Counrtry doses

ZASHAGALKA, RN · Oct 6, 2006

Do you not think that giving extra insulin is a big deal? Do you not think that dropping a blood glucose too fast can cause problems neurologically among other things? We were not educated in nursing school for dosing of sliding scale....giving extra insulin is no laughing matter and could cause a lot of problems outside of 'just lowering the blood sugar'.
Jenny

Actually, I'm on a research committee for our insulin gtt protocol and I'll have to go back to work and actually pull the research, but a major study found that when docs leave the rules much more general and give the bedside nurses wider autonomy to adjust those gtts, that there is a 50% increase in the efficacy of those protocols than occurs with tightly bound limitations.

Our insulin gtt protocol specifically points out that the listed titrations are 'guidelines' and not hard limitations on actual practice.

~faith,

Timothy.

pickledpepperRN · Oct 6, 2006

Actually, I'm on a research committee for our insulin gtt protocol and I'll have to go back to work and actually pull the research, but a major study found that when docs leave the rules much more general and give the bedside nurses wider autonomy to adjust those gtts, that there is a 50% increase in the efficacy of those protocols than occurs with tightly bound limitations.
Our insulin gtt protocol specifically points out that the listed titrations are 'guidelines' and not hard limitations on actual practice.
~faith,
Timothy.

This is the way to do it.

We must be honest!

We have protocols for insulin drips, pain medication, and sedation of ventilated patients. There are ranges that depend on the assessment of the direct care RN.

If a doctor tells me not to follow the protocol I write it as an order.

Years ago I did "beat around the bush".

NO MORE!

A patient with CHF needs treatment an it is my obligation to tell the doctor,

Believe me, as the "out" union representative on my unit if I were to cheat I would be fired and reported to the board.

suzy253, RN · Oct 6, 2006

I have never heard of such a practice until reading this and would never, ever do it.

UM Review RN, ASN, RN · Oct 6, 2006

I've seen it. I don't approve of it and I don't do it.

allnurses Guide · Oct 6, 2006

The term 'country dose' just refers to measuring something with a rough guesstimate. Kinda liek if a recipe calls for a cup of sugar, a country dose would be 'what looks like a cup'. it might end up being more or less. Also if the cup didn't make it sweet enough you might add more to suit your tastes.
This is a common term in the south and nobody was stereotyping nurses from underdeveloped areas. Please don't make it out to be something it never was.

I should have put a winking smilie . . . :wink2:

As to Tim's post about being too hard on the op . . . first I myself didn't say I have never seen this, I have and it is dangerous. You may be mixing up "standing order" stuff with actually diagnosing and practicing medicine w/o a licence.

I work in the ER and we do have more latitude to order tests and start meds per protocol than floor nurses. And I agree with this.

But deciding on your own to give a patient more pain medicine or insulin than is ordered is dangerous. I believe in teamwork and I talk to the physician about my concerns and as a team we figure out how to handle this situation.

I just hate the idea that we have to "trick" the physician into seeing things our way. It is like those magazine articles that tell women how to get their way with their husbands using subterfuge - like men are too stupid to respond to a conversation with their wives about life. It is just too much "male bashing" . . . or "doc bashing".

To act this way is degrading to me and to the physicians I work with. Unprofessional. Illegal.

steph

chris_at_lucas_RN, RN · Oct 6, 2006

Liberal? Your post scares me. As nurses, we cannot give any medication, adjust dosages, change medication routes, or order tests without an order from MD, DO, or Nurse Practitioner. Does your unit have "standing orders" for things like Benadryl, Tylenol, or routine tests/labs? If you give extra Ativan or other controlled med, how do you account for it at the end of your shift? Does the physician sign off on these "orders?"

My God, thank you! That post scared the you-know-what out of me too!

If a diabetic's glucose is high, you use the sliding scale per orders. If there isn't one, get one. Otherwise, how do you know what dosage the patient responded to?

I'm all for standing orders, that's nothing more than the physician ordering what he would for any admission (or whatever). It is still an order.

I cannot imagine "playing doctor" like the OP. A matter of time before someone dies.

Hoozdo, ADN · Oct 6, 2006

We do similar stuff at times, i guess it just depends on the severity of the issue. There's always that crazy pt in DT's that needs a little extra "love" does of ativan-- "woops i guess my eye sight isnt what it used to be, he got a little extra". Of course on paper, everything is how it should be.
Less dramatic things would be ordering chest xrays on all our vented patients every morning - even though sometimes they forget to order it, someone will eventually complain if it wasn't done.

Well, I can see this thread has a LOT of controversy. Here's my 2 cents, like it or not. I will throw out a hypothetical situation, (which really happened recently).

Say, you have a pt in ICU who is of normal mentation and has an order for 0.5 mg Ativan IV Q2H PRN. All of a sudden, he has become very agitated, won't stay in bed, is hitting nurses and kicking them. It takes 5 nurses to hold him down and restrain him and during the process he injures two nurses so severly they have to go the ER for treatment.

Am I going to wait and call a doctor to get an order for restraints? NO. Am I going to give him 0.5 mg Ativan which won't do a thing? NO. I will restrain him without an order and get one when I call the Dr. Since Ativan comes in 2 mg vials, I will give him what we call "A NURSING DOSE" of maybe 1 mg or 2 mg to knock this very dangerous patient down a notch. I will get an order from the Dr. after we get this under control.

When I talk to the Dr, we can discuss the WHYS of the incident and probably send him to cat scan or whatever interventions are needed. The bottom line is safety of the pt.

ICU is a different animal than med/surg, psych, tele......it is all of that rolled into one. You have to use good judgement, critical thinking, and can't wait around to page a doctor or one to come to the unit in every single case. The same for a coding patient......am I going to wait before starting ACLS protocol and let this patient possibly die? The answer is NO. You roll into action and let the orders come when they come, even if they come late.

Donning the abestos flame protectant suit!

pickledpepperRN · Oct 6, 2006

Well, I can see this thread has a LOT of controversy. Here's my 2 cents, like it or not. I will throw out a hypothetical situation, (which really happened recently).
Say, you have a pt in ICU who is of normal mentation and has an order for 0.5 mg Ativan IV Q2H PRN. All of a sudden, he has become very agitated, won't stay in bed, is hitting nurses and kicking them. It takes 5 nurses to hold him down and restrain him and during the process he injures two nurses so severly they have to go the ER for treatment.
Am I going to wait and call a doctor to get an order for restraints? NO. Am I going to give him 0.5 mg Ativan which won't do a thing? NO. I will restrain him without an order and get one when I call the Dr. Since Ativan comes in 2 mg vials, I will give him what we call "A NURSING DOSE" of maybe 1 mg or 2 mg to knock this very dangerous patient down a notch. I will get an order from the Dr. after we get this under control.
When I talk to the Dr, we can discuss the WHYS of the incident and probably send him to cat scan or whatever interventions are needed. The bottom line is safety of the pt.
ICU is a different animal than med/surg, psych, tele......it is all of that rolled into one. You have to use good judgement, critical thinking, and can't wait around to page a doctor or one to come to the unit in every single case. The same for a coding patient......am I going to wait before starting ACLS protocol and let this patient possibly die? The answer is NO. You roll into action and let the orders come when they come, even if they come late.
Donning the abestos flame protectant suit!

In the first example we call a "code grey" or security code. All available come to help including security, the nursing supervisor, anesthesiologist, and any physician available."

We have a standing protocol for restraining a patient and getting the order within an hour.

NO I would NOT give Ativan without an order!

The doctor must respond! It may be flash pulmonary edema, a PE, CVA, DTs, or withdrawal from a drug the patient didn't tell us about taking.

Per the second example. I will not work where there is no policy and procedure for a competent RN to run the code per ACLS protocol. I don't even know of such a place. Not in the last two decades.

chris_at_lucas_RN , stevielynn, Angie O'Plasty, RN, suzy253, and all nurses who will not practice medicine without a license:

Thank you.

allnurses Guide · Oct 6, 2006

In the first example we call a "code grey" or security code. All available come to help including security, the nursing supervisor, anesthesiologist, and any physician available."
We have a standing protocol for restraining a patient and getting the order within an hour.
NO I would NOT give Ativan without an order!
The doctor must respond! It may be flash pulmonary edema, a PE, CVA, DTs, or withdrawal from a drug the patient didn't tell us about taking.
Per the second example. I will not work where there is no policy and procedure for a competent RN to run the code per ACLS protocol. I don't even know of such a place. Not in the last two decades.
chris_at_lucas_RN , stevielynn, Angie O'Plasty, RN, suzy253, and all nurses who will not practice medicine without a license:
Thank you.

Great points! We too call for reinforcements and you are right - we don't know what is wrong with the patient and giving him more sedative might mask the real problem (as you said, flash pulmonary edema for one).

As to ACLS - the point of being ACLS certified is that you CAN follow protocols w/o the doc being right there. I don't know of any place where an RN cannot run a code.

steph

Trauma Columnist · Oct 6, 2006

Wow - this is concerning. I'm an advanced practice nurse and I do give orders. However, I do not sign orders that I did not give! Simple, end of story.

Nurses that restrain (physically or chemically) without finding a cause for the agitation are at risk for lawsuits, not to mention patient complications.

A nurse is a nurse, a doctor is a doctor. I am a very experienced RN, but that doesn't make me an MD. I would not act as one either. Any RN that fudges the rules, gives "country" or "baptist" doses is skating on thin ice. I would not sign these orders and I would report those RN's who were following this practice.

cardiacRN2006, ADN, RN · Oct 7, 2006

I read a paper by the Society of Critical Care Medicine once that flat out admitted that it was common place for nurses to 'waste drugs appropriately' - waste them IN the patient, because the doctors were simply unaware by experience of observation how to appropriately order narcotics. The article wasn't even critical of the practice - it was just an observation that nurses routinely make up the difference for the shortcomings in prescriptive habits of doctors.
~faith,
Timothy.

That's our point, Timothy. Drs habits are being created by what we are practicing. They think that their dosages are working because WE lead them to believe that they are working. They can't know better because we are lying to them. Some nurses may get the order later, but I've seen many nurses do just what you say, waste into the pt.

Again, if I have a problem with a dose or med, I'll just call. It only takes a minute.

To the agitated pt scenerio...I work in a psych based hospital. We frequently, and I mean frequently get pts who go beserk on a moments notice. I still will only give the prescribed dose of Ativan. I will call for more if I feel it is needed, but I will never give more without an order.

MistyDawnRN06, BSN, RN · Oct 10, 2006

In our unit, we tend to give a lot of "country" doses (such as adding on a couple extra units of insulin if someone's sugars are high, or giving the extra mg of Ativan to the resident Meth od). We even joke about it with some of our md's. I guess I'm just a little curious about how "normal " this is. i feel like I work in an EXTREMELY liberal unit ( we order a lot of things, labs, ekgs, x-rays, O2, and we make few med changes like changing from iv to po, or giving benedryl or tylenol) and I was just wondering what the consensus is.
It's the only unit i've worked in as an RN and I was just curious.

That's just frightening!! That's out of a nurse's scope of practice!! I'd watch my license if I were you. . . .

If a patient is violent, call security!! Nurses don't have to get hurt by whakos!! Use the facility resources! And giving meds without an order - NO WAY!!! I can't believe that!!!! ACLS is another story, you're certified in a life-threatening situation to initiate advanced life support until further help arrives. It requires training and testing!