Interventions without MD orders

elkpark · Feb 28, 2014

There is lots of nursing stuff that nurses do without physician orders. But, yes, medical interventions require physician orders. How far are you in school? In my experience, people start out being preoccupied with the medical-interventions part of nursing practice, and it takes a while to grow into appreciating all that nursing practice involves.

I've spent my career in psychiatric nursing, and, apart from giving meds, most of what I've done all day, every day, over the years didn't require physician orders, but was independent nursing practice.

Esme12, ASN, BSN, RN · Feb 28, 2014

You are a nurse. You follow doctors orders. You do as you are told. Especially in the beginning. As a nursing student I think you need to focus on learning how to be a nurse and not about what you can do procedure wise. You have mentioned in other posts about starting central lines and other procedures that are physician driven. You are in school. Learning the basics is important.

When you graduate and gain experience you will be afforded certain privileges that come with that experience. An ICU nurse doesn't need to wait to start an additional IV line if the patient needs one or applies O2 if the patient is hypoxic...but the doctor needs to be called and orders must be obtained. Personally I have never felt less of a nurse because I call the MD for orders for personally I don't want the responsibility. I'm not paid enough. Let the person getting the big bucks take the heat.

Yes if you are in home care and the patient needs an IV you need an order. What if they develop phlebitis and an infection and gangrene sets in and you started it without permission...you are in hot water. You are licensed to do as you are told. Yes you use independent judgement even with protocols in place. Just because a doctor leaves certain orders... the nurse needs to know when to initiate and use them. If you give Tylenol without an order you are prescribing medicine...something left to PCP/attending. What if the patient can't take Tylenol? What if the experience liver failure/injury because you accidentally overdosed them or they had a per-existing liver impairment and you caused them harm? do you want that all one your shoulders? I don't.

There are certain settings that nurses place PICC lines, arterial lines and external jugulars...again with an order...but that is AFTER you have mastered basic skills and can be deemed safe for these advanced practices.

So in answer to your question...you need a doctors order.

ktliz · Feb 28, 2014

Almost nothing is autonomous in nursing. Just about everything is collaborative.

Personally, I love my role. I will advocate for my patient all day and question doctors orders if necessary. But when it comes down to it, the brunt of the medical decision making is on the physician. That is why they went to school at least twice as long as we did, make hundreds of thousands more than we do, and pay thousands more in Liability Insurance than we do. I have enough on my plate right now as an RN without the added responsibility of being a health care practitioner.

HouTx, BSN, MSN, EdD · Feb 28, 2014

These are legal 'scope of practice' issues -- strictly regulated at the state level. Basically, educational preparation has to match up with the scope of practice. There are also guidelines/rules about tasks that can be delegated to people who hold different licenses (scope of practice). The decision to initiate IV therapy requires much more underlying knowledge than the task of tapping a vein and hanging a bag.

Nursing scope of practice is very clear... but receives little attention in acute care settings because reimbursement/payment is geared to "medical" interventions. Ironic, since the need for continuous nursing care is the only reason that patients are admitted to inpatient care. Heck, if hospital payment was based on nursing care, we'd probably have reserved parking spots for the best bed-bathers!

Caffeine_IV · Feb 28, 2014

Certain specialities allow more autonomy thean others such as critical care. And any intervention you do without an order, you better know what you are doing and that an MD will sign off.

For your example of the palliative patient, there is no reason to start an IV. The MD would first have to order IV medication. We follow orders and can make adjustments based on parameters and critical thinking.

nursefrances, BSN, RN · Mar 1, 2014

It's funny. I felt the complete opposite my first week of school. Before school I thought nurses did everything the doctor said, "Yes, doctor. Anything you say, doctor."

I didn't realize the responsibility we had when caring for patients for a twelve hour shift. I had to learn when it was important to call the doctor for lab results or tests, when to question a doctor's order even as he is giving it to me over the phone. Especially when a doctor gives me an order for an NS bolus on a CHF patient on fluid restriction.

The doctors are there with the patients for a few minutes while we care for them throughout our shifts. We see more than they do and some docs I worked with relied on this knowledge. One pulmonologist I worked with would call me over before seeing the patient and ask how the patient was doing and if there were any orders I needed. I actually thought this was very considerate of him. How many doctors do you know do this? (I guess that could be a thread for another day.)

Here.I.Stand, BSN, RN · Mar 1, 2014

Prescribing and dispensing meds are outside a nurse's scope of practice. You need a provider (MD, NP, PA, DO, etc.) to order meds and a pharmacist to verify/dispense. In a hospice situation you would likely have standing orders--a list of prn's that you can give based on your judgment. These have been preapproved by the provider and pharmacist. With your IV example, think of why we place IV's. It's to have access to administer meds, fluids, blood, right? So you're not going to place one without a valid prescription for something to give THROUGH it.

When you have experience and have developed nursing judgment, you will often have a good idea what to ask the provider for. :yes:

Here.I.Stand, BSN, RN · Mar 1, 2014

Although once I was working in a CVICU and the lone resident was trying to admit 3 people...one had just coded, one was pulmonary hemorrhaging, and my pt. He actually told me, "Just give your pt what you think he needs, tell me what you do, and I'll write for it later." Ummm.... that was one of those situations like they like to hammer down in school, that could have "been my license." B/C I def. don't have one to practice medicine!! :no:

TU RN, DNP, CRNA · Mar 1, 2014

You can't do anything without an order and even some of those you shouldn't follow. Your job as a nurse is to take the order, consider why it's in place, and implement it in an effective, safe, timely manner. Another job is to assess your patient closely, pay attention to details, critically think, tie certain findings together, and notify the MD (if warranted) - who will then place the orders you need to practice legally and protect your license.

nurseprnRN, BSN, RN · Mar 2, 2014

If you have a hard time getting your head around the difference, please do this. STOP all use of the word "orders." It is an anachronism left over from when nursing services were beginning to be formalized, and much of that occurred in military (war) settings.

There is a medical plan of care, and a nursing plan of care. Physicians are the only ones licensed to prescribe certain things, like medications, invasive procedures, and many other things. Nurses are legally obligated to implement some of the medical plan of care, but not all, obviously, right? Lab, dietary, PT... not nursing. Nurses are also obligated not to implement any part of a medical plan of care that we know will be injurious to the patient. This is, partly, why the concept of "following orders" is not a functional way to look at our collaborative practice.

The other reason to differentiate between the medical plan of care and the nursing plan of care and eliminate the word "orders" from our relationship with physicians is that it makes people think we are too stupid and uneducated to have any autonomy. Nursing diagnosis is not some artsy-fartsy thing that eggheaded academics dreamed up to torture students with. It is a scientifically-validated framework for autonomous practice that defines all RNs' (not APRN or NP) responsibilities for independent prescription that others do not have, including physicians.

I hear you about not being able to do some tasks without physician prescription, because they are part of a medical plan of care which we are delegated to implement. But you will find in the real world that a plethora of standing prescriptions and algorithms will offer the experienced nurse all the opportunity for judgment in that regard that s/he can handle. Fear not, and stop whining about it.

Dranger · Mar 2, 2014

Critical Care.......we do what we want :sneaky: