NOTE: Also refer to Pain Management FAQ.
BACKGROUND: Range orders are commonly used to provide flexibility in dosing to meet individual patients’ needs because a wide variability exists in patients’ responses to medications. Evidence-based clinical practice guidelines support the need for individual titration of the dose of medications such as opioid analgesics. Range orders enable necessary and safe adjustments in doses based on individual responses to treatment. In order to promote patient safety and reduce medication errors it is critical that physicians, nurses, and pharmacists share a common understanding of how to properly write, interpret, and carry out PRN range orders. (Taken from a consensus statement of the American Society for Pain Management Nursing and the American Pain Society.)
QUESTION: If the health care provider gives an order for a range dose, such as “morphine 4-8 mg IV every 4 hours PRN, is it within the nurses scope of practice to administer an initial dose, i.e. 4 mg and then give an additional 4 mg if the patient’s pain persists, as long as the maximum range (8 mg) is not exceeded within any 4-hour time frame?
ANSWER: The patient will be assessed by the nurse to determine their level of pain. After giving the “initially selected dose,” the patient is reassessed to determine if additional medication is needed. If the patient’s pain is not controlled, and the maximum dose was not initially selected and given, additional medication may be given (within time frame stated in the order) until the maximum amount ordered by the health care provider is administered.
If the health care provider writes an incomplete order for PRN pain medication, i.e., route of administration is not included, or frequency of administration is not indicated, it is not permissible to administer the medication orally or according to the “usual” frequency of the drug that is ordered.
It is essential for health care providers to write clearly stated range orders. Range orders should ideally consist of:
- The full name of the medication being ordered
- The total amount of medication to be given in a specified time period
- The order should state if the dose can be given in divided doses
- The order should state if the dose can be repeated
- If repeated, the order should indicate how frequently, and in what time frame
- The order should include what action should be taken if pain is unrelieved
Morphine Sulfate 2 mg to 8 mg may be given IV in divided doses up to a maximum of 8 mg in a 2-hour period. Call the provider if the pain is not controlled with this dosing schedule.
Morphine Sulfate 2 mg to 4 mg IV, every hour not to exceed a total of 10 mg in 3 hours. If this does not relieve pain, please notify provider for change in order, along with current vital signs.
American Society of Pain Management Nursing Position Statement
Input from the Advanced Practice Committee on 1/7/05