Concerns: Actions outside of scope of practice

Kerrigan 06 · Aug 3, 2007

Have you reviewed the post-op orders and MARs on these patients? In my facility, we have two cardiothoracic surgery groups, and each one has a standard set of orders that come back to the floor with their fresh hearts. There are prn orders for albumin, lasix, fluids, etc. etc. etc. to be given as the nurse deems appropriate to the patient's condition. (Every nurse who takes a fresh heart also goes through an extra class and extra orientation in order to be able to make these decisions!) There are just a lot of things that can go on with these patients, so everybody's day is easier if there are orders for prn drips, etc. that might be a bigger deal for someone who's going bad, but are just kind of to be expected for the first 24 hours or so after this MAJOR surgery. This way, the nurse only has to call the doctor when something unexpected comes up, instead of calling for orders every hour for the first day!

TopherSRN · Aug 4, 2007

Is this the norm in your open heart units?
It has not been the norm for me in my past nursing experiences. Anything beyond a tylenol (or in a near-code situation starting some dopamine or whatnot) would be frowned upon if the nurse administered it without an order.

Basically Yes. Open heart is a entirely different environment. Once you've been there awhile and know what your surgeons want they will expect you to be more autonomous. If you actually did call for some stuff you would probably get laughed at by some surgeons.

I've seen everything you mentioned done. Sometimes its verbaled, sometimes its not.

Another example: I had surgeon A's (he runs his cases extremely dry, a hct on admit of 39-43 isnt uncommon) patient (DOS CABGx5) hct @ 0300 was 23, was 22 on admission, day nurse gave 1 unit and then 1L albumin over the course of her shift. He was hemodynamically stable w/ a pressure 90s-100s. I went ahead and gave 1 unit then called the on call surgeon @ 0600. He gave me an order to xfuse 3 units PRBCs. I had already xfused the 1 slowly, but i didn't order the other 2. When surgeon A rounded @ 0700 I told him the oncall doc wanted 3, but I gave the 1 and held off to see what HE wanted to do. He appreciated the fact that I didnt tank his pt (again he runs his dry) and wrote to not give the other 2. Had I ran 3 units in he would have been pissed, even though his partner ordered them. He expects me to know how he wants his patients treated., and saying 'your partner ordered them' would have not be valid.

The doctors EXPECT you to be autonomous and make some minor decisions. Whether it is verbaling something or not doing something. You learn what needs to be done and it comes with experience.

tigermonkey · Aug 4, 2007

Thank you both for your replies. That helps a bit. Still, it doesn't seem as though acting without orders is covered under the nurse practice act or the "scope of practice" for nurses to give things that are not (at least) ordered prn (Kerrigan...there were not prns for these...all of the prns had already been given and the nurses moved on to giving extra doses).

Just makes me a bit unsettled, since the doc could turn around and blame the nurses if things did go poorly after the nurses act autonomously. In a lawsuit, what ground would we have to stand on if we were blamed, considering that the doctor had not provided a prn order, and he had not been contacted to okay the meds/volume?

Thanks again.

meandragonbrett · Aug 5, 2007

We are very autonomous in our CVICU with our pts. We take care of the surgical and medical populations. Albumin, dopamine, nipride, levo, etc. is expected to be given. We're expected to intervene and then call if those interventions don't work. We have an intensivist in house but they are generally not involved in management of our population except in an emergency situation.

suanna · Aug 5, 2007

Yes, by the letter of the law you are most likely not practicing completely within a nurse's scope of practice. A certain amount of flexability is required when working with a small group of doctors in a intensely critical area like CVSICU. If Dr. A says "I always want my patient transfused with a unit PRBC if thier Hgb drops below 9.0 and CVP

kcalohagirl · Aug 5, 2007

I'm not in ICU, I'm in stepdown, but our docs also give us a certain amt of leeway.

I work at a teaching hospital. Our PAs and residents take call 99% of the time. Even if something is going seriously bad w/ a patient, they generally as us, "So, what do you want to do?" They may not always agree with us, but our knowledge, experience, and instinct is taken into account.

There are certain things we know we don't need to call to write orders

for. However, if it is something to do with bp, or something that could potentially get serious, we do. We don't call for QHS Benadryl that the new resident left off the orders of Chloraseptic drops when their throat is sore from coming off the vent. If it is 10 pm we may call. if it is 2 am, we know that if we write it it will be signed during am rounds.

But even though I know that when I call at 3 in the am and they are going to be annoyed, because I know and they know that we are going to give Hydralazine for the 170sbp, we both know that there needs to be that communication.

And I think that is one of the reasons I love where I work. I feel like the surgical team, (Attendings, PAs, and even the residents sometimes) trust the nursing team's judgement and give us the credit we deserve.

CVICURN2003 · Aug 6, 2007

We have standing orders that cover us for almost anything. We know what the MD's want and we do it. One of our docs HATES cardizem, but marks it on his post op orders. Our docs know if we call them, we need their help and have exausted all of our skills (all of our heart nurses anyway). Our docs have been reluctant to give blood lately. Don't transfuse until HCT

Dinith88 · Aug 7, 2007

Thank you both for your replies. That helps a bit. Still, it doesn't seem as though acting without orders is covered under the nurse practice act or the "scope of practice" for nurses to give things that are not (at least) ordered prn (Kerrigan...there were not prns for these...all of the prns had already been given and the nurses moved on to giving extra doses).
Just makes me a bit unsettled, since the doc could turn around and blame the nurses if things did go poorly after the nurses act autonomously. In a lawsuit, what ground would we have to stand on if we were blamed, considering that the doctor had not provided a prn order, and he had not been contacted to okay the meds/volume?
Thanks again.

I suspect you're a new grad, or you're very new to ICu (esp. Open hearts!), or just need to get used to it. Like most have said, there're usually standing orders. Or... you do it...then let the doc know as soon as possible. (seems backwards but it's real-world...not nursing-school-dreamland where all nurses do is act as robotic doctor-slaves) And you DO learn what certain docs would want and when...this'll come eventually.Also, if you're not at a large center where you've got Doc's holding your hand at the bedside 24/7, you NEED to feel comfortable making decisions. Sometimes (in the real world) docs are hard to reach...or you need something NOW and not 10minutes later. If you're worried about nurse-practice acts, or losing your license, or going to nurse-jail, you need to leave.

meandragonbrett · Aug 8, 2007

or going to nurse-jail

:lol2: :lol2: :lol2:

I about fell out of my chair.

**canoehead, BSN, RN** · Aug 8, 2007

Sometimes (in the real world) docs are hard to reach...or you need something NOW and not 10minutes later. If you're worried about nurse-practice acts, or losing your license, or going to nurse-jail, you need to leave.

I think you are right, but it's pretty sad that when we do what we need to for patients we are wide open to job loss or license loss. If someone wanted to ruin your life they've got a wide open corridor.

jjjoy, LPN · Aug 8, 2007

I think you are right, but it's pretty sad that when we do what we need to for patients we are wide open to job loss or license loss. If someone wanted to ruin your life they've got a wide open corridor.

I agree. I can see the need for autonomous decision-making by the nurse. However, that being a need, it should be formally addressed and the nurse given the legal right to act as such as opposed to going beyond their legal scope on a regular basis to properly take care of their patients.