Can you give additional doses of a PRN to increase an already given dose to a range?

Hypothetical situation: Your patient is ordered 4 to 8 mg of Morphine IVP for pain>4 on 1-10 scale, Q2 hrs PRN. The first dose you give is 4mg, but 30min later he states his pain is unrelieved. I know what I "would" do, but legaly (I'm in Ohio) once you have chosen the 4mg dose, don't you have to wait until the next dose window-in this case 2hrs- before you can give an 8mg dose, or can you give an additional 4mg within the 2hr window to add up to the maximum ordered dose?
If you can give an additional dose- where do you begin the 2hr window- from when you started giving the 8mgs with the first 4mg, or from the 2nd 4mg where you finished giving the 8mg dose?
If anyone has a definitive legal answer to this question please let me know, and where you got this answer. We are in quite a discussion at work.
Titrate the morphine to 1mg/ml, administer 4mg, wait for ten minutes, then ask the patient if there's any relief. If not, or if there's only partial relief, you may then administer a further 1-2mg, wait another 10 minutes and reassess. That's how it works in PACU, and I presume that's the meaning of the script you describe. Just don't exceed the maximum dose.

Where I work you would be able to give the additional 4mg within the 2 hour window.

Where I work you can give the additional 4mg and count the 2 hour window from the 2nd dose given. I have no idea about the laws in Ohio though- sorry.But best stick with the patient or follow up within 10 minutes to see if your medication resulted in the desired pain relieve. If not give the 2nd 4mg then and don't let the poor patient suffer for another 20 minutes. IV morph is fast acting - you shouldn't need to wait 30 min to reassess.

We have been having issues with this at our hospital lately, in particular with the new barcoding system. Technically, and per our policy, we are not allowed to give an extra dose after the first one has been given (and the computer causes quite a fuss if we try to scan again). Does this mean it doesn't happen? No. If I have a fresh post-op and I am trying to get them caught up, but not oversedate them I will sometimes give a little more later. If I do, then I time from the second dose. If that still doesn't make them comfortable I call the MD and try to find another way to manage pain control. Thankfully this doesn't happen very often.

I'm in Ohio as well, and when I was doing bedside nursing I would give the 4mg, reassess in 10min (for an IV med 30-45 for PO) and if needed give more. If I gave the second dose within an hr from the first I wouldn't restart my timing, just use the first dose as my guide. Now, if the order was Percocet 1-2 tabs q4 hrs PRN pain and I gave 1 tab at 12 and then at 1330 gave the second, I would tell the patient that their next dose was available after 1730.

Quote from GHGoonetteTitrate the morphine to 1mg/ml, administer 4mg, wait for ten minutes, then ask the patient if there's any relief. If not, or if there's only partial relief, you may then administer a further 1-2mg, wait another 10 minutes and reassess. That's how it works in PACU, and I presume that's the meaning of the script you describe. Just don't exceed the maximum dose.

PICU/PACU/ICU all differ a lot from the floor. I think the main question here might be "what area do you work in?".

This is very true-but the order does say IVP...I didn't do a lot of med surg, are there many IV push orders for morphine given on the general floors?I am just curious.

Quote from TaitPICU/PACU/ICU all differ a lot from the floor. I think the main question here might be "what area do you work in?".

Whoops...not paying attention....sorry...then I stand by my original post. (which was what Goonette said)

I checked with our hospital pharmacy regarding similar situation, and they said can give additional amount up to what order covers, then time from the additional dose.

Our P&P where I work is very vague and does not cover this topic well. It is generally understood however that if you have an order for Morphine 4-8mg q4hr PRN pain then we give the 4mg first. Reassess the pain in 15 minutes. If pain is not controlled we can give more (most just give the other 4 to maximize the dose however you could technically give 1mg at a time until you reach the 8mg). Once pain control is achieved, you start the 4 hours from that last dose of med. If you end up giving a TOTAL of 8mg then that is what you start with the next time the pt. needs pain med.The PROBLEM in my unit is this: You have an order for 4-8mg of Morphine q4hr PRN pain AND you have an order for Lortab 7.5/500 1-2 tabs q4hr PRN pain. Some nurses feel like this is written so that the pt. has something for pain q2hr. Other nurses feel this means you get something for pain q4hr whether that be Morphine or Lortab. Different doctors take it to mean different things. My head is spinning trying to figure out what to do half the time. One nurse we work with will actually call ppl to the carpet for giving pain med q2hr and will call them stupid, unsafe, etc. in a very loud and inappropriate manner!