[Bethy-lynn]

In our unit, we tend to give a lot of "country" doses (such as adding on a couple extra units of insulin if someone's sugars are high, or giving the extra mg of Ativan to the resident Meth od). We even joke about it with some of our md's. I guess I'm just a little curious about how "normal " this is. i feel like I work in an EXTREMELY liberal unit ( we order a lot of things, labs, ekgs, x-rays, O2, and we make few med changes like changing from iv to po, or giving benedryl or tylenol) and I was just wondering what the consensus is.
It's the only unit i've worked in as an RN and I was just curious.

[jbp0529]

We do similar stuff at times, i guess it just depends on the severity of the issue. There's always that crazy pt in DT's that needs a little extra "love" does of ativan-- "woops i guess my eye sight isnt what it used to be, he got a little extra". Of course on paper, everything is how it should be.

Less dramatic things would be ordering chest xrays on all our vented patients every morning - even though sometimes they forget to order it, someone will eventually complain if it wasn't done.

[Morgan314]

Liberal? Your post scares me. As nurses, we cannot give any medication, adjust dosages, change medication routes, or order tests without an order from MD, DO, or Nurse Practitioner. Does your unit have "standing orders" for things like Benadryl, Tylenol, or routine tests/labs? If you give extra Ativan or other controlled med, how do you account for it at the end of your shift? Does the physician sign off on these "orders?"

[pickledpepperRN]

I can understand why and how this has become the practice.
Just imagine if it were made public.
"Practicing medicine without a license"
If there is a bad outcome and the nurse gave more medication than ordered who would be at fault legally? Even if the medication was not the cause.

With the insurance companies refusing to pay it is necessary to get a written, or telephone order for every test also.

I would write my manager first, then go up the chain of command to put a stop to this practice.

[cardiacRN2006]

I've certainly seen this with Insulin, but how with Ativan? Doesn't this affect your narc/controlled substances count?

Personally, I have no problem calling the Dr and telling him that the Ativan isn't enough if it isn't. I would think that when the next shift can't keep a pt down with the proper doses of things, but you can, that it would soon become obvious. I know I'm new, but if they Dr only wants 2 units of Insulin, then that's what he gets, and he may also get a call from me several times during the day also if the treatments he ordered don't work.
Sounds like you are playing with fire...someday, someone will work in your facility who doens't like what you are doing. You may never know who is watching what you do, it may bite you in the you-know-what sooner than you think.

[ginger58]

Originally Posted by Bethy-lynn

In our unit, we tend to give a lot of "country" doses (such as adding on a couple extra units of insulin if someone's sugars are high, or giving the extra mg of Ativan to the resident Meth od). We even joke about it with some of our md's. I guess I'm just a little curious about how "normal " this is. i feel like I work in an EXTREMELY liberal unit ( we order a lot of things, labs, ekgs, x-rays, O2, and we make few med changes like changing from iv to po, or giving benedryl or tylenol) and I was just wondering what the consensus is.
It's the only unit i've worked in as an RN and I was just curious.

Sounds like practicing medicine without a license.

[Bethy-lynn]

The last time someone actually got busted for this was for giving an un-ordered Toprol to a PO day 1 OH. Usually, especially with the insulin and the Ativan, when we see one of the MD's, that's when we tell them, usually ssomething like (fred was really froggy and tried to wack me a couple times, so he got a little extra Ativan. Now can you up that? or Ed's sugars have been running high, and since we want to prevent that whole sepsis thing, can you go ahead and switch him to high dose, or up his NPH?). It just seems like for the most part, even the MD's are pretty ok about this, and our managers are very aware. I know that out on the floor, the nurses can't get away with any of this. It's like a weird ICU phenom.

[cardiacRN2006]

At the last place I worked at (as a tech) there were nurses who were that way. Felt as if though they could write verbal orders and the hospitalist would cover it. The hospitalist went along with it all for a while, and then she just got so angry and tired of it that she reported this one random nurse to both our manager and the state board. She refused to sign the orders, and it was a big mess. He was fired on the spot, and I don't know what happened to his license.

I haven't seen this practice in my ICU. Since we are a teaching hospital, I think we have no problems 'teaching' our new docs to write the order correctly the first time. Like I said, if the dosages aren't working, I'll just call them and let them know. Maybe it's because I'm new and I cherish my license, but you never know when the nurse who doesn't approve is watching you, or when the Dr gets tired of it. Dangerous game...

[TopherSRN]

...

[JenSICU_CCRN]

While, I know that nurses give "extra" of a drug that is something that I would not do. #1 I'm not a physician (even though as RN's we know more about the pt. than they do usually) and #2 I worked too hard to get my license to lose it. If your medications aren't working, pick up the phone and get an order for it!!! I work in a trauma/SICU and I have never had a problem obtaining an order if it is needed. We can order PCXR's and EKG's and things like this without an order from the physician if needed, but not meds. I got accused of giving and writing a lasix order for a patient that the resident didn't remember giving me since she was asleep, and nothing came of it, because MY reputation is that I DON'T do that. Now, if it had been one of the nurses that had a reputation for doing those things, they would have been in big trouble. I don't know if this answers your question or not, but I'm appalled that a nurse would do this....is 1 mg of Ativan really worth risking your license for? Go get some soft wrists restraints until you can get more meds.

Jenny