bolus w/o order....yes or no? - page 3

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.... Read More

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    Nurses practicing in a specialty area for a period of time often practice in ways that "cut corners" in this instance, give the bolus then get the order. There is some jeopardy in this practice but some nurses feel comfortable enough with the physicians affiliated with the care that they are willing to walk the edge.

    Dependent upon the size and condition of a patient, a 500ml IV bolus shouldn't be too dangerous...but there are exceptions to that generalization.

    As others have said, many nurses practice in areas that have well developed treatment protocols and standing orders for medical and nursing care.
    MedChica and Orange Tree like this.

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    On the Surg/Ortho floor, we give a 1,000 mL bolus for orthostatic hypotension (drop of >15 systolic). That order comes up with each surgical patient as a protocol. If the systolic drops, we give the bolus, then call the MD and notify him/her. Granted, we technically have an order in this situation, but we also prioritize.

    A patient saying that he is dizzy is not objective. Dizzy to me may mean passing out whereas dizzy to someone else may mean feeling a little light-headed. She should have at least checked his BP before deciding it was okay to bolus him.
    Susie2310 and MedChica like this.
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    What's wrong with speaking to the RN herself? Why run to management. If you felt the need to spy on her patient care at least have the courtesy to go head on with her as well. There is too little direct communication nowadays.
    rockstar11, Altra, Hygiene Queen, and 2 others like this.
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    This happened to me when I had a knee scope/bad reaction to dilaudid. The nurse called the anesthesiologist and got the order to bolus 500ml. It took her less than 2 minutes to get the order.
    I don't know why a nurse would want to take the chance of giving something without an order- especially when it shouldn't take that long in post op to get the order.It may be a different story if someone is vagal-ing, but there should be protocols in place.
    anotherone likes this.
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    Quote from netglow
    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...
    Yep. Textbook answer to OP: No. Don't do it.
    Real life answer: It happens.
    anotherone and BelgianRN like this.
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    It really isn't spying on her patient care at all when you work in an area as small as we do. I assisted her in bringing her patient back to the chair after using the restroom and then went back to my charting about 25 feet away. I fully understand and appreciate your comment that communication is definitely key but dislike the assumption that I was spying on her patient care.
    anotherone likes this.
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    I agree with the comment about approaching the nurse first. You could say something like.."Giving IV fluids without an order is outside the nursing scope of practice, without the order you leave yourself open to malpractice lawsuits if anything went wrong." and see what she says. She has lots of exp. its possible the last unit like yours she worked on had standing orders or something like that, its possible she just is not aware the yours does not. Its possible she used to work ICU where nurse often act first then get orders later.

    At any rate you will remind her that she does not work alone and that doing things like that will be noticed by others. Maybe she will clean up her act.

    Write an incident report if it really bothers you. Its a medication error at any rate.
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    Out of her scope. I'm sorry but I won't risk my job or license doing something I "anticipate" a doctor doing no matter how sick the pt is. If the MD won't answer call a rapid response or keep paging until he answers.

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