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Don't be afraid to ask why...

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As a new nurse starting out, I remember learning multiple new things every day. Our facility has a couple physician's that are legendary for their temperments. I have always been the type of person that wants to understand why I am doing something, and would always ask why?

Why are we doing this? Why are we doing this like this? Why is this going to work?

One day I was preparing a patient for an angioplasty and the patient had a critical high potassium level. Upon notifying the physician (and expecting a kaexylate order), I received an order for an amp of D50 and insulin. After asking every nurse on my unit, and looking in all the drug books I could find, I still didn't find the answer. I gave the medications, rechecked the patient's potassium level as instructed and sure enough it had improved.

When the physician arrived on the unit later (of course one of the famous temperments), much to the surprise of my co-workers I simply asked him, "Why did we do this, and why did it work?" He happily explained it to me, and actually thanked me for asking. He also told me it was refreshing to have a nurse want to learn and has continued to go out of his way to show me new things, and actually praises me to patients, co-workers and physicians.

Don't be afraid to ask "Why?" You just don't know what you can learn.

zuzi

Specializes in trauma, ortho, burns, plastic surgery.

Jodi hugs love, you are a good nurse...!!!!!

suanna

Specializes in Post Anesthesia. Has 30 years experience.

I've found the same thing with our famously tempermental doctors. Most of the more demanding docs I've worked with just want good patient care. They are usually smarter than most and are frustrated by people that don't know as much as they do. People that just do what they are told without understanding the reason why are dangerous. The more you know the better your judgement is going to be. There guys usually understand this and are more than happy to teach.

Ms Kylee

Specializes in Med Surg, Hospice. Has 4 years experience.

Awesome! I love it when docs take the time to teach. I once asked a surgeon about gastric bypass. Not only did he share the risks and reasons why he always excused himself from these cases, he actually explained the procedure and drew me a pic. Talked me out of it for sure. :lol2::lol2::lol2:

fishchick72

Specializes in telemetry. Has 7 years experience.

Thanks so much, I am always afraid & hesitant to ask, but I do want to understand & learn more. I think I will start giving that a try. It's good to know that doctor's like to see that instead of being irritated by it as I suspected they would be.

Thank you for the post, it seems so basic . . .I don't know why I don't do it more. I will remember your experience the next time I hesitate to ask why.

Thanks for posting, Jody, and I'm glad that you spoke up and found your answer.

I do have one suggestion for you, though: next time, it may be best to ask why before giving the med or treatment.

If an order doesn't make sense to you, it might be because there's something you need to learn.... but it also might be because an error has been made. Even as new nurses, we have the right and responsibility to use our knowledge and judgement and to question or challenge an order.

I'm a new grad orienting in the NICU - a few weeks ago, my preceptor and I gave a fluid bolus to the wrong baby because the doctor had written the order on the wrong chart. The original error may have been the doctor's, but there was also a nursing error made when we gave the bolus without seeing for ourselves why this baby would need one.

No harm done, fortunately, but this incident helped me to understand the importance of checking things for myself. In the months that I've been working, I've come to realize that the hospital world is full of mistakes - prefilled syringes where the volume doesn't match the label, expired feeds sent up from pharmacy, equipment that doesn't work properly, equipment manuals that get "distal" and "proximal" mixed up. Checking for ourselves and thinking for ourselves isn't just an extra layer of caution - it's absolutely essential to safe practice.

Take care, Marion

As a new nurse starting out, I remember learning multiple new things every day. Our facility has a couple physician's that are legendary for their temperments. I have always been the type of person that wants to understand why I am doing something, and would always ask why?

Why are we doing this? Why are we doing this like this? Why is this going to work?

One day I was preparing a patient for an angioplasty and the patient had a critical high potassium level. Upon notifying the physician (and expecting a kaexylate order), I received an order for an amp of D50 and insulin. After asking every nurse on my unit, and looking in all the drug books I could find, I still didn't find the answer. I gave the medications, rechecked the patient's potassium level as instructed and sure enough it had improved.

When the physician arrived on the unit later (of course one of the famous temperments), much to the surprise of my co-workers I simply asked him, "Why did we do this, and why did it work?" He happily explained it to me, and actually thanked me for asking. He also told me it was refreshing to have a nurse want to learn and has continued to go out of his way to show me new things, and actually praises me to patients, co-workers and physicians.

Don't be afraid to ask "Why?" You just don't know what you can learn.

I agree to that. People love to explain their knowledges. If someone asked me how things work this way, I love explaining things because it shows how knowledgeable you are.

Also, it's our role to be the patient's advocate. We are the security guard. We are the voices for the patient. We speak for the patient. We need to know why this thing are being done. If we know that it is safe, then we follow Doctor's order. We don't just follow Doctor's order, we are not just Nurses anymore, we can question for every drug, intervention, that we give to the patient if we don't know why it works.

I have this patient who has an PRN order for Tylenol for Anal route for moderate pain, and Morphine for Oral route for severe pain. I questioned the physician if we could have Tylenol for Oral route, since Morphine is ordered for Oral route. I told the physician that the patient doesn't like to be inserted through rectally. Then, the physician approved my request. Cool huh?

I'm a new Nurse just like you. The Board Exam doesn't prove us we know everything. Nursing is all about learning new things.

I too am a new nurse and I am constantly amazed when I see seasoned nurses tip-toe around doctors. My opinion is "aren't we in this together" and doesn't our work include safe practice? With that in mind I do approach doc's and ask questions when my co-workers haven't the answers. So far everyone has been very helpful except for one doc and I attribute his hostility to his own insecurities. He is not the person I would seek advice from. Cheers and happy nursing!

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

I have always made it a habit to look up, check on and research anything that I ran across during my shift that I did not know or needed to know more about. I did this quite a bit as a new grad some 27 years ago and still do it today . By the way to answer a question in one of the responses----glucose and insulin will cause the potassium to shift back from the plasma to the cells. You did not state the cause of the hyperkalemia, but was most likely caused from a shift from the cells to the plasma. Remember potassium is the main intracellular electrolyte.

CCUnurse12

Specializes in Critical Care,Cardiac, PAR, Education.

I was in charge of our 20 something bed unit last year when a Not-so-new nurse gave me report on her pt. She had given D50 and insulin per an order she received that AM. She thought the resident (it is a teaching facility) was silly for ordering that. "Her sugar was fine" that morning. I lost respect for that nurse. She didn't know why she was giving it. Didn't try to find out. And she was condesending about the resident who wrote the order. A new nurse who askes why is a better assett to a unit than an experienced nurse who isn't looking to understand things that are new to her/him.

C.

Can someone please tell me the mechanism of action on this and why it works? I have tried to look it up and cant find anything

Nursing_excellence, ADN, BSN

Specializes in PCU, ICU, LTAC, LTC, SNF. Has 9 years experience.

On 1/3/2008 at 11:21 PM, kukukajoo said:

Can someone please tell me the mechanism of action on this and why it works? I have tried to look it up and cant find anything

I know this is very old post. But jic someone else is looking for answer. The insulin helps potassium uptake of the cells. And the d50 is to prevent hypoglycemia. Correct me if im wrong.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

1 hour ago, Nursing_excellence said:

I know this is very old post. But jic someone else is looking for answer. The insulin helps potassium uptake of the cells. And the d50 is to prevent hypoglycemia. Correct me if im wrong.

Kinda correct answer without details.

The reason why this method was used for patient before heart procedure is:

- dextrose/insulin combo doesn't actually removes potassium from the body but, kind of, places it in the right cupboard where it belongs. One of the last things one wants while doing something with the living beating heart is hypokalemia;

- kayexalate works slowly and OR has time frame;

- kayexalate means breaking NPO, and vomiting on the table is another last thing one wants to deal with when patient is sedated and something just pushed through a big artery is flipping around in his heart;

- kayexalate can cause diarrhea. This is yet another last thing one wants to deal with while doing angio, even if throught the radial approach.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

From that provider point of view:

I do see nurses who want to learn, although very few of them actually say so. I see way less nurses who want to think at all, and even less of them who are comfortable with doing one little step from "that's how we do it all the time".

Nursing undergrad education does not develop independent analytical model of thinking (for the fairness, not all grad programs do it too). In most cases I observe, a nurse who already made or was about to make a mistake of judgement is not able to tell me why she thought that way and not another, describe her way of coming to the conclusion and explain her action plan. Instead, she will tell one of the following: "we do it like this here all the time", "it is per policy/protocol/etc." and "I was just advocating for my patient". Either answer us the hard evidence that the nurse turned her brain off and refused to think while making the decision.

Every single time I am in hospital, there will be at least one nurse who would run "code sepsis" because "you are satisfying our criteria" and "it is just for your safety and because I care for you". She is not even able to integrate two basic facts:

- baseline BP 100/60 maximum, never goes over it; baseline HR 90 + horse level dosed albuterol, for which I am usually there for; so BP 87/55 and HR of 116 are probably warranting nothing but observation

- there are absolutely no other signs of infection. I am hanging near nursing station researching where nearby coffee machine is while waiting for the Solu -Medrol to kick in 🙂

Side effects of albuterol, Solu-medrol and other drugs are taught in school of nursing and are right in that poor Davis book gathering dust near Pixes machine. The nurse is supposed to know them. She is supposed to think, analyze the situation and make desicion to relax and continue to monitor the patient. She is plainly not able to do that and, consequently, I fire her. Later, I will have to battle additional $500 or so on my bill.

One of previous posters wrote how cool she "advocated" for the patient requesting oral Tylenol instead of rectal. Great job, except one little thing: acetaminophen administered rectally works much quicker and with more pain and especially fever - relieving potency due to lack of the first liver bypass. Rectal vs oral drug administration is NCLEX material which the nurse us supposed to know by heart and be able to educate the patient about it. What exactly this nurse proved to physician except that now her name is in that list of nurses "who call all the time and doesn't think, just do what she wants because otherwise she will just badger all hospital all night long about utter nonsense"?

The ultimate ending of this dutiful, task-oriented, caring, mindless, analysis-excluding model of thinking is what happened with Radonda Vaught who not only did not think about things that might happen with the patient sedated with Versed (and left her totally unmonitored) but also was not striken when the drug in the bottle looked like anything but Versed. She was "advocating for her patient" who was scared and she was on a dead hurryto relieve her suffering, follow the order and get back to whatever she was doing right before. She did not think, did not analyze clinical situation, did not even see what she was doing. Now we all know how it ended.

Numenor, BSN, MSN, NP

Specializes in Internal Medicine. Has 9 years experience.

7 hours ago, KatieMI said:

Kinda correct answer without details.

The reason why this method was used for patient before heart procedure is:

- dextrose/insulin combo doesn't actually removes potassium from the body but, kind of, places it in the right cupboard where it belongs. One of the last things one wants while doing something with the living beating heart is hypokalemia;

- kayexalate works slowly and OR has time frame;

- kayexalate means breaking NPO, and vomiting on the table is another last thing one wants to deal with when patient is sedated and something just pushed through a big artery is flipping around in his heart;

- kayexalate can cause diarrhea. This is yet another last thing one wants to deal with while doing angio, even if throught the radial approach.

I find Kayexelate falling out of favor in lieu of necrotic bowel risks anyways. I also find that most understand we do the D50/Insulin as a temporary measure, and that the real issue is WHY the patient is hyperkalemic.

Had a similar situation last night, ugh another reason why I dislike Bactrim...LOL

Anyways, I agree that nurses fall into two camps: those who want to learn and those who just want to check the boxes throughout a shift. I was referencing a CT scan once to a nurse recently and she literally didn't know where to see scan results on the EMR. Like she didn't even think about reading the results and I highly doubt she even read the daily progress notes. Scary stuff.

Edited by Numenor

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

1 hour ago, Numenor said:

I find Kayexelate falling out of favor in lieu of necrotic bowel risks anyways. I also find that most understand we do the D50/Insulin as a temporary measure, and that the real issue is WHY the patient is hyperkalemic.

Had a similar situation last night, ugh another reason why I dislike Bactrim...LOL

Anyways, I agree that nurses fall into two camps: those who want to learn and those who just want to check the boxes throughout a shift. I was referencing a CT scan once to a nurse recently and she literally didn't know where to see scan results on the EMR. Like she didn't even think about reading the results and I highly doubt she even read the daily progress notes. Scary stuff.

The REAL scare for me is when I admit a mildly dehydrated, pleasantly confused LOL in the second part of the day and next morning I see her sedated like a stone and tied to the bed.

What happened? Oh, they told me she was agitated at night. I do not know, I was not here, it is my first day, I know NOTHING. I did not access her yet (at 10 AM), I was busy with my other patients. If it helps, my CENA saw her and she told me she was sleeping peacefully, would you like me to call my CENA?

PM Psych consult, Haldol, Ativan, Zyprexa, no tele, creatinine, which was mildly elevated the day before, now is at the point you start to think about just calling interventional guys because you know that Nephro people will do it anyway but it will be late and there will be again no place till tomorrow. No fluids. 27 SNF meds, including Mirapex, Requip, Pepcid and, yeah, Bactrim for "UTI prophylaxis". Those mysterious "they" called "them" at 2 AM at night and told about Bactrim.

And, oh, I thought she might have UTI, she was soooo agitated, and, yeah.,. I just forgot, she vomited, can I get order for Zofran? Why no??? Oh,... Haldol and Zofran and potassium of 5.8... really, I never thought of it... we do it here every day!!

Did you see negative urinalysis from ER? No.

And, while you think what to do first with this human train wreck and shouldn't you just call ICU and beg that attending on your knees because that LOL is still very full code, this nurse makes her way in the room, tenderly touches the tied up hand of deeply sedated old woman and gently murmurs in the best (imaginable) tradition of Old Flo:

- huuuney, would you like to have a drink??

Why are you so upset with me?? Would you like me to call someone? I am just doing my job as a nurse.... what would you like me to do???

Edited by KatieMI