Interventions without MD orders

Anna Flaxis, BSN, RN · May 10, 2014

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?

There are literally hundreds of nursing interventions that are independent of physician orders. However, yes, as nurses we do have limits on our scope of practice, such as that we do not diagnose and prescribe, so yes, we do need a physician order to give Tylenol or to start an IV. This does not limit nurses to hospital settings- in your example, if you were working for a hospice/palliative care service, that service would have a medical director who would be the physician responsible for writing the protocols and standing orders that you could function under.

As others have stated, you do not need a physician's order to perform nursing interventions that are within your scope of practice.

I don't think nursing has been complacent- I think that you should remember that IV fluids are a medication. Determining the appropriate fluid, at the appropriate rate, in the appropriate amount, involves diagnosing and prescribing, which are physician functions. Carrying out those orders and monitoring the patient's response are nursing functions.

And on the term "orders", I don't think of the term "orders" as commands or directives, so much as placing an order for a product or service. It is still up to the person providing that product or service to determine if it is safe and to monitor the patient receiving that product or service for the desired response or any complications, and to act appropriately.

When a doctor places an order, I don't feel as if I'm being told to do something so much as the doctor is requesting an intervention for the patient. It might not seem like much of a distinction to some, but to me the latter feels more collaborative.

SubSippi · May 10, 2014

Almost nothing is autonomous in nursing. Just about everything is collaborative.
Personally, I love my role. I will advocate for my patient all day and question doctors orders if necessary. But when it comes down to it, the brunt of the medical decision making is on the physician. That is why they went to school at least twice as long as we did, make hundreds of thousands more than we do, and pay thousands more in liability insurance than we do. I have enough on my plate right now as an RN without the added responsibility of being a health care practitioner.

I would even say that hardly anything in any medical profession is completely autonomous. Although there are certain jobs that are completely free of collaboration, in my limited experience I have found that this is the vast minority.

I am under the impression that this is purposeful, in order to eliminate mistakes and benefit the patient. In a hospital setting, there is a checks-and-balances system between the pharmacist (when meds are involved), the MD, and nurse (with the nurse being the last "line of defense"). MDs don't usually give meds not just because it's a "nursing duty," but because that info needs to go through another person.

And on SECOND thought, I would say a patient can be the last line of defense. More than once, I have had a patient say they don't normally take something or they usually take more/less, which has prompted me to double check my meds. I'll find that I had forgotten to split the Lopressor or something like that. Always double check if your patient is hesitant about taking a medication.

ArtClassRN, ADN, RN · May 10, 2014

I know you don't understand this, but: You are looking at the situation in completely the wrong way.

Think of airline pilots; are they highly skilled, use their judgement constantly, and critical to their passengers well being? If you think they are, then you should realize your original post is inaccurate, self-pitying nonsense.

nurseprnRN, BSN, RN · May 10, 2014

However, yes, as nurses we do have limits on our scope of practice, such as that we do not diagnose and prescribe, so yes, we do need a physician order to give Tylenol or to start an IV.

Wrong-o, as I delight in telling attorneys in deposition all the time. Physicians also have limits in their scopes of practice. For example, physicians are not trained or qualified to make home visits to evaluate for and prescribe hours and levels of nursing care. (Don't believe me? Look it up.)

Physicians make medical diagnoses and prescribe interventions for medical diagnoses. I make nursing diagnoses and prescribe interventions for nursing diagnoses.

Words matter.

BrandonLPN, LPN · May 11, 2014

Wrong-o, as I delight in telling attorneys in deposition all the time. Physicians also have limits in their scopes of practice. For example, physicians are not trained or qualified to make home visits to evaluate for and prescribe hours and levels of nursing care. (Don't believe me? Look it up.)

Physicians make medical diagnoses and prescribe interventions for medical diagnoses. I make nursing diagnoses and prescribe interventions for nursing diagnoses.

Words matter.

But, he/she was right in saying we cannot administer Tylenol or start an IV without a phys. order, those being medical interventions.

I do believe that it's wrong-headed to view that as a "limitation" to the scope of practice of a RN. Medicine and nursing are two different fields, so it's rather pointless to compare what one can do and the other can't.

And didn't physicians used to make house calls all the time back in the day? How could they be unqualified to do so?

KelRN215, BSN, RN · May 11, 2014

Wrong-o, as I delight in telling attorneys in deposition all the time. Physicians also have limits in their scopes of practice. For example, physicians are not trained or qualified to make home visits to evaluate for and prescribe hours and levels of nursing care. (Don't believe me? Look it up.)

Physicians make medical diagnoses and prescribe interventions for medical diagnoses. I make nursing diagnoses and prescribe interventions for nursing diagnoses.

Words matter.

It's funny when they think they do. We had a private duty patient and when he was re-evaluated for his nursing hours, the nurse case manager determined he no longer qualified as he had fully recovered from his acute illness and had been decannulated/was independent with his care. The MD thought he could send over an order to continue nursing services and that we would have to oblige him despite the fact that the patient no longer qualified and we had no payor for these services.

KelRN215, BSN, RN · May 11, 2014

But, he/she was right in saying we cannot administer Tylenol or start an IV without a phys. order, those being medical interventions.
I do believe that it's wrong-headed to view that as a "limitation" to the scope of practice of a RN. Medicine and nursing are two different fields, so it's rather pointless to compare what one can do and the other can't.
And didn't physicians used to make house calls all the time back in the day? How could they be unqualified to do so?

A Physician can make as many home visits as he likes. GrnTea stated that a physician is specifically not qualified to evaluate a patient for level or hours of nursing service. An MD does not go to the home, evaluate a patient and say "Mr. Jones should receive 40 hrs of private duty nursing per week." Nurse Case Managers make that assessment.

BrandonLPN, LPN · May 11, 2014

A Physician can make as many home visits as he likes. GrnTea stated that a physician is specifically not qualified to evaluate a patient for level or hours of nursing service. An MD does not go to the home, evaluate a patient and say "Mr. Jones should receive 40 hrs of private duty nursing per week." Nurse Case Managers make that assessment.

Oh, ok, I see, read the sentance wrong.

Anna Flaxis, BSN, RN · May 11, 2014

Wrong-o, as I delight in telling attorneys in deposition all the time. Physicians also have limits in their scopes of practice. For example, physicians are not trained or qualified to make home visits to evaluate for and prescribe hours and levels of nursing care. (Don't believe me? Look it up.)

Physicians make medical diagnoses and prescribe interventions for medical diagnoses. I make nursing diagnoses and prescribe interventions for nursing diagnoses.

Words matter.

Splitting hairs. We are not in a deposition. You know what I meant.

beckster_01, BSN, RN · May 11, 2014

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.

In nursing school do you learn how to calculate a free water deficit? I didn't. If you don't know that how do you know what rate the solution should run at? Do you know whether a patient should have NS, d51/2, or LR? Do you feel confident enough in your knowledge of fluid/electrolyte balance to make these decisions as a new grad? Honestly maybe I went to a crappy school, but we spent about 10 minutes on each of those topics. Enough to know what is in each iv solution and which ones are isotonic. I might have learned when each might be prescribed but I did not learn how to make that decision. Our doctors regularly quiz residents on which IV fluid should be started and how fast and how long. You can really screw up someone's sodium levels with normal saline.

Novo · May 12, 2014

In nursing school do you learn how to calculate a free water deficit? I didn't. If you don't know that how do you know what rate the solution should run at? Do you know whether a patient should have NS, d51/2, or LR? Do you feel confident enough in your knowledge of fluid/electrolyte balance to make these decisions as a new grad? Honestly maybe I went to a crappy school, but we spent about 10 minutes on each of those topics. Enough to know what is in each iv solution and which ones are isotonic. I might have learned when each might be prescribed but I did not learn how to make that decision. Our doctors regularly quiz residents on which IV fluid should be started and how fast and how long. You can really screw up someone's sodium levels with normal saline.

This isn't about my knowledge but nursing as a whole. My beef is that a nurse with 30 years experience has the same scope as a new grad.

Here.I.Stand, BSN, RN · May 12, 2014

This isn't about my knowledge but nursing as a whole. My beef is that a nurse with 30 years experience has the same scope as a new grad.

A nurse w/ 30 yrs experience has definitely been able to hone his/her own critical thinking skills beyond what a new grad has, and will know better what the pt needs. This can be helpful in talking to the docs, esp. if the doc is green. I have a handful of "I don't know what to do" resident stories, and thankfully there were experienced RNs who were able to help them. (The big two that come to mind are a dangerously high ICP, and an 85% TBSA burn pt being flown in.)

Depending on the setting, a veteran RN IS able to do more than the new grad. I'm not a new grad but have only been on my current job a little over a year. I don't run ECMO. If we have a pt in my ICU on ECMO, I would not be assigned as that pt's RN.

All that said though, RNs have a Nurse Practice Act that they're bound to regardless of experience level. Prescribing falls outside of scope, unless you're an APRN. That might be something for you to consider once you're through nursing school and get some experience under your belt.