I hate my supervisor

[kikwon89]

(moderator edit of name) called my cell phone 2 am to write me up for errors that she had found because she didn't have anything else better to do than looking to write employees up for making tiny little mistakes she likes to pick on. The case was regarding a very brittle diabetic patient whose blood sugar was 70. I decided to hold her 50 units of novolin 70/30 because I know she is going to bottom out like she usually does the next morning. (moderator edit of name) stated that I do not have the authority to hold a medication without the doctor's order and that i was wrong for me to make such a decision. Do we as nurses really need to make unnecessary calls to MDs about situations like this? Tell me, criticize me, and teach me on what I did wrong and what you would have done if you were me in this exact situation?

[shuubie]

i hope "Tammy" is only a fake name for this thread........

[JulieCVICURN, BSN, RN]

@fiveofpeep...check the hospital's policy. Ours just changed to a much more strict interpretation allowing for zero holding of meds without spelled-out parameters without md order.

So in practice, this encourages the md to write orders for what should be held. Even if a patient refuses a med the md has to be notified unless it is previously accounted for as a prn med or with parameters.

I wish ours would do this. In our ICU, we have a lot of autonomy. For example, I likely would NOT be written up or even reprimanded for holding this insulin dose. I might even be told that if I didn't hold it, I wasn't using my "critical thinking skills". But every place is different as is every doctor. There are docs that I know I can write for a Zofran order or even a one time lasix without even calling them, and others that you don't even put in a foley without calling them first. It would be such a relief to have a clear cut policy - NO holding meds without calling doctor first. At least then, when I call about whether to give or hold something and the doctor has a fit about us calling for something trivial I could say, "It's policy, I'm not allowed to make that decision for you."

As far as holding insulin when someone is NPO, I've done this and I've seen others do it, but it's a tough judgment call and it's one I'd really rather have the doctor make. A true brittle diabetic will likely have their blood sugar raise even when NPO, but others may not. I'm not on insulin, but on Metformin. If I don't eat, I get hypoglycemic after about 10 hours. If I was NPO and on insulin you'd probably put me into a coma!

[mauxtav8r]

@JulieCVICURN, Our units have much more autonomy also, but then again they don't have to call for each and every held med like the floors do. And in specialty units, the parameters are blanket orders, like in cardiac icu, (duh) the cardiac meds are very much on the shoulders of the RN.

[missdeevah, NP]

for example, i likely would not be written up or even reprimanded for holding this insulin dose. i might even be told that if i didn't hold it, i wasn't using my "critical thinking skills".

as far as holding insulin when someone is npo, i've done this and i've seen others do it, but it's a tough judgment call and it's one i'd really rather have the doctor make.

my thoughts exactly! i work nights on tele, and i am yet to see a nurse call a doctor to ask whether we should hold insulin for a patient that is npo, or with blood sugar of 50. i think i will ask my supervisor what the policy is on this. it would seem to me that this is part of critical thinking, but then again, i do understand what those that say that this is making a medical decision mean. it seems that it's a fine line sometimes between "making a medical decision, and using critical thinking skills." i know for a fact that most, if not all md's would probably hang up on me if i called to ask whether i should hold insulin @ night for a blood sugar of 50. especially if the md assigned to the patient is a cardiologist. once again, i will definitely ask my sup what the policy is on this.

[CNL2B]

We hold meds all the time without express physician guidance as well. What to give/not to give certainly IS in my scope of practice if there are safety or contraindication concerns. I would have held this dose in two seconds. However -- 70/30, being a combination insulin, would have warranted a phone call to the doctor. No, she probably did not need the 15 units of regular insulin in that 70/30 dose -- but she might need the NPH in a few hours.

Anything that could potentially be detrimental to the patient I hold...antihypertensives if low B/P, etc. I also hold drugs all the time that are contraindicated for the patient's condition, e.g. what about when you hold the colace/metamucil/daily suppository for diarrhea, even though it doesn't say "hold for diarrhea" in the order? Are all of you that are saying that it isn't in your scope of practice calling the doctor every time you hold colace? If not, pretty hypocritical...

Is this really what they taught you in school? I was always taught by my instructors from wayyyy back to educate yourself on each and every medication that you give and hold if indicated. I actually remember holding meds with my instructor knowledge in school. No call was made to the doctor. I know no school is perfect, but schools are obligated to teach for passing NCLEX scores and safe practice, meaning they should know what the BON guidelines on holding meds are. This never came up. Conversely, I have seen the opposite come up MANY times -- something gets given, the patient's condition doesn't warrant it, and the doctor is FURIOUS. NURSE ARE NOT SHEEP. We should not be blindly following doctor's orders. We scrutinize those drug books in school and continue to refer to them often in our practice for reasons like this.

Not professional of your boss to call you at 2 AM to notify you that she is writing you up, regardless of the reason.

[Emergency RN]

That said, the idea of withholding medication without a doctors' order being something professionally wrong, is a non starter. We, as clinical professionals, are required by the tenets of our licensure to protect and safeguard our patients from harm, regardless of what a physicians order is, and especially if the physicians order may cause our patient harm. Our duty, first and foremost, is to our professional selves (as mandated by the conditions of our license), then our patients, and finally, to the physician. It is by considered legislative design that "the doctor" in that equation is dead last.

If a doctor's order can bring harm, then we don't follow it. We notified the MD of our findings, and the MD will then reassess, and readjust their orders accordingly. If the MD insists on doing something that is, in our professional judgment, clinically unsafe or unnecessary, then we as individually licensed professionals have the absolute right to refuse.

The OP may have went about this (complaining here) in the wrong way, but her clinical instincts were dead on. As for any supervisor calling me at 0200 HRS? I would have hung up the phone on her, then promptly filed a complaint the following morning with the hospital for harassment.

[SummerGarden, BSN, MSN, RN]

what about holding insulin when a patient is npo? especially when you work night shift, this is a decision ive seen others make. i usually give it if patient is on d5 but would hold if npo and w/o d5

this is a good question. like the others have responded to the op, there is no instance where we are allowed to withhold medications without a doctor's order. even within the er i will want to hold a medication but i inform the doctor. if the doctor disagrees with me then the order stands (most of the time this is not the case, of course). with that said, you need to have parameters and orders related to bs control for npo patients!!!! you are not allowed under your scope of practice to just withhold insulin just because a patient is npo or to give it because the patient is npo receiving d5!! if the other nurses on your floor are doing the same, they are wrong too.

[JessibeanRN]

For me personally, critical thinking and good nursing judgement would come in to play considering I knew the patient well. I am pretty sure in the middle of the night, the MD doesn't care whether you held the insulin or not. But, knowing I had a crazy supervisor that was going to blow up the whole situation, I would notify the MD. And while I was at it, I would ask him for some parameters in which to hold the insulin in the future. A part of being a good nurse is to learn from your mistakes. Always be on your toes and consider every aspect of the decisions that you make.

[makes needs known]

Live and Learn, I always hear and say. You won't make THAT mistake again!

[sharpeimom]

you must always remember to practice defensive cya nursing! always stop to ask yourself before you do or withhold a med or tx or whatever, "how would my action or refusal, look if it were under scrutiny in a court of law? would the action or refusal be the act of any reasonably prudent r.n.peer?"

as the wife of a man who has been diabetic since childhood, and whose family has a very strong positive hx of type 1 diabetes, i would want any caretaker to be darn sure s/he knew what should be done and not think think s/he probably had done the correct thing.

we work very very hard to keep his bs where it should be and any nurses caring for him, should not be afraid to call the doctor or a supervisor if no policy/order spells it out.

sometimes we forget that because a doctor yells or is disagreeable, doesn't mean we were wrong to call

him/her.

[Redhead28]

I've held meds without calling the physician. Like someone else said, colace and they are having loose stools not gonna call, Digoxin and HR of 55 not gonna call or give the med. I would have held the Insulin and reported this to the day shift. I believe that this is critical thinking. We hold other meds without written orders... Suppose you had given the insulin and bottomed out the patient. Then called the doctor when they are near zero, he's going to ask what was the last FSBS and when you tell him 70 and you gave the insulin he is going to ask you WHY! When you tell him no order to hold he will question your nursing skills with your supervisor. Your way did not harm your patient, whole point of nursing isnt it?

[rn4ever?]

Nurses are trained professionals and not robots. Critical thinking skills are very important. We make decisions that are very vital and we have to decide quickly most of the time. If Magnesium Oxide was prescribed and the patient was having diarrhea, I wouldn’t give it even if I haven’t gotten a Dr.’s order not to give it. I believe that’s what a prudent nurse would do. Wouldn’t it be scary if nurses just followed all orders and didn’t act if there was no order or didn’t question any order that was doubtful?