Range Order Proceedure 1

Center for Change Policies and Procedures

Medication Range Orders Procedure Section: Medication Management Effective Date: January 2004

Reference No: 9-204 Revised: 1/2007; 6/5/2008

Purpose Range orders, if written appropriately, can be a tool for customizing patient care based on the patient condition and their response to therapy. Inappropriate range orders, however, can lead to confusion and medication errors. The purpose of this procedure is to outline appropriate ordering and interpretation of medication range orders. Scope This procedure applies to all Center for Change facilities. This includes all professionals involved in the medication management process. Definitions Medications Prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, over-the-counter drugs, vaccines, radioactive medications, respiratory therapy treatments, parental nutrition, blood derivatives, intravenous solutions, any product designated by the Food and Drug Administration (FDA) as a drug. For this procedure, medications do not include enteral nutrition solutions, oxygen and other medical gasses, which is the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) definition. Range Order A range order is a medication order where the medication can be given over a specified dosage range. Procedure 1

There are a number of considerations for writing and interpreting range orders: 1.1

Patient’s Prior Exposure to Medication: The patient should receive the lowest effective dose. If a patient has recently received the medication with inadequate results then a higher dose within the range may be used.

1.2

Prior Response: The caregiver should evaluate the patient’s response to previous doses, which should include efficacy and adverse effects. Age: For the very young and elderly, start with the lowest dose and titrate the dose slowly and carefully. Frequent assessments are required for these populations.

1.3

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1.4

Hepatic and Renal Function: If the patient has hepatic or renal insufficiency, anticipate a more pronounced peak effect and longer duration of action.

1.5

Severity of Symptoms: As a general rule for moderate to severe pain, increase the dose by 50% - 100%. Do not increase by more than 100% at one time. To fine – tune the dose once pain is mild, titrate by 25 – 50%. Pharmacokinetics of the Medicine: The onset, peak, and duration of action should be considered when prescribing and assessing the effects of the medication.

1.6

2

3

1.7

Co morbidities that may affect Patient Response: An altered dose may be necessary in a person with one or more co morbidities. For example if a patient is to receive an opioid and has respiratory insufficiency, a lower dose should be used.

1.8

Concomitant Administration with Other Medications: Medication regimens should be adjusted when a combination of medications will result in increase or decrease side effects or therapeutic effects. For example, when a CNS depressant is given with an opioid, the desired effect or undesired effect (e.g.. over-sedation) may be achieved with doses 30% - 50% less than when each medication is given alone.

1.9

Combination Drugs: When prescribing a combination product, the maximum possible dose of each medication should be considered, such as when prescribing an opioid with acetaminophen (should not exceed 4000m.g. of acetaminophen in 24 hours).

The following components are necessary for a valid Range Order: 2.1

Completeness of Order: All components as outlined as outlined in the Medication Management Policy are required for a complete order.

2.2

Reasonable Dosage Range: The maximum dose should not be larger than four times the minimum dose. In addition, the maximum dose cannot exceed the maximum recommended dose for that medication.

2.3

A single Time Interval: Dosing interval ranges are not allowed. If an order includes an interval range, it will be transcribed with the most frequent interval allowed. For example, an order for every 3-4 hours as needed will be interpreted as every 3 hours as needed. The prescriber does not need to be contacted for this change.

Interpretation of Range Orders: 3.1

When implementing range orders, the nurse should assess the need of the patient and the potential effect of the other factors as listed in 1.1-1.9.

3.2

Nurses will administer medications that are prescribed in ranges by utilizing lower doses when symptoms are assessed to be less severe and may provide the higher doses when symptoms are more severe (see example A below).

3.3

Medications with an Increased Risk of Adverse Events: 3..3.1 The lowest dose should be used initially for medications with an increased risk of adverse events, such as central nervous system (CNS)

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depressants (i.e., benzodiazepines and opioid derivatives), antipsychotic medications (i.e. phenothiazines) and cardiovascular medications, unless other wise specified in the order. If symptomatic relief is not obtained within the expected time frame, the nurse may administer additional medication not to exceed the maximum ordered dose (see example B below). 3.3.2 If patients have been successfully treated (good efficacy and tolerable side effects) with the same medication (e.g. opioid tolerant patients), the dose used previously may be administered initially provided that it falls within the dose range specified in the order. 3.4

If supplemental doses are given during the interval time period, the total amount cannot exceed the maximum dose ordered for that time interval. The time interval is measured from the time of the initial dose. If the maximum dose is reached and the desired effect has not been achieved, the prescriber should be contacted

Example A: Diphenhydramine 25 to 50 mg orally every 6 hours as needed for itching or hives is ordered. If the patient begins itching, a 25 mg dose may be appropriate. If the patient has hives, the 50 mg dose may be appropriate. Example B: The following is ordered for opioid-naïve patient: Morphine sulfate 2 mg to 6 mg IV every 2 hours as needed for pain. An initial dose of 2 mg is given. The assessment at 15 minutes after the dose indicates the patient is tolerating the medication but is still in severe pain. Additional medication, up to 4 mg may be given to control the pain. No more than 6 mg may be given during the 2-hour interval period. Subsequent doses can be administered no sooner than 2 hours from the initial administration. If this adequately controls the patient’s pain, the following doses can be up to 6 mg. If pain is not controlled and the maximum dose has been reached, the prescriber should be contacted.

Exceptions None

Secondary Materials W.B. Saunders, The Use of as needed Range Orders in the management of Acute Pain: A Consensus Statement of the American Society of Pain Management Nursing and the American Pain Society: Pain Manag Nurse 5(2): 53-58, 2004.

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