Bizarre Med Order

[UrbanHealthRN, BSN, RN]

This is actually a kiddo on the daycare side, not preschool side, of my agency. And actually, he's a 4 month old baby, not kid. But anyways. Has bad reflux that's not under control plus I guess had a cold 6 weeks ago that involved some wheezing. Has been on multiple daily albuterol nebs ever since the cold started, and hasn't stopped. I'm new to this job, just found out about this kiddo on Friday, and have been working to make sure all med paperwork etc. is in place.

Checked him out today before the time that staff would usually give him a neb (here, classroom staff can give meds, not just a nurse), and he sounds totally fine with my stethoscope. No reason I can see in that moment to give him albuterol. He gets the neb, cries and fights it the whole time, and of course is coughing and refluxing by the end of the treatment.

I think to myself, no way did the doctor mean it when she prescribed albuterol as "give one vial every four hours" (no prn, no give for xyz symptoms), so I call the family and they call the doc. Nurse from the doc's office calls me back and is super rude, basically telling me my assessment means nothing, I don't know anything about this baby, and how dare I not follow doctors orders by not giving albuterol exactly every four hours? (Um, even the parents aren't doing q 4 hr treatments, but I guess I'm the bad guy here...) She tells me that this baby is going to need to continue q 4 hr, around the clock, albuterol treatments for probably another few months before they can cut him down to prn.

Ok. Rant over. Am I crazy? Have any of you seen a kid get this much albuterol before? I was so taken aback by her tone, I kind of just said sure, thanks for the clarification, we'll get on it, but I reallllly don't feel ok about this. Staff are going to be treating this baby 2 to 3 times daily, and for what? I guess the family is pretty worn out trying to manage his health problems, and is tired of communicating with staff about his daily condition and concerns, but I'm almost wondering if I can say this is nuts and my nursing license and staff aren't going to be involved with this medication nonsense.

[caliotter3]

Something tells me this is the nurse's doing, not the doctor. You need to speak to the doctor to get the real story.

[OldDude]

No, this is *****. There is a communication breakdown somewhere. No way a MD would order round the clock albuterol treatments for months for anyone, regardless of age.

[CoolKidsRN]

I agree with caliotter and old dude. Not to sound rude but are you sure you spoke to a nurse and not support staff? Definitely get the doctor on the phone for clarification.

[UrbanHealthRN, BSN, RN]

Thanks for the responses so far! During the phone call, I was actually wondering if I was talking to a nurse or someone else. At the end of the call, I asked her to repeat her name, and she told me "____, registered nurse". Even if she is an RN, I've decided I'm not trusting the information I was given. She never told me an exact diagnosis or symptoms that was indicating frequent neb treatments, so at the very least I want to call back for that. Plus, I'm checking in with the other staff today to see how they feel, and if they have any concerns about giving so many nebs, I'm following up on their behalf too. Time to put the big girl pants on and saddle up!

[UrbanHealthRN, BSN, RN]

Side note- those big girl pants will be pink. Happy Wednesday!

[NutmeggeRN, BSN]

Eek! What a mess. The order should be PRN BASED ON ASSESSMENT. I would document what has been done and send to MD and ask for clarification in writing.

[Flare, ASN, BSN]

it's all fun and games until the baby ends up tachycardic. Then the questions will pour in as to why the order was just blindly followed (even though you clarified it with the office.) Document the heck out of your convo with the staff and perhaps call back in your best Miss America voice and leave a cryptic message saying that you need to speak do Dr. So&so, not the nurse. Probably won't get you anywhere and will get you a bucket of attitude. Or, voice your concern with the parent and have them get it clarified.

[UrbanHealthRN, BSN, RN]

Oh lordy, the parents! Actually, they're foster parents. They didn't even want us contacting the doctor directly, and refused to sign an ROI form. The child's worker finally did yesterday. I think these foster parents are in over their heads, desperate or some sort of relief for the kid, and they're just going along with whatever medical advice they can get. I did talk to foster dad yesterday, and he said he'd be talking to the MD, so maybe I'll hear back from that end. Otherwise, I'm following up again myself.

Can you send in a new blank order from your school and require that the MD sign it? So it specifically clarifies PRN and not q4h? The longest I have ever seen q 4 h nebs is for 1 week and that was a baby with severe RDS. That kid was quickly put on inhaled steroids and a preventative.

[ruby_jane, BSN, RN]

Once upon a time when I was on rotation in the ER, we did neb a baby continuously.

In the ER. In crisis.

I have nothing else to add. With asthma meds, I document my assessment of the lungs (no adventitious breaths sounds noted bilaterally, all lobes), a pulse ox if I can, document that the student's color is WNL for ethnicity, lips pink, s/he is not posturing for comfort. But if asked, I give the med because I don't want to be "that nurse." I realize it's different for you. The little one can't ask. It's also possible that the nebulizer is being used off label for esophagitis. We had a kid at camp who had an epiglottal "issue" and that was treated with inhaled albuterol.

Having said all that - deal with the social worker. I love Flare's comment. Use that. This is nuts.

[caliotter3]

I have worked with home care clients on regularly scheduled nebulizer treatments, so there are instances where that could be the case, but if I were the OP, I would get this information from the doctor and not someone who fields the office phone calls.