Interventions without MD orders

[Novo]

So today I learned that when I graduate I can do zero pretty in the way of medical interventions without a Drs orders, not including protocols/standing orders. I'm not sure why but I just kinda assumed that RNs were allowed to minimally invasive things like giving tylenol, maybe even start an IV (with rationale). So essentially does this mean nurses are pretty much limited to a hospital setting and can only really function with a M.D nearby for medical interventions that is. For example, lets say a palliative patients family hired you and you found they needed an IV started a home do you need to get an order from an MD?

Just wondering what the reasoning behind this is? Do Drs not trust nursing judgement? I just didn't realize what people refer to as "autonomy" is actually just protocols.

[Esme12, ASN, BSN, RN]

Critical Care.......we do what we want

Covered by protocols "per ACLS protocols" and physicians who have confidence with your knowledge and experience. The OP in a nursing student....he will not walk out of school "Prepared" for this kind of responsibility. Students who think they are can be dangerous.

[RNsRWe, ASN, RN]

I have to assume, Novo, that you are a brand-new student, just in your first weeks of classes (or pre-nursing classes)? Otherwise, I can't quite get your describing giving Tylenol as a "minimally invasive thing" (it's a medication) or describing the need to obtain an MD's order to start an IV (how else does one administer IV medications....that are ALREADY ordered?).

I also don't understand the idea that nurses are "pretty much limited to a hospital setting"....I wonder if you have never seen or heard of nurses working in about a hundred other, non-hospital settings...?

Must be very, very new. Take some time to read around the message boards, particularly the Specialty forums, and I think you'll get a better feel for what nurses actually do :)

[brillohead, ADN, RN]

Most people don't understand the nursing role unless they've been through nursing school and worked as a nurse themselves.

Nursing is a different genre within the medical field. We "nurture" our patients -- we don't just see to their medical needs, but we care for the whole entire patient, body and soul, and we think "outside the box" compared to how doctors think. Doctors are taught to see the pathology of a situation and deal with it medically. Nurses are taught to look at the SITUATION and deal with whatever needs to be done to resolve it.

I know someone who is undergoing treatments that involve injections into a very personal and sensitive portion of the anatomy. Being a woman of a certain age, stress incontinence is also an issue. Normally, someone would be able to use a barrier protectant ointment to maintain skin integrity, but it was specifically forbidden by the physician because of the nature of the injections.

This person had a respiratory infection that included a nasty cough, which triggered the stress incontinence. Between the sensitivity of the area, the inflammation from the injections, and the constant presence of urine, skin integrity was beyond compromised, and she was in constant pain that increased exponentially upon urination. All her doctor -- a very intelligent, educated man who is an expert in his field -- could tell her was to deal with it and take more narcotic pain pills.

When she finally confessed her troubles to me, I was able to offer her some instant relief and also some ideas to run past her doctor for approval for additional relief. My ideas: use a sitz bath attachment on the toilet to pee into water (or fill the bathtub and pee there -- she hurt too badly to leave her home anyway); use an "ob" brand (non-applicator) tampon placed strategically in an external location to catch the stress incontinence output before it reached the inflamed tissues; check with her doctor to see if she could straight-cath for urination to bypass the excoriated areas (he said no); check with her doctor to see if she could use pure/water-based aloe vera gel to aid in healing and provide a skin protectant (he said yes--his only problem is with the "sticky" ointments that are usually used for barrier protection).

The pee-in-water idea, the tampon idea, and the aloe vera idea CHANGED HER LIFE. She was in tears thanking me for giving her her life back.

These are not "medical" ideas -- there is no prescription needed for any of these things that we ended up putting in place (the catheter is a prescription thing and the doc denied it for now; the aloe vera isn't a prescription thing, but we did run it by the doctor because of the advanced nature of her injections and the pre-existing orders to NOT use a barrier ointment).

These are NURSING ideas. I looked at the SITUATION and thought of ways to work around it. Peeing into water meant that the urine was diluted, so it didn't burn: solution = patient can urinate without howling in pain. The tampon is made to absorb liquid in a confined area... we just adjusted the type of liquid and the area involved by a couple inches: solution = excoriated tissue is no longer constantly in contact with urine, reducing pain and encouraging healing. The aloe vera gel heals, moisturizes, and lubricates: solution = a bit of barrier between urine and tissues, lubrication reduced rubbing of tissues reduced pain, and tissue healing was encouraged.

When the doctor was informed of all of this, he agreed wholeheartedly with the ideas.... but he never thought of these ideas himself, because he isn't trained to think that way. He thinks of cell pathology, pharmacology, microbiology, all related to the disease itself. "Take more pain pills" is his answer for dealing with pain. Nurses think of the patient and the needs that they have and figure out what can be done to work around the issues at hand. Instead of telling my friend to be snowed by pain pills all the time, I tried to figure out ways to stop the pain from happening in the first place.

Yes, in some cases a nurse needs to get an order / approval for something from a doctor. This is because the doctor has more training in the medical side of things (like how I didn't know enough about why a catheter was contraindicated for my friend's situation -- I'm not privy to exactly what her injections contain and where they are placed, etc., so the doctor had to be the one to make that call). But in many cases there are things we can do without getting "permission" because they are nursing actions that are within our scope of practice. And in many cases, those nursing things we do make all the difference in the world to the patient.

[MomRN0913]

Critical care certainly has more leeway. But aside from that, we never prescribe, but we do suggest.

But your comment about Tylenol worries me a little. It is a medication. OTC, but nonetheless a medication. If you have a patient with liver failure or LFT 's , Tylenol is not something you necessarily want to give, and if you do a phycisian will order a dose not to exceed I. A 24 hour period.

even when I worked home health, I could not tell a patient to take Tylenol or colace or dulcolax if there was no MD order. I working under my scope of practice as an RN under the direction of an MD .

Trust me, your nursing abilities cause you to make some major judgement calls. Knowing something isn't right in the middle of the night and calling the MD, that could save a patients life.

[Novo]

I have to assume, Novo, that you are a brand-new student, just in your first weeks of classes (or pre-nursing classes)? Otherwise, I can't quite get your describing giving Tylenol as a "minimally invasive thing" (it's a medication) or describing the need to obtain an MD's order to start an IV (how else does one administer IV medications....that are ALREADY ordered?).

I also don't understand the idea that nurses are "pretty much limited to a hospital setting"....I wonder if you have never seen or heard of nurses working in about a hundred other, non-hospital settings...?

Must be very, very new. Take some time to read around the message boards, particularly the Specialty forums, and I think you'll get a better feel for what nurses actually do :)

Actually, just finished 2nd year. It's a medication, but tylenol has some pretty basic contraindications and people take it all the time for minor ailments. If we know why to give the medication and it's contradictions, normal doses etc as we learn this in pharm - then why can't we just give it? I'm not talking about giving insulin or something here. I also wasn't referring to medications I meant IV NS.

I realize I'm student and I have some deficiencies in real world nursing but you're all acting like it's a stretch to give "some" medical treatments without orders. If you came at it from a liability issues rather than competence I guess that would seem more compelling to me.

With the advent of technology the scope of nurses has increased, a lot of the things MDs used to do is now being offloaded onto nursing and therefore it's a natural progression for nursing to do "more" in terms of medical interventions. I just feel like nursing is too complacent. I realize they already have enough on their plate but more autonomy is never a bad thing.

[SierraBravo]

Actually, just finished 2nd year. It's a medication, but tylenol has some pretty basic contraindications and people take it all the time for minor ailments. If we know why to give the medication and it's contradictions, normal doses etc as we learn this in pharm - then why can't we just give it? I'm not talking about giving insulin or something here. I also wasn't referring to medications I meant IV NS.

I realize I'm student and I have some deficiencies in real world nursing but you're all acting like it's a stretch to give "some" medical treatments without orders. If you came at it from a liability issues rather than competence I guess that would seem more compelling to me.

With the advent of technology the scope of nurses has increased, a lot of the things MDs used to do is now being offloaded onto nursing and therefore it's a natural progression for nursing to do "more" in terms of medical interventions. I just feel like nursing is too complacent. I realize they already have enough on their plate but more autonomy is never a bad thing.

Don't take this the wrong way, but I certainly hope that when you say you just finished 2nd year that you mean you have another 2 years left before graduation (for your BSN) and not that you just finished an ADN program because based on your comments I don't think you are ready to practice nursing in a safe capacity.

[jadelpn, LPN, EMT-B]

Actually, just finished 2nd year. It's a medication, but tylenol has some pretty basic contraindications and people take it all the time for minor ailments. If we know why to give the medication and it's contradictions, normal doses etc as we learn this in pharm - then why can't we just give it? I'm not talking about giving insulin or something here. I also wasn't referring to medications I meant IV NS.

I realize I'm student and I have some deficiencies in real world nursing but you're all acting like it's a stretch to give "some" medical treatments without orders. If you came at it from a liability issues rather than competence I guess that would seem more compelling to me.

With the advent of technology the scope of nurses has increased, a lot of the things MDs used to do is now being offloaded onto nursing and therefore it's a natural progression for nursing to do "more" in terms of medical interventions. I just feel like nursing is too complacent. I realize they already have enough on their plate but more autonomy is never a bad thing.

OP, this sounds as if you are personalizing the function of a nurse. What one is licensed to do does not necessarily equate intellegence.

Tylenol is a medication that may or may not be something that is warranted for an acutely ill patient. It is far different in one's own life where Tylenol may be warranted. Looking at it a different way, there may be a number of other medications that are more appropriate for a patient than Tylenol, therefore, it is up to a practioner as to which way they want to go medically.

There are many, many palliative care patients who do not want IV fluids, as indicated in an advance directive. By doing so anyways would be unethical. There are many patients where NS may seem benign, however, could cause such patient to go into fluid overload. Additionally, along the same theme, there are other fluids besides NS that depending on the medical picture may be more appropriate for the patient.

Only a practioner knows what they are comfortable prescribing. Nurses function as to gather information to assist in the implementing same. It is a complex set of whole body approaches, that ulitmately fall on the practioner. Sometimes, "just giving a Tylenol or NS" is far more than what it may seem.

Everyone has the same goal of return to highest functional level. You will find some practioners more reserved than others. Bottom line--unless it is prescribed, and you can cover your actions in writing, do not ever go forward with what you believe to be best as far as medical interventions. Nurses see patients for just a snapshot. All of the medical records in the world can not give a nurse a total picture of a MD/NP--->patient relationship, how they have discussed going forward, what the desires of a patient may or may not be.

Even Critical Care nurses have protocol. The protocols even have protocols. The art is to be able to figure out which protocol applies.

In all of the complexity, there is a level of satisfaction in that one is helping another achieve function. There is also a level of satisfaction that one has the reputation for being an amazing IV starter, who asks all the right questions, who looks at things out of the box. (Stress LOOKING at things).

The worst thing any nurse can do is to get the reputation of being a cowboy, reckless, doesn't take direction. The last thing any nurse wants is for a practioner not to trust them.

Always do the right and correct thing. Practice with integrity. That will get you farther in this business than 100 central lines combined.

With the invention of technology in the nursing field, unfortuntely there are any number of nurses who will tell you it means even MORE button pushing as opposed to hands on bedside care. Sometimes a computer is just a computer, and is far more task oriented than deciding that Tylenol is a the correct treatment.

So all this begs the question, why would you not go to medical school? This would be something that I would think be professionally satisfying to you, and give you a sense of autonomy that you seem to be craving.

Remember, as a nurse your personal goal of your profession should be integrity and character of your practice. That is on you, is hard earned, and don't ever, ever put yourself in the position that takes away from that.

[Novo]

Don't take this the wrong way, but I certainly hope that when you say you just finished 2nd year that you mean you have another 2 years left before graduation (for your BSN) and not that you just finished an ADN program because based on your comments I don't think you are ready to practice nursing in a safe capacity.

2 /4 years, yes.

Also, stop with the ad hominem, your opinion of whether I'm competent or not has no bearing to this thread/question.

[Novo]

OP, this sounds as if you are personalizing the function of a nurse. What one is licensed to do does not necessarily equate intellegence.

Tylenol is a medication that may or may not be something that is warranted for an acutely ill patient. It is far different in one's own life where Tylenol may be warranted. Looking at it a different way, there may be a number of other medications that are more appropriate for a patient than Tylenol, therefore, it is up to a practioner as to which way they want to go medically.

There are many, many palliative care patients who do not want IV fluids, as indicated in an advance directive. By doing so anyways would be unethical. There are many patients where NS may seem benign, however, could cause such patient to go into fluid overload. Additionally, along the same theme, there are other fluids besides NS that depending on the medical picture may be more appropriate for the patient.

Only a practioner knows what they are comfortable prescribing. Nurses function as to gather information to assist in the implementing same. It is a complex set of whole body approaches, that ulitmately fall on the practioner. Sometimes, "just giving a Tylenol or NS" is far more than what it may seem.

Everyone has the same goal of return to highest functional level. You will find some practioners more reserved than others. Bottom line--unless it is prescribed, and you can cover your actions in writing, do not ever go forward with what you believe to be best as far as medical interventions. Nurses see patients for just a snapshot. All of the medical records in the world can not give a nurse a total picture of a MD/NP--->patient relationship, how they have discussed going forward, what the desires of a patient may or may not be.

Even Critical Care nurses have protocol. The protocols even have protocols. The art is to be able to figure out which protocol applies.

In all of the complexity, there is a level of satisfaction in that one is helping another achieve function. There is also a level of satisfaction that one has the reputation for being an amazing IV starter, who asks all the right questions, who looks at things out of the box. (Stress LOOKING at things).

The worst thing any nurse can do is to get the reputation of being a cowboy, reckless, doesn't take direction. The last thing any nurse wants is for a practioner not to trust them.

Always do the right and correct thing. Practice with integrity. That will get you farther in this business than 100 central lines combined.

With the invention of technology in the nursing field, unfortuntely there are any number of nurses who will tell you it means even MORE button pushing as opposed to hands on bedside care. Sometimes a computer is just a computer, and is far more task oriented than deciding that Tylenol is a the correct treatment.

So all this begs the question, why would you not go to medical school? This would be something that I would think be professionally satisfying to you, and give you a sense of autonomy that you seem to be craving.

Remember, as a nurse your personal goal of your profession should be integrity and character of your practice. That is on you, is hard earned, and don't ever, ever put yourself in the position that takes away from that.

I see where you're coming from but I still think theres room for a lot more autonomy in nursing. Anyways, I've completed prereqs for medical school, not sure if that's the route i'll go though, although I do enjoy nursing.

Anyways, I appreciate your post.

[akulahawkRN, ADN, RN, EMT-P]

Actually, just finished 2nd year. It's a medication, but tylenol has some pretty basic contraindications and people take it all the time for minor ailments. If we know why to give the medication and it's contradictions, normal doses etc as we learn this in pharm - then why can't we just give it? I'm not talking about giving insulin or something here. I also wasn't referring to medications I meant IV NS.

I realize I'm student and I have some deficiencies in real world nursing but you're all acting like it's a stretch to give "some" medical treatments without orders. If you came at it from a liability issues rather than competence I guess that would seem more compelling to me.

With the advent of technology the scope of nurses has increased, a lot of the things MDs used to do is now being offloaded onto nursing and therefore it's a natural progression for nursing to do "more" in terms of medical interventions. I just feel like nursing is too complacent. I realize they already have enough on their plate but more autonomy is never a bad thing.

This is one thing that irritates me as well... people can go pick up medications and take them on their own and yet Nurses (and LOTS of others) can't provide those same medications to the patient without an order. Yet when we all go do that, it's NOT in a medical environment and that's what makes things radically different.

Here's the deal: we function under some scope of practice limitations that include NOT prescribing or dispensing medication. Only certain other providers are authorized to do that. If the patient is under our care, any medication that the patient needs or requests has to go through a provider that's authorized to prescribe and dispense that medication. Those other steps are in place to help ensure that the medications don't interact in such a way that the patient has a bad outcome from it. If you look on the OTC shelves, you'll only find a few medications and those generally don't interact badly with each other.

Here's another issue... LOTS of pain medications are combined with acetaminophen (AKA Tylenol) and it's very easy to exceed 4g/day of the stuff. Suppose the patient's family brings in some 500 mg Tylenols and gives the patient 2. That's 1000 mg (1g) right there. The patient's pain comes back a few hours later, so you end up giving the patent two 5/325 Norcos, so that's now 1650 of Tylenol. Just 4 hours later, the patient needs some more so two more are given and the patient now has 2300mg on board and the patient's family thinks you're running slow, so without telling you, they provided another 1000mg. That's 3300 mg and the day's nowhere near over. The good news at this point? The patient is likely going to survive, but their liver won't be very happy about it but the patient could come VERY close to the LD50 of Acetaminophen. (There's a reason why the max 4g/day...)

That's just ONE medication!

I also noticed that you mentioned Normal Saline as an IV infusion. How do you know if IV fluid is actually indicated? How much fluid is needed? There's lots to consider when placing an IV line. It's not exactly a benign thing.

You have much to learn, and if you're not careful, you can easily go well beyond your scope of practice and end up practicing medicine without a license. I have a LOT of education under my own belt, so to speak and I can very, very easily go beyond what I'm allowed to do, yet I demonstrably have the knowledge to accompany what I can do. Know what you can do and stick to that. If you want to expand what you're allowed to do, seek out the appropriate education.

[akulahawkRN, ADN, RN, EMT-P]

2 /4 years, yes.

Also, stop with the ad hominem, your opinion of whether I'm competent or not has no bearing to this thread/question.

Actually, some of what you said earlier does make people wonder if you're knowledgeable enough to be able to practice as a Nurse in a safe capacity at this point.

[brillohead, ADN, RN]

Sounds like the OP wants to be a NP, rather than a bedside nurse.