Thank the good lord for standing orders.

whichone'spink, BSN, RN · Sep 21, 2015

Sigh. I wish I had standing PACU orders because it is annoying as hell to ask to get orders from some anesthesiologists, especially those that have gone back home after the last case.

blondy2061h, MSN, RN · Sep 21, 2015

Zofran 5mg? Diphenhydramine 250mg?

Standing orders for diarrhea are a bad idea unless they include no antidiarrheals until confirmed c diff negative. Giving loperamide to someone with c diff puts them at risk of toxic mega colon.

Standing orders for heartburn make me concerned a cardiac event could be missed.

Tylenol PM for insomnia is about the worst thing possible. First off- if the person JUST has insomnia, you're giving them a second medication, Tylenol, that their liver has to metabolize for no therapeutic benefit at all. These are probably older adults, which means they're likely already on many medications metabolized by the liver and may not have the best liver function to begin with. Secondly, Benadryl is truly awful for sleep. It may help someone get to sleep, but it prevents the body from entering REM and getting restorative sleep. It is a bad drug for older adults, putting them at risk for delirium and falls.

I know LTC is different, but I see a lot of liability potential in this set.

akulahawkRN, ADN, RN, EMT-P · Sep 21, 2015

I truly hope that diphenhydramine order for itching isn't truly 250 mg... that's what, 5-10x the usual effective dose...

VANurse2010 · Sep 21, 2015

Zofran 5mg? Diphenhydramine 250mg?
Standing orders for diarrhea are a bad idea unless they include no antidiarrheals until confirmed c diff negative. Giving loperamide to someone with c diff puts them at risk of toxic mega colon.
Standing orders for heartburn make me concerned a cardiac event could be missed.
Tylenol PM for insomnia is about the worst thing possible. First off- if the person JUST has insomnia, you're giving them a second medication, Tylenol, that their liver has to metabolize for no therapeutic benefit at all. These are probably older adults, which means they're likely already on many medications metabolized by the liver and may not have the best liver function to begin with. Secondly, Benadryl is truly awful for sleep. It may help someone get to sleep, but it prevents the body from entering REM and getting restorative sleep. It is a bad drug for older adults, putting them at risk for delirium and falls.
I know LTC is different, but I see a lot of liability potential in this set.

You can't send everyone out for acute care workup for simple complaints. LTC is different - and most LTC residents don't develop C. Diff out of the blue

blondy2061h, MSN, RN · Sep 21, 2015

You can't send everyone out for acute care workup for simple complaints. LTC is different - and most LTC residents don't develop C. Diff out of the blue

We've had plenty of LTC's in the news in this area with c diff epidemics, and one even had a c diff related death. So it happens. Waiting a day for a c diff to come back won't be the end of the world, unless they're truly having copious diarrhea, in which case I'm guessing they'll end up acuted out for IV fluids anyway.

Substituting melatonin for sleep and hydrocortisone cream with Benadryl if that's ineffective seem like better alternatives to me.

I'm in no way against standing orders, but they have to make sense and be safe.

I would think even in long term care and patient with new onset shortness of breath and hypoxia and no pulmonary history would at least warrant a phone call?

SleeepyRN · Sep 21, 2015

I truly hope that diphenhydramine order for itching isn't truly 250 mg... that's what, 5-10x the usual effective dose...

LOL

That's one heck of an allergic reaction. There's no way. I'm positive that must be a typo.

ixchel · Sep 21, 2015

Itching: Diphenhydramine 250mg q6 PRN

Holy Benadryl, Batman! lol

We have some docs who are amazing at ordering PRNs and some we have to push hard just to get a dose of Tylenol. I hate calling the outpatient docs at night, but thankfully they tend to think ahead quite well.

What bugs the crap out of me if when a patient comes in with a situation causing obvious severe pain, they come up to the floor after getting a dose of something in the ED, and then they come up with no PRNs in their admission orders. Then we get THAT ONE HOSPITALIST, queen of the one-time underdose, afraid of an actual timed PRN, who will say, let's do 325 of Tylenol.

SleeepyRN · Sep 21, 2015

I second everything Blondy stated. And I work post acute rehab which is very similar to a nursing home. In fact, so many people use the terms interchangeably (which drives me NUTS.)

downsouthlaff, LPN · Sep 22, 2015

It most certainly was a typo lol this iPhone screen is cracked! Diohenhydramine 50mg hahaha

downsouthlaff, LPN · Sep 22, 2015

I really think Blondy that you misunderstood some of these standing orders. Again, what your saying makes sense but it's the Physicians license and his standing orders. I'm sure when he put these standing orders in place, he didn't just expect the nurse to blindly just give these meds repetitively. Nurses are supposed to assess too. The nurse could take into consideration the circumstances, is there a virus going around in the facility, is the stool very foul smelling consistent with CDIFF.

VANurse2010 · Sep 24, 2015

We've had plenty of LTC's in the news in this area with c diff epidemics, and one even had a c diff related death. So it happens. Waiting a day for a c diff to come back won't be the end of the world, unless they're truly having copious diarrhea, in which case I'm guessing they'll end up acuted out for IV fluids anyway.
Substituting melatonin for sleep and hydrocortisone cream with Benadryl if that's ineffective seem like better alternatives to me.
I'm in no way against standing orders, but they have to make sense and be safe.
I would think even in long term care and patient with new onset shortness of breath and hypoxia and no pulmonary history would at least warrant a phone call?

It happens, but it's not the norm. Bear in mind that many LTC facilities no longer send people out for IV fluids - they are given in house via clysis or PIV.

I would wager that most of those c. diff. patients are those with obvious vulnerabilities like recent hospital stay and/or antibiotics. Assessment matters.