Bizarre Med Order

[UrbanHealthRN]

This is actually a kiddo on the daycare side, not preschool side, of my agency. And actually, he's a 4 month old baby, not kid. But anyways. Has bad reflux that's not under control plus I guess had a cold 6 weeks ago that involved some wheezing. Has been on multiple daily albuterol nebs ever since the cold started, and hasn't stopped. I'm new to this job, just found out about this kiddo on Friday, and have been working to make sure all med paperwork etc. is in place.

Checked him out today before the time that staff would usually give him a neb (here, classroom staff can give meds, not just a nurse), and he sounds totally fine with my stethoscope. No reason I can see in that moment to give him albuterol. He gets the neb, cries and fights it the whole time, and of course is coughing and refluxing by the end of the treatment.

I think to myself, no way did the doctor mean it when she prescribed albuterol as "give one vial every four hours" (no prn, no give for xyz symptoms), so I call the family and they call the doc. Nurse from the doc's office calls me back and is super rude, basically telling me my assessment means nothing, I don't know anything about this baby, and how dare I not follow doctors orders by not giving albuterol exactly every four hours? (Um, even the parents aren't doing q 4 hr treatments, but I guess I'm the bad guy here...) She tells me that this baby is going to need to continue q 4 hr, around the clock, albuterol treatments for probably another few months before they can cut him down to prn.

Ok. Rant over. Am I crazy? Have any of you seen a kid get this much albuterol before? I was so taken aback by her tone, I kind of just said sure, thanks for the clarification, we'll get on it, but I reallllly don't feel ok about this. Staff are going to be treating this baby 2 to 3 times daily, and for what? I guess the family is pretty worn out trying to manage his health problems, and is tired of communicating with staff about his daily condition and concerns, but I'm almost wondering if I can say this is nuts and my nursing license and staff aren't going to be involved with this medication nonsense.

[MrNurse(x2), ADN]

I am shocked at the lack of professionalism from that doctor('s office). I have always spoken to the doctor when I call. They have even gone so far as to interrupt a visit so I can speak to the doctor.

[Farawyn]

Sounds like your hands are full, but you've gotten great advice.

Thanks for the pink.

[pedi_nurse]

Once upon a time when I was on rotation in the ER, we did neb a baby continuously.

In the ER. In crisis.

I have nothing else to add. With asthma meds, I document my assessment of the lungs (no adventitious breaths sounds noted bilaterally, all lobes), a pulse ox if I can, document that the student's color is WNL for ethnicity, lips pink, s/he is not posturing for comfort. But if asked, I give the med because I don't want to be "that nurse." I realize it's different for you. The little one can't ask. It's also possible that the nebulizer is being used off label for esophagitis. We had a kid at camp who had an epiglottal "issue" and that was treated with inhaled albuterol.

Having said all that - deal with the social worker. I love Flare's comment. Use that. This is nuts.

I'm a former acute care pediatric pulmonology nurse... we NEVER discharged patients with q4h treatments beyond 2-3 days with a follow up with their own doc. I also worked at a pediatrician's office for a bit. Again, NEVER prescribed more than 2-3 days of q4h treatments. Anything requiring more than that needs a prescription for steroids. As for the off label esophagitis stuff... I don't know much about that, but it seems to me that steroids would be more appropriate.

OP, definitely keep pursuing this until you get clear direction from the doctor. The only cases I've ever seen with q4h or QID albuterol was for chronic/complex care kids such as kids with trachs, cystic fibrosis, or pulmonary dysplasia.

[UrbanHealthRN, BSN, RN]

SUCCESS!!

I called the pedi's office, asked for the doctor to call me back, and she did. Which, by the way, I'm glad I called today, because she's going to be out of the country starting tomorrow! Laid it all down to her about what staff and myself have been observing with this baby, and what my concerns are. New plan is albuterol nebs every 4 hours as needed, based on my assessment. Also, the foster family has been majorly struggling with giving the once daily reflux med, so I am going to take over that administration with staff and we're going to make sure he gets his med every day, because most of the respiratory issues are coming from- surprise!- the reflux.

Thanks for the support, folks. I've gained a lot of good perspective and clarity with this situation, and I'm going to use that to keep me moving forward in my new job with other situations that might come up.

[NutmeggeRN, BSN]

Yay, great result!!!

[scuba nurse, BSN, MSN, RN]

SO glad it worked out the way it should have!!

[Nurse SMS, MSN, RN]

Well done! :)

[MrNurse(x2), ADN]

Great follow up. I would recommend going forward to not allow office staff to respond to what the doctor should address. Sometimes nice doesn't win, firm works better.

[tining, BSN, RN]

Great patient advocacy - that's our job.

[ATTACH=CONFIG]26950[/ATTACH]

[nekozuki, LPN]

Honestly, q4h albuterol is normal in our facilities (different medical daycares and groups homes with patients of various ages and conditions, some ventilator dependent, some that are highly functional and eat/breathe on their own). For a few of my patients with significant reflux/vomiting, they were kept on that regiment for years. Pulmonology wanted it that way due to chronic issues + potential aspiration/overlap issues from reflux + being fragile while around other kids. Possibly excessive, but definitely not unheard of.

Bless school nurses. You all are such a catch-all for everything under the sun.

[Neats, BSN]

I would send in a request saying you have to have the actual signed physician order with start and stop date that include what medication and dose amount and dose times, you could contact the pharmacists who would be happy to call the provider.

[Tenebrae, BSN, RN]

Friend of mine had a nurse tell her that her surgical wound post op was fine (this was over the phone and wound was never sighted)

2 days later my friend was admitted to hospital for insertion of a drain to remove excess fluid post op) and IVABs for a post op infection.

My point, if it sounds like the nurse is talking brown stuff, consult directly with the doctor, advise him of your assessment findings, the fact that the child gets super distressed with the q4 salbutamol and request that he makes the order PRN