Without Orders - page 4

by Apollo8933 | 8,099 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


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    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?
    RNfaster likes this.
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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.
    GrnTea likes this.
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    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.
    Soon2BNurse3 and RNfaster like this.
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    Quote from Apollo8933
    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????
    Last edit by Esme12 on Mar 25, '13
    RNfaster, joanna73, and BrandonLPN like this.
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    Quote from Esme12

    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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    Quote from Apollo8933
    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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    OP perhaps you should review some of the guidelines outlined by your BON. Unless you have the knowledge, skill, and judgment to safely perform a nursing action, then you need to refrain from doing so.

    We've all learned various skills in nursing school. However, unless you are competent in that area (ie delivering a baby), it isn't safe for you or anyone else involved. That means you would perform basic life saving measures only until the ambulance arrives.

    To think that because we're nurses so this alone provides autonomy to act is false. You need to know what you're doing since you are liable.
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    Firstly read what is written and respond please. Secondly there is a difference between what CAN be done legally and what people will do legally and be comfortable with cut the attitude people.
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    Also I have clearly stated earlier that I ask for responses that are within legality and scope of practice. I am asking across the board interventions people can do without a doctor. And yes the fact that we are nurses do mean that we can act and work autonomously. That is actually written in my nurse practice act. I ask for answers to the question and not attitude that does not pertain to the actual question which I will restate: "what interesting, yet legal, interventions can you or have you done that does not need the order of the doctor because there may not be a doctor around?"
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    Your question has been addressed in a reasonable manner by many of us. You don't seem to appreciate the responses you're receiving. In a nutshell, there is very little a nurse can legally do safely without a standing order.
    Esme12 and BrandonLPN like this.


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