Would you do this?

[TX.RN.Shannon]

This situation came up at work a few shifts ago. Had 20ish year old admitted for acute appendicitis. All meds IV or PR since he was NPO for surgery. Next day--surgery went great, tolerating clear liquids, doing well. C/O headache that he wants Tylenol for at 0215. That is the one med the MD didn't switch the route on, so it's only ordered PR. The pt refuses of course, so I wrote a telephone order from the MD to change it to PO. He got the Tylenol, headache went away, yay. MD comes in, sees order, says thank you for not calling me for that. I think I did okay.

I'm not prescribing/writing orders liberally or often, but some things we know how to handle.

Another nurse is freaked out by this. Everything is straight by the book for her. There is no nursing judgment or using your brain. She calls the doctor for every, stinking little thing; but then cries when the doctor gripes at her.

[TX911]

Just got my nursing license and it's gone

Yet another reason why I value my Paramedic license far more than my nursing license.

[wooh, BSN, RN]

Tylenol interacts with a ridiculous # of other drugs metabolized by the liver.

So PO tylenol acts with a ridiculous # of other drugs metabolized by the liver that PR tylenol does not interact with?

[PMFB-RN, RN]

....What also irks me the most is when nurses preface calls "Dr soandso, I am SO sorry to call you at this time"... Usually, if he's always been a donkey, this won't make it any better. Do NOT be sorry, they are on call and getting paid, so deal with it.

I am fortunate enough in our unit to staff residents 24/7 (PICU) and do not miss grumpy MDs!

YA THAT!!!!

The only time it is EVER ppropiate to tell a doctor your sorry for calling is if you make a mistake and call a doctor who isn't on call. For what they get paid to be on call all the nurses could call me every night!

[Murse901, MSN, RN]

Yet another reason why I value my Paramedic license far more than my nursing license.

Just an education opportunity here: If you lose one, you're probably going to lose the other in the aftermath. It may be beneficial to value both equally.

[mariebailey, MSN, RN]

So PO tylenol acts with a ridiculous # of other drugs metabolized by the liver that PR tylenol does not interact with?

Woo, come on, the point was that OTC meds weren't necessarily safer than prescribed ones & should not be given more leniency when it comes to following MD or NP orders. It was a response to a statement that implied the drug was harmless. I was not comparing PO to PR route.

[mariebailey, MSN, RN]

In the situation she described, she did nothing wrong. And Tylenol 650mg PO is a standing order in our ICU for pain and fever. Are you suggesting Tylenol in the absence of liver failure and allergy is inherently dangerous?

Bottom line, technically you should've called at 3am for a tylenol order. Fundamentally you did nothing wrong.

Absolutely. Yes, I am saying Tylenol can be a dangerous drug. It's misuse is the leading cause of acute liver failure in this country. However, that was far from the main point I was making.

I think we disagree in this respect, but I bet we can agree on this. She had positive intent. She wanted to meet the health needs of her patient by managing his pain and simultaneously meet the needs of the doc.

[nursemike, ASN, RN]

It's not what could happen in this particular situation with this particular drug & route of administration that matters in this discussion. Decisions like this can set a precedence that negatively impacts our patients. What could happen to patient care in general if we all chose to make decisions outside of our scope on a regular basis? A lot of us who lack the formal education and credentials do have the intellectual capacity and the knowledge base to make informed decisions in the absence of an MD or APN. Some of us think we do when we actually do not. That's one way these licensing boards, educational standards, rules/regs, etc. safeguard patients.

As a side note, just b/c it's an OTC med doesn't make it any safer to write an order on behalf of a doc. Tylenol interacts with a ridiculous # of other drugs metabolized by the liver.

I actually agree, but I've seen a bit too much of the other extreme, like nurses paging at 0300 for colace. The "that's what they're getting paid for" argument is valid up to a point, but part of we get paid for is using our judgement. Ideally, a nurse would have caught early on that Tylenol was still ordered PR and got it fixed right away. But it's an easy thing to miss. Fixing the route in the situation the OP described is rather different from writing a new order. I'm not saying it's okay, but I think some of the reactions have been a little extreme. I would think back-ordering the doc's verbal all meds to p.o. would be legit. Paging to get the tylenol order corrected would also be legit. It's a pain med that's needed now, which is not the same as something like colace that could wait for morning.

I recognize it isn't fair to project what I've seen on my unit to the posts on these boards, but what I've seen on my unit has been that the nurses most likely to have a knee-jerk response to a situation like the one described seem a bit inclined to have a knee-jerk response to every situation. The quoted post makes a reasoned argument as to why the OP's actions were not correct. To me, that's a more important point than the actual situation: we need to think about why we do what we do. But yes, in this instance, waking the doc was the lesser evil.

[wooh, BSN, RN]

It's a pain med that's needed now, which is not the same as something like colace that could wait for morning.

I think one of the reasons that docs tend to like me is I'm the queen of planning ahead when it comes to orders. Patient has J-tube that regularly gets clogged? I don't wait until the clog, I go ahead and ask for a order when I see the doc on the floor to have a PRN order for the clog zapper so we don't have to call when it does clog or if I'm working nights, I leave a note on the chart asking for it when they next come in. I don't think an IV will make it through the night? I go ahead and get an order to switch to PO or IM if IV has to come out. I see it's 10pm and a patient hasn't yet peed since surgery? I call THEN and get an order to straight cath PRN they don't void in a few more hours instead of waiting a few more hours. And if a patient is on antibiotics, I get an order for culturelle asap. So much easier than dealing with diarrhea, butt skin breakdown, and WAY easier than dealing with c.diff.

It would be nice if the docs planned ahead, but I think a lot of phone calls during the night could be avoided if we took the initiative to plan ahead when the doc misses the boat.

And it's not solely for their convenience. It's so much easier for me to get an order ahead of time, so that when I eventually do need it, I don't have to call and wait for the call back. I can just do what needs to be done and move on with my shift.

I'm not going to say that OP was wrong (although I sure won't admit in public that I would do the same, but once OP clarified that doc said all was changed to PO, I will admit that I'd have considered that a verbal order as well.) But I think the planning ahead is where "nursing judgment" really comes into play. It's not pretending I got telephone order at 2am. It's looking ahead to what I might need at 2am and getting an order for it at 2pm just in case.

[R. Obias Jr., R.N.]

most critical would be an allergic reaction to the medication if given thru another route, you only have minutes toreactto the condition, maylead to death.

[crazy oldnurse]

I am with you. Some nurses are taught critical thinking and some do not have the mindset to do that.It is not wrong to do either in my opinion. I would have to be in this situation to absolutely make a decision. A lot of if's needless to say. Is it not ludicious to have to have this amount of angst over this? I believe it is because we have so many levels of education doing essentially the absolute samething?

[mariebailey, MSN, RN]

I am with you. Some nurses are taught critical thinking and some do not have the mindset to do that.It is not wrong to do either in my opinion. I would have to be in this situation to absolutely make a decision. A lot of if's needless to say. Is it not ludicious to have to have this amount of angst over this? I believe it is because we have so many levels of education doing essentially the absolute samething?

I think your last statement is so true; experience matters too. Your opinion is the polar opposite to what I said, & I'm willing to bet you have more experience than me. One of my many shortcomings as a nurse is that I sometimes think in black & white - like something is either right or wrong with no in between. I find that more seasoned nurses see the grey, which is prob a more accurate view of the situation. I don't think it's angst necessarily; it's just a good topic that generated a lot of debate.