I have a two nursing degrees, going for a third and have a whole lotta common sense. When I see stupid or hear stupid orders I may or may not carry them out..here are my all time favorites:
1) Male patient with active lower GI bleed...HGB of 5...Hypotensive and tachycardic..has 2 large bore IVs running with NS wide open as fast as it will go...blood bank working as fast as possible to get me my units of PRBCs ASAP...BP barely 90 systolic.
Order from resident: "We need orthostatic vitals on this patient"
Maybe they had some liver problem and couldn't take tylenol,
maybe they had some kidney disease and couldn't take NSAIDS either.
Are you referring to the post about the pt allergic to asprin? The point of the stupidity is that the resident orders asprin and nurse states that pt allergic. nurse asks if resident wants to change order, resident says no. The resident insisted on ordering a med the pt was allergic to. That is dumb.
We have an MD that frequently orders urine Hcg's to R/O pregnancy on abd pains and before getting back or abd. films. That's fine, but on our hysterectomy patients?? Also he will order a urine hcg and beta hcg at the same time. I understand maybe urine first then blood to confirm approx. gestation, but really! I often wonder what these patients insurance companies have to say...or how much of these test cost we have to eat.
These docs are like freakin robots--mark the same boxes over and over and over. Just look at the trige sheets, please. Save me some busy work!!
Actually HcG are a standing order on all females of reproductive age in our ER. Even on the "sterilizated" or hystorectomy pts, maybe it's thy same in your facility?
Actually on females of child bearing age i.e. 11 or 12 to 65 ish with an intact uterus or still has her ovaries we do get urine pregnancy tests on them. In my 20 years I have seen 2 ectopics in post tubal ligated women. So it can and does happen and needs to be ruled out. One would be negligent not to.
Inferior MI, CP ,Hypotensive, allergic rx to morphine (yeah found that one out the hard way, I gave it), trying to leave the bed, oh yeah brady-28, altering LOC
Orders: Gravol for the allergy(me: you mean benedryl iv?)
Atropine for the symptomatic Brady(me:Actually, I've already got the pacing
pads on)
Nitro gtt for the persistent CP(me:Are you sure? Have you consulted a cardiologist in the city? What did they suggest?)
Lasix IV for the "fluid" in the lungs, Can you say wheezing following an allergy?(me: are you sure, how about some ventolin nebs?)
Fortunately the pt survived. Airlifted from our rural site.
Specializes in Emergency/Trauma/Critical Care Nursing.
I was working night turn on med/surg and got a"possible OD" from the ER...she had been Narcaned in the ER and we were told she was OK for admission. About 4 hours later (3am), she crashed and was a nice dusky shade of blue when we found her....I immediately grabbed more Narcan figuring that was what would be ordered while another RN called the Dr and explained what was going on.....the order we received....."Give D50 IVP, feed pt and get glucometers q 1 hour until blood sugar is > 125" and he hung up.
HELLO!!?? can we say...NEEDS NARCAN!??? Tried to call him back and he didn't answer so we ended up calling the ER doc to come up...FINALLY got the Narcan order, narrowly missing a full code and sure enough....she came right around for us.....
only to die about 2 months later of another OD
regardless on what the docs thought she had "possibly OD'ed" on, most of the usual suspects are much longer acting than narcan anyways, so if this pt didn't stay in the ER for very long after the first doses there should've been a PRN order for it anyways. In my ED unfortunately the wait for a room upstairs can sometimes be quite a long time so a lot of times when pts come in OD'ed on heroin and respond to narcan they end up starting to go back downhill within a few hours because the narcans wearing off but the heroins still in their system.:icon_roll docs can be dumb sometimes eh? lol
Specializes in Emergency/Trauma/Critical Care Nursing.
ok this one is a little off the subject because it was an issue i recently had with pharmacy, not a doctor, and it was about my script.. I have been dx'ed ADHD for five years and have been on regular adderall, not the XR, for five years... as you know its a controlled substance therefore i have to get a new script every month and turn it in, no rapid refills for me lol. well i've always taken it to the CVS down the street, every month for FIVE years.. i don't know if this was a new pharmacist or what but i turned my script in and its a computer generated script ordered for the Adderall rx 314.9 etc etc, well the pharmacist gives it back to me and says "i can't fill this, this is a new brand of adderall that i don't have in stock yet, if i call to order it its going to take a couple weeks to get it in, you need to check a different pharmacy" and i say.. umm what new brand of adderall would that be that ur talking about?? and she says Adderall DX, we don't carry it. so i roll my eyes at her and say " you ARE kidding i hope.. there is no such thing as adderall dx, thats the DIAGNOSTIC CODE for the prescription! check my file here i've gotten the same exact script every month for five years filled here! and she refused to check it and said i was wrong and that i needed to go to another pharmacy... :angryfireso i'm livid at this point because i just got off a 16hr shift on midnights, stayed awake till the pharmacy opened, and had to work again that afternoon so i was hoping to get this done quickly so i could go to bed...
so i drive down to walgreens four miles away, when the pharmacist asks if she can help me i say "i hope so, the other place refused to fill this script for me because she doesn't have 'adderall RX' in stock" and the lady starts laughing and saying, please tell me ur not serious... a PHARMACIST said that to u? thats the diagnostic code! THANK YOU THATS WHAT I SAID! so she then proceeded to call that pharmacy and give the pharmacist a refresher course on medication abbreviations lol she asked her "what did u think DX stood for? Doesnt eXist?? i thought that was funny... so in the end the pharmacist that actually graduated college instead of buying her degree on line filled my script for me, who knows if any of u will find this as dumb as i did but i think its kinda scary when our pharmacists are dosing out meds when they don't even know whats real and whats not... especially to elderly people who don't understand half the meds anyways!
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
Pt info:
Inferior MI, CP ,Hypotensive, allergic rx to morphine (yeah found that one out the hard way, I gave it), trying to leave the bed, oh yeah brady-28, altering LOC
Orders: Gravol for the allergy(me: you mean benedryl iv?)
Atropine for the symptomatic Brady(me:Actually, I've already got the pacing
pads on)
Nitro gtt for the persistent CP(me:Are you sure? Have you consulted a cardiologist in the city? What did they suggest?)
Lasix IV for the "fluid" in the lungs, Can you say wheezing following an allergy?(me: are you sure, how about some ventolin nebs?)
Fortunately the pt survived. Airlifted from our rural site.
I'm interested about the "fluid in the lungs"...
Did they see "fluid" in the CXR? If so it probably wasn't from an allergic reaction.
When listening to the lungs; "fluid" would be rales probably, whereas lung sounds with wheezing are just that "wheezes" (musical) not "wet sounds"....the allergic reaction causes bronchoconstriction not pulmonary edema....
However, it is more common to suspect that an inferior MI (as well as, but not as commonly as a R sided MI) can decrease diastolic function, leading to heart failure and pulmonary edema. Matter of fact, this is one thing that must be ruled out before you consider a new diagnosis of CHF - you have to rule out occult MI.
Also in an inferior MI (as well as R sided MI), you need to reduce the pre-load (due to the dec diastolic function) and a nitro drip will help with that, it will actually increase the cardiac function and decrease the workload.
Oh, also, Morphine helps to reduce pre-load as well; that's one of the reasons to give it for acute MI as well.
I forgot one of my all time favorite dumb orders. We had a pt admitted for a TURP. Doc comes in and writes his usual pre-op orders. 1) Senekot S 2 tabs po at hs. 2) Tap water enema in AM. 3) Bilateral below TED hose. Great orders with the exception of the fact that this pt had bilateral BKAs. We were debating whether we should send the prostheses to the OR with the stockings on or what. The OR nurses read the order and ripped the doc apart all during the surgery. Poor doc couldn't get out of the hospital without passing through our ward. We were lying in wait for him. We started peppering him with questions like "What is the incidence of DVT in wooden legs?" He couldn't get out of there fast enough.
Great thread!! Very funny orders, but as stated previously, SCARY!
I don't know what I would do without the other ED docs and hospitalists to fix the crazy orders. Now that we have CPOE, taking orders over the phone is a NIGHTMARE; "Just order the set, okay?" Click. Order set is 7 sections long with lots of content that is obviously not applicable. So we call back. And we call back. And again, to clarify the meds (even after recon is done.) We have just about got them all trained to get the hospitalist to do the orders.
In the ICU where I work, according to our protocol if the blood glucose is 110-150, we give two units of regular insulin. It doesn't matter if the patient is NPO. They get insulin coverage no matter what. Tighter glycemic control leads to less infect and better wound healing.
Blood glucoses of 150 should be covered with insulin. I don't know how it is at other hospitals but for every patient that is admitted they are automatically put on the SQ insulin protocol whether or not they are diabetic. Patient heal better and have less infection with tight glycemic control. I wish I could post how long the insulin protocol is on my unit. It's almost ten pages. If our patient is NPO we cover glucose levels 110-150 with two units of regular insulin and if they are greater than 150 they go on an insulin drip.
Michigan RN, as I read these posts, I remembered this recent study. Seems "tight glycemic control" only leads to management of more hypoglycemia. I thought it was a very interesting study.
Thanks for the info, just to clarify a few things.
1."fluid" there was none in the lungs, no rales auscultated, only wheezes.( Yes I did the listening and can tell the difference) No CXR done, no portable xr machine and the pt went from ok to worse. [ just me and 9 beds ER+ triage+ treatments.]
2.Can you explain to me how decreasing the preload will increase cardiac function in a bradycardic(28 bpm), symptomatic and hypotensive (
3. Morphine, I know that it is vital in any acute MI, the pt had no known allergy to it yet when it was given immediatley developed redness, itching and a rash on the arm it was given IV that spread rapidly, so really my remark about the morph was to give context about how inappropriate gravol would have been in that circumstance.
This particular MD was really pleasant but didn't know his meds, consistently ordering two or three times the normal dosage, meds not related to the condition (not even off book uses). So I was really hesitant to start a nitro gtt without him consulting a cardiologist.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
mwboswell
Thanks for the info, just to clarify a few things.
1."fluid" there was none in the lungs, no rales auscultated, only wheezes.( Yes I did the listening and can tell the difference) No CXR done, no portable xr machine and the pt went from ok to worse. [ just me and 9 beds ER+ triage+ treatments.]
2.Can you explain to me how decreasing the preload will increase cardiac function in a bradycardic(28 bpm), symptomatic and hypotensive (
3. Morphine, I know that it is vital in any acute MI, the pt had no known allergy to it yet when it was given immediatley developed redness, itching and a rash on the arm it was given IV that spread rapidly, so really my remark about the morph was to give context about how inappropriate gravol would have been in that circumstance.
This particular MD was really pleasant but didn't know his meds, consistently ordering two or three times the normal dosage, meds not related to the condition (not even off book uses). So I was really hesitant to start a nitro gtt without him consulting a cardiologist.
WOW, I re-read my post and I BLEW it, I was actually muti-tasking at the time and got my posts/wires crossed.....
You are CORRECT; IWMI/RSMI nearly ALWAYS require fluid resuscitation to prevent cardiogenic shock! Multiple fluid boluses usually. That being said sometimes acute pulmonary edema can result also...it's a difficult balancing act.
For IWMI/RSMI diuretics/nitrates/morphine should be avoided if possible, unless there is another compelling reason to give them. But the rule of thumb is to intervene before cardiogenic shock ensues, if anything maybe an inotrope or pressor....
Please accept my apology for my errant posting..sorry about the confusion!
mwboswell
561 Posts
Maybe they had some liver problem and couldn't take tylenol,
maybe they had some kidney disease and couldn't take NSAIDS either.