Followed MD Order--Now Do I Look Incompetent?

[LaurenBoog]

I feel that I may have made an error in judgement and made myself look incompetent to my supervisors. In the interest of not stirring up any drama at work, I want to post the situation here in order to gain insight about what you all think.

I am new to the ICU, but not a new nurse.

I took care of a patient going through ETOH withdrawal. This was my second day of having the patient. The patient was originally admitted to a step-down unit, but later transferred to ICU with uncontrolled withdrawal symptoms.

The patient slept through most of the first day. I titrated the sedative drip down. Towards night shift, the patient became less groggy. The next nurse kept the sedative drip on the same level overnight. The next day, I knew that the MD would want the patient transferred back to the floor (no other medical issues requiring ICU care). I decided to stop the sedative drip and begin giving Ativan, so that I could give the MD an accurate picture of how the patient would tolerate the Ativan. The patient was cooperative and nonviolent but restless and impulsive when awake. The patient was in a vest restraint.

The MD came in that afternoon and as I suspected, wanted the patient transferred back to step-down. I shared my concerns with the MD that I felt that the patient may require higher levels of Ativan than are safe to give outside the ICU. The MD saw the patient awake, restless, but also A & O x 3. I decided while waiting for a room assignment to give the patient the max dose of Ativan our protocol allows just to see if that would help the patient stay calm. I gave the patient the max PO dose three times in the next three hours, but it didn't help the patient's restlessness. The patient had now learned how to un-snap the vest restraint!

I called report to the step-down RN and I was honest in my report (i.e. patient is able to unsnap vest restraint despite receiving the max dose of Ativan). Immediately after speaking to me, the receiving RN called my charge and protested the assignment, stating that she felt the patient was too high of a fall risk to come to step-down. (BTW, my charge nurse and my assistant supervisor were already aware of the situation). I paged the MD and had him come down again to re-assess the patient and see if he still felt that the patient was stable to go to step-down. At that time, the MD saw the patient again attempting to remove the vest restraint and get out of bed. I informed the MD that the patient had receivied the max dosage of Ativan for the past 3 hours. The patient was still A & O x 3. The MD stated that he still wanted the patient to transfer to step-down. We placed wrist restraints so the patient could not unsnap the vest restraint.

I did end up transferring the patient, but the situation became a mess. The charge RN of the step-down unit made some angry comments to me when I was transferring the patient. The receiving RN paged her nurse manager, my nurse manager, my nurse educator, and the MD to have a meeting about the appropriateness of the patient being transferred to step-down. (The patient was not transferred back to ICU). My nurse educator spoke to me afterwards and said that a patient receiving such high doses of Ativan should never leave the ICU. She called it a "learning experience" for me. I felt like she was frustrated with me. I have never had any issues with my educator before; she has always been supportive.

It has been several days but I am still upset over the situation. I am a sensitive person and I do not feel confident about being in the ICU already. Now, I feel that I have a target on my back and that my supervisors will not trust me to make good decisions. I am angry because I feel that I was talked down to by my nursing educator. As I said, I am not a new nurse. There is no protocol at my hospital for when a patient receiving high doses of Ativan can or can not leave the ICU. It is entirely MD judgement. I know that there are risks to giving large doses of any sedative, but I felt that I did all I could by sharing my concerns with the MD and having him come back and re-assess the patient. Theoretically I could have refused the MD order, but I was not 100% convinced that the patient needed ICU care. Even though it was against my better judgement, I followed the MD order.

Thank you to anyone who read this long and winding post. All comments or suggestions are appreciated.

LaurenBoog

[Caffeine_IV]

I think you did everything right and even went above and beyond. You spoke with the MD on more than one occasion of your concern.

We get patients like that on my medical unit and they don't go the ICU unless they need the Ativan on a drip because we don't do those.

We slap them on CIWA protocol and go from there..if they keep requiring a max dose, the MD may send them to a monitored bed or give 'em some Librium.

We don't have sitters either.

[RevolutioN2013]

Question from a future student here. Was the OP criticized because she gave the max allowable dose of Ativan or was it because the patient was being xferred to step down? If it is the former, then it seems that the MD would be the one to criticize that decision if it was warranted. He did not do so, therefore it sounds like it was a reasonable course of action. If it is the latter, then that is illogical of them because the OP was in agreement with them that the pt should NOT be xferred. Also, I don't think the OP stated whether or not she documented her thoughts, what she did, and what the doctor responded to her questions. Is it correct to chart all of that? If it was all charted then she would be "covered" right?

[casi, ASN, RN]

My hospital would have thrown them in step-down or tele with a sitter and 5-point restraints. There is no reason this guy had to be taking up an ICU bed. I've sat for psych patients who were acting out and couldn't have any narcotics because they came in with a narc overdose. Let me tell you this is scary as all heck. They however remained on tele because they didn't need the ICU for behaviors.

To the OP I think you handled this really well. You assess and re-assessed and let the MD know you had concerns. Honestly I think the step-down nurse was just throwing a little bit of a hissy fit about a heavy patient.

Quick question how much ativan was the patient recieving?

[suanna]

If your proceptor thought this was a "learning experience" she needs to explain what it was you were supposed to have learned. As far as I can see you went above and beyond the call of duty to manage this patient. Alcoholics have a very high tollerance to benzos so the dose of Ativan appropriate for an alcoholic may be 4-5 times what a person with little ETOH hx would require for the same effect. If I was the stepdown nurse I would have been annoyed if you didn't max out your protocal for sedation before sending him to a unit where they have less latitude. I used to work detox and only in the last few years has the hospital I work for developed an ETOH withdrawl protocal that is based on behavior and response to meds, not a programmed PRN schedule. I can tell you, what you did is more consistant with a good understanding of the alcoholics physiology than what is usualy provided. Some people you have to deal with are your superior in title only. You are a nurse, and responsible for your personal clinical judgement. Don't let less insigntful staff bully you into second guessing what you know to be good clinical judgemant.

[nyrn5125]

It's not you. Some, not all, nursing educators are not very educated on reality. You are taking up a bed that a soon to be intubated pt may need. Emergencies happen all the time and you do need open beds in the ICU. She should be citing where in your hosp policy it states that a fall risk/ po ativan pt with etoh withdrawal is an ICU designated pt. Always ask the policy and how is this evidence based? get them to answer your questions before they tell you this is a learning experience. They probably won't be able to. If you were comfortable and the doc was fine with the transfer then they should value your clinical judgement. In our stepdown we would have set up having a 1:1 prior to the pt coming and anticipate giving iv ativan since it doesn't sound like the po was helping

[indigonurse]

If you knew that the MD was doing something that was harmful to the pt. you could have refused to follow his order and asked him to take the pt. to the step down unit himself. You could have put the situation in your supervisors hands. You could have called the medical director to intervene. Since nursing is a team effort you could have asked the step down nurse who protested the res. transfers advice on how to handle the situation. You did the best you could do and no harm came to the patient. You are new to this situation and still learning. In time your team will learn to regain their trust in you.

[kessadawn, BSN, RN]

Sounds to me that you advocated for your patient as best you could, what did they expect to do, block the guys doorway so he couldn't leave the ICU? The problem seems to be a stepdown that didn't want this patient and you got to be the scapegoat newbie nurse. As far as your nurse educator, you should go to her, ask her exactly what she thinks you should have done differently, what would she have done in your shoes? I don't see in your post how you could have done any differently. This was not an ICU patient, it was a floor or stepdown patient that required a sitter. Don't beat yourself up over this, you tried!

[indigonurse]

In my state RN's cannot write medical orders, admit, or discharge patients unless they call 911, if an MD gives a verbal order or a written order a licensed nurse is expected to follow it unless it is out of the RN's scope to do so or if it will place the pt. in danger. Then the RN needs to transfer the care of the pt. to a person who is capable of providing it or needs to consult her supervisor and or the medical director about an MD who is telling the RN to put the pt. in danger.