Saturday, March 26, 2011

Protocols Are Not the Gospel

As telephone triage nurses, sometimes we get tunnel vision. By that, I mean, all we see are the protocols and not the rest of the picture. We forget that first, we are RNs, meaning we have the ability to work independently and make independent decisions.
Protocols are a guideline and only that. They give us the minimum action that should be taken and guidelines for advice, but we should be using our nursing judgment and assessment skills to complete the picture. Too many times I hear nurses say, "But the protocol calls for them to be seen in the ED" when the child is screaming with an earache.
Yes, it does say that, but other factors have to be taken into consideration as well. Is the correct dose of medication being given for the child's weight? If I were a betting girl, I would bet 50 percent of parents are under dosing their children when it comes to giving OTC pain relievers and fever reducers. Also, keep in mind each child is different, one medication make work more effectively for some children than others. Nothing wrong with suggesting to try Ibuprofen if Acetaminophen is not working, unless of course the child has an allergy or has been previously instructed not to use by the primary physician.
Read the protocol! Lots of helpful information in there on how to get the parent through the night until the office opens in the morning. Has the parent tried heat or ice for 20 min? Is the child's head elevated? What about a humidifier running? If there are co-existing cold symptoms, maybe relieving those symptoms will help with the ear pain and pressure.
Also, never forget, kids are real little drama kings and queens. With some children, they will scream over a hang nail. And, the best judge of that is the parent. Ask them how well the child tolerates pain.
Finally, once all of these measures have been tried and exhausted, then of course, follow your protocol guidelines. Remember, we are here to give the best advice possible, and if that means we can go the extra mile to keep the patient out of the ED when it is not necessary, then our job has been well done.
Learn to use what we were trained to do friends! Take those blinders off and be the independent decision maker you were trained to be, follow your guidelines, but take all factors into consideration before giving your disposition.