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?
Specializes in Clinical Education, Urology, Gen Surgery, Gastro.
A nurse's clinical judgment should always be evidence-based and decisions should be documented at the time. In my opinion, it is perfectly acceptable to withhold medications as long as an immediate review is requested - whether doctor, specialist diabetes nurse or whomever has prescribed.
Patient safety is paramount and communication is essential both with the patient themselves and the relevant health professional.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
If I am holding a med, it is based on assessment data. Parameters are written because most folks are okay in that range. Some folks are not. A person who is accustomed to walking around with a systolic of 170 might feel faint with a systolic of 110. I don't want that. I don't need the guy falling because I was following doctors orders when I should have used my judgment to hold the med. Same goes for short acting insulin, but not long acting.
I do have a nurse sixth sense and it is useful, but I don't hold meds based on that alone. There is always some clinical evidence.
If I think doc's order is wrong, I am going to call right away. If the dose is not appropriate, if I think a lab was overlooked or the order should have been discontinued and doc forgot, I am on the phone right away. Also if the patient can't tolerate the med or I suspect toxicity, allergy, etc.
If I held short acting insulin or an antihypertensive it's probably just a casual mention.
We shouldn't muddy the waters surrounding this topic. Physician orders legally are more than a plan of care that nurses can independently decide not to follow, and discussing concerns about medical orders with the physician isn't a should, it is a must. Nursing judgment comes into play (or, "is a thing") because it allows us and the patient the benefit of time for clarification - not because we are actually licensed to independently decide to not follow the prescribed plan/orders/directives/whatever you want to call them.
We are generally legally expected to enact medical orders unless we have good reason to temporarily hold off in order to register our concern through appropriate channels and receive a response.
When wecall physicians to register our concern or question about a medical order that we have not enacted, that isn't simply a nursing custom or some kind of courtesy - it is our legal duty and it protects the patient in more ways than one.
I do not hold any meds without an order;we've been told this is company policy.That said, i hang on to it til i get that order.and if i get told to give it anyway,I make sure the progress note states that so and so provider ordered to give it despite< situation>.
Specializes in Psych, Addictions, SOL (Student of Life).
Well some BP meds are given to slow and strengthen the heartbeat to improve cardiac output. I once called a cardiologist to say I was with-holding metoprolol for a blood pressure of 100/60. He was actually pretty nice about it but did explain that the parameters were to hold if systolic below 100 or diastolic below 60. So I should go ahead and give the medication as ordered because it was actually for a-fib!
It’s definitely putting patients at risk for a nurse to hold any medication order without contacting the physician. If the prescriber is unaware that a medication has been held once or the entire hospital stay, the patient could be discharged with that order and take it as directed and have serious complications. Documentation should be your evidence so that when you say “Dr. A I just wanted to be sure Your aware that yesterday when the metoprolol was given to Mr C his B/P 170/62 and an hour later he was symptomatic with a Systolic drop by 30-40. Today his B/P is 160/58. I’m concerned that he will drop agin to much to fast if given the same dose.
Even Dr’s don’t know how each individual person will respond with what could be a typical or even lower dose of a medication. Especially if it’s new to that particular patient or if the patient is new to the Dr. A good medical Hx May not be available etc. so without the nurse following the orders and evaluating the effects, the Dr is unable to determine the correct & appropriate dose To stabilize that individuals B/P. Communication with the patient and the physician are vital. Mr. C may have already decided himself not to take the medication again because of how he felt yesterday or may not understand whatever symptoms he had weren’t related to that particular medication at all.
The Dr depends on “your nursing judgment” which includes communicating vital information of an ordered medication held for any reason and the outcome/result of withholding it, just Like if a wrong med was given.
I do not hold any meds without an order;we've been told this is company policy.That said, i hang on to it til i get that order.and if i get told to give it anyway,I make sure the progress note states that so and so provider ordered to give it despite< situation>.
If it turns out that the order was incorrect, unsafe, deviates from SOP, and the patient is injured, you will not be able to cry "company policy" or "doctor insisted." Nurses have a legal obligation to give safe and reasonable care-company policy and a doctor's directive does not override this legal obligation.
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Nurse SMS, MSN, RN
6,843 Posts
Long-acting insulin is not very well understood by a great many nurses it seems, as it frequently gets held, when it almost never should be.