LTC and med orders

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I work in LTC, and I am having difficulty writing requests for medications or treatments. I am told that I can not ask for a medication or a treatment? I am told I have to watch my wording??? And should be writing the request like a doctor order's. I had a pt who had dry and itchy scalp. Faxed Md "pt has dry and itchy scalp" suggestions? MD wrote back " moisturizing shampoo" I had to get it clarified because, it didnt say how often? I was told I should of included that in my first request. I was told I should of written

"pt has dry itichy scalp, suggestions, as PRN? Any suggestions on exactly what is meant by I cannot ask for something???? Confused!!!

I know of no state that would say a nurse is practicing medicine without a license by using moisturizing shampoo on a resident. It's not going to harm them. At worst, they may get some greasy hair, and that is not going to do a bit of harm, aside for appearance, especially for a dry scalp. And sure perhaps there is more going on than JUST dry skin, it's a normal part of the aging process though, and moisturizing shampoo is not going to put someone in their grave early or at all.

We pretty much need a order for everything, I was actually told by my supervisor to get a order for the shampoo, because that was my first thought, and was told ...fax the doctor first!!!

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Lots of controversary over shampoo, it was only one example I came across that I could think about in the moment. The point is I am having difficulty with the statement other nurses tell me, that I can't ask for a medication, and when making a request I need to write it more like a MD order because when they are faxed to the MD office they read and sign. I had a gentlemen who was prescribed a prn of vicoden every 6 hrs for pain, and we were giving it every six hours, would you make a request for the MD to make this a routine medication and if so how would you make the request, without asking?

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Specializes in pediatrics, geriatrics, med-surg, ccu,.

This is a very good question. I worked in a hospital setting for 20 years and have been in LTC since August. I don't know how you would write it without asking either... I have always asked/suggested when I have faxed the doc.. We have some standing orders that can be written, which I have done but we have 4 physicians-one that doesn't mind suggestions, one that doesn't like having suggestions and 2 that depending on their mood goes either or. So I am like you, how do you do this without suggesting or asking?

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Lots of controversary over shampoo, it was only one example I came across that I could think about in the moment. The point is I am having difficulty with the statement other nurses tell me, that I can't ask for a medication, and when making a request I need to write it more like a MD order because when they are faxed to the MD office they read and sign. I had a gentlemen who was prescribed a prn of vicoden every 6 hrs for pain, and we were giving it every six hours, would you make a request for the MD to make this a routine medication and if so how would you make the request, without asking?

Requesting something is asking for something. :rolleyes:

Can't you call the doc and speak to them? Its easier to get a point across verbally. If not, you just need to work it in a suggestion. Mrs x is taking her vicodin q 6 hrs and it is effective in her pain relief. Can we just make it a regualar order? Thats what I would write or ask? Of course my next sentance would be " can you call or fax the pharmacy at 444-4444 and change that order?

If we get a verbal order we write it on our physician order sheet and fax it to the md. They sign it and send it back to us. I guess the next part to your question deals with how your facility handles verbal orders. Is that why they are upset with the way you are getting the suggestions/ requests or what ever you call it?

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Specializes in Gerontology, Med surg, Home Health.

Dr Suess,

Mrs Jones is taking the PRN Vicodin every 6 hours for pain. May we make it scheduled? Thanks so much.

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Thanks for the suggestions, helped alot!!!

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If we didn't suggest things for our residents, we'd never get anything done. I've sent faxes with a cover sheet: Dear Dr Jones..sign the next page...on the next page would be the order I wanted written the correct way. If he signed, great. If he didn't then we'd discuss it. Always have something in mind when you call or fax the doc...Dr Smith, Mrs X has a very congested cough, decreased O2 sats, and noisy lung sounds....how about a chest xray?

Yeah...I thought it was condescending, too.

Good advice, thank you, I am a new nurse and working for only 2 months, with very little training in LTC, about 8 hrs, if that. I am trying to keep my head above water right now, without running and screaming from the facility!!!

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Specializes in LTC, assisted living, med-surg, psych.
Good advice, thank you, I am a new nurse and working for only 2 months, with very little training in LTC, about 8 hrs, if that. I am trying to keep my head above water right now, without running and screaming from the facility!!!

Welcome to LTC, where critical thinking is a (strongly discouraged) art form! :lol2:

You'll get a feel for wording faxes as you become more comfortable in your role. And as another poster said, if we don't "suggest" treatment modalities, we'll never get anything accomplished because primary care providers don't have the time to pore over every single complaint, look up all the possible treatments for it, and then fax an order back to the facility. In fact, I've had many of them thank me for recommending a medication or treatment because they know I've checked the patient's allergies and done my homework on potential interactions with the other meds/tx s/he is already taking. While some PCPs don't like nursing input (and these are usually the "old-school" types whose practices are less than up-to-date) I'd have to say the majority of them actually embrace our solutions, because a nurse who knows his/her "stuff" makes their job much easier.

Yes, you do have to take care with how you phrase your requests, not because certain MDs freak whenever a nurse dares to tell them how to practice medicine, but because you don't want to be accused of practicing medicine yourself. Don't put "Please prescribe Macrodantin 100 mg. PO QD for chronic UTI"; write "May I suggest trying an antibiotic such as Macrodantin daily to see if we can head off some of Mrs. G's urinary tract infections? Please advise---thank you" and leave space for the prescriber to write the order, or explain his choice of a different mode of treatment. (It's amazing how they will often take the time to do this when they know the nurse is looking out for their patient's best interests!)

I will also take advantage of facility protocols for topicals like T-Gel and Calmoseptine to get the resident immediate relief from itching, excoriation caused by incontinence etc. If there is no protocol, I'll write a nursing order for a specific house-stock treatment to be given until/unless the PCP states otherwise, and THEN get the formal imprimatur from the provider (which is going to match what I've written 99.9% of the time anyway). I believe that the authority to do so depends on each individual state's nurse practice act; mine is fairly liberal (in OR a registered nurse can even change a PRN pain med to scheduled), but you'd have to check with your own state's laws to be sure.

These are only a few of the ways nurses can steer the patient/resident care process without exceeding our scope of practice or alienating the physician/PA/NP. Again, it takes time, and it takes experience, and yes, it takes falling on your face at least once or twice to develop this skill set. Be patient........you've got your whole career ahead of you.:)

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Thanks for your input, can I come work with you !!! LOL I wish the nurses I worked with...were just like you..I feel they think I should know all of this!!! After two month!!! You give me hope and also some good words of advice!!! Thanks a bunch!!!

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