Need advice

[quiggles]

Last week had a patient post angio, another nurse with a new grad pulled sheath. Patient had uncontrolled hypertension during the pull. Nurse doing the pull administered 4 mg of morphine and started a ntg drip. I wrote the order and put a call out to the doctor. He did not call back. I knew for patient safety that the relationship with this doctor it would be covered. The night nurse decided that the ntg order was to be used other than for just sheath pull that was said on the order. The morning MD came in upset over ntg started during the night and spoke with the supervisor. Md said that the order in which I wrote he is covering, although the other nurse needed to be educated on starting home meds that were ordered instead of starting ntg. Supervisor made it clear to the MD that he would not allow him to cover my order and state reeducation of the other nurse. The supervisor is trying to fire me with practicing medicine without a license. And possiblely go after my liscense as well. Any and all advice would be helpful.

[quiggles]

I forgot to say that the meds were not ordered prior to the sheath pull. I also had to chart the meds given on the med sheet because the nurse and new grad did not. I stand up for what I did, in ICU we sometimes work in a gray area, although the fostering of the doctor nurse relationship is needed. I have worked with these doctors for the last 8 years.

[TazziRN, RN]

Bottom line is, without protocols you had no orders to administer meds. I worked ER for many years and often did things that the docs would cover me later, but I always knew that there was always a chance it would backfire. Even though the doc is willing to cover you, technically the supervisor is right. Tread very carefully and don't be surprised if there is some heavy fallout from this.

[angel4gramma]

I have had experience with this. I had a coworker who was too helpful and when she answered a light for me, she came and said my pt was nauseated and she would give her something for me. I said thanks but I have to call the MD because she didnt have anything ordered. Minutes later she came and told me she gave her phenergan without calling the MD and now she was having a reaction. My coworker told me the MD would cover the order because they were friends(which he did). My problem was now my patient was having a reaction to something not ordered and I did not give her. The MD got very agitated through the day because the family was very upset over it and kept asking to speak to him re: the med he ordered. The MD started to yell at me "get the family off my back, you are the nurse go talk to them and get this problem solved". He was willing to cover the order for the other nurse but not deal with what happened because of it. The family did not find out it was given without an order but a week later I did write it up because I was now being questioned by a manager on another floor that knew the family. They wondered why another nurse gave her the medication then they never saw her again and the MD had not gone in to see the pt. The MD was a hospitalist so he was there most of the day. You can not trust that the MD will back you up and you also dont know how the pt will react to the med you are giving. I wish you luck

[leecian]

It was a tricky one!

[bill4745, RN]

Morphine and NTG with no order? You may loose your license! Isn't there a house doc or resident that you could have called?

[ERRNTraveler, RN]

Morphine and NTG with no order? You may loose your license! Isn't there a house doc or resident that you could have called?

I agree- this is absolutely practicing medicine without a license! If the doctor didn't call back right away, you keep paging, have the operator or answering service call them at home, and if they still do not respond, send the police to their house (yes, I have seen this done at several different hospitals when Dr's didn't respond to pages). If all else fails, call the hospitalist, another Dr, or even the ER doc if you absolutely can't get ahold of anyone. Bottom line, you can't give meds like Morphine & Nitro with no order.

[madwife2002, BSN, RN]

I just wouldnt have given anything without an order and I come from another country and have never heard of orders until I got here. Now to be more helpful who do you have to turn to to get advice

[TazziRN, RN]

If all else fails, call the hospitalist, another Dr, or even the ER doc if you absolutely can't get ahold of anyone.

In many places (like in my area), the ER docs will not respond if the pt isn't coding or birthing. This is not laziness, it is because their contracts read that they have no privileges outside the ER except to work a code, pronounce an expectant pt if requested by the PMD in the off hours, or attend an imminent delivery if the OB doc hasn't made it in yet.

[AnnieOaklyRN, BSN, RN, EMT-P]

hi,

Just a quick question, if the patient had uncontrolled HTN why wouldn't a doctor be called for orders BEFORE the sheath was pulled???

Swtooth EMT-P, RN

[bigsyis]

Bottom line is, without protocols you had no orders to administer meds. I worked ER for many years and often did things that the docs would cover me later, but I always knew that there was always a chance it would backfire. Even though the doc is willing to cover you, technically the supervisor is right. Tread very carefully and don't be surprised if there is some heavy fallout from this.

What Tazzi says has been my experience as well. In ER, especially, the MDs knew the nurses well, and knew whose judgement they could trust, and gave us verbal standing orders. I never had a problem, but I can see how it could happen. You are right about the gray area. ER/Critical care nurses have advanced knowledge and critical thinking skills. The doctors expect more from us than the average nurse, and I think it is very unfortunate that you got caught in this mess. Keep us posted on how things develop.

[CritterLover, BSN, RN]

why wasn't the patient given his home bp meds before the sheeth was pulled?

[color=#483d8b]why did you end up writing the order, when someone else gave the meds?

[color=#483d8b]whose decision was it to give the morphine/ntg?

[color=#483d8b]and really, why a ntg drip?

[color=#483d8b]i can see the logic in the morphine (and shouldn't a patient that needs a sheeth pulled have some orderd pain meds??), but not the ntg. it really isn't that good of a drug for controlling bp......and then you have to titrate it off.....