Range orders

[hogan4736]

We would all agree that with an order that reads: Percocet 2 tabs po q 4 hours, that giving 3 tabs is considered prescribing...

What if the nurse decides to give 1 tab (based on the pt only wanting 1 tab)

I personally think this is also considered prescribing.

Thoughts?

I would get an order.

[miko014]

Why, thank you Kymmi. For a second there, I thought I must be an idiot! Glad someone agrees with me .

Hogan - yes I can have it both ways. Lopressor is a scheduled BP med that the pt needs. If they say they are not going to take it, or not going to take all of it, and their BP/HR is high, I am calling the doc. If their pressure is 104/62 HR 68 and they say that they don't take it at home when their pressure is like that, I chart "refused" and in the comments state why. If they do that more than once, doc gets a note on the chart about it. We have a dropdown menu in med admin for reasons why we didn't give a med, and "refused" is an acceptable choice. After all, the pt has the right to refuse any treatment that they don't want. PRN pain meds are different. If the pt doesn't take them at all, should I call the doc and tell him that??

And the docs don't "glean" anything from my charting. They sign onto their computer program and read it. There is no difference between them looking at the pt's VS and labs vs. them looking at the MAR. And they do look, especially at pain meds.

I do not HAVE to call the doc because the pt wants only one perc instead of 2. That's ridiculous. No wonder docs get annoyed with nurses if you are going to call them for every little thing.

I work palliative care. I give a LOT of pain meds. The pts have choices. If they have scheduled pain meds, they get them ATC. That happens quite frequently where I work. The people who have ATC pain meds usually need them. That's different from someone who had surgery a couple of days ago and has percs ordered prn.

I would never suggest that a pt take anything different from what is prescribed, and I would never give more than what was prescribed, even if they ask for it. That's when I would call the doc. But if taking fewer pain meds is effective, good for them. I hate the way perc makes me feel, and I can totally understand why someone would only want the minimun necessary to control their pain.

Say the order is for 10 mg oxycodone Q4 prn. If the pt asks for just 5mg, you can give 5mg, but if they want more before the 4 hours is up, then you have to call. The order is for 10 q4, not 5 Q2. As I said, that is considered normal procedure for us.

[herecomestrouble]

The last hospital I worked at didn't allow range orders,the docs had to write two orders-Pecocet 1 q 4hrs for moderate pain and then a second-Percocet 2 q 4hrs for severe pain.This way the pt could decide what they wanted,of course there were always the ones who wanted 1 and two hrs later asked for another 2 since there were two orders.that could cause a problem.

[hogan4736, BSN, RN]

...There is no reason to call a doc because the pt wants LESS pain meds - and that is considered acceptable at my facility...

I disagree...

You are assuming all the nurses taking care of that pt are doing as thorough (and the same) of an assessment as you...

You have now taken away the constant (dosage) (see other posters about doing away with range orders) - You have essentially made your own range order, as you see fit...

Well, you go home in 8-12 hours, and someone else may have a different idea for this pt...

if the order is 2 mg dilaudid q 2 hours, and you give the pt 1 mg every 2 hours, the doc absolutely needs to know...not telling him leads to inconsistent dosage administration...perhaps the nurse following you may be a new grad, and gives 2 mg, because that's what the order says...

The doc needs to know so he can maybe tweak the regimen...

And of course calling him at 0220 would be lame...We all get that...Letting him know can mean leaving a note on the chart...

...Say the order is for 10 mg oxycodone Q4 prn. If the pt asks for just 5mg, you can give 5mg, but if they want more before the 4 hours is up, then you have to call. The order is for 10 q4, not 5 Q2. As I said, that is considered normal procedure for us.

I've been doing this 12+ years... NEVER, has going outside the prescribed parameters (under or over) been the standard at any facility I've worked...

The reason to give the prescribed dose is exemplified exactly in your above example...You did your own thing by underdosing, now, at 0220, you have to make the call...

I am with you as far as the pt having the final say. If the guy wants only 5 mg of the oxy, great, I'll give it. BUT, let's say he finally got up the courage to tell you at 0220, that 10 mg is too much (after 3 days of receiving 10 mg)...Is halving his dose at 0220 the best plan, as he is likely not to have effective pain relief, since he's used to 10 mg. THIS is why it's important to let the doc know (in the AM). Maybe vicodin would give him less side effects, and still provide adequate pain relief.

I'm not advocating against nursing judgement. But keep the doc in the loop with any changes you have made...It will make for better outcomes for your patients...

[hogan4736, BSN, RN]

We are not allowed range orders for anything... I have no problem giving less pain meds than ordered. ..

As I stated above, giving less is making your own range, thereby contradicting your policy...

...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.

This supports my reasoning...

You absoultely keep the doc in the loop w/ a BP med not working properly "because some other treatment might be needed to manage the B/P"

Wouldn't you afford the doc the same shared info when it comes to pain control??

Substitute "pain" for BP