Counrtry doses - page 4

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... Read More

  1. by   humglum
    I've seen nurses do this, too, but I don't condone it and I would NEVER do it myself. In my facility an RN can initiate a physical restraint for safety. We'd call a code, manually take the patient into seclusion and then call the doctor to evaluate/co-sign the restraint order and possibly order stat/PRN medication.
    There are many things you can do for the safety of your patient, your co-workers and yourself that doesn't involve administering a medication without an order. That's hardly an excuse and you'd likely be laughed out of court.
  2. by   Marie_LPN, RN
    1, when we have to give a different dose than what was needed (higher or lower), we do tell the md's, we are not lying to them.
    Before or after?

    If it's before, then it wouldn't be a "country dose" it would be carrying out MD orders.

    2, the original question was whether or not this seemed to be common, not whether or not it was practicing without a license.
    Ok, well, it's not common where i work, because it is practicing w/o a license, unless there are standing orders or protocols.
  3. by   chris_at_lucas_RN
    Quote from Bethy-lynn
    Just a couple of things here. 1, when we have to give a different dose than what was needed (higher or lower), we do tell the md's, we are not lying to them. 2, the original question was whether or not this seemed to be common, not whether or not it was practicing without a license. Like I mentioned, this is the only place that I have worked as an RN, and I was just curious. 3, i say "we" because it is a practice that i see around me, in my UNIT frequently. and Finally, I am very aware of the effects of decreasing someones glucose too fast. I am also aware that when someone is rec'ing D5, TPN, Solumedrol, is Diabetic, Septic, and all they have is low dose sliding scale ordered, it's not going to be effective in maintaining their fsbs's between 80 and 110. (we usually start an insulin gtt for this, which is unit policy, not physician ordered). As for the Ativan issue, the only time I have ever given someone an extra dose of Ativan is a patient that was in dt's, extremely violent, restraints not working ( because Meth makes you very strong), and that was still according to our standard dosing, which I then had the physician sign. I have never written an order for a med without asking the physician.
    Sounds defensive. You say this is your only RN experience? Then be extra grateful for the nurses on this board--they are teaching you good nursing. If you listen to them, they may save you a lot of heartache, possibly prevent injury to a patient, possibly protect your license.

    We have all been around nurses whose practice of our profession got a little loose over time. We have seen situations where patients were put at risk. Some of us, myself included, have walked away from otherwise good jobs because we could not stand to watch poor nursing. We all hope we will never be less than the best we can be--and I hope you don't either. Good luck to you.

    And spacenurse, thanks for your little note--I just saw it as I was scanning recent posts. You can take care of me anytime!
  4. by   Spidey's mom
    Quote from chris_at_lucas_RN
    Sounds defensive. You say this is your only RN experience? Then be extra grateful for the nurses on this board--they are teaching you good nursing. If you listen to them, they may save you a lot of heartache, possibly prevent injury to a patient, possibly protect your license.

    We have all been around nurses whose practice of our profession got a little loose over time. We have seen situations where patients were put at risk. Some of us, myself included, have walked away from otherwise good jobs because we could not stand to watch poor nursing. We all hope we will never be less than the best we can be--and I hope you don't either. Good luck to you.

    And spacenurse, thanks for your little note--I just saw it as I was scanning recent posts. You can take care of me anytime!

    Nice post . . . and spacenurse, you can take care of me too, anytime.


    steph
  5. by   neneRN
    I can see both sides of the issue here, and I guess I'm guilty of practicing medicine without a license too, but in different scenerios. I'm in the ER, and we do have a lot of autonomy..we're expected to do a lot before the doc sees the pt and are covered by protocols for most things. But there are instances that I am frequently involved in that put me in the position to act without an order or risk harm to the pt. These are at times when the wait to see a doc is several hours or all docs are tied up with critical pts; certain times of the day there is only one ER doc for the whole ER.
    Read these examples, maybe you'll see that situations aren't always black and white, sometimes you have to go with your gut and do what's best for the pt.
    Last week, had a guy come into the ER confused, coworkers said he gets this way when his blood sugar is low; do an Accucheck-47. He's alert enough to drink the OJ, but is confused, a little combative, and refusing to drink it. Our protocol says we can give D50 for symptomatic hypoglycemia <40. Can't find the doc, he's tied up or whatever. So I push the D50 anyway; is that worse than letting his sugar drop even lower?
    Or, and this happens all the time, COPDer comes in, he's tight/wheezy, sats a little low, working to breathe...the doc's in a trauma/code/out of the dept getting coffee...I don't have a protocol to cover Neb Tx unless the pt has asthma, but I'm gonna call RT and have them give a treatment anyway; should I let his breathing get worse instead and risk him going down the tubes?
    Or one of our brittle diabetics who always comes in with DKA; glucose is 500, she's tachycardic, vomiting. No, I don't technically have an order to give her IVF, and she'll be seen by the doc fairly quickly because of her acuity; but I definitely can't give her insulin until the doc sees her, so yes, I'm going to bolus her with a liter of NS until he does see her.
    And this doesn't just apply to meds; on a daily basis, I order labs that aren't technically covered under protocols because I know what the docs want and I know that it may be hours before the doc gets to even see the pt. And I'm talking no-brainers here; if I have any doubt at all that the test won't be ordered by the doc, I certainly won't order it. Like a pt who comes in with seizures/takes Dilantin at home, obviously we need a Dilantin level and it will benefit the pt for the doc to have that result when he sees the pt so we can load him up with Dilantin if needed. Or a syncopal pt coming in on Dig with a HR of 50; hello, Dig level.
    I just think that if most nurses thought about it, they could come up with a time in their career where they had done something without an order...maybe it wasn't a med, but when it comes down to it, anything that's not strictly an independent nursing intervention/unit protocol/standing order is practicing medicine without a license...and sometimes you just go with your gut and do it if that's what you need to do to protect the pt. (Obviously I am not talking about giving any meds that are for nurse convenience or to avoid "bothering" the doc)
    Last edit by neneRN on Oct 14, '06
  6. by   chris_at_lucas_RN
    Quote from neneRN
    I can see both sides of the issue here, and I guess I'm guilty of practicing medicine without a license too, but in different scenerios. I'm in the ER, and we do have a lot of autonomy..we're expected to do a lot before the doc sees the pt and are covered by protocols for most things. But there are instances that I am frequently involved in that put me in the position to act without an order or risk harm to the pt. These are at times when the wait to see a doc is several hours or all docs are tied up with critical pts; certain times of the day there is only one ER doc for the whole ER.
    Read these examples, maybe you'll see that situations aren't always black and white, sometimes you have to go with your gut and do what's best for the pt.
    Last week, had a guy come into the ER confused, coworkers said he gets this way when his blood sugar is low; do an Accucheck-47. He's alert enough to drink the OJ, but is confused, a little combative, and refusing to drink it. Our protocol says we can give D50 for symptomatic hypoglycemia <40. Can't find the doc, he's tied up or whatever. So I push the D50 anyway; is that worse than letting his sugar drop even lower?
    Or, and this happens all the time, COPDer comes in, he's tight/wheezy, sats a little low, working to breathe...the doc's in a trauma/code/out of the dept getting coffee...I don't have a protocol to cover Neb Tx unless the pt has asthma, but I'm gonna call RT and have them give a treatment anyway; should I let his breathing get worse instead and risk him going down the tubes?
    Or one of our brittle diabetics who always comes in with DKA; glucose is 500, she's tachycardic, vomiting. No, I don't technically have an order to give her IVF, and she'll be seen by the doc fairly quickly because of her acuity; but I definitely can't give her insulin until the doc sees her, so yes, I'm going to bolus her with a liter of NS until he does see her.
    And this doesn't just apply to meds; on a daily basis, I order labs that aren't technically covered under protocols because I know what the docs want and I know that it may be hours before the doc gets to even see the pt. And I'm talking no-brainers here; if I have any doubt at all that the test won't be ordered by the doc, I certainly won't order it. Like a pt who comes in with seizures/takes Dilantin at home, obviously we need a Dilantin level and it will benefit the pt for the doc to have that result when he sees the pt so we can load him up with Dilantin if needed. Or a syncopal pt coming in on Dig with a HR of 50; hello, Dig level.
    I just think that if most nurses thought about it, they could come up with a time in their career where they had done something without an order...maybe it wasn't a med, but when it comes down to it, anything that's not strictly an independent nursing intervention/unit protocol/standing order is practicing medicine without a license...and sometimes you just go with your gut and do it if that's what you need to do to protect the pt. (Obviously I am not talking about giving any meds that are for nurse convenience or to avoid "bothering" the doc)
    There are some differences between your post and the OP's.... at least it seems this way to me.

    You have protocols for most things. That's like orders. She doesn't mentioned protocols, orders, standing orders, attempts to locate a doc, etc. And it seems the "country doses" (what a term!) are for nonlethal, nondangerous situations in the case of the OP.

    Joking about it with the docs? I'm not sure I buy that one, no reflection, no harm intended. (But if it's true, man, get out of that hospital and make sure people around you know you want to go somewhere else!) neneRN, you sound like a serious experienced nurse who knows this is not a joking matter.

    The other situations, you have worked with before, you have a relationship with the docs, you know if they are going to back you or not. The OP doesn't reference this, just a lot of "the other nurses do it."

    And it sounds like you have been a nurse for a while. The OP is a newbie.

    The sad commonality? If, God forbid, there is something you don't see, don't know, someone doesn't tell you, and a patient is injured, it is your license (and peace of mind).
  7. by   Spidey's mom
    Quote from chris_at_lucas_RN
    .

    The sad commonality? If, God forbid, there is something you don't see, don't know, someone doesn't tell you, and a patient is injured, it is your license (and peace of mind).
    This is what screams out at me . . . . good good point.


    steph
  8. by   PANurseRN1
    Quote from Bethy-lynn
    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.
    Not only is it not normal, it's illegal and if you're smart you'll stop it immediately before you lose your license.

    I agree with the other poster...this is terrifying.
  9. by   PANurseRN1
    Quote from Hoozdo
    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!
    Please do not try to play the "ICU is a different animal" card...it just doesn't work. Safe nursing practice should be applied to all areas. Many of us work in specialties where nurses are given a lot of latitude and where emergent conditions arise all the time (I work in the ED prn in addition to my real job).

    In your scenario, yeah, maybe you sedated the pt., and maybe you also took away an important clue to why he was so agitated to begin with. There could be dozens of reasons why he was agitated. And maybe in his scenario, Ativan was the last thing you should have given. Congratulations! You just lost your license.

    Operating under standing orders/protocols is one thing, playing fast and loose with meds is another. I'd love to know where these hospitals are where nurses feel they can just medicate as they please...I want to make sure to never be a pt. there!
  10. by   PANurseRN1
    Quote from traumaRUs
    I would still bet you are in trouble with practicing medicine without a license unless protocols are already in place.
    Yep. And as far as the old "everyone else does it where I work," you know the old expression "If everybody jumped off a cliff..."

    You can't give a med and then retroactively get the order. OK, well, you can, but that still doesn't make it legal. (ACLS is a different situation and does not apply here.) Right now you may have docs who go along with this, but I can guarantee you that someday something will happen and someone is going to get in big time trouble. Then you'll see just how "tolerant" the docs are. And if the BON does any investigating and finds out that other nurses practiced this way, they could find themselves trying to explain their actions to the BON, even if they weren't personally involved in the incident reported to the BON.

    Please, take the words of the experienced nurses like marla, space, trauma and others seriously. They know what they're talking about. I'd love to see what Siri's take would be on this. As an LNC, I'm sure she'd have plenty to say.
    Last edit by PANurseRN1 on Oct 15, '06
  11. by   Bethy-lynn
    Thank you, neneRN, for understanding the grey areas. Just to clarify...we do have standard orders, IE DT protocols (Librium and Ativan), low, med, and high dose ss, insulin gtts, ccu standing orders, cp standing orders, vent orders, sedation orders, the list goes on. YES, YES, Yes, we do have them. the Hospital I work in is a smaller hospital, 38 bed ICU, and so yes, I know most of the MD's VERY well (many of them live in my neighborhood and I've had dinner with them on more than one occasion. My next door neighbor is one of them). As for the ones that I don't know verywell, I definantly call before I do anything that Is not protocol. We do not have ICU residents, nor a CCP, nor a hospitalist, and so yes, sometimes it is difficult to get a hold of a doc when you need one most (IE, when your Meth od just doesn't want to stay down, or, as recently happened, a fresh post op that had too much morphine and got so confused that it took eight people, including three male orderlies to get him to sit back in bed). I also mention the "other Nurses doing it" because those are the people that are around me doing it, many of whom have been nurses, and worked in my unit for 20+ years, and are the first ones to say Oh, just give a little extra, that doc will be here soon. As for the "joking", Many times its something along a sarcastic line, a wink and nod, a light chuckle, and a "yeah, no problem, I got ya" from the docs, not a "hey that's really funny that I just over medicated your patient, Ha Ha Ha". Yes, I very much value my license, and I didn't go into nursing to kill people. I posted this question, not because I wanted to know if it was a Legal practice, but simply because I wanted to know how common this was. I have spoken with other people on my unit about how common it is, and most of them just give me the "Yeah, it's done" answer. I really just wanted to know if other units seemed this liberal, and automic, because yes, I have questioned it which is what I was trying to do when I posted this to begin with.
  12. by   slinkeecat
    I have to say that this is a practice that is risky business. I have to say that if I was aware of a nurse doing this, i would report her/him to the board. This is why.... You are jepordizing the safety of this patient.

    We had a patient who was in pain. The order was for 12.5 mg Demerol w/ 12.5mg phenergan IV. A nurse thought that because the Demerol vial dispensed from the accudose was 25mg/ml Demerol prefilled syringe, she would give 25mg..charted that she gave ordered dose, but wasted into the patient We would never have known as waste was done in the accudose w/ another nurse's badge. The other nurse did not actually observe the waste , but saw her toss a glass syringe of demerol into the sharps @ the accudose and beleived that she wasted properly., but she actually gave 25mg, her reasoning was this was a difficult patient and she ( nurse) was tired and she thought she was doing the oncoming shift a favor to settle her down... Well, she pushed the iv Demerol w/ phenergan in this patient and left the room thinking everything was fine... A nurse tech entered the room and found the pt not breathing well. Resperations @ 8 per minute, diaphoretic..she called our rapid response team
    this pt was a post op hip fx 68 yo female. w/ dementia & diabetes.. We followed our protocol and assessed her, finger stick was 110, so it was not a diabetic crisis so, w/ our doc who came up w/ rapid response team, we adminstered narcan.
    She survived...but was so frightened she refused any pain meds the rest of her hospitalization.

    The nurse, however... after investigation..... was fired for obvious reasons...and has been reported to the board.
    When you step out of your scope of practice, you better be ready to take the consquences....

    I call for orders... I do utilize our protocols and standing orders and when I need something for a patient i call... I don't give a rat's tushy if i am "bothering a doctor"...
  13. by   pickledpepperRN
    When we have had difficulty getting a doctor when a patient needs medical care we use the chain of command. From nursing management, to the medical director, to the CEO. I have been cursed at by a doctor asking, "Why are you calling me at three in the morning?"
    Answer, "Because your patient needs a doctor!"

    I've reported physicians to the medical board for not answering for as many as five hours.
    That one showed up after his patient had been to emergency surgery ordered by our medical director.

    Any physician who admits a patient to the hospital must ensure a doc is available at all times.
    Any emergency department must have enough doctors, NPs, PAs and nurses to save all patients who can be saved.

    What are WE going to do about this?
    I have gone with a delegation of fellow nursing staff (RN, LVN, CNA, and clerk) to the office of the CEO. We promised to spend at least two hours a day wearing sandwich boards and handing out leaflets that DR. so & so doesn't answer when nurses call for him to help his patient snd the hospital has not done anything about it. Call the newspaper too. The CEO promised to do the right thing and in this case he did.

    That MD was off the hospital staff after the third event. (Incident reports to the hospital attorney too)
    The web site of the medical board states his license is "retired".

    Could we be fired?
    Yes.
    But we only have one license. It is not up to the nursing staff to practice medicine without standard procedures and/or written protocols.
    It IS the responsibility of the facility to provide what is needed to care for patients.
    The community needs to know if it is not!

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