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Discussion

Autonomy?

I recently moved to a new state and took a PRN position at a teaching hospital. I have noticed the nurses at this facility will not consider any interventions unless a resident is by their side. Nothing!

Some examples:

1) nurse enters the room and the patient seems clammy, pale and slow to respond. I suggested she recycle a pressure and get a quick blood sugar. The nurse looked at me like I was from another planet and said, "we don't do that without an order". What?? don't you want to have some information before you call the provider? She did not!

2) Surgical patient who lost tons of blood suddenly became very tachy and the BP was slipping quickly. I mentioned, "I'll open up his fluid, lay him flat while you call the resident." She responded - "NO! We don't give medications unless the doctor orders it."

I later had a conversation regarding a patient coding and initiating ACLS protocols and again I was told by more than one nurse at this facility they will not even initiate ACLS medications until the physician enters the room.

What planet is this??

This cannot be the norm everywhere. The last facility I worked we used clinical judgement and critical thinking to approach a problem. Many times we started the appropriate medications before even informing the physician. Nothing outrageous just the protocols we utilized.

You have a patient with a blood glucose of 30 - you give an amp of D50 then you tell the doc. However, i would probably be burned at the stake in this place.

I could see over the years nursing has been moving towards a non-thinking role where we check boxes on the computer all day and never question orders - but this facility is an eye-opener. If you are not thinking and responding appropriately why do you even need a license to do this job?

I am so thankful that my bedside nursing days are numbered.

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    What's the point then? They should just staff the unit with residents and fire all the nurses.

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    Wow..... everywhere I have worked has had a hypoglycemia protocol. No glucose check or D50..... Sounds dangerous! As far as fluids, in one of the ICU's where I worked, we did occasionally give fluid boluses with no order. Where I work now, this would not be acceptable. It all depends on your patient population. If you are dealing with a cardiac/CV surgery patient, you could seriously anger some doctors by giving their patients fluid. That being said, all of our CV surgeons give us their personal cells and answer 24/7 so that we do not intervene on their patients without discussing with them. If I had a true emergency and was unable to get orders, I would probably just risk it and bolus to keep the patient from coding.

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    Considering that lowering the patient's head of bed during an episodeo of hypotension is considered a solid NURSING intervention, that sounds very strange to me.

    Generally, ICU nurses are allowed a slight increase in autonomy for obvious reasons.

    If you have previous ICU experience at other institutions, I might consider presenting your observations to your nurse manager in an attempt to initiate positive dialogue. I am wondering if there is a group of nurses at this facility that have spent their entire careers there and simly do not know of how other ICU nurses function.

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    • Author
    Trendelenburg Position

    CCN : Critical Care Nurse

    AJCC : American Journal of Critical Care

    FYI. Many argue that trendelenberg is not an acceptable intervention for hypotension.

    Current EBP is hob flat with legs elevated not trendelenberg. AACN had a CEU online with 7 myths of critical care - it was interesting. It covered residual amounts and not turning off TF for position changes. I admit I get stuck into practices that I have always done until someone shows me the new research (like years ago when we STOPPED check foley balloon before insertion). Things are always changing!!

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