Can you hold medications without a doctor's order?

[Guest878640]

Like insulin or for example if someone had a head injury and you hold trazadone so that symptoms of head injury isn't mistaken for side effects of the sleep aid.

[JKL33]

On 12/16/2021 at 12:36 PM, FolksBtrippin said:

We hold meds. I think that verbiage is even used on NCLEX.  Holding a med based on your nursing assessment is not putting a med on hold, which is what I think you’re talking about. 

I see your point. Clears up how this issue becomes confusing. Part of the distinction your explanation makes has to do with time—at least in my mind. Putting the med on “hold” status implies a longer-term than just “this dose is not going to be given.” And in acute care we don’t do much putting meds on hold; we collaborate with prescribers to know that they are not going to be given at this time, but are not discontinued. Where I have been we haven’t referred to that as putting on hold, but rather just holding. 

I can believe NCLEX refers to this as you say but I bet it is mostly along the lines of “hold the med and notify prescriber.” But I believe that whether it’s a single dose being held or a medication being put on hold for a longer term, that is not an independent nursing function. The semantics of needing an order vs collaborating with a provider or notifying them of an assessment finding that may alter the plan of care, are a matters of word choice. 

I have certainly never heard that nurses independently decide that someone shouldn’t have something and so they just don’t give it—whether that act is called holding, putting on hold, whatever. 

[guest1143647]

In home care Pdn  this hold thing is even more complicated.

 

I had a parent that refused to let us nurses give her daughter with a trach and vent  albuterol at night. That had been going on for months before I got there. Not sure of moms reasoning. When I told the supervisor if she could  just ask the doctor to d/c the nightly albuterol she just said to keep initial it and circle it in the MAR, no need to call the doctor.I thought that was stupid, but hey she was the supervisor.

[FolksBtrippin, BSN, RN]

23 hours ago, JKL33 said:

I see your point. Clears up how this issue becomes confusing. Part of the distinction your explanation makes has to do with time—at least in my mind. Putting the med on “hold” status implies a longer-term than just “this dose is not going to be given.” And in acute care we don’t do much putting meds on hold; we collaborate with prescribers to know that they are not going to be given at this time, but are not discontinued. Where I have been we haven’t referred to that as putting on hold, but rather just holding. 

I can believe NCLEX refers to this as you say but I bet it is mostly along the lines of “hold the med and notify prescriber.” But I believe that whether it’s a single dose being held or a medication being put on hold for a longer term, that is not an independent nursing function. The semantics of needing an order vs collaborating with a provider or notifying them of an assessment finding that may alter the plan of care, are a matters of word choice. 

I have certainly never heard that nurses independently decide that someone shouldn’t have something and so they just don’t give it—whether that act is called holding, putting on hold, whatever. 

I’m not sure if our disagreement is semantic in nature or not.
 

If it’s semantic, I’d rather just let it go.

But if we’re talking about whether or not a nurse has the responsibility and authority to not give a med and notify the provider when the assessment justifies that action— it’s worth saying here— yes she does have that authority and responsibility. Of course this means the nurse must also have adequate information and comprehension of the plan of care, and maybe this is the problem sometimes. 

Example:

Pt is vomiting, c/o headache and frequent urination, Lithium lab just came back at 1.8. Pt due for Lithium dose. The nurse should hold the Lithium and call the prescriber. To give the lithium is wrong. The nurse is responsible for harm done to the patient if she gives the lithium anyway. The nurse needs to know the meds she’s giving and that includes knowing when to hold them. 

Of course you call the doc when this stuff happens. The point is that the order needs to be changed and that you’re catching something. That’s our job.  You call right away if it’s urgent and if it isn’t you mention it in rounds or whenever it’s convenient. I’m not going to call the doc right away over holding dulcolax for diarrhea but I am going to call right away for possible lithium toxicity, or for probable hypernatremia because doc forgot to d/c salt tablets and the labs are showing that and my assessment agrees. Or any number of things that warrant a right away phone call. 

I think it’s unfortunate that some nurses lack the proper support to do their jobs correctly. But that doesn’t mean that I’m going to come here and say, oh you can never hold a med for any reason. If you have to hold a med to protect your patient then you’d better do it. And of course you’re going to follow up appropriately. Also basic nursing stuff.

[sandman88]

check with the provider who ordered his/her meds.  screw your supevisor.   I made that mistake and did what the supevisor told me to do.  the patient almost went to the er.  the supevisor doesnt care.  cover your own a$$, call the Dr and document!

[kbrn2002, ADN, RN]

On 12/11/2021 at 1:18 PM, londonflo said:

No, I don't call for every little thing --( 1.patient on stools softeners and having diarrhea? 2. Patient on an antihypertensive and now low normal BP on a low sodium diet) and I would pass it on in report. The next  nurse seeing the physician would communicate it to the MD. 

I attended a great professional program that stressed .... when you call an MD what do you want them to do? You provide the assessment info and what are you expecting?

A telephone call:

MD: Hello

RN: Mr. JJ Smith is having loose stools, actually diarrhea  .

MD: OK

RN: Ummm should I hold his Dulcolax tabs?

Communication is the key to the plan of care being effective but communication doesn't mean calling the MD in the evening, and at night.  Do you not trust your co-worker following you to communicate your decision? If the plan of care depended on that one medication, why is the patient still in the hospital? (I am not talking about IVPBs such as antibiotics). Rather it seems like the patient is doing well on the plan of care and can continue it at home. A decision like that can be made the next morning.

I will give you an example. I was an evening (3-11PM) nurse. Old days when people came in the night before their surgery. It was one of our jobs to review the CXR results and labs that were done prior to surgery. I didn't get around to it before after my shift ended..like midnight. One man (who was going to have a mastectomy) showed he had TB on his CXR. I called the OR and alerted them to cancel his surgery. (YES, On MY OWN I DID THAT). You cannot have someone in the OR, on the respiratory equipment unless it was life threatening ).

I reported to the midnight nurse what I had done and said wouldn't it make more sense to call the surgeon in the morning a couple of hours before the case was scheduled?. He was a surgeon with a long day of cases ahead of him. 

Since this is before we had special rooms  with negative air floor, and no additional hooded masks, I suggested the night nurse wear a  (already plentiful )mask if she had to go in there,. The man  had come in from the community earlier that day. ...Oh no she had itchy fingers (or the "I'm awake so you should also be awake" syndrome) and called in the MD at 2:00 for an order for an isolation cart outside a door. Yeah she got the isolation cart with the masks...the same stuff available already on the floor. 

That's not an "I'm awake so you should be awake" decision. I don't know where you work but in my experience any emerging condition that requires isolation needs to be reported in a timely manner.  There first needs to be a diagnosis confirming the new condition and need for isolation.  While you may be 100% positive this patient has TB based on the chest x-ray it is not within your scope to enter a medical diagnosis, therefor a call to the provider even after hours is warranted.  

These communicable diseases are tracked and need to be reported to the state which as a floor nurse is also something you would not be responsible for but it is something that needs to be done. If said report is not submitted within the state's required time after a positive diagnosis is confirmed the facility could be looking at a tag that may or may not include a fine for failure to report. 

[londonflo]

13 hours ago, kbrn2002 said:

There first needs to be a diagnosis confirming the new condition and need for isolation.  While you may be 100% positive this patient has TB based on the chest x-ray it is not within your scope to enter a medical diagnosis, therefor a call to the provider even after hours is warranted.  

First of all, I was NOT making a diagnosis. The CXR was clear that the surgery could not progress at 0700 AM.

13 hours ago, kbrn2002 said:

I don't know where you work but in my experience any emerging condition that requires isolation needs to be reported in a timely manner. 

Midnight is a timely manner? Who are you going to call?

13 hours ago, kbrn2002 said:

There first needs to be a diagnosis confirming the new condition and need for isolation. 

A diagnosis would not be made in the middle of the night. In the morning, the process of diagnosing the patient began. 

13 hours ago, kbrn2002 said:

therefor a call to the provider even after hours is warranted.  

And what would you expect them to do at midnight? When you call a MD you should be thinking about possible medical interventions. Besides isolation what are you expecting? And it was NOT my place to tell the patient there was a possible Dx of TB. 

13 hours ago, kbrn2002 said:

These communicable diseases are tracked and need to be reported to the state which as a floor nurse is also something you would not be responsible for but it is something that needs to be done.

Tracking does not start at midnight. Yes, the patient's work up began the next morning and was reported to public health. 

I never said there was no further reporting or workup. But no one answers the phone at public health at midnight.

13 hours ago, kbrn2002 said:

If said report is not submitted within the state's required time after a positive diagnosis is confirmed the facility could be looking at a tag that may or may not include a fine for failure to report. 

I doubt the time frame is 8 hours or less.