I Hate Surg!!!

[ChristineN]

I work on a pediatric medical floor. Today I was taking care of a 4 year old sug pt that was overflow. He had a lap appy the day before, and had only been ordered Tylenol for pain. Mom thought Tylenol was not cutting the pain, and I agreed that it didn't seem to be helping. I called the surgery team for an order for Morphine. They told me that they would love to give the boy Morphine, but there was a kicker. Surgeon asked me if I knew what a safe dose of Morphine was for a 4 year old. I did not off the top of my head, I normally work with teenagers, and know their dosages better. The surgeon then told me Welll, why don't you just guess a safe dose, and put it in as a verbal order under my name." I was furious someone would even consider guessing a med dose for a 4 year old!!! Not to mention, at my facility, nurses are not allowed to take verbal orders for narcotics. What an idiot.

[eriksoln, BSN, RN]

"Let pharmacy run its checks, check them against your book and there you have it, morphine safe to give." -ericksoln

Wouldn't you rather facilitate the pharm and the surgeon, or anesthesia to figure out? I'd want a completed order in the end from that doc before I give, even if it's verbal again...

Eh, depends on the culture of your hospital/unit. Some places want you to practice autonomy, others want everything by the book.

My first hospital, the one I learned at, was heavy on autonomy. Doctors didnt want phone calls about diet order changes and things like that. They liked rounding at our hospital because the unit ran so independently.

Other places I've been, they want everything by the book, down to getting an order for the fan being placed in the pt. room.

I dont think either way is better/right or wrong. Just, different ways to swim.

In this case though, I'd be concerned about the pain not being addressed. I'd have pharmacy help me out and double check everything so I could get the pain relieved ASAP. Calling again or waiting for the doctor to round could mean the pt.'s pain going untreated for a long time. Not good.

[netglow, ASN, RN]

No, not diet etc... thats something I wouldn't call about. But meds... morphine, IDK, OP sounded like the doc was like, yea, don't know how to prescribe it, just put anything in the order, if its wrong pharm or somebody will catch it. Just didn't like the idea of being in the middle of that if it should go wrong. And, no the pt shouldn't have to wait. The team should have had their ducks in a row.

[ChristineN, BSN, RN]

While frustrating (and where was he coming from, what was his point he was trying to make, or does he always act that way), its not that hard of a situation to deal with. He did give you permission to write a verbal order. From there, just let your nursing skill take over.

Check allergies. If none, get out your book and call pharmacy. If you want, you can even write a pharmacy consult. I would suggest that actually. Write a pharmacy consult for "management of morphine dose/pain control". Nothing wrong with it, its kosher.

Let pharmacy run its checks, check them against your book and there you have it, morphine safe to give.

Eriksoln,

As I stated in my first post, it is against policy at my hospital to take a verbal order for narcotics. When I pointed this fact out to the doctor, he acted as if he had never heard that.

[ChristineN, BSN, RN]

A wee bit off topic but it is legal for a pharmicist to dose a medication based on numerous factors such as pt age, ht/wt, renal function and peak/trough levels. We see this most with antibiotics because the pharmacists know the med doses based on the peak/trough way better than the docs do. Also, we see docs writing orders for Lovenox but then pharm changes the dose based on the pt's creatinine clearance. It really is safer for the pt.

Hmmm, interesting concept. I'm not sure if I've ever seen it done at my facility. Being in pediatrics, alot of things are stricter than adult hospitals

[ChristineN, BSN, RN]

That's what they're trained for. I think they have doctoral degrees in it - DPharm.

What's the proper role of the RN in this? Obviously it s/he should never guess - that's one crazy doctor for suggesting it but what is with the heavy emphasis on drug dosage calculations in nursing school if not for these type of situations?

I thought the nurse's role would be more to see the dose ordered by the doctor and make sure the dose was safe. Or, had I known a safe dose of morphine for a 4 year old off the top of my head, I could have said "The safe doese is 1mg. Is that what you would like to order?" However, I was very uncomfortable with the whole situation.

[eriksoln, BSN, RN]

Eriksoln,

As I stated in my first post, it is against policy at my hospital to take a verbal order for narcotics. When I pointed this fact out to the doctor, he acted as if he had never heard that.

Ah, I see. Like the poster before me was talking about with antibiotics and lovenox, I've seen pharmacy take over a lot of med orders before. If its policy not to allow verbal narcotic orders though than thats not any help to you.

I agree that the ducks should have been order before it got to this point. Having a nurse call and ask for better pain management and the doctor not wanting to have anything to do with it is not how I imagine a hospital gets good PG scores.

[ChristineN, BSN, RN]

Ah, I see. Like the poster before me was talking about with antibiotics and lovenox, I've seen pharmacy take over a lot of med orders before. If its policy not to allow verbal narcotic orders though than thats not any help to you.

I agree that the ducks should have been order before it got to this point. Having a nurse call and ask for better pain management and the doctor not wanting to have anything to do with it is not how I imagine a hospital gets good PG scores.

You're absolutely right. The mother was very frustrated, although she seemed to understand I was trying to get something ordered to get her son's pain under control. I don't see alot of post op appy's, but only being ordered Tylenol seemed a little to conservative of a treatment plan, IMO.

[debthern]

All of our drugs are ordered based on patient weight not age but if you are taking a phone order you should know what the safe dose is...We don't take verbal orders but we do take phone orders but need another nurse to verify what the doctor said if it's a narc.

[ChristineN, BSN, RN]

All of our drugs are ordered based on patient weight not age but if you are taking a phone order you should know what the safe dose is...We don't take verbal orders but we do take phone orders but need another nurse to verify what the doctor said if it's a narc.

I was not planning on taking a verbal or phone order, as both are against my hospital's policy for narcotics. Yes, our drugs are all weight based, and I'm not used to dosing 22kg kids.

[FireStarterRN, BSN, RN]

I've often seen doctors order a medication, with "Pharmacy to dose". I think that's a fairly acceptable practice.

Next time perhaps you can prompt the physician to order it this way.

[nrsang97, BSN, RN]

I have never seen narcs as pharm to dose. I have seen that with antibiotics though.

[ChristineN, BSN, RN]

I've often seen doctors order a medication, with "Pharmacy to dose". I think that's a fairly acceptable practice.

Next time perhaps you can prompt the physician to order it this way.

Hmmm, ya'll are making me wonder if this would be acceptable at my hospital.