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					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

Policy
( ) 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 staff will follow this procedure: I. PRN medications where the Dose is written as a Range, the staff will follow these steps: 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 symptom. 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 symptom. 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

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1.4. Doses of medication less than the range prescribed (e.g., administering 25 mg when 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 specified. 1.5. A subsequent dose may be administered within the ordered parameters, e.g., 2-4mg; (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 side effects. 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 Pain Rickert SAS Dose to Administer Pain Rating Intensity (Sedation/Agitation Scale) 0 (zero) 1–3 4–6 7 – 10 Pain Free Mild Moderate Severe 1-2 3-4 5-6 7 No medication Lowest of dose range Middle of dose range Highest of dose range

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 starting dose. 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 response can be assessed. 2. The nurse may adjust subsequent frequency to a shorter time interval, within the 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

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1. For orders written as IM (intramuscular) or IV (intravenous), IV is the preferred route of administration. 2. For orders written as IV (intravenously) or PO, the medications will be given 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. DEFINITIONS A. Range Orders are defined as licensed independent provider (LIP) orders where the dose or interval allows licensed staff that have been delegated clinical judgment to select an appropriate 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 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

Education Website to Register for: -Pain Management Curriculum -Moderate Sedation DOCUMENT APPROVAL & TRACKING Clinical Education 2-6313
Item Owner Consultant(s) Contact Director, Clinical Education Irene Zamora, MSN, RN, CNS Pain Management Education Date 10/10/2005 Approval Y

_________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06

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Committee(s) Nursing Officer Medical Director/Officer Human Resources Finance Officer Legal (Required) Official Approver Official Signature 2nd Approver (Optional) Signature Effective Date Origination Date Issue Date

Quality Management Clinical Affairs Nursing & Pharmacy Medication Safety Judy Spinella, MSN, MBA, Chief Nursing Officer David Pitcher, MD, Chief Medical Officer [Name], HR Administrator, [UNMH or UNM] [Name, Title], [UNMH or HSC]

3/15/2006 3/15/2006 3/15/2006 Y Y Y N/A N/A Y Y

Judy Spinella, MBA, MSN, RN, Chief Nursing Officer 12/01/06

[Day/Mo/Year] 12/1/06 10/2005 Clinical Operations Policy Coordinator

ATTACHMENTS Appendix I: Examples

_________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06

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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 Pharmaceutical Category Often considered as a First Line for Mild Symptoms
Acetaminophen (Tylenol) Ibuprofen Celebrex Tylenol #3

Symptom Often considered as a Second Line for Unresolved Symptoms
Percocet 5/325 (1) tab Vidocin 5/500

Often considered as a Third Line for Persisting Symptoms

Analgesics

Percocet 5/325 (2) tabs Vicodin ES 7.5/750 Oxycontin 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) MS Contin (long-acting) Methadone (long-acting) Demerol

Anti-emetics

Benadryl Reglan

Marinol Compazine Vistaril Ativan Phenergan Tigan Scopolamine patch

Decadron Thorazine Zofran/Anzemet

Anti-diarrheals Anti-spasmodics

Kaopectate Pepto-Bismol Donnatal 1 tab Levsin 0.125mg Bentyl 20 mg

Imodium

Lomotil

Donnatal 2 tabs Levsin 0.25mg Bentyl 20-40mg

Levsin 0.375mg Bentyl 40mg

_________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06

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Librax

Anxiolytics/Sedatives

Benadryl Vistaril

Xanax Ativan PO Librium Klonopin Valium

Chloral hydrate Haldol Ativan IV

Antihistamines

Benedryl 25 mg

Vistaril Benadryl 50 mg. Phenergan Claritin/Zyrtec/Allegra

Benadryl IV

Muscle relaxants

Flexeril 10mg Parafon Forte DSC 250mg Dantrium 25mg Robaxin 500mg Lioresal 5mg

Flexeril 20mg Parafon Forte DSC 500mg Dantrium 50mg Robaxin 750mg Soma Soma Compound Norflex 100mg Lioresal 10 mg

Flexeril 40mg Parafon Forte DSC 750mg Dantrium 100mg Norflex 60mg IV Robaxin 1500mg Soma Lioresal 20mg

Decongestants Antitussives

Sudafed 30mg Robitussin DM Benadryl Tessalon 100mg

Sudafed 30mg Robitussin DM Robitussin AC Hycodan 5mg Tessalon 100-200mg

Sudafed 60mg Hycotuss Hycodan 10mg

_________________________________________________________________________________________________________________ Title: Range Orders & Decision-making for Medications Owner: Director, Clinical Education Effective Date: 12/1/06

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