Will you give out a medication without the order yet?

[rn4ever?]

Just wanted to vent.....yesterday was a very busy day. The charge RN did an admission and apparently forgot to ask the dr. for a nicotine patch for a patient who was a heavy smoker when she asked for the admission orders of the patient. I gave out all the STAT orders and then the patient asked for the nicotine patch. I said, as soon as I get the order, I'll give it. Apparently, patient told charge nurse about it. Charge nurse barges in the medication room upset asking why I was making a big deal out of "just a nicotine patch" and also said that as an experienced nurse, she knows that it was not something to make a big deal of. I replied that I was uncomfortable giving something that was not ordered for legality's sake and it wasn't even an emergency! I don't care even if they say it's "just" Tylenol, Motrin, or a Nicotine patch-----if a patient gets a reaction and there's no doctor's order, I don't want to be in trouble. Because before, one patient told me that one of her allergies was a nicotine patch-----so it's possible to have an allergy from that. To the highly experienced nurses out there, was I out of line? What are your thoughts on this? How would you have reacted?

[PMFB-RN, RN]

"I don't know, do whatever you think is best"

That is the order I recieved Sunday night from a 4th year surgical resident when I called at 0130. My patient suffered a head injury, had undergone a crani then later went back for bone flap removal. ICP's where rising but I had standing orders to deal with that, BP was declining thus making it hard to maintain an acceptable CPP. I told him well what I want to do is start Levophed (already had CVP around 18 and a PAD in the mid 20's with great urine output) and is that what he wanted to order? I was trying to pin him down on something. "Ya, whatever" was the responce.

Another one I often hear from the first and second year residents when I call them for orders for a problem is "well what do you usualy do?". It's really practicing medicin by proxy. My goal is to take care of my patient, if that means encouraging, suggesting, or educating a physician about what the right choice is then that's what I do and what most of us do I suspect. I just consider it as advocating for my patient.

[jlcole45]

You were right to refuse.

[nursejudy15209]

NO MEDS WITHOUT AN ORDER! I work in corrections and a perfectly reasonable and seasoned nurse was let go for that very same issue! It's not worth loosing everything just to please somebody else. Do the right thing and W-A-I-T for the order. First and foremost, the patient does not dictate orders, other nurses cannot dictate orders either, so back to the basics of nursing care. Doctors give orders, the nurses carry out those orders. If the order is unreasonable, then use good nursing judgement and voice your concerns.

I do like the post about "back-pedling" So we all agree that you made the right choice -- good job!!!

[imintrouble, BSN, RN]

I'll put oxygen on before I call the doc for someone in resp distress. I'd never give a PO or IV med without an order. I know 02 is technically a drug. I don't apply unless sats are way down, and I immediately call the MD.

[NeoNurseTX, RN]

We can't even get stuff out of the pyxis unless we fax the order to pharm first.

[PMFB-RN, RN]

We can't even get stuff out of the pyxis unless we fax the order to pharm first.

*** In the SICU where I work we can override any drug in Pyxis and take out anything on any patient. You must have some emergency drugs you can override?

Also we give ACLS drugs without a specific order when needed but we have a protocol in place that allows us to do so.

IMO most routine problems encountered in a unit should be covered under standing orders and protocols. For example we have standing orders with sliding scales for electrolyte replacement, blood products and a bunch of other things.

[javanurse2000, BSN, RN]

Ha! I was once "corrected" by a (former) DON for not giving LORTAB without an order...couldn't get a hold of the MD - late at night. New admit CA patient in pain. I just kept alternating between his cell phone and his house phone (private facility, one doctor) until he picked up and ok'ed the order. Later, my DON came to me to tell me I just should have given it...I don't think so :uhoh21:

[filipina in Australi]

if the patient is using nicotine patch before admission,the patient can applied it as self-administered then ask the doctor to have an order,

[mightymitern]

OK so what happens if you had put the patch on, or in this case the Charge nurse had, and the pt had a reaction, or the Doc said no i am not writing an order for that because....., guess who gets in trouble. Not the Pt, the nurse who gave the med before the order came in. I agree 100% with everyone else no meds before orders! period. It was not an emergent med, the pt was not in critical condition. Bravo to you for doing your job right.

[RhiaRN75, RN]

You did the right thing!

There is no "...just an xyz" that will save you if something bad happens.

The doc may not want a nicotine patch. Nicotine can effect neurotransmitters, BP, HR, drug efficiency, peripheal circulation, etc. and there may be a good reason to not order it.

At the very least the pt could have a reaction to the patch, or sneak a smoke/dip while the patch is on and that would come back to bite you.

[SaraO'Hara]

Your CN is a twit.

[katnursey]

You were right not to apply the nicotine patch without having the order first. If something would have happened to the patient, you would have been held responsible.

Those patches can have severe side effects, which do not always occur right away. I used the patch a few years ago.....I was perfectly healthy. I do have a heart murmur- grade 2. I was absolutely fine for a week or so, then one day, I developed a severe headache, and I could feel my heart pounding and racing. I thought my head was going to explode. I usually run a low B/P 90/60, but when I checked it, it was 150/104 and my heart was racing. I never had read the side effects before using the patch. I saw my physician that day. He told me, he felt it was from the patch which got removed immediately. He told me, there has been problems with those patches in patients with even mild cardiac abnormalities. He also told me, he had a patient one time with hyperthyroidism, who experienced severe side effects from the using the patch and had to be hospitalized for observation.