Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to call the doctor. The doctor then signs the order some time later, often not seeing the patient ever.
Here's my problem. I had a patient that just had a very painful ankle surgery. The surgeon wrote for a dilaudid PCA. I called the pain nurse to come and set it up. In the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. The pain nurse told me it would take her a while to get there and that I could give the patient some dilaudid IVP. Nothing wrong with that, we do it all the time. Basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the PCA set up.
So, I give her 1mg IVP. Waited 5 minutes, gave another 1mg. The patient's pain went down and I left it at that. I wrote my order for it. The patient had a good outcome and had pain relief. This was earlier in the week.
Fastforward to today. I get called into my charge RN's office. The anesthesiologist is refusing to sign this order. I got sent home and they are going to talk to the pain service nurse later today when she comes in at 3 pm. I'm not sure if I'm going to have a job and it's up to "how far" the doctor wants to take this.
Basically, I was going by our protocols and giving the patient a medication in a manner consistent with its guidelines. I don't know what to do.
I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.
Specializes in Vents, Telemetry, Home Care, Home infusion.
dilaudid issue:
i'm a rn working in a pacu. at my facility, crnas do the cases and there is one float md that is there as a resource. we have "protocols" to give meds for pain/nausea without needing to call the doctor. the doctor then signs the order some time later, often not seeing the patient ever.
here's my problem. i had a patient that just had a very painful ankle surgery. the surgeon wrote for a dilaudid pca. i called the pain nurse to come and set it up. in the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. the pain nurse told me it would take her a while to get there and that i could give the patient some dilaudid ivp. nothing wrong with that, we do it all the time. basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the pca set up.
so, i give her 1mg ivp. waited 5 minutes, gave another 1mg. the patients pain went down and i left it at that. i wrote my order for it. the patient had a good outcome and had pain relief. this was earlier in the week.
fastforward to today. i get called into my charge rn's office. the anesthesiologist is refusing to sign this order
pain nurse is saying that she gave me an order to medicate the patient, not necessarily a dilaudid order.
here's some facts. the hospital is not jcaho so their standards don't apply here.
the pain nurse is a rn, not ap.they write orders all the time that later get signed by the anesthesiologist, just like i do, only they write much more... po opioids, sleep aids, toradol, etc etc.
ordering prescription medications, dispensing and administering said medications is regulated by federal drug laws along with boards of medicine/osteopathy/podiatry, nursing and pharmacy within each state as to which practitioners may write prescriptions/medical orders for patients.
evidenced based practice guidelines, especially if from medicare/ insurance company do need to be followed...if facility expects to get paid for care.
national patient safety goals are well established form several sources re needing to adequately treat pain and have safety guidelines in place for pca meds.
issues in your narrative include:
a. the surgeon wrote for a dilaudid pca.
b. we have "protocols" to give meds for pain/nausea without needing to call the doctor.
c. pain management nurses (who are not advanced practice nurses) are only staff permitted to setup pca infusions. this patients pca set-up was delayed in getting hooked-up so you administered first dose pca then consulted with pain management nurses who told you to give additional dilaudid; you wrote order under name of anesthesiologist--collaborating md of pain mgmt rn's.
d. the pain nurse is an rn, not ap. who writes orders all the time that later get signed by the anesthesiologist... they write much more... po opioids, sleep aids, toradol, etc.
e. anesthesiologist now refusing to sign for pain mgmt nurse order.
protect your license. the following concerns need to be addressed at your meeting:
1. have you read your nurse practice act? what does it say regarding who can give orders to rn's in your state? can you carry out orders written by another rn who is not an advanced practice rn? are crna's permitted to write for narcotics/anesthesia orders in your state. .in this facility or is anesthesiologist person doing preop assessment and writing anesthesia care plan?
you need to have read and understand regs in order to defend yourself.
2. anesthesiologist never gave the order for dilaudid pca --surgeon did. that's who should have been contacted re delay in pca setup and ok to give ivp meds. that's why they are balking to signing order from pain mgmt rn's. (might be turf war over who orders meds; some surgeons want privilege while others could care less. if anesthesiologist doesn't write for initial orders....unable to bill for time/care "supervision" of patient, etc...)
3. i suspect this facility may be outpatient surgery center where things are more loosely run. they still have to adhere to state/federal guidelines.
in this day and age, there is no reason why there are not preprinted check lists that surgeon/ anesthesiologist signs off on preoperatively or at end of surgery for pacu care including pain management.
that would eliminate need for pain management nurses to write any orders, just the need for them to set-up pca infusion.
4. during meeting, i'd play it low until you get the wind of how parties are acting. might let nurse manager give your side of story, and let her run interference with anesthesiologist. if they adamantly refuse signing, you have he said/she said situation---would surgeon go to bat for patient and co-sign orders??
you are on very thin ice...especially if questioning p+p in defensive tone you have posted here: could possibly even be reported to bon if doc plays hardball and management chooses not to support you. use a soft approach even if you have to sit on your hands during meeting.
unfortunately you have stepped into one of they grey areas re nurses accepting status quo, rather than trying to find better way to have standardized postop pain mgmt and discharge orders written by the person responsible: surgeon + anesthesiologist.
traumaRUs, MSN, APRN
87 Articles; 21,287 Posts
I think we have exhausted all the helpful advice we can provide to the OP. We wish you the best - let us know how things progress.