Difference between nursing judgment and MD order

[txnurse2014]

I am a fairly new nurse and have been told by my NP when asked for orders on different situations what I asked was considered nursing judgement thus not needing a order for it. Heres an example.pt had blood suddenly in his cath bag.NP ordered flush and empty bag, hold lovenox and aspirin x 2 days.i then asked if she wants me to notify her of continual blood in cath bag she said thats why we are holding the lovenox and aspirin.I was trying to find out at what point I do need to notify the NP if he continues to have dark blood in the cath bag. So i then asked do you want me to put a order to monitor for signs of bleeding and notify MD in case he has increased bleeding or bruising etc.The NP said no thats nursing judgement.Of course with any patient you would monitor for bleeding especially if the pts on lovenox.Is there a simple way to figure out what you need an order for and whats nursing judgement?Also at what point do i inform the MD if the pt continues to have dark blood in the cath bag which is not normal for the pt.

[BostonFNP, APRN]

Here is what I would expect:

1. Document the color/consistency of the urine each time it is checked.

2. Monitor the patient for signs of symptomatic anemia.

3. Monitor the patient for any worsening or new bleeding.

4. Notify if there is a change in the patient indicating symptomatic anemia, instability, or increased bleeding.

Sent from my iPhone.

[guest358111]

Developing 'nursing judgement' takes some time.

Assessment is a huge part of nursing judgement.

For example, if this patient starts to exhibit changes related to blood loss: low blood pressure, lethargy, tachycardia, then the MD would need to be notified.

If you work the next day, and you see that the patient's H and H has dropped and the patient still has blood in the catheter bag, then you want to notify the MD.

I don't think there is a simple way to figure out what you need an order for and what nursing judgement is until you have a little more experience. :)

The best thing to do is watch the patient, very carefully, and let the provider know of any changes. Assess, assess, assess!

There is much to be considered with a scenario like this: for example-was the catheter just inserted? Is the blood just from the insertion? Why was the patient on Aspirin and Lovenox? Is the patient ambulatory? Now that those blood thinners have stopped, is the patient at a higher risk for a clot? What is the patient's INR? What is the patient's blood pressure?

Ask yourself tons of questions in scenarios like this, and your judgement will develop!

All the best!

[psu_213, BSN, RN]

Assessment/monitoring is not something that needs an order from a provider--it is an expectation of proper care. Using your example, if the patient continued to have bleeding after D/C'ing the aspirin and Lovenox, and the patient had a negative outcome, you could not just say "I didn't call the provider since she/he did not specify it."

Expectation for monitoring that is needed for a specific medication comes along with administration of the medication--a separate order is not needed. For example, if a patient is on heparin, a nurse monitors for bruising and abnormal bleeding even if there is not a specific order for such. If giving a BP med, there may be parameters for that med--i.e. "hold dose for SBP

[txnurse2014]

thank you all good examples.my struggle seems to be with the example i gave when do i notify the MD of continued bleeding from the established catheter.Makes sense in comments to notify when changes occur.