Without Orders

hodgieRN · Mar 22, 2013

There's usually an order to insert a PIV, and then the system will automatically reorder it every 96 (on EMR). As long as the the admission orders have an order for an IV, any reinsertion is covered per protocol.

There are many things that you don't need a doctor's order for. These days, hospitals have moved toward evidence-based medicine and many of the bundles are already pre-approved by hospital administration and medical directors. You are allowed to insert an NG on intubated pts, you are allowed to program feeding pumps to flush with 30 ml water every 4 hrs unless the volume is specified different, you can use clog-zapper on clog feeding tubes, etc.

Many orders also fall under nursing or ancillary order sets and they don't need a doctors order. You can initiate fall precautions and a dietician can order PO vitamin C and zinc for wound healing without a doctors order.

If you are ACLS certified, you can initiate CPR, you can defib, and you can pass ACLS drugs like (epi, atropine, vasopressin, etc) without a doctors order. That's because it's already pre-approved and the time of response in a code is vital.

Almost everything these days has a protocol. If a pt was obviously septic, I'm not gonna wait for a call back before I start the nursing portion of the sepsis bundle. Most things that don't need an order is already technically ordered by the medical directors.

BrandonLPN, LPN · Mar 22, 2013

But even protocol or ancillary order sets are still physician's orders. They're all standing orders. They were all developed by physicians and I'm sure they're all approved by the medical director and the official document, wherever it is, bears his signature.

Non invasive or non pharmicological interventions such as repositioning or breathing exercises are purely nursing interventions. But so many other interventions, ranging from bowel care to catheterization, Tylenol for fevers, inserting an IV, hypoglycemia protocol all are dependent upon pre determined physician order sets. Where I work, even ear irrigation follows standing orders. Can we really say we're doing any of these things "without orders"?

psu_213, BSN, RN · Mar 22, 2013

You may want to doublecheck your facility's policy. I'm pretty sure a iic/heplock requires a physician order. It's invasive. Could be wrong, wouldn't be the 1st time.

I know in our ER we need an order...

psu_213, BSN, RN · Mar 22, 2013

From the ER perspective...we need an order for pretty much everything (even to give a pt food or water, I have to consult a physician and I bring this up in my nurses note) except a blanket--although you sometimes get an order for cooling or warming blankets.

On the other hand, I know that, within reason, I can verbal order basic "stuff." For instance, on a chest pain I can enter EKG, line, labs (CBC, coags, BMP, trop), chest X-ray. On someone who has had tarry stools for a week, dizziness, on coumadin, I will enter IV (probably 2), CBC, coags, T&S, etc orders. I will not enter for meds (even a bolus) or more in-depth studies (like a CT) without actually consulting a doc. I know our docs will back me up on the basic stuff even though I did not actually talk to them before placing the orders.

PMFB-RN, RN · Mar 23, 2013

This is one of of the things you learn as you go along with help from your coworkers, and it varies greatly by facility and field. I recently had a urologist tell me, "Take out that foley and put in a 24 Fr. irrigation catheter and make sure he has something for pain."
That sentence gave me free reign to enter a crap ton of orders.

*** LOL! I think you and I work at the same place! I get similar orders all the time. "PMFB (not just me, insert any of the RRT RNs names here) will you sedate that guy", "PMFB will you start a drip on that patient, look at his BP!", "PMFB can you go down to (insert name of unit with crashing patient) and keep a lid on things until I can there? (says doc who is up to his eyes balls in a differnt crashing patient)". What do you want me to do about his pain doc? "You know, whatever you think is best". Hey doc what do you want me to do about XYZ? "Um, let's see, what do you usually do about XYZ?"

To the OP: My experience is whatever I need to do. I have a VERY supportive medical director who backs us up. We have a vast number of protocols and standing orders but somtime we have to go "off reservation" and when that happens our medical director will back us up, that is if anyone even notices. If I didn't trust the docs I work with I would limit myself a lot more.

Penelope_Pitstop, BSN, RN · Mar 23, 2013

If a facility has standing orders for giving Tylenol or starting an IV in certain situations, you're still technically following doctor's orders. Such policies were still written bu medical staff, and I'm betting there's some sort of document somewhere detailing these orders that bears a physician's signature.
I'm pretty sure there's just about nothing in the way of medication administration that nurses initiate completely independently of some sort of physician's order. At least not in a hospital or LTC facility.

I've pushed epi in a code situation before a doctor showed up. But I'm ACLS certified and was tested on running my own codes. I think that's still an example of carrying out doctor's orders though.

Esme12, ASN, BSN, RN · Mar 23, 2013

Hey all! Have been reviewing multiple websites, state government and blogs and found that laws are very vague. I know this is to allow grey areas to occur to allow patient safety as well as protect nurses and other health professionals in emergencies but I was wondering...what are some of the things that you all can do without doctors orders? Obviously comfort is a consideration here but name some examples all responses welcome :)

I am curious....what do you need this information for so I can better know how to answer.....know what exactly you are looking for......is this for a school project?

Nurses are covered by individual hospital policy and state legislation that varies facility to facility and state to state. It also varies with different department within a facility and the level of training of the nurse for example there is a difference between a floor nurse nad the ICU nurse and there is obviuosly a difference between a bedside nurse and a Nurse Practitioner.

joanna73, BSN, RN · Mar 23, 2013

We have standing orders for a whole list of medications at my facility. Aside from that, if we need to administer O2, or remove a catheter or an IV that's gone sour, we will do so and inform the MD later.

This is dependent on your facility and the MD. Our Docs expect us to make reasonable decisions on our own. They will want to be informed, but they don't want to be bothered for every little thing.

Nursey103, ADN, RN · Mar 23, 2013

I wouldn't be entering orders for pain meds without the doc giving me specific orders...that's practicing medicine & out of our scope of practice....I value my license too much...

eatmysoxRN, ASN, RN · Mar 23, 2013

I think many times it depends on the doc. Some doctors have pages of routine orders. Others don't. Some you know you can order their patient a lunesta at 1 am because if you called them for that you'd get yelled at.

If the patient is under hospitalist services, the resident or hospitalist has to put orders in and we cannot write them.

On my floor we get a bunch of chest pain obs. We are expected to get an EKG for c/o cp. We also put them on tele if we feel they need it when the doc forgets to write it.

IVs are just required. Unless it's an order set that's preprinted they don't always write it but it's done.

My facility gives nurses a fair amount of independence. Peaked t waves? Run of VT overnight? They'll be cool with me ordering a mag and a K.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

RNfaster · Mar 23, 2013

Nurses who write orders without speaking to the provider or without basing them on a protocol are technically practicing medicine as I see it. But nurses are doing this to help save lives and to avoid waking up or bother a provider, right? It seems to me that the institutions come out on top by not having to adequately staff providers and/or create protocols, and/or create order sets (that help a provider write adequate orders). Additionally, providers come out on top as they have less of their time infringed upon. The liability then is placed on the nurse. That seems inappropriate to me. It's nice for the institution and the providers as they are not inconvenienced.

Institutions should support their nurses by having in place adequate numbers of providers, adequate orders, and adequate protocols. Providers should not be allowed to yell at nurses. Institutions should devise systems that help providers write adequate orders. On the other hand, if this is not to occur and nurses are to blur the lines and write orders on their own, nursing practice laws should be changed to cover them.

There is at least one story on this site that I recall someone saying they lost their job over writing a Tylenol order at night without calling the MD...and then the MD refused to back it up...even though nothing happened to the patient...

Twinmom06, ASN, APN · Mar 23, 2013

the hospital I'm doing clinicals at has a standing "titrate O2 to keep sats above 92%" and also if someone isn't feeling "right" and is on room air we can put them on 1L N/C without an order...