What are your most dreaded Dr.'s orders to hear- you know, the ones that tell you that you're in for one heck of a night? For the past couple of nights, I had a patient with ammonia levels in the 260s, who had an order for a Lactulose drip (at first, it was full-strength via DHT- yeah, THAT worked out well ). Needless to say, it went how I had envisioned it: the DHT kept occluding, until I finally got new orders for 1/2 strength via NGT, the pt was out of it, and was code-browning the whole time. Man, I hope I never see orders like that again! What are some of your dreaded orders?
Oh, yeah!!! How could I forget the dreaded "awaiting nursing home placement" patients! 9:10 they are cunfused wanderers with new hip replacements or C-spine injuries, 0 psych meds, 0 restraints, and 0 sitter. :stone
LOL Yes, I've been on admissions review for a nursing home, and nothing flags brighter red than "sitter" in the hospital nursing notes!
My favorite orders come from doctors "on-call" who are not familiar with the restrictions nursing homes labor under. Usually given at 2am. "I'm sorry, doctor, we can't give Haldol IM... there are no restraints of any kind in the building ..." It's going to be the shift from Hades because even if I can convince him to let me send the person out for extreme behaviors, the ED staff is going to call me and (worst case) question my skills as a nurse and worth as a human being for sending the person in ("what do you want us to do?") or (best case?) say the person is coming back with a dose of IM antipsychotics having been given. I send the person in with a doctor's order to route through the ED to geropsych. But of course, no behaviors are shown in the ED. New environment and bright lights tend to take the fight out.
And I'm not trying to put down ED nurses, please don't think that! I know the last thing you want to see come in at 3am is a combative frail nursing home resident. We don't have the options a hospital has, they're not even physically available to us, and taking care of up to 60 residents with 1-2 aides makes 1:1 impossible. The on-call doctor has already stressed out the nurse with his attitude when regs are explained, so you will hear frustration in the NH nurse's voice when you call and ask why we followed the doctor's orders...
Specializes in Geriatrics/Oncology/Psych/College Health.
One doc continually insists on writing the order "continue home meds" no matter HOW many times I tell him that's not a legal order and it's not going to prevent me from calling him to give him the list and get the real approval for each med. It usually means the pt is a confused elderly person who hasn't the faintest notion what he/she is taking (and no family to call) OR someone who has a list of meds 10 feet long and he just didn't want to write them.
Another doc still occasionally writes "restrain prn." He needs slapped. Repeatedly.
Another order I dread is for an NG tube to be put down and a digital disimpaction to be done on a demented, combative NH patient with suspected bowel obstruction...........
I agree. And if they are expelling nasty old bloody stuff from both ends the whole unit suffers doesn't it.
Let alone the nurse trying to keep the NG down, keep him clean, keep safe, yada yada..
Specializes in LTC, assisted living, med-surg, psych.
Then yesterday I had a confused, paranoid Alzheimer's patient who needed an abdominal CT and was refusing to drink the oral contrast solution because she thought we were trying to poison her. Nothing the doctor or the nursing staff could say would convince her that it was safe, and the more we encouraged, the more vigorous was her resistance. So we called the MD, and HE said "If she won't drink it, put an NG down and give it to her that way, then take the NG out".:angryfire
RIGHT!! Like this poor woman isn't already feeling violated and terrified.......now I'm supposed to go in there, shove a tube up her nose and down into her stomach and FORCE the solution into her??! No way was I going to carry out that order.......not only was it cruel and invasive, but I knew I'd get the crap beaten out of me if I so much as approached her with that tube in hand.......she'd already clawed the lab tech when he tried to get some blood, and yelled bloody murder whenever we tried to give her the contrast.
Fortunately for all concerned, I had enough sense to ask her son and daughter to come in to sit with her and talk with her quietly........and do you know, they got that solution down her within minutes! Problem solved! And the rest of the shift went just fine with this patient........she was calm, she asked questions, she stopped trying to climb over the rails. She even smiled at me and called me "a dear". And she got her CT done without incident.:)
-Golytely prep (especially when ordered for an incontinent, elderly patient with limited mobility).
-Tap water enema until clear.
-Fleets III bowel prep (18-hour bowel prep with 8 oz. clear liquids q1h, Fleets Phosphosoda at 1900, 4 Dulcolax tabs. at 2200-- Ordered for an elderly woman who probably drinks 8 oz. fluid/DAY!)
-Milk and Molasses enema.
-Wound care for a stage IV sacral pressure ulcer that needs to be performed after each bowel movement, and the patient is on tube feedings with almost continuous oozing stool.
"Or restricted diets on terminal patients.. YOU going to tell him he can't have salt or caffine or sugar or whatever he wants after telling him he only has a few weeks or months?"
Oh I just dealt with that one recently. We had an elderly woman in acute endstage renal failure. She was (Goodness knows why) on 20 mEq of Klor-Con. Big surprise that she ended up with a K+ that was critical. So genius boy doctor puts her on kayexalate and a potassium restricted diet. This after getting angry with us because she was on Klor-Con, when we had faxed him asking for clarificatation of his orders when he set up her med orders and the Klor-Con was on there and he reamed us for asking about it. So here we have acutely ill woman on extremely restricted diet who was hardly eating to begin with, and now we have precious few food choices we can offer her. Gee, that makes alot of sense, especially when she was supposed to be on comfort measures only once that stupid Klor-Con order was DC'd.
Yes, let's make her confortable, but let's not allow her some decent food choices in the small amount of time she has left.
). Needless to say, it went how I had envisioned it: the DHT kept occluding, until I finally got new orders for 1/2 strength via NGT, the pt was out of it, and was code-browning the whole time. Man, I hope I never see orders like that again! What are some of your dreaded orders?
rn 2b lnc
17 Posts
LOL Yes, I've been on admissions review for a nursing home, and nothing flags brighter red than "sitter" in the hospital nursing notes!
My favorite orders come from doctors "on-call" who are not familiar with the restrictions nursing homes labor under. Usually given at 2am. "I'm sorry, doctor, we can't give Haldol IM... there are no restraints of any kind in the building ..." It's going to be the shift from Hades because even if I can convince him to let me send the person out for extreme behaviors, the ED staff is going to call me and (worst case) question my skills as a nurse and worth as a human being for sending the person in ("what do you want us to do?") or (best case?) say the person is coming back with a dose of IM antipsychotics having been given. I send the person in with a doctor's order to route through the ED to geropsych. But of course, no behaviors are shown in the ED. New environment and bright lights tend to take the fight out.
And I'm not trying to put down ED nurses, please don't think that!
I know the last thing you want to see come in at 3am is a combative frail nursing home resident. We don't have the options a hospital has, they're not even physically available to us, and taking care of up to 60 residents with 1-2 aides makes 1:1 impossible. The on-call doctor has already stressed out the nurse with his attitude when regs are explained, so you will hear frustration in the NH nurse's voice when you call and ask why we followed the doctor's orders...