I have noticed a dangerous trend of fellow nurses just flat out ignoring doctors orders. I'm not talking about wrong/dangerous orders like giving the wrong amoutn of medication. I'm talking about stuff where a doctor orders a CBC on a patient and the nurse just flat out ignores the order and doesnt do it.
I believe that if a nurse doesnt implement a doctors order, then you'd better page/call them and tell them why not. For example, say a CHF patient comes in and the doc orders daily weights. Its very common in my hospital for the nurses to just ignore that order and not take daily weights because they dont want to bother with it.
If a doc orders something wrong/dangerous such as an obviously wrong medication, then of course nurses have to step up and say no we cant do that. But as long as the order is correct then its absolutely inexcusable for the nurses to just ignore it. IF you have a problem with the order, then page/call the doctor and talk to him about it.
So whats your protocol? If you ahve some kind of reason for not implementing an order, then you call/page the doc and explaint it to him, right? I think its unethical, unprofessional, and dangerous to just ignore a doc's properly-written order without talking to him about it.
I will occasionally ignore a physician's order--and with this supposed "relationship based care" philosophy we are going to, I have that right. I just have to document my butt off to make sure I can back it up.
Example--SCDs and ted hose. Some of our docs order these on every pt. Well, that's just not appropriate. People who are walky-talky; people who are anxious and combative--they don't need SCDs and ted hose. It's a waste of time, resources, and money. I'm not going to put them on everyone; only people who actually meet the criteria for being at risk for DVTs.
Example--daily wts and I/Os. I'm not doing these on certain patients. It's not necessary. There are some situations for which this doesn't make sense.
Example--q4hour VS. Even if they are on tele or a PCA, I'm not necessarily waking someone up during the middle of the night to get their vitals. I check on them every hour, and I'll sure the heck wake them up if they are a new pt, or if they in any way are unstable--but if they've been there a while, have completely stable vital signs, and I just gave them a sleeper two hours ago, how does that make sense for me to wake them up to do vitals?
I *will* leave a note on the chart for the doc, explaining why some order wasn't followed, and asking them to clarify.
Couldn't agree with you more. Some orders are quite silly. SCDs for a patient who goes out to smoke every hour? Some doctors' orders are so rehersed. You know if Dr.123 is on the phone for orders that he is going to order: VS Qshift, strict I/Os, CBC, Chem 7, BNP, in am in peadi tubes...and so on..
Example--q4hour VS. Even if they are on tele or a PCA, I'm not necessarily waking someone up during the middle of the night to get their vitals
Yikes ....
I have taken vital signs in the middle of the night without waking someone. I think not taking vital signs, particularly if a patient is on a PCA, limits your ability to quickly identify a problem. And if a problem develops, and you have no vital signs recorded (or limited vital signs) then I think you'll have a big problem on your hands.
I personally feel the same way about daily weights and I/O. These are simple things to accomplish - they don't take really any time to do (and in a lot of facilities, CNAs are allowed to do these tasks.) I just think these things provide you with important information that can alert you to a problem before the problem becomes huge. And if problem does develop and you don't have that information, how do you justify that?
And ignoring doing lab work because you think it's a "silly" or "reheorificed" order? Yikes ... I would not want to be the nurse following someone who ignored those types of things and had to clean up that mess.
I don't think it's okay to ignore orders without having some kind of discussion with the prescribing doctor about it. If the doctor write an order and the nurse does not follow it and then a problem occurs, who is going to get blamed? Not the doctor, that's for sure.
Riiiiight; So you think I should call the doc at 2AM to discuss whether I should wake up the guy who is going to be discharged tomorrow (where no one will be taking his vitals at all), because the doc ordered q 4 vitals on him when he was admitted four days ago and hasn't changed that order since then? That my patient who has been on a PCA for three days and is now only using his PCA with no basal only a couple of times per shift, transitioning to po meds and who finally got to sleep, I should wake him up for a complete set of vitals? Just in case something might go wrong? You contradict yourself, because then you go on to justify not doing daily wts and I/0s. Those can be important, too. What if your healthy walky-talky pt receiving a new med suddenly develops renal failure, but because you are not doing i/os you don't catch it until he gets really edematous and ill? You know?
You trust your nursing judgement. I can't believe you can't find a situation with, for example, a pt on a PCA who doesn't need to be woken up for vitals twice during the noc. You know you can. I see you work intensive care--I'll bet you agree that not everyone needs to be admitted to ICU. But if we want to practice "Just in case" medicine, then we will do away with acute care and step-down floors and only have intensive care units. Anyone can throw a clot. Anyone can suddenly develop renal failure.
I've never had a fairly healthy pt who hasn't woken up when I do vitals. Bringing that loud, rattling cart in to the room, placing and inflating the cuff, sticking the thermometer under the tounge or their armpit, the stupid beeping our machines emit to indicate they've finished taking the vitals (uh, hello, I kind of got that from the numbers that come up on the screen), these things tend to wake my patients.
I agree, a note of some sort should be left. But I'm not calling at 2 am to discuss with the on call doc all my reasons for only taking the 10pm and the 6am vitals, and skipping the 2ams. I suspect I'd be deaf from the yelling. I'll stick with my very competent nursing judgement! It's done well so far.
You contradict yourself, because then you go on to justify not doing daily wts and I/0s.
I didn't contradict myself. I said that I think things like daily weights and I/Os are just as important as doing vital signs, and that not doing those simple tasks leaves you vulnerable to missing a potential problem. I'm not sure how you got from my post that I "justified" not doing daily weights and I/Os ... perhaps it was my statement, "I feel the same way about daily weights and I/Os." ? If so, please re-read my post as I feel the same way about daily weights and I/Os as I do about vital signs ... that they are important assessment tools.
So you think I should call the doc at 2AM to discuss whether I should wake up the guy who is going to be discharged tomorrow (where no one will be taking his vitals at all), because the doc ordered q 4 vitals on him when he was admitted four days ago and hasn't changed that order since then?
Um, no, I don't think you ought to call the doctor. Personally, I think you just ought to take the vital signs. But that's just me and my nursing judgment. Perhaps I feel this way because I do work in the ICU; vital signs are a very important part of my assessment.
I also think it's possible to take vital signs without waking a patient. I take vital signs on babies all the time while they are napping without waking them. When I worked nights, I took vital signs all the time without waking patients.
But then, I work days, and in my unit, all of our monitoring/vital signs equipment is right there in the room. So there aren't any noisy machines to bring into a patient's room or loud beeping to worry about. Perhaps that explains the difference in our philosophy on vital signs?
I don't really think that's the issue at hand, though .... my thoughts on this topic are that ignoring doctor's orders is not good practice. If you disagree, that's fine with me.
Um, yeah, I fail to see how I totally misread your daily wt paragraph.
I still disagree with you; but I suspect part of this comes from working on an acute floor vs working in an ICU. Different acuity of patients.
Also, I think many of our orders come from caresets that are automatically ordered, no matter what. They simply aren't always appropriate.
I guess we'll just disagree. I think it's okay to use nursing judgement to not perform a physician's order when it's not necessary. Like holding a stool softener when someone pooping liquid. Taking VS in the middle of the noc on a completely stable pt. That sort of thing.
Um, yeah, I fail to see how I totally misread your daily wt paragraph.
I'm not sure how to clarify because I'm not sure where the misinterpretation is coming from. Here is what I said concerning vital signs, daily weights, and I/Os:
I have taken vital signs in the middle of the night without waking someone. I think not taking vital signs, particularly if a patient is on a PCA, limits your ability to quickly identify a problem. And if a problem develops, and you have no vital signs recorded (or limited vital signs) then I think you'll have a big problem on your hands.
I personally feel the same way about daily weights and I/O. These are simple things to accomplish - they don't take really any time to do (and in a lot of facilities, CNAs are allowed to do these tasks.) I just think these things provide you with important information that can alert you to a problem before the problem becomes huge. And if problem does develop and you don't have that information, how do you justify that?
I first explained that I don't think it's a good idea to ignore an order for vital signs. Then I stated, "I personally feel the same way about daily weights and I/O." From my perception (when I wrote it and rereading it) this says that I don't think it's a good idea to ignore an order for vital signs and I think the same thing (that it's not a good idea to ignore an order) about daily weights and I/O. I further go on to state, "I just think these things provide you with important information that can alert you to a problem before the problem becomes huge." Again, from my perception, I'm stating that daily weights and I/O give you important information which can allow you to find a problem before it becomes a major problem. And I further state that if a problem does develop and you don't have the information (information being daily weights and I/O) how do you explain/justify that?
I've re-read my post multiple times now, trying to figure out how it is I"m not communicating effectively, and I'm can't see where the misinterpretation is coming from.
However, I do believe that vital signs, daily weights, and I/O are important assessment tools, and I don't think orders for any of those things should be ignored.
I hope that statement communicates my opinion on the subject a little more clearly.
ETA:
Like holding a stool softener when someone pooping liquid
In a situation like this, I would certainly hold a stool softener, but I would definitely discuss this with the doctor. I don't consider holding a medication while I discuss a change in patient status with the doctor to be ignoring a doctor's order.
Susan, I was agreeing with you. As in, I was having a mental fart and I have no idea how I misread your second paragraph. As near as I can tell, between the activity going on around here, a phone call, and posting, I somehow completely misread it. Cleared up now?
I think we operate in completely different areas. First of all, day shift/night shift. Secondly, ICU vs floor. Thirdly, at our hospital we have care sets. Every pt who gets admitted, for example, with a PCA automatically gets a stool softener ordered. Some docs have it on their routine admit orders. The docs expect us to use our common sense and not give a stool softener if someone is having diarrhea, and to not have to call at night to ask this question.
I am not going to call at 10 at night to discuss with the on-call physician that I am going to hold the stool softener that was routinely ordered because of diarrhea. I might call to get some lomotil, but not to do discuss this with the doc. A note on the chart and in the nursing notes is more than sufficient in a nonacute, minor situation.
Difference of opinion, I guess. I see we arent' going to agree. So I'll just be done.
I will occasionally ignore a physician's order--and with this supposed "relationship based care" philosophy we are going to, I have that right. I just have to document my butt off to make sure I can back it up.
Example--SCDs and ted hose. Some of our docs order these on every pt. Well, that's just not appropriate. People who are walky-talky; people who are anxious and combative--they don't need SCDs and ted hose. It's a waste of time, resources, and money. I'm not going to put them on everyone; only people who actually meet the criteria for being at risk for DVTs.
Example--daily wts and I/Os. I'm not doing these on certain patients. It's not necessary. There are some situations for which this doesn't make sense.
Example--q4hour VS. Even if they are on tele or a PCA, I'm not necessarily waking someone up during the middle of the night to get their vitals. I check on them every hour, and I'll sure the heck wake them up if they are a new pt, or if they in any way are unstable--but if they've been there a while, have completely stable vital signs, and I just gave them a sleeper two hours ago, how does that make sense for me to wake them up to do vitals?
I *will* leave a note on the chart for the doc, explaining why some order wasn't followed, and asking them to clarify.
I dont agree with that. If you have a reason for questioning a doctors order then you are in the wrong if you dont get clarification. For you to just ignore it without talking to them first is a dereliction of duty. For some things it is in fact trivial, such as stool softeners. Docs dont care about that. But if a doc orders a blood draw in the middle of the night, then its absolutely irresponsible for you to just ignore it because you dont want to bother the pt. Call the doc and get clarification.
Docs can order all kinds of things that dont seem appropriate to you at the time but in fact are very useful for managing that patient. If in doubt, then its YOUR RESPONSIBILITY TO call them about it, not just sit there and ignore it.
The bottom line is that plans change and just because somebody is planned to go home tomorrow doenst mean jack. I'd estimate at least 30% of our patients stay longer than "planned" for various reasons. So I dont think you can use that as justification to ignore something.
P.S. Vital signs should be done regardless. Just because it wakes somebody up is not sufficient reason to ignore it.
According to my hospital, I am in the right. We have had many meetings regarding our new hospital philosophy, many hours of staff meetings regarding our scope of practice.
If we want to go against a physician order or a protocol, we have to notify the physician in a phone call or writing, our judgement. We have to have clear documentation as to why we chose not to implement the order. This is our hospital policy.
We have also been told by our administration that the number one and two complaints in our Press Gainey surveys are that the patients get woken up too much at night, and night time noise. We have been instructed by administration to use our judgement in regards to whether a pt needs the 2 am vitals.
I guess it is a difference of philosophy here. I do not think that using my judgement in these situations is wrong, and apparently the physicians that work with us, the administration, the director of nursing, and my coworkers don't, either.
I am still in awe that anyone would call a doc in the middle of the night to clarify a stool softener order for someone who has diarrhea. Common sense, people. SOmethings can be taken care of in the morning.
I'm sorry! I read your answer as sarcasm ... my fault. It's hard to interpret tone over the internet. :)
It's been a long time since I worked on the floor and not in the ICU, so perhaps it's all a matter of the area in which you work. It's also been a long time since I've worked nights, so again, that probably colors my perspective on things.
As I understand the original post it was about nurses not following perfectly appropiate doctors orders. The example used was weights on CHF pts. I would think nurses would do that daily with or without doctor's orders. I can see missing them somethimes espcially in the ICU when respirations are a bit more important, but scanning the post (I am watching Wake v. BC) no one addressed the real issue. Laziness. Why talk about questioning inapproprate orders, etc. Lazy nurses are the issue here.
According to my hospital, I am in the right. We have had many meetings regarding our new hospital philosophy, many hours of staff meetings regarding our scope of practice.
If we want to go against a physician order or a protocol, we have to notify the physician in a phone call or writing, our judgement. We have to have clear documentation as to why we chose not to implement the order. This is our hospital policy.
We have also been told by our administration that the number one and two complaints in our Press Gainey surveys are that the patients get woken up too much at night, and night time noise. We have been instructed by administration to use our judgement in regards to whether a pt needs the 2 am vitals.
I guess it is a difference of philosophy here. I do not think that using my judgement in these situations is wrong, and apparently the physicians that work with us, the administration, the director of nursing, and my coworkers don't, either.
I am still in awe that anyone would call a doc in the middle of the night to clarify a stool softener order for someone who has diarrhea. Common sense, people. SOmethings can be taken care of in the morning.
Hypotheticals:
#1 Doc orders a CXR on a patient. Nurse cancels the order and doesnt tell the doctor about it. Nurse writes note in the chart, "patient does not have shortness of breath and does not need a CXR"
#2 Patient is supposed to go home tomorrow. Doc orders 24 hour urine collection before departure. Nurse ignores order, doesnt call/page doc. Nurse writes in chart "pt going home tomorrow and has no renal issues. 24 hour urine not needed"
SAC101
23 Posts
Couldn't agree with you more. Some orders are quite silly. SCDs for a patient who goes out to smoke every hour? Some doctors' orders are so rehersed. You know if Dr.123 is on the phone for orders that he is going to order: VS Qshift, strict I/Os, CBC, Chem 7, BNP, in am in peadi tubes...and so on..