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Putting in orders without an order.

Nurses   (2,055 Views | 42 Replies)

Kastiara has 2 years experience as a ASN, RN and specializes in Critical Care.

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You are reading page 4 of Putting in orders without an order.. If you want to start from the beginning Go to First Page.

Tweety has 28 years experience as a BSN, RN and specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

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We have protocols and standing orders for things like Potassium levels and magnesium levels, but the doctor first has to order the protocol.  If no protocol is ordered we can't order labs and give potassium, etc.  

It would be nice if this were part of the admission orders but it isn't.  Something things such as renal status need to be considered and it's always a good idea to not practice medicine and cover your butt with an actual order received from a prescriber.   

 

 

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Music in My Heart specializes in being a Credible Source.

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I've never entered orders without a verbal but I have initiated therapy on occasion (a) if the doc was someone with whom I had a strong relationship, (b) the doc was tied up, (c) it was urgent/emergent, and (d) I was certain that it's appropriate and that the doc would back me up, which they always have.

Some examples include starting a bolus, initiating a neb treatment, oxygen, and starting BiPAP.

It's been the rare occasion, though.

♪♫ in my ♥

Edited by Music in My Heart

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Lorie Brown RN, MN, JD has 31 years experience and specializes in Medical Legal Consultant.

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If you put in an order without a physician's order, your license is at risk. You are practicing outside the scope of your nursing license.  You must have a policy and procedure or standing orders which allow you to put in an order.  In addition, there are strict policies and procedures on when you can take a verbal order.  I have represented dozens of nurses who say this is the way we have always done it and we write these orders.  The Board looks at it as practicing medicine without a license.  You are smart to trust your gut and not do it because everyone else is.

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Kastiara has 2 years experience as a ASN, RN and specializes in Critical Care.

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On 2/10/2020 at 9:21 AM, turtlesRcool said:

How does your hospital have patients on critical drips, and not have standing orders on titration?  Are you sure you're understanding that correctly?   

The titration parameters are in the order. The order will read something like:  titrate by 1 mcg every 5 minutes to keep the MAP greater than 65. If we go up or down by more or less than the order states, we are supposed to fill out a form with how we titrated and why and then have the physician sign it. A lot of the nurses don't want to do that so instead they'll modify the order to reflect how they titrated the drip. 

I had a patient not too long ago where the physician had me turn off their propofol due to low BP (they were on two pressors). At that point, all I had for sedation was fentanyl that I had orders to titrate up on by 25 mcg every hour. I had five nurses in there holding this patient down to keep them from pulling out the ETT. I went up on the fentanyl by 100 mcg every 30 minutes or so until the patient settled down a bit. I filled out one of those forms for the physician to sign and got a lot of crap from some of the other nurses. They told me to just modify the order which I refused to do since I had not actually got an order from the physician to do so. 

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yournurse has 2 years experience.

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On 2/6/2020 at 9:23 PM, Kastiara said:

Do you ever or have you ever put in orders without actually getting an order from the doctor? 

The other nurses on my unit do it all the time. Lab orders, restraints, modifying medication orders, and I've seen some even put in medication orders. I can't bring myself to do it, mainly because I'm worried it will land me trouble both at work and with the BON. The other nurses say I'm too cautious. 

It depends on your facility protocols. We have a lot of nursing driven policies such as removing foleys, doing repeat blood work, EKGs, giving atropine/épi/defibrillating during critical situations, doing ABGs and others. When nurses enter orders, doctors always have to co-sign. I also work in the ICU, I feel like nurses have more autonomy there. More importantly, Is it an order that will expedite patients’ care to prevent a problem? Is it an order that will potentially harm the patient? You have to always know that your priority is your patients’ safety. 

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12 Followers; 3,938 Posts; 29,913 Profile Views

6 hours ago, Kastiara said:

I had a patient not too long ago where the physician had me turn off their propofol due to low BP (they were on two pressors). At that point, all I had for sedation was fentanyl that I had orders to titrate up on by 25 mcg every hour. I had five nurses in there holding this patient down to keep them from pulling out the ETT. I went up on the fentanyl by 100 mcg every 30 minutes or so until the patient settled down a bit. I filled out one of those forms for the physician to sign and got a lot of crap from some of the other nurses. They told me to just modify the order which I refused to do since I had not actually got an order from the physician to do so. 

The situation (of nurses and what they do with orders) sounds like a bit of a mess.

I'm not sure why they would critique you for following the procedure your employer has in place (with the form, etc.) but then also why not immediately inform the physician that the whole propofol plan isn't working out too well or...when s/he first ordered you to shut it off clarify what their plan is for increased agitation? Then you wouldn't need to bother with the form at all.

Edited by JKL33

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FolksBtrippin is a BSN, RN and specializes in Psychiatry, Pediatrics, Public Health.

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On 2/9/2020 at 11:13 PM, Kooky Korky said:

Can you give some examples of nurses not taking any responsibility?

If doc is a jerk, he/she needs to be corrected.  Nurses should take responsibility to get said jerk to do his job and be courteous about it.  They know that nurses are going to need orders sometimes and they need to behave.  The days of catering to prima donas should be over.  We save their butts plenty of times and they need to respect us.  We do not need to tolerate being in fear of them. 

An example of not taking appropriate responsibility would be to fail to hold a med that should be held. We aren't med techs. If we know something is wrong, it's our responsibility to stop it. It's also our responsibility to know about the meds we are giving, and what to look out for. We aren't blindly following orders.

At this point, it's clear that this isn't what is happening for the OP. There is a communication issue that has snowballed here. 

As far as jerk docs needing to be corrected, I agree fully. 

 

Edited by FolksBtrippin

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