I respect the role that nurses play. And nurses who are good at what they do are simply...priceless and indispensable.
However, the nurse's role is not as the primary decision maker.
And a lot of conflict is avoided when every participant in the healthcare field acts within the boundaries of his/her job specifications.
Okay I'll hold off on the offended for the moment because we may just have a problem with semantics.
I absolutely agree that a nurse is not the
primary decision maker. On a slow day I may not make any decisions of substantial value but other days I do.
Let me give you this scenario. I have arrived for day shift and I have responsibility for two stable post op hearts. Two surgeons arrive at the same time and both hearts are stable and I cannot be in two places at once so I talk to one doc and the other doc does his thing and leaves me orders. The patient's weight is 3kg up from preop. One of the orders is 40 mg IV lasix now and repeat the dose in 6 hours. The patient's potassium is 2.8 and I have standing orders for IV potassium replacement. Patient is having occasional multiform PVCs.
Should I
A. give the lasix now and try to play catch up with the potassium
B. give enough potassium to get the patient's serum potassium within normal range and then give lasix
????????
This is not a huge decision. But it is an example of a simple decision. Simple in that it does not require a lot of knowledge of physiology and medications but possibly huge to this particular patient if I make the choice to start diuresis before I get the potassium stable and the ventricular ectopics worsen because the potassium drops and drops.
Do I need to notify the physician of my decision? In this instance in my hospital with most physicians, no. They would say, why are you telling me this, you already know what to do. But I would document in my nursing notes the rationale for administering potassium and rechecking levels before giving lasix.
Do you see what I am saying? I don't want to be a physician and I don't want the job of a physician but I am darned proud to be an expert critical care nurse. Good nurse plus good physician equals good team.
I absolutely stay within my boundaries of nursing practice. Once I had a patient that "should" have been doing better post op but cardiac output was dropping and BP sagging. I don't remember all the specifics now but the surgeon was busy so I grabbed the cardiologist and said, I see xyz and that is consistent with posterior cardiac tamponade, what do you think? We did some stuff, I can't recall now if it was a cxr or ultrasound but it showed nothing. But something wasn't right. Surgeon became available. We are all standing at bedside and patient just isn't reacting as he should. So back to the OR for a look see. Guess what they found? A posterior tamponade. Now please understand that I did
NOT diagnose the patient with tamponade rather I said "I see this, this, this which is
consistent with tamponade". I was within my boundaries of practice and I did the right thing to notify the physicians that something isn't right here and ultimately the diagnosis was made on return to OR.
And again I am rambling on way past the point I should stop. Too much caffeine??
Friends?
🙂
