I'm going to step out on a limb here. I know this might be specific to specialty, facility, co-workers, etc...
What ever happened to nurse's discretion? I know there are multiple threads on autonomy, but good god.
(1) Case in point: Pt with GI bleed. Starts having frequent bowel movements of bright red clots/blood. BP remains stable but not for long. I page MD about 4 times before he responds. In the meantime her fluids are at 50cc/hr. I ensure pt is not CHF/Renal/Hypernatremic etc.. and turn fluids up to 200cc. Systolic now in mid 80s after being about 115. Pulse up etc etc... I'm literally grabbing the phone to call a RRT and the doc finally shows up and xfers her to an appropriate level of care and personally thanks me for turning fluids up etc... (other VSS btw)
The first thing I hear out of my charge nurse's mouth is that I acted inappropriately because I did not have a physician's order (to turn up fluids) and that I am receiving a warning "this time."
(2) I'm looking up the results of an abd ultrasound. There is some medical verbiage I don't understand and I look it up to clarify. When passing along the info in report. (just as an FYI) I get a response from the receiving nurse, "Oh, we don't have to worry about that, it doesn't really involve nursing."
(3) I have a pt that is in mild resp distress. Crackles to lungs. Just came up from ED. 5L NC isn't cutting it. Pt is not COPD. I run to grab mask. Charge nurse walks by and the first thing out of her mouth is: "You can't have an O2 mask on a med-surg floor, and plus, you need an order for that." (just for the record, ran to get Lasix IV shortly after once I had the all-powerful "order")
(4) Oncoming RN is ****** at me because there are three spots of blood on sheets of disoriented pt who I had to physically wrestle down and stimultaneously draw a PTT for a Heparin gtt. Noted increased PTT and had gtt titrated down before change of shift so oncoming RN would not have to deal with it.
I'm not sure if these examples truly represent what I'm trying to communicate. I just constantly see a growth in nursing as task oriented vs. brain oriented. Is there such thing as nurse's discretion anymore?
I feel as though the focus is so much on protocol and procedure as though you are acting as a robot vs. real critical thinking. Sometimes I want to scream at the top of my lungs, " Who gives a flying **** if we can't have a non-rebreather on this floor! The point is, at this time, the pt needs it for adequate oxygenation!"
Don't get me wrong, there is a time and place for procedure/protocol. But let's re-evaluate what is and what is not important. I don't profess to be an MD. I'm not going to do open heart surgery etc... without an order. However, god forbid I want to go above and beyond and learn as much as I can about my patients because it helps me see the "whole picture." God forbid I'd like to take an immediate action that I feel is necessary for the stability of my pts.
I'm bright eyed and bushy tailed. Those of you with years of experience, please tell me I'm not insane for my mode of thinking.:confused:
Ok I am a little confused. IVP Metoprolol is used when a pt is NPO on my hospitals med/surg floors. I work on a cardiopulmonary med/surg floor and use it for the same reason, but have also used for A Fib or just a pt that BP is high and they want to give an extra dose. So that one time dose has to be administered by your RRT?? Our team is called an MRT and I can't imagine they would be thrilled to be called to do that? I question if there has been a problem or situation at your hospital that brought on this policy.
The first place I worked we had a lot of NPO pts who got IVP metoprolol q6h with no telemetry monitor. My next job also gave IVP metoprolol, but they had to be on a monitor. Not just remote telemetry, but on our unit (a step down unit with monitors at the bedside) or in an ICU. Kinda silly if you ask me, but that was the policy. Really silly to only allow RRT to push it IMHO. (P.S. I realize that the person who originally brough this up in a CNA and not involved in making the unit/hospital policy on such an issue)
The first place I worked we had a lot of NPO pts who got IVP metoprolol q6h with no telemetry monitor. My next job also gave IVP metoprolol, but they had to be on a monitor. Not just remote telemetry, but on our unit (a step down unit with monitors at the bedside) or in an ICU. Kinda silly if you ask me, but that was the policy. Really silly to only allow RRT to push it IMHO. (P.S. I realize that the person who originally brough this up in a CNA and not involved in making the unit/hospital policy on such an issue)
A solution to this wold be to get the metoprolol as an IVPB and run it in over 30 minutes. That's what we do where I work, metoprolol IVP is only for emergent situations, and then only if patient is on bedside monitoring.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
a solution to this wold be to get the metoprolol as an ivpb and run it in over 30 minutes. that's what we do where i work, metoprolol ivp is only for emergent situations, and then only if patient is on bedside monitoring.
*** uh, why? don't you have _registered_ nurses where you work?
I've only read as far as this post but THANK YOU WOOH for saving me the time to post. My response would be absolutely identical....... word for word !!
In general I think nurses should stay within thier scope and folllow the rules. These rules are in place for a reason and that is to protect everyone involve, inlcuding the patients. Someone posted that she has seen nurses give patients oxygen when they did not need it or something like that. I'm not suprised becuase these nurses were acting outside what they should be doing in the first place. Let the doctors do what they do. That's what they get the big bucks for.
I'm comfortable with the amount of autonomy nurses have. The more autonomy you have the more responsibility you have when things go wrong. No? That is why I would never want to be an M.D.
There was this patient from PCU transferring to CV ICU. The patient's LOC had changed and there was an order to transfer and to get the lady BIPAP. The patient came to the ICU with a NC and the women skin was turning kinda mottled/greenish purple.
The response from the PCU nurse was that the order was to TRANSFER first, then (apparently someone else) get BIPAP. They hadn't even called respiratory. Really? She can't at least prioritize orders?
This is why I like PACU. With time and experience sliding into PACU is one of the few areas left with autonomy. Because of the way our protocols are worded we can go ahead and do things medically needed for the patient which also make sense without waiting until the doc runs to the bedside or calls back (though they are usually right there in a flash)
I can fluid bolus, change levels of oxygenation and other things depending on what I see is happening with the patient, and am covered by the protocol that the anesthesiologists sign when they arrive in PACU.
Anywhere else you just stand there waiting for the RRT team to show up when the doc doesnt call back.
Thats why I stopped floating in house for extra cash. If my patient had chest pain I was calling for a 12 lead, and then getting fried by the charge even though the doc always covered me afterwards. Its a different environment, and it isnt for me anymore.
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psu_213, BSN, RN
3,878 Posts
The first place I worked we had a lot of NPO pts who got IVP metoprolol q6h with no telemetry monitor. My next job also gave IVP metoprolol, but they had to be on a monitor. Not just remote telemetry, but on our unit (a step down unit with monitors at the bedside) or in an ICU. Kinda silly if you ask me, but that was the policy. Really silly to only allow RRT to push it IMHO. (P.S. I realize that the person who originally brough this up in a CNA and not involved in making the unit/hospital policy on such an issue)