Counrtry doses

PANurseRN1 · Oct 15, 2006

I would still bet you are in trouble with practicing medicine without a license unless protocols are already in place.

Yep. And as far as the old "everyone else does it where I work," you know the old expression "If everybody jumped off a cliff..."

You can't give a med and then retroactively get the order. OK, well, you can, but that still doesn't make it legal. (ACLS is a different situation and does not apply here.) Right now you may have docs who go along with this, but I can guarantee you that someday something will happen and someone is going to get in big time trouble. Then you'll see just how "tolerant" the docs are. And if the BON does any investigating and finds out that other nurses practiced this way, they could find themselves trying to explain their actions to the BON, even if they weren't personally involved in the incident reported to the BON.

Please, take the words of the experienced nurses like marla, space, trauma and others seriously. They know what they're talking about. I'd love to see what Siri's take would be on this. As an LNC, I'm sure she'd have plenty to say.

Bethy-lynn · Oct 16, 2006

Thank you, neneRN, for understanding the grey areas. Just to clarify...we do have standard orders, IE DT protocols (Librium and Ativan), low, med, and high dose ss, insulin gtts, ccu standing orders, cp standing orders, vent orders, sedation orders, the list goes on. YES, YES, Yes, we do have them. the Hospital I work in is a smaller hospital, 38 bed ICU, and so yes, I know most of the MD's VERY well (many of them live in my neighborhood and I've had dinner with them on more than one occasion. My next door neighbor is one of them). As for the ones that I don't know verywell, I definantly call before I do anything that Is not protocol. We do not have ICU residents, nor a CCP, nor a hospitalist, and so yes, sometimes it is difficult to get a hold of a doc when you need one most (IE, when your Meth od just doesn't want to stay down, or, as recently happened, a fresh post op that had too much morphine and got so confused that it took eight people, including three male orderlies to get him to sit back in bed). I also mention the "other Nurses doing it" because those are the people that are around me doing it, many of whom have been nurses, and worked in my unit for 20+ years, and are the first ones to say Oh, just give a little extra, that doc will be here soon. As for the "joking", Many times its something along a sarcastic line, a wink and nod, a light chuckle, and a "yeah, no problem, I got ya" from the docs, not a "hey that's really funny that I just over medicated your patient, Ha Ha Ha". Yes, I very much value my license, and I didn't go into nursing to kill people. I posted this question, not because I wanted to know if it was a Legal practice, but simply because I wanted to know how common this was. I have spoken with other people on my unit about how common it is, and most of them just give me the "Yeah, it's done" answer. I really just wanted to know if other units seemed this liberal, and automic, because yes, I have questioned it which is what I was trying to do when I posted this to begin with.

slinkeecat · Oct 16, 2006

I have to say that this is a practice that is risky business. I have to say that if I was aware of a nurse doing this, i would report her/him to the board. This is why.... You are jepordizing the safety of this patient.

We had a patient who was in pain. The order was for 12.5 mg Demerol w/ 12.5mg phenergan IV. A nurse thought that because the Demerol vial dispensed from the accudose was 25mg/ml Demerol prefilled syringe, she would give 25mg..charted that she gave ordered dose, but wasted into the patient We would never have known as waste was done in the accudose w/ another nurse's badge. The other nurse did not actually observe the waste , but saw her toss a glass syringe of demerol into the sharps @ the accudose and beleived that she wasted properly., but she actually gave 25mg, her reasoning was this was a difficult patient and she ( nurse) was tired and she thought she was doing the oncoming shift a favor to settle her down... Well, she pushed the iv Demerol w/ phenergan in this patient and left the room thinking everything was fine... A nurse tech entered the room and found the pt not breathing well. Resperations @ 8 per minute, diaphoretic..she called our rapid response team

this pt was a post op hip fx 68 yo female. w/ dementia & diabetes.. We followed our protocol and assessed her, finger stick was 110, so it was not a diabetic crisis so, w/ our doc who came up w/ rapid response team, we adminstered narcan.

She survived...but was so frightened she refused any pain meds the rest of her hospitalization.

The nurse, however... after investigation..... was fired for obvious reasons...and has been reported to the board.

When you step out of your scope of practice, you better be ready to take the consquences....

I call for orders... I do utilize our protocols and standing orders and when I need something for a patient i call... I don't give a rat's tushy if i am "bothering a doctor"...

pickledpepperRN · Oct 16, 2006

When we have had difficulty getting a doctor when a patient needs medical care we use the chain of command. From nursing management, to the medical director, to the CEO. I have been cursed at by a doctor asking, "Why are you calling me at three in the morning?"

Answer, "Because your patient needs a doctor!"

I've reported physicians to the medical board for not answering for as many as five hours.

That one showed up after his patient had been to emergency surgery ordered by our medical director.

Any physician who admits a patient to the hospital must ensure a doc is available at all times.

Any emergency department must have enough doctors, NPs, PAs and nurses to save all patients who can be saved.

What are WE going to do about this?

I have gone with a delegation of fellow nursing staff (RN, LVN, CNA, and clerk) to the office of the CEO. We promised to spend at least two hours a day wearing sandwich boards and handing out leaflets that DR. so & so doesn't answer when nurses call for him to help his patient snd the hospital has not done anything about it. Call the newspaper too. The CEO promised to do the right thing and in this case he did.

That MD was off the hospital staff after the third event. (Incident reports to the hospital attorney too)

The web site of the medical board states his license is "retired".

Could we be fired?

Yes.

But we only have one license. It is not up to the nursing staff to practice medicine without standard procedures and/or written protocols.

It IS the responsibility of the facility to provide what is needed to care for patients.

The community needs to know if it is not!

PANurseRN1 · Oct 16, 2006

It seems like the OP is not interested in knowing whether or not this is legal, and certainly not interested in hearing from the many experienced nurses here. I get the impression she only wanted others to validate what her unit does.

All I can say is, take your question to your BON. Ask them how they feel about "country doses." Tell them "everybody does it." See what kind of reaction you get.

allnurses Guide · Oct 16, 2006

I posted this question, not because I wanted to know if it was a Legal practice, but simply because I wanted to know how common this was. I have spoken with other people on my unit about how common it is, and most of them just give me the "Yeah, it's done" answer. I really just wanted to know if other units seemed this liberal, and automic, because yes, I have questioned it which is what I was trying to do when I posted this to begin with.

Well, then your question is answered by those of us who have chosen to respond and that is that NO, this is not common and it is wrong and dangerous and unprofessional. "Yeah, it's done" doesn't mean it is common or right.

slinkeecat's post is just one frightening reason NOT to do this.

Spacenurse and others have given concrete examples of how to handle situations where a pt MAY need more medication.

I see no real need to do this other than professional laziness (sorry to be so harsh but patient's lives are at stake here). There are always ways to handle that meth patient who doesn't want to stay down or the over-dosed post-op pt (narcan?? - which WOULD be protocol) without practicing medicine w/o a licence.

The docs who allow this are also being unprofessional.

steph

dorimar, BSN, RN · Oct 18, 2006

I have to agree with timothy. Never say never. It's not about not calling, but is often about time. I have saved lives by NOT waiting for the physician to call back, and getting the order after the fact. Those of you who haven't, either haven't been practicing in ICU for long, or haven't been practicing well in ICU.

pickledpepperRN · Oct 18, 2006

I have to agree with timothy. Never say never. It's not about not calling, but is often about time. I have saved lives by NOT waiting for the physician to call back, and getting the order after the fact. Those of you who haven't, either haven't been practicing in ICU for long, or haven't been practicing well in ICU.

I've only been full time in critical care since 1980. We have worked very hard for standardized procedures. Of course we can initiate ACLS.

We also have residents and an anesthesiologist available 24/7 and our medical director or designee by phone.

When the Northridge earthquake hit our phones didn't work, electricity was out.

Monitors, IV pumps and vents didn't work.

One patient who was on CPAP prior to extubation was frantic. Her IV Ativan had been changed to something else but everything was off the shelves and on the floor in the complete darkness.

With others ventilating both my patients I went to the med refrigerator with a flashlight in my mouth and got a tube of Ativan. I gave 1/2 of it as the ordered dose was 1 mg. The patient was alert, frightened, and so agitated I was afraid she was using too much oxygen. It was impossible to get to the locked drawer with the newly ordered med. I was writing everything on the narrative in the dark, flashlight in teeth. (It was a little keychain squeeze type light.)

That was about 5:00 am. The nursing supervisor and charge nurse knew.

Before six when the sun came up our medical director came in and wrote orders for whatever was given. Of course he approved one more dose of the Ativan she had been on since intubation.

I can truly say that is the only tome I have given a med without an order. AND I gave the dose she had been on.

ONLY in an unavoidable and unpredictable emergency should this ever be needed. NOT because the facility does not provide sufficient medical staff for the ER, NOT because the doctor won't return a call, NOT to avoid "bothering a physician. Certainly NOT when the dose charted is not the dose given.

dorimar, BSN, RN · Oct 18, 2006

Spacenurse,

Firstly, WOW!! What a postion to be in!!! I cannot imagine.

Secondly, that was exactly what i meant about never say never. I have been in situations not so dramatic but with potentially worse outcomes if i didn't act because the phisician hadn't yet returned the call. If you have been practicing since 1980, then I'm sure you've had vented patients develop pneumo's and you got stat CXR's while you were waiting for the doc to call back. I believe that should be a standing order, but it is not where i work. Same goes for stat labs. Last week my post op patient was tachycardic with a low cvp and decreased u/o, but not yet hypotensive. labs 2 hours prior showed a stable H&H. I spoke to the surgeion several times and boluses were ordered and given. As he got more tachycardic I continued to speak to the surgeon and repeated labs with orders. Then i got orders to transfuse due to hemaglobin dropping form 10 to 8.5, patient still tachycardic with low cvp and low urine output, but not yet hypotensive. I had spoken to the surgeon already several times with prompt phone call returns and was continuing to implement orders. By the time the patient actually got hypotensive it was drastic and rapid and I started dumping blood product in while waiting for the surgeon to call back. At this point his answereing service couldn't arouse him and I had them call Q 3 minutes while i notified my admin supervisor of the probable need to call the OR crew in and ppossibly the cheif surgical officer,and I dumped blood product in and got repeat stat labs. As it was he called back stated he'd be right in and asked for th OR crew to be called in stat (big surprise). By the time he got in, the crew was here, I had dumped 5 untis PRBC into my patient and his SBP was 55. They wisked him off to surgery and his spleen was ruptured.

He came back pink and stable. The physican thanked me, and when i came back three days later the patient profusely thanked me, as he was awake and aware and knew what i had done for him.

I'm not saying it's ok to be in that situation, but I wouldn't have acted differently.

dorimar, BSN, RN · Oct 18, 2006

Another big difference is, as you stated ,you have residents and anesthesiologist available 24/7. That is very nice for you and your patients.

cardiacRN2006, ADN, RN · Oct 18, 2006

There is a difference between your examples (earthquake, hypotensive patient) and giving a little extra insulin or wasting the ativan into the pt.

Being a pt advocate and doing what you know is best in spite of Dr's not returning calls is what makes good nurses. It is based on years of experience and judment. You wouldn't do it if you didn't know that's what the pt needed. Thinking that the insulin scale is not appropriately dosed and making your own adjustments is not, in any way, similiar. Lying about the amount of ativan needed by wasting it into the pt and falsifying legal documents also is not similiar.

ZASHAGALKA, RN · Oct 19, 2006

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

Just to complete a thought on the subject of nurses and glucose control.

http://www.pulmonaryreviews.com/mar06/nurses.html

"In the ICU, insulin therapy is a job better left to nurses, suggest study findings presented at the Society of Critical Care Medicine’s 35th Critical Care Congress. In the study, a nurse-driven protocol for giving intensive insulin therapy to medical and surgical ICU patients achieved more effective blood glucose control than did standard physician-initiated insulin therapy.

Blood glucose averaged 126 mg/dL among the patients assigned to the nurse-driven protocol, 153 mg/dL among those who received insulin from a physician, and 166 mg/dL in the sliding scale group.

The patients in the nurse-driven protocol were normoglycemic 51% of the time versus 32.4% and 16.8% of the time, respectively, for those who received physician-directed and sliding scale insulin therapy."

~faith,

Timothy.