Without Orders - page 3

by Apollo8933

7,452 Views | 54 Comments

Hey all! Have been reviewing multiple websites, state government and blogs and found that laws are very vague. I know this is to allow grey areas to occur to allow patient safety as well as protect nurses and other health... Read More


  1. 0
    I wouldn't be entering orders for pain meds without the doc giving me specific orders...that's practicing medicine & out of our scope of practice....I value my license too much...
  2. 0
    I think many times it depends on the doc. Some doctors have pages of routine orders. Others don't. Some you know you can order their patient a lunesta at 1 am because if you called them for that you'd get yelled at.

    If the patient is under hospitalist services, the resident or hospitalist has to put orders in and we cannot write them.

    On my floor we get a bunch of chest pain obs. We are expected to get an EKG for c/o cp. We also put them on tele if we feel they need it when the doc forgets to write it.

    IVs are just required. Unless it's an order set that's preprinted they don't always write it but it's done.

    My facility gives nurses a fair amount of independence. Peaked t waves? Run of VT overnight? They'll be cool with me ordering a mag and a K.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
  3. 0
    Nurses who write orders without speaking to the provider or without basing them on a protocol are technically practicing medicine as I see it. But nurses are doing this to help save lives and to avoid waking up or bother a provider, right? It seems to me that the institutions come out on top by not having to adequately staff providers and/or create protocols, and/or create order sets (that help a provider write adequate orders). Additionally, providers come out on top as they have less of their time infringed upon. The liability then is placed on the nurse. That seems inappropriate to me. It's nice for the institution and the providers as they are not inconvenienced.

    Institutions should support their nurses by having in place adequate numbers of providers, adequate orders, and adequate protocols. Providers should not be allowed to yell at nurses. Institutions should devise systems that help providers write adequate orders. On the other hand, if this is not to occur and nurses are to blur the lines and write orders on their own, nursing practice laws should be changed to cover them.

    There is at least one story on this site that I recall someone saying they lost their job over writing a Tylenol order at night without calling the MD...and then the MD refused to back it up...even though nothing happened to the patient...
  4. 0
    the hospital I'm doing clinicals at has a standing "titrate O2 to keep sats above 92%" and also if someone isn't feeling "right" and is on room air we can put them on 1L N/C without an order...
  5. 0
    Officially, nurses cannot do anything without a doctor's order or stardardized procedure or hospital policy to cover what they are doing! We put in IV's in all telemetry patients even if the doctor doesn't write an order because our policy states all monitored patients must have patent IV access. At some hospitals, nurses and RT's need a doctors order to put a nasal cannula on the patient even if the O2 sat is 70%. Luckily, my hospital and doctors are ok with that! Each doctor and facility is different.
  6. 0
    My point of this thread was to learn of interesting nursing actions that can be done WHEN THERE IS NO DOCTOR I do not work for a hospital but an urgent care clinic we get crazy cases like chain saw wounds to necks etc etc. But I am a nurse outside of work too....what nursing actions do you feel comfortable doing outside when you are simply a nurse...not an ICU nurse not an ER nurse etc....
  7. 0
    Without a doctor you are still a nurse....so what are interesting things you can do that may be uncommon but still legal to do per state or county
  8. 3
    Quote from Apollo8933
    Without a doctor you are still a nurse....so what are interesting things you can do that may be uncommon but still legal to do per state or county
    This is a rather curious thread. The majority of RN independent practice is with nursing diagnoses and the implementation of the same. I can assess a patient with say, atelectasis, and implement a plan that includes hourly deep breathing, coughing, spirometry, and ambulation. I can do the teaching with the patient of how to complete all of this and why it is going to help. I can evaluate the effectiveness of my interventions and change the plan as necessary. All of this is independent nursing practice.

    I suspect however that when you say interesting things you mean psychomotor skills, in which case, the previous responses are totally correct: when we start an IV, defibrillate a patient, run a fluid bolus, enter labs or give Tylenol, aspirin, zofran etc. we are acting on protocols or standing orders.

    There is a plan where I live to start some limited prescribing for RNs but that is probably a few years down the road still.

    Anyhow, long post, but my point is I act "without orders" daily. But I act within my scope of independent practice, not as glamorous, but important and challenging nonetheless.
    GrnTea, joanna73, and PMFB-RN like this.
  9. 0
    Quote from CodeteamB

    This is a rather curious thread. The majority of RN independent practice is with nursing diagnoses and the implementation of the same. I can assess a patient with say, atelectasis, and implement a plan that includes hourly deep breathing, coughing, spirometry, and ambulation. I can do the teaching with the patient of how to complete all of this and why it is going to help. I can evaluate the effectiveness of my interventions and change the plan as necessary. All of this is independent nursing practice.

    I suspect however that when you say interesting things you mean psychomotor skills, in which case, the previous responses are totally correct: when we start an IV, defibrillate a patient, run a fluid bolus, enter labs or give Tylenol, aspirin, zofran etc. we are acting on protocols or standing orders.

    There is a plan where I live to start some limited prescribing for RNs but that is probably a few years down the road still.

    Anyhow, long post, but my point is I act "without orders" daily. But I act within my scope of independent practice, not as glamorous, but important and challenging nonetheless.
    Thank you for answering the actual question lol
  10. 1
    Quote from BrandonLPN
    But even protocol or ancillary order sets are still physician's orders. They're all standing orders. They were all developed by physicians and I'm sure they're all approved by the medical director and the official document, wherever it is, bears his signature.

    Non invasive or non pharmicological interventions such as repositioning or breathing exercises are purely nursing interventions. But so many other interventions, ranging from bowel care to catheterization, Tylenol for fevers, inserting an IV, hypoglycemia protocol all are dependent upon pre determined physician order sets. Where I work, even ear irrigation follows standing orders. Can we really say we're doing any of these things "without orders"?
    I am saying by doctor's order is calling the primary and getting an order and placing it on the chart. Of course some computerized signature is locked away on some file in the basement of the hospital for pre-approved sets. If a pt was to get a feeding tube, there is an order set that is ordered by the doc. But I don't need to call him and get an order and specifically enter the order to flush it with 30 ml every 4 hrs. That is the standard. I don't need an order on the chart. A dietician does not need to call the doc and tell them to enter an order for vitamin c and zinc. Yes, it was already pre-approved by a committee long ago, but if you ask whether or not the doc approved that new order, the dietician will tell you that the primary does not need to approve it and they do not need to be called. The dietician can enter it based on their own evaluation. There is no signature that needs to be on that admissions chart.

    You are correct that order sets do need an active physicians signature. I don't think anyone is saying that order sets are being done without a signature. There are things on the order sets that can produce harm or present risk and that's what the signature is for. But, if it falls under strictly nursing, we don't need an order for everything. We don't need an order to initiate fall precautions. If a fall risk assessment is high, the chart will recommend starting fall precautions with side rails up, lowered bed, etc. I enter that as a nursing/ancillary order. A doctor does not need to order it. I don't need an order to place a pt in a roll belt. I need an order for restraints, but if a pt is a risk for getting out of bed, a self-releasing roll belt does not need an order. So, we do have some autonomy.

    But I think the OP was asking our scope and then specifically asking in terms of emergency. Sometimes, you have to act quickly and every once in a blue moon, you need to make a decision that can save them. What I was saying, was I would start the sepsis protocol. I am not going to wait for an actually order before I draw blood cultures. If there isn't an order for oxygen, I am not going to withhold that until I get the order. If the blood pressure 60/30, I'm not going to sit on it until the doctor calls back. I will start fluids or grab a pressor and then let them know when they do call. I've seen a pt that have been on the floor for an 2 hrs with a bp of 70/35 with no intervention b/c the nurse couldn't get a hold of the doctor. The bed with flat though. I have worked in the ER and ICU. Sometimes, you have to act in order to save someone. There is a threshold when things turn into life or limb. Pts go downhill on the floor and those pts may also need saving. I go absolutely insane when a pt is sent to ICU with so many untreated issues simply because "it took a while for the doctor to call back. I think the pt's septic because he is now in renal failure." NO! He's in renal failure because his blood pressure was in the 70's for an 2 hrs!" Most nurses got into this profession because they wanted to help people. Well....freaking help them. (this isn't directed toward anyone specific, I'm just venting in general b/c there are nurses that say our job is to simply carry out the orders of doctors and nothing more. We have a little more importance than that...drives me crazy).
    joanna73 likes this.


Top