Wednesday, April 26, 2006

An order is an order, isn't it?

I had another good week!  We did have a code blue, but it wasn't my patient & her heart never stopped beating...she just was unresponsive.  They ended up intubating her & sending her to ICU.  What was strange about that is earlier in the night, the patient kept saying "I don't want to be intubated."  She was stressing out over's like she had a premonition about what the morning would bring.  Weird!

I won't go into details about my patients this week because there really isn't much to say.  They were all alert & oriented, no drama queens or was a peaceful week for me....until this morning.

I received a woman in her mid-80's from ER with a diagnosis of dyspnea (in layman's terms...she was having difficulty breathing).  The orders were short & simple... basically said "Patient on bipap, ABG's in the morning."  ABG's are a lab test "Arterial Blood Gas."  She had already had 2 sets of ABG's done in the on 5 liters & one a couple hours later on bipap.  Her results were much, much better on bipap.  Anyways...the patient comes up from ER...not on bipap, rather on a 50% venti mask at 15 liters.  Hmmmm...ok, maybe for some reason they couldn't transport her with the bipap, even though they managed to bring the machine up with her at the same time.  I ask the ER nurse why she is on a venti mask instead of the bipap & she said "I don't know, respiratory set it up."  Hmmm...ok, so I ask for the respiratory therapist to be paged to come set up this patient's bipap.  He calls back & basically says the patient is fine, she doesn't need it.  Ummm, helloooo, the doctor wrote that he wants the patient on bipap.  It doesn't say "do whatever the respiratory therapist says to do."  I page him again, this time instead of calling back...he shows up & we assess the patient together.  I am saying to him "Don't her lips look kind of bluish?"  He replies "It's kind of hard to tell in this lighting."  What?????  Open your eyes.  So he asks if I have an 02 sat monitor.  Ummm...YOU'RE the respiratory therapist, where is yours?  He knows we don't have them laying around the units as much as I would love to have one readily available...we don't.  Only respiratory has them.  He gets one & returns, her 02 sat is 96%...which is good.  So he says she's fine, if she has trouble breathing, then call him & he leaves.  I ask a couple of other nurses what they think of this & how do I cover myself for not following what the doctor specifically ordered.  They were all agreeing that it is not up to the resp therapist to make the decisions without the doctor being aware of it.  I discussed it with my clinical leader...she also said it was wrong for him to refuse to put the patient on it...but advised me to document, keep a close eye on the patient & notifty the doctor in the morning. 

Hmmm, decisions, decisions.  The patient was a DNR, however, that doesn't mean we purposely assist her to have difficulty breathing.  Plus she has a history of COPD...which I always thought that when they have COPD...they aren't supposed to receive more than 4 or 5 L of oxygen.  I discuss it again with my fellow nurses & they encouraged me to either call the doctor & let him know what's up or to call the respiratory therapist & tell him the bipap has to be put on the patient.  I much prefer calling someone who is already awake & at I opt to call the respiratory therapist.  I tell him that I reviewed the orders with my clinical leader & that since the doctor has specific orders for this patient to be on bipap, that I need him to come up & put it on her.  He replies "She's fineeeee!!!!!!  She doesn't need it."  I told him I understood that, but that I have to cover myself & follow the written orders.  He begins to say "It's my call", but he stops just in the middle of saying call & then tells me I'm making too big of a deal about this.  I was being as nice as possible because I really don't like conflict.  I tell him "Ok, I'm just going to run it by the Dr. so he's aware of the situation."  I had no problem if the patient was fine on a venti mask, but I wanted the Dr. to be aware of it & not throw a fit because his written orders weren't followed.  Respiratory replies "You'd wake a Dr. up at 2:30 am over this?"  Ummm, yeahhhhh.  Then he says in a smart aleck tone "Don't you need your charge nurse's permission to call the Dr.?"  I tell him I would have no problem getting that for this situation.  So he finally says "Fineeeeee, if you're going to make this big of a deal, I'll come up & put it on."  It took him like less than 60 seconds to do this.  He came stomping up the hallway like a little baby, goes in my patient's room & says to her "Your nurse wants me to put this on you", puts it on & then stomps back down the hallway.  The other nurses were saying "I think he's mad at you!"  Oh well!

I mean seriously...I pictured myself trying to explain if anything happened to this patient through the night...and I'd be the one taking responsibility for it.  I don't know why he was giving me such a hard time about it.  I remember back to last year when I was brand new at nursing & I had a patient telling me she was having difficulty breathing, that it felt like an asthma attack.  I page respiratory for a breathing treatment.  This same respiratory therapist calls back & says "I just saw the patient an hour ago, she's fine."  Ummm...noooooo she's not.  He finally shows up & then jumps into action because she was truly in distress.  I remember the nurse that helped me out that night told me that for some reason, our respiratory department has an attitude...that they can't stand a nurse telling them what to do or something to that effect.  I don't understand why some of them give us a hard time.  All we're asking is for patient care to help the patient breathe better. I'm not asking them to do my job or to assist me with anything...just follow what the doctor ordered.  Am I wrong?

I'm sure he'll get over it.  I'm off until Monday, although I mighttttt work Saturday &/or Sunday.  We'll see.  My nephew's team starts districts tomorrow.  Did I mention that according to Sports Illustrated his team is ranked #4 in the nation overall???  WOW!  They are ranked #1 in the state for their division.  I sure hope they do well these next few weeks.  Wish them luck!  I'll keep ya updated!

Oh, one other thing...I found out this week that I was chosen as one of the guest editor's favorite journals.  Thanks Donna!  I hope y'all find my journal interesting.  Feel free to leave comments or to email me!  :)





molly146012 said...

Great journal...i'm a new reader!

You did the right thing following Dr.'s orders  :)

Hugs, Molly  

lacaza3 said...

your welcome
donna In TEXAS

myheartsaysso2 said...

Sounds like you are a rare gem.. a caring nurse.. :) Mel

godsfava8 said...

I knew the life of a nurse was busy and important of course, but your blog gives even new definition to it.

am4039 said...

being a nurse I'm sure can be very exciting and I'm sure it's hard working with some of those doctors. Happy you had a good week.

cste609371 said...

What a hard yet rewarding job!

julie0878 said...

Hi!  I just wanted to tell you that I'm a new reader and I love your journal.  I am in nursing school at the moment, and will soon be on clinicals.  It is so helpful and informative to read some of the situations you are going through.  You definitley made the right call on following orders.  Take care and can't wait to see what next week brings. Thanks for sharing.