Nurse Independent Prescriber?

elkpark · Oct 22, 2009

but what about standing orders and protocols? can't nurses make clinical judgements and administer meds within the framework of protocols and standing orders?

Yes -- but protocols and standing orders are physician orders. We make "clinical judgments" about medications all the time -- but it's done within the framework of an existing physician's order (or involves getting a physician's order).

SnoopysAunt · Oct 22, 2009

Elk park- how does this typically work? We discussed this in class the other day, my prof gave the example that there could be a order that all patients with x get y med. That' s a pretty independent judgement IMO

Coffee Nurse, BSN, RN · Oct 22, 2009

Elk park- how does this typically work? We discussed this in class the other day, my prof gave the example that there could be a order that all patients with x get y med. That' s a pretty independent judgement IMO

It's exactly the opposite of independent judgment, actually (if by that you mean the nurse's independent judgment). It means somewhere along the line, an MD (or, much more likely, a team of MDs) sat down and wrote an order to cover a very specific, well-defined situation -- e.g., someone in anaphylactic shock receives epinephrine. Nurses are trained to assess and determine that someone is in anaphylactic shock, but once that determination is made, the standing MD order kicks in and directs the nurse to administer epinephrine -- and the specific, prescribed dose of the protocol, not however much the nurse thinks is appropriate.

elkpark · Oct 22, 2009

Elk park- how does this typically work? We discussed this in class the other day, my prof gave the example that there could be a order that all patients with x get y med. That' s a pretty independent judgement IMO

Not sure I see what's "independent" judgment about "all patients with x get y." :) However, the way it works is that the hospital's medical staff have officially approved a particular protocol or set of "standing orders" as being acceptable/standard practice for clients with particular diagnoses (or particular physicians have a specific set of standing orders for their admissions). It's a big deal, and a long, tedious process to get a protocol or set of standing orders approved for use within a hospital -- but, once approved and put into use, those are physician's orders, same as an order hand-scribbled on an order sheet by an individual physician. (They're also a good idea because they make sure that a particular physician doesn't overlook or omit an important "regular" order on a client just because s/he is rushed or preoccupied at a particular moment -- all the basic, necessary orders for good care of a particular dx are included in the preprinted orders.)

Also, just wanted to add that the issue with an LPN or RN administering OTC meds without physician involvement is not that the LPN or RN isn't "safe" to give people Tylenol, etc., on her/his own initiative -- the concern is the possibility of missing something important that should be diagnosed by a physician. A fever, for instance, for which one might give someone Tylenol, might mean many different things, some serious, some not. A sore throat can be many different things, some innocuous, some serious. By deciding that giving an OTC medication for a symptom is sufficient without any further intervention, the nurse is essentially, legally, making a (medical) diagnosis, which is outside the scope of basic nursing practice. Hope that clarifies things somewhat.

VICEDRN, BSN, RN · Oct 23, 2009

You know if we are talking about Tylenol then I have to say that even in my limited experience, not everyone can take Tylenol. I had a patient who had to take Ibuprofen instead. The nurse told me the reason but I can't remember it now. What I do remember is that I would rather not pretend that Tylenol is Tylenol when I am with patients and not at home...

SnoopysAunt · Oct 23, 2009

Thanks elkpark! I guess "independent judgement" isn't a good description, but the nurse better have good assessment skills and know what she's (or he's) doing!

BmoreCRNP · Oct 23, 2009

Someone asked what you needed to do to get prescriptive authority. I'm an APRN (family nurse practitioner to be specific). Each state has it's own laws that govern the APNs. Basically you go through whatever APRN program you're interested in, take the boards with one of the certifying bodies (there are several, it depends on your specialty), & apply for a license in your particular state. Some states require a practice agreement with a Physician before you can apply for a DEA#, which will enable you to prescribe narcotics. My particular state requires a DEA# and a CDS# to prescribe narcotics, as well as a practice agreement. You may also need to register with the national prescribing index. Again, this depends on your state. Long story short........it's a pain in the ass.

allnurses Guide · Oct 23, 2009

Someone asked what you needed to do to get prescriptive authority. I'm an APRN (family nurse practitioner to be specific). Each state has it's own laws that govern the APNs. Basically you go through whatever APRN program you're interested in, take the boards with one of the certifying bodies (there are several, it depends on your specialty), & apply for a license in your particular state. Some states require a practice agreement with a Physician before you can apply for a DEA#, which will enable you to prescribe narcotics. My particular state requires a DEA# and a CDS# to prescribe narcotics, as well as a practice agreement. You may also need to register with the national prescribing index. Again, this depends on your state. Long story short........it's a pain in the ass.

Thank you, in the UK once we have done the prescribing training you are able to prescribe any medication listed in the formulary with the exception of narcotics, for these you need an agreed and signed management plan from a supervising physician so it sound a similar arrangement.

systoly · Oct 23, 2009

Of course this thread is concerned with the civilian practice, but military nurses (used to) have prescriptive authority. I did (however very limited) even as a LPN.

HM2VikingRN, RN · Oct 23, 2009

Here's a real life example of why nursing judgement needs the support of a licensed Independent Practitioner.

Ibuprofen for pain/fever. Absolutely OTC.

What if your patient takes Lithium for bipolar illness?

Is it still indicated?

No. (Ibuprofen can raise serum lithium levels to potentially toxic levels.)

As a nurse I quite often talk to residents about patient problems and will ask them for a med. It is still the responsibility of the LIP to make the call for the appropriate medication intervention. (The might ask me about what med is usually used and how often it is usually given but the provider makes the call for writing an order.)

Here's an example of differing philosophy in practice. Its not clear whether we can apply topical antibiotic ointment without an order. I usually have. My mentor suggested that I should get an order in the future. During the same conversation he acknowledged being willing to give nicotine replacement without an order and get an order later. I won't do that because it is crossing the mouth barrier and entering the body.

I think the correct answer is to always get an order and stay within the scope of practice.

HM2VikingRN, RN · Oct 23, 2009

Of course this thread is concerned with the civilian practice, but military nurses (used to) have prescriptive authority. I did (however very limited) even as a LPN.

As an HM I could hand out comfort meds sans order.....

chenoaspirit, ASN, RN · Dec 30, 2009

Nope, cant administer anything without a doc order, even tylenol. Imagine giving a tylenol to a patient with a headache but later find out he has liver failure. You cant give anything to any patient without an order.