DYLANB

The hospital I work for has for several years now used a system where they will float two nurses, one from a critical care area (ICU/CVICU) and one from a medical/tele unit, to the ER when they are holding pts. (pts with admission orders but no room in the hospital to accomodate them). If it is your units turn on the schedule to float and the ER is holding pts reagrdless of what staffing looks like for that day on your unit you will be forced to float a nurse. Now to make things worse, they have recently started to float a nurse from units not scheduled to float to ER to the unit who is floating a nurse to ER leaving you short a nurse even though its not your day to float. This whole thing drives me crazy. I am a charge nurse in the ICU and I end up having to float nurses away from my unit while already short to begin with. I asked my director if we could have a meeting to solve this problem and his response was "I don't see what the problem is we've been doing it like this for years". I explained what I felt the issues were and he was very short with me stating he had to leave and we could talk later. Any thoughts on this situation or similiar situations in your hospitals?

In the hospital I work for, we have a "paper lite" chart and a CPOE (computerized provider order entry) system in which all orders and medications for the patients are entered and viewed. We have to open an icon on the desktop, log in and this gives us access to the pts entire chart. We have computers in all of the pt rooms so we are able to view the pts chart from CPOE while in the room with the pt. We also have what we call a bedside chart which contains the pts flowsheet for I/O's and vitals. We use communication boreds (dry erase) in the pt rooms that list the pts MD's, diet, activity status, pain level and notes pertinent to the pts care. We switched over to this system about two years ago and initially I was heistant for the same reason you stated, it doesn't seem ideal. I feel like a slave to the computer. But now I perfer this method to the old paper chart. No more trying to guess what the chicken scratch order the MD left says, or flipping through pages and pages of orders. It is all now at the click of a button. Hope this helps.

I thought it was clever. You're right, I didn't indicate directly in my initial post that I and other nurses had experienced abuse by family members starting with blatant disregard for hospital policy. Others in this thread seemed to have understood where I was going with my first post. I have read numerous posts on this thread of outlandish requests from family, rude and nasty behavior, feelings of entitlement, intimidation etc... which in my opinion are forms of abuse. But you're right again, that is good jumping off point for another thread altogether.

I understand full well we are not McDonald's but, if you look at health care trends we are heading in that direction. ie core measures, satisfaction based reimbursement by medicare. We are heading towards prepackaged healthcare for everyone. I don't think this is all bad but that's for another thread. The point I was trying to make is that some patient families are overbearing, rude, disrespectful and demanding. I stated in my first post that I am sympathetic with the families that want to be with patients in their time of crisis. I understand the family centered care modality. But I won't and shouldn't have to tolerate abuse. Simply stating.. " I need everyone to step out now".. or... "please direct your questions to the designated spokesperson" will NOT resolve ALL nursing concerns. Trust me, I have been there, done that.

5thflrnrse, You are right, I have never been a patient but, I have been a family member to a patient admitted to a critical care unit. I know based on that experience alone how to behave in a hospital. I also know what manners, common courtesy and respect are. Some families have none of these qualities.

Just curious to hear about other nurses experiences with the total disregard patient families have for visiting hours and hosptial policies. I have been a nurse now for 3 years and have split time between ICU and CVICU. Patient families skirt the rules all of the time and get away with it. Moreover, nurses I know have been reprimanded for inforcing policies set forth by the hospital after family memebrs complain to administration. I understand that since I work in critical care that that patient acuity is high and family memebrs are worried about the patients well being but, how are we as nurses expect to perform our jobs at the highest level if we can't care for the patient because 100 family memebrs wont stop asking the same questions over and over or crowd the room to the point we can't even see the patient? I sometimes feel that rules people normally follow in far less important situations go out the window when they eneter a hospital. You don't go behind the counter at McDonalds and watch them cook your hamburger or stand over the cashiers shoulder while they process your transaction. Why is this behavior allowed in the hospital setting?

I have never used or even heard of Roxanol before reading this post. I breifly looked it up and I found it was morphine sulfate. I assumed it was an injectable form not realizing it was strictly an oral/sublingual form of morphine. I should have looked through the med info more carefully before posting. How embarassing. After speaking with my facilites pharmacist he stated that because they are two separate orders and they have no set maximum dose to be received within a time frame the scheduled and prn can be given without regard to the amount of time passed between the last dose given. As long as the meds are given with regard to the time frames established within their respective orders. Although I still feel that my original post has some merit, I was wrong. If only the MD would write a max dose to be given within a set time frame the order would not be up for interpritation. PS: I do advicate for my pts. I would never have allowed a pt to writhe in agony for 4 hrs because the next dose wasn't due. I would have called the MD without hesitation to increase the frequency of the dose or add an additional med for pain relief to the pts MAR.

I understand your desire to keep the patient alive until family arrived. I can see your dilema but, there does come a time when treating a rapidly declining DNR is like beating a dead horse, no offense or pun intended. A patient that sick requiring drips and bolus' should probaby have been in an ICU or CVICU to begin with regardless of code status. If that had been me I would have sought a Withdrawl of Care from the family. Assuming the family agreed, I would have then called the MD and notified him of the families decison to withdraw care and asked him to make the patient Comfort Measures only which in most case means death is immanent. Generous amounts (hopefully) of morphine would have been prescribed and the pt would have been allowed to pass in his/her own time comfortably. if the family did not agree to withdraw care despite having explained the pts situation and the fact that death was not a matter of if but when, then I would have called the MD and asked for a set of standing orders related to blood pressure maintenance and pain control. I don't know that this answers your question entirely but hopefully it helps.

5-20mg q4 is considered an incomplete/incorrect order. When ever an MD writes an order for a medication the order must have the name of the medication, the dose, the route and the frequency. Pain medications must have an accompanying pain scale. ie. Roxanol 5mg IV push q4h/prn for mild pain Roxanol 10 mg IV push q4h/prn for moderate pain Roxanol 15 mg Iv push q4h/prn for moderate to severe pain Roxanol 20 mg Iv push q4h/prn for severe pain. Drips, IV pushes or medications expected to exact a somewhat immediate change should have a similar accompanying scale. ie. Tylenol 650 mg PO q6h/prn for temp > 101.0F Cardizem IV drip titrate to keep heart rate less than 110 bpm. IV bolus of 0.25mg/kg over 2 minutes Follow with 5mg/hr IV drip and titrate increase by 5mg/hr q30min with a maximum dose of 15mg/hr. MD's assume that facilities have protocols in place (usually they do) for titration of meds and they neglect to write complete orders which puts us nurses in a tight spot. All you can really do in these situations is call the MD and ask him to clarify and hope he/she is not in a bad mood.

Is the strength of the prn dose the same as that of the scheduled dose? If so, it seems to me that by giving a q8h order the ordering MD intended for the patient to receive a minimum of 3 doses within a 24 hour period and by leaving a q4h prn order the MD intended for the pt to receive the medication a maximum of 6 doses within a 24 hour period. To give the medication more frequently than q4hs, in my opinion would be wrong. Say the pt has a scheduled dose at 1000, the prn dose is then given two hours later at 1200 then again at 1600 followed by the scheduled dose at 1800. This means the pt is receiving the medication in 2 and 4 hour intervals when the order calls for 4 and 8 hour intervals. This also means the pt could potentially receive a total of 8 doses in a 24hr period. Two more doses than what then original order implies. After reading the comments posted I feel as if many nurses responding to this post feel like because there are two seperate orders here (scheduled and prn) you can give the prn whenever the nurse deams necessary using "nursing judgement" disreagrading the amount of time that has passed between doses. If you follow that logic you have essentially changed the intention of the original order. If the pt is requiring more medication for greater pain control the MD needs to be called and the prn medication frequency needs to be changed to ,for example, q2h. Still the pt should not receive doses more frequently than what is allowed by the prn order. So to answer your question if the "Q8 is being given at 6a, 2p and 10p. Does that mean I can only give the prn at at 10a, 6p and 2a?" I believe yes, the medication should only be given in 4 hour intervals. To solve this dilema in future situations you may ask the MD for a maximum dose allowed/per 24 hour period. This would prevent you from having this problem again.