Had a pt. on diltiazem gtt, 10mg/hr, HR 96, A fib. Pressure was trending down, SBP 94. MD order was to titrate gtt for HR 90-100, and we have unit specific protocol.
Checked with resource RN who is very knowledgeable and experienced, who agreed we should go down to 5mg/hr due to BP trending down and rate remaining stable. An hour passed, HR increased to 107, BP back up to one teens systolic. Checked with charge, who agreed that it sounded like we had jumped the gun a bit and that we should go back up to the 10mg rate.
Back up we go, but an hour later, HR still elevated, increasing to 117 and taching into the 120s. So, again, checked with charge, and increase rate to 15mg/hr.
Within an hour, rate is 70s and patient converted to NSR, SBP holding in one teens. Back down to 10. Rate, rhythm, and pressure all still holding an hour later. I'm thinking we need to go down to 5, but by this time, it's end of shift. Oncoming nurse comes on, and I'm giving report, and he gives me a boatload of grief over "not following MD order" of keeping HR 90-100. I explained the rationale for every rate change, that I had not personally touched the pump (outside my scope of practice), and that every decision had been run by and backed up by the charge nurse.
Oncoming nurse disagrees with my charge nurse's decisions (made a face when I told him that the charge nurse had been involved), stated that *I* should have gone over the charge nurse's head and called the MD for orders (even though we have parameters that are unit specific PLUS I am an LPN so I always run things by my charge before making calls to docs). He pointed to the protocol that I had printed out and placed with the chart for my information and said the "MD's order trumps *this*." with what looked to me like a sneer.
Before I left, I asked oncoming nurse if he would like me to do anything with this situation before I went home. I didn't want to dump a load of #### in his lap (and said so; I do not want to be one of those nurses that other nurses hate to follow). He said no, that he was going to decrease the gtt to 5 (exactly what I would have done, or rather, asked my charge if we should do, and have an RN to make the rate change since I won't touch the pump).
I *thought* I had followed protocol and used sound nursing judgment. I did not personally touch the pump nor make any decisions regarding rate changes without running them past my charge. I simply monitored the patient and reported any changes to my charge, staying within my scope of practice. The gtt rate never went outside of either the MD's parameters nor our unit protocol. The outcome was positive; patient in NSR with rate in the 70s, ready to be titrated down and possibly transitioned to PO.
My confidence is shaken by my co-worker's attitude.
Did I really misjudge the situation, or was this a case of a nurse eating his young? Maybe he was just mad because he'd have to call the doctor in the middle of the night if the gtt needed to be DCd (our protocol is to call MD when gtt is DCd, and there was no "notify MD" parameter order otherwise).
