Nurses that write their own orders

[Kanani_Ikike]

Hello, all in allnurses.com universe. It's me again. I have a concern that I would like to share with you all and ask for your opinion.

At my new job, I am seeing a whole different culture of nursing that I have ever been used to. I work night shift in a rural hospital. And as we all know, there are times when calling the doctor is easier said than done. We have doctors that, when you page them, just won't call back. I understand that we don't need to bother the doctor for things that can wait until morning, but some things just can't wait. And I don't think it's right to be subjected to disrespect just for calling about our patients. As we all know, sometimes a patient can be fine all day and take a turn for the worst at night.

For instance, the other night, I had a pt. with a Foley cath. When I came on shift, this pt. was draining dark yellow, clear urine. About 2 hours into my shift, I noticed that the urine became bloody. Since this was something new, I called the doctor on call. First of all, he's obviousy not too thrilled about being on call. When I told him about the blood, which by the time he called me back, had increased with clots apparent, he said, "Well, you'll have blood with foley cath insertion." Then he proceeded to give me orders for labs to be drawn in the am. Well, I disagree, I've never had a patient bleed on me just due to the foley insertion itself. Of course, if it hasn't been inserted correctly (like in the neck of the bladder) or if it's been pulled down, THEN I can understand bleeding. But for the pt. to just start bleeding wasn't a good sign to me.

So, after I got that order, I continued to observe the pt. At first, it appeared that the urine was clearing of blood. Then after a couple of hours, I noticed that there had not been an increase in output at all. And I didn't see any urine draining in the tubing. So, this is when I start thinking that this pt. needed his catheter irrigated because it may be a clot blocking the urethra. The pt. started complaining of a burning sensation, but nothing like pressure and I didn't palpate any distention of the bladder at that time. So, I, again, page the doctor on call. Well this time, he didn't call me back. So, I paged him again. Still didn't get a call back. So, I contacted the house supervisor for assistance. Well, when I talked to her, she said, "Why do you need to contact him (the doctor) ?" I told her about the situation and she replied, "well, we can just write an order for irrigation, we don't have to bother him." I was like, "but we need an order for that" and she said, "well, I'll just tell him I told you to write it". Well, as you know, I didn't write that order on my own. So, when the smoke cleared, the patient was irrigated by the supervisor and he clot was cleared. He started draining urine again and lived happily ever after.

Okay, so this is where I am concerned. This is not the first time I've been told to write an order instead of calling the doctor. I've never heard of this and it makes me uneasy. Where I have worked the past, we had standing orders. I don't know why this facility has none. But since they don't have any, then I feel I should call the doctor for all orders. But they don't do this at this hospital. And there's more.

First of all, the supervisor letting the doctor get away with not calling back bothers me. Why do we have doctors if we can't call them when we are concerned about a patient? Why do they take call or even become doctors if they don't want to be bothered? Why not have standing orders for the simple stuff if you don't want to be bothered?

Secondly, I am very standoffish about writing orders without actually speaking to the doctor. I won't even write an order for Tylenol without talking to the doctor. This is because, #1, I'm not a physician. It's not in my scope of practice to write orders. #2, I am covering my behind. The first time something happens from me taking it upon myself to write an order, I know I'm going to be the one going down. But it seems like, in my facility, it is the norm for the nurses to write orders themselves. I understand that some of them are used to the doctors and feel that it's okay to do this. I just want to know if this is the norm in other facilities.? Do you all think I'm overreacting and being obssessive for not doing this? I mean, I understand not to call the doctor for every little non-urgent situation. But when I feel uneasy about something, you better believe I will call him in a heartbeat. Even if it means getting chewed out. What do you all think?

I just want to know if I'm doing something wrong by not going along with this practice? Comments and opinions will be greatly appreciated. I appreciate every post. I'm wanting to be a good nurse. I just would like to do the right thing, that's all. Thanks in advance for your replies.

[Kanani_Ikike]

Why irrigate when you can easily do a non-invasive bladder scan to see if the foley is non-patent? I don't really understand the logic behind jumping to irrigation. Unless of course, your facility doesn't have bladder scanners.

Err sorry don't want to derail the thread.

Thanks for your reply. I understand what you're saying, but you would end up having to irrigate anyway.

[Kanani_Ikike]

Wouldn't you just hate to be the pt. of the doc that nurses are afraid to call?! I wonder if they knew we told people which docs won't respond to nurses and that these people listen and go elsewhere, if it would make a difference in how the treat nurses?

Thanx for replying.

I know if it were me lying in that bed, I would want my nurse to always call the doctor if any concerns arose. I would feel nervous if my nurse was scared of the doctor. I have learned that most of them have an attitude at night or day. So, I call them and deal with them. I don't let them intimidate me. I think they really, secretly, appreciate it when nurses really look out for their patients. I wish the patients only knew what we knew.

[Kanani_Ikike]

Well, that's another issue really. Something tells me that having a 'legitimate' order wouldn't have changed what you describe here.

And you were right in being concerned about sudden bleeding in a patient who'd received chemo. Good for you :)

Thank you for those supportive words.

[cmo421]

We used to have problems with a doc calling back or taking forever to call at night. When this happened we would recall twice, after that, we would call the head of the unit at home(chief of ICU) and let him gives us orders.We had a house officer who u could call, but sometimes they just were not enough. Eventually the offending doc had to give up pt's that required ICU per the Chief. Once this starting happening, other doc's took notice and returned calls quicker. We also kept a log of when we called and response time. It helps when u have evidence to back u up!

[ZippyGBR, BSN, RN]

once again good basic nursing care derailed by billing and the whole 'orders' thing

at 300 USD many urology patients ought to be given their own bladder scanner at the end of their hospital stay... or are the portable single function USS bladder scanners we use in the UK unknown in the US becasue it's more billing to get Medical imaging to come and do it with a full sized ultrasound machine wasting the time of the sonographer ?

irrigating a cather ?40USD ? the bind moggles - a jug, a basic sterile pack, gloves , an bottle of sterile water and a bladder tip 50 ml syringe doesn't cost that much ...

as for orders to irrigate? surely maintainance interventions etc are or should be either part of the care plan implemented when the decision to insert a catheter is made or part of the facility policy for catheterisations ...

[leslie :-D]

dang, i shudder to think of what would happen if the foley wasn't irrigated?

seriously.

what are the implications of the pt sustaining serious trauma in the presence of an obstxn?

and let's say it goes to court.

are we limited in our actions r/t the absence of an md order?

or, do our parameters define our practice in what a "prudent nurse would do"?

and if we act as a prudent nurse, what will our bon say about this???

if the pt presented with distended bladder, no uo, and other acute s/s, i would irrigate.

but what if no one made the decision to do so, and all awaited the order of an md?

again, are we bound by our scope of practice or the actions of a prudent nurse?

leslie

[Kanani_Ikike]

We used to have problems with a doc calling back or taking forever to call at night. When this happened we would recall twice, after that, we would call the head of the unit at home(chief of ICU) and let him gives us orders.We had a house officer who u could call, but sometimes they just were not enough. Eventually the offending doc had to give up pt's that required ICU per the Chief. Once this starting happening, other doc's took notice and returned calls quicker. We also kept a log of when we called and response time. It helps when u have evidence to back u up!

Thank you for replying. It also helps when the doc has an answering service that forwards calls to them. That way, there's a record of attemtped calls in two places, not just one.

[Kanani_Ikike]

once again good basic nursing care derailed by billing and the whole 'orders' thing

at 300 USD many urology patients ought to be given their own bladder scanner at the end of their hospital stay... or are the portable single function USS bladder scanners we use in the UK unknown in the US becasue it's more billing to get Medical imaging to come and do it with a full sized ultrasound machine wasting the time of the sonographer ?

irrigating a cather ?40USD ? the bind moggles - a jug, a basic sterile pack, gloves , an bottle of sterile water and a bladder tip 50 ml syringe doesn't cost that much ...

as for orders to irrigate? surely maintainance interventions etc are or should be either part of the care plan implemented when the decision to insert a catheter is made or part of the facility policy for catheterisations ...

Thank you for replying.

It sure would be nice if it was. I don't think somebody had these types of situations in mind when they were writing policy. I don't know why. I guess because the nurses just always did it as a part of the care plan. And I would, too, if things were not like they are today. I always won't something to cover me.

[Kanani_Ikike]

dang, i shudder to think of what would happen if the foley wasn't irrigated?

seriously.

what are the implications of the pt sustaining serious trauma in the presence of an obstxn?

and let's say it goes to court.

are we limited in our actions r/t the absence of an md order?

or, do our parameters define our practice in what a "prudent nurse would do"?

and if we act as a prudent nurse, what will our bon say about this???

if the pt presented with distended bladder, no uo, and other acute s/s, i would irrigate.

but what if no one made the decision to do so, and all awaited the order of an md?

again, are we bound by our scope of practice or the actions of a prudent nurse?

leslie

Thanks for replying. It's definitely a Catch-22. Your doomed if you do, doomed if you don't. You well-paid lawyer will make a case out of anything. So, you never know. We could always do it without orders and tell the patient not to tell anyone. Then if something went wrong, you know they'll sing like a canary. But I would hope that in the end, the good intentions ans good nursing care would prevail. Unfortunately, that's no enough in this day and time.

[P_RN, ADN, RN]

Look on your board of nursing site. I'm happy to say I worked at a teaching hospital and it had physician residents up the ying-yang.

I'm in SC and on our BON there are multiple scope of practice for RN and/ or LPN advisories.

For urinary catheters: http://www.llr.state.sc.us/POL/Nursing/forms/genti.pdf

[queenjean]

Thank you for replying. I've never had irrigating a foley as policy in any of the places I've worked. That would be nice to have, but it's not the norm in the places I've been. I would think that if the doctors didn't want to be bothered at 2 or 3 in the morning, then they should establish standing orders.

Did you check your floor's protocol for foley management? In our protocol, with adults we can write an order for irrigation under certain parameters. If the docs don't want the catheter irrigated without being contacted first, they must write an order specifying that.

So we don't need an order to irrigate, any more than you need an order to put a patient on oxygen and get an EKG in the event a patient is having chest pain--these are part of our (and I suspect any typical) chest pain protocol. Often we do these things, then call the doc with the results if they are abnormal or need additional follow up. If everything is normal, we either leave a note for the doc, or call first thing in the morning.

If it's not covered by a protocol or a standing order, then I call the doc. Whatever the outcome, I always document it in the computer chart (nurse's notes come up on the front page and cannot be erased). So if the doc doesn't call back, I chart it. If the doc says, "I don't give meds for headaches in the middle of the night, he can tough it out until morning," I chart that the doc states no new orders. I always always always tell the patient what the doc said, or if the doc doesn't call back. They have a right to know if they have a crappy, uncaring, unprofessional doctor.

[suanna]

Thank you for replying. I've never had irrigating a foley as policy in any of the places I've worked. That would be nice to have, but it's not the norm in the places I've been. I would think that if the doctors didn't want to be bothered at 2 or 3 in the morning, then they should establish standing orders. And if a doctor, is for instance, going to be performing surgery the following morning, then it will be his negligence for doing without enough sleep. That would be like me driving and crashing into and killing someone after working an all nighter. If I knew that I was too sleepy to drive, then I'm liable for my poor judegement. There is no excuse for me not to call a doctor when I'm concerned. Especially when this pt. started bleeding out of the blue like that. I suspected a blood clot, but it could have been something more serious. I think that's a problem when nurses don't call because they don't want to disturb the doctor. I trust my instinct always. But I understand what you're saying. To harrass the doctor is not my intention. I just want to care for my patients within my scope of practice.

I can understand your concerns but I still feel that it would be impossible to write for every contengency that may happen- the orders would be so long the doctor may as will spend the night on the unit- he/she will be there checking off orders for hours and stil won't cover all the bases. The problem is with a physician in single practice, residents don't cover his service, and he has 20-30 patients at various stages of recovery in the hospital at any one time. "got too many phone calls last night so I have to cancel your moms heart surgery- hope she doesn't infarct today" isn't going to be a good answer. An experienced nurse should be able to discern an evolving crisis from basic patient care and act in the patients best intrest- his/her patient and the ones being done the next day. When in doubt call, err on the side of caution, but we are educated in assessment skills.