administering meds during emergencies without a standing PRN order

wooh, BSN, RN · Sep 7, 2011

- well said! then again, would the board of nursing see it that way? I dont have any problems giving the D50, i would do it in a heartbeat. But then again, practicing medicine as a nurse is grounds for revocation of license

I've said before, I'd rather defend my license in front of the board than stand by and watch someone die. But I also try to be as proactive as possible and make sure I have all the prn orders I might need, especially if it's a doc that's hard to get hold of OR won't cover my butt when I'm covering his/hers.

patrickrlim · Sep 7, 2011

I'll sell shrimp out of a roadside van if I have to. Everytime I put myself on the line I think of that. Life if too precious and fleeting, and I couldn't live with myself knowing I let someone die unnecessarily because I was afraid for my license. I could hold my head high and look the board of nursing straight in the eye if they're going to tell me a person has to die because of their rules.
I'd never tell another nurse to take that chance. That's a decision each nurse has to make for themselves. It's safer to obey all the rules and laws.

-yes i completely agree with you. It just sucks that we get into those situations as nurses. kudos!

MunoRN, RN · Sep 7, 2011

You're not necessarily protecting your license by not giving a med that wasn't ordered. A nurse I work worth had to go before the board to defend her license after she failed to give a med that wasn't ordered.

She had a patient who wasn't doing well which she quickly identified as opiate over-sedation. We have no standing prn narcan orders, so she paged the Doc, got the order and gave the med. At some point while the patient was oversedated, the patient aspirated, got tubed and developed ARDS. The patient survived but it was a sentinel event which how the Nursing Board got involved. She kept her license, but the Board found that she acted inappropriately in waiting for an order and waiting for Pharmacy to OK the order since what you are held to is what most reasonable nurses would do to protect patient safety, which they felt should include giving un-ordered meds in some situations.

When it comes down to it though, I can't imagine coming to work everyday with your main goal being to keep your license. I come to work to do what's right for each patient, if I lose my license for doing that then so be it.

patrickrlim · Sep 7, 2011

does this apply for BP meds too like clonidine?

wooh, BSN, RN · Sep 7, 2011

She kept her license, but the Board found that she acted inappropriately in waiting for an order and waiting for Pharmacy to OK the order since what you are held to is what most reasonable nurses would do to protect patient safety, which they felt should include giving un-ordered meds in some situations.

Rock, meet hard place. Hard place, meet rock. Please ignore that nurse stuck between the two of you.

ZippyGBR, BSN, RN · Sep 7, 2011

- well said! then again, would the board of nursing see it that way? I dont have any problems giving the D50, i would do it in a heartbeat. But then again, practicing medicine as a nurse is grounds for revocation of license

is the US definition of 'practising medicine without a licence considerably wider than elsewhere in the world or is this just yet another AN 'panic point'... ?

wooh, BSN, RN · Sep 7, 2011

I'm imagining me in front of the board right now:

I see you gave D50 without an order for the blood sugar of 5. Is that true?

Me: Yes.

Why didn't you get an order?

Me: Doctor didn't call back.

Wouldn't you agree that's practicing medicine?

Me: Well someone had to.

(Of course in real life, I'd be crying, PLEASE don't take my license! I don't want to HAVE to work at Taco Bell!)

psu_213, BSN, RN · Sep 7, 2011

When a doctor enters an order for insulin on our computer system, a 'hypoglycemia protocol' is automatically entered into the MAR (my guess is the MD can alter the protocol if they see fit). Basically it says something to the

In your case, I think you would have been justified to give D50. First, I cannot sit there and watch someone slip away in such a circumstance. Second, every doctor I know would have gladly cosigned an order for D50 if her BS was so low. Finally, in the grand sceme of things, D50 is fairly innoucuous. It's not as if you said "they were a bit dizzy with a HR of 50 so I pushed some Atropine."

Horseshoe, BSN, RN · Sep 7, 2011

the important point is that the patient was able to take the oj by mouth. sounds like d50w wasn't needed. good job.
there are no meds a nurse can give without direct or standing orders. you put your license on the line by doing so. that said, many times i've given d50w, narcan, defibrilated patients, and on and on to end an immediate life threatening emergency. yes, i put my license in jeopardy each time, but believed a life was more important, and when working on ems i quickly learned that it's always easy to justify doing what's needed in the patients best interest. rules are nice, but they can't cover every contingency.

acls protocol protects you in cases such as these. you do not wait for an order to defibrilate someone who is in v-fib. you follow the protocol and give the meds as directed in acls algorithms.

patrickrlim · Sep 7, 2011

yeah its easy to say D50 is just D50 but nevertheless, it is still giving medicine without an order. I agree with one of the posts, being proactive by asking for a standing order for a pt if you expect something to happen in the future is the best thing to do

Esme12, ASN, BSN, RN · Sep 7, 2011

is the US definition of 'practising medicine without a licence considerably wider than elsewhere in the world or is this just yet another AN 'panic point'... ?

This is just one states position......

6521. Definition of practice of medicine. The practice of the

profession of medicine is defined as diagnosing, treating, operating or

prescribing for any human disease, pain, injury, deformity or physical

condition.

6522. Practice of medicine and use of title "physician". Only a

person licensed or otherwise authorized under this article shall

practice medicine or use the title "physician".

6524. Requirements for a professional license. To qualify for a

license as a physician, an applicant shall fulfill the following

requirements:

(1) Application: file an application with the department;

(2) Education: have received an education, including a degree of

doctor of medicine, "M.D.", or doctor of osteopathy, "D.O.", or

equivalent degree in accordance with the commissioner's regulations;

(3) Experience: have experience satisfactory to the board and in

accordance with the commissioner's regulations;

(4) Examination: pass an examination satisfactory to the board and in

accordance with the commissioner's regulations;

http://law.onecle.com/new-york/education/EDN06524_6524.html

Practicing medicine without a license.....

An individual who practices or holds himself out as practicing a health profession subject to regulation without a license or registration or under a suspended, revoked, lapsed, void, or fraudulently obtained license or registration, or outside the provisions of a limited license or registration, or who uses as his own the license or registration of another person, is guilty of a felony. For the purpose of the offense of practicing medicine without a license, the "practice of medicine" means the diagnosis, treatment, prevention, cure, or relieving of a human disease, ailment, defect, complaint, or other physical or mental condition, by attendance, advice, device, diagnostic test, or other means, or offering, undertaking, attempting to do, or holding oneself out as able to do, any of these acts.

There are very strict regulations and rules that govern the practice of medicine and how that practice is carried out, how it is carried out and by whom. These can vary from state to state and each state have nuances that govern the practice of all medical professionals and techs. Restrictions to practice and how to practice are covered in state nurse practice acts and it is the individual nurses responsibility to know his/her own states act,

For example........ http://www.nursingboard.state.nv.us/pinfo/pracdecs.htm. T

That being said, a nurse is also responsible for her own actions and the law states that your practice is judged if you acted an another "reasonable and prudent nurse would"

.... a nurse is both responsible and accountable for his or her individual nursing practice and will determine the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care

...Nurses with specialized training or extensive experience are held to a higher standard of care, corresponding to what a reasonable and prudent nurse with the same training or experience would have done in the same or substantially similar set of circumstances. A nurse will be liable in tort if harm ensues because he or she does not have or use such knowledge, skill, care, or diligence.

A nurse that works for a hospital is legally obligated to be aware of these policies and procedures and to comply with the institution’s rules and regulations. Procedures, rules, regulations, and by-laws of various health care institutions can be used to define the nursing standard of care. For example, a hospital ‘s procedure manual for nurses or a nurse’s job description may set forth in detail specific rules of conduct for nurses. On occasion, a nurse may be confronted by a physician’s order which directly conflicts with written hospital policy. If an order is not in accord with accepted medical standards, practices, customary procedures, hospital policies, or regulations, the nurse must defer, question, and even contravene the order.

http://www.rkmc.com/Nursing-Negligence.htm

"Avoiding Malpractice: Know the Standard of Care"

To avoid malpractice, nurses must first understand what Malpractice really is. In general, malpractice is negligence by a professional. Negligence is perhaps the most prevalent tort claim filed in civil court today. Most cases routed in negligence involve some type of personal injury as a result of another person's failure to use "ordinary care."

http://findarticles.com/p/articles/mi_qa4102/is_200602/ai_n17170231/

Malpractice/negligence

Defined in a nursing malpractice situation, negligence means the following:

The doing of something which a reasonably prudent person would not do, or the failure to do something which a reasonably prudent person would do, under circumstances similar to those shown by the evidence. It is the failure to use ordinary or reasonable care.

Lawyers call this principle the Ordinary Reasonable Prudent person rule, and it simply means that nurses are held to this "reasonable" standard. In addition, it is important to define "ordinary or reasonable" care:

That care which a person of ordinary prudence would use in order to avoid injury to themselves or others under circumstances similar to those shown by the evidence. You will note that the person whose conduct sets the standard is not the extraordinarily cautious individual, nor the exceptionally skillful one, but a person of reasonable and ordinary prudence.

So........ to the OP.....In this situation you did fine. The patient was conscious and able to take fluids so the "prudent" thing to do was to give OJ and sugar until the MD could be reached and orders recieved. If however, the patient was obtunded and unable to respond and take po fliuids without asparation........Waiting for the MD would NOT be the "prudent" thing to do and failing to give the D50 would be negligent and you would be held liable and responsible for your actions. It is confusing and ambigious but...... First....do no harm. Second...always act in the best interest of the patient. Third....when in doubt call for help and fourth..... carry malpractice insurance.

I agree with dthfyr.....

Originally Posted by dthfytr

I'll sell shrimp out of a roadside van if I have to. Everytime I put myself on the line I think of that. Life if too precious and fleeting, and I couldn't live with myself knowing I let someone die unnecessarily because I was afraid for my license. I could hold my head high and look the board of nursing straight in the eye if they're going to tell me a person has to die because of their rules.

I'd never tell another nurse to take that chance. That's a decision each nurse has to make for themselves. It's safer to obey all the rules and laws.

CoffeeRTC, BSN, RN · Sep 7, 2011

Your facility needs a p and p for this.

If they are able to take po's the oj was appropriate to give.