Would you question this order?

[dura_mater]

A little background first, I am a new grad, still on orientation and the other day I had a MD write an order that just didn't seem right. I asked some of my colleagues, and they all seemed to be ok with it, but I wanted to get some more input.

So I was taking care of a pt admitted for ALOC, dehydration and weakness. The pt's history was advanced AIDS, MI x2, pacer, BPH, and atrial thrombus. When this pt was admitted the INR was 6.7, he was on coumadin at home but obviously it was not to be continued while admitted.

Fast forward to the next day, when I was getting report on him, his INR is now 7.7. The off going nurse and I catch the MD and bring up the high INR to him, and his response was basically: "well, I'm not going to do anything about it, because he has an atrial thrombus, so I don't want to clot him up any more".

The MD proceeded to write an order that stated:

Don't call unless the INR is >10 or the pt is actively bleeding

Our policy is to call the MD for any critical lab values, and an INR gets to be critical way before it reaches 10. This order just seemed to be weird to me, it almost seemed like I was just waiting for him to bleed out before the MD wanted to address the situation.

I would love some input from you all, as I am just in the process of learning what/when to question and/or stand up to improper orders.

Thanks

[coolpeach]

I am also a new nurse, and had a great educator. Her point of view was its your license, and if you make a Dr. mad so what...he will get over it.

[blondy2061h, MSN, RN]

It hospital policy says it has to be called, it has to be called. Most hospitals will not let doctors write orders that override hospital policy. Just like a doctor can't write an order that it's okay for you to give levophed on a non-monitored patient, he can't decide he doesn't want to hear about critical lab values.

[HamsterRN, ADN, RN]

I'm not sure what the rationale was the first Doc was using. It's not unheard of to have supratherapeutic INR and a thrombus, since the the thrombus could have formed when the INR was lower and Coumadin won't dissolve a clot.

Usually what I see done is to reverse the coumadin and start the patient on a high dose heparin drip since the heparin is a thrombolytic and the coumadin is only an anticoagulant.

[PMFB-RN, RN]

I wouldn't question it. I would ignore it. If policy states you must notify for critical lab then notify. I would also notify each time it went up. As my patien't advocate I would suggest a hematology consult. If it get critical I would go over the physicians head to his boss, like the department head or the chief of staff.

Don't apologize for the notifications either. The only time it is apropiate for a nurse to apologize for calling a physician is if you misread the call schedual and called a physician who wasn't actually on call.

[SweetOldWorld, BSN, RN]

I'm not sure what the rationale was the first Doc was using. It's not unheard of to have supratherapeutic INR and a thrombus, since the the thrombus could have formed when the INR was lower and Coumadin won't dissolve a clot.

Usually what I see done is to reverse the coumadin and start the patient on a high dose heparin drip since the heparin is a thrombolytic and the coumadin is only an anticoagulant.

Heparin is not a thrombolytic.

[Ruby Vee, BSN]

what were the liver function tests like?

if you have questions about a doctor's order and you don't feel as though you can ask the doctor to explain the rationale, ask your preceptor or the charge nurse for advice. could be he just has a hissy fit and writes an order like "don't call me unless the patient is bleeding out" and doesn't really mean it or expect you to follow it. or there could be other rationale . . . inr is rising, but we don't want to reverse it unless the patient is actively bleeding because we don't want a pe or an embolic cva. (not that a hemorrhagic cva is any better.)

i work in a large teaching hospital, and our policies are always a generation or two behind current practice. sometimes, as a last resort, we try things that haven't been proven or haven't been tried or that no one i know of has ever seen. (asystolic lady on bivads for six months -- she finally got a transplant and is now home with her small children!) i've learned to make sure i understand the rationale for a doctor's order like that. if i understand it and don't agree with it, or if i've asked the physician and still don't understand it, i can either go up the nursing chain of command and/or the physician chain of command. there are always going to be "iffy" orders, and one solution does not fit all situations. if you're brand new, you don't want to be making the decision of whether or not that's a reasonable and sensible order. check with your charge. as you gain more experience, you'll get a feel for what's reasonable and what isn't.

[nurse grace RN, BSN]

Question the order, and defend your license! If it is policy to call all critical values call them. You are the RN, if the MD gets mad, he will get over it. He had poor judgement in not ordering a repeat study. You are on your way to being an excellent nurse because you already have critical thinking skills and care about your patient. Good job!:)

[Robbind]

I agree with te doctor. The patient has a tendency to clot. The dehydration is also adding to the elevated INR. If the patient is not actively bleeding , I agree. No anticoagulant.

His order is reasonable. The INR will usually go up before it goes down. I would go along with the hospital policy though.

If the patient is still clotting though, I hope a hematology consult was ordered.

Or perhaps a hospice consult if the patient is end stage HIV

[dura_mater]

what were the liver function tests like?

they didn't do any lfts. just yesterday, i was wondering the same thing. hindsight is always 20/20

[nurse2033, MSN, RN]

In my experience, some docs are really experienced and confident with situations that are outside the norm. That said, I would watch this patient like a hawk. Can a doctor make an order that goes against policy? That is an issue above my pay grade. I would clarify with someone higher in the food chain and go with their advice and document it. This patient sounds like they are better off a little watery than too thick. That doesn't mean you can't call if you then see any signs of bleeding.

[nurse grace RN, BSN]

WHere I work we are written up if we do not call critical labs to the doc even if he writes an order not to call! He of course can say to leave the patient go without any type of intervention as long as the info is passed on and documented.