How much can a nurse do????

  1. I was just reading an article about a patient that came to the emergency room after an automobile accident. The nurse established an IV and then after assessing the patient suspected a ruptured diaphragm. This is what the nurse did next...

    "What must you do immediately?

    Notify the physician of Ms. Harrison's condition. Establish a second I.V. line with lactated Ringer's solution and insert a nasogastric (NG) tube to decompress the stomach. Obtain a portable chest X-ray. The X-ray shows the tip of the NG tube above the level of the diaphragm, a hollow mass above the left diaphragm, and a potential mediastinal shift to the right. In up to 30% of patients with ruptured diaphragms but no displaced abdominal organs, however, the chest X-ray appears normal."

    I am a student so please bare with me, but when I was admitted into the hospital, the nurses I had did nothing unless the doctor ordered it, including x-ray's, starting an IV, etc. Which is more the norm....the above scenario or having to wait for the doctor to decide what to do?? Thanks!!
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  2. 15 Comments

  3. by   tonchitoRN
    I was taught that you cannot do anything unless a MD orders it. Now I know in reality many nurses do first then get the order later. Correct me if I am wrong but if you do something and it turns out to be wrong you can be held liable. Not only that if the MD disagrees with you he does not have to give the order. Then you are stuck because you have "just practiced medicine without a MD license". So you have to choose if you want to play hero or play by the rules. Just a thought. I'd like to hear what others say.
  4. by   misti_z
    There's one MD in the hospital I work at that you better not give as much as a tylenol without his order!
    He doesn't even allow hospital substitution for meds.

    I work on a renal unit and we have a nice list of standing orders that make things a lot easier. Ex--Dulcolax, Tylenol, D50, there are more that I can't remember but these are used most frequently. And working with the same team of doctors you can anticipate what will be ordered for some situations and be prepared for when you get off the phone with the MD, for ex--panic high potassium we get 1 amp d50 and 10 units reg insulin for IV administration, 1 amp NaHCO3, 60mg oral kayexalate, and sometimes 1 amp CaGluconate (depending on which nephrologist), and prepare pt for HD in am if necessary.
  5. by   MollyJ
    In the real world, nurses cannot start IV's, order tests etc etc UNLESS there are standing or actual orders to back their behaviors OR they have a very decent relationship with their ED or ICU docs and a pretty good idea of what they will back you on. Ordering medical tests and procedures and meds is in the medical domain strictly speaking and if and when you cross this line, your nursing supervisor has no defense for you due to the basic legality of the situation.

    In ED's I've worked in, our _standing orders_ included starting lines, placing cardiac monitors, placing oximeters, giving meds in certain parameters (code drugs, nitro) etc on unstable or potentially unstable patients. I have also worked in the ED's where our ED docs wanted and expected us to xray (for example) ankle sprains before they saw them so that they could come in and pronounce them sprained, but _you should never assume this relationship until you have it_. You should never assume that staff doctors will grant you the same leeway, though many will. Nurses also have to understand their limitations. Nothing is more disheartening than to order a foot when the doc really needs an ankle to make his decision because you haven't saved anyone time and you have cost the client or the hospital money.

    ***The key is to know your docs, know your standing orders and do not assume you've been given leeway to do procedures you haven't because a nursing license doesn't give you license to do these procedures without and order.***

    That said (now I get to contradict myself) most ED docs will get mighty impatient with you if you DON'T get IV's started, monitors on etc in situations where they are warranted. They want us assertive when it serves them but woe betide if you assert when they didn't want you to.

    One of my favorite stories involved a gal who came into the ed with vague abdominal pain and she told me she had dysuria but denied it to the doc. (one main rule of the ED is that everyone--triage nurse, nurse and doc--all get different stories.) I had already sent the urine over when the doc saw her and said, "I don't think we need the UA." I gulped and announced that I'd already sent it over---and it was positive for WBC's and RBC's. This was a cool doc and he was pretty gracious about it, too. (not only had I done a test he didn't order, but I made the dx doing it....)

    I remember reading those nursing mags and thinking the same thing, "So I am supposed to this stuff or not?" I think the authors show off in those mags but they are also trying to get an article as condensed down as possible and so you may not get the context that they had an on-unit intensivist or ED doc managing the patient's care.
  6. by   Zee_RN
    I agree with MollyJ. You gotta know your docs and know your standing orders. And be pretty sure you're practicing as a "reasonably prudent nurse" if you do something without an order...check with a charge nurse or co-worker if you're unsure. We bounce things off each other all the time.

    I know if an attending physician has consulted, say, an orthopedic guy because of a sore leg/arm/neck, etc., the first thing the orthopod will say when he calls in is "is the xray available?" Umm, not ordered.... If the attending is on the ball, he will have already ordered it. If he didn't but is approachable (some don't take suggestions well), you can suggest an xray order prior to ortho seeing pt.

    Knowing what and when all comes with experience; there is no easy answer.
  7. by   dhenceroth
    At our hospital, nurses are given authority by the medical staff to do specific interventions (XRs, foley, IV access, etc) by developing protocols and/or critical pathways for specific diagnoses, or certain presenting symptoms in the ED (i.e. musculoskeletal pain). Just make sure you have documentation that these protocols have been officially approved by the physicians....reliance on a physician relationship is a gamble....I would want something in writing that backs you up. I'm an RN risk manager and I try to make sure we have good p/p in place to back up the nurses.
  8. by   P_RN
    that scenario looks like one in the nursing 2001 journal. i've written the editor more than once about the wording.

    i've often wondered about the phrasing they use. i believe it implies "what you--(will probably be ordered to) do" sort of an expected sequence of events.

    i have read some that mention you will insert a chest tube....etc, etc, etc.

    standing orders are great, but i don't think many nurses would be backed up if a serious event occurred no matter how much "their" docs trust them.

    so no, you won't do anything in that instance without a doc's order, but that doesn't mean you won't have the supplies and a suggestion or two if the doc seems to falter.
  9. by   prmenrs
    I think sometimes the docs expect us to practice medicine w/o a license (which is what we're talking about) and then sometimes get upset if we do!

    Just be real careful out there!!!
  10. by   RNforLongTime
    I have done some things, such as checking a blood sugar (with a bedside monitor) or inserted a saline lock, without an order. We get chest pain pt's on the unit I work on and sometimes the doc will not order an IV, and one wasn't started in the ER either. I go ahead and insert one on these types of pt's per nursing judgement. God Forbid, the pt go into cardiac arrest and not have any IV access!

    I have "slipped" pt's tylenol and Maalox without an order. I find that most doctors do not like being woken up at 3 am so I can ask for a tylenol or Maalox order.

    Anything major, such as the scenario described by essarge, I will not and cannot do. I was always told that I must have a doctors order before I do ANYTHING!

    When in doubt, check with the house supervisor and Always check your individual state's Nurse Practice Act.

    Kelly
  11. by   CEN35
    I have to much to say here............think I'll wait
  12. by   RNforLongTime
    Don't hold back Rick!
  13. by   essarge
    Wow!! Never expected this many replies!! Thanks!!

    Yes it was a scene from nursing 2001, that's why I asked about it. Seem's like the editor's would be more careful about the wording in there stories!! Especially since this journal is read by many, many, students!!

    Any more opinions would be great....maybe I could make a paper out of this subject!!
  14. by   janine3&5
    In the ER, we do have protocols stating that certain things can be done before the pt is seen, i.e. EKGs, monitor for CP, extremity Xrays for injuries, very basic stuff.

    However, most nurses, including myself, do go a little further. For example, pts with chest pain, I'll go ahead and put them on the monitor and 2L O2, get a line in, draw blood and order CBC, SMA 7, and Troponin, order a CXR, and do an EKG. You KNOW these things will be ordered- so go ahead and get it going. Things that I'm not SURE will be ordered, I'll hold back on it. I don't give any meds without an order.

    In our ER, it seems as if its almost expected sometimes. The doc will see the pt and ask if any labs are back yet (before they've been ordered) I was taught by my preceptor to go ahead and do these things, I never really questioned the legality of it, so its interesting to read these replies.

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How much can a nurse do????