I'm new to a facility and I love the people there. Fresh hearts and thoracotomies, etc. are quite interesting. It's a great challenge and I'm enjoying it.
However, I am concerned that the nurses are telling me that it is the norm to treat symptoms without notifying the MDs.
Today alone, extra albumin, bicarb, lasix, calcium, & bolus fluids were given without calling the doc to tell him all of these things being administered. It made me uneasy, as it doesn't seem to be within our scope of practice.
I'm told that "you just learn what certain docs want" so they don't have to be bothered, but the bottom line that I consider is the additional training they've (the MDs) received that may give them additional insight into what would treat the low blood pressure (or other issue) that was occuring.
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.
Am I over-reacting? I just think about the safety of my license, and as much as I like this place, I don't want to end up being sued because the nurses made a judgement call that would've been better addressed by a doc.
Tiger, I too am a new nurse in the CICU where we get many open hearts. I've had some of the same concerns that you have. But as most have pointed out we are suppose to get to know what they want. My suggestion is to find a couple seasoned nurses and ask them what you should do...after coming up with your plan to run past them.
I think everyone has done a great job in giving the "real world" answer to the OP's question. We all know the textbook answer, but reality is that in any specialty unit, experienced nurses who know their pts, know the docs, and have the trust of the docs, will daily perform outside the actual scope of nursing. Those that are new to these areas or are new grads will realize this with time and experience, or they will not be able to function with these critical pts. If you always act in the best interest of the pt, use your critical thinking, and know which boundaries not to cross, you'll be fine...just takes time to get there.
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
I second the notion that you need to check out your standing orders. Heart ICUs run mostly by protocols that allow for much more autonomy of the nurse. Most likely you have standing order sets for each surgeon.
I totally agree with knowing your Docs and adjusting your care and communication accordingly. However, we just attended a JCHCO (sp?) meeting to recap our recent visit from therm. One of the changes they want us to make is in how our Docs write their orders. They are saying that for example, an order such as "Start Nitroglycering gtt IV - Titrate to chest pain free" is not specific enough. It is to now include something like, "Start at 5 mcg/min and increase by 5 mcg/min q15 minutes until patient reports chest pain or pressure at 0/10". Then a specific order would have to be written if/when they want to tritrate the gtt to off. They are explaining it to us as - If we are using our judgement to treat our patients to achieve a desired goal, we are practicing medicine which would be outside our scope of practice. The audience included nurses from all areas including ICU. I just don't see how a doc can write an order to cover every single response a patient may have. Surely there will be exceptions made for ICU. Just wondering if any of you have heard anything about this yet. We are a level 1 trauma, 1,000 bed teaching hospital. Nurses using their critical thinking, judgement ("practicing medicine") is essential to patient survival!
I'd like to clarify my previous post. My understanding of the new regulation regarding MD orders, was not presented as due to something we had done wrong, just something they are trying to crack down on in the future.
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.
I am not a new grad and have been called in on a lawsuit, and I will tell you the docs you thought would back you up were on one side and we the nurses were on the other. They had their lawyers and we were supported by the hospital lawyers, and I am glad, more than glad that I had not given anything without an order, because when it comes down to it giving drugs or treatments without an order IS outside our scope of practice. I have no trouble following standards of care orders and making a decision, but I am not going to give them span because I think they are dry , I always call , and if I need to lead the resident to that decision then that is okay too, at least I am covered legally, and I do need my job to pay the bills still so this is the way I practice!
I work in Post open heart unit with similar patient population. Apart from the post operative orders that cover a wide array of medication that can be used, we have unit protocols (with more leeway) that allow us to manipulate hemodynamics independently. I appreciate the level of autonomy that we have. As long as you have a sound rationale in your treatment, I believe you will not ‘go to jail’.
APNgonnabe
141 Posts
Tiger, I too am a new nurse in the CICU where we get many open hearts. I've had some of the same concerns that you have. But as most have pointed out we are suppose to get to know what they want. My suggestion is to find a couple seasoned nurses and ask them what you should do...after coming up with your plan to run past them.