What have you done without a Dr. order?

[noahsmama]

I guess I'm wondering why you find it necessary to do these things without a doctor's order? Are the doctors that slow in responding that you can't get the order you need in a timely fashion? When I worked in a hospital (I'm in public health now), doctors were generally very good about responding to pages, especially since we had the option of sending a text page, in which I could explain exactly what I needed and why. If I had a pt in respiratory distress, I could get an order for a stat X-Ray and ABG within minutes. And nurses weren't allowed to enter an order for X-rays or labs -- there was no way I could enter it into the computer even if I wanted to, and the lab would not do any tests unless a doctor had ordered it.

I could see saving a stool sample without an MD's order, but I would ask for the order before submitting the sample to the lab. What if the doctors want to test for other things besides C-diff?

Since we weren't allowed to take verbal orders except in emergencies, I wouldn't even give a med, even if I had spoken to the doctor and they had assured me they would enter the written order, until the order actually came up -- if I had to call the doctor again to remind them to enter the order, so be it.

I only worked in a hospital for a short period (1.5 years), but I don't think I ever once during that time did anything that required a doctor's order without actually having the order. To do otherwise is to risk losing your license, and why in heavens name would you want to do that?

[elkpark]

I don't feel comfortable doing anything that requires a physician's order without that order, and the facilities in which I've worked don't permit that, anyway. It's been a long time since I've worked anywhere that one could get away with doing stuff like that -- i.e., computerized systems for entering orders that would require you to lie about having a physician's order in order to enter the order into the system, pharmacy systems that require you to scan the actual written physician's med order to the pharmacy, etc.

"I don't think I'm too bad" is a justification/rationale that makes me v. uncomfortable. I'm not saying this as a personal criticism of you, or anything, but I'm shooting for a higher professional standard than "not too bad." :) IMO, if people want to be able to order meds, procedures, etc. (outside of established, legitimate facility protocols, standing orders, etc.), there are educational/professional pathways to legitimately accomplish that -- pursue an advanced practice role that suits you. Otherwise, you are ultimately taking chances with your license. If a situation goes bad and comes back to bite you (even if it's just a matter of a physician taking offense and complaining), you won't have a leg to stand on -- is that a risk you want to take?

However, I'm v. "old school" when it comes to scope of practice, and I'm sure I'll turn out to be in the minority on this question (as I so often do on this site). :)

[PsychNurseWannaBe, BSN, RN]

I only order things that I have standing orders for; which include things like get xray if fracture is suspected, obtain UA with C&S if S/S of UTI, etc.

[StNeotser, ASN, RN]

We've all done things, such as giving o2 to a patient that has desatted without a doctors order. However, that's written in most standing orders anyway.

If anyone here admits to doing so, there'll be the holier-than-thou replies.

[MassED, BSN, RN]

like you wrote, xrays (for a resp distress, febrile, productive cough) obvious fractures, etc. EKG's for cp, order labs, u/a's. I know some nurses give Zofran for nausea/vomiting without an order and go back for an order, but I never give meds without an order. I might pull it up and ask the doc "I have 4 of Zofran pulled up for the pt in such and such room for n/v - can I give it IV" ? I insert Foley's for hip fractures and ask after for an order, if the MD forgot.

I now work at a teaching hospital, so my autonomy has been stolen on what I might have done at "other" places.

[blondy2061h, MSN, RN]

I gave meds twice without an order in situations where the MD was just not calling me back and I was genuinely worried about what would happen with my pt if they didn't get the med. Both times I got the medication ordered shortly after. Once was IV benadryl to a patient who was having a bad platelet reaction and clearly beginning to lose their airway (hives coulda waited). I can't recall the other time.

Both times occurred before my hospital had a rapid response team.

We have standing orders for c-diffs.

[nursel56]

Saving a specimen that might be harder to get later on for a test you know will be ordered based on taking care of hundreds of people and working with Doctor X and knowing his/her habits doesn't seem like it would be risking a license to me, but honestly I look forward to seeing the spectrum of opinions on this.

[all_over_again]

I have given IV dextrose to a diabetic in an emergency. Immediately after, I called the doctor to get an order. The patient lived. I would have preferred to lose my job than allow someone to die unnecessarily.

[grandmawrinkle]

I will advance diets and ambulate post-op patients if need be before the patients actually get orders for these things if the resident is slow in getting to the floor to write transfer orders. I will pull lines (swans, artlines) if they have transfer to floor orders as it is implied that those are going to come out if they transfer to the floor as the floor won't monitor them, even if it isn't explicitly written. Some things are common sense and you more or less know what is on the "pathway" even if the pathway isn't explicitly written. If there are contraindications or any question about it, I'll run it by the doc first.

We have protocols for hypoglycemia and respiratory distress, etc. that covers oxygen, ABGs, D50 or other choice of sugar. I will not do cultures, including stool, for diarrhea as some have mentioned here. Diarrhea does not always mean c. diff and when I have ran whether or not to cx by the doc, they do occasionally say that they don't want the cx done. I will do ANY emergency interventions -- a very wise stepdown nurse (where I started, a while ago now) told me in a medical emergency/near code situation that you can do a lot of stuff if you have ACLS because as a provider as your certification covers you, as long as you are within their guidelines. I haven't forgotten that.

I run into problems the other way, occasionally. I had a post-op that was oozy the other PM and the CBC hadn't been checked since immediately post surgery. I suggested a CBC check that PM -- the doc said no, they didn't think it was necessary. I came in the next day and his HgB was 6.4 with his AM labs and had already gotten 2 units of blood . Unfortunately, sometimes we do know best, but we are not listened to. I documented my suggestion (MD was notified re: drainage, dressing reinforced x3, no new orders received.) What else do you do? Had patient been hemodynamically unstable and/or hemorrhaging, I would have drawn the CBC -- per ACLS differential dx, but that wasn't the case.

[kids]

If it's in the standing orders you're not doing it without an order.

To answer the original question - with the exception of O2, no.

"Knowing the doc" is all well and good until that doc is in a mood and refuses to sign an order to cover you. Or you're like co-workers I've had who gave milk of mag to someone in renal failure or harmless 'ol Tylenol to a patient with liver failure.

I enjoy my license, I even like my job sometimes. I'd prefer to keep both.

[litbitblack, ASN, RN]

I used to work ortho and the docs pretty much let the nurses they trusted order labs and stuff and get orders from them, but that did backfire on one of the nurses as the doc said he wouldn't have wanted that cbc and refused to sign the order. Not sure what ever happened. Just remember they have a license to protect to and they may one day decide not to sign what you did therefore you are then practicing medicine not nursing

[nurse_mo1986]

it also depends on where you work. I work in a smaller ruraal ICU in a smaller hospital and know all of our docs one on one. That means I know when they do vs. Don't wanna be called. Certain docs don't even wanna be called about a resp distress unless I've already done portCXR, and drawn ABG's. Then we have other docs who wanna be called stat and then will direct care.

I will say that in this setting we are expected to have a certain degree of autonomy. With certain docs I'd think nothing of giving tylenol at two am for a headace IF THERE ARE NO CONTRAINDICATIONS. A lot of times it just means thinkin for oneself.

And as far as the oxygen thing...i believe in treatin the pt as needed. If a pt has a sat of 60% and I think a code is looming, I'll do whatever it takes while waiting on the doc to return page/arrive in unit.

just my opinion, nurse_mo1986