New nurse and critical patients - page 3

Hi I am a fairly new nurse. Graduated from school a year ago and was hired into the ER straight away. Been on the floor for 11 months and on my own the last 5 or 6. I work at a community hospital... Read More

  1. by   PMFB-RN
    Quote from FlyingScot
    Not every hospital works from unit protocols. And seriously, you have physicians ordering a drug that they don't know correct dosages?!

    Yes I know there are many old fashioned hospitals out there. I guess I have been lucky enough to mostly work in more forward thinking hospitals who are concerned with EBP.
    As for the docs, I assume so given all the times they ask us for dosages. I am not responsible for, nor do I care about what physicians do or don't know.
    I am responsible for what our nurse residents know and basics of starting and titrating the dips common in their unit, and the "why" behind them.
  2. by   emtb2rn
    Quote from PMFB-RN
    I am not sure how to respond to this because I can't determine if it is a serious question or sarcasm or supposed to be funny?
    I would consider an order to "hang levo" to be without parameters while I would consider an order to "hang levo to sbp >90" to be an order with parameters.
  3. by   FlyingScot
    Quote from PMFB-RN
    Yes I know there are many old fashioned hospitals out there. I guess I have been lucky enough to mostly work in more forward thinking hospitals who are concerned with EBP.
    As for the docs, I assume so given all the times they ask us for dosages. I am not responsible for, nor do I care about what physicians do or don't know.
    I am responsible for what our nurse residents know and basics of starting and titrating the dips common in their unit, and the "why" behind them.
    Hey now! Not every hospital that doesn't use protocols is old-fashioned, not forward thinking or don't use EBP. Maybe they don't have the money for departments dedicated to evidence-based practice. Maybe they don't see critical patiens all the time. Maybe it's a critical access hospital that staffs only two nurses. And I'd like to see the research that says it's okay to not have specific orders for vaso-active drugs.
  4. by   FlyingScot
    And just to be clear, protocols ARE orders so I'm not asking for the research on protocol-based nursing care.
  5. by   PMFB-RN
    Quote from FlyingScot
    Hey now! Not every hospital that doesn't use protocols is old-fashioned, not forward thinking or don't use EBP. Maybe they don't have the money for departments dedicated to evidence-based practice. Maybe they don't see critical patiens all the time. Maybe it's a critical access hospital that staffs only two nurses. And I'd like to see the research that says it's okay to not have specific orders for vaso-active drugs.
    I have worked at a number of small rural critical access hospital ERs. My experience is that the smaller hospitals need / should have more protocols than the big teaching hospitals who have residents standing around all the time.
    Generally the evidence I have seen indicates that those decisions should be made as close to the beside as possible and that empowering nurses results in better patient outcomes.
  6. by   FlyingScot
    Quote from PMFB-RN
    I have worked at a number of small rural critical access hospital ERs. My experience is that the smaller hospitals need / should have more protocols than the big teaching hospitals who have residents standing around all the time.
    Generally the evidence I have seen indicates that those decisions should be made as close to the beside as possible and that empowering nurses results in better patient outcomes.
    Purely anecdotal and as such not evidenced-based. My question is, I will rephrase it, on what planet is it okay for a nurse to decide initial, titrating and max doses of vasopressive drugs in the absence of protocols. How is this not practicing medicine? Do you honestly believe that if there is a poor patient outcome the nurse will not be thrown under the bus by everyone from housekeeping to the BON?
  7. by   sevo87
    Unless the ordering physician is an intensivist working in a purely intensive care environment it has been my experience that they have NO CLUE what to 1. Start the drip at 2. Titrate by or 3. What the max should be. They will look at the same drug book a new nurse does to find this information.

    If the doc tells you to start a Norepi drip what do you think he wants it for?? A systolic of 170? As has been mentioned previously every er or unit I've ever worked in has a drip book that gives you standard concentrations, typical starting parameters, max doses and so on. Certain drugs have different maxes from facility to facility. I'm reasonably sure that every hospital has protocols for this.

    I don't get why, after having an order for something, some nurses want to be micromanaged by the MD. Why not just have him come in the room and push the buttons on the pump for you?
  8. by   PMFB-RN
    Purely anecdotal and as such not evidenced-based.
    Oh really? Um, OK then.

    M
    y question is, I will rephrase it, on what planet is it okay for a nurse to decide initial, titrating and max doses of vasopressive drugs in the absence of protocols.
    Why are you asking that question? Did someone suggest that was OK and normal? Obviously I mean in another discussion because I have read this one and nobody is advocating for nurses deciding to initiate, and titrate in the absence of protocols.

    How is this not practicing medicine?
    I suggest you ask the person who is advocating for what you described.

    Do you honestly believe that if there is a poor patient outcome the nurse will not be thrown under the bus by everyone from housekeeping to the BON?
    I am well aware that nurses are the primary target for being thrown under the bus by everybody else in health care.
  9. by   PMFB-RN
    Quote from sevo87
    Unless the ordering physician is an intensivist working in a purely intensive care environment it has been my experience that they have NO CLUE what to 1. Start the drip at 2. Titrate by or 3. What the max should be. They will look at the same drug book a new nurse does to find this information.

    If the doc tells you to start a Norepi drip what do you think he wants it for?? A systolic of 170? As has been mentioned previously every er or unit I've ever worked in has a drip book that gives you standard concentrations, typical starting parameters, max doses and so on. Certain drugs have different maxes from facility to facility. I'm reasonably sure that every hospital has protocols for this.

    I don't get why, after having an order for something, some nurses want to be micromanaged by the MD. Why not just have him come in the room and push the buttons on the pump for you?

    Well said.
  10. by   FlyingScot
    Quote from sevo87
    Unless the ordering physician is an intensivist working in a purely intensive care environment it has been my experience that they have NO CLUE what to 1. Start the drip at 2. Titrate by or 3. What the max should be. They will look at the same drug book a new nurse does to find this information.

    If the doc tells you to start a Norepi drip what do you think he wants it for?? A systolic of 170? As has been mentioned previously every er or unit I've ever worked in has a drip book that gives you standard concentrations, typical starting parameters, max doses and so on. Certain drugs have different maxes from facility to facility. I'm reasonably sure that every hospital has protocols for this.

    I don't get why, after having an order for something, some nurses want to be micromanaged by the MD. Why not just have him come in the room and push the buttons on the pump for you?
    What poster said they wanted to be micromanaged? It certainly wasn't me. All I said was that in absence of protocols (which are defacto orders) no nurse should start a drip without a clear order. Especially not a new one.
  11. by   FlyingScot
    Quote from sevo87
    I've never had a physician tell me what to start a drip at or how much to titrate it by. As a nurse you should know that you don't start a nitro gtt out at 200mcg or a cardene gtt at 15mg/hr.
    No mention of protocols here.
  12. by   sevo87
    I didn't specifically say anything about protocols there because I don't have to run to the book every time I start a drip. I understand that a new nurse may have to. Like I said, I've never worked in a hospital that didn't have such protocols, therefore I assumed it was understood. If not, my bad.
  13. by   FlyingScot
    Quote from PMFB-RN
    Oh really? Um, OK then.
    Well you did go on about the backward thinking, old-fashioned hospitals that didn't follow EBP.

    Quote from PMFB-RN
    Why are you asking that question? Did someone suggest that was OK and normal? Obviously I mean in another discussion because I have read this one and nobody is advocating for nurses deciding to initiate, and titrate in the absence of protocols.
    Yes, see above post.



    Quote from PMFB-RN
    I am well aware that nurses are the primary target for being thrown under the bus by everybody else in health care.
    You might be aware but I bet there are a few less experienced nurses here who need to know the tightrope they could be walking in this situation.

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