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What have you done without a Dr. order???

Nurses   (21,227 Views 69 Comments)
by PureLifeRN PureLifeRN (Member)

PureLifeRN has 4 years experience and specializes in OR.

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grandmawrinkle specializes in adult ICU.

6,885 Visitors; 272 Posts

I will advance diets and ambulate post-op patients if need be before the patients actually get orders for these things if the resident is slow in getting to the floor to write transfer orders. I will pull lines (swans, artlines) if they have transfer to floor orders as it is implied that those are going to come out if they transfer to the floor as the floor won't monitor them, even if it isn't explicitly written. Some things are common sense and you more or less know what is on the "pathway" even if the pathway isn't explicitly written. If there are contraindications or any question about it, I'll run it by the doc first.

We have protocols for hypoglycemia and respiratory distress, etc. that covers oxygen, ABGs, D50 or other choice of sugar. I will not do cultures, including stool, for diarrhea as some have mentioned here. Diarrhea does not always mean c. diff and when I have ran whether or not to cx by the doc, they do occasionally say that they don't want the cx done. I will do ANY emergency interventions -- a very wise stepdown nurse (where I started, a while ago now) told me in a medical emergency/near code situation that you can do a lot of stuff if you have ACLS because as a provider as your certification covers you, as long as you are within their guidelines. I haven't forgotten that.

I run into problems the other way, occasionally. I had a post-op that was oozy the other PM and the CBC hadn't been checked since immediately post surgery. I suggested a CBC check that PM -- the doc said no, they didn't think it was necessary. I came in the next day and his HgB was 6.4 with his AM labs and had already gotten 2 units of blood :uhoh3:. Unfortunately, sometimes we do know best, but we are not listened to. I documented my suggestion (MD was notified re: drainage, dressing reinforced x3, no new orders received.) What else do you do? Had patient been hemodynamically unstable and/or hemorrhaging, I would have drawn the CBC -- per ACLS differential dx, but that wasn't the case.

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18,776 Visitors; 2,334 Posts

If it's in the standing orders you're not doing it without an order.

To answer the original question - with the exception of O2, no.

"Knowing the doc" is all well and good until that doc is in a mood and refuses to sign an order to cover you. Or you're like co-workers I've had who gave milk of mag to someone in renal failure or harmless 'ol Tylenol to a patient with liver failure.

I enjoy my license, I even like my job sometimes. I'd prefer to keep both.

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7,602 Visitors; 545 Posts

I used to work ortho and the docs pretty much let the nurses they trusted order labs and stuff and get orders from them, but that did backfire on one of the nurses as the doc said he wouldn't have wanted that cbc and refused to sign the order. Not sure what ever happened. Just remember they have a license to protect to and they may one day decide not to sign what you did therefore you are then practicing medicine not nursing

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nurse_mo1986 has 3 years experience.

4,162 Visitors; 181 Posts

it also depends on where you work. I work in a smaller ruraal ICU in a smaller hospital and know all of our docs one on one. That means I know when they do vs. Don't wanna be called. Certain docs don't even wanna be called about a resp distress unless I've already done portCXR, and drawn ABG's. Then we have other docs who wanna be called stat and then will direct care.

I will say that in this setting we are expected to have a certain degree of autonomy. With certain docs I'd think nothing of giving tylenol at two am for a headace IF THERE ARE NO CONTRAINDICATIONS. A lot of times it just means thinkin for oneself.

And as far as the oxygen thing...i believe in treatin the pt as needed. If a pt has a sat of 60% and I think a code is looming, I'll do whatever it takes while waiting on the doc to return page/arrive in unit.

just my opinion, nurse_mo1986

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JenniferSews specializes in Professional Development Specialist.

9,827 Visitors; 655 Posts

I don't do much, but will gladly collect a stool sample prior to getting an order. :D I did give 02 without an order just this morning. It was purely therapeutic and taken off minutes later. But it got a lung CA pt through a few minutes of fear. If I had waited hours before the doc called back he may have been in actual distress. But a little O2 and a PRN pain med made it all better. We have no standing orders in our facility. If I want a colace or a Tylenol on a Saturday night I have to call unfortunately.

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2,326 Visitors; 54 Posts

Be careful what you post people.......

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klone has 13 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

3 Followers; 113,911 Visitors; 13,167 Posts

If anyone here admits to doing so, there'll be the holier-than-thou replies.

I like to consider it "self-preservation" rather than "holier-than-thou".

Would I ever announce on a public internet forum that I've done something outside my scope of practice without a doctor's order? Hell no.

Have I ever done something outside my scope of practice without a doctor's order? Well...um...I guess I'll have to say no.

(self-preservation, remember?)

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klone has 13 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

3 Followers; 113,911 Visitors; 13,167 Posts

well first of all, we should be anonymous on here, and any other internet site, if you're concerned about privacy.

You're naive if you don't think things like this can somehow be traced back. NOTHING is anonymous on the internet.

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Sugarcoma has 2 years experience and specializes in Trauma/Tele/Surgery/SICU.

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I am suprised and frankly kind of jealous at some of the responses in this thread. At my facility we are responsible for inputting all orders, take multiple verbal orders per shift and are often waiting on doctors who are very slow to call back......we have had patients leave AMA after waiting upwards of 12 hours for orders for diets, pain meds, etc. It is ridiculous and an environment where "cowboy" RN's thrive. I WISH we were not allowed to take verbals except in emergencies and that the docs had to enter their own orders. I also wish we got quick call backs. Noahsmama I would love to work in facilities such as the ones you have described!!!!

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8,812 Visitors; 558 Posts

When it comes to meds, labs, tests - no order, no action. Commonsense tasks such as turning up 02 - sure, why not? The docs are not your buddies. All it takes is one MD to say "nope, I never ordered that" and you/your license are toast. Even an ABG. And I work in a critical care environment. I have no legal/ethical responsibility to perform any task outside my scope of practice. My license (i.e.: ability to earn a living) comes first...

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dthfytr has 30 years experience as a ADN, LPN, RN, EMT-B, EMT-I and specializes in ER, Trauma.

12,257 Visitors; 1,159 Posts

Ultimately, when you come right down to it, you can always defend doing what's best for the patient. Working in ER's, for example; I'd much rather face a jury for giving a minor good medical care without parental consent, than face a jury for letting a minor suffer or deteriorate for lack of parental consent. I might lose my job, my license, the $67 I have in the bank, but I wouldn't lose 1 minute of sleep. Somehow the human race survived a long time without doctors orders, so they just might not be the hallowed message from the Gods we're told.

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dthfytr has 30 years experience as a ADN, LPN, RN, EMT-B, EMT-I and specializes in ER, Trauma.

12,257 Visitors; 1,159 Posts

Oops, I'm sorry, I've erred. No consent, no Dr's orders, and we can't bill for it. You see, the ultimate power in the universe is the almighty freaking dollar. But then I have a weird sense of priorities.

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