Counrtry doses

Pompom · Oct 10, 2006

Yes it happens, I personally don't agree with it, how does the doctor know to write a proper dosing if you lie? Just call and get the order changed, it is safer for the patient. Not to mention you could harm a patient or lose your license. Plain stupidity!

Bethy-lynn · Oct 13, 2006

Just a couple of things here. 1, when we have to give a different dose than what was needed (higher or lower), we do tell the md's, we are not lying to them. 2, the original question was whether or not this seemed to be common, not whether or not it was practicing without a license. Like I mentioned, this is the only place that I have worked as an RN, and I was just curious. 3, i say "we" because it is a practice that i see around me, in my UNIT frequently. and Finally, I am very aware of the effects of decreasing someones glucose too fast. I am also aware that when someone is rec'ing D5, TPN, Solumedrol, is Diabetic, Septic, and all they have is low dose sliding scale ordered, it's not going to be effective in maintaining their fsbs's between 80 and 110. (we usually start an insulin gtt for this, which is unit policy, not physician ordered). As for the Ativan issue, the only time I have ever given someone an extra dose of Ativan is a patient that was in dt's, extremely violent, restraints not working ( because Meth makes you very strong), and that was still according to our standard dosing, which I then had the physician sign. I have never written an order for a med without asking the physician.

Trauma Columnist · Oct 13, 2006

I would still bet you are in trouble with practicing medicine without a license unless protocols are already in place.

humglum, BSN, RN · Oct 13, 2006

I've seen nurses do this, too, but I don't condone it and I would NEVER do it myself. In my facility an RN can initiate a physical restraint for safety. We'd call a code, manually take the patient into seclusion and then call the doctor to evaluate/co-sign the restraint order and possibly order stat/PRN medication.

There are many things you can do for the safety of your patient, your co-workers and yourself that doesn't involve administering a medication without an order. That's hardly an excuse and you'd likely be laughed out of court.

Marie_LPN, RN, LPN, RN · Oct 13, 2006

1, when we have to give a different dose than what was needed (higher or lower), we do tell the md's, we are not lying to them.

Before or after?

If it's before, then it wouldn't be a "country dose" it would be carrying out MD orders.

2, the original question was whether or not this seemed to be common, not whether or not it was practicing without a license.

Ok, well, it's not common where i work, because it is practicing w/o a license, unless there are standing orders or protocols.

chris_at_lucas_RN, RN · Oct 13, 2006

Just a couple of things here. 1, when we have to give a different dose than what was needed (higher or lower), we do tell the md's, we are not lying to them. 2, the original question was whether or not this seemed to be common, not whether or not it was practicing without a license. Like I mentioned, this is the only place that I have worked as an RN, and I was just curious. 3, i say "we" because it is a practice that i see around me, in my UNIT frequently. and Finally, I am very aware of the effects of decreasing someones glucose too fast. I am also aware that when someone is rec'ing D5, TPN, Solumedrol, is Diabetic, Septic, and all they have is low dose sliding scale ordered, it's not going to be effective in maintaining their fsbs's between 80 and 110. (we usually start an insulin gtt for this, which is unit policy, not physician ordered). As for the Ativan issue, the only time I have ever given someone an extra dose of Ativan is a patient that was in dt's, extremely violent, restraints not working ( because Meth makes you very strong), and that was still according to our standard dosing, which I then had the physician sign. I have never written an order for a med without asking the physician.

Sounds defensive. You say this is your only RN experience? Then be extra grateful for the nurses on this board--they are teaching you good nursing. If you listen to them, they may save you a lot of heartache, possibly prevent injury to a patient, possibly protect your license.

We have all been around nurses whose practice of our profession got a little loose over time. We have seen situations where patients were put at risk. Some of us, myself included, have walked away from otherwise good jobs because we could not stand to watch poor nursing. We all hope we will never be less than the best we can be--and I hope you don't either. Good luck to you.

And spacenurse, thanks for your little note--I just saw it as I was scanning recent posts. You can take care of me anytime!

allnurses Guide · Oct 14, 2006

Sounds defensive. You say this is your only RN experience? Then be extra grateful for the nurses on this board--they are teaching you good nursing. If you listen to them, they may save you a lot of heartache, possibly prevent injury to a patient, possibly protect your license.
We have all been around nurses whose practice of our profession got a little loose over time. We have seen situations where patients were put at risk. Some of us, myself included, have walked away from otherwise good jobs because we could not stand to watch poor nursing. We all hope we will never be less than the best we can be--and I hope you don't either. Good luck to you.
And spacenurse, thanks for your little note--I just saw it as I was scanning recent posts. You can take care of me anytime!

Nice post . . . and spacenurse, you can take care of me too, anytime.

steph

neneRN, BSN, RN · Oct 15, 2006

I can see both sides of the issue here, and I guess I'm guilty of practicing medicine without a license too, but in different scenerios. I'm in the ER, and we do have a lot of autonomy..we're expected to do a lot before the doc sees the pt and are covered by protocols for most things. But there are instances that I am frequently involved in that put me in the position to act without an order or risk harm to the pt. These are at times when the wait to see a doc is several hours or all docs are tied up with critical pts; certain times of the day there is only one ER doc for the whole ER.

Read these examples, maybe you'll see that situations aren't always black and white, sometimes you have to go with your gut and do what's best for the pt.

Last week, had a guy come into the ER confused, coworkers said he gets this way when his blood sugar is low; do an Accucheck-47. He's alert enough to drink the OJ, but is confused, a little combative, and refusing to drink it. Our protocol says we can give D50 for symptomatic hypoglycemia

Or, and this happens all the time, COPDer comes in, he's tight/wheezy, sats a little low, working to breathe...the doc's in a trauma/code/out of the dept getting coffee...I don't have a protocol to cover Neb Tx unless the pt has asthma, but I'm gonna call RT and have them give a treatment anyway; should I let his breathing get worse instead and risk him going down the tubes?

Or one of our brittle diabetics who always comes in with DKA; glucose is 500, she's tachycardic, vomiting. No, I don't technically have an order to give her IVF, and she'll be seen by the doc fairly quickly because of her acuity; but I definitely can't give her insulin until the doc sees her, so yes, I'm going to bolus her with a liter of NS until he does see her.

And this doesn't just apply to meds; on a daily basis, I order labs that aren't technically covered under protocols because I know what the docs want and I know that it may be hours before the doc gets to even see the pt. And I'm talking no-brainers here; if I have any doubt at all that the test won't be ordered by the doc, I certainly won't order it. Like a pt who comes in with seizures/takes Dilantin at home, obviously we need a Dilantin level and it will benefit the pt for the doc to have that result when he sees the pt so we can load him up with Dilantin if needed. Or a syncopal pt coming in on Dig with a HR of 50; hello, Dig level.

I just think that if most nurses thought about it, they could come up with a time in their career where they had done something without an order...maybe it wasn't a med, but when it comes down to it, anything that's not strictly an independent nursing intervention/unit protocol/standing order is practicing medicine without a license...and sometimes you just go with your gut and do it if that's what you need to do to protect the pt. (Obviously I am not talking about giving any meds that are for nurse convenience or to avoid "bothering" the doc)

chris_at_lucas_RN, RN · Oct 15, 2006

I can see both sides of the issue here, and I guess I'm guilty of practicing medicine without a license too, but in different scenerios. I'm in the ER, and we do have a lot of autonomy..we're expected to do a lot before the doc sees the pt and are covered by protocols for most things. But there are instances that I am frequently involved in that put me in the position to act without an order or risk harm to the pt. These are at times when the wait to see a doc is several hours or all docs are tied up with critical pts; certain times of the day there is only one ER doc for the whole ER.
Read these examples, maybe you'll see that situations aren't always black and white, sometimes you have to go with your gut and do what's best for the pt.
Last week, had a guy come into the ER confused, coworkers said he gets this way when his blood sugar is low; do an Accucheck-47. He's alert enough to drink the OJ, but is confused, a little combative, and refusing to drink it. Our protocol says we can give D50 for symptomatic hypoglycemia
Or, and this happens all the time, COPDer comes in, he's tight/wheezy, sats a little low, working to breathe...the doc's in a trauma/code/out of the dept getting coffee...I don't have a protocol to cover Neb Tx unless the pt has asthma, but I'm gonna call RT and have them give a treatment anyway; should I let his breathing get worse instead and risk him going down the tubes?
Or one of our brittle diabetics who always comes in with DKA; glucose is 500, she's tachycardic, vomiting. No, I don't technically have an order to give her IVF, and she'll be seen by the doc fairly quickly because of her acuity; but I definitely can't give her insulin until the doc sees her, so yes, I'm going to bolus her with a liter of NS until he does see her.
And this doesn't just apply to meds; on a daily basis, I order labs that aren't technically covered under protocols because I know what the docs want and I know that it may be hours before the doc gets to even see the pt. And I'm talking no-brainers here; if I have any doubt at all that the test won't be ordered by the doc, I certainly won't order it. Like a pt who comes in with seizures/takes Dilantin at home, obviously we need a Dilantin level and it will benefit the pt for the doc to have that result when he sees the pt so we can load him up with Dilantin if needed. Or a syncopal pt coming in on Dig with a HR of 50; hello, Dig level.
I just think that if most nurses thought about it, they could come up with a time in their career where they had done something without an order...maybe it wasn't a med, but when it comes down to it, anything that's not strictly an independent nursing intervention/unit protocol/standing order is practicing medicine without a license...and sometimes you just go with your gut and do it if that's what you need to do to protect the pt. (Obviously I am not talking about giving any meds that are for nurse convenience or to avoid "bothering" the doc)

There are some differences between your post and the OP's.... at least it seems this way to me.

You have protocols for most things. That's like orders. She doesn't mentioned protocols, orders, standing orders, attempts to locate a doc, etc. And it seems the "country doses" (what a term!) are for nonlethal, nondangerous situations in the case of the OP.

Joking about it with the docs? I'm not sure I buy that one, no reflection, no harm intended. (But if it's true, man, get out of that hospital and make sure people around you know you want to go somewhere else!) neneRN, you sound like a serious experienced nurse who knows this is not a joking matter.

The other situations, you have worked with before, you have a relationship with the docs, you know if they are going to back you or not. The OP doesn't reference this, just a lot of "the other nurses do it."

And it sounds like you have been a nurse for a while. The OP is a newbie.

The sad commonality? If, God forbid, there is something you don't see, don't know, someone doesn't tell you, and a patient is injured, it is your license (and peace of mind).

allnurses Guide · Oct 15, 2006

.
The sad commonality? If, God forbid, there is something you don't see, don't know, someone doesn't tell you, and a patient is injured, it is your license (and peace of mind).

This is what screams out at me . . . . good good point.

steph

PANurseRN1 · Oct 15, 2006

In our unit, we tend to give a lot of "country" doses (such as adding on a couple extra units of insulin if someone's sugars are high, or giving the extra mg of Ativan to the resident Meth od). We even joke about it with some of our md's. I guess I'm just a little curious about how "normal " this is. i feel like I work in an EXTREMELY liberal unit ( we order a lot of things, labs, ekgs, x-rays, O2, and we make few med changes like changing from iv to po, or giving benedryl or tylenol) and I was just wondering what the consensus is.
It's the only unit i've worked in as an RN and I was just curious.

Not only is it not normal, it's illegal and if you're smart you'll stop it immediately before you lose your license.

I agree with the other poster...this is terrifying.

PANurseRN1 · Oct 15, 2006

Well, I can see this thread has a LOT of controversy. Here's my 2 cents, like it or not. I will throw out a hypothetical situation, (which really happened recently).
Say, you have a pt in ICU who is of normal mentation and has an order for 0.5 mg Ativan IV Q2H PRN. All of a sudden, he has become very agitated, won't stay in bed, is hitting nurses and kicking them. It takes 5 nurses to hold him down and restrain him and during the process he injures two nurses so severly they have to go the ER for treatment.
Am I going to wait and call a doctor to get an order for restraints? NO. Am I going to give him 0.5 mg Ativan which won't do a thing? NO. I will restrain him without an order and get one when I call the Dr. Since Ativan comes in 2 mg vials, I will give him what we call "A NURSING DOSE" of maybe 1 mg or 2 mg to knock this very dangerous patient down a notch. I will get an order from the Dr. after we get this under control.
When I talk to the Dr, we can discuss the WHYS of the incident and probably send him to cat scan or whatever interventions are needed. The bottom line is safety of the pt.
ICU is a different animal than med/surg, psych, tele......it is all of that rolled into one. You have to use good judgement, critical thinking, and can't wait around to page a doctor or one to come to the unit in every single case. The same for a coding patient......am I going to wait before starting ACLS protocol and let this patient possibly die? The answer is NO. You roll into action and let the orders come when they come, even if they come late.
Donning the abestos flame protectant suit!

Please do not try to play the "ICU is a different animal" card...it just doesn't work. Safe nursing practice should be applied to all areas. Many of us work in specialties where nurses are given a lot of latitude and where emergent conditions arise all the time (I work in the ED prn in addition to my real job).

In your scenario, yeah, maybe you sedated the pt., and maybe you also took away an important clue to why he was so agitated to begin with. There could be dozens of reasons why he was agitated. And maybe in his scenario, Ativan was the last thing you should have given. Congratulations! You just lost your license.

Operating under standing orders/protocols is one thing, playing fast and loose with meds is another. I'd love to know where these hospitals are where nurses feel they can just medicate as they please...I want to make sure to never be a pt. there!