Running KCL without knowing the pt's baseline K

[Erin 321]

So. The patient presents to the ED with a chief complaint of dizziness and generally feeling unwell over the past few days. No chest pain, no shortness of breath and his ECG shows a left bundle branch block only. He's a little tachy, a little hypotensive, but he's alert and in no acute distress, just appears dry. The physician orders an NS 1L bolus followed by NS with 20KCL 1L (into a peripheral line) over an hour. I take issue (politely) with him ordering a bolus of 20 meq of KCl over one hour without a single lab test having been drawn on this patient (we have no idea what his baseline potassium level is, never mind his creatinine, urea, or anything else). He assures me that it would take 200 mEq of potassium to boost this patient's potassium by a single mmol/L (his words) and therefore I'm making too big a deal over nothing. The other nurses who overhear this part of the conversation agree and tell me it's safe to go ahead. What do you think?

P.S. The patient's potassium came back at 4.7 mmol/L (normal range in our hospital 3.5-5).

[Virgo_RN, BSN, RN]

I didn't get that the OP was bashing the doc. I'd be curious to hear the doc's rationale as well.

[GilaRRT]

No, the bashing comment was in jest.

[Nurse Salt]

the docs have far more education and experience working with patient problems than do nurses. so, i say to do what he wants, unless it's something totally out of this world.

If this is your stance on how to deal with MD orders, I fear for your license... Please realize we are the LAST line of defense for the pt, and if a nurse gives a med "because the doctor said so" and the pt goes south, s/he will NOT be let off the hook. As a matter of fact, said nurse will probably take the fall for the doctor's mistake. Ignorance is not a defense.

May I ask what nursing school you went to? Because the above is HEAVILY stressed most schools...

[canoehead, BSN, RN]

I also would have looked at the order and concluded that the doc has more experience than myself, and the order would do no harm. The labs were ordered, just hadn't come back yet. I see no problem with what the doc or the nurse did in this case. At some point we need to acknoledge that docs have more education than nurses- but also that nursing has a responsibility to protect the patient from blatant errors. So long as the patient has a history of normal renal function I think the oreder was reasonable.

[sirI, MSN, APRN, NP]

the docs have far more education and experience working with patient problems than do nurses. so, i say to do what he wants, unless it's something totally out of this world.

I also would have looked at the order and concluded that the doc has more experience than myself, and the order would do no harm. The labs were ordered, just hadn't come back yet. I see no problem with what the doc or the nurse did in this case. At some point we need to acknoledge that docs have more education than nurses- but also that nursing has a responsibility to protect the patient from blatant errors. So long as the patient has a history of normal renal function I think the oreder was reasonable.

Many times, medical/nursing errors can be avoided and litigation never occur if the nurse questions, respectfully, situations such as these. Nurses should question authority. This act alone avoids many a lawsuit. Just because the physician has "more education/experience than nurses" is not a good reason to blindly follow orders.

Clinical presentations such as the OP outlined, oftentime deem the treatment course, especially in emergent situations. In this situation, the KCL benefit outweighed the risk of administering it w/o lab results. Obviously the physician deemed necessary (after clinical presentation), the order.

But, the OP questioning this is admirable. Rationale should be explained, not, "it won't hurt".

[GrumpyRN63, ADN, RN]

Would be nice to hear from coreO or TiredMD....hmmm

[Altra, BSN, RN]

Would be nice to hear from coreO or TiredMD....hmmm

Why? As an RN with 20 years of experience, I have confidence that you have the knowledge base to know the indications for different IV fluids, and to make judgements on physician orders.

the docs have far more education and experience working with patient problems than do nurses. so, i say to do what he wants, unless it's something totally out of this world.

Wow. :stone

He couldn't give me a better reason than that and so I was wondering if any of you could. If not, forget it. I'd hold the KCL and just bolus NS till I get the results back next time and we can make an informed decision as to whether or not the patient really needs it.

That is what I would have done. I would have started the NS, knowing that while it's running I have time for the labs to come back & also to dig a little further into what's going on with the patient. Is the patient on Lasix with poor p.o. intake recently? That's one example of a patient that you *know* the K+ is likely to come back low. Absolutely question orders when necessary ... but have all the pertinent information before doing so. I agree that the MD could have ideally been a little more communicative than, "it won't hurt."

[november17, ASN, RN]

the docs have far more education and experience working with patient problems than do nurses. so, i say to do what he wants, unless it's something totally out of this world.

Hahahahaha.........

hahahaha.....

ohhhhhhhhh.......wooo.......hahahaha....

rofl

Wait till you have an MD write this order; "250cc bolus of 0.9NS over an hour now" as a knee jerk reaction for low urine output for a little old lady that's all congested from CHF. You may change your mind about physicians expertise, it happens all the time! Not knocking physicians but sometimes they can overlook the bigger picture, they're human (and erring is a human thing to do). Just don't do the dumb thing and actually hook that IV up.

[canoehead, BSN, RN]

I've been in nursing 20 years, so yeah, I've questioned docs. In fact the docs in my ER may find this thread and use it to blackmail me. No kidding, I'm the loudmouth of my ER, and that's pretty darn loud.

I guess I should add a little clarification- pick your battles. Sure it's not the order I would have written, and 90% of docs would order just NS, but likely with summer weather and dehydration potassium will be helpful. Just as likely this doc will write bizarre orders some day that will actually harm a patient. If you question him today and go along with it though you've expressed some doubts he will take it seriously when you question it and then say "no, " or "HELL NO" as the case may be.

[Virgo_RN, BSN, RN]

You can't really state that 100meq will raise the serum level by one,.without taking other things into consideration,.

I know. I was just stating a general rule. There are always exceptions.

[uscstu4lfe]

just to clarify, i think it's important to clarify orders that are abnormal, which is what i meant by out of this world...

however, questioning something mild is pointless