Tylenol ordered for pain.

SarahJ08 · May 1, 2015

Just out of curiosity, would if you did work nights would you call the doc in the middle of the night to get the order changed, or would you have given it?

gouranga · May 1, 2015

I hope I didn't sound mean, I was not intending too haha. We as nurses are expected to administer and maintain drip like heparin, cardizem, amiodarone, or give iv pain medications, or whatever else potentially dangerous drug. (I've worked tele/stepdown for three years) but I need a doctor's order to give Tylenol for fever when it's ordered for prn pain. What kind of messed up profession is this. Going back to school so I can make the orders and not follow them hah.

Yeah, I get it. But I've been told repeatedly by nurses and doctors to cover my own ass, and that's always on my mind. I've worked too hard for my license, like all of you, to lose it over an egotistical doctor and OTC tylenol. So much of what nurses do can be turned around to seem negligent in court. So let's ignore the fact that it was tylenol, but that I technically administered it for a symptom it wasn't ordered for. Does that make sense?

gouranga · May 1, 2015

Just out of curiosity, would if you did work nights would you call the doc in the middle of the night to get the order changed, or would you have given it?

I probably would have talked to the other nurses on the floor and got their opinions before just giving it to the pt. Let's be clear that I called the doc to let him know about her fever which was > 103, not to ask if I should give the tylenol. I just wondered how other nurses would justify giving it.

Pangea Reunited, ASN, RN · May 1, 2015

Well these are things you learn with experience, right? It's not my job to decipher vague orders and make them something they're not. Orders are supposed to be clear and specific. Maybe if it wasn't for something as seemingly harmless as tylenol, you could take my question more seriously.

Honestly, I would have been comfortable giving the Tylenol my very first day working as a nurse. I deviate with other medication orders, too. I'm not trying to be insulting, so please don't take it that way ...I'm just genuinely surprised.

I guess we're all taught differently, along with having different personalities and being immersed in different work-place cultures. People sometimes do things that seem very weird to me, but maybe they think I'm weird, too.

tyvin, BSN, RN · May 1, 2015

Tylenol for pain or not, I would have given the Tylenol for the fever...over 103; come on. You can be way too literal in the nursing field and someone ends up with brain damage. I can see why the doc was pissed. Just saying; you need to own things...

:)

gouranga · May 1, 2015

Tylenol for pain or not, I would have given the Tylenol for the fever...over 103; come on. You can be way too literal in the nursing field and someone ends up with brain damage. I can see why the doc was pissed. Just saying; you need to own things...
:)

I need to own what?

Tenebrae, BSN, RN · May 1, 2015

Yeah, I get it. But I've been told repeatedly by nurses and doctors to cover my own ass, and that's always on my mind. I've worked too hard for my license, like all of you, to lose it over an egotistical doctor and OTC tylenol. So much of what nurses do can be turned around to seem negligent in court. So let's ignore the fact that it was tylenol, but that I technically administered it for a symptom it wasn't ordered for. Does that make sense?

I would have administered it for pain, given how narly pyelonephritis pain can be and asked the doctor to clarify the order when I next saw them. Then again I dont work in such a highly litigious country as you do. You were right on the money with the coolling cares BTW

Yes, you had given an NSAID previously however as long as there is no Hx of GI bleeding or gastric ulcer or liver problems it is safe to give the two in quick succession or together

Dont be too hard on yourself however. As you stated you have been out on the floor for a month learning loads.

calivianya, BSN, RN · May 1, 2015

I wouldn't have thought twice about the Tylenol either. Tylenol for pain is perfectly appropriate for someone with a fever if you look at pain and discomfort as being the same thing. I had a temp of 101 a few months back and it felt like I was being boiled alive. Muscle aches, constant shaking, etc. I would say relieving a fever and relieving pain are pretty much interchangeable terms because having a fever is painful. Maybe I just have a low tolerance for pain.

OP, you just have to know your doctors well. That's just going to come with time as you work with them more. Technically speaking, you are correct about needing an order clarified before doing something. However, that's kind of like being in NCLEX-land. In a perfect world you have orders for every possible ailment before you need orders for them. In the real world, it doesn't always happens that way. It doesn't mean you just sit on the patient and see what happens because your orders are not clear.

Since you did ask what we would do if it was another drug and not Tylenol, here is an example my preceptor told me - when one of my coworkers was a new grad, she had a patient on a Cardizem drip because he went into a-fib with RVR. His heart rate had come down significantly already. My preceptor was her preceptor at the time, and my preceptor suddenly noticed the patient's HR was down in the low 30s. She found this new grad and asked her what the drip was on, and was shocked to learn the drip was still at the max dose. My preceptor asked why, and the new grad replied, "There's no order to titrate the Cardizem drip. I have it on what it's ordered at." The new grad insisted that she was doing the right thing because she was following the order. My preceptor had to be the one to go and turn the drip off.

The nurse would have been following orders if that patient had coded because yes, technically, the provider forgot to put the word "titrate" in the Cardizem order, but it would have also been the nurse's fault the patient coded. Following orders exactly as they are written may sometimes lead you down a rabbit hole that will result in a patient being harmed or even dying. This is obviously a more serious example than Tylenol, but it just goes to show - you can't always trust your orders sometimes. That's what tyvin meant when he talked about owning it.

We are licensed professionals and we are ultimately responsible for what the patient is given, and yes, we can lose our licenses for practicing out of our scope, but we can lose our licenses for following orders that aren't right or aren't clear. It is a double-edged sword that we can lose our licenses either way. Tylenol is pretty small fish in that nobody has died from not getting Tylenol in the first 30 minutes of someone noticing the patient had a fever (at least, as far as I am aware), so in this situation, it was fine to wait and get the order adjusted. However, there will be situations where you cannot wait to get an order or get it clarified to help the patient, and I hope in those situations, you would not wait for an order to do what needs to be done.

Stuff like this is just going to come with time. Be gentle with yourself; learning the intricacies of being a nurse in the real world, outside of NCLEX land, is a long process.

Elvish, BSN, DNP, RN, NP · May 1, 2015

I'm of two minds about this.

1) Doctors need to be specific about orders. If you want me to use Tylenol for pain and fever (and not just one or the other), then write your order as "PRN fever > XYZ or pain". This was not a well-written order to begin with. Either way, a temp of 103 is probably something a doc should know about.

2) On the other hand, plenty of mother/baby nurses have given Nubain after a Duramorph c/section for "itching" when the patient was nauseated. Nubain works beautifully for nausea, but anesthesia would not always order it for that even though it's clearly an option on the preprinted orders (sometimes ordering nothing at all for n/v). Exact same dose and all. It worked, the patient felt better, and no one ever thought twice about it.

Sometimes when you're a nurse you're damned if you do and damned if you don't.

LadyFree28, BSN, LPN, RN · May 1, 2015

It's not my job to decipher vague orders and make them something they're not. Orders are supposed to be clear and specific. Maybe if it wasn't for something as seemingly harmless as tylenol, you could take my question more seriously.

Ahh, but it is...

As nurses, we are to advocate for our pts; because you went to school and not just learn to "follow orders"; we learned to think as nurses; we assess that the pt is going to have pain, so looking over the orders during our assessment, one would look and find, "hey, there's no order for pain," and assertively suggest for pain medication, and discuss with the provider what meds are available and will keep the pt comfortable.

It's our jobs to advocate, not blindly "follow orders". You will learn to devils a think skin and protect your pt's and you license, assertively.

And as my siggy line says "Don't go in with a chip, go with a bat, and use it when only necessary"....remember that you are going to deal with challenging behaviors, not just from pts and families, but from your peers, and the doctor is your peer. Never let them see you sweat. Be confident in you nursing judgement, even when you are learning, and you KNOW you are in the right.

Best wishes.

Guest219794 · May 1, 2015

You did the right thing.

I would not have. I would have given it. I might have been creative in my documentation to support the choice. Or I would have just given it.

Of course, if I knew the Doc was a schmuck, I might have called him to order it correctly. He's the dunce that didn't order a PRN for fever.

BTW- You treated the fever with Toradol. You're new, and might not realize that it is an antipyretic. What is Dr D***head's excuse?

gouranga · May 1, 2015

calivianya, thanks so much for your response. i'm trying to understand others' perspectives to see where i went wrong. i guess i am still practicing in nclex-land.