Without Orders

  1. 0 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
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  3. Visit  Apollo8933} profile page

    About Apollo8933

    Joined Dec '12; Posts: 10; Likes: 1.

    54 Comments so far...

  4. Visit  Born_2BRN} profile page
    0
    On my floor, we don't need order to start IV but do need if the access is other than IV.
  5. Visit  MN-Nurse} profile page
    0
    Quote from Apollo8933
    what are some of the things that you all can do without doctors orders?
    I can't do anything outside my scope of practice without an order, and I am getting very good at getting those orders (or entering them myself) before doing any of them.

    This is one of of the things you learn as you go along with help from your coworkers, and it varies greatly by facility and field. I recently had a urologist tell me, "Take out that foley and put in a 24 Fr. irrigation catheter and make sure he has something for pain."

    That sentence gave me free reign to enter a crap ton of orders.

    Hospitalists and residents, bless their hearts, are much easier - they enter all the order sets themselves and if you need to add or change something they are just a page away.

    It's scary at first, but you get pretty good at knowing what to do when and with whom - and which coworkers are helpful to you in this process.

    No easy answers for this one.
  6. Visit  Apollo8933} profile page
    0
    Really? That's pretty incredible and surprising actually! So you don't need an order for just NS? For hydration?
  7. Visit  VANurse2010} profile page
    3
    I think she means just placing a peripheral IV - not running fluids
    IowaKaren, psu_213, and bebbercorn like this.
  8. Visit  emtb2rn} profile page
    3
    Quote from Born_2BRN
    On my floor, we don't need order to start IV but do need if the access is other than IV.
    You may want to doublecheck your facility's policy. I'm pretty sure a iic/heplock requires a physician order. It's invasive. Could be wrong, wouldn't be the 1st time.
    tnmarie, psu_213, and elkpark like this.
  9. Visit  DedHedRN} profile page
    0
    I have what we call progressive orders. Otherwise, its business as usual.
  10. Visit  WeepingAngel} profile page
    0
    We have some older nurses who are comfortable with our docs, so if the patient's BP tanks out they will start a fluid bolus immediately and then call the MD to tell him later once the patient is ok. The MD is always like, "yeah, yeah, that's fine". I guess technically the order is covered then but I'm not brave enough to do that
  11. Visit  puroticorico} profile page
    1
    Each hospital varies due to their policies and procedures. Since I'm in the ICU, we often are required to take action without a doctor being there right away. We receive all the necessary orders after the fact, and then some. The nice thing is your can receive the orders in person or over the phone, and enter them yourself .
    SummitRN likes this.
  12. Visit  VANurse2010} profile page
    0
    Quote from emtb2rn
    You may want to doublecheck your facility's policy. I'm pretty sure a iic/heplock requires a physician order. It's invasive. Could be wrong, wouldn't be the 1st time.

    Technically it does at my facility also, but it's part of a standard order set that *every* patient in the hospital is on.
  13. Visit  Born_2BRN} profile page
    0
    I need to clarify what I wrote. I meant if their old IV (not fluid, we talk PIV insertion) had gone bad or they come up for blood transfusion not through ER. Yes, I know you suppose to get order everything. I remember I got ding for given patient a bandaid after he bumped himself. He asked for it and as a new nurse I didn't know better. Can you imagine being punished for given patient a bandaid?
  14. Visit  BrandonLPN} profile page
    2
    If a facility has standing orders for giving Tylenol or starting an IV in certain situations, you're still technically following doctor's orders. Such policies were still written bu medical staff, and I'm betting there's some sort of document somewhere detailing these orders that bears a physician's signature.

    I'm pretty sure there's just about nothing in the way of medication administration that nurses initiate completely independently of some sort of physician's order. At least not in a hospital or LTC facility.
    tnmarie and DeLanaHarvickWannabe like this.
  15. Visit  hodgieRN} profile page
    2
    There's usually an order to insert a PIV, and then the system will automatically reorder it every 96 (on EMR). As long as the the admission orders have an order for an IV, any reinsertion is covered per protocol.

    There are many things that you don't need a doctor's order for. These days, hospitals have moved toward evidence-based medicine and many of the bundles are already pre-approved by hospital administration and medical directors. You are allowed to insert an NG on intubated pts, you are allowed to program feeding pumps to flush with 30 ml water every 4 hrs unless the volume is specified different, you can use clog-zapper on clog feeding tubes, etc.

    Many orders also fall under nursing or ancillary order sets and they don't need a doctors order. You can initiate fall precautions and a dietician can order PO vitamin C and zinc for wound healing without a doctors order.

    If you are ACLS certified, you can initiate CPR, you can defib, and you can pass ACLS drugs like (epi, atropine, vasopressin, etc) without a doctors order. That's because it's already pre-approved and the time of response in a code is vital.

    Almost everything these days has a protocol. If a pt was obviously septic, I'm not gonna wait for a call back before I start the nursing portion of the sepsis bundle. Most things that don't need an order is already technically ordered by the medical directors.
    GrnTea and psu_213 like this.

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