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...

[FLmomof5]

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

Esme, I was replying to a prior post without using the quote feature....so it didn't indicate the link. Libran1984 indicated that she/he uses it for low BP.... sorry for any confusion.

[Esme12, ASN, BSN, RN]

I thought what????? I missed that completely. Thanks.....

[Anna Flaxis, BSN, RN]

As the others have said, it all depends upon the protocols at your facility. In the ED where I worked, we would have been expected to hang the fluids and give the Tylenol if indicated. We had Nurse Initiated Protocols in place, which were standing orders from the ED Medical Director. To not initiate treatments per protocol based upon the chief complaint/patient condition, instead waiting for an MD order, would have resulted in a delay in treatment and irritated docs. It's possible that your ED is different, but it would be worthwhile for you to check into this.

[hiddencatRN, BSN, RN]

As other people have mentioned, different ERs will have different protocols....but they'll also have different cultures and expectations. One place I've worked, unless it's a respiratory issue, we're expected to be pretty conservative in what we initiate. We don't slap lines in patients without a doctors order unless the patient is REALLY sick (I work in peds so we try to minimize IVs). Another place I work, you'd be considered a weak nurse to not anticipate the basic orders and get that going while the patient is waiting to be seen.

I don't think it's fair to expect a nurse new to the facility and that specialty though to be comfortable giving medications without an order in place.

[brainkandy87]

As has been said, it certainly depends on the facility/department protocols. My ED is very liberal on protocols and what our docs will let us do. I toss in all sorts of orders for meds, labs, etc. I don't throw in orders for narcs, but Tylenol, Zofran, ASA, Toradol, and NS.. Yeah, not a big deal at all.

But it's whatever you're comfortable with. It's your license, not hers.

[julianne.00]

Like stated before, I think you did the right thing. It all depends on the policies in your ER, if there are standing orders for things like Tylenol, etc. I put lines and get labs on people all the time to get things going-- that's just what we have in place for our triage/ambulance triage, etc. Depending on vitals (and labs if they've been lingering in the WR forever) I might have started fluids, and if I need more I just go talk to a doc. Ad long as there is reason for what you are doing, and it's within your scope... and in the ER policy, you're golden. Sounds like that nurse was just a bit sauced up because she was busy. No worries... send her an anonymous candy bar with a smiley face on it :)