Critical Care Nurses: How Much Do You Question MD Orders?

Critical LPN · Jul 5, 2006

lizz, Welcome to the world of Critical Thinking Skills. I am proud that you think of your patients first and foremost. Never question your gut instinct. It is good to ask both the doctor and your charge/precepting RN their thoughts but remember ultimately you are responsible for your actions.

If you really are feeling their might be a problem, do not be afraid or fear for you ego, to ask the reasoning WHY?, and present yourself as truly wanting to gain knowledge base. After all, you are the one who has been caring for the patient during and prior to the order and know them best. If you present yourself as truly wanting to gain knowledge along with addressing your concerns, sometimes the people you ask are then on the spot for more than the (because I said so) answer. Many times in the hussle-bussle, others in charge of the patient care(ie: physician, Charge nurse,etc.) get caught up in the problem(pt. lab results, heartrate etc.) and routine order response game and not what it is best for that particular pt. Again, there are times you have to punt but always watch that patient a little closer. Let your knowledge, gut and mind lead you. It won't always be the popular road with the co-workers, but it is safer for both you and your patient. In the long run, If the RN or the physician you consult is "worth their salt" as the old saying goes, they will appreciate your sincere drive to learn as well as your commitment to your patients. After all, if you do well, it only makes them look better too.

"Do onto others as you would have done onto you"--Even if you are not religious in belief, this is a wonderful thought to keep in your head. We all sometimes need to think for a moment and remember no one individual/patient is the same or has just one physical as well as emotional problem we are addressing. Textbooks tend to teach us the cure or response to one problem but most of the patients that you referred to had other contributing factors that could change the outcomes of the standard treatment. I especially was concerened with the lasix order as keeping the potassium level normal could be a further concern. Most situations that I had simular to this, we gave the first dose of potassium I.V. to get into the bloodstream quicker to prepare for the increased u/o that would surely drop it more. Oral potassium, depending on type, as well as the patient's digestive patterns could take several hours to absorb as well as sometimes causes diarrhea, further decreasing potassium loss. Also many cardiologists prefer to keep the the level around 4.0 so in case of diarrhea or fluid overload it is high enough to prevent arrythmias. But then you must also look at the BUN, Creat., Sodium levels as well as the Hgb and Hct, sometimes as the the labs may have been due to recent influx of too much fluids too fast in a patient who was already slightly low on his K. Dilutional readings are something to watch closely as then you may give too much potassium and when the body goes back to normal stasis, all that K will catch up at once. Also if the patient has renal impairment, potassium is a big issue. The Lovenox issue is one where the physician needs to be reminded that Lovenox was given and also if you ask the radiology department their policy on this, Most, unless procedure is an emergengy would have cancelled the procedure as they would not want the liability. Also look and remind doctor if patient is on anything else such as blood thinners, extra Vit. E or C or has been taking any suplements at home for a long period. (ie: ginko bilboa, Vitamins, Omega fish oils) These all could cause bleeding. In the case of the A-fib patient, she needs her meds but since she did have surgery that day and probably NPO the night before as well as most of the day and you did not say if she was on I.V. fluids, if the heartrate is high and B/P is low, question hypovolemia. Easy enough to check, can the patient sit up or you sit her up without further increase of HR and B/P fall or c/o of dizziness. These could be reported to the doctor and then meds given as appropriate for pt. Again, pt. history is inportant, is she used to running a lower B/P? Is she symptomatic? Sometimes we also rush to correct to given "normals" for V/S and not to the patient typical response. B/P may go low for a short time after med and then return to "normal". I think in this case, it sounded like your patient was "dry" due to possible NPO prior to and during recovery of pacemaker surgery plus might have held (? Your Policies) cardiac meds pre-op that, all contributing to the situation you described.

You are doing fine and do not let anyone make you feel that questioning an order is wrong. Its how you approach it that can be tricky. I have had several charge nurses, fellow staff and doctors try to make me worry about calling this doctor or questioning that doctor and that they will "have my job" and it never happened. If it ever did, I would still defend my right to ask and voice concern as it is my license on the line once I carry out the order, and how quick will they be there to defend you. More than likely, the same doctors and nurses that had a problem in the first place, will be the ones to state that you should have let them know about your concerns and why did'nt you let them know about this or that relating to the patient that they would have changed the order.

Keep up the good work, sorry so long a response but I feel that some of the so called " Nursing Shortage " is related to caring individuals just like you who felt they could not stand up for their patient's wellbeing and fear the rath of highter up in the field. You are the patient's voice and advocate. Plus you can only learn by asking questions. And sometimes, just sometimes, you make others think and even remember they are there for the patient not just a robot spitting out orders based on the "norm".

GOOD LUCK and GOOD JOB!!!!!!!!!!!!!!!!!!!!!

Sheri257 · Jul 5, 2006

I especially was concerened with the lasix order as keeping the potassium level normal could be a further concern. Most situations that I had simular to this, we gave the first dose of potassium I.V. to get into the bloodstream quicker to prepare for the increased u/o that would surely drop it more. Oral potassium, depending on type, as well as the patient's digestive patterns could take several hours to absorb as well as sometimes causes diarrhea, further decreasing potassium loss. Also many cardiologists prefer to keep the the level around 4.0 so in case of diarrhea or fluid overload it is high enough to prevent arrythmias. But then you must also look at the BUN, Creat., Sodium levels as well as the Hgb and Hct, sometimes as the the labs may have been due to recent influx of too much fluids too fast in a patient who was already slightly low on his K. Dilutional readings are something to watch closely as then you may give too much potassium and when the body goes back to normal stasis, all that K will catch up at once. Also if the patient has renal impairment, potassium is a big issue.

First, thank you very much for the detailed response. It really helps alot.

I too was wondering why we didn't give the K IV, particularly since I have noticed that some docs like the levels at 4 or higher and, while I didn't notice a renal diagnosis in the chart and urine output was normal, the patient did have elevated BUN and creatinine levels so I assumed that may be the reason why they didn't do it. On the other hand, the patient did tell me that low K has been an ongoing problem prior to hospitalization ... so would the potential renal impairment be reason alone not to give the K IV?

In the case of the A-fib patient, she needs her meds but since she did have surgery that day and probably NPO the night before as well as most of the day and you did not say if she was on I.V. fluids, if the heartrate is high and B/P is low, question hypovolemia. Easy enough to check, can the patient sit up or you sit her up without further increase of HR and B/P fall or c/o of dizziness. These could be reported to the doctor and then meds given as appropriate for pt. Again, pt. history is inportant, is she used to running a lower B/P? Is she symptomatic? Sometimes we also rush to correct to given "normals" for V/S and not to the patient typical response. B/P may go low for a short time after med and then return to "normal". I think in this case, it sounded like your patient was "dry" due to possible NPO prior to and during recovery of pacemaker surgery plus might have held (? Your Policies) cardiac meds pre-op that, all contributing to the situation you described.

Actually I did think hypovolemia was a possibility and pointed out that the IV fluids had not been re-ordered post op but, by then it was time to change shift so ... I didn't really have time to follow up although I did point it out to the night shift nurse. I also was questioning the calcium order just because I thought it might send her HR back up without solving the potential fluid/volume problem.

Overall ... I'm in an awkward position as a student and am riding a fine line. As an RN I would have no problem challenging these things with the docs, albeit in a polite way. But I feel like I can only go so far as a student. My preceptor prefers to deal with the MD's herself and, the RN's kind of make fun of me for asking so many questions ... not in a bad way but, I think it's because they don't always know the answers.

Anyway, thanks again. I just want to know if I'm on the right track.

:typing

Critical LPN · Jul 6, 2006

lizz,

Always glad to help if possible. You have guessed by my sign on that I fight a battle too. I'm an LPN. Though all of my years but two have been in critical care type settings, taking care of the most critical patient's at times, due to I had more training and experience than my RN teammates and even many times my charge nurses, I always question if I were concerned. Surprising enough, most staff I worked with did not have the RN,LPN,CNA etc. stigma except for a few. Sadly enough, they were the ones who constantly beat the drums about degrees and what a "Real Nurse" does but in a crisis, were the ones who froze up or made sometimes caustic decisions. An education is very important but there is a difference in Education/Degrees and Titles, and learning as well as continuing to learn that which will make you a "real" as well as a respected nurse down the line. It was amazing to me that I took many nursing/medical periodicals and constantly bought books on the area that was to be my expertise as I took care of critical patient's everyday. I went to seminars etc. to keep abreast of the current practices and new drugs, equipment and new trends in patient care only to hear some nurses with much higher degrees to be satisfied with what they were taught in school only. Some go on to get specialty area certifications, but still fail to be able to apply what is learned due to not questioning "why" as they learned . Did they do it just to get more letters behind their name and degree, or to make the care they provide better for the patient?

Again, remember that if you fear asking questions now when you have the best of all excuses(you are a student, you are learning), then you might just carry that fear after you have the degree when then, everyone expects you to know the answers. After all......You have a degree then.

Take care and remember that it is for your preceptor to decide how she wants to handle issues with the physicians but you have the right to at least ask why? You might like to keep a journal to write down your concerns and how they were handled at the end of your shift or when you get home.(of course keeping without names/privacy) Again each patient and situation is sometimes treated differently even with similar circumstances. It can provide a guideline for you, especially if you are going to continue to work in the same facility when you graduate. Then you will know the doctor routines as well as preferences and who you feel comfortable with asking questions of .

Our patient's are our business and we each are responsible for their service. "Why" are they ill? Can it be as simple as a cool cloth to the forehead or finding out in the middle of a hour long code blue.....someone forgot to turn that stopcock on their piggyback meds and they have not been getting their meds for the prior 2 hours? ...hummmm..Why?

:studyowl:I'm in the process of going back for my RN now as reality is that experience does not count except to those I've served.

dfk, RN, CRNA · Jul 6, 2006

First, thank you very much for the detailed response. It really helps alot.

I too was wondering why we didn't give the K IV, particularly since I have noticed that some docs like the levels at 4 or higher and, while I didn't notice a renal diagnosis in the chart and urine output was normal, the patient did have elevated BUN and creatinine levels so I assumed that may be the reason why they didn't do it. On the other hand, the patient did tell me that low K has been an ongoing problem prior to hospitalization ... so would the potential renal impairment be reason alone not to give the K IV?
not sure if it has been answered, but pay attention to the creatinine levels more so than the BUN. creatinine is more specific for renal function. BUN can actually simply signify hypovolemia. the reason for keeping an eye on electrolytes for a renal pt is that their clearance is much more slower, hence the dialysis. a renal pt can have a K level of 2.3 in the am and end up at 4 by the end of a shift. take care to keep this in mind, because hyperK or any other lyte can cause arrhythmias and death just the same.

as for the cardizem (Ca++ channel blocker), if the pt has current cardiac dz, it is still necessary for the pt.. yes, there are usually parameters to give/hold a medication. remember, you technically have that two hour window to space beta blockers/channel blockers/pressors and the like.. as using your critical thinking skills, spacing these meds even farther apart have been know to occur. again, it's in the best of the pt. besides, how much difference is there if you are waiting for a stat med to come from pharmacy (for those of us not lucky to have a pyxis-type machine fully stocked and loaded!!) that takes three to four hours.. (boy, i hate that) - -
it never hurts to question, and don't just give it b/c it's an order. you still have the right to refuse (albeit, you may lose your job), but you will not lose your license. of course, utilize all resources before saying "i'm not giving it" -

hope this helps in any way - -

gradcare, LPN · Aug 8, 2006

Excuse the length of this post but I'm a student who's working in a critical care stepdown unit. I've had a few patient cases lately where I'm trying to figure out how much do you question doctor's orders. Sometimes it seems like we're potentially doing more harm than good or, maybe I just don't know what I'm doing as a student. That's why I'm looking for some input here:
A couple of weeks ago I had a CHF patient. The patient was stable however, the K was very low ... like 2.1 Nevertheless, Lasix was prescribed and 20 meq K PO was given every hour to try to boost the level. I asked if we should give the Lasix and was told to do so anyway, that the oral K should cover it but, by the time the labs came back it was better but only at 3. Patient was discharged later in the day with instructions to take more K but, should we have held the Lasix in the first place?
I had a lung cancer patient with a PE. Her platelets at one point were incredibly low at 20,000 and had improved 80,000 but it was still low for Lovenox. I was told to give it anyway because her platelets had improved. Meanwhile, without much notice, the MD sends her downstairs for an inferior venous cava filter where there was some problem and she ends up with an arterial bleed. She was ok and platelets were prescribed and given later on but, I can't help but wonder, should we have held the Lovenox? She already had a tendency to bleed just from the Lovenox injections alone.
In another case the patient is A Fib and just got a new pacemaker where the old one had to be replaced. Her BP was fine but her HR was in the 120's so we give Digoxin and Lopressor. She was also scheduled for Diltiazem later in the day but, by then, her HR is fine but the BP is in the low 90's and we're supposed to hold it at 90 so I ask if I should give it. The MD and RN says yes and, sure enough, her BP drops to the low '80s so, later on we have to give her calcium gluconate.
In each case I asked ahead of time whether we should give these drugs but, I guess they felt the benefits outweighed the potential adverse effects. I'm just wondering as a future RN if my instincts were right to question these orders or, if I'm missing something here and am perhaps not understanding the big picture.
:typing

Re the CHF Fluid overload with these guys can be a huge issue, holding the lasix may result in them becoming overloaded and depending on how bad that becomes may require CPAP or worse.

That said never be afraid to ask questions, sometimes medical staff can get so wrapped up in "their" bit of the patient that they forget about their co-morbidities eg ordering captopril in a patient with borderline renal function. That is where nurses and in particular nurses who think critically come in. Usually the first person to start seeing the patient as a whole is the nurse. Medical staff initially get trained to see the patient holistically but when they specialise it is a rare medical officer indeed who keeps this view in mind when reviewing their patients.

Keep thinking and keep asking:saint: :yelclap: :cheers:

Corvette Guy · Aug 8, 2006

Hey Lizz, great Thread! Keep up the great critical thinking! You are going to be an awesome critical care nurse.

:cheers: