Nursing Dose

[guest449786]

On orientation, at a previous facility, I was told about nursing doses. Normally it involves giving extra narcotic to a person in severe pain. This occurred in a emergent setting where patients would have been ordered Morphine 1mg IV and the dose comes in 2mg vials. The extra 1mg was to be wasted and witnessed. However, if a nurse determined that may not be enough due to the severity of pain, weight, past history, etc., they may decide to give 1.5mg and waste the .5, etc.. I have not heard about it outside the emergent setting, but I'm guessing it occurs in other areas.

Have you ever heard the term "nursing dose"? How do you feel about it? Have you ever given a "nursing dose"?

[mmc51264, BSN, MSN, RN]

nope. we have prn orders where we can give for breakthrough pain. The only time I have given an extra dose is if the MD is there doing something (like a painful dsg change) and they give a verbal BUT then they have to go in an add the order. I always make sure I get them to do that.

[roser13, ASN, RN]

Never heard of a "nursing dose." We also have standing orders and do not independently operate outside of those without a verbal or written order.

Quite frankly, it sounds an awful lot like prescribing, which of course is illegal.

[ArmaniX, MSN, APRN]

I know exactly what you're talking about.

1. If you decide to do a "nurses dose" realize you're putting your license at risk and further consequences.

2. It mistakenly sets up the next nurse for failure.. while you were able to give the "1mg of morphine" (but instead gave 2mg each time) you controlled the patients pain.. 1mg won't cut it for the next nurse and the doctors will suspect something is wrong.

I think it's much easier to call the doctor and say hey the patients pain is not being controlled. Can we increase the dosage?

You save your license and in the long run look out for the patients safety.

I always enjoy getting report and the off going nurse tells me how she's truly been giving the patient a nursing dose all night. Looking for trouble.

[Dranger]

Yes I have, mostly in the ICU setting with haldol or Ativan in non tubed patients.

Sometimes nurses will run sedation like versed or fentanyl higher for a while as well and drop it back down. Never propofol though.

On the floor it sounds sketchy in the ICU when you want to avoid a 3am call to a sleeping doc it is more common. You can anticipate what they want usually. Is it the correct way? No but it happens

[klone, MSN, RN]

Nope. Sounds like "practicing medicine without a license" to me. Besides, don't you need a witness to waste? If the order is 1mg, and you CHART 1mg, but you're only wasting 0.5mg, wouldn't that set you up for a diversion accusation? Or, you chart 1.5 mg and then you get nailed for a med error.

[Mavrick, BSN, RN]

A nurse may "decide" to give that extra .5 and call it a nursing order but without a legal physician's order you take it upon yourself to practice medicine outside your scope of practice and will be subject to any and all repercussions of such illegal action.

Not to say that I haven't heard of it being done. Sometimes called a "healthy" 1mg (wink, wink). It is NOT legal and I will disavow any knowledge of having done any such action in any of my years of nursing.

[Spidey's mom, ADN, BSN, RN]

As hospice, I have parameters with drugs like Morphine Sulfate for pain and/or SOB.

When I worked ER - I had never heard of this "nursing dose".

[guest449786]

This subject may be the equivalent of asking a police officer if they carry a throw-down.

It's definitely not something I'm advocating for or believe is the right thing by the patient. It was brought up to me by a very competent nurse, who has over 18 years in an extremely busy ED, and was the nurse of the year 6 times in her career. She has a MSN, multiple certifications, and was an EMT in the inner-city for over 5 years. Not that any of that justifies what I was told by her, but those were her "credentials".

The topic came up when the MD assigned to the patient was dealing with multiple traumas. This facility had a standing order for Morphine 1mg IV when a patient was having a MI. You were not able to go to an alternative MD to get an order for an increase in the dose. Up to this point, every time an increase was needed the MDs trusted the nurse's judgement and would okay it without assessing the patient.

I am aware of what is considered to be outside of the scope of practice for nurses. Again, I'm not advocating for it, and just curious if this practice was common or just an isolated incident.

[Karou]

I have heard of nurses doing this. It is never referred to directly, but indirectly... Something like a "therapeutic" or "nurses" dose.

To clarify, I am not talking about ranged orders. I am talking about when there is a specifically ordered dosage and the patient receiving a higher dosage administered by the nurse. Most commonly with IM haldol, which does not require a waste at my facility.

This is not okay to do. It is prescribing medications, something out of a nurses scope of practice. If a negative outcome or sentinel event were to occur where a nurse had administered a medication in a way/dose not prescribed, you can bet that nurse will be in hot water.

If a nurse thinks the prescribed amount of whatever medication might not be effective, they need to call the doctor for a new order. There have been times when the doctor has ordered a dose that I think won't cut it... So I call the doctor and explain why I think we need a higher dose and usually ask for some other PRN's in case. Like breakthrough pain orders if that's the issue or a second sedating medication if it's a combative patient.

In an emergency the house supervisor night okay an "emergency" order for a sedating medication, but we have a specific protocol that covers that and the physician has to be notified.

[Karou]

klone said:

Nope. Sounds like "practicing medicine without a license" to me. Besides, don't you need a witness to waste? If the order is 1mg, and you CHART 1mg, but you're only wasting 0.5mg, wouldn't that set you up for a diversion accusation? Or, you chart 1.5 mg and then you get nailed for a med error.

I assume that the administering nurse would chart the prescribed amount and falsify the charting. The witnessing nurse would either not actually watch the waste or would be in agreement to falsify the waste. The documenting would appear correct and not raise a red flag.

I actually had a nurse offer to do this for me when I was giving an agitated patient Ativan... The prescribed dose was less than what came in the vial. I declined. She still walked off before actually watching me waste. It made me feel really uncomfortable.

[Karou]

ArmaniX said:

2. It mistakenly sets up the next nurse for failure.. while you were able to give the "1mg of morphine" (but instead gave 2mg each time) you controlled the patients pain.. 1mg won't cut it for the next nurse and the doctors will suspect something is wrong.

This frustrates me more than anything else. The patient isn't getting the correct treatment. The next nurse suddenly has an agitated or distressed patient in pain, and there appears no reason why the pain or behavior is now uncontrolled. Because the previous nurse was giving higher doses.