Giving meds without an order

[momnursewriter]

I work in long term care. This morning I had a resident complaining of constipation. She had been on several bowel meds prn before going to the hospital but she had been back from the hospital for 5 days and when she was readmitted none were ordered. I went back to the nurse's station and paged her doctor to get orders. He called back about 20 mins later and I got the order for her meds and was filling out the paperwork, faxing to pharmacy, etc. It was about 30 mins after she was complaining to me that she fell out of her chair (the other shift had taken over by now, she told me about the constipation on my last med round and I was wrapping this up before I left, instead of leaving it for the next shift like many do). She said she was so uncomfortable because of her constipation that she had to get up (and instead of calling for help like she usually does decided to do so by herself).

My unit manager was talking about me like I was a dog in front of everyone, saying it was nursing judgement to go ahead and give her some medication first and then call the doctor for the orders. She has fussed at me for the same thing before, because I have waited to get orders from a doctor before doing procedures that we need an order for (such as putting in a catheter). I was taught that we are supposed to get an order before giving any medication, even a tylenol but I see many nurses give unordered medication and either call later or more often forget to call and then I have to call in the middle of the night to get an order. I am not trying to give a medication with no order and be charged with practicing medicine without a license. What if you give the medicine and something happens, then the doctor says "I didn't give the order for that medication"--you know he is going to protect himself.

Do you consider it nursing judgement to give medication without an order before calling the doctor? (by the way, I would usually try prune juice, etc but this lady says prune juice, milk of mag, and even laxatives don't help, she wants suppositories and enemas when she is constipated.

thanks for your feedback.

[pagandeva2000, LPN]

I am a relatively new nurse, so, at this time, I would also say that I wouldn't want to be the one to administer meds without an order.

Is your unit manager an RN? If so, then, I would have told her to go ahead and give it, since she is the higher licensed person than I. I suspect that she was more upset about the fall, than the reason behind it (not that this fool is correct, by any means). It seems to me that she would rather that YOU ride it if the meds were administered without an order rather than HER. Now, what if the doctor wanted to order something else besides what you expected, and the effects were compounded?? Maybe the next time, she would have fallen because she was trying to run to the bathroom to avoid a nasty code brown!!

I have been in a few situations that were dicey...in my hospital, LPNs cannot take verbal or telephone orders. Yet, once I had a patient who was to go to the emergency room for chest pains. Resident orders 81mg of aspirin, we had 325 mg available. Because of the chest pains, and knowing that aspirin can help if it is an impending MI, I felt to give it, but went to the resident first to tell him what was available and asked if he wanted me to administer that instead. He says 'yes' and then, I told him that he must immediately write me an order. He was on his way to meet the preceptor, so, I wrote a note and taped it to his computer screen to remind him. Something told me not to document just yet that I administered it, and then, the resident disappeared for the rest of the day (shift was over in my clinic) and he did not change the order.

I went to the attending and explained to her what happened and she covered the order for me and the patient was transported safely to the ER. I then documented what was administered. But, that was not comfortable for me. Next time, I will tell the doctor that I will not administer anything without an order...period. Can't trust them. I think you did the right thing.

[TheCommuter, BSN, RN]

Unfortunately, the practice of giving meds without orders has been common in many of the nursing homes where I've been employed. In many cases, you have a medical director who also serves as the attending physician for most of the residents at the facility. This medical director has publicly expressed the desire to not be bothered with "unnecessary" phone calls, and the DONs, ADONs, unit managers, and supervisors coddle to the MD's request for minimal phone calls.

Therefore, these various people will pressure staff into writing simple orders with the expectation that the MD will sign it later. However, your butt will be fried if something goes terribly wrong.

I am not the doctor, so I don't intend to practice medicine without a license.

[momnursewriter]

Thank you both. No, the unit manager is an LPN also. only the DON is an RN and she is scarce. We do not have an MD medical director either. We have to call the doctors for any orders.

[pagandeva2000, LPN]

I'll tell you one thing. though...and I am sorry to say it. But, if the need should ever arise where you really think that you have to, don't document it until the order is covered. Things like this are issues that really place the nurse's rear end on the line. Just like that time with that aspirin...I saw a clinical need to give it, but believe me, I was not going to document it until it was covered FIRST.

[pagandeva2000, LPN]

Thank you both. No, the unit manager is an LPN also. only the DON is an RN and she is scarce. We do not have an MD medical director either. We have to call the doctors for any orders.

I am sorry to hear that this happened, but, as TheCommuter stated, this can fall into a regular practice. The unit manager handled it poorly by talking down to you. She would have been better off to at least take you to the side and explain how they do things and leave it up to you to decide.

[elkpark]

I am sorry to hear that this happened, but, as TheCommuter stated, this can fall into a regular practice. The unit manager handled it poorly by talking down to you. She would have been better off to at least take you to the side and explain how they do things and leave it up to you to decide.

Well, yes, it would have been nice if the NM handled it differently, but the larger problem, as I see it, is that "how they do things" is illegal, unless there are standing orders/protocols/etc. from the physician in writing.

I agree with TheCommuter; I wouldn't be willing to put my license on the line because the physician doesn't like to be bothered.

[Jolie, BSN]

I'll tell you one thing. though...and I am sorry to say it. But, if the need should ever arise where you really think that you have to, don't document it until the order is covered. Things like this are issues that really place the nurse's rear end on the line. Just like that time with that aspirin...I saw a clinical need to give it, but believe me, I was not going to document it until it was covered FIRST.

Please don't go down that road. We all know that we need orders to administer medications. With no order (and no protocol), we are practicing medicine without a license if we choose, dose and administer a medication, regardless of the setting (LTC, acute care, ICU, etc.)

The only way I can imagine to step deeper in **** is to give a medication without an order and then fail to document it, so that the on-coming nurse has no way of knowing that the medication was given. S/he may then obtain a legitimate order for the very med that we just gave, and unwittingly double-dose the patient.

If one is to be so forward as to give a medication without an order, one must be professional enough to document it, for the sake of patient safety.

[pagandeva2000, LPN]

I understand what you are saying. What I am also seeing is so many issues where the nurse is/can be left holding the bag. The aspirin incident I mentioned earlier, could have been a disaster. But, the time I would have taken to argue and chase this doctor who did not change the order may have also placed the patient in jeopardy. Or, the asthmatic patient who needs a nebulizer treatment immediately...what then (I witnessed such a thing happen, too, where the doctor gave a verbal order to a nurse, but refused to back it up)? Do we let them panic and possibly lose life? I have been very lucky...this time. I didn't have to totally compromise myself. But, I can easily see how it can happen.

Being reminded of the possibility of double dosing meds makes me agree with you wholeheartedly and I thank you for that.

[canoehead, BSN, RN]

I would give ACLS meds by protocol without an order if the patient was unable to wait, but I would be calling the doc immediately. I would give meds by unit protocol, and document them as such. If the boss wants things done that she "knows" the doc would be OK with then she needs to get a house protocol approved, and then everyone would be covered. Otherwise, no go.

Unofficially when you know the doc and the patient there are times when a stool softener or Tylenol might be given, and ordered in the AM. But your boss should NEVER order you to do something that is illegal since you both can lose your license. Never do something on the say-so of a third party, because it just messes up the works of communication and accountability. If she wants the med given she is welcome to do so, and you'll put in the call for an official order in the meantime.

[morte, LPN, LVN]

nope, no order=no meds.....however in the big picture....this shouldnt have happened in the first place..the nurse who did the readmit should have questioned the doc and gotten those orders reinstated..all nursing home residents (excepting chronic diarhea patients, of whatever cause) should have a bowel regimen ordered.

[momnursewriter]

I agree, the admission nurse should have noticed this woman had several bowel meds ordered before going out the the hospital. Or any of the nurses in the last 5 days could have noticed she had no bowel medications ordered (especially the day shift nurses who were used to giving this woman scheduled bowel meds and she came back without them).

And just because something is what other nurses at the facility are used to doing, doesn't make it right. I guess that's my view on this. And if the other nurses want to put their butts on the line, that's one thing. But to say I was wrong for NOT doing something that is outside of my scope of practice...that is why I'm so upset.

thank you all for your feedback