More leeway in the ICU?

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Specializes in Med surg, cardiac, case management.

I was talking to a former classmate, who also does med-surg, and we were talking about how we were using so few of our skills in our present positions. I also noted that we don't have a lot of leeway in what we do, lots of rules and a lot of time calling the residents.

I was wondering if you have a bit more freedom in critical care. I know in our hospital the ICU nurses can adjust heparin drips on their own, but the nurses on the GMF have to call the doctor. And I've heard that in critical care the doctors expect you to take the initiative when a patient's condition changes.

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Specializes in Critical Care.

At my hospital that is true. Most of the time if we suspect something or want to draw labs for one reason or another we usually do it with no issues. BUT if there is something that we find that is either critical or abnormal then we have to call the intensivist on it. As far as drips go, we usually adjust them on our own depending on what we are trying to do. For pressors If my MAPs are >60 and my SBP is >90 then I try to wean them off. The longer the patients are stuff the worse off they are IMHO. The same thing goes for vented patients, I try and get them extubated as soon as possible, the longer you're on that thing the worse off you are. We are trauma hospital and people come in really really banged up and those who become chronic vents are usually trached/PEG'd. But to answer your questions yes the doctors expect us to 'grab the bull by the horns' so to speak and take care of things before they comprise a patient who is already critical.

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Specializes in SICU.

It can vary greatly. Is it an ICU in a rural area, community hospital, large teaching hospital? Do they have doctors/residents on the unit 24 hrs a day? In some you get more leeway, in others you don't. As for the heparin changes, that is done via a witten potocol, so the nurse ARE following doctors orders even if the do not have to call them to make the changes based on lab results.

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Specializes in Critical Care.

It can vary greatly. At other hospitals in which I worked the nurses were expected to do a lot more than where I am now. Some hospitals allow for greater autonomy and encourage critical thinking, some do not. It saddens me, actually, to see what a task-monkey I'm now expected to be. Pardon the vent...sigh....

You have to go with the flow, wherever you are. Doing more than you are "allowed" will get your butt in the fire.

In ICU you will always be expected to titrate gtts as per order.

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Leeway is one of the perks and one of the downsides to being in the ICU.

We have a ridiculous amount of protocols which give us autonomy, but they are actually doctor's orders. You're not actually doing anything without an order. Sedatives and sedative bolus' for vented patients, heparin, pressors, DKA, sepsis protocols where you're giving them bolus' based on CVP readings, etc.

There are times where you're "expected" to do something without an order. Hang a bolus' on someone crashing, draw labs/ABG's, etc. Maybe 1 time out of 100 you'll get the powertrip doctor who thinks you're a horrible person for giving a 500 cc bolus to someone with a MAP of 45 but most of our fellows know we're just doing what we expect them to order and it's only in the patient's best interest.

There's a fine balance between leeway and overstepping your boundaries and that's why I say it's one of the more stressful things we deal with the ICU.

It takes some time to figure out what not to call the doc for and just take the initiative to do it yourself knowing they will want it done anyways.

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