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Someone please let me know what my rights are for following orders

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declappy declappy (New) New

Specializes in Urgent Care, general, Cardio.

Someone please let me know what my rights are for following orders that I believe will HARM the patient. Also will not following orders that are not written down and unclear, should you loose your job over these orders.

I had a 17 y/o male at wt 151 lbs come in to the care unit. Written orders were for 1 liter NS Bolas rate, one gram Rocephin and 275 mg of Solumedrol IV pust. Rocephin was adm by 500 unit of NS piggy backed with one liter of NS, solumedrol was administed first than I ran the 500 units of Rocephin and NS and then 500 units out of the one liter bag. When approching the PA I asked for furture orders. He stated to hang another one liter of NS, I informed him that the first liter was not finished, he said to finish it. After the bag ran out I again asked for orders. He started yelling at me because 30 minutes prior he stated to hang a second bag. Pt b/p had dropped to 90/52 pulse 88 o2 100. :mad: I was concerned about fluid overload. Do I have the right not to carry out the order and be possibly fired. Next thing I now I was in the nuse mgn office getting yelled at because I questioned a PA. Please somebody give me an idea on how to handle this problem. :confused:

declappy

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 14 years experience.

Moved to the General Nursing Discussion forum for more feedback.

Temp? ABGs? Lung sounds? Sx? CC? Dx? Hx?

BittyBabyGrower, MSN, RN

Specializes in NICU, PICU, educator.

You should never be reprimanded for clarifying orders. I work in a large teaching facility and all of my staff would have been fired 100x over for questioning things. You have the right to question ANY order you are given.

Were there written orders for all the fluid? Did your assessment lead you to believe the kid would be overloaded? Is the BP you stated after the boluses or before?

PMFB-RN, BSN, RN

Specializes in burn ICU, SICU, ER, Traum Rapid Response. Has 16 years experience.

First his orders seem totally normal to me. A couple liters of NS is no big deal for most adults. We regularly give up to 5 or more L NS plus colloids in our ICU. That said you are completely correct to clarify orders and should never be chastised over it. Questioning orders is a normal thing in all the ICUs and ERs I have ever worked in. If an order doesn't seem right to you you have a RESPONSIBILIETY to question them. If I get a questionable order the provider WILL either change the order, or explain to me why it is the right order.

It is totally unacceptable for anyone to be yelling at you, in particular a PA or physician. You can not tolerate that. You need to take action immediately! You need to first let that PA know in no uncertain terms that you will not tolerate such behavior, you need to write the incident up and get you manager involved.

iwanna

Specializes in behavioral health.

This would have been an excellent opportunity for a teaching experience instead of a yelling one. And, the NM was yelling at you, as well? You have a right to question anything that you are unsure of, a simple explanation was all that was necessary.

Temp? ABGs? Lung sounds? Sx? CC? Dx? Hx?

Um, yeah. What was the kid admitted for?

canoehead, BSN, RN

Specializes in ER. Has 30 years experience.

I'd hang the second bag. None of the assessment items you mentioned suggest fluid overload, the vitals suggest he's dry if anything.

If you asked for clarification he still doesn't have any reason to yell at you, even if he thought you were wrong. A suggestion...if you don't want to give a med ask politely what the purpose is. If you are still uncomfortable after the explanation, or if he yells just say "would you mind giving that, I am concerned about fluid overload." Then you have not refused, and have opened the door to teaching should he choose to do it.

No yelling is appropriate.

How much experience do you have? I would not have "yelled" at you nor had you in the office for disciplinary action, but we two would definitely have had a discussion about procedure and protocol. It was clear to me while reading this that the PA ordered a second liter of fluids, period. However, it was not clear to you, so you were correct to clarify it. Meanwhile, I have no idea of the approach you used with the PA (and, to be fair, vice versa). I don't know what was said, only what you've written. Did you get defensive with the PA while clarifying the order? By BP and HR numbers and no lung assessment and urine output data, my guess is that the kid was not in overload.

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

It is very unlikely you will fluid overload a adult-sized 17-year old with 2L of NSS, unless s/he has major comorbidities.

I don't know if the Rocephin came from Pharmacy in a 500mL bag, but if you mix it yourself - it doesn't have to go in such a large bag - 50 or 100mL will do just fine.

As others have said, there is nothing wrong with clarifying orders. But the process should be a two-way street: if you are going to go back to the provider with a concern about an order, be prepared to make your case why you are concerned. In this case, did you have some data (vitals, lung sounds, edema, etc.) that suggested fluid overload?

Edit: I had originally assumed that OP was a fairly new nurse, but have since seen on OP's profile that s/he is not. OP may be unfamiliar with peds patients, however, and upon getting a pediatric patient was immediately concerned about fluid status. (being a cardiac nurse does that to you, too) But as has been said -- in an adult-sized 17-year old without major comorbidities, fluid overload is unlikely. And even using the common pediatric fluid resuscitation formula 20mL/kg/hr. would equal more than 1360mL of fluid per hour for this patient.

Edited by Altra

declappy

Specializes in Urgent Care, general, Cardio.

these are the thing that i forgot to post. i am sorry it was a very long day yesterday

temp 99.0

dx possible abscess on tonsil LT side

lungs wet with some crackles but air moving well

hx asthma, born with rt kidney 50% smaller resulting with some renal insuf.

diane227, LPN, RN

Specializes in Management, Emergency, Psych, Med Surg. Has 32 years experience.

What was the underlying condition of the patient? Did he have co-morbidities? What was the chief complaint of the patient? Had the patient received IVF prior to coming to your unit? There is nothing wrong with the orders given and that is not too much fluid depending on what is wrong with the patient. It is OK to clarify orders, but some people get touchy when asked so you have to phrase your questions in a non threatening manner unless it is an emergency. If your manager is angry then you need to sit down with him/ her and discuss 1. How did you ask the question, 2. What your concerns where, 3. How does your manager what you to deal with this type of issue in the future?