the risks behind the refusal and then I would notify the doctor that patient refused because some other treatment might be needed to manage the B/P however if the patient requests only 1/2 the amount of pain med and that controls the pain then no harm done.

Pain meds are frequently BID, or as I've seen on occasion "A.T.C." around the clock...

Let me be clear. I would give 1/2 the pain med per pt request.

An order should still be obtained.

Elvish, BSN, DNP, RN, NP · May 14, 2007

Where I am, Percocet is always ordered 1-2 tabs anyway. (Or if it is another pain med that can be taken as 1 or 2 tabs, it is written 1-2 tabs, not just 2). So we are covered either way.

However, JCAHO expects us to start with the lowest dosage first, then if that doesn't work the next dose can be 2. If we give 2 tabs to start out with we have to document why. (can be anything from pt requests 2 tabs, pain is 9/10 , pt is transitioning from epidural fentanyl, 2 tabs is pt's home dose, etc.)

The lowest dosage goes for all meds. The other night I really wanted to give a lady 10mg of Ambien cause she is a pretty big lady, but JCAHO rules being what they are I gave her I gave her 5, as the order was written Ambien 5-10mg qhs prn, since that was the 1st dose. Wouldn't you know it worked beautifully.