be honest, now. how many of you find a patient that you think has an emergent problem and actually call the doctor and get orders first?
before icu (where we have standing orders), when i worked on the floor, i would ask someone to page the md but immediately start drawing needed labs, place o2, etc., while waiting for the md to respond.
when the md called, i would report the prob and say i drew this-and-that and did such-and such and what else do you want?
of course, i had worked with the same mds for years and could antipicate what they would want done. technically wrong, but i felt waiting on a return page that could take up to 20 min or more was worse in an emergent situation.
what about the rest of you guys? what's your procedure?
There was this case of a lady who was a direct admit with c/o of bloody stools.
Around 0400 vitals check, tech came and told me she had assisted pt. to bedside commode and and there seemed to be a lot of blood in her "stool" and that she had a difficult time getting patient back to bed.
Well, there was a lot of "blood" but no 'stool' - it was all either fresh blood or dried blood! (about 600 cc's worth!)
*uh oh!*
Did a stat orthostatic hypotension test. I couldn't get her to stand up long enough to get a BP reading - she was on verge of passing out!
*cue omminous music playing!*
Laid patient down and raised foot of bed. Told her to sit tight and hang on. Called a colleague and requested that she start another IV line on her.
STAT ordered a Hemocue, CBC, Type and Cross 2 units. Paged MD. Notified House supervisor of possible ICU transfer.
MD calls back, told him story so far. He only orders an add on - CMP and EKG. Approves transfer to ICU.
Pt. admitted with Hgb - 11.6
STAT CBC showed Hgb - 5.8!!
Was half way through first unit of blood as we wheeled her into the ICU and I gave report....
I guess for me, it's a "case by case" thing. Nominally, I call for orders. I guess working nights it lends a different perspective.
At one time I may have done something without an order first but with the way things are now I would never do that. As for a patient with a blood sugar of 20 we have a hypoglycemic protocol so I have no problem doing anything that needs to be done for a hypoglycemic patient then notifying the doctor to see what he wants to do about routine insulin the patient is on.
I wouldn't do anything without the signed order available. Too risky. But I have followed protocols when available and sent orders for the doctor's signature. I wouldn't do this with doctors that are known not to cooperate with this practice. This is info that is supposedly passed on by coworkers who know the doctors and their habits.
be honest, now. how many of you find a patient that you think has an emergent problem and actually call the doctor and get orders first?
before icu (where we have standing orders), when i worked on the floor, i would ask someone to page the md but immediately start drawing needed labs, place o2, etc., while waiting for the md to respond.
when the md called, i would report the prob and say i drew this-and-that and did such-and such and what else do you want?
of course, i had worked with the same mds for years and could antipicate what they would want done. technically wrong, but i felt waiting on a return page that could take up to 20 min or more was worse in an emergent situation.
what about the rest of you guys? what's your procedure?
stacie - those things are fine for us older nurses who know the docs - but even then you have to be careful. a new nurse should always check with someone before going full-bore ahead without orders.
i did things that i knew the docs would approve of because they knew and trusted me from years of association - but they wouldn't have felt the same way about someone they didn't know.
There was this case of a lady who was a direct admit with c/o of bloody stools.
Around 0400 vitals check, tech came and told me she had assisted pt. to bedside commode and and there seemed to be a lot of blood in her "stool" and that she had a difficult time getting patient back to bed.
Well, there was a lot of "blood" but no 'stool' - it was all either fresh blood or dried blood! (about 600 cc's worth!)
*uh oh!*
Did a stat orthostatic hypotension test. I couldn't get her to stand up long enough to get a BP reading - she was on verge of passing out!
*cue omminous music playing!*
Laid patient down and raised foot of bed. Told her to sit tight and hang on. Called a colleague and requested that she start another IV line on her.
STAT ordered a Hemocue, CBC, Type and Cross 2 units. Paged MD. Notified House supervisor of possible ICU transfer.
MD calls back, told him story so far. He only orders an add on - CMP and EKG. Approves transfer to ICU.
Pt. admitted with Hgb - 11.6
STAT CBC showed Hgb - 5.8!!
Was half way through first unit of blood as we wheeled her into the ICU and I gave report....
I guess for me, it's a "case by case" thing. Nominally, I call for orders. I guess working nights it lends a different perspective.
Yes, it does. As a night nurse, I've acted where I know for a fact the day shift wouldn't. Without all the higher-ups and ancillary people to fall back on, we tend to be a bit more autonomous (for lack of a better description).
I had a very similar incident happen to a patient I'd admitted one night--- only it was vomited blood. Patient got a funny look on her face, leaned over the rail and spewed; the blood covered the floor underneath the bed from head to foot. Like you, I'd paved the way for the transfer and treatment by the time the doc called back (and he returned the page promptly, too). You learn pretty quick how to get things rolling when you work night shift
If I don't have standing orders, I get orders. That's a limitation I took on myself when I accepted my license.
If it just stopped there, that would be irresponsible. What I try to do is look things over, forsee where things might get bad, and paint a simple picture for the doctor's action, carefully excluding irrelevancies. I don't diagnose. I tell him what I see, and I do it as soon as I figure out something is very wrong.
I don't want to be a hero. A hero is someone who does his stuff in the nick of time. Instead, I want to show up early and be a good anonymous team member. If I am a hero, that means I didn't forsee or prevent something. Or I did but I wasn't reassessing frequently enough. Or I wasn't able to "sell" my concern to the doctor. To me, very simply, it means I failed.
Well of course I'm talking about my unit, a tele unit. And sure, there are times when someone dumps an unstable pt on our doorstep they should've held onto. I'm not typing about that.
So my process goes something like this. First I know something's very wrong. Then I go through the labs and chart carefully to get evidence. As I do, I yak with every nurse who has general experience with this picture, or specific knowledge of the patient. Generally this creates a little knot of folks discussing the whole situation. Then I go through my "what-if"s and present a plan for them to shoot holes in. When the group is satisfied, I make the call. This all happens very fast, 5 to 10 minutes.
My goal is to make the call before something is an emergency, but to be able to work it up into a clear-cut area of concern that any doctor would want to address before it blows up.
I really need to develop some doctors as gurus so I can sharpen up my sales strategies. One key is probably going to be learning how to sell cardiologists on calling consults instead of trying to get them to do stuff they're uncomfortable dealing with. I am a total newbie at this, it is going to take a lot of work for me to get reliable results.
Reading this thread has left me wondering. I am a UK trained nurse and have not started work in the US yet. You are all talking about needing orders for things like O2, EKG's ..etc... and I was wondering now much autonomy you have as RN's. I gather it varys from unit to unit but in the UK, we do not need to get orders to draw blood, do EKG's, start O2, etc..In codes we can defib and give adrenaline and atropine without a doc being present. We also have standing orders similiar to yours. Obviously, some of you are happy to do things without an order but just so I don't get myself into trouble oneday, what basic things need an order and what doesn't?
Reading this thread has left me wondering. I am a UK trained nurse and have not started work in the US yet. You are all talking about needing orders for things like O2, EKG's ..etc... and I was wondering now much autonomy you have as RN's. I gather it varys from unit to unit but in the UK, we do not need to get orders to draw blood, do EKG's, start O2, etc..In codes we can defib and give adrenaline and atropine without a doc being present. We also have standing orders similiar to yours. Obviously, some of you are happy to do things without an order but just so I don't get myself into trouble oneday, what basic things need an order and what doesn't?
I haven't phrased this question very well!
There's no one answer to that...
Some hospitals will have certain policies and protocols that cover us to do certain actions without an order.
For example, we were allowed to collect cultures (wound, urine, sputum, catheter tip, etc.) without an order (with the exception of blood cultures). If a blood sugar was critically low, we could treat before calling and if either high or low, could draw lab values without orders. We could pronounce patients expired.
The hospital I'm at now can't do any of that; a nurse can pronounce, but needs an order to do so. But they are allowed to order simple meds and procedures that we were not allowed to do.
The other hospital in town allows their RT's to order nebulizer treatments, ABG's, and O2 when requested by the nurses (or on their own assessment of need), whereas those at mine needed orders before placing an extension tubing lol.
I've known some nurses who've worked outside the hospital setting who had a great deal of latitude in their practice.
So it all depends on where you are working. And as I described in my above post, I was expected to take certain actions in an emergent situation while awaiting the doc to return the page, because of the time I'd worked with them and our level of mutual trust.
As I said, our hospital didn't have (and still doesn't have) a Rapid Response team. In those I've worked in since that have this system, those actions you describe can be done without MD orders. ACLS certified staff could run a code as you describe without a doc present regardless of whether there is a rapid response team.
Specializes in SICU, EMS, Home Health, School Nursing.
At my hospital in the ICU and tele floors we have a lot of standing orders and there are a lot of things we can do per nursing protocol or acls protocol such as place O2, draw ABGs, get x-rays, certain meds, etc. There are certain things I will do before calling a doc, but I will not give meds, etc. that are not part of our protocol I value my license a bit more than that.
NO - not usually. In a TRUE emergency I WILL go AHEAD and do the expected critical interventions to save the life of a patient.
I have been functioning on "standing orders/protocols" for a looooong time - so, although I'm NEVER trying to "practice" medicine without a license - I WILL generally choose action over inaction. Even in the absence of protocols, there ARE generally accepted STANDARDS OF CARE!
Of course, I will note any attempts to contact MD.
Although I pray to never be in a circumstance of having to explain my ACTIONS to a BON - I still maintain that ACTION will be easier to justify in a TRUE LIFE THREAT!
I guess I would RATHER explain ACTION over INACTION as a rule!
So, this is just my humble opinion --- I can always EXPLAIN without fail ANY ACTION or INACTION that I take part in - so......
After all, once you've seen certain conditions hundreds of times and you know the Dr.s well, why not do your best for the pt in an emergent condition? My worst fear as a medical professional is having to stand by and watch a patient die while waiting for an order.
I love working in the er becasue we are able to act before the MD see the pt. There are tiems when we run a code without an MD present. Act first, Ask later
Roy Fokker, BSN, RN
1 Article; 2,011 Posts
There was this case of a lady who was a direct admit with c/o of bloody stools.
Around 0400 vitals check, tech came and told me she had assisted pt. to bedside commode and and there seemed to be a lot of blood in her "stool" and that she had a difficult time getting patient back to bed.
Well, there was a lot of "blood" but no 'stool' - it was all either fresh blood or dried blood! (about 600 cc's worth!)
*uh oh!*
Did a stat orthostatic hypotension test. I couldn't get her to stand up long enough to get a BP reading - she was on verge of passing out!
*cue omminous music playing!*
Laid patient down and raised foot of bed. Told her to sit tight and hang on. Called a colleague and requested that she start another IV line on her.
STAT ordered a Hemocue, CBC, Type and Cross 2 units. Paged MD. Notified House supervisor of possible ICU transfer.
MD calls back, told him story so far. He only orders an add on - CMP and EKG. Approves transfer to ICU.
Pt. admitted with Hgb - 11.6
STAT CBC showed Hgb - 5.8!!
Was half way through first unit of blood as we wheeled her into the ICU and I gave report....
I guess for me, it's a "case by case" thing. Nominally, I call for orders. I guess working nights it lends a different perspective.