Giving O2 without an order??

Skylar86 · Jun 12, 2012

im not sure what your policy includes but in the emergency department that i work at we have ''standing orders''. We can give paracetamol (tylenol), oxygen and normal saline without it being charted... we just need to get it charted/signed at some stage.

strawberryfields · Jun 12, 2012

But at 3L NC? I was a little weary about it.. but he was having a hard time breathing and the O2 sat wasn't increasing.. so I documented that as well. "Pts O2 sat is at 83% on 2L NC administer 3L and pts O2 is at 92%. Will f/u with Dr. in the AM for PRN O2 orders." Is something along the lines of what I put. His oxygen was more important to me at the time than my license... but I don't want my license disciplined for 3L O2 without an order clearly stated in documentation.

sauconyrunner · Jun 12, 2012

I really do not think the worry here should be that you gave oxygen. My concern reading this is that you have a patient who normally is sleeping well, find him sitting bolt upright in bed, and with a sat of 75%. Yes, you treated with Oxygen and the pt improved, but WHY did the patient have such a sudden change? Everywhere I have worked (And I admit, i have only worked in Hospitals, it sounds like you are in a long term care kind of place, since you know the pt fairly well) that would be an immediate call to the MD, not a follow up in the morning. I realize your supervisor told you to follow up in the morning, so in that sense you would not need to worry, but why on earth- with a very sudden change in Airway and respiration, would you not call that physician immediately.

strawberryfields · Jun 12, 2012

My immediate response was to Raise his head of the bed,give him oxygen, and assess lung sounds not to wake up the doctor and say my patient cannot breathe ... At 3am to just hear them say well did you give them oxygen? Mind you the patient was AAOX3. It is a Rehabilitation floor. I jumped on the oxygen ... Administered it , o2 gradually went up and patient was stable... Now that the patient is stable with an o2 at 95% and responsive+ totally concious was there a need to call the doctor at 3 in the morning ... I didn't think so. Unless, he had an episode I couldn't fix with 3L of o2.

He has a prn order ipra-albut by nebulizer cause he does have episodes as noted by the nurse working on that floor but oddly enough still no prn o2 order.

So my concern was the charting because I think I did the right thing.

jadelpn, LPN, EMT-B · Jun 12, 2012

I agree that I would be most concerned on why the sudden change in condition. If patient has prn duoneb, then one could assume that this patient has a history of SOB? My first reaction would be a duoneb on O2, then call the doctor if that intervention did not work (and you had an order for that, so one would assume this has happend before). Never the less I would not concern myself with the fact that it is 0300--I would call the MD with any change in conditon, unchanged with the current orders that you have on hand--and get further orders. There's so much that can happen in rehab after surgery--I would think clots and the like--do you have a rapid response team? This would qualify. If not, I think that after assessment, use the interventions you have on hand, and familiarize yourself with them.

allnurses Guide · Jun 12, 2012

Agree 100% with the above posters.

strawberryfields · Jun 12, 2012

He has been there for 3 months .. My supervisor was there and said there was no need to call because he was fine after oxygen so I didn't call. Because I even said I was going to call and they said no need just call at a regular hour. Maybe next time I'll take matters into my own hands?Again though my question was about charting ... Anyone?

jadelpn, LPN, EMT-B · Jun 12, 2012

You documented that you did something that you did not have an order for. You did not do what you did have an order for. You do not have standing orders for prn o2 on your patients or do you? I would not chart anything nor would I get in the habit of doing stuff without orders. That is lovely that your supervisor says not to call the MD in the middle of the night, but is your supervisor going to co-sign your documentation? Additonally, if you have a duoneb order, there may be a reason that the MD did not want this patient on o2, or perhaps it would have been ordered to begin with. Nursing judgement is one thing, critical thinking skills are something entirely different. Do not get into the habit of doing stuff without orders, and documentation should not be an issue. In this instance, I would speak to the Dr about prn o2, maybe scheduled nightly duonebs (if this happens often at night) and whatever else the MD thinks this patient needs (r/o pneumonia perhaps??). Depending on your facilities polices, you may be in the wrong, and now you have documented same. Get the supervisor to co-sign the documentation, as she was also aware of this.

Esme12, ASN, BSN, RN · Jun 12, 2012

Charting your interventions is fine. But in your charting you document that there was an abrupt change in the patients condition with life threatening/profound decrease in the O2Sat and the application of O2 without an order....but you would call the MD in the morning to tell him the patient had trouble last night and get the order for the O2.

So, you documented the event well. I think you should have documented that the supervisor was notified and she advised you to call the MD in the morning. My question is......Why didn't you give the PRN neb treatment....the med you had an order for?

Your documentation should read....Pt found in high fowler's position c/o SOB. Pulse Ox 75%, RR ?, B/P?, breath/lung sounds xyz. Stat PRN Neb iprat-albut with O2 given as per orders......patient O2sat now is ?? O2 per nasal prongs applied patient still c/o SOB breath sounds xyz...MD notified....orders received or not received

OR.....Pt found in high fowler's position c/o SOB. Pulse Ox 75%, RR ?, B/P?, breath/lung sounds xyz. Stat PRN Neb iprat-albut with O2 given as per orders......patient O2sat now is ?? O2 per nasal prongs applied patient still c/o SOB breath sounds xyz...house supervisor notified states/advised to endorse to AM nurse to notify MD.

Lets say......IF.......What IF the patient did well for a while, then suddenly crashed because the Pulmonary emboli "moved" to an even worse place or there was further showering of emboli and the patient coded and died. In a court of law you will be asked....Why didn't you call the MD and why did you not give the PRN Neb?

You are now liable for this and your lack of calling the MD becasue

#1) you are responsible for your own actions. "My supervisor told me so" will not save you from liability in a court of law if another reasonable and prudent nurse would have called the MD regardless of what the supervisor said.

#2) The MD will say....if you had called me I could have done something. Making you liable again and because you ordered a medicine (oxygen) without an order that makes it practicing medicine without a license.

Normally? A few whiffs of O2 first, no biggie, Right? but something went terribly wrong and by all accounts......

#1) you gave a medicine that you did not have an order for....

#2) you failed to give the med you have ordered and.....

#3) you failed to notify the MD of a significant change in condition therefore leading to the patients demise.

Your actions were correct, sort of... and the follow up was a little off. I don't know what the other nurses do...... it matters what you do. The patient was SOB, he has an order for the PRN Neb....Give the neb ( the med he has orders for) on O2. If he is still not better leave him on the O2 and then......call the MD

Is that clearer????:loveya: YOu didn't do bad but you can do better.

zumalong · Jun 12, 2012

Never be talked out of calling dr with problems. This patient could have thrown a clot or if he was a Copd pt too much oxygen may have suppressed his resp. You can't change what course you took this time, but next time contact who is on call. Follow your gut and CYA. For the patient's safety and your hard earned license

Born_2BRN · Jun 12, 2012

I was once as a new RN put a bandaid on a patient after he scrapped himself bleeding everywhere. I notified the physician that he hurt himself and supervisor knew, but I got written up because I didn't have order to put a bandaid on the patient. So yes you do need order pretty much on anything related to patient care. In hospital you have some room to breath for instance you can change an IV site PRN or facility policy without physician order. The nature of the beast in nursing. I myself still learning and everyday is a learning experience.