Microsoft word - rangeorders.doc

Applies To: All HSC Hospitals, CRTC
Component(s): UNMH
Responsible Department: Clinical Education/Clinical Affairs
Title: GPC Range Orders Decision-making for
Medications
Patient Age Group:
( ) N/A (X ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult
POLICY STATEMENT:
To maintain the safe, clear and consistent administration of those medications which have been
prescribed with a range in dose, frequency of administration or multiple routes of administration.
APPLICABILITY
This applies to licensed staff who administer medications based on licensure and education.

POLICY AUTHORITY
A. Nursing Leadership
B. Clinical Affairs
C. Pharmacy Services
REFERENCES
Briefings on JCAHO Vol. 14 NO. 3 March 2003.
The Nursing, Medical and Administrative Leadership of the Organization as recommended by
the JCAHO have determined the need for a policy. This conceptual format as a “best practice”
has also been provided by the JCAHO consultants and recommended by the Survey Team.
Opioid tolerant and opioid naïve definitions from McCaffery, M., Pasero, C. (1999) Pain:
Clinical Manual.2nd Ed. Mosby.
Patient Care Standards of the Unit
Medication Administration
Care of the Patient Requiring Pain Management

PROCEDURE:
The order by the licensed independent practitioner (LIP) will have exact criteria for
administration (e.g. indication {pain, sedation, restlessness, specific blood pressure, etc}). Range
orders contain only one range parameter, e.g., dose, frequency or route.
A. To determine the dose / route to administer/frequency with a range order only if
parameters for the administration of a medication are not written in the physician orders, the
I. PRN medications where the Dose is written as a Range, the staff will follow these steps:
Formatted: Bullets and Numbering
1.1. For mild pain (e.g. 1-3, see table below), nausea, agitation (e.g. 3-4) or other symptoms, the nurse will administer the lowest dose of the drug ordered for the Formatted: Bullets and Numbering
1.2. For moderate pain (e.g. 4-6), nausea, agitation (e.g. 5-6) or other symptoms, the nurse will administer the mid-range dose (if applicable) of the drug ordered for the Formatted: Bullets and Numbering
1.3. For severe pain (e.g. 7-10), nausea, agitation (e.g. 7), or other symptoms, the nurse will administer the highest dose of the drug ordered for the symptom. _________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06 1.4. Doses of medication less than the range prescribed (e.g., administering 25 mg when Formatted: Bullets and Numbering
the order was for 50-75mg) cannot be given based on the higher dose order. Contact the LIP for authorization to administer a dose lower than the range previously 1.5. A subsequent dose may be administered within the ordered parameters, e.g., 2-4mg; Formatted: Bullets and Numbering
(up to 4mg) may only be given, after the expected time-to-peak for the initial dose. For suboptimal effect from the ordered amount, an additional order must be received From the LIP prior to subsequent dosing. 1.5.1. Opioid Naïve Patient: a patient who has not taken opioids on a regular basis. These individuals are more sensitive to the side effects of opioids. 1.5.2. Opioid Tolerant Patient: a patient who has taken opioids regularly for approximately 7 days. It is assumed that these patients have developed tolerance to most of the opioid side effects and the occurrence of respiratory depression is rare. Opioid Tolerant patients are generally able to tolerate faster escalation in larger doses of opioid drugs without experiencing life-threatening B. Determination of symptom (e.g. pain) severity
1. Interpret the patient’s intensity of pain and/or agitation or symptom utilizing the designated age-appropriate or conscious ability scales, such as the Rickert SAS scale: Patient’s
Rickert SAS
Dose to Administer
Pain Rating Intensity (Sedation/Agitation Scale)
2. Observe patients response to medication per Pain Management Policy. 3. Provide a plan of care to base further dosing of medication by repeat monitoring of patient’s pain rating, sedation / agitation rating, and medication effect, after initial 4. The Alcohol Withdrawal: Screening and Treatment policy has detailed specifications for scoring that are not addressed in this document. II. PRN medications ordered where the Frequency is Written as a Range, the staff will
follow these steps:
1. The initial frequency shall be planned at the longest time interval, so that the patient
2. The nurse may adjust subsequent frequency to a shorter time interval, within the Formatted: Bullets and Numbering
parameters of the orders, if he/she has assessed that the medication effects are not lasting the entire duration as originally administered.
III. PRN medications ordered where the Route is Written as a Variable (where the routes
determine which medication to give when the physician has ordered more than one route for a medication or two different medications by two different routes): _________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06 1. For orders written as IM (intramuscular) or IV (intravenous), IV is the preferred 2. For orders written as IV (intravenously) or PO, the medications will be given Deleted: PRN
parenterally until the patient takes fluids by mouth without complications. 2.1. If the patient takes POs without complications, the nurse will give PO PRN medications, unless the medication is only dispensed in parenteral form. 3. For orders written as PO or PR (rectally), the medications will be given orally as long as the patient is taking fluids by mouth without complications. 3.1. If the patient takes POs without complications, the nurse will give PO PRN medications, unless the medication is only dispensed in rectal form. Deleted: Exception: Nurse’s
DEFINITIONS
assessment of the patient such as number of days post-operatively, the level of A. Range Orders are defined as licensed independent provider (LIP) orders where the dose or
functioning GI tract, or the patient’s interval allows licensed staff that have been delegated clinical judgment to select an appropriate preference may influence the route of administration.
dose or interval based on patient factors or treatment guidelines, such that each licensed staff
member follows the orders in a similar fashion.
B. Taper or Wean: The gradual withdrawal of a medication, such as steroids. Tapering may
occur quickly over several days and then stop or may occur more gradually over weeks e.g.
Prednisone - reduce by 1 milligram a day until off of medication.
C. Titrate: The increase or decrease of a medication to attain a patient-specific response that
has been specifically ordered: e.g. Titrate Dopamine to keep mean blood pressure between 60-70
mmHg. Contact physician if greater than 20 micrograms per kilogram per minute is required to
achieve desired blood pressure.
DOCUMENTATION :
Patient Care Flow Sheet: including Pain Scale as appropriate
Formatted: Bullets and Numbering
Patient Progress Notes
Multidisciplinary Plan of Care
Patient and Family Education Record

SUMMARY OF CHANGES
Range Orders, Decision-making for Medications, 3/06.
KEY WORDS: Range orders, PRN orders, Pain Management
RESOURCES/TRAINING
Resource/Dept
Internet/Link
-Pain Management Curriculum -Moderate Sedation DOCUMENT APPROVAL & TRACKING
Approval
Director, Clinical Education Irene Zamora, MSN, RN, CNS 10/10/2005 Y Consultant(s)
_________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06 Quality Management 3/15/2006 Clinical Affairs Committee(s)
Nursing & Pharmacy 3/15/2006 Medication Safety 3/15/2006 Nursing Officer
Judy Spinella, MSN, MBA, Chief Nursing Officer Medical Director/Officer
David Pitcher, MD, Chief Medical Officer Human Resources
Finance Officer
Legal (Required)
Official Approver
Judy Spinella, MBA, MSN, RN, Chief Nursing Officer Official Signature
2nd Approver (Optional)
Signature
Effective Date
Origination Date
Issue Date

ATTACHMENTS
Appendix I: Examples



_________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06 Appendix I: Example of medications that increase in effect. All medications have various dose
responses. This appendix is designed to give the beginning practitioner some additional
information as to selection of medications in a category that are considered generally stronger
given a “standard dose”. Dose, frequency and route are all important considerations.
To determine which medication to choose when more than one medication is ordered for the
symptom, the following guidelines may be followed:
GUIDELINE FOR ADULTS Symptom
Pharmaceutical
Often considered as a
Often considered as
Often considered as a Third
First Line for Mild
a Second Line for
Line for Persisting Symptoms
Category
Symptoms
Unresolved
Symptoms
Fentanyl (immediate onset/short duration) Morphine (intermediate onset/longer duration) Dilaudid (intermediate onset/longer duration) {if true allergy to morphine and Fentanyl, may be used) _________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06 _________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06

Source: http://unm.cancercenter.cc/files/2010/07/Rangeorders.pdf