Nurses that write their own orders - page 5

Hello, all in allnurses.com universe. It's me again. I have a concern that I would like to share with you all and ask for your opinion. At my new job, I am seeing a whole different culture of... Read More

  1. by   ZippyGBR
    once again good basic nursing care derailed by billing and the whole 'orders' thing

    at 300 USD many urology patients ought to be given their own bladder scanner at the end of their hospital stay... or are the portable single function USS bladder scanners we use in the UK unknown in the US becasue it's more billing to get Medical imaging to come and do it with a full sized ultrasound machine wasting the time of the sonographer ?

    irrigating a cather ?40USD ? the bind moggles - a jug, a basic sterile pack, gloves , an bottle of sterile water and a bladder tip 50 ml syringe doesn't cost that much ...

    as for orders to irrigate? surely maintainance interventions etc are or should be either part of the care plan implemented when the decision to insert a catheter is made or part of the facility policy for catheterisations ...
  2. by   leslie :-D
    dang, i shudder to think of what would happen if the foley wasn't irrigated?
    seriously.
    what are the implications of the pt sustaining serious trauma in the presence of an obstxn?
    and let's say it goes to court.
    are we limited in our actions r/t the absence of an md order?
    or, do our parameters define our practice in what a "prudent nurse would do"?
    and if we act as a prudent nurse, what will our bon say about this???

    if the pt presented with distended bladder, no uo, and other acute s/s, i would irrigate.
    but what if no one made the decision to do so, and all awaited the order of an md?
    again, are we bound by our scope of practice or the actions of a prudent nurse?

    leslie
  3. by   Kanani_Ikike
    Quote from cmo421
    We used to have problems with a doc calling back or taking forever to call at night. When this happened we would recall twice, after that, we would call the head of the unit at home(chief of ICU) and let him gives us orders.We had a house officer who u could call, but sometimes they just were not enough. Eventually the offending doc had to give up pt's that required ICU per the Chief. Once this starting happening, other doc's took notice and returned calls quicker. We also kept a log of when we called and response time. It helps when u have evidence to back u up!
    Thank you for replying. It also helps when the doc has an answering service that forwards calls to them. That way, there's a record of attemtped calls in two places, not just one.
  4. by   Kanani_Ikike
    Quote from ZippyGBR
    once again good basic nursing care derailed by billing and the whole 'orders' thing

    at 300 USD many urology patients ought to be given their own bladder scanner at the end of their hospital stay... or are the portable single function USS bladder scanners we use in the UK unknown in the US becasue it's more billing to get Medical imaging to come and do it with a full sized ultrasound machine wasting the time of the sonographer ?

    irrigating a cather ?40USD ? the bind moggles - a jug, a basic sterile pack, gloves , an bottle of sterile water and a bladder tip 50 ml syringe doesn't cost that much ...

    as for orders to irrigate? surely maintainance interventions etc are or should be either part of the care plan implemented when the decision to insert a catheter is made or part of the facility policy for catheterisations ...
    Thank you for replying.

    It sure would be nice if it was. I don't think somebody had these types of situations in mind when they were writing policy. I don't know why. I guess because the nurses just always did it as a part of the care plan. And I would, too, if things were not like they are today. I always won't something to cover me.
  5. by   Kanani_Ikike
    Quote from earle58
    dang, i shudder to think of what would happen if the foley wasn't irrigated?
    seriously.
    what are the implications of the pt sustaining serious trauma in the presence of an obstxn?
    and let's say it goes to court.
    are we limited in our actions r/t the absence of an md order?
    or, do our parameters define our practice in what a "prudent nurse would do"?
    and if we act as a prudent nurse, what will our bon say about this???

    if the pt presented with distended bladder, no uo, and other acute s/s, i would irrigate.
    but what if no one made the decision to do so, and all awaited the order of an md?
    again, are we bound by our scope of practice or the actions of a prudent nurse?

    leslie
    Thanks for replying. It's definitely a Catch-22. Your doomed if you do, doomed if you don't. You well-paid lawyer will make a case out of anything. So, you never know. We could always do it without orders and tell the patient not to tell anyone. Then if something went wrong, you know they'll sing like a canary. But I would hope that in the end, the good intentions ans good nursing care would prevail. Unfortunately, that's no enough in this day and time.
  6. by   P_RN
    Look on your board of nursing site. I'm happy to say I worked at a teaching hospital and it had physician residents up the ying-yang.

    I'm in SC and on our BON there are multiple scope of practice for RN and/ or LPN advisories.
    For urinary catheters: http://www.llr.state.sc.us/POL/Nursing/forms/genti.pdf
  7. by   queenjean
    Quote from Kanani_Ikike
    Thank you for replying. I've never had irrigating a foley as policy in any of the places I've worked. That would be nice to have, but it's not the norm in the places I've been. I would think that if the doctors didn't want to be bothered at 2 or 3 in the morning, then they should establish standing orders.

    Did you check your floor's protocol for foley management? In our protocol, with adults we can write an order for irrigation under certain parameters. If the docs don't want the catheter irrigated without being contacted first, they must write an order specifying that.

    So we don't need an order to irrigate, any more than you need an order to put a patient on oxygen and get an EKG in the event a patient is having chest pain--these are part of our (and I suspect any typical) chest pain protocol. Often we do these things, then call the doc with the results if they are abnormal or need additional follow up. If everything is normal, we either leave a note for the doc, or call first thing in the morning.

    If it's not covered by a protocol or a standing order, then I call the doc. Whatever the outcome, I always document it in the computer chart (nurse's notes come up on the front page and cannot be erased). So if the doc doesn't call back, I chart it. If the doc says, "I don't give meds for headaches in the middle of the night, he can tough it out until morning," I chart that the doc states no new orders. I always always always tell the patient what the doc said, or if the doc doesn't call back. They have a right to know if they have a crappy, uncaring, unprofessional doctor.
  8. by   suanna
    Quote from Kanani_Ikike
    Thank you for replying. I've never had irrigating a foley as policy in any of the places I've worked. That would be nice to have, but it's not the norm in the places I've been. I would think that if the doctors didn't want to be bothered at 2 or 3 in the morning, then they should establish standing orders. And if a doctor, is for instance, going to be performing surgery the following morning, then it will be his negligence for doing without enough sleep. That would be like me driving and crashing into and killing someone after working an all nighter. If I knew that I was too sleepy to drive, then I'm liable for my poor judegement. There is no excuse for me not to call a doctor when I'm concerned. Especially when this pt. started bleeding out of the blue like that. I suspected a blood clot, but it could have been something more serious. I think that's a problem when nurses don't call because they don't want to disturb the doctor. I trust my instinct always. But I understand what you're saying. To harrass the doctor is not my intention. I just want to care for my patients within my scope of practice.
    I can understand your concerns but I still feel that it would be impossible to write for every contengency that may happen- the orders would be so long the doctor may as will spend the night on the unit- he/she will be there checking off orders for hours and stil won't cover all the bases. The problem is with a physician in single practice, residents don't cover his service, and he has 20-30 patients at various stages of recovery in the hospital at any one time. "got too many phone calls last night so I have to cancel your moms heart surgery- hope she doesn't infarct today" isn't going to be a good answer. An experienced nurse should be able to discern an evolving crisis from basic patient care and act in the patients best intrest- his/her patient and the ones being done the next day. When in doubt call, err on the side of caution, but we are educated in assessment skills.
  9. by   leslymill
    dang, i shudder to think of what would happen if the foley wasn't irrigated?
    seriously.


    Okay not so seriously,
    Pt exibits signs of increasing restlessness......
    Pt begins to thrash and moan.......
    Two things can happen......two things you might hear...one.....
    ..............POP
    Find pt holding foley with balloon intake in one hand, dangling over the siderail and other hand holding groin....
    he has a smile on his face.
    .............two
    .............BANG............
    Pt is poorly responsive and his v/s are plummetting..
    Emergency Surgery is scheduled.
    He has a look of shock on his face.
  10. by   NRSKarenRN
  11. by   Tweety
    I'm going to have to check to see if we have standing orders for that, because in cases like that I would deflate the ballon, make sure it's in place, and irrigate. My bad.

    However, as I tell my coworkers and new grads, never ever do anything your not comfortable with, and never step out of your scope of practice, and cover your butt.

    A coworker of mine gave Ativan IV for a restless patient, but the order was for while intubated and the patient was extubated 30 minutes prior, thinking "I'll get the MD to cover me later". Well the MD turned her in and she lost her nursing license for one year and had to work at a fast food restaurant.
  12. by   NRSKarenRN
    nys professional discipline summaries - february 2005

    virginia bon examples of reportable / non-reportable conduct


    i strongly recommend to nurses that they work with clinical managers to get standing orders implemented for common illnesses seen on a unit or standardized orders per physician practice---saves so much time, minimizes after hour physician calls and bottom line improves patient care.
    Last edit by NRSKarenRN on Oct 5, '07 : Reason: spelling of course!
  13. by   Kanani_Ikike
    Quote from P_RN
    Look on your board of nursing site. I'm happy to say I worked at a teaching hospital and it had physician residents up the ying-yang.

    I'm in SC and on our BON there are multiple scope of practice for RN and/ or LPN advisories.
    For urinary catheters: http://www.llr.state.sc.us/POL/Nursing/forms/genti.pdf

    Thank you for replying. I didn't think about going to the Board of Nursing. But you know, at this hospital, a lot of things the Board of Nuring condones, this hospital doesn't have in their policy. The BON should trump hospital policy, right?

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