[rnkalee]

I saw a home patient yesterday who had a new pressure sore on her little toe. She requested Duoderm and I had some in my car so I cut some small ovals, applied one to her toe, and left the remainder for her to use. I charted a progress note on it. My D.O.N. said that I should have gotten a physician order before applying the Duoderm. She said I was practicing medicine without a license. Is that true?? I come from an neurosurgical ICU background and could use supplies such as Duoderm as I saw fit so this was news to me.

Thanks for the help!
Karen

[emmycRN]

I don't see how this is out of your scope of practice. Nurses frequently make judgements about patient needs and then follow-up with MD. The duoderm could not have hurt the pt and should not require a doctors order. Possibly your NM is confusing policy with scope of practice for nurses.

[cookie102]

technically you do need an order for the duoderm, but you did the right thing by applying it, so many times in HH you need to use nursing judgement, if we called the doctor for every little thing they would not be happy
i would of done the same thing, assessed the patient, applied duoderm and wrote the order. no doctor is going to be made at that decision, what he/she isn't going to like is a nurse not knowing what to do

[cookie102]

i forgot this was a hospice question, in hospice you have a little more "freedom" than in HH, so you definitly did the right thing

[GerryG]

The nurse practice act applies to hospice just as well. Technically you do need an order. We have dressing application orders on our standing orders which covers us. In the past what I have done is to initiate the treatment and then write an order. The last thing a doctor wants to be called on is something regarding a dressing since this is one area that they realize nurses know more about than they do.

[caliotter3]

Technically your DON is right. However, as stated before, matters of policy are involved here. Familiies/patients do all sorts of things in the home that are without an order or contradict the MD orders. You should have sent in an order for the MD to sign. Order comes back signed, no problem. Doctor does not sign order or has questions; then you act from there. That is why, in most cases, better to wait for signed order, if you are not familiar with the MD and what he/she will readily sign without questions. I never add anything to the plan of care or treatment/medication records until there is a signed order in the house.

[river1951]

At our hospice we do realize docs look to us to know what to do without pesting them to death. Our solution is to call, let them know our plan and request a return call if the doctor wants something different. This wastes less of their time and our time. We very seldom have a doc not sign and if that happens our medical director backs us up and signs for it. It only happened once to me and it was a cardiologist not signing for a foley in a dying patient- puleeze!
Have a lovely weekend,
River

[sharlyb]

Officially we're supposed to get the order first. In reality, when it comes to things like duoderm, we just apply it and then send in the order. Most of our docs do not want to be called for this and, in any event. we are fortunate to have a medical director who is sane and who is always behind us for things that clearly are appropriate and necessary. We can always count on her signing for things if the attending balks but for the most part we have not had any problem with the attending physicians.

[aimeee]

We have standing orders that allow us to initiate orders for minor dressings like this.

[burn out]

Applying the duoderm is within your scope but you can't just put the duoderm on and nothing more, it will have to be added to the plan of care with a new diagnosis that may allow for more frequent visits, and of course you will need reimbursed for the care and supplies...none of these can happen without an order. So save yourself the trouble in the long run and just write the order.