Pros & Cons of LTC physician standing orders

[rnstudent]

A fellow student and myself are preparing a proposal to a LTC facility to implement physician standing orders to reduce telephone time for Charge nurses.

We are hoping to get some input from other nurses as to whether standing orders are helpful and where they are appropriate in a LTC setting...

Any thoughts?

Thanks,

rnstudent

[tinkertoys]

Standing orders can be WONDERFUL in LTC, but should be utilized with caution. During a recent viral outbreak in our facility, we had standing prn orders for phenergan and lomotil for the pts of some of our Doctors. The orders had a time limit covering the weekend, which saved us a lot of time, and the on-call MD from a sleepless weekend. We have also had standing orders at times, OKing prn tylenol, MOM, fleets enemas, etc. We have to be mindful, however of the conditions of the patients involved. Sometimes the standing order is not appropriate given the medical problems involved, or the extent that illness has affected the patient...That's where your nuring judgement comes in. And even if the standing order is utilized, it is still very important the the MD be notified of the pt's problem at the first opportunity.

[mustangsheba]

I wouldn't work long at a LTC if there were not standing orders for at least Tylenol. We need protocols for pain management, bowel care, restraints (I know, I know), wound care, and individualized parameters for agitation, combativeness, and sundowners. If pediatricians can design information sheets for parents to follow in treating their infants, I see no reason why the same couldn't be done for nurses working in gerontology.

[km rn]

We utilize standing orders in our community. The standing orders are the same for all nursing home residents in our city. The physicians, nurse practitioners and nursing home nurses get together every 2 years and review the current standing orders and make changes.

If a physician disagrees with one aspect of the standing orders - he draws a line through it. The hospitals make it part of the transfer process to ensure that the resident arrives to the nursing home with signed standing orders.

Our standing orders include: PRN acetaminopher for aching/fever - criteria included, bowel management protocol, catheterization parmeters, Cough treatment parameters, diabetes monitoring, diarrhea treatment, dry irritated eys - tx, dyspnea, gi distress, immunization, lab work, skin breakdown, TB screening, replace N/G or G-tube per faciity policy.

We have had very few problems with standing orders in the 7 years I have worked in the facility.

[Kimmyjc]

I sure would be interested in seeing your bowel management protocol if I could, thanks.

[night owl]

At our LTC facility we do not have standing orders for anything. It sure would be nice to get an order for tylenol at least for a headache. There's nothing like waking the on call Dr. for something like a tylenol and then listening to him bit*h on "why did you wake me for that?" Hello??? Because he needs it????????

And because you're getting paid a whole lot of money for me to wake you up to get this order? IDIOT !

[squaw nurse]

We have always used standing orders at our facility and they have been wonderful. They were developed by the LTC nurses and the team of physicians in our community and are updated annually.

However, the Louisiana State Board of Nursing recently issued a statement as follows: "it is not within the scope of practice of a registered nurse to initiate standing orders without contacting a physician for patient specific orders in accordance with the Law governing nursing...".

The whole purpose of the standing orders is to enable the nurses to administer a Tylenol without having to contact the physician. Have any of you out there had similiar statements issued by your state boards? What alternatives have you used? Help! I feel like I'm in quicksand and need some answers. I just sent out the revised standing orders for 2002 for MD signatures. Not only will my nurses be livid, but the doctors are going to scream when I break the news we can no longer use standing orders.

Please help if you have any suggestions.

[NurseKimberley]

Our facility utilizes PRN orders for each patient, such as to have pain reliever as needed (for pain OR temp), usually APAP, and for most to have SUPP q 3 days, etc. This works very well, and transfers month to month on the MAR, so they are always available, should the occasional headache or bout of constipation come up.