When given narcotic gtt or prn orders with no set parameters (instead you get "titrate as needed", etc.) for a nonresponsive, terminal patient, what guides you in your interpretation of these orders? Families wishes, your work or professional ethic, your moral or religous beliefs regarding comfort and/or assistance in the dying process, etc? This scenario comes up frequently on the oncology unit I work on and of course there are always quite a number of interpretations that arise. But now I've become more interested in what actually guides nurses choices. Anyone have any thoughts or comments on the subject they'd feel comfortable sharing?
Oct 22, '98
PLEASE BE AWARE THAT IT IS THE "PHYSICIANS" RESPONSIBILITY TO WRITE THE ORDER EXACTLY AS IT IS TO BE GIVEN UNLESS YOUR FACILITY HAS ESTABLISHED A SPECIFIC POLICY TO CLARIFY WHAT IS ROUTINE AND OR STANDARD AS IT APPLIES TO THAT SPECIFIC ORDER (WHICH PROBABLY IS NOT THE CASE FOR DRUGS) IT IS YOUR RESPONSIBILITY TO CLARIFY THE ORDER WITH THE PHYSICIAN TO GET HIM TO ESTABLISH SPECIFIC PERIMETERS. THIS IS A NOT WITHIN THE PERIMETERS OF YOUR LICENSE AS A NURSE AND YOU RISK YOUR LICENSE IN USING YOUR BEST JUDGEMENT HERE. REMEMBER WE DO NOT PRESCRIBE MEDICATION DOSAGES OR ROUTES OR REGIMENS WE ADMINISTER AS DIRECTED ONLY. I HOPE THIS HELPS YOU.
EXAMPLE: MORPHINE 2-10 MG IV Q 3-4 HOURS PRN PAIN (WRONG!!!)
CALL THE DOCTOR AND REQUEST A NEW ORDER!!!
YOU NEED HIM TO NAME THE DOSE THE FREQUENCY AND THE ROUTE WITHOUT ANY RANGES!!REMEMBER YOU COULD BE HELD RESPONSIBLE FOR ANY ILL EFFECT THE PATIENT HAS OR IF THIS WAS REVIEWED BY THE BOARD OF NURSING, HOW WOULD YOU EXPLAIN THAT YOU(A NURSE) DECIDED THE PATIENT NEEDED IT.(IN OTHER WORDS PRESCRIBED IT TO THE PATIENT) YES THE DOCTOR WILL PROBABLY BUCK YOU BECAUSE THEY HAVE BECOME USED TO NURSES HELPING THEM OUT BUT WE ARE NOT LICENSED TO DO IT SO DON'T. ASK YOUR NURSING ADMINISTRATOR TO ADDRESS THIS PROBLEM AT THE NEXT MEDICAL STAFF MEETING SO ALL THE DOCS WILL KNOW YOU HAVE BACKUP IT WILL MAKE IT EASIER ON YOUWHEN YOU HAVE TO CALL THEM TO REWRITE THE ORDERS.GOOD LUCK AND BE SAFE. TAM37
EXAMPLE MORPHINE 2MG
Oct 26, '98
Thanks Tam for your comments. According to your understanding of PRN orders I've been practicing in error my entire nursing career. I thought that the whole purpose of PRN orders was to give nursing room to use their professional judgement of the patients needs within the parameters given by the MD. In the example MS 2-10mg IV q 3-4 hrs prn, I agree the 3-4 hrs part is useless, but I disagree about the 2-10 part. Pts do not have the same amount of pain at all times. It's not feasible to be calling the MD for new orders every couple of hours because the ordered prn dose is either not sufficient or too much. We as nurses have come a long way in our assessment and skill level. Being at the bedside with that painful patient puts us in a better place to assess their response to the ordered pain med. Of course if an order appears to be unsafe in my professional judgement I will question it, but that judgement comes with experience and training. You have made me question the way prn orders are written and interpreted though, I looked through the Nursing Practice Act which has no guidelines and neither do any of my other current text books. As for the hospital I work at, I'm still looking into it. Again thanks for your comments and giving me more food for thought.