Can you recommend a medication?

emmy27 · Dec 4, 2015

Especially when calling a hospitalist who has dozens of patients and probably doesn't have that patient's chart in front of them, and who might have been in the middle of anything when I called, I tend to give a brief explanation of the problem and make a specific request- ie, "The patient has some swelling and itching around her mouth, she says she takes 25 mg benadryl at home for this, can I get an order for that?" or "The patient is having pain of 7/10 with ambulation but doesn't want the ordered morphine, do you want to try toradol?"

Once in a while somebody might bite your head off, whether because they have a god complex or are just having a rough day, but this is a perfectly reasonable way to conduct yourself. You're not dashing in to a doctor mid-assessment and telling them what to diagnose- you're making a reasonable assumption about likely treatments for a patient whose situation you are likely much more directly immersed in at the moment and asking the provider for the order. If they don't agree with your suggestion, they'll let you know.

It's definitely not practicing medicine. Just giving meds without an order, yes, but suggesting them? No. That's silly.

cayenne06, MSN, CNM · Dec 5, 2015

Um the people you work with obviously haven't been taught SBAR - Situation, Background, Assessment and Recommendation (SBAR) technique. I'd get them some reference material on that. Here's a link for you SBAR. The R part of SBAR is RECOMMENDATION. This is what they are teaching in school that nurses should make recommendations. I think you coworkers are completely wrong. I think you made the right call asking for benadryl.

Yes, this exactly. NOT practicing medicine. That is called consulting.

As a CNM, I love nothing more than a good SBAR from the RNs (or even my clinic assistants) about the patients we are caring for. When I get a call waking me from my 30 minute nap at 2am ( I SO do not miss being on call, lol), or am interrupted for a consult when I am knee deep in problem visits, it seriously helps me reorient myself and make sure I am understanding the problem. I might not always agree with the suggestion, but regardless, knowing what she/he is thinking helps me understand the situation much better.

Jmira.BSN.RN · Dec 5, 2015

I, like many of the other nurses who have posted, make recommendations to doctors frequently. Whenever the doctor is thinking something different, they simply give that order instead. I havent yet had a doctor get upset with me for making a recommendation

Tenebrae, BSN, RN · Dec 5, 2015

Oh dear god. A touch over dramatic.

I do alot of work in palliative care, and often end up making suggestions to the doctor of what may be helpful for my patient based on my experience. If they choose to follow it great, if not, their choice, they are the ones getting paid the big bucks.

Many GPs dont have alot of experience in palliative care and are happy to take suggestions from us. After all its about the best possible outcomes for the patient

FurBabyMom, MSN, RN · Dec 5, 2015

We suggest things all the time. I did it as a floor nurse and do it all the time as an OR nurse. The docs I work with now genuinely appreciate our thoughts. Both of traumas I was in where the patient coded this year - when we finished listing what we'd tried, we went around the room. Time of death was called after everyone had a chance to speak (voicing suggestions, etc). I can't say this is new or not, as I had my first and second OR deaths this year. It wasn't a surprise really (considering the value our institution places on communication and teamwork).

I ask about things all the time. Most of the time they agree with me. Some of the time they want something else. Others, they just don't (and don't know what they want either). All of which are okay. No feelings hurt.

As a floor nurse I did it - paged NPs/PAs/MDs about a situation and had suggestions. Only a specific service line was resistant to this when I worked as a floor nurse (probably more indicative of the practice than the specialty overall). Most appreciated that we were able to expand upon why we were calling - were there assessment issues, did we need more information (labs, tests, monitoring), were there critical labs (which you expected orders to fix it) or what was the overall situation. Many of the providers I worked with were at home, and sleeping when I paged - so they generally appreciated the assessment and recommendation.

I think though, this is possible to be a thing that may ruffle feathers - depending on the culture of your workplace and how physician practices are.

anjalidevit · Dec 5, 2015

I believe it was appropriate ... after a through assessment of the situation u have presented your objective assement and identified the problem and have recommended your solution .... Worst case scenario the doctor will say no ... Nothing wrong in that......but on a caution note .... Please do be mindful of patient allergies and side effects of medications .... Because when u get comfortable suggesting medications and this one night when u are calling and the doctor is half asleep ... They might not even give it a thought just because they are used to u being careful ......hope u understand ......

JustKeepSmiling, ADN, BSN, RN · Dec 5, 2015

I have always utilized SBAR. From working in a community non-teaching hospital full of seasoned doctors to a huge teaching hospital full of residents. Never once got ripped by a provider or coworker.

I once even called a very seasoned doc and said I need to move this patient to ICU asap and he responded with I'm writing the orders and I'll meet you there. Pt was decompensating quickly on bipap and was minutes away from needing to be intubated. Which she then was and was successfully extubated a few days later.

I've always tended to build relationships with the providers in a sense that they know I mean business, I don't BS when I call you with a concern and I won't shut up until I feel my patient is safe and problem addressed. Be it a new consult, medication, transfer to higher level of care, etc.

ESPECIALLY working in an ICU with residents now, I recommend orders all the time. "So I've seen X given a lot in this situation and it worked well"

I tell them experiences I have had in the past and they appreciate the insight.

Be concerned of older docs and their "cook book" of medicine. Each doc has a way about doing things and it doesn't work that way all the time. By being an advocate for your patient, using SBAR, and presenting a suggestion in a gentle way can break them of their usual recipe and get your patient better treatment. For example, lortab doesn't treat neuropathic pain.

I truly enjoy having good interdisciplinary relationships and when the patient gets good results or relief from my suggestion, I enjoy seeing the provider happy too and know that we work well as a TEAM.

Lord now I'm on my soapbox here but the residents are TERRIFIED of ordering benzos and getting ripped by certain attendings. If that was your mom intubated on crappy precedex with a resident trying to place an IJ and scared so she can't hold her head still because she's delerious from poor day/night regulation, nonstop alarms, frequent vitals etc. wouldn't you want her to be calm enough to reduce the risk of a pneumo?? I try to put things in perspective for them. This is not just a procedure you are doing. This is a human being and there are real risks here especially with an uncooperative patient.

I suggest a bit of ativan and you tell me no because it causes delerium and drops BP? First of all she's already scared out of her mind and delerious. Secondly 0.5 ativan in the hundreds of times I've pushed it in various levels of care has NEVER dropped a pressure to a concerning point. So if I can't convince you to start propofol and/or fentanyl to get her off this crappy precedex then at least please order a short acting benzo so the patient can relax and you can more safely place this IJ. Then said patient starts biting down on the ETT and I can't go up on the precedex anymore at this point. So now your AGITATED and delerious patient is trying to bite through the ETT. So now not only do they need an IJ but I'm calling anesthesia for back up reintubation in case she manages to bite through the tube because no one can get a bite block in. The resident did not know that is was possible to bite through an ETT.

Needless to say, this resident did not get to do the IJ.

I HATE precedex.

Off the soapbox. [emoji58]

allnurses Guide · Dec 5, 2015

Most of the doctors I work with I have known for 15 to 20 years - I am not afraid to suggest something to them - Your best bet would have been to assess the cause of the reaction your patient was having did she start a new medication? Having done this I would have called with the results of my assessment plus vitals and then said - Would you like me to give Benadryl? Most will tell me to go ahead? one or two will be grumpy by it but I stand by my actions as advocating for my patient.

Hppy

Cola89 · Dec 6, 2015

I would and have... but some doctors don't take kindly to that and rebel by ordering something unhelpful. Or wayward when the solution could be simpler. I've had the best luck getting what I want when I build my case and lead the doc to what I want without directly asking for it. Like making them think it was their idea.

MistyMD · Dec 6, 2015

In my earlier years of nursing, it was frowned upon to suggest a medication, but in the last several years, I find that some doctors actually welcome a suggestion (especially the younger ones who are less experienced ). I have been a nurse for over 40 years so some of them value my input.

OldPhatMC · Dec 6, 2015

In hospice nursing we make evidence-based recommendations all the time. Many attending physicians are not well versed in hospice care and they actually ask for recommendations. If they don't like it, they will explain way. Some physicians will become irritable if you don't have some sort of plan in mind. Occasionally we end up asking for something and it ends up being a phone call from the hospice medical director to the attending. If you develop credibility and rapport with the doc, you'll very rarely get a poor response. Add to that the obvious: try to be respectful of their time, so save little things for the morning and call on stuff earlier rather than when things have gone downhill.

Creamsoda, ASN, RN · Dec 6, 2015

Your co workers are a bunch of, oh I don't know, I just will keep my mouth shut. Where I work we are expected to use the SBAR format.

Situation, Background, Assessment, recommendation. RECOMMENDATION. WE tell the docs whats up, tell them what WE think is going on while they are forming their own opinions as well, and ask for what we think is needed. They may disagree, and will tell us their rationale, and 99% of the time I will see their side of things and agree (I'm lucky enough I guess to work with a bunch of awesome doctors? Ranging from the intensivitst, to hospitalists, to other specialists.) Not every solution is right or wrong and they may want to try one thing over another depending on what the latest practice is. The docs generally want our opinion. Your calling the doc for a reason. You know what the patient wants/needs. (and sometimes not. I hate the phone calls more where something weird is going on and I have NO IDEA whats going on despite critically thinking about it and just saying "so uhhh something weird is happening to Mr. Smith...I dunno what should I do?" I sound like an idiot and the doctor is thinking, well what do you want me to do?)

Any way, it kind of sounds like your patient was having an allergic reaction. What happened to them when they were left for hours with zero intervention because the doc was gonna see them "later". Your damn rights, I'm going to call, describe whats happening and ask to treat the allergic reaction. Stay strong and professional in your interactions with the doctors knowing now that there is potential for backlash. But if you sound like a reasonable, well informed nurse, I can't see there being a problem. You are all professionals. If you find out this is not the case, go somewhere else ASAP