Nurses that write their own orders - page 6

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   Kanani_Ikike
    My mistake, response is below.
    Last edit by Kanani_Ikike on Oct 1, '07 : Reason: duplicate posts
  2. by   Kanani_Ikike
    Quote from queenjean
    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.

    Thank you for replying. Now, I was surprised with the Chest Pain protocol at my hospital. The other night, one of my patients was having chest pain, so I called respiratory for a STAT EKG. I thought that this was protoco in most facilities, so I ordered it. It wasn't abnormal and I let the doctor know about it in the am. However, I was told that I needed an order for that. Now, that's something that shocked me.
  3. by   Kanani_Ikike
    Quote from suanna
    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.
    Thanks for replying. I can understand your point of view. In the real world, that they wouldn't ever get that many calls to drastically alter their sleep. I'm pretty sure they can make good judgement calls on issues such as the ones you presented. However, I'm going to call them for any order if their is no policy present stating otherwise. Standing orders would be for the most basic things, such as this. I bet that if they get enough calls, they'll eventually get those standing orders drafted. I'm the nurse, they're the doctor. I didn't go to school to write orders, I just follow them. Experienced or not, no nurse should have to write orders for things that they need. And doctors have no business not returning phone calls when they're paged. If they don't want to be bothered, then they should get out of medicine.
  4. by   Kanani_Ikike
    thank yor for your reply and thank you for those resources. i'm glad you posted them. i think nurses need to know how fragile an issue this can be. i don't trust a physician to have my back because i know that when the ball is dropped, it'll be put in my court, even if it wasn't. i take no chances. there's no excuse for it.
  5. by   cappuccino
    I absolutely would not go ahead with any patient procedure or treatment without md orders. Period. You're just basically opening yourself up for potential litigation.................
  6. by   leslie :-D
    Quote from cappuccino
    I absolutely would not go ahead with any patient procedure or treatment without md orders. Period. You're just basically opening yourself up for potential litigation.................
    i understand your reluctance.
    so let's say that you didn't irrigate, and ultimately, the pt ended up dying.
    and it goes to court.
    you don't think the nurse wouldn't be a target of potential litigation, for not acting as a prudent nurse?
    personally, i think we're hung either way.

    leslie
  7. by   TrudyRN
    Quote from RainDreamer
    NO NO NO NO NO!!

    That is absolutely wrong and not within the RN's scope of practice.

    I don't know the details, but we just had a nurse that was fired for this not too long ago .... taking it upon herself to write orders that weren't ordered by the doc/NNP. It was then submitted to the board of nursing.

    I don't care how "little" of an order it is, I would never do it, as it's not worth risking my license.

    I'd find a new place to work. You're not being at all obsessive or overreacting. I find it very disturbing that the nursing supervisor is condoning/initiating this!
    It might be the same at her new job. That is not the way to handle this.
  8. by   TrudyRN
    Quote from suanna
    I agree you shouldn't write for anything you are not comfortable ordering but as you gain experience with your docs you will hear things like " of course I want you to irrigate a blocked foley...that's basic patient care" Once you know your physicians preferences for basic requests you both will have quieter nights. I would never write an order for a Rx med but to irrigate foley seems like a basic nursing policy rather than a medical decision; (providing there is no reason not to). I have said this in other threads- how would you like the surgeon that got 2 hrs sleep due to frequent phone calls to do surgery on your husband or mother the next day at 8am. They can't forsee every possible need that may arise throughout the night or the standing orders would be 10 pages long. I'm suprised your peers aren't more help. When we have a new nurse on our floor the senior staff will frequently write the "expected"orders for the doc taking the new people somewhat off the hook. Just remember-the life you save may be his next case.
    So you condone nurses writing orders, practicing medicine without a license.
    The list would not be ten pages long. They'd hone it down to the necessary items. They're not dumb, just no one has helped them do it. They most certainly can foresee a great, great percentage of all possible needs that might arise. And better to have pre-printed standing orders if they don't want to be bothered with after hours calls.
  9. by   Kanani_Ikike
    Quote from cappuccino
    I absolutely would not go ahead with any patient procedure or treatment without md orders. Period. You're just basically opening yourself up for potential litigation.................

    Thank you for your reply. Also, thank you for understanding how I feel. I feel the same way. There is so much are so many litigious people out there. Some people are looking to get rich quick. They don't care if you save their life, they just look at the negative. What if that man gets a UTI from the non-sterile irrigation from the nurse supervisor and it's bad enough to shut his kidney's down? Who will get the blame? Not me, because I certainly didn't write the order and I didn't irrigate without orders. I just hope other nurses realize that we are limited as to what we can do simply because we are not doctors. We just can't do things without a doctor's order unless it's an emergency. Even then, I don't know where to draw the line. Thank you for seeing what I'm trying to convey.
  10. by   Kanani_Ikike
    Quote from earle58
    i understand your reluctance.
    so let's say that you didn't irrigate, and ultimately, the pt ended up dying.
    and it goes to court.
    you don't think the nurse wouldn't be a target of potential litigation, for not acting as a prudent nurse?
    personally, i think we're hung either way.

    leslie
    Thank you for replying.

    You are absolutely right, Leslie. We are hung either way we go. But I think we shouldn't have to even deal with that type of decision. The doctor should be calling back no matter what. What nerve he/she has to not return phone calls. Someone could be dying. They need to call back.
  11. by   Kanani_Ikike
    Quote from TrudyRN
    So you condone nurses writing orders, practicing medicine without a license.
    The list would not be ten pages long. They'd hone it down to the necessary items. They're not dumb, just no one has helped them do it. They most certainly can foresee a great, great percentage of all possible needs that might arise. And better to have pre-printed standing orders if they don't want to be bothered with after hours calls.
    Thank you for your reply. Thank you so much, Trudy, for understanding. I don't think that many realize the ramifications for doing things without a doctor's order. Like you said, they need standing orders. That would help them and US out a lot. I don't think they should be allowed to get away with such behavior. I mean, we, as nurses, are tired, too. I know on night shift, I'm tired. I haven't been able to adjust. And although it's been hard on me and I'm tired, I can't not answer the call light just because I don't want to or because I fall asleep. I try to anticipate pt. needs to keep them off of the light if at all possible. That's exactly how these doctors should start thinking. They need to anticipate the problems that can arise and have standing orders available. Like someone else said, they can't anticipate every need, but they sure can cover the basic stuff. Thanks for understanding.
  12. by   cappuccino
    You're welcome. I believe you can render care without jeopardizing your license. It can be so FRUSTRATING at times. That goes without saying. In your case , what if irrigating the catheter didn't work? You would still need to change the catheter-which also requires an md order. So no matter what , always contact the md or make sure that your manager or supervisor gets one for you. Just make sure you document all the attempts you made to contact the attending physician..............:spin:
  13. by   TheCommuter
    Quote from ZippyGBR
    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 ...
    In U.S. hospitals, items cost triple and quadruple what they would cost on the streets. Some patients are billed $5 for two 325mg aspirin pills or $40 for a pair of cheap slippers on their itemized hospital bills.

    Healthcare in America is all about profit margins and the almighty dollar.

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