Thoughts on pain med with a range

MunoRN, RN · Aug 27, 2015

What position statement says that you can deviate from a physicians order? The op
desired input on whether you could give additional pain medicine after only waiting for 1/2 of the prescribed interval.
It does not matter that we don't think that we should wait until the prescribed interval has passed to give an additional dose of pain medicine. We can't do it. It's called trafficking in a controlled substance.

You're still within the prescribed interval and haven't exceeded the maximum for that interval.

I have to assume you're probably just joking, since I'm not got at reading sarcasm here, particularly since "trafficking in a controlled substance" is so far off the mark. Nobody is flying 50 pounds of cocaine across the border here.

toomuchbaloney · Aug 28, 2015

In my view the OP interpreted the MD order in a professional and effective way.

That practice would be considered Standard of Practice in every hospice or acute care setting in which I have worked.

What JC does not like are orders which have a range for BOTH dose AND frequency...too confusing and too easily messed up.

People who are saying that the OP was wrong or has made a med error or similar are NOT practicing pain management with a high level of confidence and skill, they are simply following a written order according to a very strict interpretation (which is not required nor likely intended by the ordering provider) rather than using the order as a tool to treat the pain of their patient.

The OP should consult facility rules regarding this practice. IF there are no specific guidelines which prohibit this then it is allowed. OP should take comfort in knowing that palliative care and hospice professionals all across this country would utilize those orders exactly as he/she did.

For decades I have observed those sort of orders safely and effectively utilized in PACU, ED, Burns, Ortho, etc.

well done OP

I seriously think that some nursing schools and employers really need to invest in better pain management training for nursing professionals.

HOPEforRNs, ADN, BSN, MSN · Aug 28, 2015

Our range orders specifically say if we give the lower dose, we can give another dose up to the higher end of the range in 1 hour to avoid that type of confusion.

Oxycodone 5-10mg q4h. Give 5mg and repeat dose if pain not controlled after 1 hour. Then, may give 10mg for initial dose if needed.

SleeepyRN · Aug 29, 2015

What is prompting you to chart that the oxy is effective if the patient is stating that his pain is an 8? Is the patient also telling you that his pain was previously higher and that the oxy helped? I think perhaps to cover yourself you could write a note explaining why you are charting "effective"?

When we click on a prn med, there is an automatic pop up that we have to click "effective" or "ineffective." If we don't answer it, it turns "red" meaning it is a task that is undone.

SleeepyRN · Aug 29, 2015

What is prompting you to chart that the oxy is effective if the patient is stating that his pain is an 8? Is the patient also telling you that his pain was previously higher and that the oxy helped? I think perhaps to cover yourself you could write a note explaining why you are charting "effective"?

And when we click on a pain med, it prompts us to enter a number. So my example would go like this:

My pt. wants his oxy at 1600 stating his pain is an 8. I click Oxy. It prompts me to enter a pain scale number. I enter 8. After clicking this, the box turns yellow, meaning I have follow up documentation to do.

At 1700 my pt then asks for norco stating his pain is an 8. I have to click on the yellow box for the Oxy and click "effective" or "ineffective" AND click 8 for a pain scale number for the Norco. (This happens every day all day because he likes his narcs and knows how to work this system.) If one were to believe him, that his pain was still an 8 after getting the oxy, (everyday)then one should interpret that the Oxy was ineffective, meaning, there is no justification to keep giving it, and we should contact the MD and let him know that it is ineffective.

I frankly don't care that it is a game on the patient's end. I just want to be able to stand by my documentation and be and be able to say, yes I feel good about this clinical decision.

JayHanig · Aug 29, 2015

Sitch321, I understand your reasoning. I certainly understand why you'd prefer not to have to ask the doctor as many of them can be unpleasant when their orders are questioned or a modification offered. That being said, I would hate to try that defense in front of a disciplinary board. I think you'd lose.

Your best bet is to call the doctor, explain the situation, and pray his reason trumps his ego. If not, be sure the patient understands why you are delivering the meds as you are... that you tried to get them changed but the doctor refused. Let the doctor justify his decision to the patient. You've done what you can do.

I would not give meds q2 unless I saw q2 in his order. You're likely to get singed otherwise.

tacn · Aug 30, 2015

Your example is the reason ranges are not used, and need clarification.

The example you gave tells us several things,

(1) If you are having to give medication every two to three hours for relief the dosage isn't high enough. May need to change medication all together

(2)The decision being made on the amount of medication is not based on pain scale guide lines. It is opening you as a nurse up for a malpractice episode, based on how the physician wanted the medication given.

(3) If you feel that giving the medication every two to three hours works, then the order must be changed.

(4) We would never be allowed to take an order like that from a doctor without clarification. Our biggest problem comes when the doctor is in a hurry and says 1-2 every 4 hours as needed. I know doctors get upset with nurses for calling them on things like this, but we have to do our job and look out for the patient and ourselves.

I personally would go for the following: pain med 1 tablet for pain rating of 3-6 and 2 tablets for pain rating above 6 on a verbal scale of 0-10 every 4hours as needed

mrsmason · Aug 31, 2015

I agree, this was the way I was taught and practiced in LTC and acute hospital.

Beverage · Sep 1, 2015

When I have a range of 1-2 tablets q4 hours and the patient asks for only 1, then two hours later wants the second tablet, I will give it to complete the "range". I interpret the orders as the 4 hours starts from the second dose as I do not want to be medicating q 2 hours. After 4 hours has passed if the patient is requesting pain meds, I will give 2 tablets at that time. If the ordered meds are consistently ineffective, I always call the MD. I also assess my patients LOC and VS before giving a second dose in the range. Someone who has a BP of 90/50 and nods off while answering questions is not going to get more pain medication until I have spoke to their MD.

nincompoop · Sep 19, 2015

this is two [2] orders combined into one. the provider SHOULD have written as two separate orders,

one being a] oxy 5mg q 4 hrs , and document or

b] oxy 10mg q 4 hrs, and document.

This will alleviate confusion on the MAR, maintain safety for both the patient AND the med-nurse.

The providers writing orders like this need to be RE-EDUCATED to that effect.

plain and simple.

MunoRN, RN · Sep 20, 2015

this is two [2] orders combined into one. the provider SHOULD have written as two separate orders,
one being a] oxy 5mg q 4 hrs , and document or
b] oxy 10mg q 4 hrs, and document.
This will alleviate confusion on the MAR, maintain safety for both the patient AND the med-nurse.
The providers writing orders like this need to be RE-EDUCATED to that effect.
plain and simple.

In my experience having separate orders for the same opiate is what's unsafe. I don't really see anything unsafe about having an order that supports both adequate but at the same time not excessive pain med administration, that's the definition of proper pain management.

Nursing Au · Apr 6, 2019

Regarding the PRN range analgesia, there are many different understandings on this forum.

Please compare your understanding with one article at the journal - Pain Management Nursing.

Nurses’ opinions on appropriate administration of prn range opioid analgesic orders for acute pain.

http://yanis.patel.free.fr/TFE/DOULEUR%20AIGUE/Nurses%92%20Opinions%20on%20Appropriate%20Administration%20of%20PRN%20Range%20Opioid%20Analgesic%20Orders%20for%20Acute%20Pain.pdf

At page 135, one example of prn range analgesic administration is as follows:

------------------------

A range order reads morphine 2 to 8 mg IV every 2 h PRN. The patient receives the following doses: 2 mg at 12:00 (no relief); 3 mg at 13:30 (no relief); 6 mg at 14:00.

A next dose can be given as early as what time?

The appropriate or preferred response is 15:30 or 16:00

------------------------

Please compare your understanding with this example, regarding the timing of next partial dose and the interval between the last partial dose and the potential next prn initial dose according to q4h or q6h.

If somebody disagrees with the example from the journal - Pain Management Nursing, please provide your rationale.