Upping a med dosage towards upper limits of safe range

[LPN1974, LPN]

okay, i had posted the following question to the thread titled "almost fired today." it was reccommended that a new thread be started with this question i posted. i did add to my post just to clarify and make it clear exactly what i am asking.

i know that nurses always should know safe ranges on meds, but i thought that the drug books give that information for the doctor to make those decisions to up a dosage. just because a book says the upper limit safe range for a drug is such and such doesn't mean that i, as a nurse, can go that high on administering a medication.

isn't that practicing medicine without a license if a nurse does that? ?

when i look something up in a book, i'm just looking to be sure the doctor is within the safe range for the order he wrote and it's safe for me to give the med as the doctor has ordered it {they make mistakes, too,}....not for me to take it upon myself to give more medication towards the upper limit of the "safe range" just because the book says it's safe to go that high.

am i wrong on this, or is it within a nurse's scope of practice to do that?

personally, i couldn't do it, no matter how much literature you come up with. i feel that's the doctor's place to make that decision.

now if he wrote something like this.....

haldol 5-10mg po or im q4-6hrs prn for mild to severe agitation/aggressive behaviour. to me, this order would be giving the nurse some choices here.....

if my patient were only mildly agitated, i might be able to get him/her to take a 5mg po tablet, whereas a severely agitated patient might have to have 10mg im. but i would adhere to the instructions in the order as the doctor wrote it, as long as it is in the safe range, and not go outside of the order that the doctor wrote regardless of what the drug book says.

[canoehead, BSN, RN]

I think a range gives some choices within a safe limit, but coming up with your own frequency is practising medicine.

[all4schwa]

Practicing medicine is what the previous Op did by taking advantage of the lack of parameters on the docs originial order. Looking up the high safe range shows this intent....

...at clinical last week ( not my patient, i was evesdropping), the instructor was asking the nurse about and order that said 4-8ml ivp, to which the nurse said, using my nursing judgment, i would only give two because she hasn't talken anything since surgery. the two went back and forth for a sec and finally my instructor (who is new @ the school with 10yrs experience with the BON yanking licenses) says to the nurse...

"no, the order says 4-8ml, giving two would not be nursing judgment, that is called practicing medicine." that shut her up...

...and i do believe the instructor is exacltly right...

[traumaRUs, MSN, APRN]

Titrating meds (such as the Haldol) is fine as long as you are aware of the upper limits. In the other thread, there was concern that the use of drug books alone doesn't always give the full picture. You must also factor in info from your hospital pharmacy as well as your facility's policies and procedures manual.

[spidermonkey]

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[CoffeeRTC, BSN, RN]

Well, I don't have to worry much about this one since I work LTC. All orders must clearly specify the dosage to be give. Even a 1-2 percocet order needs clarified. 1 tab for moderate pain or 2 tabs for severe pain, etc. If we ever need to titrate a med we need to call docs. Leaves little room for nursing judgement.

[LPN1974, LPN]

Well, I don't have to worry much about this one since I work LTC. All orders must clearly specify the dosage to be give. Even a 1-2 percocet order needs clarified. 1 tab for moderate pain or 2 tabs for severe pain, etc. If we ever need to titrate a med we need to call docs. Leaves little room for nursing judgement.

Well maybe that's the difference for me, too.

I have never worked in an acute unit, like ICU, only worked in a hospital for a year after I got out of school at Long Beach Community Hospital, Long Beach California in 1974-75, and not even in an acute unit there.

I've worked mostly LTCs and where I work now is with the state of Arkansas, with the mentally challenged. We give aLOT of behaviourial meds, but we have psychologists available all the time, and we have a psychiatrist who visits regularly. They monitor and make med adjustments often. It is just not left up to the nurse to make any medication titrations. Only time any PRN adjustment would be if someone started behaving very inappropriately with aggressive and violent behaviour. Even then other measures are used before chemical restraint is called upon. It has to be really bad before we go chemical. And the nurse does not make the descision.....

The RN on call, the superintendent, the doctor.....there are many people notified before we can even give an injection even if we have an order. It just isn't done here. They are so strict about PRN chemical restrtaints.

That's okay, because that takes that responsibility off of me. If any PRN is needed for behavior, there are plenty of others who will help make that determination for it to be given .

I remember one instance where one of our people became so violent, they had him restrained on a papoose board and he was still fighting and caused himself some injuries. They used chemical on him. The kid got mad because he wasn't allowed to go on a trip that some others went on. He was very spoiled by his family, and this had been building up for awhile. He had to be transferred to a unit where he could be monitored more closely.

Personally, I think it's better this way. I'd hate to know that a nurse gave me Haldol because I was moaning. Maybe it was pain and I needed something for pain, not Haldol.