SCD orders

[inspir8tion]

Hi:

In my hospital the surgeons are required to write an order before we can place SCDs on a pt/ turn on the machine in the OR.

We have a pre-op check in area for day surgery patients. The doctor admits them to this ward of the hospital and on there they write any orders including "SCDs in the OR". The nurse in that ward signs off on the orders and the pt comes to the OR on another floor and waits in a holding area before being brought into the OR room.

I ask the surgeons to write another order for "B SCDs in the OR" so that I can sign off on it. This pisses a lot of them off. I don't want them mad at me. However, I feel that the OR is a completely different ward than the pre-op check in area. Also, those orders are already signed off by another nurse.

Does anyone have a similar situation and if so, how do you handle this? Do you not request another order and put them on? Do you request another order and put them on? Or do you initial next to the SCD order for the other ward and sign your name, date, time below the nurse for that ward?

Any advice would be appreciated.

Thanks!

[OR male nurse]

OR male nurse, is there a reason that you feel that this thread must turn into a pi**ing match, because in my humbly opinionated opinion, that's what it's become. I'm sure that after three whole years in the OR you have a great knowledge base on which to build upon; however, I have found after twenty plus years, that EVERY day in the OR is a learning experience. If you think you know it all and that only your answer is the right one, karma will come back to bite your butt, I guarantee it. For this issue, I don't think there is a right or a wrong, but a 'different'. Different places do different things and it works out fine for them. It never works to shove one's way of thinking down anyone else's throat, whoever is doing the thinking. As long as the end result is safe patient care, that is what matters. We are all in the OR to make sure that our patients are well cared for and and have great outcomes. It is not a place for nurses to have big egos, as we must all work together for the common good...even if we don't agree with colleagues who work with us, or across the country from us.

No.. I don't think it should be at all. I merely expressed my opinion to this thread and offered up how I've seen it done. I wasn't trying to shove anything down anyones throat (more fantasy to bolster your opinion) and all I did was state how each of two places I've worked at handled their orders. Never said either was right or wrong. All I said was that a preference card isn't a standing order. You two jumped all over it, and threw in your 50+ years of experience line like that was the end all and gave each other childish high fives and thanked each other for your posts. I have an opinion and offered it. Yes.. I merely have a measly three years experience... throw that in my face while you're at it. Karma back at you. One thing is for sure, I won't be bragging that I have 20 or 30 years experience on any issue and think everyone is supposed to agree just because, or be personally insulting because someone only has 3 years experience. Let's cast insults and then stand on higher ground which is what you are doing.

No wonder they have the saying that the older nurses eat their young... hmm.. perfect example. RN with only 3 years experience makes a statement. Two RN's with an amazing 50+ years of experience eat him alive for having an opinion and throw their years of wisdom in his face. How nice. I'm so proud for you and your years of wisdom.

:bowingpur I bow down to you and pray to the gods of karma to spare me and allow me to be as wise as you.

[Circl8r]

I'll never cease to be amazed at how some people can twist another's words to fit their needs. I am neither standing on higher ground, nor am I casting insults, young man. I merely stated that your current knowledge base after three years can and will be built on daily and you'd continue to learn new things every day. How do you see that as having your experience thrown in your face? And trust me, after a few years in the OR you WILL count on those years of experience when speaking to issues that you are passionate about. On that note, I am not one to insist on doing things because "that's how we've always done it" and when I am wrong, I admit it. I believe in continuing education and keeping current on all issues and practices that affect my nursing practice and my patients. I am passionate about what I do, and if you see that as looking down on you, I must say that I am sorry that you see it that way. Neither did I say that you were personally trying to shove anything down anyone's throat. IF you read my statement, it was a generic generalization about thrusting one's opionion upon another.

[OR male nurse]

I am neither standing on higher ground, nor am I casting insults, young man.

There ya go again...you cast an insult and then stand on higher ground. Young man ? What the heck does that have to do with anything.....Make no sense you do. You throw around your 20 years experience spin and then talk down to me with "young man?" Please pat me on my head and pinch my cheeks too.

[core0]

Not to get into the middle of this however, the real question is what makes a standing order. First of all not all states allow standing orders and some that do only allow them in very specific circumstances. I will refer you to the NY BON opinion on this:

http://www.op.nysed.gov/nurse-standingorders.htm

This allows nurses to treat anyphylaxis, immunize and test for PPD and HIV in certain populations. This can be done without a provider relationship which is necessary for any other order.

Depending on where you work, SCDs can be either a nursing intervention or an order. I have seen it both ways. In my current situation, when I admit someone I have to order SCDs on the DVT prevention order set. When we take the patient to the OR I am asked do you want SCD's. Usually at 2am I give an affirmatory grunt. But if we are doing bypass I may not want them on one leg. After surgery I have to reorder them. So clearly in this situation it is an order item (I'm not even sure if standing orders are allowed in GA).

In my previous job on the rare occasions that I wandered onto the ortho floor there was a posting by the unit secretary that stated standing orders for DVT prophylaxis. There was a column with each surgeons name and what they wanted:

Dr. Smith Lovenox 30 mg BID

Dr. Jones Coumadin Protocol

Dr. Phillips Call on each patient.

For each physician that had a medication standing order there was an order on file which stated "Standing order for all TKA patients 30mg Lovenox SQ BID" or similar signed and dated. They had to fill out a new one every six months. That was the hospital policy.

Now other ORs may operate differently than the 10 or so that I have been in but I have never seen a covering order like this. Most of the times it is things written on the preference card like SCDs for all cases. Now if that is a nursing intervention then all is well and fine. If it is not then technically there should be an order or verbal order in the chart. In our case it is done in the room or when the surgery is ordered the surgeon or fellow will put "To OR in AM, Type of surgery, SCDs with patient. 10 units PRBC's with 10 units on call". What happens a lot is the nurses know the physician always wants SCDs so they stop asking. Is that right? Thats between the nurse and the hospital/BON. The issue is that its only a problem when its a problem.

As far as the preference card - as far as I know its just a list of the physicians preferred instrumentation and set up. I have never heard of it being regarded as a standing order. The name pretty much says it all.

The other issue is nursing protocols. You can initiate a lot of orders with one order this way. For example if I write "initiate fulminant hepatic pathway" then a whole lot of labs get ordered, meds get started, neurosurgery gets consulted, etc. This happens without me having to write any more orders. You can have something similar happen in surgery where "take the patient to the OR" means that other things get done according to the protocol/pathway.

David Carpenter, PA-C

[OR male nurse]

the real question is what makes a standing order. First of all not all states allow standing orders and some that do only allow them in very specific circumstances.

As far as the preference card - as far as I know its just a list of the physicians preferred instrumentation and set up. I have never heard of it being regarded as a standing order. The name pretty much says it all.

Thanks so much.. This is all I was trying to say.

[ebear, BSN, RN]

We implemented an "Intraoperative Order Sheet" years ago.

This covered:

1. Which prep solution to use

2. Foley cath (removed in O.R. or not) and straight cath pre-op

3. Blood components (type and X match, FFP, packed cells, whole blood etc.)

4. Drains

5. SCM's (teds are no longer used as an adjunct)

6. Meds., including locals, Heparin, Papaverine, antibiotic irrigants,etc.

7. Irrigation solutions and amount on field

8. X-Rays (flat plate or C-Arm)

9. Dressings

10. Other

The doc signed the order sheet usually in PACU. Appropriate box was "checked" as an order.

Worked out well and everybody was covered.

ebear