Nursing judgement in emergency situation without Dr.s order

[Nocturnal123]

Hi! I work nights, today I had an emergency situation at 6:50am, 10 min. Before going home, my patient complaint that she cannot breath upon assessment the patient is wheezing, I did my nurses judgement and gave nebulizer without doctors order, the patient is a smoker and always have breathing problems and had orders from the past of nebulizer, i also elevated head of bed after giving medication I checked on patient and patient said "I feel much better" vitals are ok and SpO2 as well. I called the supervisor to notify her, she got mad telling me that I didn't let her know early while she was talking to doctor and she complained that I only let her know when it's 7 and that I'm gonna put her name on the documentation that I made her aware of the situation and she asked "what do you want for me to stay here all day?". I also endorsed it to AM nurse and told her to ask for an order of PRN nebulizer. upon giving written report to supervisor she said he same things as above and added " you gave medication with an order and you documented it I know you use your nursing judgement but you need to have doctors order, i worked hard for my license for you to just put my name on the paper saying you made me aware, now I have to finish this and I'm going home at 9 and dyspnea is a big thing". Driving home she called again saying " I'm not gonna write you up this time, I'm giving you verbal notice if this happens again I'll write you up, now you're going home and I'm still here, I put the order for nebulizer just sign it later, next time once it happens call me immediately, I want facts, have a good day" and she hung up on me.

[brownbook]

Yuck, yuck , and double yuck!

I hate policies....yes technically you gave a medication without a doctors order. Ignore your supervisor, you know she is a CYA idiot.

For future incidents, since you work. 11-7. Is there any easy way to notify the doctor, without having to call them on the "off" hours? Some units have a specific log, written or in the computer, where the doctor checks for requests from the "off" shifts. Hopefully the 7-3 nurse followed up and got a PRN nebulizer order.

[JKL33]

It's really interesting that she is crabbing about the documentation of when she was notified more than she's worried about you having administered medication without an order. Honestly, I'd take it; it would be hard to cause serious trouble for you based on the thing particular issue she's whining about.

Now. For the future. I know it's no fun to call on-call providers during 11-7 hours, but because of things like this (and primarily because we should be first and foremost concerned with our patients' best interests) the days of doing everything under the sun but calling the provider, are looong gone. Just call them. If a patient has had an acute/serious change in condition, call them. This is for the patient's own good and yours too. What if the neb hadn't helped, and by the time it was set up, administered, completed and the patient was reassessed 20 minutes had gone by with the patient getting worse? What if, in the excitement of the patient's change in condition you had overlooked a contraindication to your planned intervention? There are a dozen reasons why you should get input/orders/direction ASAP in a situation like this.

Even if you think it's prudent/best to start a neb without an order - you should be contacting the on-call even as the neb is in progress; in other words, right away. And since your lovely supervisor is very concerned about when she is notified, I'd call her too, as soon as you hang up with the physician.

It sounds like you did well and helped the patient, so kudos for that. Just the same I would suggest these modifications next time. ^

[Nocturnal123]

Yes the AM nurse did actually got the PRN order. the patient was fine there wasn't any episodes after my shift. And yes in regards to calling someone on off shifts we can call the doctor anytime as well as the on call NP but only for particular patients. I do follow what you guys said I usually assess the situation and do the best I can in the situation, call my supervisor, doctor or NP depending on the situation, but this particular supervisor hates it when you call her without doing anythig first yourself and fixing the situation, but also she hates when you put her name on the documentation even just putting that you notified her, and she will complain about you to other nurses as well as supervisors. After the incident she's been more hard to work with because now she she treats me like an idiot and she's not listening to me and questions everything I do.

[JKL33]

but this particular supervisor hates it when you call her without doing anythig first yourself and fixing the situation...

Take whatever steps are needed immediately and then call her ASAP.

She doesn't have to like it. Keep doing the right thing and let her answer for her own attitudes.

Hope tensions die down soon. Take care ~

[Daisy Joyce]

You can't give a med without an order.

It sounds like the supervisor was on-site at the time?

I understand why you did it, but if something had gone Horribly Wrong, it would have been her butt as well as your butt.

Next time, decide to call the doctor, then call your supervisor to tell her what you are going to do, then actually call the doctor.