[canoehead]

Originally Posted by Dinith88

Sometimes (in the real world) docs are hard to reach...or you need something NOW and not 10minutes later. If you're worried about nurse-practice acts, or losing your license, or going to nurse-jail, you need to leave.

I think you are right, but it's pretty sad that when we do what we need to for patients we are wide open to job loss or license loss. If someone wanted to ruin your life they've got a wide open corridor.

[jjjoy]

Originally Posted by canoehead

I think you are right, but it's pretty sad that when we do what we need to for patients we are wide open to job loss or license loss. If someone wanted to ruin your life they've got a wide open corridor.

I agree. I can see the need for autonomous decision-making by the nurse. However, that being a need, it should be formally addressed and the nurse given the legal right to act as such as opposed to going beyond their legal scope on a regular basis to properly take care of their patients.

[APNgonnabe]

Tiger, I too am a new nurse in the CICU where we get many open hearts. I've had some of the same concerns that you have. But as most have pointed out we are suppose to get to know what they want. My suggestion is to find a couple seasoned nurses and ask them what you should do...after coming up with your plan to run past them.

[neneRN]

I think everyone has done a great job in giving the "real world" answer to the OP's question. We all know the textbook answer, but reality is that in any specialty unit, experienced nurses who know their pts, know the docs, and have the trust of the docs, will daily perform outside the actual scope of nursing. Those that are new to these areas or are new grads will realize this with time and experience, or they will not be able to function with these critical pts. If you always act in the best interest of the pt, use your critical thinking, and know which boundaries not to cross, you'll be fine...just takes time to get there.

[BBFRN]

I second the notion that you need to check out your standing orders. Heart ICUs run mostly by protocols that allow for much more autonomy of the nurse. Most likely you have standing order sets for each surgeon.

[CPICU]

I totally agree with knowing your Docs and adjusting your care and communication accordingly. However, we just attended a JCHCO (sp?) meeting to recap our recent visit from therm. One of the changes they want us to make is in how our Docs write their orders. They are saying that for example, an order such as "Start Nitroglycering gtt IV - Titrate to chest pain free" is not specific enough. It is to now include something like, "Start at 5 mcg/min and increase by 5 mcg/min q15 minutes until patient reports chest pain or pressure at 0/10". Then a specific order would have to be written if/when they want to tritrate the gtt to off. They are explaining it to us as - If we are using our judgement to treat our patients to achieve a desired goal, we are practicing medicine which would be outside our scope of practice. The audience included nurses from all areas including ICU. I just don't see how a doc can write an order to cover every single response a patient may have. Surely there will be exceptions made for ICU. Just wondering if any of you have heard anything about this yet. We are a level 1 trauma, 1,000 bed teaching hospital. Nurses using their critical thinking, judgement ("practicing medicine") is essential to patient survival!

[CPICU]

I'd like to clarify my previous post. My understanding of the new regulation regarding MD orders, was not presented as due to something we had done wrong, just something they are trying to crack down on in the future.

[meandragonbrett]

Joint Commission really just needs to jump of the deep end and never be found again.

[Dinith88]

Originally Posted by meandragonbrett

Joint Commission really just needs to jump of the deep end and never be found again.

I second that!

[agent66]

Originally Posted by Dinith88

I suspect you're a new grad, or you're very new to ICu (esp. Open hearts!), or just need to get used to it. Like most have said, there're usually standing orders. Or... you do it...then let the doc know as soon as possible. (seems backwards but it's real-world...not nursing-school-dreamland where all nurses do is act as robotic doctor-slaves) And you DO learn what certain docs would want and when...this'll come eventually.Also, if you're not at a large center where you've got Doc's holding your hand at the bedside 24/7, you NEED to feel comfortable making decisions. Sometimes (in the real world) docs are hard to reach...or you need something NOW and not 10minutes later. If you're worried about nurse-practice acts, or losing your license, or going to nurse-jail, you need to leave.

I am not a new grad and have been called in on a lawsuit, and I will tell you the docs you thought would back you up were on one side and we the nurses were on the other. They had their lawyers and we were supported by the hospital lawyers, and I am glad, more than glad that I had not given anything without an order, because when it comes down to it giving drugs or treatments without an order IS outside our scope of practice. I have no trouble following standards of care orders and making a decision, but I am not going to give them span because I think they are dry , I always call , and if I need to lead the resident to that decision then that is okay too, at least I am covered legally, and I do need my job to pay the bills still so this is the way I practice!