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Writing Bad Orders

Geriatric   (1,230 Views 14 Comments)
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How would all y'all transcribe this order:

Daily weights

Lasix 40 mg by mouth daily.

If weight increases by 2 kg over 2 days increase Lasix by 20mg

If weight decreased by 2 kg over 2 days decrease Lasix by 20mg.

today I'm 110, tomorrow I'm 112, the next day I'm 115-so I should get 60mg

Then I'm 115, 115...I keep getting 60 mg

Then I'm 110...back to 40mg

then I'm 105...20mg???

Our providers refuse to change the order because 'that's how she was being managed in the hospital'....hate to break it to you, ladies, we are NOT a hospital.

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Yes, I would refuse that order too. A recipe for disaster. At the very least, can't the order read something like a sliding scale insulin? If wt is 110-115 give 20mg, if weight is 116-120 give 40mg, etc.

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We tried that...and were told "This is how she was being managed in the hospital."...Right...we're NOT a hospital. There is no sub in sub acute any more. We're taking med surg level patients with nursing home level staff. I'm glad my career doesn't have too much longer to go. Add to this a patient who's on Midodrine and Labetalol and who needs her B/P checked every half hour or so...with parameters for both those meds AND fluids running through a port-a-cath...

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This is the sort of occurrence that makes me glad I left LTC and floor nursing behind five years ago. That order makes NO sense and it's dangerous to boot...too many things that can go sideways. Like you said, you're not working in a hospital, and the provider needs to be contacted again and told in no uncertain terms that you cannot manage this patient in that fashion. I wish you luck!

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Call the doctor every day to report the weight and ask for that day's dose. Just say, honestly, that you don't understand the order if Doc c/o being called.

As I read the order and the weights you give, she'd be getting 80 mg. See how confusing this ridiculous order is? What a coward that Doctor is.

What does your DON say? She needs to go to bat with the doctor. If no clarification by doctor, bring Admin in.

Is there another doctor over this one?

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That is a dodgy as hell order.

I would be asking the provider to clarify the order and if they wont sort it get your higher ups involved

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That order makes NO sense and it's dangerous to boot...too many things that can go sideways.

Far too much room for interpretation, and it opens the door for the provider to claim that the nurse misinterpreted the order if anything goes wrong.

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Well that's a nightmare of an order in any setting. I work in LTC and have several CHF residents managed with diuretics based on daily weights. All of those patients are managed by the heart center and the orders are always to contact the provider with weight gain/loss. With few exceptions the standard orders are report a gain or 2lbs a day or 5 lbs a week and a loss of 5 lbs a week. All diuretic dosing is then adjusted by the provider.

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Thanks for all the feedback. Unfortunately, the doctor is afraid of the NP and PA and they don't really believe in team work. We're just going to keep calling and clarifying every dose. Maybe then they'll get the message.

Fluid resuscitation in a SNF...yeah, we've had to that too. Ridiculous

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This was a number of years ago, and I don't recommend it as a general rule, but ... When a doc complained about my charge nurse calling him so often for clarifications on his orders, she said to him, "Well, Dr. M_____, if you would learn to write a clear and complete order, then I wouldn't have to call you, would I."

She did not get into trouble, because when the doc griped to the supervisor about it, she told him, "Well, she's right, you know...." :)

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I would tell them there is to much room for error with that order and if this person needs to be managed acutely then she needs to return to acute care for continued monitoring. This is a med error waiting to happen. Maybe make a PRN order based on daily weights..I had one where lasix and aldactone alternated days w/ a PRN order to give them both together x 2 days for c/o SOB. We created a new order each time it needed to be initiated so it was not missed if the routine nurse was not there

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lol....return to acute care...no one listens and it's getting worse. Our liaisons send referrals for people who need IV push meds (4 of them) every 15 minutes...including IV push Morphine. They have no clue. We have 20 patients per nurse. What are the other 19 supposed to do when their nurse is sitting with this person who needs ICU level of care? Time to get out of the business!

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