What would ja do?

[JRD2002]

You are on a night shift. You have a renal/diabetic patient that is going for surgery tomorrow. A surgeon has seen the patient and evaluated the need for surgery. In this case it is a ulcer on the left foot that has lead to gas gangrene. However, the surgeon that will be performing the surgery has not seen the patient and therefore the consent for tomorrows operation is not signed. Operating surgeon will see patient on day of operation.

Order on the chart that were written by a Dr. on the hospitalist program are as follows:

D5NS@40ml/hr starting @7AM

Would you start the infusion?

I did not start it. My rationale:

Patient is a renal patient on fluid restriction who does dialysis 3x/wk

Permits are not signed and surgeon has not talked to patient so why start pre-op treatment when patient may not have surgery until the afternoon or even the next day.

The hospitalist's order was written after the renal Dr. had seen the patient so he was not aware of the IVF.

Patient is very non-compliant and does not adhere to any type of fluid restriction which has lead to a gain of 10+lbs in 48hrs.

To me the choice seems obvious not to start the IVF until the patient is scheduled for surgery and when the renal doc has ok'd the fluids. I am only asking because during report the oncoming nurse made the comment that "if it was ordered we have to do it." That was news to me. I didn't realize that we blindly follow orders. Anyone think that I should have started the fluid?

[nightmare, RN]

Nurses today are trained to be rational, analytical people,not handmaidens blindly following orders but........doctors still think we should blindly follow orders!!I think you were right BTW

[Jolie, BSN]

I applaud you for using nursing judgement and withholding a treatment that you believed to be inappropriate and potentially harmful to the patient.

My question is whether you contacted your nursing supervisor and the patient's physician (the physician who ordered the treatment) and notified them of your intent to withhold. If not, I believe that you should have done so. The ordering physician has a right and a need to know if his/her orders are not being carried out, so that he can adjust his plans accordingly. Even though the patient had not yet been seen by the surgeon, you don't know what communication the surgeon has had with the patient and other physicians. Your concerns may have already been discussed and settled among the physicians involved in the patient's care.

[RobLPN]

You are on a night shift. You have a renal/diabetic patient that is going for surgery tomorrow. A surgeon has seen the patient and evaluated the need for surgery. In this case it is a ulcer on the left foot that has lead to gas gangrene. However, the surgeon that will be performing the surgery has not seen the patient and therefore the consent for tomorrows operation is not signed. Operating surgeon will see patient on day of operation.

Order on the chart that were written by a Dr. on the hospitalist program are as follows:

D5NS@40ml/hr starting @7AM

Would you start the infusion?

I did not start it. My rationale:

Patient is a renal patient on fluid restriction who does dialysis 3x/wk

Permits are not signed and surgeon has not talked to patient so why start pre-op treatment when patient may not have surgery until the afternoon or even the next day.

The hospitalist's order was written after the renal Dr. had seen the patient so he was not aware of the IVF.

Patient is very non-compliant and does not adhere to any type of fluid restriction which has lead to a gain of 10+lbs in 48hrs.

To me the choice seems obvious not to start the IVF until the patient is scheduled for surgery and when the renal doc has ok'd the fluids. I am only asking because during report the oncoming nurse made the comment that "if it was ordered we have to do it." That was news to me. I didn't realize that we blindly follow orders. Anyone think that I should have started the fluid?

I think it could go two ways:

1)start it and then have the day nurse follow up with md. 2-3 hours not going to send the pt over the edge.

2) call MD at 7am to clarify.

If your not going to carry the order out, you have to have a justifiable reason. I'd probbaly would have started it myself especially if the pt is NPO and hasn't drank or going to eat breakfast.

[JRD2002]

I discussed it with the charge nurse and she agreed. Our nursing supervisor was coming in at 0600 and we notified her then. My charge notified the oncoming charge. Since the order was for 0700 I did not notify the ordering physician. If it had been ordered earlier I would have had no choice but to notify him. The renal Dr. usually comes very early in the morning usually before 0800 so I didn't think it would be a problem to wait until he saw the order.

[Sunflowerinsc, ADN, RN]

What was the pt's b/p, FSBS, lung sounds ? You would at lest want to have a IV access ready. A diabetic who has been NPO since midnight might need fluid so blood sugar would not drop. I would check with the OR ,they wouldn't want pt the dehydrated or BS or b/p bottomed out. I guess more information is needed, but I don't think that I would have not followed the orders with out assessment and consult with the DR.

[JRD2002]

BP was 170s/80s which was actually good. Pt's norm is 200/90. Sugar was 165 at 0600