How much can a nurse do????

[essarge]

I was just reading an article about a patient that came to the emergency room after an automobile accident. The nurse established an IV and then after assessing the patient suspected a ruptured diaphragm. This is what the nurse did next...

"What must you do immediately?

Notify the physician of Ms. Harrison's condition. Establish a second I.V. line with lactated Ringer's solution and insert a nasogastric (NG) tube to decompress the stomach. Obtain a portable chest X-ray. The X-ray shows the tip of the NG tube above the level of the diaphragm, a hollow mass above the left diaphragm, and a potential mediastinal shift to the right. In up to 30% of patients with ruptured diaphragms but no displaced abdominal organs, however, the chest X-ray appears normal."

I am a student so please bare with me, but when I was admitted into the hospital, the nurses I had did nothing unless the doctor ordered it, including x-ray's, starting an IV, etc. Which is more the norm....the above scenario or having to wait for the doctor to decide what to do?? Thanks!!

[janine3&5]

In the ER, we do have protocols stating that certain things can be done before the pt is seen, i.e. EKGs, monitor for CP, extremity Xrays for injuries, very basic stuff.

However, most nurses, including myself, do go a little further. For example, pts with chest pain, I'll go ahead and put them on the monitor and 2L O2, get a line in, draw blood and order CBC, SMA 7, and Troponin, order a CXR, and do an EKG. You KNOW these things will be ordered- so go ahead and get it going. Things that I'm not SURE will be ordered, I'll hold back on it. I don't give any meds without an order.

In our ER, it seems as if its almost expected sometimes. The doc will see the pt and ask if any labs are back yet (before they've been ordered) I was taught by my preceptor to go ahead and do these things, I never really questioned the legality of it, so its interesting to read these replies.

[DanRn]

I hate those nursing mags because of those scenarios. Too much practicing medicine, and not enough nursing skills.

i dropped my subscription after the article on documenting the site and needle used for blood draws. who has time??

I think those articles are written by people that wanted to be doctors, but aren't. Or people with way too much time on their hands and havent worked on the job for a long time.

get the doctor. put the pt on a monitor. THEN be prepared to do 6 things at once.

But

[Mijourney]

Hi. In home health, the level of autonomy that I have experienced is similar to what I experienced in critical care or what I know some of my ER friends have experienced. However, I have to acknowledge that things are much more tighter in home health with oasis and all the additional rules and regs as a result of the BBA of 1997. Also, staffing shortages in home health and some of the documented abuses by home health agencies, which the BBA has taken care of in part, has caused many physicians to be more cautious about where they refer their patients. As far as liability, it does not matter whether you have a doctor's order or not, if something adverse happens to that patient, you can get hauled into court. This is why there are times, when I will run a doctor's order by the office for them to sign during office hours and stay in regular contact with a doctor's office about their patient.

In home health, it can get hairier than the ER sometimes when a patient goes bad, because you're out there by yourself. There are times when the patient's doctor or his/her backup is not available, you may not be able to find a supervisor, etc. It's important that you have established a good rapport with the patient and family, the physician, and have a supportive administrative staff backing you. Some of you have indicated in your posts that you have to know your doc, know your orders. You also have to be versed on your nurse practice act, local, state, and federal and private organization, like JCAHO rules and regs.

[nightmoves]

It depends on your protocols (standing orders) and your personal training, competency, and experience. It also depends upon your state's nurse practice law.

Some of the nursing unions have opposed credentialing for certain nursing activities, but when these programs are administered properly they are almost a waranty of level of competence. I strongly support appropriately administered credentialing programs (i.e., ones where the required training is given along with the biologic principles involved and where competency is observed by an instructor rather than informal ones where nurses are trained on a new procedure without enough didactic content or enough knowledge of the pathophysiology involved to make this just accomplishing another task.)

Let's be honest about it: Many EDs are staffed by moonlighting physicians. Patient safety may well depend solely upon the presence and intervention of a properly educated, experienced nurse in that setting.