Question regarding Dr. orders....(sorry, long)

[TinkRN8]

Hi,

I am a pre-nursing student. I have a question that has been bugging me for a while, and I hope maybe you out there in cyberspace can answer it for me. The end of May I had surgery to remove some fibroids and clean up my endometriosis. Unfortuantely, I ended up with a major infection. I had 3 separate abcesses; one in my uterus, one near my liver and one in my abdomen. I was also severly anemic, and required blood transfusions. Now, let me just say that the majority of nursing care I received was exceptional, but there were a few nurses that were, IMHO, not the best. This is where my question comes in. The first 2 days I was back in the hospital, I was NPO and since I was running a fever, that meant suppository meds to reduce my fever. Such fun! Well, the 3rd day I was finally able to eat and drink and take meds orally. The Dr.'s treating me (a total of 5) all came in and OK'd that. During that day, the day nurses gave me the oral meds, I ordered food, etc. Well, when the night nurse came on I was still running a fever so she came in with the suppository. I told her that I had been OK'd to take oral meds now. I am assuming that the Dr.'s had written this in the chart as the day nurses seemed to know this. Well, she wouldn't take no for an answer. I kept telling her that I wanted the regular Tylenol and not the suppository. I absolutely refused. I was tired of things being stuck up my rear! Plus it hurt to turn on my side because of the JP drains. She said, "So you won't let me give this to you?" as she is opening the package. She was very flustered that I would let her give this suppository to me. I said NO! Finally, she said, "Well, I will call the Dr. and I guess I will have to waste this" (meaning the suppository she opened after I repeatedly told her I wasn't going to take it), and threw it in the trash. She came back in about a 1/2 hour later all happy as can be saying she called the hospitalist and he had OK'd the oral Tylenol. Then she said, "Aren't you happy I called?" Like it was her idea and I should be so grateful to her.

Here is my question, what kind of leeway to nurses have in administering medication? In a case like this, I am sure it was in my chart, even though I never saw my chart, because all of the day nurses allowed me to eat, drink, take meds orally. I am guessing that it was overlooked to actually change the medication order from suppository to oral med on the chart. So, in this case, would a nurse be able to go ahead and administer the oral med rather than the suppository WITHOUT having to call the Dr. for permission. I mean, I could understand if it was a medication that was "dangerous", but this was Tylenol. I just don't understand why the nurse couldn't just give me the Tylenol without having to call the Dr. for permission. I would think it would just be common sense, if the patient is now able to take things in orally, the patient will not need the suppository. Why would she need Dr. permission? It just seemed wierd to me. Any input?

Chihmom8

[SuesquatchRN, BSN, RN]

So, in this case, would a nurse be able to go ahead and administer the oral med rather than the suppository WITHOUT having to call the Dr. for permission. I mean, I could understand if it was a medication that was "dangerous", but this was Tylenol. I just don't understand why the nurse couldn't just give me the Tylenol without having to call the Dr. for permission.

No.

I am going to guess that this nurse did not realize that you were no longer NPO. Were you still NPO b/c of the surgery or if you had liver problems even Tylenol could be a dangerous med.

We do not determine the route.

[fultzymom]

Tylenol is a dangerous drug, depending on what the diagnosis is. We are not allowed to give something orally if you are NPO. I would just be guessing, but maybe the doc told the day nurse he was going let you take oral meds, eat again, then maybe got busy and forgot to write the order. I know that it can happen. If the nurse would have given you the oral meds and there was not an order, she would have been in a lot of trouble.

Leslie

[TinkRN8]

Thanks for your responses. I figured it was just overlooked. I was NPO because when I came into the emergency room, I was vomiting and had diarrhea, and then had the drains put in and the blood transfusions. So, a lot going on and with the additional procedures, plus the vomiting, they didn't want me eating or drinking anything. I guess I think of Tylenol as innocuous, but it isn't. I know that. I guess I just couldn't understand why the day nurses were able to give me the Tylenol orally, but the night nurse wouldn't. Plus, it was more of the way she acted that kind of bugged me. Not just in this instance, but in general. And, again, I was tired of things going up my rear. It is kind of humiliating and I was in a lot of pain. One thing for sure, with the whole experience in general, I learned a few things: 1) How I will act toward my patients as a nurse and 2) I REALLY want to be a nurse. It was really a life-changing experience. Thanks again for the replies!

[truern]

Sounds like the doc gave the day nurse a verbal order and she didn't write it in your chart.

Regardless, the night nurse was absolutely correct. Nurses administer medications (even those not considered "dangerous") according to the route prescribed by the MD. If no new order was written then she only had the PR route to follow.

[jmgrn65, RN]

A new order for PO needed to be written. As the others have said we administer what is ordered.

[widi96]

Even if the dr wrote an order that said you could eat, if he did not write a new order for the Tylenol to be PO, then it couldn't be given that route. I'm guessing that part was overlooked by the doctor.

I can see this being frustrating both ways. You said it was night shift - I don't know what time we are talking here, but if a nurse has a patient with a fever and has the med to correct it, then it gets frustrating when the patient refuses and it requires calling the doctor. (Not all doctors are pleasant at 2am). I am completely understanding your point also though - if there is an alternative route other than rectally, I would certainly opt for that option.

[steelcityrn, RN]

All of this should have been given in report. Perhaps this nurse was doing it correct, if no order was written. Only way to know is to read the orders in your chart.

[SuesquatchRN, BSN, RN]

Plus, it was more of the way she acted that kind of bugged me. Not just in this instance, but in general. And, again, I was tired of things going up my rear.

She soudns like a one step away from baby talk nurse. "Oh, is 'oo 'iddle hiney hurting? We-ums can fix that."

Gag me.

[ZippyGBR, BSN, RN]

A new order for PO needed to be written. As the others have said we administer what is ordered.

or work with your lead clinicans and pharmacy to allow multiple routes in the prescription and allow the Nurse to adminster the most approrpaite route for the med ...

[IMustBeCrazy]

You have just discovered the principle of patient autonomy.

You have just learned to *always* listen to your patients, and, even if it's a busy night, take that extra 5 minutes to call the MD to get the order corrected for the patient so they can be involved in their own care and be comfortable. Even though the nurse eventually did do the right thing by calling and changing the order for you, always remember how you felt when you weren't believed at first.

I bet this is a mistake that you won't be likely to make in your own practice some day.

[TinkRN8]

Again, Thanks for all the responses. Was curious how the whole system worked. I can understand that even something as seemingly harmless as Tylenol can have devistating effect on someone with liver issues & such, so as a nurse I would need to be in consultation with the Dr. to make sure the patient is safe. It also tells me how important it is to make sure the chart is noted for any updates and changes in the status of the patient. If the nurses on the previous shift or Dr. had noted my chart of the change, then the next shift would have been aware. Always learning something to make myself a better nurse and coworker! Thanks!