What meds/labs can ICU nurses give without a doctor's order?

[platon20]

RN friend of mine told me they are allowed to give pressors without a doc's order in NON-CODE situations that are not a part of the ACLS protocol. I was shocked but curious to find out if this is the norm.

So can ICU RNs give pressors on their own for non-codes?

What about antibiotics?

What about non-pressor cardiac drugs?

What about labs and procedures? Can ICU RNs order ABGs, arterial lines, intubations or order vent settings to be changed?

Can ICU RNs do central lines or any other advanced procedures that other nurses usually dont get to do?

Whats the bright line between drugs an ICU RN can order on thier own vs drugs that need a doctor's order?

[BBFRN, BSN, PhD]

We have standing ICU orders for pressors, Mg, K, ABGs, ACLS drugs, labs, etc. when needed. They automatically come up on the patient's EMAR when they are admitted to us. Anything else, and we call the MD.

We don't order A Lines or Central catheters, and we don't intubate. As for vent settings, the Pulmonologist will write an order to begin weaning parameters, and the RT's take it from there.

Maybe your friend also has standing orders for certain things?

[meandragonbrett]

There are a myriad of standing orders that can be initiated by the RN.

[castens]

It sounds like her unit (as are many) is covered by a slough of standing, or preprinted, orders. That is, the doc will write, "Admit to ICU using Intensive Care Unit orders." That order set then has things along the lines of:

"RN may order XXX at his/her discretion under YYY circumstances." OR

"To maintain blood pressure parameters of X, RN may start and titrate dopamine. If dopamine ineffective, nurse may start Y."

Things along those lines.

Those orders may also include the necessary authority to order central line placement if central drugs are to be given. It's not uncommon for these order sets to have EKGs, x-rays, CT scans, and various lab work listed for RN discretion.

[platon20]

OK I gotcha now. Sounds to me like ICU RNs make the vast majority of decisions on patients in the ICU. Makes me wonder why the hell you need an MD if there are protocols for every little thing going on.

[icuwant2rn]

OK I gotcha now. Sounds to me like ICU RNs make the vast majority of decisions on patients in the ICU. Makes me wonder why the hell you need an MD if there are protocols for every little thing going on.

I know I'm med/surg not icu, but (at least at our facility) we have a list of standing orders that most of the docs have been asked to sign off on (some didn't) that covers everything from Tylenol for a fever to ordering stat EKG, cardiac enzymes, etc. for new onset chest pain (of course you call the doctor as soon as you do these). One doc wrote his own list that basically covers everything but death (Really hates being woke up if he can avoid it!)

[Hoozdo, ADN]

OK I gotcha now. Sounds to me like ICU RNs make the vast majority of decisions on patients in the ICU. Makes me wonder why the hell you need an MD if there are protocols for every little thing going on.

Yeah, I wonder that every time I am at work and I don't have protocols unless the MD orders the protocols. The last night I worked I had two vented pts, no lab orders, no CXR orders........I did take the liberty of ordering those. When the same thing happened the next night I had a hissy fit.

I will give meds not ordered if they fit into ACLS protocols. Anything else, and some doctor somewhere is going to get a wake up call.

[castens]

I will give meds not ordered if they fit into ACLS protocols. Anything else, and some doctor somewhere is going to get a wake up call.

Yup. That's the point of something like ACLS - you're covered in an emergency (if you're doing the correct things, mind you), but as soon as a physician is around to take over, they do.

How often I would wake up docs would depend on our working relationship and the extent of the need. It was not uncommon for me as a staff nurse to meet the MD in the AM and say, "this is what I did over night... sign here." Now, in order to do that, you need a very special relationship and you need to know what you are ABLE to do and what they really need to know. You have to be careful with this, because if you screw up, it's completely on your head. 99% of the time, I would start something if needed as I am making the call to discuss.

Now, I'm talking medical management here. Labs/tests are a completely different story. No doc wants to be called for chest pain and actually have to order the 12-lead and troponins; they would much rather hear, "He's having chest pain and this is what the 12-lead shows."

[Darth Nightingale]

OK I gotcha now. Sounds to me like ICU RNs make the vast majority of decisions on patients in the ICU. Makes me wonder why the hell you need an MD if there are protocols for every little thing going on.

Standing orders are nice and very helpful and very much a good thing. There are many situations where the Nurse obviously knows what should be done and standing orders allow for it to be done.

On the other hand, MD's, especially, specialist are nice to have around too. They know so much more than the Nurses about their specialty. They also know so much more about their field than other specialist which is why their may be several MD's on a single case. Neurology doesn't write orders for vent changes etc... everyone has a scope of practice.

Darth Nightingale

It's all about team work. Standing orders just empower the Nurse, and protects the hospital, and allows doctors a higher chance to sleeping through the night.

Net Net...

[BBFRN, BSN, PhD]

Darth Nightingale makes some very good points. (Love that name, BTW.)