Here’s some advice for the new ICU nurse. Here’s an example of some of your orders:

Notify House Officer (NHO) if HR 100
NHO if MAP < 60
NHO if 02 sat < 92%

and so on and so on…

One of the challenges of a new nurse in the ICU is learning when to notify the MD of changing conditions. If you look at the above orders it would seem that you have some pretty clear guidelines, right? Well, not exactly. You might have a patient whose heart rate has been steadily in the 110’s. In that case, when do you NHO (Notify House Officer)? When the heart rate reaches 115? 120? 130? In my experience, when a patient’s condition changes it is rare for the MD to actually change the parameters in the NHO order. In a perfect world the nurse will request an MD to change the parameters, but in my experience this rarely happens. More often than not you end up going by common sense.

Once upon a night shift I received a patient who was hypotensive. In report I was told that the patient had been on and off levophed for the past 48 hours, and currently it was off. I also had an order to restart levophed if his MAP fell below 60. I ended up having to restart it at around 3:30 AM. The intern was asleep and my impression was that the patient had been on and off Levophed so it wasn’t really noteworthy that I was restarting it. The next day I found out that the medical team (or more likely just the intern) was irked that I hadn’t notified them about the change. Okay, fair enough. I supposed that there was an unwritten rule of the ICU that I had been ignorant of: Always NHO if you have to restart a pressor. Even if you have a current order for it, and even if it is 3:30 AM and the House Officer is sleeping.

But here’s the conundrum: There are some residents that I know if I woke them to apprise them of that situation, they would say, “Why are you waking me for this? You know what to do and you you have the order.” So as a nurse, you have to first figure out the unwritten rule, then you have to figure out who it applies to. New interns? Yes. Senior residents? Perhaps not.

Unfortunately, the only way to get to know what to do in these situations is through experience, and trial and error. It’s kind of scary in a way, but after awhile a wisdom based on common sense takes over and you gain more confidence in your decisions. Until then it’s going to be a challenge and you should recognize it as such. Bottom line: Think about the safety of your patient and always err on the side of giving the MD too much information rather than too little.