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?

[barlowjb]

Once I had a pt who for three consecutive days at dinner time had BS between 60 and 70 and had and order for both scheduled and sliding scale Humulin. The first two days I called the MD she said hold the scheduled dinner time insulin. On the third day I told her that this was becoming a trend and suggested for her to give me some parameters so I wouldn't have to keep calling her about the same thing everyday at dinner time, so she said hold all scheduled regular insulin for BS

LiKwonie, I noticed you said "I know she is going to bottom out like she usually does the next morning" one of my peers suggested to me the other day that If I noticed a trend to either call the MD or leave a note detailing the trend and suggest an adjustment be made to the insulin regimen. Making a decision to call an MD about holding a med is also a part of critical thinking.

I think a lot of these issues are common sense and because of that some nurses (and I have been guilty of this in the past) make those "final" decisions to hold meds especially because quite frankly a few MDs make us feel bad about calling about "simple medications issues that "could have been dealt with in the morning". I have been told on more than one occasion by my charge nurses not to be afraid of calling MDs (even if its in the middle of the night) about holding meds - if parameters were not previously given.

You did what a lot of nurses have done and still continue to do and get away with, but we have to always be mindful of the limits of our scope of practice - You were on the right track in terms of wanting to hold the med, the mistake you made was in not contacting the MD about the matter.

I'm sorry that it had to get to the point of you being written up. However, while some supervisors may be more lenient than others (via verbal warnings), based on your description of the situation I cannot in good conscience say your supervisor did anything wrong.

Although it hurts, think of this as a lesson learned.

"This Too Shall Pass"

[caroladybelle, BSN, RN]

Part of critical thinking is making the decision to call the MD for these issues, and not to arbitrarily just hold 50 units of insulin from a very brittle diabetic because the sugar is low. Presumably the brittle diabetic is most likely an insulin dependant diabetic and at least needs some insulin, though maybe a different type or lower amount, ar a snack of a set amount of carbs before hand.

You can hold the digoxin for a lower heart rate, but if this is new situation for the pt, this may be an issue to notify the MD who may need to order a digoxin level. In addition, digoxin is presumably being given for a reason - perhaps the MD wishes to order a different med. Mag oxide is given for a reason - the pt still may need it, despite diarrhea. Are you going to let your pt suffer from a cardiac arrhythmia d/t serum mag of ohh, say 0.7, because they have diarrhea or you going to call the MD and maybe find a substitute med or get an IV dose ordered?

Recently I had a coworker that held a pt's stool softener because of loose stools. MD hits the ceiling the next day. Pt is very pancytopenic and has mucositis from stem to stern plus mucositis and we cannot risk this pt getting even small abrasions, or even minor bleeding. The MD is deliberately keeping the stools loose for that reason.

Current data shows that even NPO diabetic pts should get at least some insulin for proper management. Thus we are not supposed to just hold all insulin for the.

Yes, nurses are expected to have critical thinking. But we do not have prescribing rights and need to contact the prescriber when contemplating holding a med.

[rn4ever?]

Following every Dr.’s order is not a guarantee to a lawsuit-free career in nursing. Remember that as a nurse, you also should lobby for your patients. If a dose or order is incorrect, do not give it…..you have to say something and have it corrected. If the order was erroneous and you carry it out and something bad happens to the patient-----guess what, it’s still your fault-----not just the Doctor’s (if he is at fault at all-----they'll probably grill you and say, why did you give it if you knew it was not right!?). I don't think answering: "Because there was no discontinue order and the Dr. that I paged didn't respond until three hours later, so instead of holding the med, I gave it because the order was active." will fly.

[ThankANurse]

I agree with mauxtav8r. It's tough, but here you are open to constructive criticism ... kudos to you for that!

[imintrouble, BSN, RN]

I never hold anything without calling the MD first. It's not my call to make. Nothing new in my response, just wanted to add my voice.

[sissykim]

:jester:The right choice was made by the wrong person. That was totally the doctor's call. What has happened is we nurses protect the docs who don't want to be called instead of protecting the patient and our self. Next time call him, wake him up. At lease he has the balls to call you a fish to your face instead of writing you up behind your back and costing you your nursing license. In the long run you would be gratefull for the nasty attitude as oppose to the sweet face back stabber.

Now go and do the right thing.

[Redhead28]

So riddle me this batman...................

Standard orders include an order for heparin flush for CVL. CVL is running fluids, therefore I "HOLD" the heparin. Are you saying I have to call the MD for this? Get real your butt would never grow back. There are circumstances when you would hold a med without notifying the MD.

[koalafiedRN, ASN, RN]

Per hospital policy I would have to call a doctor if I hold a medication or a patient refuses medication. I would say know your hospital policy and use common sense. You are not a doctor so can't just hold something because you think it's the right thing to do. Also the supervisor could have waited til you came to work to discuss the situation instead of ruining your night and waking you up at 2am.

[sasha2lady]

I see both sides here...I too would have held that insulin. I have never been told where I work that we have to get an order to hold insulin on someone whos bs is 50...they tell us its nursing judgement. Now,if this pt is low 4 out of 5 am in a week...Id surely be on the phone or what not...telling the doc this is whats happening so far this week...what do we need to do about it? .....We give our insulins at 6 and 630 am....which I think is stupid since they dont eat breakfast til around 8am. But, again, where I work we have never ever been told that we cant hold a med, but we have been told that we have to document why we held it. Tough question. Good answers. Makes me want to question it at work also as we do not have nor have we ever had parameters on insulins to hold them.

[3dayRN]

Just found this post. I work on a stepdown floor and I would have held the insulin WITHOUT a dr. order also. Happens all the time on my floor. If I called the doctor about this, I work 7p-7a, I would get reamed from the dr. about calling this. We are expected to make our own judgement about this. I then would tell the dr. in the morning that insulin was held d/t low bs and he would then write or not write new order, whatever he decided.