OK-I really need to vent!!!!

[christvs, DNP, RN, NP]

I was more than a tad bit ticked off at work tonight. I informed the doc (an intern) of our pt's fever (38 C) & I also mentioned to her that since there was no order written for tylenol, could she please write for that. So she did & handed me the order sheet with her order on it. I took it, said thank you, and went to go fax it down to pharmacy. Just as I was about to do that, I noticed what she wrote. She wrote "1000 mg PO tylenol q 4 hrs prn pain, fever" !!!!!!! HELLLLLLLLLLOOOOOOO! That would be 6 grams per day!! And we all know the limit is 4 g/day. So I went back up to the doc and I said very politely and very nicely " I just wanted to double-check something with you before I gave this tylenol. Did you mean 1000 mg q 6 hrs?" And she looked at me and said "No." then I said "But the limit is 4 g/day. This would be 6 g/day." And then she goes "But I write that all the time. Fine. I'll change it if you want me to." !!!! What does that mean?!! If I want her to? She needs to change it cuz it's unsafe! So then I said "I just wanted to check with you because I know not to give more than 4 g/day." And she said to that "Whatever. " !!!! What the *$*$*?!! Then this is the best part. She said "It says right on OTC tylenol bottles that you can take that much per day." NO IT DOES NOT LADY!!! I'm not hallucinating am I ? So the point is not that she was upset that I caught her error, the point is she still didn't get it that it was an error. Now I'm afraid of other orders that she writes if she gets something as simple as tylenol dosing wrong. I'm not saying I'm perfect and know a ton of things, but I mean come on! And the part that gets me is that I'm super polite to everyone and when I find an error, I say it as gently as possible but that's crazy to try to kiss someone's behind so their ego is spared, and then they basically act like I'm inconveniencing them. Oh boy, I needed to vent. :)

[Chaya, ASN, RN]

I've frequently seenthe order written "Tylenol 1000 mg po q. 4-6 hours; limit 4 gms per 24 hours"

[christvs, DNP, RN, NP]

I've frequently seenthe order written "Tylenol 1000 mg po q. 4-6 hours; limit 4 gms per 24 hours"

That would be fine with me, as long as the no more than 4 g/day part was included in there. But when I mentioned the 4 g/day limit she looked at me like I was crazy or making it up or something!

[Justhere, BSN, RN]

We have a standard orders for our post partum unit for some of our doc's for Ibuprofen 800mg q4 hrs prn. But when the pharmacy prints it up on our MAR's they have the MAX 3200mg/24hrs. So we just have to watch that we don't give more than 4 pills in 24 hours.

The tylenol is the same, because alot of our narcotics have tylenol in them also so we have to watch the mg not only with just giving the tylenol but the amount of tylenol in the other med.

[Indy, LPN, LVN]

The doc can write for 6 grams a day, but our pharmacy is going to ask for an order clarification before they will enter it into the computer. If I can't get one then they won't put it in, won't print on the MAR's either because it's unsafe. I like that backup. Sometimes physicians who want something done a little different (rocephin for a PCN allergy comes to mind) will write it in the orders, "yes I know this (whatever) but I want it done this way." Pharmacy doesn't get excited about that because that's the doc saying that he knows it's not normal, he intends it to be done the way it's written and assumes liability for the fact that he wrote the orders that way. It would be nice if they'd all do that but... sigh. They don't. Trying to get double titrated orders to stop was a great big headache all by itself. (time may be variable or dose may be variable but not both)

And I've never met a patient who wanted tylenol every four hours. If the fever won't go down, maybe call back (I know, you don't enjoy talking with this particular doctor) and ask if they wanted blood cultures or antibiotics, or both? (with the antibiotics being after the cultures drawn of course)

There are those who need to have the suggestion of what to do put up in their face before they will do it. At least you're getting orders, even if they're skewed and the doc doesn't seem to care about the correct dosing.

[JaneyW]

I also work at a teaching hospital and have encountered this kind of thing more than I like. Most of the residents are very nice and remember that they are learning. Some have an attitude from day one and can't believe how stupid all the nurses are. Sounds like you have one of those. Is she on your unit all the time or just rotating through? As you gain more experience, you will be able to be a bit less nice and a bit more assertive in your role of helping to guide them. Hang in there.

[Tweety, BSN, RN]

The point is that it is a prn order. You give it, and if the temp is not down in four hours you give it again. Hopefully by then it's down and you're not going to have to give around the clock every four hours and exceed safe dosages. This is why our Pharmacy flags these orders with a warning not to exceed. This is where your own judgement comes in. You would call the doc say when they reached to 4gms and say "they've reached the max and they still have a temp."

Many prns, if given around the clock would not necessarily be safe. We often have prn orders for Percocet 2 q4h prn, and on the same order Tylenol 650 q4h prn. It's up to us to use our good common sense not to overdose the patient on acetmenophen.

edit: I see your next post above. The MD should not have known what the safe dosing was. It's good you asked for a clarification I suppose. I probably wouldn't have bothered myself.