Would you do this?

Nurses General Nursing

Published

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.

What really makes this story interesting is that this doctor had always been the one who flipped out about phone calls during the night.

And that's why you don't reward MDs who behave badly when you call them during the night. You're going to be a donkey about my phone calls at night asking you to do your job? You're getting the call for tylenol at 2am.

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Specializes in PeriOp, ICU, PICU, NICU.

Nope, would have never done that. My license is precious to me and equates to my bread and butter. Friends, long-time partners or not, it is out of your scope of practice. Reality is if cow dookie hits the fan, you are will be thrown under the bus and ran over.

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Specializes in PeriOp, ICU, PICU, NICU.
And that's why you don't reward MDs who behave badly when you call them during the night. You're going to be a donkey about my phone calls at night asking you to do your job? You're getting the call for tylenol at 2am.

....What also irks me the most is when nurses preface calls "Dr soandso, I am SO sorry to call you at this time"... Usually, if he's always been a donkey, this won't make it any better. Do NOT be sorry, they are on call and getting paid, so deal with it.

I am fortunate enough in our unit to staff residents 24/7 (PICU) and do not miss grumpy MDs!

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Specializes in Emergency, Case Management, Informatics.
I am fortunate enough in our unit to staff residents 24/7 (PICU) and do not miss grumpy MDs!

Definitely one of the perks of working in the ER as well. I can ask mother-may-I to the physician all day long and he/she won't care, since they're sitting right next to me :D

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I think that failing to change the route of the APAP was clearly an oversight by the surgeon, and I would have written "May give medications PO" as a verbal order by the surgeon, timed at the time (as best as you can approximate) that you had the conversation with him.

Had I not had that conversation, I would have called.

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Specializes in Rodeo Nursing (Neuro).

Just curious: What could happen? Pharmacologically, I mean?

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Just curious: What could happen? Pharmacologically, I mean?

I've been wondering the same thing. Aside from anaphylaxis, which is rare and if it were going to occur, would occur even if the APAP were given PR, what kind of scenario are people imagining when they say "If something were to happen....."?

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Specializes in CVICU.

I think it totally depends on your relationship with the doc. Why in the world would you need an order to give someone some tylenol? Are they allergic? In liver failure? No? Give them some tylenol. You didn't do anything inappropriate in my estimation.

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Specializes in Emergency, Case Management, Informatics.
Why in the world would you need an order to give someone some tylenol?
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Specializes in Rodeo Nursing (Neuro).
I've been wondering the same thing. Aside from anaphylaxis, which is rare and if it were going to occur, would occur even if the APAP were given PR, what kind of scenario are people imagining when they say "If something were to happen....."?

I do have to be aware of aspiration risk, since I take care of a lot of stroke patients, but if he's clear for other p.o. meds, Tylenol should be okay. I'm not unreservedly endorsing the OP's decision, and particularly posting it on the 'net, but it isn't exactly an OMG kinda moment, either. I've known more than a few docs who've said they'd sign anything that can be bought OTC. Frankly, I haven't taken them up on it, in part because nothing OTC is likely to be all that stat, and if it is--Benadryl for an allergic reaction comes to mind--the doc needs to know about it. In the stated situation, it's pretty hard to imagine the matter ever coming before the BON, and even if it did, it's pretty unlikely any major discipline would result.

I faced a situation awhile back in which a patient's spouse was on portable O2, but her supply was exhausted. Family couldn't be reached, pt refused to go to ER, where she could have been admitted, assessed, and provided with a legal supply. Pt was elderly, anxious about her spouse, and cyanotic. I weighed the variables, including jeopardy to my license and potential liability to my facility, then did the least wrong thing I could think of, then wrote myself up. Whatever you think of putting the visitor on our O2, it was a reasoned decision, and I think we owe it to our profession and our communities to make reasoned decisions.

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I think it totally depends on your relationship with the doc. Why in the world would you need an order to give someone some tylenol? Are they allergic? In liver failure? No? Give them some tylenol. You didn't do anything inappropriate in my estimation.

It’s not what could happen in this particular situation with this particular drug & route of administration that matters in this discussion. Decisions like this can set a precedence that negatively impacts our patients. What could happen to patient care in general if we all chose to make decisions outside of our scope on a regular basis? A lot of us who lack the formal education and credentials do have the intellectual capacity and the knowledge base to make informed decisions in the absence of an MD or APN. Some of us think we do when we actually do not. That’s one way these licensing boards, educational standards, rules/regs, etc. safeguard patients.

As a side note, just b/c it's an OTC med doesn't make it any safer to write an order on behalf of a doc. Tylenol interacts with a ridiculous # of other drugs metabolized by the liver.

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Specializes in CVICU.
It's not what could happen in this particular situation with this particular drug & route of administration that matters in this discussion. Decisions like this can set a precedence that negatively impacts our patients. What could happen to patient care in general if we all chose to make decisions outside of our scope on a regular basis? A lot of us who lack the formal education and credentials do have the intellectual capacity and the knowledge base to make informed decisions in the absence of an MD or APN. Some of us think we do when we actually do not. That's one way these licensing boards, educational standards, rules/regs, etc. safeguard patients.

As a side note, just b/c it's an OTC med doesn't make it any safer to write an order on behalf of a doc. Tylenol interacts with a ridiculous # of other drugs metabolized by the liver.

In the situation she described, she did nothing wrong. And Tylenol 650mg PO is a standing order in our ICU for pain and fever. Are you suggesting Tylenol in the absence of liver failure and allergy is inherently dangerous?

Bottom line, technically you should've called at 3am for a tylenol order. Fundamentally you did nothing wrong.

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