RN Functions

In the ER, do the RNs have more independent functions that they normally wouldn't have on other floors? (ie what you would normally need a signature for)

I find that you have a great working relationship w/ the ED docs-quite a team approach. Many times I offer suggestions that they didn't think of. I worked with one who would routinely tell me- "give me what I want, not what I asked for". She would say this all the time during critical pt's-- the team-partnership feeling is very rewarding and empowering--but comes usually with time and trust. The docs need to know how you work-- Also-we deal a lot with verbal orders in the ED - sometimes you can't wait until the doc "writes it down" for you to start the treatment. ask anyone who arrives in the ED w/ a kidney stone--Putting that IV in ASAP so they can get their painmed as soon as the doc sees them is great patient care.

Anne

I agree....same here.

ditto what needsmore$ said

I find that you have a great working relationship w/ the ED docs-quite a team approach. Many times I offer suggestions that they didn't think of. I worked with one who would routinely tell me- "give me what I want, not what I asked for". She would say this all the time during critical pt's-- the team-partnership feeling is very rewarding and empowering--but comes usually with time and trust. The docs need to know how you work-- Also-we deal a lot with verbal orders in the ED - sometimes you can't wait until the doc "writes it down" for you to start the treatment. ask anyone who arrives in the ED w/ a kidney stone--Putting that IV in ASAP so they can get their painmed as soon as the doc sees them is great patient care.

Anne

alanpe:)

Alanpe, your question does not make sense to me. Are you saying that accidents happen when nurses make judgements to start an IV without an order? Are you saying that someone could give too much fluid to a renal patient if not careful? Are you saying that nurses may give the wrong pain meds? That is what I got from your post.If that is what you are saying, then I will respond, if not, then I clearly did not understand your concerns. First of all....an ER nurse is not likely to start an IV on a renal patient and leave it wide open to cause fluid overload. The above poster said we would start the IV so when the physician saw the patient, we would be ready to quickly give pain meds. We are not advocating choosing pain meds randomly to give, but to be ready when the order is received. It is a huge timesaver for the patient, the nurse and the physician to already have the basics done. When a patient comes in with classic symptoms of kidney stone, chest pain, etc....why wait until the physician has seen the patient to proceed? You KNOW the chest pain patient needs O2, EKG, monitoring, CXR, IV and basic labs. You also should have protocols for NTG or morphine as well. Waiting until a physician can hold your hand and "tell" you to do these things is not necessary and is dangerous to the patient. The nurse is generally the first one to see the patient, time is essential.

To answer the original question, yes, ER nurses definately have more autonomy than general floor staff. The same can be said for ICU, PACU as well. All of these staffs have a closer working relationships with the physiians they work with than general floors. I suspect L&D may be the same way. A large degree of trust must be established for this to be effective, but when you are working closely day in and day out with the same staff of doctors and nurses, that trust is established. ER nurses must be able to think on their feet, act independently within reason, and be trusted to make good decisions. Lives depend on fast, accurate intervention.

Dixie-ditto-well said. I did not say that ED nurses practice medicine, but with the protocols developed combined with the team approach-we tend to "get things started"- most ED nurses follow the ENA standards of practice and our held accounrtable for these standards. If a patient came to my ED complaining of chest pain, and the ED doc was seeing someone else just as ill- should I delay performing and/or obtaining those treatments because the doc hadn't written it down somewhere? I shouldn't get an ECG, apply O2, cardiac monitor and place an IV because the order wasn't written? What if the pt was experiencing a cardiac event--(not all MIs look "terrible") and I have taken care of many who develop an arrhythmia while waiting for the doc--good thing they had a line in place so I could give the appropriate med STAT to correct a potentially life threat. "Tis better to have it and not need it, then need it and not have it"-as long as standards of care/practice are followed you shouldn't have any problems...the ed docs expect this level of care.Anne

Sometimes an illness can suffer an accident

alanpe:)

If you know what the patient needs and that the actions are not harmful to the patient, you will provide good care and save precious time if you act before ordered. If you are not sure, ask for orders. When a critical patient comes to ER the doc´s expect me to see to EKG, o2, IV, basic labs and if it is a trauma inform CT-lab without being told. If something is not clear, communicate.

Autonomy = responsibility.

I have more responsibilities now and I feel more part of a team than on the floor, that is two differences.

Yah.... what Dixie said.... We do have more autonomy, it has to work that way. In fact, our ED is even building bigger and better protocols to allow the RN's to work more independantly from the docs.

Dear colleage:

I am not saying "that accidents happen when nurses make judgements to start an IV without an order"; I am just saying that even with good practice it is possible some problems, any of these problems is an allergic reaction, my question is who explain the reason of that possible reaction to illness.

I am sure the situation you say is more comon in ER, ICU, ...though I am sure a nurse in other service will possible do what you say in any vital emergency.

My question is about reported consent and information rights. Who does explain a possible reason of a reaction or other problems, eg a breadth depression by morphine.

I understand that ER nurses need more autonomy than general floor staff and this is right for ICU, PACU as well, but not because all of these staffs have a closer working relationships with the physicians. That looks no good.

Your suspect about L&D may are in the same way, in this service is needed more implication by all nurses.

My question is who does explain to illness; as long as you are doing very often theses actions, I think you propably are reporting illness, I do not know, each country has its own rules.

I am sorry that my message has not been understood, moreover i want to say thank you for your answer. I hope we can see good friends.

To end I want to say that your reports are very good and I have learned with them. THANK YOU VERY MUCH.

Kind regards.

alanpe

Alanpe-

I think I understand what you are asking - if there is a bad reaction to something that we take the initiative to start without an order (like an IV), how do we explain that to the patient? Also I think you are asking who obtains "informed consent" from the patient for a procedure we don't yet have an order for - am I right?

I have only worked ER and L&D, so I don't know how other units work. But in these areas we get to know over a period of time what the routine procedures are for a certain complaint, and what the Dr will want. We should NEVER give medications without an order - although I know we have all had our moments when we have "bent" that rule a little. And you are right, if I started an IV before I had an order and the patient got cellulitis or something from it, there is always the chance that could be used against me I suppose. I have never had that happen, but it is something to consider.

As for informed consent, that is something that is pathetically neglected in the 4 hospitals I have worked in, anyway. As far as I'm concerned, the doctors should be the ones who explain things to the patient IN TERMS THEY UNDERSTAND and then get the consent signed. But it never happens that way. I personally feel that is a serious problem.

I think like you it is a problem;

thanks.