gray areas of nursing...

[glovedgoddess]

things i haven't gotten straight! (thread #1...):

1) do doctors make rounds every single day? say a patient is in the hospital for 3 days only, is the doctor going to come see this patient each day?

2) how the heck does pharmacy work...? is pharmacy always open (what if you need a med stat that is not in stock)? do pharmacists make rounds as well (like doctors make their rounds), do they go around to each ward at certain times of the day? (are there general times that they prefer to come up, like early in the morning and in the mid-afternoon?). if you do not have a medication in stock that you need to give in ½ hr, do you phone pharmacy and let them know? will they bring the med up to or do you go down to retrieve it?

3) can a nurse adjust iv drip rates, based on own discretion? or do we follow the order and than if we feel that the flow rate needs to be increased or decreased do we phone the doctor for a change in order for iv rate?

4) a topic that came up in class last week was pain management... example: patient is having 7/10 pain and has a prn order for morphine 3-5mg q3-4h. nurse gives 3mg at 0800 and patients pain decreases to tolerable level, then at 0930 patient pain is back at 7/10. can the nurse still give 2mg of morph because that total is still within the safe dose range? i would think that this would be better pain management, small amounts more often; rather than large amount less often. would this be considered legal or best practice? or is it tweaking with the doctors order too much? .....another scenario, if you have given the full 5mg and the patient is having 7/10 pain in 2 hours and there is no other prns meds available would i need to phone doctor and let him/her know that the pt's pain is not under control and is in need of another prn for pain?

5) if a doctor writes an order for a patient and the nurse carries out the order, if the medication is contraindicated with the patient's condition and the patient is harmed...who gets in trouble? (nurse or doc?) what if somehow something was missed, does nurse get hell because she didn't catch the contraindication?

thanks to all those who reply!!!

[Adlib]

Answer 1: It depends on hospital policy, and at the doctor's discretion. Only call the physician for emergencies and changes in patients' condition. But theoretically, yes, the doctors should make their rounds on their work days.

Answer 2: Again, that depends on your hospital policy and the facility's administration and opening hours. The pharmacy does make their rounds and replenish the supply, and if the med is not there, you call pharmacy and they either send it up or, if you deem it an emergency, go pick it up. Again it depends on your facility and how they do things. If the med is not up on time for administration, call the pharmacy and see what's up and just wait for the med, nothing you can honestly do about it.

Answer 3: It depends what exactly your giving. Some IV meds need to be titered like Dopamine, etc, and again depending on hospital policy, it is up to the nurses' discretion on how they titer it following the titer policies and formulas that they need to use. Bottom line though it is up to the physician/ pharmacy that decides how fast it goes. Oh and administration of blood, it depends on hospital policy on how fast you run it depending on your patient's tolerance.

Answer 4: You do not give the other 2mg of Morphine until the wait time is up because you are causing the medication to pile up on top of each other, and causing a high risk adverse reaction of Morphine which is respiratory depression and coma. Yes, it may end up causing the patient more pain waiting that is why we have non pharmacological therapy such as guided imagery, deep breathing, etc. And this is a good baseline for your patient if you know that in an hour he/she is going to have pain after you gave them their morphine, next time give the full 5mg.

If your patient's pain is uncontrolled then yes, you call the physician about that.

Answer 5: The nurse gets hell, even if its the physician's fault because it's the nurses' job to catch that contraindication, and the nurse ends up administrating that medication. If the nurse was able to find that contradiction early, they can call up the physician and tell them the situation and hopefully the physician will agree with you and cancel that med, but if they don't agree, the nurse can always refuse to give the med, and report to the charge nurse about the situation.

[Jonathank]

The first replier might have more real world experience related to to these scenarios than I do, but #5 looks like something we've covered in class.

You're responsible for the meds you administer. According to what we've been taught, you should always double/triple check all the details of each med. Upon catching a mistake, conflict, contraindication, or an order beyond the safe range, you wouldn't give the med, you would contact the provider to get a new order, and you would document ALL of this. Even if all this might not keep you out of "trouble" in the real world, it certainly must be better to at least try to CYA than to not make the effort.

[glovedgoddess]

Thx! MUCH appreciated, both of you!!

...CYA

[MunoRN, RN]

#1 In all acute care settings, (most hospitalized patients), daily rounding is a requirement of Medicare and Medicaid reimbursement, as well as most insurance reimbursement. Aside from that, if a patient is in the hospital but not sick enough to be seen by a Doc at least once a day, then they don't need to be in the hospital.

#4 This is a surprisingly commonly, but completely false misconception. If you have an order for Morphine 3-5mg q 3-4 hours (which is really 3-5mg q 3hrs, I have no idea why MD's write "3-4hours), and you give 3mg at 0800, you can give another 2mg at 0930. At 1100, you can give up to 2mg, unless you wait untill 1230 when you could give the full 5. Each dose of morphine that you give counts against the maximum limit for 3 hours after it is given.