ICU Autonomy

As I'm no longer an ICU nurse, I've found that I didn't really have as much autonomy as I thought I did. Rather, I was given the opportunity to use my critical thinking skills and judgement to make adjustments based on pre-established protocols.. for example, titration of vasopressors, sedatives, etc. Using judgement to decide to make changes, but the guidelines for those changes are already in place

Your patient will be on 5 pressors. They all have orders to titrate for specific parameters, but some will be the same parameter, so if I'm titrating 2 gtts to keep MAP>65, for example, I can choose which one I go up and down on, see which the patient responds to better, and roll with it. Doctors treat you differently. Your opinion is often gold to a resident. A lot of them order what you tell them to with little convo or pushback unless there's a reason your suggested thing is inappropriate, and then they give a rationale.

You have protocols to draw labs for ectopy, to replete electrolytes, to diurese, to draw ABGs or istats. To go up or down on sedation or fentanyl drips based on pain scores/RASS/CPOT etc.

Obviously not all ICUs have the same autonomy, but that's been my experience.

in our postop OHS order set for example I can

1: draw h/h for any bleeding, CT output above 200/h

2: order PRBCs if HCT

3: order cxr if I place an NGT or change in status/sob

4. basically draw any labs whenever I feel like it because there are enough orders and protocols to cover my butt

5. Start/titrate/stop Levo, Dopa, Neo, Vaso, Epi, Propofol, Precedex, Fentanyl drips essentially at my leisure. Again, specific titration protocols and orders and such, but when you basically have that much wiggle room...

6. Give up to 4L of IVF and albumin postop

and I mean, I tell someone about some of these things afterward, or when they round, which on the first 24h postop is every few hours minimum to check on post extubation gases, etc.