Me vs. the charge nurse - page 2

Was I wrong in what I did? I need some other perspectives. I was working a few days ago and had a conflict with my charge nurse. It was basically about whether to call the doctor about something... Read More

  1. by   CritterLover
    Quote from all_smiles_rn
    it's my understanding that most docs want the bp to be a little on the higher side post cva. 180 being the upper limit of where they want it. any thoughts on this?


    i believe that is correct for an ischemic stroke (trying to keep the brain perfused). it depends somewhat on how much swelling there was in the brain. the more swelling of the brain, the higer the icps would be, and the higher the bp would need to be to keep the brain perfused.

    however, since the doc had noted the bp in the progress notes, and ordered a tx, he wanted it somewhat lower. or, at least no higher. cozaar, if that was indeed the drug, isn't all that powerful, and most likely wouldn't have caused a huge drop in bp (unless a diuretic is on board as well).

    cozaar is also used to prevent strokes, so it is possible that the doc wanted it given for that reason.

    they certainly don't want the bp going any higher, and it would be appropriate to put her on some kind of bp med to keep the bp controlled. i would have questioned any order that would have caused a huge drop in bp, but not cozaar.
  2. by   TazziRN
    The OP states the high BP was addressed in the MD's notes and a med order was written and just given. I'm sorry, but I'm not understanding........why should she have called the doc about this? I could see it if the BP didn't come down after the med was given, but.....?
  3. by   jen123321
    There's no problem with an ischemic CVA pt. being in the 160-180 range...if you just started PO meds, the MD isn't going to do anything else...it's basically unsafe to bring the pt any lower...they need perfusion to the brain etc....
  4. by   Inquisitive one
    So. was the doctor called? If so, what was the response? Any new orders?
  5. by   CritterLover
    Quote from jen123321
    there's no problem with an ischemic cva pt. being in the 160-180 range...if you just started po meds, the md isn't going to do anything else...it's basically unsafe to bring the pt any lower...they need perfusion to the brain etc....


    Quote from tazzirn
    the op states the high bp was addressed in the md's notes and a med order was written and just given. i'm sorry, but i'm not understanding........why should she have called the doc about this? i could see it if the bp didn't come down after the med was given, but.....?


    i can't figure it out, either.

    i was wondering if the charge nurse maybe thought the med was going to bring the bp down too much for an ischemic stroke????

    unless the doc wrote for the drug to be given stat (and i don't know why he would have), i don't understand what the big deal was.

    the only other thing i can think of would be if the patient's baseline was quite a bit lower than 180/80.

    op, do you think you can ask? finding out the rationale would be beneficial to you.
  6. by   rn/writer
    Quote from DebRN325
    Was I wrong in what I did? I need some other perspectives. I was working a few days ago and had a conflict with my charge nurse. It was basically about whether to call the doctor about something related to my patient. She saw a blood pressure and freaked (was 180's over 80's), I saw the doctor had noted this in his progress notes just 2 hours prior and ordered some PO meds to be given, which I just had. I tried explaining this, but it was no use and she practically ordered me to call the doc. I was really upset about this because this was MY patient and I thought she had no right to tell me what to do. Or does she? Basically I am wondering that as a staff nurse, do I have to respond and do (within reason of course) what my charge nurse tells me to do regarding my patients? I am really torn about this and could use some feedback. Thanks!
    Medically, it's kind of a toss-up about whether a call needed to be made. There are rationales for either decision.

    Politically and practically, I would have made the call, done the documentation, and only then, after the fact, would I have approached the charge nurse for further discussion. If you don't make the call and anything happens, you're goose is cooked.

    The charge nurse really is in charge. Unless she's telling you to do something that violates Policy and Procedure or basic medical principles, your best bet is to do what she says. Then the responsibility is hers. You can certainly ask questions, but if she's about to blow a gasket and what she is requesting will not put the patient in harm's way, do it her way and work it out later.

    This isn't only about patient care. It's also about chain of command. If you refuse to do what she asks (without a compelling reason), you can find yourself accused of insubordination.

    DO follow up later when things have settled down. Express your thinking then and you're likely to find a more receptive audience. If you conduct yourself with this combination of discipline and self-respect, you increase your chances of being taken more seriously in the future.
  7. by   newnurse2t
    Was this your first time taking care of a CVA patient? Maybe the charge nurse was really trying to be helpful and thought that you wanted or needed her help. How did the charge nurse see your vitals anyway?
  8. by   qt314nf
    I agree that the best thing you can do for yourself is speak to your charge nurse and find out why she wanted you to call the doctor and have her walk you through the situation as a learning experience. Your charge nurse should be a resource for you, not some one to yell at you and point out your mistakes.
  9. by   Dolce
    I would have called the doc if it had been 30-60 minutes since the patient had received the BP med and the BP was the same. However, if the med was just given there is no new information to relay to the physician. There is no point in calling a doc to tell them what they already know. If the charge nurse was insistent that he be called I would have been curious as to why she didn't call him herself. Maybe there is more to the story that I am missing, but it seems kinda weird to me.
  10. by   jojotoo
    Quote from newnurse2t
    Was this your first time taking care of a CVA patient? Maybe the charge nurse was really trying to be helpful and thought that you wanted or needed her help. How did the charge nurse see your vitals anyway?


    As the charge nurse in the ER, I know what's going on with the other RNs patients. I know if they have abnormal VS or labs. I know where they are in the evaluation process - awaiting imaging, awaiting results, awaiting callback from PMD, awaiting admission (lots of waiting!).

    I talk to the RNs, the patients, the MDs on what the plan is. I look at the charts. I confirm that MD orders have been implemented and that nursing documentation is complete. I try to anticipate problems and correct bad situations before they get out of control.

    Is this not what other charge nurses do?
  11. by   Tweety
    Quote from All_Smiles_RN
    it's my understanding that most docs want the bp to be a little on the higher side post cva. 180 being the upper limit of where they want it. any thoughts on this?
    Yes. When I worked neuro we would let the BP get as high as 220/110 before intervening per our protocol for non-hemopharrghic ischemic strokes. This assures perfusion.
  12. by   Tweety
    Quote from rn/writer
    The charge nurse really is in charge. Unless she's telling you to do something that violates Policy and Procedure or basic medical principles, your best bet is to do what she says. Then the responsibility is hers. You can certainly ask questions, but if she's about to blow a gasket and what she is requesting will not put the patient in harm's way, do it her way and work it out later.
    Nothing at all wrong whatsoever in making the call. One can never go wrong with informing an MD of a patient condition.

    What I disagree with is that just because the charge nurse is involved and you're following her/his directions, the responsibility still lies with the licensed nurse who is the primary care provider. A shared responsiblity for sure. If a sentinal event occurred and the nurse states to the BON "I'm not responsible because my charge nurse said to do it......." they aren't going to buy that.
  13. by   pegbord
    hmmm. . . As a new nurse, I would tend to do what my charge nurse asked of me, UNLESS I feel it puts my patient in harms way. In one of my clinicals as a student nurse, I opted to withhold a medication that had been ordered as I felt it unsafe for my patient. I checked with my precepting nurse for verification, she told me that it was my decision. I called pharmacy for confirmation and the director of pharmacy told me that he agreed I should withhold the med and document why; next I paged the attending physician (pt doc was not available) and attending physician concurred not to give the med.The charge nurse didn't like the idea of a student nurse paging an MD. I told my precepting nurse, (who told me to page the doc for confirmation) that the doc had concurred, not to give the med. Precepting nurse asked me if, while talking to the doc, I informed him that the patient was going home today. I had not, so she told me to page him again as that information may sway his decision. I paged him again . . . and this is what set the charge nurse off. . . In the middle of my talking with the paging operator, she started making faces and hand gestures and talking to me about how "You can't be bothering doctors every time you have a question." I got all flustered, because I was conveying info to paging operator at same time charge nurse was "going off on me." By the time I got off the phone, the charge nurse was unavailable for me to get clarification about what I was doing wrong.I proceded to give the patient his meds, except for the one that I was withholding. While giving the meds, the charge nurse came to the door of the patient's room and sharply said, "I need to talk to you." I replied, "okay, I have one more med to give, then I'll be right out." Her response, with sharp authority, "I NEED TO TALK TO YOU NOW." I politely told the patient that I would be right back to give the rest of his meds - then went out to see the charge nurse.She was standing in the hall reprimanding me loudly, waving her pen in my face, and ordering me to give that med as his labs indicated it was perfectly safe. She carried on with such outrage and anger, it totally caught me off guard!I still did not give the med, but immediately called my instructor to summon help. When my instructor arrived, she witnessed the charge nurse "attacking me" and immediately said, "this is not the place, we need to discuss this elsewhere." By now the nurse manager was coming to the nurses station as she was hearing the charge nurse's loud harshness. My instructer pointed to the managing nurse and said (paraphrased) "I want you, charge nurse, precepting nurse, my student and myself to discuss this in the nurses lounge, this is not appropriate out here." My instructors was great, kept her cool and just wanted to find out where the breakdown happened. In the end, the charge nurse apologized for attacking me.Bottom line, I, as a student, did NOT follow the charge nurses orders because I felt it harmful to my patient. I had confirmation from pharmacy as well as attending doc, (precepting nurse seemed to be hiding someplace). I was vindicated by the nurse manager as well as my instructor for getting confirmation from pharmacy as well as attending doc, and following the ethics of knowingly doing no harm. charge nurse was reprimanded for her behavior. Again, if charge nurse tells me to do something (within reasonable realm of nursing, of course), and I don't see how it will harm my patient, I will do it. In your case, calling the doc and saying something like, "My charge nurse wanted me to check in with you about pt _____, regarding her blood pressure. . . "Had the charge nurse ordered me to do something that I did not deem harmful to the patient, I would have done it. I am a student and learning, so even if I dont her rationale, I would do it and ask her to help me understand the reasoning behind it.Wow, this got really long-winded. Sorry!

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