Dr. orders or nursing judgement???

mittels · Jan 27, 2004

always get an order for every thing you do unless there are standing orders. If you dont then you could be the one in trouble for ordering without MD behind your name. CYA, for everything you do no matter how little you think it may be.

Alie · Jan 27, 2004

should I argue then with the question that I got wrong b/c I said I would need to call the Dr. instead of starting IV without one.

ADNRN · Jan 27, 2004

I'm a nursing student, too. And every test, since level one, has had a couple of questions that some bozo instructor fumbled up. It's because they have MSNs in Nursing and not in Education. It's hard to right appropriate test questions. In a previous life, I wrote many tests, so I know. The first example you give doesn't have a correct answer. We get those questions all the time, too. It sickens me.

Technically, given the MD's order, you should have drawn it up in a syringe with a needle and injected it in a vein--just like heroin. But the closest answer was to start a new line. It's not enough to study, you have to make up for the instructors inability to write a simple test question, too.

How irritating.

elkpark · Jan 27, 2004

If a medication (digoxin, in this case) is ordered IV, then the order to stick the needle in the person's arm is built into the med order. You don't have to start and maintain a peripheral line to give an IV med ...

llg, PhD, RN · Jan 27, 2004

As mittels' post suggested, a lot of hospitals have policies and standing orders about this sort of situation. Therefore, the answer to the question will be different depending upon the hospital in which you are working.

If, in the institution where you are going to school, doing your clinicals, etc. has a policy or standing order ... and that is the "protocol" under which you have been taught, then starting the IV on your own is the proper thing to do. If there is no policy, written protocol, or standing order, then calling the doc to get one is the correct thing to do.

So, you see, a bunch of strangers on the Internet can't really tell you what to do with a patient in this situation -- because the legalities of practice depend upon the written policies etc. of the institution in which the situation occurs.

llg

Alie · Jan 27, 2004

There is not a written protocal. I go to a local community college and we do clinical at all of the local hospitals. There are six hospitals that we go to. I just think in nursing school we should go by the standard orders and when we go to work somewhere we go by hospital protocal.

RNPATL, DNP, RN · Jan 27, 2004

Most generally, if a patient is getting digoxin IV, then I would think they would be monitored. If that is the case, the hospital should have a standing order for an open IV line in the event that ACLS drugs need to be pushed. I think the question on the test could be mis-leading.

As a practicing RN, it is important to ask if an order is needed (if you do not know). As a rule of thumb, if the intervention is medically related and there are no standing orders for reference, then you will need a physician's order. However, if the intervention is in response to the patient's physical care, then a nursing order is sufficient. For example, if you assess that the patient might be getting skin breakdown or is at risk for skin breakdown, you can order interventions such as special matress, etc. Now, if the patient develops a stage III skin breakdown, you will need a physician's order for a specilaity bed as well as a treatment (thats because Medicare will not pay for it without a physician's order).

Hang in there .... it takes time to learn the ropes, but once you do, it will come a little easier to you. Good luck with those tricky nursing school exams. I also hated them.

Tweety, BSN, RN · Jan 27, 2004

Good luck in school.

The reality is most of us with six or more patients aren't going to start a new peripheral IV is they have a central line, single lumen or no. Especially if it's a single, one-time dose.

The reality is most of us with a patient in shock is going to run the IV wide open while getting further orders.

But don't listen to me, this is where reality and the book are two different things. Sorry.

mittels · Jan 28, 2004

Originally posted by Alie
should I argue then with the question that I got wrong b/c I said I would need to call the Dr. instead of starting IV without one.

Yes you should, unless there is a standing order. Esp on a pt with a central line. Tell your instructor to throw the ? out. Need for clarification. Oh and as far as the dig. med goes, in the drug book it says to have the pt on a monitor.

bellehill, RN · Jan 28, 2004

Personally I would have shut off the TPN and pushed the digoxin, I am guessingthey need the med worse right now. I have never called an MD to ask about placing a peripheral line, however, I have told them if they want me to run 4 things at once they better start a central line. If I have a pt that is not doing so good, I automatically start another line, just in case.

The only time I would hesitate is on an immuno-compromised patient or someone who is spiking temps.

Alie · Jan 28, 2004

Originally posted by bellehill
Personally I would have shut off the TPN and pushed the digoxin

From what I have learned in school if someone is getting TPN you never use that port for anything else due to the high glucose content and the extremely high risk for infection. You don't want to open it for any additional reasons than just to change out the bag. Of course I know what we learn at school is sometimes different than real life so I am not doubting what you say. Although knowing the high risk for infection I would prob try to stay away from the TPN port.:)

Thanks everyone for all of your helpful information and you taking the time to answer my post.