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Discussion

Nursing Judgement

I have just found out that during our last department meeting that we as RN's are not allowed to change a med time. This information is all hear say from multiple people at the meeting as I was working that day and the minutes have not been sent out. Its said this way of thinking came down from pharmacy, as they feel changing a med time is practicing medicine.

One example is BP at 6am elevated and there is BP medication due at 10 (timing for daily meds). We are not alowed to give the medication early at 6am with out a doctors order. That is the main example discussed. Another one is if on nights the pt wants their meds at 8 rather then at 10 (timing for hs meds) this essentially would need a order or per our director documentation on pts request.

I don't have all the facts but it seems that this is only on daily and BID medications. I don't see RN's adjusting TID and QID, more then the half hour window before and after schedule time, if they do then yes that would be an issue.

There are many times I have held a BP medication due to a low BP at 10am and given it later in the day if the BP increases and if med is BID depending on how close doses can be given. This is nursing judgement as is giving a medication early. Do we need a order to hold medications that's changing the MD's orders and can be taken as practicing medicine.

Taking this part of nursing judgement away will mean alot more calls to doctors that are going to get very annoyed. If there is a issue with certain RN's talk to them directly don't take a vital part of our jobs away. Has any one else had issues with this? What are the rules at your hospitals?

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    • Featured Replies

    Unless the MD has specified a time for the meds to be administered, or if it is scheduled for eg 6 hourly, 4 hourly etc you should be able to employ your own discretion.

    An arbitrary ruling such as you describe is likely to result in some irate responses to unnecessary phone calls. Makes you wonder what the purpose is of all that nursing training if you're not allowed to think for yourself...

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    • Expert

    pinky22786:

    Many times, administrators will attempt to deal with a single area of concern with a blanket rule. In other words, they're trying to fix "stupid".

    From the sound of your post, you are a conscientious professional who utilizes good judgement in providing care. However, not all act with a similar method. So, in order to deal with a nurse with poor decision-making abilities, a rule is established which all have to follow.

    To answer your questions:1) Yes, we have similar rules. 2) Act prudently, inform the Docs, discuss the situation with them, and document, document, document.

    Dave

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    We can eek our med times around. Say if a baby is supposed to get KCL supplementation with feeds but pharm schedules them for times that are not around feeds, I print out a med sheet & write please change to x x x times and fax it down to pharm.

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    Where I work if a med is daily twice etc regular times are 8&4 or 9&5etc. Day nurses are bad to pile on as many meds to us night nurses. We aren't supposed to be giving some meds at night unless specifically ordered

    I have wrote clarifications before on med times with no problems. Now my boss did tell me it's out of my scope to "educate" a pt or family on anything since I'm an lpn...that's odd since the nurses who admit and discharge all of our pts are lpns.

    I think pharmacies and corporations just nit pick way too much. They worry about the dollar. Not the pt

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    Op, I just re-read your post, and I have to ask this; the "med times" you refer to- are these set by the doctor, or by the pharmacy?

    I have yet to encounter a daily med where the doctor actually specified a time for it to be administered, except for certain items such as anticoagulants and other time-critical meds. The most they're likely to do is write "before meals" or "after meals".

    The crux of my question is, are your pharmacists actually dictating-and thus "prescribing" here? Are they setting these rules for their own convenience?

    What is the protocol for daily meds that are prescribed "prn"?

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    • Guides

    Along a similar "annoying the doctor" line - I work in home health and we had a meeting recently where they told us, "each time the patient refuses a medication you must call the doctor and inform him and ask what to do". I said, "every time a patient refuses to take any med at any time?"

    "Yes."

    That if taken literally would mean conceivably calling the doctor at 2200 to inform him the patient refused to have Lotrimin cream on his index fingernail fungus infection, or interrupt his or her weekend activities to call in and be informed their patient refused their multi-vitamin. Gahhh. Once daily Singulaire needs an order to give at 10am instead of 12pm? Seems excessive to me - doctors won't adapt to the new rules very well, I'm sure. Many of them already complain about knee-jerk calls for all out of range labs - even the ones expected to be out of range due to the patient's diagnosis.

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    It seems like we're discussing different issues here.... can nurses change the med schedule or can nurses hold and resume meds at their own discretion? We have standardized med times, yet we can adjust the schedule per the home routine, to enable us to be able to get in all the different IV meds, etc. However, if we want to hold a BP med, we do get an order to hold x1, or ok to give at noon, etc.

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    Just nod and smile, then do what is best for the patient.

    Your docs that admit regularly to your floor might be interested in this policy change. Perhaps they could counter with standing orders that would be more appropriate. For example, "Nursing may give meds ordered once a day, at any time of the day, at their discretion" or "Nursing may change med times to coincide with patient's home routine."

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    • Author

    Yes pharmacy is the one that sets the time. More times then not we have to start or give meds at non scheduled times due to not having med available on the floor. Wonder how that fits in to the new definition of practicing medicine.

    Thanks for your responces. I will be looking further in to this when I go back to work. Just wanted to make sure I'm not wrong in my thinking.

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    On my unit all pts have PRN orders for BP meds (Hydralazine, Labetalol, etc.) that can be given if the pts need them inbetween their scheduled meds. If there is no PRN on the MAR, we page the doctors and get an order. I don't think that rescheduling medications is necessarily playing doctor, there are so many times when a pt has no IV access for whatever reason or their meds didn't come up from pharmacy in a timely manner and things need to get shifted. If every med time was set in stone we'd be screwed!

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    That is the strangest policy ever, our med times (od, bid, tid, qid) are standardized for sake of convenience but we often cross out a time to put "patient's time." Especially true with hs meds, why would someone want to receive a sedative at 2100 if they normally watch tv until 2300? Of course insulins and Coumadin are the exceptions.

    Just because a medication is ordered once daily doesn't mean it needs to be at 0800 unless it's recommended to be taken in the am, a once daily med can just as easily be taken at any time of day. For example, many of the SSRIs can be taken either am or hs (sedation or insomnia effects) and our system will automatically allocate once dailys to 0800 but if patient normally takes it at bedtime, I'd just cross it out and write hs. No big deal.

    If they're going to take our professional judgment away, they might as well just replace us with robots.

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