Doctors orders for the small stuff and third shift

Posted
by tsm007 tsm007 Member Nurse

Has 2 years experience.

This is driving me crazy and I'm not sure how you deal with this. I am a new nurse and an agency nurse right now. I float to 4 different nursing homes so far and I have so much to learn. My question for you veteran nurses is how do you deal with requests for things that are not in the standing orders, but things I don't really want to wake up a doctor in the middle of the night for. Here's an example, resident asks for saline nasal spray because his nose is really dry. I asked the outgoing nurse about it and she said "I'd just write an order for it." Then of course when I was asking the unit manager for help with it I get "You can't just write an order for that. It's not in the standing orders." So what's a nurse to do? Do I really need to call a doctor at midnight because this guy's nose is dry? I also ran into this with needing to put on a dressing on weeping cellulitis. There are protocals for skin tears, but not other dressings. In this case I did just apply the dressing. She had cellulitis in another area with a dressing and I wasn't going to let her leg sit, but I'm really frustrated on writing orders. Some nurses say I just write the order (knowing the doc will sign off on it), but others tell me right the opposite - you have to call the doctor for everything. I've ran into requests for cough drops and other simple requests. Do I just start waking the doc up? Do I tell the resident, sorry suck it up buttercup until morning? Do I just give it to them anyway and not write an order like I've seen other nurses do?

tsm007

tsm007

Has 2 years experience. 675 Posts

Oops replied to the wrong post

Edited by tsm007
replied to wrong post

middleagednurse

middleagednurse

Specializes in nurseline,med surg, PD. Has 50+ years experience. 554 Posts

You really can't write your own orders. Those other nurses are playing with fire. Pass it on to the next shift what the patient needs, or leave a note for the MD. Having a stuffy nose is not an emergency.

DierkyBrewster

DierkyBrewster

20 Posts

Depending on how well you know your doctors, and depending on what needs to be ordered is how I determine whether I write my own orders or not. Technically, no, we cannot just write orders. The facility I work at has one doctor for about 90% of the residents. He's very laid back and is one of those doctors that actually would rather the nurse take charge and offer suggestions to him for the residents. His number is in my cell phone, I can usually text him if it's before 10pm and get a quick response for an order I need, but after 10pm, if it's something that can wait until the morning, it waits. If it's something like a dressing or I believe a R may have a UTI, and I KNOW our MD well enough to know that if I explained the situation to him this is exactly what he would order, I will go ahead and write it. I will also fax him a notification of what happened/is happening and the orders that i wrote so that he is not in the dark on the subject.

tsm007

tsm007

Has 2 years experience. 675 Posts

You really can't write your own orders. Those other nurses are playing with fire. Pass it on to the next shift what the patient needs, or leave a note for the MD. Having a stuffy nose is not an emergency.

Thanks for the advice. I did just this on my last shift when a resident asked for something. I don't know why it didn't occur to me to just tell them I'd let the doctor know and in the morning we can get an order for that.

quiltynurse56, LPN, LVN

Specializes in LTC and Pediatrics. Has 3 years experience. 953 Posts

Where I work, I would send a fax to the Dr. to answer in the morning.

Forever Sunshine, ASN, RN

Specializes in LTC. Has 7 years experience. 1,261 Posts

You really have to use your judgement with that. If its tylenol or minor bacitracin treatment, I don't see why you need to wake the doctor up. I would just put the order in but check their allergies first.

As for the patient asking for the nose spray, I would tell them to wait until the morning. Be honest; tell them its the middle of the night and you need a doctors order. This isn't the Ritz Carleton Medical Center. Get them a couple paper towels with warm saline and have them breathe deep.

kbrn2002, ADN, RN

Specializes in Geriatrics, Dialysis. Has 20 years experience. 3,662 Posts

This can be somewhat of a tricky problem. One of those questions with a lot of "grey area" answers. It really does depend on the culture of the facility and your relationship with the provider. As an agency nurse you probably don't have that relationship with the provider that makes it OK to write the minor orders yourself and trust that the provider will sign off on it later.

Some providers encourage this from nurses they trust, some providers are absolutely against this practice. Not knowing with absolute certainty that the provider is OK with you writing an order for saline nasal spray instead of making the resident wait or calling in the middle of the night means you should wait until morning to get the order.

I am also a little surprised that basic dressing orders other than for skin tears aren't covered under standing orders. Again, unless you have the type of relationship with the provider that makes it OK to write the order and update him or her in the morning a phone call would be in order as that really can't wait until morning.

I would also be asking the facility DON if these orders could be added to the facility standing orders to prevent these situations from being an issue in the future.

tsm007

tsm007

Has 2 years experience. 675 Posts

This can be somewhat of a tricky problem. One of those questions with a lot of "grey area" answers. It really does depend on the culture of the facility and your relationship with the provider. As an agency nurse you probably don't have that relationship with the provider that makes it OK to write the minor orders yourself and trust that the provider will sign off on it later.

Some providers encourage this from nurses they trust, some providers are absolutely against this practice. Not knowing with absolute certainty that the provider is OK with you writing an order for saline nasal spray instead of making the resident wait or calling in the middle of the night means you should wait until morning to get the order.

I am also a little surprised that basic dressing orders other than for skin tears aren't covered under standing orders. Again, unless you have the type of relationship with the provider that makes it OK to write the order and update him or her in the morning a phone call would be in order as that really can't wait until morning.

I would also be asking the facility DON if these orders could be added to the facility standing orders to prevent these situations from being an issue in the future.

That is a wonderful idea. I think I have been doing a better job using good judgement on this lately. I just picked up a new facility so you just reminded me I need to take a peak at all their standing orders.

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience. 6,089 Posts

First off I'm concerned that you're an Agency nurse as a new grad...scary stuff.

Secondly, you get to know the docs. I've had several over the years to "write whatever you want and I'll sign off'. I drew the line at medication orders, but always wrote my own wound care orders. Some of the other docs wanted to be called for A&D to the buttocks....they are all different. When in doubt, call or fax them for a signed order.

tsm007

tsm007

Has 2 years experience. 675 Posts

First off I'm concerned that you're an Agency nurse as a new grad...scary stuff.

Well, I do totally get that, but they started me a a facility that was super easy and great nurses and very low acuity. I worked there for a while before going to any of the harder places. The nurses there were all very helpful and there's always a second nurse there to run things by. It's just when I go to other places I am finding there are definitely big differences in staffing and quality of care from one place to the next. I do get to orient for 2 days at each facility (which is honestly what I have seen seems to be the norm for orientation at a lot of facilities for regular hires). I also can decide if I'm comfortable working at the facility and if it's out of my level of comfort I can not pick up there. There is one place that I went to and they gave me 2 halls 45 patients, trachs, feeding tubes, tons of treatments, and a very heavy med pass for the 3rd shift, and very rude and unhelpful nurses. They are extremely short staffed and the whole place seems to be run with agency. I did not go back there. That is one of the perks that I have found is that I can pick and choose the facility. I also think it's been a fantastic learning opportunity for me. I thankfully have very good organization and time management skills. That's been my saving grace.

I am still developing a lot of my clinical skills though, especially assessments so that part I do understand reservations with me being a new grad. However, I am never by myself and there is always somebody to run a second opinion by. I have had no complaints about me thus far and I've had compliments that I do a great job for being a new grad.

Anne36

Anne36, LPN

1,360 Posts

I only call the Doctor for emergencies on third shift. If there is no standing order than I write a communication to the Doctor for the request or I pass it on to the next shift. If I am unsure about a dressing, I do what I think is best at the time (without writing an order up) and leave a message for the care manager and a communication for the Doctor.