Nursing judgment question??

[SamJS, BSN, RN]

Hi all! I have a question / wanting opinions on this...

At the facility I work at, nurses often hold medications for what they consider “nursing judgment”. I do understand nursing judgment, but sometimes am unclear where that line crosses over into disobeying the orders?

A few examples:

Metoprolol with usual parameters (SBP<100, HR<60) - nurses holding for SBP anything 110 or under, or HR <70 because of “nursing judgment”

Standing insulin order (I.e 5 units with meals in addition to sliding scale) - nurses holding if not giving sliding scale (aka <200).

I do understand their point that it’s “close to the parameter” and they don’t want to bottom someone out. But to what extent is that covered under our judgment? Shouldn’t they communicate with the MD first? Or communicate with the MD that they bottom out at that point (if that’s the case) and push for the parameters to be increased?

[Kitiger, RN]

If I'm holding a med because, in my judgment, it shouldn't be given, then my next step is to notify the physician.

[LovingLife123]

I feel if I’m close on metoprolol, I will ask the physician how they feel. I always give though unless the HR is close to 60, I’m mean like 61, or if the systolic is actually under 100.

Insulin I always give unless the blood sugar is less than 95. Then again, I call and ask if they want me to give it. We’ve never had a standing humalog though, it’s always sliding. It’s the levamir that’s standing.

[Sour Lemon]

On 8/28/2019 at 7:17 PM, SamJS said:

Hi all! I have a question / wanting opinions on this...

At the facility I work at, nurses often hold medications for what they consider “nursing judgment”. I do understand nursing judgment, but sometimes am unclear where that line crosses over into disobeying the orders?

A few examples:

Metoprolol with usual parameters (SBP<100, HR<60) - nurses holding for SBP anything 110 or under, or HR <70 because of “nursing judgment”

Standing insulin order (I.e 5 units with meals in addition to sliding scale) - nurses holding if not giving sliding scale (aka <200).

I do understand their point that it’s “close to the parameter” and they don’t want to bottom someone out. But to what extent is that covered under our judgment? Shouldn’t they communicate with the MD first? Or communicate with the MD that they bottom out at that point (if that’s the case) and push for the parameters to be increased?

This seems to vary a lot by region and facility. The answers become more clear as you get to know your doctors, nurse managers, unit culture, etc.
I don't think there's an absolute formula that can be applied everywhere.

[Horseshoe, BSN, RN]

Holding medications should be discussed with the physician. I would never just hold a med, particularly if it deviates from the parameters given by the doc, without letting him know.

BTW, I don't like the term "disobeying orders." Physician orders are more of a plan of care, not commands that must be "obeyed." Nurses have the right to question orders and can refuse to implement them if they believe they are in error or are unsafe. But they should always notify the doc of this and of their rationale.

[Nurse SMS, MSN, RN]

If the physician took the time to write out parameters I call for anything outside of those if my spidey sense is going off and I am inclined to hold. My "nursing judgment" is valid but if I am openly disregarding physician orders I have crossed over into the realm of practicing medicine. Nursing judgment does not trump physician orders.

[RNNPICU, BSN, RN]

I think instead of the word "nursing judgement" it should be replaced with "Clinical Jundgement". Based on clinical findings by me the nurse, I may need to hold the medication and inform the LIP of my rationale for holding a medication, make a recommnedation, and wait for the decision by the LIP.

[SamJS, BSN, RN]

On 8/28/2019 at 9:53 PM, Horseshoe said:

Holding medications should be discussed with the physician. I would never just hold a med, particularly if it deviates from the parameters given by the doc, without letting him know.

BTW, I don't like the term "disobeying orders." Physician orders are more of a plan of care, not commands that must be "obeyed." Nurses have the right to question orders and can refuse to implement them if they believe they are in error or are unsafe. But they should always notify the doc of this and of their rationale.

Poor word choice on my part - I wasn’t really sure how to word that. Definitely didn’t mean to insinuate that we have to obey the MD, sorry!!

[ruby_jane, BSN, RN]

7 hours ago, not.done.yet said:

If the physician took the time to write out parameters I call for anything outside of those if my spidey sense is going off and I am inclined to hold. My "nursing judgment" is valid but if I am openly disregarding physician orders I have crossed over into the realm of practicing medicine. Nursing judgment does not trump physician orders.

I love the way you phrased this. My nursing judgment does not necessarily apply to parametered orders. My judgment would actually be to call the doc if I feel the med should be held.

[mmc51264, BSN, MSN, RN]

If there is a medication that has parameters and I don't feel comfortable giving, I send the provider a text page what the situation is and that I am holding until I get clarification. Not notifying provider is not following orders and not within our scope.

We have issues with nurses holding Lantus for low BG and not telling providers. Next morning, we deal with elevated BG.

[canoehead, BSN, RN]

The answers above are very correct and by the book. The real life, pressed for time answer is that if the order says to hold metoprolol for pulse less than 60, you get 62, but the patient feels dizzy (or you have concerns) you retake the pulse, get 58, and hold it. Then you can watch the patient for a while and see if anything develops. You might see the physician in the next hour and get their opinion, or the patient might wake up more after breakfast, go up to 80bpm, and you can give it then. If you finally don't give it, call the physician, but an hour or two of watching with a purpose has never been frowned on by physicians I've worked with.

It's also easier to go see all that doc's patients, and make a list, then make one call rather than several.

[pr0dr0me, BSN, RN]

I agree with previous comments stating nursing judgment is OK to hold meds, but that the LIP needs to be notified so they can change the dose or at least be aware that the patient is hypotensive/borderline hypoglycemic/borderline bradycardic. Or they might tell us to give it with continued monitoring because of xyz reason why the risk of skipping it outweighs the benefit.

My facility has also had issues with RNs acting outside of scope on insulin, apparently. I get we are afraid of hypoglycemia more than hyperglycemia, but the LIP needs to be kept in touch, and prolonged hyperglycemia is also bad for most medical-surgical patients.