bolus w/o order....yes or no? - page 2

greetings all!! bolusing without an order....yes or no? background story to the question: i work same day surgery and we had a patient, male, late 30's, in phase 2 recovery s/p knee scope. he got 5 of versed and 200 of... Read More

  1. 3
    Quote from Altra
    This is a textbook/NCLEX answer with little relevance in real-world practice.

    This is a same-day surgery patient recovering from a procedure -- he already has IV access.

    Take a look at the bottle/cup of water/soda/whatever that's closest to you. If it's a standard bottle of water that's 507 mL. Have you ever consumed a bottle of water within 10 minutes? Does that 500mL bolus still sound so shocking ... in terms of a patient in his 30s who is healthy enough to have just had a same-day surgery procedure?

    However, the MD should be notified before discharge so that there is an order(s) to match the total amount of fluids given.
    An oral "bolus" takes some time to become intravascular, but an IV one is instant. RNs can make a call on oral fluids (assuming the patient isn't NPO). That's the difference.

    I think what should happen is that there should be a line in the unit's standing orders that covers this for nursing discretion, and perhaps some consideration to saying that it should be, oh, the charge nurse's or clinical specialist's call (I am making the hopeful assumption that the charge nurse is experienced enough to do so).

    Otherwise, I'm not seeing any emergency here and the nurse could have gotten an NP, CRNA, or some wandering-through physician to say, "Yeah, sure, give him 500 cc, where do I sign?"
    MedChica, tewdles, and anotherone like this.

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  2. 3
    Yes I know I gave a textbook answer as I believe that is necessary. So many nurses I work with do no know their own nurse practice act and how to protect themselves legally.Moreover, I see many that do not use that leeway very well and it has gotten them into trouble. I also know as a practicing nurse for 32 years that that leeway is necessary especially in the fast paced setting of hospital nursing. We are after all there 24 hours a day! I take advantage of that leeway as well but I do it prudently and intiate the standarized procedure and call the MD when I can and tell them what I did or send them a message

    I once had an an oncologist get so angry with an oncology nurse that ordered a chest X ray to verify a PICC tip on a patient that came in with an existing PICC . My colleague had instructed them to verify the tip before they gave the chemotherapy. I had to go take the call and he got that nurse in big trouble for practicing medicine. The irony is that PICC was malpositioned with it having made a big flip back down the arm with the tip residing now in the Basilic vein near the ACF. Enough of that I said and changed the policy so a nurse can order a CXR if a patient comes with a PICC from an outside facility or if we suspect malposition.

    Some Licensed practitioners will however, not tolerate any of this behavior and have a hissy fit so you need to find out the norm in your area and your setting.
    MedChica, GrnTea, and anotherone like this.
  3. 1
    Quote from netglow

    True, but depending on the nurse, and in what role that nurse has worked and what she knows about this particular surgeon, etc. this might not be soooooooooo odd. Each nurse decides what they are going to do about any given situation. Maybe a call had been made, or will be made and the surgeon will sign without any hoopla... I've seen PACU and ICU nurses (especially) get and give first, let MD know after often. Again, you don't probably know this nurse...
    When I worked in ICU we would often order labs, X-rays, etc and let the md know afterwards. But that's once they knew and trusted us.
    MedChica likes this.
  4. 1
    Quote from SionainnRN

    When I worked in ICU we would often order labs, X-rays, etc and let the md know afterwards. But that's once they knew and trusted us.
    Yup. This. We often know what the patients need and what the MD is going to order. If they are unavailable, or it's the middle of the night, we do what we need to do and let them know after. This is limited to labs, EKGs, CXRs, if it's a more emergent situation, maybe some fluid. I'd rather use common sense than let a pt decompensate. Again- this is only with certain MDs who know us. They usually just thank us. However, every workplace, every situation is different.
    MedChica likes this.
  5. 0
    I wouldnt have done it . i have seen drs through major temper tantrums for nurses doing ekgs without an order on pts having chest pain
  6. 0
    I had a pt with a terribly low bp who I cranked fluids up on and trended them before I thought about calling the md. She was symptomatic. It wasn't secondary to a med reaction. The doc said good job and put in the order. We hang fluids on people in the early morning if their condition warrants and they don't have chf. If it was questionable I'd call.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
  7. 2
    Quote from anotherone
    I wouldnt have done it . i have seen drs through major temper tantrums for nurses doing ekgs without an order on pts having chest pain
    Seriously?? They're angry because an EKG was done on a patient with chest pain? Get over yourself!
    kogafietsen and anotherone like this.
  8. 0
    she is relatively new to the area....perhaps about 4 months there vs myself and everyone there being there for a year or so.....and this isn't something the MD would have ordered. can almost guarantee it.
  9. 4
    Quote from eatmysoxRN
    I had a pt with a terribly low bp who I cranked fluids up on and trended them before I thought about calling the md. She was symptomatic. It wasn't secondary to a med reaction. The doc said good job and put in the order. We hang fluids on people in the early morning if their condition warrants and they don't have chf. If it was questionable I'd call.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
    The "nursing bolus". Do them all the time in the er, get the doc to put in the order so everything matches up. It's all about critical thinking. The environment counts a lot too.
    NurseOnAMotorcycle, MedChica, GrnTea, and 1 other like this.
  10. 0
    Quote from limaRN
    Seriously?? They're angry because an EKG was done on a patient with chest pain? Get over yourself!
    Yes, It was pathetic. This doctor always threw ( i typed "through" instead of throw before lol) temper tantrums for everything. It was pretty comical. As this pt was pretty old and had a ton of cardiac problems.


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