Dr.'s orders for feedings/water

PediLove2147, BSN, RN · Feb 17, 2011

I can only imagine the doctor's reaction if you called to ask if you could stop/slow the feeding.

I actually had something very similar happen with my home peds case the other night. She had a very rough day and the father asked me to withhold some of her feeding as well as slow what she was receiving. I did exactly that.

I could understand if you were giving more than what was ordered but with less, per the parent.. I can't see that needing an order.

GHGoonette, BSN, RN · Feb 17, 2011

I don't see why you would need a dr's order; the parent is the child's legal guardian, and if s/he elects to politely decline a minor aspect of the child's care on behalf of the child, neither you nor the doctor can override it anyway.

Of course, you would need to document such refusal to cover yourself; the only other thing I can think of is that any deviation from a prescribed care plan might be somehow breaching the company's contract with the client, or that it is written into company policy.

caliotter3 · Feb 17, 2011

I would never call the doctor in the middle of the night to do this. I would have followed the directions of the parent and charted indicating it was at the "request of PCG". However, if the child has ongoing or frequent problems tolerating the feeding, I would contact the doctor at a reasonable time of day, discuss the matter, and attempt to get the doctor to change the order to indicate, "may slow or stop feeding as tolerated" or some such wording, to give you the leeway to tinker with the feeding, "as tolerated". That way, you can adjust matters as needed and you are following the doctor's order without having to bother him in the middle of the night for something that trivial. And when you follow the parent's instructions, you can always chart "per PCG request", to cover yourself. If you do not want to deviate, but the parent does, then insist that the parent do it themselves, but still chart that they did whatever it is they want to do, again, so that there is a record that they did it, not you.

Akeos · Feb 17, 2011

I would feel like a complete moron if I called the doctor in the middle of the night for this. I would feel dumb even if it was the during the day. It was something that only required common sense to fix that i didn't even give it a second thought to just stop the feeding. I'm not worried about it I was just really confused when i was told I needed an order, it still makes no sense to me, I should have had the case manager clarify for me why I would need one but I was so thrown off when she said that, plus it didnt help that she called at noon when i worked til 7am and had to be at work again at 4, i couldn't really think of anything to say other than "huh? ok" and I did chart that it was at the parents request (which apparently it was ok when i charted that when i was asked to give an extra dose of chloral, but not when to adjust the feeding). Thanks for your responses, I'm glad it's not just me who thinks its completely ridiculous.

Esme12, ASN, BSN, RN · Feb 17, 2011

You changed the MD's order...even though it was common sense to stop the feeding.....the feeding is a treatment with specific treatment orders the define their administration, anything outside the said parameters requires an order to start and stop. That being said it is common sense to not feed a patient that is not tolerating the feeding that itself can cause serious issues and pneumonia/death if asparated. YOur documentation was impeccable as to the events. Just curious did you have a may repeat order for the chloral????

Anyhow this is one of those damned of you do damned if you don't situations. You needed to notify the MD prior to you going home that the patient was not tolerating the feeding especially if this was a new development and get and order before you went home but at the very least that you notified the MD. Devils advocate....lets say the MD hears later that the feeding was/wasn't tolerated and for whatever reason the family decided to sue the MD because the patient was "starving" or ended up hospitalized due to an ileus or got asparation pneumonia because the next nurse kept feeding the patient not realizing it wasn't tolerated. The MD can point straight to you and blame you and say "she never called me....I had no idea!" and you're at fault because you failed to notify the MD......but if you continued to give the feeding and something happened it is your fault anyway....so I always error on the side of bugging the MD in the AM.....You may get in trouble for bugging him but you can't get sued for that you just get yelled at....big deal I've been yelled at before :).......always cover your own butt....no one else will xo

caliotter3 · Feb 17, 2011

Next time this happens, call the nursing supervisor in the middle of the night to get her to instruct you to stop the feeding. (But don't let the child choke to death while you are getting the supervisor on the phone). BTW, I have been told in the past that stopping a feeding when someone is vomiting the feeding, is the correct nursing intervention. I have never been told I had to call the doctor unless the situation warranted it. Of course, the doctor will want to know that the child vomited during each of the last five attempts at feeding. He will not appreciate being called at 2 am to hear that Suzy burped and upchucked less than 15 ml and all was ok after you resumed the feed, 15 minutes later. Sometimes you have to use your common sense. I think your nursing supervisor is being anal. I'll bet she would not follow her own advice if she were working in the field.

leslie :-D · Feb 17, 2011

esme is 100% correct.

no one is questioning whether you should've stopped the fdg or not...

but the bottom line is, that it is a dr's order and so, the dr needs to be updated as to how the pt is doing.

it needn't be done at 2am, but s/he certainly needs to know what's going on with his/her pt.

maybe this pt needs a change of fdg...

maybe something's going on medically with the pt.

all i'm saying, is we cannot perform our own interventions, and not tell the dr.

i'm sure you know that, though.:)

leslie

lili718 · Feb 17, 2011

Hello,

I was reading the above posts and they all make sense, but I can tell you my particular situation. I also do homecare as an LPN and the parent makes all decisions as far as feeds, medications, etc based on reccomendations by the doctor of course. The case manager never even talks to the Dr.'s she just gets all of the information from the mom as far as medication changes, etc. But, for instance if the mom wants a mediation held that is what happens and I can say I have never talked to a Dr. since I have worked there and the only time we have to call is if there is a medication change which is told to us by the mother, which I can verify by the prescription, but I have never seen a doctor's order for it. As far as feeding changes and medications I do document per parent as far as the changes, but have never called the doctor. I do like the other responses as my job has quite a few things that I don't think are right, such as there being no on- call RN for nights/ weekends which I am sure there is supposed to be and even if you call during office hours they are unlikely to call you back...