Counrtry doses

[Bethy-lynn]

In our unit, we tend to give a lot of "country" doses (such as adding on a couple extra units of insulin if someone's sugars are high, or giving the extra mg of Ativan to the resident Meth od). We even joke about it with some of our md's. I guess I'm just a little curious about how "normal " this is. i feel like I work in an EXTREMELY liberal unit ( we order a lot of things, labs, ekgs, x-rays, O2, and we make few med changes like changing from iv to po, or giving benedryl or tylenol) and I was just wondering what the consensus is.

It's the only unit i've worked in as an RN and I was just curious.

[JenSICU_CCRN]

I don't mean to beat a dead horse, but I can't get this posting out of my mind. I just re-read the original post, and I'm appalled that you all joke about this with physicians. It isn't funny to me that you give meds without an order....it is illegal and wrong. Just had to get that off of my chest and mind.

Jenny

[VivaLasViejas, ASN, RN]

"Country" doses? Never heard it called by that name.......but I have heard of practicing medicine without a license, and what they call THAT is trouble.

Nope, I worked too long and hard for my RN license, and even if I do happen to know more about a given patient than some doctor who sees them for two minutes, I'm not going to risk my livelihood by doing anything outside my scope of practice. I don't care if the doc doesn't like being called at 3 AM, that's what they get paid the big bucks for!

[Spidey's mom, ADN, BSN, RN]

"Country" doses? Never heard it called by that name.......but I have heard of practicing medicine without a license, and what they call THAT is trouble.

Nope, I worked too long and hard for my RN license, and even if I do happen to know more about a given patient than some doctor who sees them for two minutes, I'm not going to risk my livelihood by doing anything outside my scope of practice. I don't care if the doc doesn't like being called at 3 AM, that's what they get paid the big bucks for!

I agree with you Marla - and we are stereotyping nurses who work in the country as nurses who skirt the law. And I live in the country and don't skirt the law. I too worked very hard for my RN licence.

This is sloppy nursing.

steph

[TopherSRN]

I agree with you Marla - and we are stereotyping nurses who work in the country as nurses who skirt the law.

The term 'country dose' just refers to measuring something with a rough guesstimate. Kinda liek if a recipe calls for a cup of sugar, a country dose would be 'what looks like a cup'. it might end up being more or less. Also if the cup didn't make it sweet enough you might add more to suit your tastes.

This is a common term in the south and nobody was stereotyping nurses from underdeveloped areas. Please don't make it out to be something it never was.

[JenSICU_CCRN]

This is a common term in the south and nobody was stereotyping nurses from underdeveloped areas. Please don't make it out to be something it never was.

Really, this isn't the main issue of the OP....the main issue is that giving more drugs than are ordered is not legal and is practicing medicine without a license. And then calling it a country dose is like making light of it, in my opinion of course. Yes, as critical care nurses we do have docs that under-order meds, but in referring to this post....is it because the nurses are giving more than ordered illegally and the docs think their ordered doses are enough? So, in the future this doesn't help ANY patient because the docs will order on past experience and also according to standards. There are consequences to these actions aren't there? So, are you all really helping patients in the long run?

Jenny

[Marie_LPN, RN, LPN, RN]

Oh, and as an afterthought after hitting submit....think about it like this. If you are giving extra insulin and extra ativan...the physicians think those doses are working and will be hesitant to write orders for more when you really need them.

Excellent point.

[Marie_LPN, RN, LPN, RN]

Sounds like practicing medicine without a license.

That's because it is.

[cardiacRN2006, ADN, RN]

Oh, and as an afterthought after hitting submit....think about it like this. If you are giving extra insulin and extra ativan...the physicians think those doses are working and will be hesitant to write orders for more when you really need them. Blood glucose levels are nothing to mess around with, and if the physician thinks that sliding scale is effective then when the patient goes to the floor where they are less staffed and have less time to pay such close attention to specifics like the intensive nurses are....what happens? They won't heal, and it could lead to longer hospital stays. Please think of the larger scale when you are doing these things. It isn't always just about the right then and there in these cases.

Jenny

I couldn't agree more...

[CHATSDALE]

this is dangerous, a dangerous practice both for you and for the patient

the doctor is not going to sign behind you if something goes wrong and they won't be laughing with you either #1 medical rule cover your own hiney, believe me the docs know and practice this

you can't change the other nurses but you can change the way that you do your work

please do

[TennRN2004]

We call it a "baptist dose" down here. It's not a common practice to my knowledge where I work, but on occasion I have been told in report someone recieved a baptist dose of insulin, morphine, ativan, etc. I have honestly never actually done it myself that I can recall. I know that if it was a common practice that was discussed openly, it would be quickly stopped.

Instead of giving a baptist dose intentionally and charting the correct dose, I have actually had the opposite happen. I was in the room with a crashing patient, and my other patient was a climber trying to get out of the bed. The RN who had this patient the night before yelled in and asked me what it was time for the patient to have. I yelled back ativan, so the other RN goes to pull it and doesn't check the med record to see that the dose had been reduced.

I charted the med and I charted the actual dose given, instead of lying and going back and wasting 1 mg that was actually given to the patient. I felt that if something were to happen, the physicians needed to know exactly how much the patient had gotten, but I got mouth about it when giving report the next morning that I had not given the proper dose. Funny thing though when I came in that night, the nurse tells me ..."now I actually gave her more, but I only charted the proper dose that was ordered." To my mind, neither is okay for us to do, but at least what my co worker did was an honest mistake, and not intentionally done to give the pt more than what was ordered.

I can see times when it may happen, and I think for the most part ICU nurses have good enough judgement to not place patients at risk by overdosing medications. However, I think there is a fine line here, and nurses should tread very cautiously when giving baptist doses of meds, regardless what type of med it is.

[ZASHAGALKA, RN]

I think the OP is getting lot of unearned grief.

Nurses, every single day, go above and beyond to 'massage' the system, or else it would break down. The lines are blurred and always have been.

Just like nursing school, there is the 'official' way things are done, and the way things are really done.

Maybe it's more pronounced in critical care, but still: all you people crying that you know where the boundaries are and stay within them all the time - I don't believe you.

From - Nursing Against the Odds by Suzanne Gordon:

"In some institutions, nurses simply do a number of things on their own and the doctor rubber-stamps them afterward. . . Nurses are always ordering things that they consider to be pro forma when the doctor is unavailable. . . Why do doctors tolerate these private 'liberties' when their organizations are so vociferous in publicly denouncing nurses who want more authority? If nurses 'work to rule' by calling a doctor for every little thing . . . the system would grind to a halt. . . Sociologist Andrew Abbot calls this bypassing of onerous and extensive restrictions "workplace assimilations". . . A great deal of effort, on both the part of doctors, and ironically, nurses, is spent making sure the public doesn't know how much medical diagnosis, treatment, and prescription nurses actually undertake."

I read a paper by the Society of Critical Care Medicine once that flat out admitted that it was common place for nurses to 'waste drugs appropriately' - waste them IN the patient, because the doctors were simply unaware by experience of observation how to appropriately order narcotics. The article wasn't even critical of the practice - it was just an observation that nurses routinely make up the difference for the shortcomings in prescriptive habits of doctors.

It is common place. I've seen docs throw fits because the xray, am labs, and abgs on vented patients that they DIDN'T order weren't done. It's 'pro forma'. I've had more than one doc say that, if they didn't order it, they DID order it because it's a 'standard verbal order'.

Can that get nurses into a mess? Of course. But, don't beat up on the OP because those things happen everyday. They do, and my guess is that most of you know it, whether you approve or not. And, whether you approve or not, just like everybody else, you 'pretend' that the system is actually more cohesive than it actually is.

Or, in a more subtle fashion, how many of you call a doc and beat around the bush with symptons until the doc 'gets' the diagnosis you are making and orders treatment for it. We can play that we are merely pointing out observations if we want, but we darn sure aren't going to let the doc off the hook until the lasix is ordered to treat the CHF that we are, in fact, diagnosing. Such calls aren't about objective symptoms, but very subjective attempts to attain specific treatments for medical diagnoses. Yep, happens every day.

Nurses are infamous about going out of their way to convince doctors, the public and themselves that the real jobs they do are merely 'delegations' of authority. The result is some deep despair about why nurses aren't respected.

Why? Because we excel at hiding our true roles. In fact, it's second nature for us. Maybe THAT is the problem.

~faith,

Timothy.

[JenSICU_CCRN]

I don't think that anyone here has denied that it happens....nurses doing things without orders and so on and so forth. What we are saying is that it is illegal and giving extra medication is practicing medicine without a license. You did elude to the fact that nurses give extra because physicians don't order what is needed....well, maybe because what they have ordered is what they think is working when in fact it isn't because the nurse is taking matters into their own hands. If I feel that pain medication or sedation, etc...isn't working I call and get orders for a larger dose. As far as labs, PCXR's, ABG's, etc....yes, we do have standing orders for that in my facility for our patients in the Trauma/SICU so we can order those without calling. But, NOT MEDS....I would never dose a patient how I thought appropriate. Not my job, nor in my scope of practice to determine. I just don't feel it is right to make light of something so serious. YES, we generally know more than the docs about the patients....YES, we assess the effects of medication....YES, we are educated and smart enough to know whether meds are working or not....so, CALL THE DOC and get orders. Do you not think that giving extra insulin is a big deal? Do you not think that dropping a blood glucose too fast can cause problems neurologically among other things? We were not educated in nursing school for dosing of sliding scale....giving extra insulin is no laughing matter and could cause a lot of problems outside of 'just lowering the blood sugar'.

Jenny