Is this practicing without a license??

emmycRN · Mar 1, 2007

I don't see how this is out of your scope of practice. Nurses frequently make judgements about patient needs and then follow-up with MD. The duoderm could not have hurt the pt and should not require a doctors order. Possibly your NM is confusing policy with scope of practice for nurses.

cookie102 · Mar 2, 2007

technically you do need an order for the duoderm, but you did the right thing by applying it, so many times in HH you need to use nursing judgement, if we called the doctor for every little thing they would not be happy

i would of done the same thing, assessed the patient, applied duoderm and wrote the order. no doctor is going to be made at that decision, what he/she isn't going to like is a nurse not knowing what to do

cookie102 · Mar 2, 2007

i forgot this was a hospice question, in hospice you have a little more "freedom" than in HH, so you definitly did the right thing

GerryG · Mar 2, 2007

The nurse practice act applies to hospice just as well. Technically you do need an order. We have dressing application orders on our standing orders which covers us. In the past what I have done is to initiate the treatment and then write an order. The last thing a doctor wants to be called on is something regarding a dressing since this is one area that they realize nurses know more about than they do.

caliotter3 · Mar 2, 2007

Technically your DON is right. However, as stated before, matters of policy are involved here. Familiies/patients do all sorts of things in the home that are without an order or contradict the MD orders. You should have sent in an order for the MD to sign. Order comes back signed, no problem. Doctor does not sign order or has questions; then you act from there. That is why, in most cases, better to wait for signed order, if you are not familiar with the MD and what he/she will readily sign without questions. I never add anything to the plan of care or treatment/medication records until there is a signed order in the house.

river1951 · Mar 2, 2007

At our hospice we do realize docs look to us to know what to do without pesting them to death. Our solution is to call, let them know our plan and request a return call if the doctor wants something different. This wastes less of their time and our time. We very seldom have a doc not sign and if that happens our medical director backs us up and signs for it. It only happened once to me and it was a cardiologist not signing for a foley in a dying patient- puleeze!

Have a lovely weekend,

River

sharlyb · Mar 7, 2007

Officially we're supposed to get the order first. In reality, when it comes to things like duoderm, we just apply it and then send in the order. Most of our docs do not want to be called for this and, in any event. we are fortunate to have a medical director who is sane and who is always behind us for things that clearly are appropriate and necessary. We can always count on her signing for things if the attending balks but for the most part we have not had any problem with the attending physicians.

aimeee, BSN, RN · Mar 10, 2007

We have standing orders that allow us to initiate orders for minor dressings like this.

burn out · Mar 11, 2007

Applying the duoderm is within your scope but you can't just put the duoderm on and nothing more, it will have to be added to the plan of care with a new diagnosis that may allow for more frequent visits, and of course you will need reimbursed for the care and supplies...none of these can happen without an order. So save yourself the trouble in the long run and just write the order.

**canoehead, BSN, RN** · Mar 11, 2007

Ahhhh, remember that the Duoderm and dressing change will not be PAID FOR by insurance without an MD order. I think it's a financial issue rather than a practice one.

aimeee, BSN, RN · Mar 14, 2007

Ah, but hospice is paid per diem so dressing supplies are just paid out of the per diem. And you get paid the same whether you visit every day or only once a week.