This situation came up at work a few shifts ago. Had 20ish year old admitted for acute appendicitis. All meds IV or PR since he was NPO for surgery. Next day--surgery went great, tolerating clear liquids, doing well. C/O headache that he wants Tylenol for at 0215. That is the one med the MD didn't switch the route on, so it's only ordered PR. The pt refuses of course, so I wrote a telephone order from the MD to change it to PO. He got the Tylenol, headache went away, yay. MD comes in, sees order, says thank you for not calling me for that. I think I did okay.
I'm not prescribing/writing orders liberally or often, but some things we know how to handle.
Another nurse is freaked out by this. Everything is straight by the book for her. There is no nursing judgment or using your brain. She calls the doctor for every, stinking little thing; but then cries when the doctor gripes at her.
Unless you have standing orders (which would cover you), I would have called the MD. I don't care if it was 0215 and I'm calling for Tylenol. My license is important and I worked VERY hard to get it. What if something happened with that PO Tylenol dose, for whatever reason? The MD wouldn't cover you because really, they didn't write or give you the verbal order.
You did receive the order to change medications to po. However, it should have been written at the time the order was taken. You should have ensured that all of the medications had changed accordingly. I wouldn't have falsely written the order in the way that you had done, I would have wrote the order by the facility's policy for backdated orders. My facility usually has us write it as an order clarification. There is such a thing as nursing judgement, however, that doesn't include changing the route of medications and writing orders.
Sorry, I'm "by the book" also. Its too bad the doctor doesn't want to be called for things like this. It is their responsibility to write the orders and I think too many MD's do not "pay attention to detail".
Agree 100%.
I think they should "cover the basics" with all of their patients. Have orders for PRN Tylenol, Zofran, something for pain, constipation, Benadryl and something for sleep unless contraindicated, of course. I'm sure that would cut back on the amount of calls they receive and maybe they wouldn't be so grumpy all of the time!
I totally would have done the same thing! The key is knowing how the doctors practice. Some/most are lenient about that type of thing, but there are a few who would lose their minds because they weren't consulted. Your co-worker, however, can practice nursing the way she is comfortable. But, it's not like you were giving a controlled substance! If nurses bothered doctors for everything we're "supposed" to, we'd all be miserable and never get anything done! The patients would be the ones to suffer the most too, because we would have even less time for them because our time would be spent on the phone! I say it was a good call!
A MD would be under obligation for any order he gave, and it would be nursing judgement to give or not give that medication, so the nurse is also obligated in that case.
I've worked in Critical Care where patients usually get ill in the odd hours of the night, our MDs would never inhibit their judgement on nights when they were on call, and even if they did, it was our job to know if the orders we recieved were appropriate.
Specializes in Med/surg, Telemetry/PCU, Bone & Joint.
Many MD's LOVE when a nurse takes the initiative rather than call them at 3am for a Tylenol order or something on that level. However, as stated in previous posts, if something goes wrong, do you really think the MD is going to take the fall? Heck no! He/She is going to deny ever giving you the order, which in the case we are discussing, was never given. So, the judgment call is yours. Risk your license to do the MD a favor? Not me.
I think we have very different views on what "nursing judgment" & "using your brain" truly mean. Operating within your scope of practice & following the rules & regulations dictated by hospital policy & your state board of nursing - that's what I consider good "nursing judgment" & "using your brain".
Who knows if the MD is fully awake and aware of what he is authorizing at that hour. What if he went to a dinner party earlier and had a few drinks, or took an Ambien? You CYA when you have a second nurse on the line when you take a telephone order in the middle of the night and the MD and facility can't throw you under the proverbial bus if something goes wrong.
A MD would be under obligation for any order he gave, and it would be nursing judgement to give or not give that medication, so the nurse is also obligated in that case.
I've worked in Critical Care where patients usually get ill in the odd hours of the night, our MDs would never inhibit their judgement on nights when they were on call, and even if they did, it was our job to know if the orders we recieved were appropriate.
Nursing judgment is a wonderful thing but it does not include writing orders. Do I like to get yelled at by doctors? Of course not. But it is my job to call them for orders when they're needed & that's what I'm going to do regardless of how the doctor feels about it.
I would not of have changed the route without an order to do so. I have had several doctors say that they are ok with you using your brain,but then when it comes down to an incident with that patient they will turn on you and hang you out to dry....
You will then be wrote up as practicing medicine out of your rhelm of practice...crazy I know,but you can't go on having a good relationship with them. Because believe me it will be you without a license not them...
I work at teaching hospitals all over the US and you have a little autonomy, but I have seen RN's be written up for route changes for electrolyte coverage and other meds that shouldnt have been an issue..
What I'd do in the real world and what I'd admit to on a nursing forum might be two very different things.
I know many docs that would appreciate that route change without bothering them, and if one knows that they'll be covered by that provider, then for many, that's a risk they may be willing to take.
I can say that most doctors know that I'll only call if it's something that TRULY needs them to be called. So when I call, they actually listen rather than thinking to themselves, "This is the one that called me last night just to change PR Tylenol to PO, ugh!" while I'm talking.
But doing what one is legally supposed to do is the "right" thing to do. :)
turnforthenurse, MSN, NP
3,364 Posts
Unless you have standing orders (which would cover you), I would have called the MD. I don't care if it was 0215 and I'm calling for Tylenol. My license is important and I worked VERY hard to get it. What if something happened with that PO Tylenol dose, for whatever reason? The MD wouldn't cover you because really, they didn't write or give you the verbal order.
Consider it a lesson learned.