Can you give an opioid without a Dr's order?

[Nurse Beth, MSN]

Dear Don't Understand,

What I don't understand is whether I am being pranked or not.

At first I thought I was, so I sat on this question for a short time. But just in case this question is for real, and with all due respect, here is my answer.

You can never give an opioid without a provider's order. You can never give a Tylenol without a provider's order. You cannot give a meal, or decide an activity level, or draw a lab without a provider's order.

Please check your facility's policies and procedures. Consult with your nurse educator or manager for practice questions and please do not take advice from this co-worker.

Best wishes,

Nurse Beth

[Hoosier_RN, MSN]

I'm still thinking, doesn't matter what MD said/alluded to. If the order for opioid  is there, no issues. If not, giving it will land you in one of the hottest pots of water that you could ever imagine 

If MD did say they would order, I'd follow protocol to get that order correctly 

[JKL33]

Tenebrae said:

I disagree. 

If a patient is symptomatic with a UTI, we take a urine sample, dip stick it and send it for testing. 

If a patient is unwell, and we check obs and I'll often check a BGL to make sure someone isn't having a low blood sugar.

If a patient is medically unwell and the vitals/pt hx supports a cardiac diagnosis I'll get an ECG done because I know the house officer will ask for it. 

Generally in the US, many nurses do these things under protocols that have gone through committees and ultimately approved/signed by the relevant medical director...in other words nurses have standing/protocolized orders for "if X then y."  This type of activity is covered legally.

There are also lots of situations where the medical staff and nursing staff have worked together enough that nurses generally know what kinds of orders are likely to be entered and will get them started and usually there is no problem. But it isn't a good legal position to be in and as soon as one provider puts their foot down and says "I didn't order that" there will be some degree of trouble, usually relatively minor but there's nothing (legal) stopping it from becoming a big hairy mess if someone wants it to--even with the types of orders that don't involve controlled substances or even medications at all.

[JKL33]

When acting without an order and outside of protocols, problems arise especially when people don't know what they don't know, are overconfident and it strokes their ego to "order" things on their own--and at the end of the day nurses are a little more likely to be working off of pattern recognition than a reasonable differential. For example, not all severe back pain + restlessness + clamminess is a slam dunk "kidney stone." In fact it could be much worse and about the time a nurse thinks a never-ordered ketorolac administration in that scenario is going to be signed by the provider, they will be wrong and they will be in big trouble.

[EdieBrous, BSN, MSN]

Quote

I disagree. 

If a patient is symptomatic with a UTI, we take a urine sample, dip stick it and send it for testing. 

If a patient is unwell, and we check obs and I'll often check a BGL to make sure someone isn't having a low blood sugar.

If a patient is medically unwell and the vitals/pt hx supports a cardiac diagnosis I'll get an ECG done because I know the house officer will ask for it. 

As long as we can provide a clinical rationale for our actions I've never had a doctor chuck a wobbly on the OP, is this person taking the mickey?

Nurses doing these things without orders are exceeding their scope of practice.  RNs are not allowed to diagnose or prescribe, but are restricted to following the regimens ordered by those who are.  This practice can also lead to charges of billing fraud because the patients are charged for these diagnostics.  Clinical rationale or not, there must be specific orders or standing orders/protocols to order an EKG, U/A, etc.

[Tenebrae, BSN, RN]

EdieBrous said:

Nurses doing these things without orders are exceeding their scope of practice.  RNs are not allowed to diagnose or prescribe, but are restricted to following the regimens ordered by those who are.  This practice can also lead to charges of billing fraud because the patients are charged for these diagnostics.  Clinical rationale or not, there must be specific orders or standing orders/protocols to order an EKG, U/A, etc.

You realise nurses exist outside of the US right? 

We are allowed to use our initiative based on the clinical picture infront of us so we can provide an accurate clinical picture to the doctors. 

Eg this is the handover I would give to the Dr eg patient is complaining of flank pain, burning on micturition, passing cloudy smelly blood tinged urine. Dipstick showed positive 2+ protein, 2+Leuc, postive for blood, positive for glucose. Patient is febrile. Did a BGL test due to glucose in the dipstick and it came back 18mmol (patient has no history of diabetes). Using an ISBAR I would also suggest that the patient needs antibiotics due to being symptomatic as well as follow up for the high BGL.

Never had an issue with a doctor getting snotty, I think they like it if we can make their job easier

[EdieBrous, BSN, MSN]

Tenebrae said:

You realise nurses exist outside of the US right? 

We are allowed to use our initiative based on the clinical picture infront of us so we can provide an accurate clinical picture to the doctors. 

Eg this is the handover I would give to the Dr eg patient is complaining of flank pain, burning on micturition, passing cloudy smelly blood tinged urine. Dipstick showed positive 2+ protein, 2+Leuc, postive for blood, positive for glucose. Patient is febrile. Did a BGL test due to glucose in the dipstick and it came back 18mmol (patient has no history of diabetes). Using an ISBAR I would also suggest that the patient needs antibiotics due to being symptomatic as well as follow up for the high BGL.

Never had an issue with a doctor getting snotty, I think they like it if we can make their job easier

In the U.S. your "initiative" does not include diagnosing/ordering diagnostics or prescribing & I am glad you have had good experiences with doctors, but the nursing boards still consider this to be practicing outside of your legal scope.  You are taking a risk by thinking you can do this without standing orders or protocols.  Just ask any nurse who has been disciplined for doing so.  Look at your own nurse practice act and see what it says - maybe also look at posted disciplinary actions.

[kp2016]

I'm going to assume the OP meant their colleagues are giving medications based on a verbal order or some sort of standing order  from the Dr that hasn't actually been written/ signed yet. 

If that is the case I would say speak to a manager about this and clarify your facilities policy. I have taken verbal or telephone orders in the past, I always documented them and had a 2nd RN hear and counter sign the order as per our unit policy and frankly to protect myself. I have been around long enough to witness Dr who for various reasons refused to order medications after they had been given.  You will hear lots of advise that starts with "I've always been told... blah blah blah.

I always ask to see the written policy! 

[Hoosier_RN, MSN]

Nurse Beth said:

Dear Nurse Beth,

Can you give an opioid without a Dr signing off on it? I say no but my co-worker says yes. I just don't understand if the Dr hasn't signed it than how can I legally give that? Instead I offered Tylenol which had a Drs order. Did I do the wrong thing?

Dear Don't Understand,

What I don't understand is whether I am being pranked or not.

At first I thought I was, so I sat on this question for a short time. But just in case this question is for real, and with all due respect, here is my answer.

In all reality, I hope this is a prank situation 

[Nurse Beth, MSN]

Hoosier_RN said:

In all reality, I hope this is a prank situation 

Let's go with that

[JKL33]

Really curious about why a coworker would ever advise that this could be done!

[Nurse Beth, MSN]

JKL33 said:

Really curious about why a coworker would ever advise that this could be done!

I wonder, too. I would love to know the context here.