Without Orders

Nurses General Nursing

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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 professionals in emergencies but I was wondering...what are some of the things that you all can do without doctors orders? Obviously comfort is a consideration here but name some examples all responses welcome :)

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.

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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....

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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

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Specializes in Emergency.
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.

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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 :)

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Specializes in ER trauma, ICU - trauma, neuro surgical.
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).

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Specializes in geriatrics.

Exactly. Your role as the nurse is to intervene on behalf of your patient and act as advocate, not simply follow Doctors orders, or wait on the Doctor.

If you realize that a particular order and course of action will have a negative outcome, then you need to inform the Doctor to revise the order.

I'm not about to wait to apply O2 for example when my patient is turning blue and sating 70 percent. By the time the Dr shows up, they could be dead.

It depends on your policies, the situation, and the Dr, but most Doctors are appreciative that you've used your nursing judgment. Otherwise, why are we there?

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Exactly the point of this thread. We are taught to be more than servants working on orders and in our world RNs are being given more and more rights and privileges. The idea of this was to help myself and others interested with what we can do without doctors in the hopes to learn and gain further autonomy.

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Specializes in Emergency.

I agree that we need to help our patients. By protocol I can slap as much O2 as I feel necessary on my patient, start as many IVs as I need, order most labs, hang normal saline to bolus or KVO, request ECGs, give some medications and defibrillate. The key word there is protocol. These are not independent nursing practice, that is something completely different, but equally important to our jobs.

Acting within independent practice, as I said before, may not be as exciting as the things we do under physicians orders but we are definitely not servants. Acting to our full potential as nurses can be extremely beneficial to the health and wellness of our patients.

By all means tell the Doc s/he needs to order something else because the order is inappropriate, or that an order is necessary for your patient, but please, please act within your scope!

Hanging pressors is in the scope of an RN, hanging them without a valid physician's order is not (at least not where I come from). By all means, draw it up, mix it, set the pump, but don't hook it to your patient; that, my friends, is a bridge too far. (Just an example since it was mentioned earlier, this applies to many other interventions as well).

There has to be a line, and we need to respect it, but this does not make us automatons or servants.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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....

If they had a chainsaw injury to the neck they should go to the ED from the urgent care.Most ED's and urgent cares have "standing orders" that are called triage protocol that give you the standard of treatment guidelines and orders.

Outside the hospital? As a Certified ED nurse, Critical care nurse, flight nurse.....for 34 years....I will call 911, perform CPR, hold pressure on a wound,use the AED......basic first aid....and that's it. my malpractice will not cover me for anything else and with 911 response times so close these days there is NO reason to do anything else. I mean if I am stuck on an elevator and the elevator is stuck and some lady is going to give birth I will "help"by begging the woman to pant and blow.....and pray very hard that the fire department gets there real quick.

There are standards of practice that allnurses follow and in the ED or ICU setting there are standing orders where there is a standard of treatment protocol that is followed.....these protocols are approved and implemented by the MD's and are considered standing orders....so you still have to have a doctors order. There is plenty of automony when nurse use their critical thinking skills in titrating drips, starting IV's,implementing emergency protocols for you better be right.

All nurses should be aware and know their particular stated Nurse practice acts and abide by them accordingly. Out side of the hospital I stick pretty close to first aid.....

What do you want to do????

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If they had a chainsaw injury to the neck they should go to the ED from the urgent care.Most ED's and urgent cares have "standing orders" that are called triage protocol that give you the standard of treatment guidelines and orders.

Outside the hospital? As a Certified ED nurse, Critical care nurse, flight nurse.....for 34 years....I will call 911, perform CPR, hold pressure on a wound,use the AED......basic first aid....and that's it. my malpractice will not cover me for anything else and with 911 response times so close these days there is NO reason to do anything else. I mean if I am stuck on an elevator and the elevator is stuck and some lady is going to give birth I will "help"by begging the woman to pant and blow.....and pray very hard that the fire department gets there real quick.

There are standards of practice that allnurses follow and in the ED or ICU setting there are standing orders where there is a standard of treatment protocol that is followed.....these protocols are approved and implemented by the MD's and are considered standing orders....so you still have to have a doctors order. There is plenty of automony when nurse use their critical thinking skills in titrating drips, starting IV's,implementing emergency protocols for you better be right.

All nurses should be aware and know their particular stated Nurse practice acts and abide by them accordingly. Out side of the hospital I stick pretty close to first aid.....

What do you want to do????

You would only help a woman in labor that much? Right in my nursing textbook it tells you how to deliver a baby we an do that without a doctor if no one is around...? And yes we have chainsaw wounds come into my urgent care because people hate the ER and the treatment they receive there. I did not call the ambulance right away rather I assessed first rather than ignorantly called 911 first and I cleaned the wound and checked vitals and called for the doctor who would've stitched it herself if it wasn't so busy so I placed a pressure dressing and sent him to the ER. To simply call 911 or depend on only the ER is a waste of our skills. And nursing practice acts are actually uninformative simply because they are vague; reason being to help us when we are in emergency situations so that we can still be protected AND to also give additional aid to the patient. This thread is meant to be progressive I suppose, not latent. What I want to do was written earlier...the point of this is to find unusual or interesting interventions people have done that are legal and without doctors orders because there is no doctor around; NOT meaning standing orders or protocols.

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You would only help a woman in labor that much? Right in my nursing textbook it tells you how to deliver a baby we an do that without a doctor if no one is around...? And yes we have chainsaw wounds come into my urgent care because people hate the ER and the treatment they receive there. I did not call the ambulance right away rather I assessed first rather than ignorantly called 911 first and I cleaned the wound and checked vitals and called for the doctor who would've stitched it herself if it wasn't so busy so I placed a pressure dressing and sent him to the ER. To simply call 911 or depend on only the ER is a waste of our skills. And nursing practice acts are actually uninformative simply because they are vague; reason being to help us when we are in emergency situations so that we can still be protected AND to also give additional aid to the patient. This thread is meant to be progressive I suppose, not latent. What I want to do was written earlier...the point of this is to find unusual or interesting interventions people have done that are legal and without doctors

orders because there is no doctor around; NOT meaning standing orders or protocols.

No urgent care center in their right mind would try to deliver a baby.

And unless you work on a L&D floor, most nurses could only encourage breathing exercises if stuck on that elevator. To try and deliver a baby based on something briefly gleaned in nursing school is reckless and dumb.

I worked briefly for a LTC center that was formerly a county hospital that had fairly recently been transformed into a skilled nursing facility. Every now and then someone would stumble in with a wound thinking we had an ER. For me (or a RN) to do any more than try and stop the bleeding and call 911 would be an incredibly stupid move. We are NOT protected in such a situation. Nor do we have the resources to handle something like this.

And what you did in the urgent care setting amounts to no more than first aid as well. If it was really a major chainsaw wound, someone better have called 911 right away. Nothing ignorant about that.

Most of the "interesting" interventions nurses do ARE doctor's orders in one form or another. Even in the ER, nurses act upon standing orders in emergent situations. I bet your clinic has some sort of physician approved protocol for 99% of the cases that wok through your door.

How many nurses work "without a doctor around" or on-call or without standing orders and protocol? The answer is not very many.

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