Nursing judgement in the community setting

CapecodMARN · Oct 5, 2018

I would hold miralax definitely if the pt has diarrhea. We don't need a hold order, just use our own nursing judgement. Some of the pts are going to refuse it anyway. Document it why hold the med or why pt refused it. Other meds to low BP or heart rate, we hold it as well even though there is no parameter if pts bp/hr is low.

allnurses Guide · Oct 17, 2018

Can nurses in the community setting choose to hold a medication without obtaining a hold order first? For example if you have an order to administer miralax every day at 3:00pm but the patient has diarrhea. Can the nurse choose to not administer it without obtaining a hold order from the physician due to appropriate nursing judgement, and documenting the hold as such? This may be a silly question but I have found that there seems to be more grey areas in this setting due to difficulty in communicating with the physician directly in a timely manner. Sometimes it can take up to a week to get a response/clarification to the order, which could result in negative outcomes. At the same time, I'm not sure if such a decision is outside of our scope of practice. Any insight or thoughts would be greatly appreciated!

My caveat on this is to let the PCP know especially if it is an ongoing issue!

For learning purposes, I not too long ago had one of our local VNAs holding one of my patient's lactulose every day because of loose stools. Only problem was the patient was on lactulose for HE and without the lactulose he decompensated and ended up in the ICU.

KelRN215, BSN, RN · Oct 18, 2018

Yes, you can hold meds per nursing judgment but I agree with BostonFNP to call the prescriber if this is something that's happening regularly. I have a patient with CF who has intestinal malabsorption/chronic diarrhea but is ordered to get MiraLax regardless because they are always worried he could be stooling around something when he has diarrhea. When I was a visiting nurse, I once held a daily leukine injection because I got to my patient's house and he was covered in hives, tachypneic and tachycardic (and his mother had left him that way all night knowing I was coming in the morning) so I wanted the ER to evaluate him before he got anything else.