Thoughts on pain med with a range

Nurses General Nursing

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I'm curious to see what the feedback will be to this question. I've had some agree and some disagree.

Scenario: I have a patient who can get 5-10mg oxycodone q4h. Can I give her 5mg of oxycodone every 2h? She doesn't like to take the 10 all at once and her pain was very well controlled with 5mg every 2-3h. The oncoming nurse said we couldn't do that. But it's not overdosing. So long as she only gets 10mg total in a 4 hour period its all the same thing, is it not? I just make sure there's at least 4 hours between every other dose. So if she gets 5mg at 10 am and then works with PT and wants the other 5 at 11am, I now will until at least 2pm to give another 5. The daily max is the same: 24h/4 =6, and 6x10mg= 60mg/day. 24/2=12, and 12/5= 60mg.

What do you think??

Specializes in Emergency & Trauma/Adult ICU.

This illustrates exactly why Joint Commission strongly frowns on range orders.

IMO, your interpretation is incorrect. The order, such as it is, contains not only dose but also frequency - and that frequency is every 4 hours, not q 2.

Specializes in Acute Care, Rehab, Palliative.

I agree with your interpretation.

Specializes in Critical Care.

Unless there is a specific facility policy against it, which would be stupid, the generally recommended way to deal with range orders is to interpret it the way you do, which helps both adequately control pain while at the same time avoiding overmedication, which are the two main goals of good pain management.

When nurses believe that they only have one chance every four hours to give the right dose they are essentially encouraged to give a dose that might be more than what the patient needs, believing it's better to overshoot it than undershoot it since you only get one chance.

Proper pain control using a range order involves starting with the lower end of the range, reassessing in about 1 hour for PO pain meds, and re-medicating as necessary while staying within the ordered range (not exceeding a certain amount over a specified duration of time). This ensures adequate pain control initially, which has been shown to actually reduce cumulative pain med amounts, while not giving more than is necessary.

1 Votes
Specializes in Critical Care.
This illustrates exactly why Joint Commission strongly frowns on range orders.

IMO, your interpretation is incorrect. The order, such as it is, contains only dose but also frequency - and that frequency is every 4 hours.

The JC doesn't actually oppose the use of range orders, they only require that there be some way of ensuring that the prescriber and the nurse are both understanding the order in the same way, they actually endorse the Society of Pain Management Nursing position statement on range orders which encourages the OP's interpretation. To meet this requirement some facilities get lazy and just say "no more range orders, because they JC said so".

So if they take 5 and the pain is still there you make them wait 4 hours?

Specializes in Oncology; medical specialty website.

If your patient is taking 60mg of oxycodone/day, s/he needs to be on a long-acting opioid like OxyContin, with a short-acting med like OxyIR for breakthrough. It makes no sense to b medicating someone q2h, for a multitude of reasons.

1 Votes
Specializes in Critical Care.

From the American Society for Pain Management Nursing / American Pain Society position statement on this specific question:

Avoid making a patient wait a full time interval after giving a partial dose within the allowed range.

http://americanpainsociety.org/uploads/about/position-statements/ps-opioid-dosage.pdf

Agreed. She was no where close, but 5mg every 2-3 hours allowed her to stop needing IV morphine. And it's been less and less each day.

Specializes in Stepdown, PCCN.

I used to do what you are doing OP for post-op pts especially. Now, however, in my facility you need a frequency range (q 2-4 hours) to administer the med in that manner. Administration has declared that you only get to give the med once for every time period, I now notice a lot more IV meds being given on the off hours.

Specializes in Med-Surg.

If it's 1-2 tablets every 4 hours, I would make sure that the patient didn't receive more than 2 tablets in any 4 hour period. My logic that is you start with the lowest dose and increase if necessary. Our policy is that from the time of that second dose THEN the four hour time period restarts. So pill 1 at 10:00, 2nd pill at 12:00, next dose available at 16:00 (four hours after the 12:00 dose). If the patient really consistently taking it q2 hours, I would ask for an order for 1 tablet q2.

You could always clarify it with the physician, describe how the patient is requesting to take it and verify that that is okay.

If your patient is taking 60mg of oxycodone/day, s/he needs to be on a long-acting opioid like OxyContin, with a short-acting med like OxyIR for breakthrough. It makes no sense to b medicating someone q2h, for a multitude of reasons.

Wouldn't it seem prudent to actually know things about the patient and situation before making a blanket statement about their pain medication regimen?

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