PACU Orders

[Andrew, RN]

I'm working in a PACU. We use CRNAs and there is a float doctor that we call if we have a problem with patients/need further orders.

The RNs write orders without officially getting an order. Routinely, this is 1-5 mg Morphine IVP q 7 min for a max of 20 mg for inpatients and Fentanyl 25 mcg IVP q 5 mins for a max of 100 mcg for outpatients. Same with antiemetics and other drugs routinely used in a PACU.

The RNs write in whatever they're giving and then sign the order "R+V by Dr. Anesthesiologist." The doctor will never see the patient or sign the order unless there is a problem.

I asked if this is a standing order/protocol/whatever and they said "No, this is just the way we've always done it"

I have a problem with saying I got an order verbally from a doctor and charting as such, when I did not. I told the nurses in this unit "What would prevent me from writing in whatever I want like a blank check?" and they responded with "Your ethics as a nurse"

I'm not a doctor/PA/NP, I have no prescriptive authority. So, how can they do this?

[tryingtohaveitall]

That is bad practice and extremely risky with their licenses. That's all fine and good while a dr is willing to cover their rear ends, but the first time there's a poor outcome related to this practice,the doctors will all be backing away denying they know anything about the nurses writing "verbals" without ever talking to the MD.

[Southern Fried RN]

Wow! There is NO way I would ever do that. The 2nd post summed it up perfectly. The first time some one has a bad outcome you better believe the RN is getting thrown under the bus. That doesn't even sound legal.

We use CRNAs and have a float MD to call for problems. The CRNA uses the pre-printed order sheet to check off drugs, frequency, parameters, max dose, etc. The MD must sign this order sheet before the pt goes to Phase 2 and also sign off their anesthesia sheet as well.

If I were a patient I would NOT feel comfortable with nurses who gave whatever without an MD seeing me. I think many nurses are capable of making good decisions on treating pain, but sometimes there are other factors to consider. Factors that a PACU nurse may not know about right off the bat, or have time to investigate as opposed to the anesthesiologist who did the pre-op interview.

[Andrew, RN]

I agree completely.

The way it stands right now, I have no idea which patient I'll be getting until they arrive. The OR calls an intercom and says "we're coming over with Dr. So-and-So's patient" and then within 5 mins they usually show up, however there could be more than one coming out at the same time, so I really don't know which one it is until they're in my bay. I would really like to know ahead of time who I'm getting but I don't know if I'll ever be able to.

So, it would be nice to have some orders written all ready for me to use. I came from a CVICU that had 4 pages of pre-printed orders, so we were covered in many situations to care for our patients.

It's a smaller hospital, the RNs have been there forever, a lot of rationale for things has been "well, that's the way we do it here" "that's the way it's always been done"

I'm a relatively new grad, I'm inquisitive, I go by ASPAN and AORN standards, as well as my state's nurse practice act. I don't really care how they've always done it, especially if it's wrong. =)

[OC_An Khe]

We use CRNA's also with MD backup. The patient must be accompanied by either CRNA /MD from OR to PACU. Orders are written and signed by rhe anesthesia provider before patient is accepted into PACU. There really isn't any reason to do otherwise.

[meandragonbrett]

It's kind of odd that they come to the PACU without any orders written for pain and N&V.

[Penelope_Pitstop, BSN, RN]

i cut my teeth in perioperative services (as an extern/tech, not ever as a licensed person), and behavior like this, sadly, was not the exception.

the pacu rns had order sets, and i knew a few of the more experienced ones would call out to the anesthesia team, "mr. blah blah has had a bunch of dilaudid and is now itching...i'm giving 25 mg of benedryl iv x 1 now, okay?" as they were drawing the med up, and the anesthesia team member would walk over and okay it. that, to me, isn't necessarily the best idea, but it's not what you're talking about, op.

the same day surgery nurses, on the other hand, "knew" what the surgeons would order, so would write a verbal order in the chart and then show the physician in the morning when he or she came to write discharge orders. that, to me, was risky practice. i worked midnights the vast majority of my career, and, yes, i've angered more than one doctor with a middle of the night order clarification or a request for a benedryl order. as a medsurg nurse, not doing this would be a death sentence, whereas in sds, it would have been grounds for teasing by my peers and a tongue lashing by mds.

i think a lot of times it's the culture of the department. do what you know is correct, not what everyone else is doing! i learned a lot from those perioperative nurses, but it was up to me what practices i utilized in my own nursing career.

*~jess~*