Counrtry doses - page 5
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... Read More
Oct 16, '06It seems like the OP is not interested in knowing whether or not this is legal, and certainly not interested in hearing from the many experienced nurses here. I get the impression she only wanted others to validate what her unit does.
All I can say is, take your question to your BON. Ask them how they feel about "country doses." Tell them "everybody does it." See what kind of reaction you get.
Oct 16, '06Quote from Bethy-lynnWell, then your question is answered by those of us who have chosen to respond and that is that NO, this is not common and it is wrong and dangerous and unprofessional. "Yeah, it's done" doesn't mean it is common or right.I posted this question, not because I wanted to know if it was a Legal practice, but simply because I wanted to know how common this was. I have spoken with other people on my unit about how common it is, and most of them just give me the "Yeah, it's done" answer. I really just wanted to know if other units seemed this liberal, and automic, because yes, I have questioned it which is what I was trying to do when I posted this to begin with.
slinkeecat's post is just one frightening reason NOT to do this.
Spacenurse and others have given concrete examples of how to handle situations where a pt MAY need more medication.
I see no real need to do this other than professional laziness (sorry to be so harsh but patient's lives are at stake here). There are always ways to handle that meth patient who doesn't want to stay down or the over-dosed post-op pt (narcan?? - which WOULD be protocol) without practicing medicine w/o a licence.
The docs who allow this are also being unprofessional.
Oct 18, '06I have to agree with timothy. Never say never. It's not about not calling, but is often about time. I have saved lives by NOT waiting for the physician to call back, and getting the order after the fact. Those of you who haven't, either haven't been practicing in ICU for long, or haven't been practicing well in ICU.
Oct 18, '06Quote from dorimarI've only been full time in critical care since 1980. We have worked very hard for standardized procedures. Of course we can initiate ACLS.I have to agree with timothy. Never say never. It's not about not calling, but is often about time. I have saved lives by NOT waiting for the physician to call back, and getting the order after the fact. Those of you who haven't, either haven't been practicing in ICU for long, or haven't been practicing well in ICU.
We also have residents and an anesthesiologist available 24/7 and our medical director or designee by phone.
When the Northridge earthquake hit our phones didn't work, electricity was out.
Monitors, IV pumps and vents didn't work.
One patient who was on CPAP prior to extubation was frantic. Her IV Ativan had been changed to something else but everything was off the shelves and on the floor in the complete darkness.
With others ventilating both my patients I went to the med refrigerator with a flashlight in my mouth and got a tube of Ativan. I gave 1/2 of it as the ordered dose was 1 mg. The patient was alert, frightened, and so agitated I was afraid she was using too much oxygen. It was impossible to get to the locked drawer with the newly ordered med. I was writing everything on the narrative in the dark, flashlight in teeth. (It was a little keychain squeeze type light.)
That was about 5:00 am. The nursing supervisor and charge nurse knew.
Before six when the sun came up our medical director came in and wrote orders for whatever was given. Of course he approved one more dose of the Ativan she had been on since intubation.
I can truly say that is the only tome I have given a med without an order. AND I gave the dose she had been on.
ONLY in an unavoidable and unpredictable emergency should this ever be needed. NOT because the facility does not provide sufficient medical staff for the ER, NOT because the doctor won't return a call, NOT to avoid "bothering a physician. Certainly NOT when the dose charted is not the dose given.
Oct 18, '06Spacenurse,
Firstly, WOW!! What a postion to be in!!! I cannot imagine.
Secondly, that was exactly what i meant about never say never. I have been in situations not so dramatic but with potentially worse outcomes if i didn't act because the phisician hadn't yet returned the call. If you have been practicing since 1980, then I'm sure you've had vented patients develop pneumo's and you got stat CXR's while you were waiting for the doc to call back. I believe that should be a standing order, but it is not where i work. Same goes for stat labs. Last week my post op patient was tachycardic with a low cvp and decreased u/o, but not yet hypotensive. labs 2 hours prior showed a stable H&H. I spoke to the surgeion several times and boluses were ordered and given. As he got more tachycardic I continued to speak to the surgeon and repeated labs with orders. Then i got orders to transfuse due to hemaglobin dropping form 10 to 8.5, patient still tachycardic with low cvp and low urine output, but not yet hypotensive. I had spoken to the surgeon already several times with prompt phone call returns and was continuing to implement orders. By the time the patient actually got hypotensive it was drastic and rapid and I started dumping blood product in while waiting for the surgeon to call back. At this point his answereing service couldn't arouse him and I had them call Q 3 minutes while i notified my admin supervisor of the probable need to call the OR crew in and ppossibly the cheif surgical officer,and I dumped blood product in and got repeat stat labs. As it was he called back stated he'd be right in and asked for th OR crew to be called in stat (big surprise). By the time he got in, the crew was here, I had dumped 5 untis PRBC into my patient and his SBP was 55. They wisked him off to surgery and his spleen was ruptured.
He came back pink and stable. The physican thanked me, and when i came back three days later the patient profusely thanked me, as he was awake and aware and knew what i had done for him.
I'm not saying it's ok to be in that situation, but I wouldn't have acted differently.
Oct 18, '06Another big difference is, as you stated ,you have residents and anesthesiologist available 24/7. That is very nice for you and your patients.
Oct 18, '06There is a difference between your examples (earthquake, hypotensive patient) and giving a little extra insulin or wasting the ativan into the pt.
Being a pt advocate and doing what you know is best in spite of Dr's not returning calls is what makes good nurses. It is based on years of experience and judment. You wouldn't do it if you didn't know that's what the pt needed. Thinking that the insulin scale is not appropriately dosed and making your own adjustments is not, in any way, similiar. Lying about the amount of ativan needed by wasting it into the pt and falsifying legal documents also is not similiar.
Oct 19, '06Quote from JenSICU_CCRNJust to complete a thought on the subject of nurses and glucose control.Do you not think that giving extra insulin is a big deal? Do you not think that dropping a blood glucose too fast can cause problems neurologically among other things? We were not educated in nursing school for dosing of sliding scale....giving extra insulin is no laughing matter and could cause a lot of problems outside of 'just lowering the blood sugar'. Jenny
"In the ICU, insulin therapy is a job better left to nurses, suggest study findings presented at the Society of Critical Care Medicine’s 35th Critical Care Congress. In the study, a nurse-driven protocol for giving intensive insulin therapy to medical and surgical ICU patients achieved more effective blood glucose control than did standard physician-initiated insulin therapy.
Blood glucose averaged 126 mg/dL among the patients assigned to the nurse-driven protocol, 153 mg/dL among those who received insulin from a physician, and 166 mg/dL in the sliding scale group.
The patients in the nurse-driven protocol were normoglycemic 51% of the time versus 32.4% and 16.8% of the time, respectively, for those who received physician-directed and sliding scale insulin therapy."
Timothy.Last edit by ZASHAGALKA on Oct 19, '06
Oct 19, '06I heard about "country" dosing from a former nursing supervisor when I first started OB in a new hospital. I thought well, everywhere there are different ways of doing things, and decided to just watch and learn.
Two years later that nurse was up before the Board for drug diversion, four years later she has charges against her and had fled the state.
I admit I have given tylenol without an order, pushed fluids, started emergency treatment without an order, but never, never, never would mess around with any sedating med.
Possible exception being if a patient was threatening staff with bodily injury- but even then.... AND I would write an incident report, and notify the MD afterwards.
A reputation for being less than meticulous with controlled drugs will do you absolutely no good.