Clinical Exemplar
Noticing
While in the ED, a patient was brought in by the ambulance for dyspnea related to CHF and COPD. The patient was started on a CPAP machine. Also, the patient was found to have symptoms of sepsis. One of the physicians was talking with the sepsis coordinator and according to the protocol for septic shock the patient was supposed to receive 30 ml/kg of fluids. However, the patient was obese so according to that protocol the ordered amount was about 6 liters of fluid. My preceptor and I did not agree with following that protocol because the patient has CHF and already has dyspnea, crackles, labored breathing, and spitting up pink frothy sputum. We did not feel comfortable loading this patient up with that much more fluid.
Interpreting
My preceptor emphasized the importance of looking at your patient and not just doing things according to orders or protocols. He challenged me to as a future nurse to not blindly follow orders without assessing your patient and the situation and when you are unsure or uncomfortable with an order to not be afraid to ask the physician. I know it is important to weigh the benefits and risks of a procedure/order. My preceptor and I went into the physician dictation room and asked him about the order and told him the patient’s current situation. The ordering physician still said he wanted to follow the protocol so my preceptor stated he was not comfortable giving the 6 liters and that he would start one liter but did not want to give all of it. He also asked the opinion of another physician in the room. After assessing the patient’s chart and hearing the physical assessment, the other physician pointed out to the ordering physician that technically the patient is just septic and has not reached septic shock so that protocol is not necessary anyways and that he did not think it was a good idea to give 6 liters. After the other physician’s opinion the ordering physician told my preceptor to just give one liter for now. This patient already has dyspnea and fluid overload. By giving the 6 liters of fluid, we could worsen the patient’s dyspnea and cause even more fluid overload.
Responding
As a future nurse, I plan to always assess my patients before providing interventions and orders because I want to be able to make sure I am critically thinking about their current situation and the outcomes of the order and its effects on my patient's health and safety. In this situation, we were not comfortable with the order and wanted to do something in the moment and ask before starting the fluids so that we were on the same page in this patients care. By waiting and watching it would be risky to the patient. We were advocating for our patient and taking into consideration the patient’s presentation which is always the best decision in my opinion.
Reflecting
We did our job as nurses by assessing our patient and critically thinking before providing care. We did make the right decision by questioning the order, explaining our reasoning, and asking another physicians advice. The ordering physician did end up changing the order to one liter which we were comfortable with administering. I noticed that the order was a lot of fluid and that I did not think my patient would be able to tolerate it. However, my preceptor did all the talking to the physicians and stated his opinion about it because I was still a student nurse. In the future as a nurse, I want to gain experience through practicing skills and critical thinking.
I want to become comfortable with speaking with physicians and questioning orders that I don’t understand or agree with so that I can receive clarification and continue to learn. Patient safety and patient advocating are top priorities of mine and my goal is to provide quality care.
While in the ED, a patient was brought in by the ambulance for dyspnea related to CHF and COPD. The patient was started on a CPAP machine. Also, the patient was found to have symptoms of sepsis. One of the physicians was talking with the sepsis coordinator and according to the protocol for septic shock the patient was supposed to receive 30 ml/kg of fluids. However, the patient was obese so according to that protocol the ordered amount was about 6 liters of fluid. My preceptor and I did not agree with following that protocol because the patient has CHF and already has dyspnea, crackles, labored breathing, and spitting up pink frothy sputum. We did not feel comfortable loading this patient up with that much more fluid.
Interpreting
My preceptor emphasized the importance of looking at your patient and not just doing things according to orders or protocols. He challenged me to as a future nurse to not blindly follow orders without assessing your patient and the situation and when you are unsure or uncomfortable with an order to not be afraid to ask the physician. I know it is important to weigh the benefits and risks of a procedure/order. My preceptor and I went into the physician dictation room and asked him about the order and told him the patient’s current situation. The ordering physician still said he wanted to follow the protocol so my preceptor stated he was not comfortable giving the 6 liters and that he would start one liter but did not want to give all of it. He also asked the opinion of another physician in the room. After assessing the patient’s chart and hearing the physical assessment, the other physician pointed out to the ordering physician that technically the patient is just septic and has not reached septic shock so that protocol is not necessary anyways and that he did not think it was a good idea to give 6 liters. After the other physician’s opinion the ordering physician told my preceptor to just give one liter for now. This patient already has dyspnea and fluid overload. By giving the 6 liters of fluid, we could worsen the patient’s dyspnea and cause even more fluid overload.
Responding
As a future nurse, I plan to always assess my patients before providing interventions and orders because I want to be able to make sure I am critically thinking about their current situation and the outcomes of the order and its effects on my patient's health and safety. In this situation, we were not comfortable with the order and wanted to do something in the moment and ask before starting the fluids so that we were on the same page in this patients care. By waiting and watching it would be risky to the patient. We were advocating for our patient and taking into consideration the patient’s presentation which is always the best decision in my opinion.
Reflecting
We did our job as nurses by assessing our patient and critically thinking before providing care. We did make the right decision by questioning the order, explaining our reasoning, and asking another physicians advice. The ordering physician did end up changing the order to one liter which we were comfortable with administering. I noticed that the order was a lot of fluid and that I did not think my patient would be able to tolerate it. However, my preceptor did all the talking to the physicians and stated his opinion about it because I was still a student nurse. In the future as a nurse, I want to gain experience through practicing skills and critical thinking.
I want to become comfortable with speaking with physicians and questioning orders that I don’t understand or agree with so that I can receive clarification and continue to learn. Patient safety and patient advocating are top priorities of mine and my goal is to provide quality care.