Night shift RN giving sleep aids w/o order..

[HillaryC, RN, CRNA]

Hi everyone,

I'm a new RN working in Critical Care. I've been working for about 2 months, the last 3 weeks being night shift. Now, I understand that, in real world nursing, a lot of what they teach us in school goes out the window. I recognize that I'm a brand new nurse and have a lot to learn about real world nursing.

Anyway, here's my question. One of the nurses that was assigned to precept me on night shift apparently has a habit of medicating pts w/sleep aids that aren't ordered for them. First I noticed her giving a restless pt. diphenhydramine IV that she'd snuck out of the pyxis. She quietly told me what she was doing as she was pushing the drug, and I just stood there kind of dumbfounded. The next night he was c/o itching, and instead of making any attempt to get an order, she told me how to get the diphenhydramine out of the pyxis w/o any record. I just said, can't we try to get an order first? It was no big deal -- the resident ended up giving me an order, and it just took a few minutes. It certainly made me feel a whole lot better.

The next night, a different pt. was c/o insomnia. Anyway, this same nurse went over to the med cart to see what other pts had in their drawers. First she found some PO diphenhydramine, but with further looking, she found leftover chloral hydrate in another pt's drawer. She grabbed it, handed it to me, and said "this is better. give this." I wimped out and took it from her, but I put off giving it to the pt. When she saw me looking the drug up in my PDA, she came up to me and seemed very nervous. She tried to tell me what the drug is and tried to make it sound benign. Basically, I ended up putting the drug back in the med cart, and when she confronted me, I just said "I just don't feel comfortable giving it." She tried to convince me that it wasn't a big deal, and even said "think about it. Who's going to know? Just me, and your conscience." I was very disturbed by her attitude. I'm not willing to do something that could hurt my pt., especially when I know damn well it's beyond my scope of practice. I'm not licensed to prescribe medicine, even if it is something as benign as Benadryl and it's very unlikely to cause a problem. I'm not so arrogant as to believe I know everything I need to know to decide whether a pt. can have diphenhydramine. If I want to prescribe, I need to go to school to become a prescriber.

I know that legally, I was right not to give the meds w/o an order. My question is, am I being totally naive? Is this practice commonplace? I heard some other nurses joking about an order for 20mcg of Fentanyl (the vial is 100 mcg). They were commenting on how low a dose it was, and how in reality "one vial is one dose" -- basically saying, they'll give the whole thing, even if in the computer, it says they wasted 80mcg. This was again, night shift, with an agitated pt that was driving her nuts. I couldn't tell, but I think they weren't kidding.

What do you think? Am I totally naive about this? Oh, and by the way, the first nurse has mysteriously not shown up the last couple of shifts, and everyone's being very hush-hush about it. I have a feeling she's not coming back.

Thanks,

Hillary

[jayne109, RN]

I think you were right getting the order. I would not give something without an order. I work on a neuro floor and a lot of docs don't want them sedated because it could mask a change that would need to be picked up quickly. SOmething I noticed that some of the nurses on my floor do because the physician in the past has said "it is okay for you to write an order to do this on my pt (insert a foley when they have 1000 cc in their bladder, give MOM if they are constipated, etc.)" this scares me to do this and I have been a nurse for almost 2 years. Take it up with you Nurse manager. Find out more if you can. YOu worked hard for your license for it just to be taken away because you were told that it was okay to do that.

[CCU NRS]

NO do not give any med without an order. I would also personally have to make a report to the Manager or DON about the practice of this nurse, what she is doding is illegal, your knowledge of it is compliance, you are risking your lisence. Bottom Line

[SouthernLPN2RN, MSN, RN, APRN, NP]

You are totally in the right. Don't ever do something you don't feel comfortable about.

[SmilingBluEyes]

wow you work with some dangerous people. I would be really careful there were I you.

[emsboss]

DO NOT GIVE/DO ANYTHING ON ANYBODIES WORD!!!!!!!!!!!!! I learned this the hard way in clinicals...Was doing my OB rotation and my instructors "pet peeve" was teaching sheets. Asked the charge RN about the sheet on my PT. she said "It is already filled out and completed." My instructor asked me about it AFTER I had discharged the pt/baby and I repeated what the RN had said, my instructor then held up the BLANK sheet...Got a "clinical U" for the day:angryfire ...Now I trust NOBODY!!!!!!!!!!

[Genista, BSN, RN]

Good for you for trusting your gut instinct. Never do anything that will compromise your integrity. I work with several nurses who give meds without orders from time to time. Their "rationale" is that they know the doc well enough, that they know they can get an order. Well, one time I came on shift and a patient had a medication patch on without an order (the previous shift just put it on). They didn't even try to get an order, but left a note on the chart for the next day. The patch was taken out of pyxis much like you described. It made me see that nurse in a new light. It's just plain bad nursing, and lazy if you ask me.

It IS not in the RN scope of practice to prescribe meds. You are right- it takes just a few minutes to get the order. Stick by your guns and don't back down. These nurses you work with are not following procedures and policies- and are risking their licenses and patient safety. I liked the way you looked up the meds ahead of time- I can tell you are going to make a great nurse.

[Nurse Ratched, RN]

If this nurse's attitude is typical of the other nurses on that unit, methinks I would be finding someplace else to work...

If it's just her, a quiet talk with your NM is in order, with the knowledge that you may still need to find someplace new to work.

[canoehead, BSN, RN]

Getting an order takes five minutes, it's the doctor's and your job, and it is safer for the patient and for you. Even if you KNOW the doc would be OK with what you are doing, just make a call and get the order. If you know he wouldn't be OK with what you are doing then that's the time to think about how badly you want your license during the next 6 months, especially if you are messing around with narcs like Fentanyl.