bolus w/o order....yes or no?

  1. 0 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 fentanyl total, on top of gen anesthesia. c/o being slightly dizzy during most of his stay, not unusual. after he got up to go to the bathroom and came back to sit, he was still c/o dizziness but no nausea. the RN taking care of him decided that on top of the 2L of LR he had already gotten, that she was going to bolus him. so that is exactly what she did. 500 mL LR bolus in 10 minutes...without an MD order.

    i feel like this shouldn't have happened or was even necessary....thoughts? opinions? reasoning either way?

    thanks!
    Last edit by sarahbeth2006 on Jan 23, '13 : Reason: wrong information
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    About sarahbeth2006

    Joined Jan '13; Posts: 4; Likes: 2.

    27 Comments so far...

  3. Visit  SaoirseRN profile page
    2
    She should not have done that. Without being there and seeing the patient, I cannot speak to her thought process in doing so, but no. She was practicing medicine, which is beyond her scope.

    In my facility, there is are a few select protocols in which a nurse might initiate a fluid bolus without an MD order (our Early Sepsis Management Protocol), however it is based on specific criteria and one of those included notifying the MD of the patient's status and that the protocol was initiated.
    poppycat and MedChica like this.
  4. Visit  iluvivt profile page
    1
    Unless she was working under an established protocol or standardized procedure that would then need to be initiated in the medical record then NO she should should not have done this on her own. An IV infusion is a prescription that entails an order to establish ann acess they typ of solution to be administered and then the rate at which to infusi=e it and then the RN to administer and assess the response to the prescribed treatmnet. So you can see when I word it that way she was practicing medicine and therefore she is practicing out of her scope of practice. I would have called the MD with report and got any orders. Hey maby he was havin a side effect or reaction to the medication. The MD will decide that basd upon the assessment the nurse should have provided him or her..tat is theri job in this case...assess and report any change in condition or concerns of this nature.

    Look over you policies and orders to see if this is covered....report this to your manager to fix.
    MedChica likes this.
  5. Visit  sarahbeth2006 profile page
    1
    thanks to the two of you. i told my supervisor and he wasn't concerned about it at all. he said the pt was a healthy, young man so the bolus wouldn't have affected him and that it wasn't a patient safety issue. while yes patient safety was a thought of mine, my main reason for bringing it to his attention was the fact that she was practicing out of her scope of practice. she has been a nurse probably 12 years longer than i have but i feel like this is common sense.....apparently not.
    anotherone likes this.
  6. Visit  netglow profile page
    0
    At first I thought the info would be that he was having a hypotensive episode... I wonder if he went down a little too much, and she thought that a bolus would fix that or something. Wow, kinda weird.
  7. Visit  iluvivt profile page
    3
    He is missing the point! It has nothing to do with whether the patient can handle the fluid or not it has to do with the fact that it is illegal. If anything should happen to the patient or if the chart is ever audited there will be no order to cover this. This is not a gray legal area it is very clear. If he is going to let her practice medcine then let her do the surgery as well. What about future patients what is she going to order on the next patient?
    poppycat, MedChica, and GrnTea like this.
  8. Visit  Altra profile page
    6
    Quote from iluvivt
    An IV infusion is a prescription that entails an order to establish ann acess they typ of solution to be administered and then the rate at which to infusi=e it and then the RN to administer and assess the response to the prescribed treatment.
    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.
    Boog'sCRRN246, wooh, Esme12, and 3 others like this.
  9. Visit  netglow profile page
    2
    Quote from iluvivt
    He is missing the point! It has nothing to do with whether the patient can handle the fluid or not it has to do with the fact that it is illegal. If anything should happen to the patient or if the chart is ever audited there will be no order to cover this. This is not a gray legal area it is very clear. If he is going to let her practice medcine then let her do the surgery as well. What about future patients what is she going to order on the next patient?

    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...
    wooh and tyvin like this.
  10. Visit  imintrouble profile page
    2
    Where I work, the MDs I work with? Not in a million years.
    anotherone and netglow like this.
  11. Visit  NurseOnAMotorcycle profile page
    3
    It is out of her scope of practice, but most likely she already knew the MD and anticipated their order before calling for it.
    MedChica, tyvin, and nrsang97 like this.
  12. Visit  GrnTea profile page
    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.
  13. Visit  iluvivt profile page
    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.
  14. Visit  SionainnRN profile page
    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.


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