Procedural Question regarding Phys. orders

Nurses General Nursing

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Hi everyone,

I am currently doing a summer externship at a large community hospital. I have one year of nursing school under my belt and will start my last year this fall.

I have a "procedure" question regarding Dr.'s orders and who to call about them.

I had a patient admitted c a wound infection to his inner thigh r/t a mass removed from his scrotum, member and inner thigh region. After his surgery he was d/c but 5 days later returned to the hospital because of wound infection. Byt the time I had him as a patient he was 7 days post op. Was passing some gas, voiding well but had not had a BM since before his operation. He was complaining of abd. pain and distention. I knew that doctors would be making rounds relatively soon and told him that I would keep an eye out for the doctor or resident to address this with them and that if he should see them when they come to check on him, that he should also bring it up to them at that time. He had allready tried colace for 2 days and an enema the day before which did not work for him. The patient requested a phos. soda because he had used those before and they worked very well for him.

As the evening wore on I became busy with other patients and when I went to check on this particular patient later on, he said that the doctor had seen him and that he explained to the doctor that he wanted the phos. soda. I said I would check for new orders and see what the dr. wrote. I checked the chart and the doctor wrote an order for another enema. I explained this to the patient who refused the enema because he only wanted the soda. He was very adamant about this.

I went to my preceptor who looked at the order and instructed me to page the doctor (who is not normally on our service) that wrote the order for the enema to see if we could d/c the enema and get the 30mL of phos soda. We did not know if there was a particular reason that the phys. did not write for it in the first place.

I paiged the doctor who wrote the order, he was still in house. He was really sarcastic about being paged to order a phos. soda to clear this guys bowels and how he was a Chief, etc. etc. He did allow me to take a verbal for the phos. soda, so my patient was happy.

I guess my question is, if I wasn't supposed to call this doctor that was in house and wrote the original order, who else should I call, one of his residents? And how are you supposed to know what level of phys. a doctor is if you don't normally work with them?

I say if he didn't want to be called about a phos. soda, he should have listened to his patient better and written right the first time, but I'm just a student, perhaps this is a wrong ideology?

My preceptor had no problem with me contacting this doctor directly to change his order. Another preceptor I had for a day a few weeks later and probably didn't know the whole story said she would never call a Chief for an enema/phos. soda. I wonder who she would have called then?

Is there some sort of protocol in dealing with doc.'s?

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Specializes in Emergency & Trauma/Adult ICU.

Hi Colleen,

Hmm ... the first thing that stands out at me is that, if I understand your post correctly, you (a student) took a verbal order. Is that allowed? I was under the impression that it was not, and I know that in PA only recently have LPNs even been allowed to take verbal orders.

The way things work in my particular program, we as students do not call MDs, although we can & certainly are expected to interact with MDs while they are with the pts. we're assigned to. If something needs clarified or there is some other reason to contact the MD later, the RN assigned to that pt. will do it.

As far as the specifics of who to call for an enema vs. soda ... I've already seen that some MDs will NEVER be happy about being called EVER, regardless of the reason or who makes the call. If I got this attitude as an RN, I'd probably be inclined to just let the sarcasm roll off my back. I don't see where it matters that this guy is dept. chief -- it's still his pt., and his pt. still needs to have a bowel movement.

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If your patient has a complaint such as pain or a change in assesment then you will want to get the intern or resident. Usually they will communicate with the patient's primary physician or the doctor they were admitted under in determining what should be done or just to inform them of what they the intern had ordered.

But when a doc writes an order and you want to change that order or it needs clarified then it is okay to page that doctor. I might have grabbed an intern to change that order. But you didn't do anything wrong.

Just an FYI. A sarcastic doctor who needs to inform you of their high status is usually a pain in the butt. Don't take it personal.

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Your preceptor should have been the one to decide which doctor to call. The preceptor said call the one who wrote the order. Interns and residents are loathe to change the chief's orders anyway, and they probably would have told you to call the one who wrote the order.

Can't win for loosing. Don't feel bad. You did what you needed to do to take care of the patient. This is not going to be the first time an MD is going to chastise you for calling them and the bottom line is you do what you have to do for the patient. I would have done exactly what you did, call the one who wrote the order in the first place, or follow the direction of your preceptor.

You did good.

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Im with MLOS, be careful what you let your preceptor get you into - just because she doesnt want to deal with it. Ive never known any situation where a nursing student could take a verbal order. Anyway, once you get to know certain Doctors - you will learn what they do or dont want to be beeped for/ what orders you can or cannot modify. That comes with time and experience. Whenever in doubt - dont be afraid to ask. Believe me, when your sitting in court trying to explain why you did what you did - the CHIEF wont be anywhere to be found and he sure as heck had nothing to do with it. You're on your own. You did fine (although, I would let the preceptor do the negotiating with Docs.)

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Im with MLOS, be careful what you let your preceptor get you into - just because she doesnt want to deal with it. Ive never known any situation where a nursing student could take a verbal order.

Ditto that.

As for the doc, I don't know who he thought he was

Chief Resident?

Chief of Staff?

Commander in Chief?

Kansas City Chief?

BUT - no matter WHO he is, he's there for the PATIENTS - same as we are. Sounds like he needs to get over himself. You'll encounter these types a lot over the course of a career, or a lifetime for that matter. Those that act if just speaking to you is putting them out. They are not gods - despite what they may think.

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Specializes in Renal, Haemo and Peritoneal.

You could have been guided through the process a little more effectively but good on you for advocating for your patient and getting a more appropriate medication order. Never be afraid to stand up for your pateints!

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Specializes in ICU, CM, Geriatrics, Management.
... you (a student) took a verbal order. Is that allowed? I was under the impression that it was not...

Agree. :uhoh3:

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Specializes in ICU, CM, Geriatrics, Management.

[quote name=RN4NICU...

Chief Resident?

Chief of Staff?

Commander in Chief?

Kansas City Chief?... [/quote]

Hahahahahahahahahahahahahahahaha!

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Specializes in Neurology, Neurosurgerical & Trauma ICU.
Ditto that.

As for the doc, I don't know who he thought he was

Chief Resident?

Chief of Staff?

Commander in Chief?

Kansas City Chief?

Don't forget Indian Chief! :chuckle

Anyway, as it's been said many times before...a nurse extern or a GN should NOT be taking verbals. It's not legal and you can get yourself in a lot of trouble before you even get started in your career.

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Hi everyone. Thanks for all of your responses. I don't just willy nilly call the doctor. I work with my preceptor on what I specifically need to ask the doctor, what information they will probably want from me and what order they will probably ask me to take. I never talk with the doctor alone, we have multiple phones on single lines and my preceptor will listen in to verify what I and the doctor are communicating but will not interject anything into the conversation unless I am not covering all of my bases. I had heard that some doctors can be real jerks but this guy was a complete a--. Just didn't know if I was completely missing something here.

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.
I had heard that some doctors can be real jerks but this guy was a complete a--. Just didn't know if I was completely missing something here.

Yes doctors can be awful, but then so can nurses and dietary aides, lawyers and doormen. You advocated for your patient and that's what was important. Try to find out what the chain of command is where you are. Mine was a teaching hospital with residents and also had private attendings who did not have residents. My best source was the telephone operator. A quick "who do I call for"......usually got me to the correct person. I wonder if your patient may have asked for "Fleets" which can be an enema or an oral med. Anyway keep up the good work.

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