Range Order Proceedure 1

Center for Change Policies and Procedures
Medication Range Orders Procedure

Section: Medication Management Reference No: 9-204
Effective Date: January 2004 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.
1.3 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.
Medication Management Page 1 of 3

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%.
1.6 Pharmacokinetics of the Medicine: The onset, peak, and duration of
action should be considered when prescribing and assessing the effects
of the medication.
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).
2 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.
3 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)

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.


Range Order Proceedure 1

Uploaded by

Copyright:

Available Formats

Range Order Proceedure 1

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Range Order Proceedure 1

Uploaded by

Copyright:

Available Formats

Center for Change Policies and Procedures

Medication Range Orders Procedure

Range orders, if written appropriately, can be a tool for customizing patient

1.1 Patient’s Prior Exposure to Medication: The patient should receive

Medication Management Page 1 of 3

1.5 Severity of Symptoms: As a general rule for moderate to severe pain,

1.7 Co morbidities that may affect Patient Response: An altered dose

1.8 Concomitant Administration with Other Medications: Medication

1.9 Combination Drugs: When prescribing a combination product, the

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

2.1 Completeness of Order: All components as outlined as outlined in the

3 Interpretation of Range Orders:

3.2 Nurses will administer medications that are prescribed in ranges by

3.3 Medications with an Increased Risk of Adverse Events:

Medication Management Page 2 of 3

depressants (i.e., benzodiazepines and opioid derivatives), antipsychotic

3.3.2 If patients have been successfully treated (good efficacy and

Medication Management Page 3 of 3

You might also like