Maybe I just don't know...

[Kdids520]

A little background on myself: I've been an LPN for 5 years and am almost done with my RN. I expect to graduate in December. I took a per diem job working in a Level II ER. There is so much to learn and I'm doing my best to ask good questions, follow along, and pick up everything that I'm expected to. For the most part, I've worked hand-in-hand with an experienced RN who is great about giving me direction while letting me use my own critical thinking...I had a bad experience the other night though, when I was working with a different nurse. Here's the story...

I came in at 11p. This nurse (let's call her "Donna") had been there since 7pm. I had never met her before so I introduced myself and she just said, "What can you do? I've never worked with an LPN before." She was clearly swamped and stressed so I gave her a quick run down of what I could do and I asked her for a brief overview of the patients that we had in our section. She told me that she was too busy at the moment and would tell me later...

In the mean time, the charge nurse brought a new pt to us who reported n/v x 5 days. Donna quickly said, "Can you line an lab him, and start fluids?" It struck me as odd that she wanted me to start fluids on him when he hadn't been seen by a doc yet. I did his line and labs, came back to the desk to get a bag to send it to the lab and she said, "Wait--my lady in 7? She needs Tylenol. Can you give her a tylenol?" So I said sure. I pulled the lady's chart and she had no order for it. I asked her if I was missing it somewhere and she said, "No, just give it. I'll get an order later." Ultimately, I told her I wasn't comfortable doing that. She got mad and started to give me a major attitude. It carried on for quite some time until I (politely) said, "I'm doing the best I can to get us caught up here---the attitude from you isn't really helping the situation." She told me she didn't have an attitude.

Anyway...my question here is this: What would you have done in this situation? I guess it wouldn't have hurt the n/v guy to give him some fluids but I wasn't comfortable doing it without an order. Same for the Tylenol lady. Am I just being too stringent with my personal nursing practices? Any thoughts and feedback would be great...

[Esme12, ASN, BSN, RN]

It depends on your department and their triage/ treatment protocols. I have worked departments that the EDMD wanted complete control and you had to ask to put O2 on someone having chest pain and SOB(I quit there very quickly). Other departments where there are extensive treatment protocols, labs IV, fluids, x-rays Tylenol for temp, in place to expedite the care of patients. I would check your department.

Depending on the vitals of the N/V patient I would line and lab him and give the Tylenol to the other. But Only with proper protocols in place. Many ED nurses take verbal orders even though is is usually stated specifically that verbal orders are for emergencies only. Most never find themselves in hot water over this.....but some have been fired. Check your policies.

[libran1984, ASN, RN]

I think it goes without saying, but I'll say it anyway. I think you did the right thing!

^_^

Line and labs is as far as I'll go on anyone unless BP is super low after initiating Trendeleburg.

[emtb2rn, BSN, RN, EMT-B]

Agree with esme (as usual) on checking local protocols. Most pts with hx of multiple days n/v are going to get fluids but not all (don't want to flood the chf). So, know your protocols and use good judgement.

Note: good judgement is based on experience and experience is based on bad judgement. Just sayin'.....

[BelgianRN]

I agree I wouldn't be comfortable hanging meds that someone else will get orders for later on. My policy is I only ask my colleagues to give what has been ordered. And if I decide to deviate and give something without orders I'll do it myself. That way my head is in the firing zone if it does come to legal/ego issues.

[NurseOnAMotorcycle, ASN, RN]

Where I work there are pre-set orders and protocols for presenting conditions. For example, we have a pain protocol for x1 morphine (with a calculation for dosage) and another for nausea if the pt is having major issues before triage is finished and an MD has officially signed onto a patient. These are covered by the main MD of our department.

[FLmomof5]

Just wanted to point out that research has shown that Trendelenburg is not effective and is no longer being recommended.

[Esme12, ASN, BSN, RN]

Trendelenburg??? I know it's no longer recommended but I am not sure what this has to do with the post.

[Altra, BSN, RN]

It does depend on the protocols of your department, but in the ED it is often expected that the nurse will initiate certain treatments - fluids for vomiting or diarrhea, neb tx for SOB, Tylenol for a fever, etc.

[itsnowornever, BSN, RN]

Most EDs have certain things in line that RNs can do without the doctor telling them. I would have hung the fluids...if you are going to be an RN you could have checked the chart and figured out why the tylenol...if liver values are ok, there are no contraindications and that is a standing order in the ED then why not give it? If she was swamped, finding the protocols and checking that out would have been in line. How long have you been there? As a student in the ED I've done fluids without orders, given tylenol as well as ordered xrays all without orders because it's protocol and as long as you can articulate why you did what you did you are fine.

[itsnowornever, BSN, RN]

Also wanted to add, in most EDs (here at least) the nurse usually will tell the doc whats going on and for the sake of saving time and taking care of the patient will just double check and put in the orders themselves and the doctor will sign off later on. I've even seen this on MedSurg floors.

[LalaJJB]

Tylenol, no. Fluids, as long as the guy didn't have a hx of CHF, yes. In my dept, we have standing orders that RN's can initiate without the docs telling us to...then they go back and sign the orders. But if you weren't comfortable doing either, you are right to refuse. The RN you were working with, although she seemed overwhelmed, should know better than to get upset with you for not doing something without an order when you are new. I'm sorry that happened. It's sucky and situations like that can really make you feel down. You did the right thing.