What nursing interventions should be considered when writing orders for patient care?

Nursing Interventions for Writing Patient Care Orders

Nurses should develop standardized order sets that address specific clinical pathways including blood glucose control, fever management, multidisciplinary consultations, and symptom management protocols, as these improve care coordination, reduce hospital costs, and enhance patient outcomes. 1

Core Components of Nursing Order Sets

Clinical Pathway Development

• Implement standing orders that guide nursing actions for common clinical scenarios, including parameters for treating hyperglycemia, fever thresholds requiring intervention, and criteria for specialist consultations 1
• Develop condition-specific order sets tailored to patient populations (e.g., stroke, heart failure, palliative care) that include diagnostic tests, therapeutic interventions, and care coordination elements 1
• Utilize standardized protocols from professional organizations such as the American Heart Association and Brain Attack Coalition, which provide evidence-based templates for order development 1

Assessment-Driven Orders

• Base all orders on systematic patient assessment that identifies nursing problems using standardized nursing language, with individualized care plans documented within 24 hours of admission 2, 3
• Prioritize orders using urgency and importance criteria, recognizing that priority setting directly impacts patient outcomes and resource utilization 4
• Include baseline assessments that determine risk stratification (high-risk vs. low-risk patients) to focus intensive interventions on those most likely to benefit 1

Essential Order Categories

Monitoring and Surveillance Orders

• Specify frequency of vital signs monitoring based on patient acuity: 1:2 nurse-patient ratio for first 24 hours in high-risk patients (e.g., post-thrombolysis), then 1:4 if stable 1
• Include neurological assessment parameters with validated tools for patients at risk of deterioration, as 30% of stroke patients worsen in the first 24 hours 1
• Order bleeding assessments for patients receiving anticoagulation or thrombolytic therapy, with specific monitoring intervals (every 15 minutes × 2 hours, then every 30 minutes × 6 hours, then hourly × 16 hours) 1

Symptom Management Orders

• Write tiered intervention protocols for common symptoms (e.g., pain, nausea, dyspnea) that allow nurses to escalate treatment based on patient response without requiring repeated physician contact 1
• Include specific medication parameters: dosing ranges, maximum daily doses, routes of administration, and reassessment timeframes 1
• Specify non-pharmacologic interventions alongside medications (e.g., positioning, oxygen therapy, environmental modifications) 1

Prevention Orders

• Order prophylactic interventions for complications including deep vein thrombosis, pressure ulcers, aspiration, and healthcare-associated infections 1
• Include fall prevention protocols with specific risk assessment tools and corresponding interventions 1
• Write orders for early mobilization with specific targets (e.g., 30 minutes on day of surgery, 6 hours daily thereafter) 5

Palliative and End-of-Life Care Orders

Comfort-Focused Interventions

• Develop orders that address both discontinuation and continuation of care, explicitly stating what comfort measures will be maintained when life-sustaining treatments are withdrawn 1
• Include anticipatory symptom management with around-the-clock opioids, anticholinergics (scopolamine 0.4 mg subcutaneous every 4 hours PRN), and secretion management (glycopyrrolate 0.2-0.4 mg IV every 4 hours PRN) 1
• Write orders for individualized end-of-life preferences including music, spiritual ceremonies, family presence, and personal care activities 1

Communication and Support Orders

• Order consultations with palliative care, pastoral care, and hospice services for patients with uncontrolled symptoms, life expectancy ≤6 months, or major medical decisions 1, 6
• Include family support interventions such as educational programs, ICU diaries, bereavement support, and designated family support zones 1
• Specify advance care planning discussions with documentation requirements for goals of care, surrogate decision-makers, and POLST completion 6

Discharge and Transition Orders

Post-Discharge Follow-Up

• Schedule follow-up appointments within 7 days of discharge from skilled nursing facilities or hospital, with specific provider types identified (primary care, specialists) 7
• Order formal assessments of mobility, activities of daily living, and cognitive/communication function within 30 days for stroke patients 7
• Include medication reconciliation orders with clear instructions for continuing, discontinuing, or modifying medications 7

Care Coordination Orders

• Write orders for bidirectional communication between facilities that include clinical data, medication lists, important events, and patient/family education documentation 7
• Order home health services based on self-management capability assessments, with specific services identified (nursing, physical therapy, occupational therapy) 7
• Include caregiver support orders with scheduled contact points (1,4,6, and 12 months post-discharge) and referrals to support groups 7

Implementation Strategies

Educational Components

• Incorporate educational meetings into order implementation, using interactive approaches with case discussions, hands-on exercises, and simulation scenarios rather than passive lectures 1
• Provide educational materials in multiple formats (written, pictorial, video) for both patients and caregivers 5
• Include audit and feedback mechanisms to monitor order set utilization and outcomes 1

Organizational Support

• Adapt order sets to local context through participatory co-creation with frontline staff, which improves implementation success 1
• Use external facilitation to support order set adoption and troubleshoot barriers during implementation 1
• Implement changes to organizational policy that support standardized order use and remove barriers to nursing-driven protocols 1

Common Pitfalls and How to Avoid Them

• Avoid generic, non-specific orders by including exact parameters, dosing ranges, and reassessment timeframes rather than vague instructions like "monitor closely" 1
• Prevent care fragmentation by ensuring all orders are documented in a centralized location accessible to all team members, avoiding reliance on verbal communication alone 6
• Do not delay palliative care discussions until the final month of life; integrate these conversations early when patients have multiple hospitalizations or declining function 1, 6
• Avoid inadequate nurse-to-patient ratios by specifying appropriate staffing levels in orders for high-acuity patients (1:2 for first 24 hours in critical situations) 1
• Prevent medication errors by including "medications to avoid" lists in order sets (e.g., NSAIDs in heart failure patients) 1