I'm having a lot of trouble discerning the gray areas of nursing. OTC medications mostly. I'm a new nurse, I just passed my NCLEX last month, had a couple weeks of orientation, and last night was my first solo night at a LTC facility.
When is it okay to "bend the orders" for OTC medications? In school, I would have said, never, you always need an order. But since I've been at this new job it seems common practice to bend the rules. For example we have a resident who always asks for tums. They are OTC but she doesn't have an order for them. We would give them to her anyway. This happened for about 2 weeks before we got a prn order for the tums.
It doesn't seem like a big deal. Tums certainly won't HURT anyone.
So last night, one of my residents was complaining of shoulder pain. I gave her PRN Tylenol at 4 and 8pm. At 10pm she rang her call bell. She was practically in tears saying her shoulder was hurting. Well I checked her chart and she didn't have any other prn pain medications, it was too early to give her more tylenol. She did have an order for a bengay patch at 5am. I asked the resident when the pain is worse for her and she said at night when she lays down she has the worst pain, not in the morning.
So I put the bengay patch on her shoulder, she went to sleep, and I left a note in the doctors book to consider changing the order to have her patch applied at bedtime.
Apparently this was a big NO-NO. I got chewed out by the night nurse when I gave her report because now she won't have enough bengay patches to get through the weekend. I guess I really don't see what the issue was, especially since I ran it by the nurse in the other hallway and she agreed with what I did.
I felt like crap on my drive home, but at the same time, I still feel like I made the right choice. Am I over thinking things here? I mean it's a bengay patch..
Jul 21, '13
I don't want to sound harsh here and it might be different in your facility (and your state) but I am a charge nurse in a LTC/SNF facility and I would never allow one of my nurses to give ANYTHING without an order. You can call the doctor and get a PRN order for Tylenol or get a patch for NOW if pt needed one that badly but if something ever happens you are putting your license at risk by doing the things you are doing without an order (unless you have house standing orders for those things, we do for certain OTC meds). Please think about what you're doing, even if everyone else does it, it doesn't make it ok... Just my two cents of advice
No order, no meds. Period.
Jul 21, '13
There are times when even Tylenol and Tums are contraindicated and can do harm. That's why they need to be run by the MD first. If someone is in pain and Tylenol isn't cutting it, a Ben Gay patch isn't going to either. It's time to call the MD for uncontrolled pain and hopefully get an order for something different/stronger.
No order, no meds. That's the law and CYA.
Jul 21, '13
That's why I'm asking! thank you for you input. It doesn't seem like a facility that bends the rules so often is a good place for a new grad to start out. I'm hoping to only be here for 6 months or so.
I guess I was more confused at why the night nurse was upset with me. It wasn't "you gave this without an order" - honestly, I would get that. I probably SHOULD have called the on call, and next time certainly will. But she was upset because "Now there won't be enough for the weekend" (Which there is. two full boxes in each med cart and more in the supply room downstairs. Which I did mention)
Jul 21, '13
Standing orders (where allowed) can solve some of these pesky issues. It's easy to have a list of them, in each chart, and certain orders can be crossed out- such as Tylenol, if there's an allergy. But then again, even with SO I've worked in places that required a SO to be written out on a TO also, before being implemented, which was just a waste of having a list of SO in the first place?
Jul 22, '13
The facility can bend the rules but you never should. NOTHING can be applied or admin without an order in LTC-not even blistex or artificial tears. That's the regs in this state. Were I work you would be counseled for a med error (wrong time) Anyone can place a note in the physician's folder if you have a suggestion for a resident- ,make sure you sign and date your note, make sure it's legible and back it up with a good progress note.
If you felt the resident was in distress why not call the MD yourself at that time and get her some relief? Did you try other interventions, 1 to 1,a snack,a drink,repositioning? Send a request to housekeeping for a new mattress? Maybe she really wants a sleeper.Or maybe it's time to go up the pharm ladder with something a little stronger.PT evaluation? Plenty of options available.
As for the "Tums" situation- heartburn can certainly be masking a lot of things that should be treated ( ?? cardiac?) NOT a good idea to just pass out those tums without following up.That's poor nursing and not a habit you want to pick up. When you've been doing this for awhile you learn that geriatric patients often present with atypical symptoms and are poor historians. Throw in a little cognitive dysfunction and assessment becomes even more challenging.
Jul 23, '13
TUMS actually could hurt a resident who is prone to kindey stones or has hypercalcemia. Especially if everyone's giving it "off the books" and no one knows how many she's really getting.
I'd just put her on sick call, and most likely the doctor will order something.
Jul 23, '13
While the facility may bend the rules, you as a nurse that worked so hard for her license should not. Giving meds without an order is considered 'practicing medicine without a license'. Not something that you would want to be charged with, ever.
If Tylenol was not working for her pain, you should have followed what your nursing practice tells you to (if you did, you did not mention it in your OP) and completed a full evaluation and followed this up with a call to the doctor. Often times, especially in women, a heart attack is presented with shoulder pain. While this may be an extreme example and the patient may have this history, it wasn't really mentioned in the OP. Also, when you 'bend the rules' and just try to throw medications at the problem, you could just be masking a symptom that could cause further injury...just something to consider.
Please, if this facility is what is causing you to be so casual with this type of nursing practice, find another one to work at. Even though you have graduated nursing school and have obtained a license, your real training is now. Right now for you and will form the basis of your real 'working' nurses knowledge and I hope that you get the best training to give you a good solid nursing base. As another poster wrote, CYA but also, you really want to use the best nursing practices possible. Best of luck to you.
Jul 27, '13
I wouldn't be willing to give ANYTHING that was not ordered by the MD. In that situation the resident may have needed something stronger and a call should be placed to the MD. In my facility each time the TUMS were given without an order & the bengay patch given at the wrong time would be med errors.
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