Ativan, insulin, alcohol drips on floors? - page 4
For those of you who work in med-surg, do you do ativan, insulin, or alcohol continuous infusions on your floor? If so, how do you handle the frequency of the vitals you need to do, as well as... Read More
May 19, '02We're suppose to monitor these.
On Oncology, only rarely do we see insulin drips - usually in tandem w/TPN & Lipids - frequent GS are done but no monitors or special vitals. We have to call the lab for stats, no glucometer on the floor.
Alcohol drips are common - ETOH users that are NPO - once able to take po, they can have tranxene protocol (if wish to detox) or beer/whiskey/wine TID - the surgeons hate tranxene for their pts, feel that it is too sedating and prefer ETOH.
Ativan gtts don't bother me. We use them frequently in tandem with either Dilaudid or MS04 drip. Most of our nurses have found that the narcotic causes the respiratory depression, not the Ativan. Even though not all of the pts are DNR - none are on monitors.
Our NOC ratio is 4-6 pts per nurse, so we keep a close eye on them - many of ours are regulars - so it is easier to assess changes. But I wish they would stop trying to send us Nitro drips!!!!!!
May 19, '02Susanmary, it sounds as though you might be new to nursing and if you are welcome to one of the best professions you can get. I worked in med/surg for 18 years until I became disabled. Many times u will see Ativan and Haldol used as chemical restraints. I never liked it but in some cases it really is for not only the patient's safety but the staffs as well. After giving those two drugs, particularly if IV make frequent checks. Just call the patient by name or gently shake to be certain they arouse. I would take vitals before hand unless the patient is extremely combative then I would give the med and take the vital signs as soon after the patient becomes drowsy. I have found that either of these medications can make it even worse so be prepared. If it is too bad and your facility permits it use soft restraints. Sometimes they are better than Hudini in getting them off. If you can't and a vest restraint is still in supply then use a bed sheet and go around the lower chest and abd. Also, if you just don't have soft restraints and the patient is in a chair with arms take 2 towels and go around the wrist and arm using tape under the arm to secure it. Be sure with any of these restraints you are able to get a fingers breath in there so as not to occlude circulation or anything. As far as the alcohol drip, if you are hanging it initially check your facilities policy. I would get a set of vitals before attaching the drip get vitals then in 15 minutes times 2 then q half times 2. I had a patient on an alcohol drip and it was to keep him away from DTs so that he could go into surgery without difficulties. If you are not sure just take a deep breath and go over the reasons why and how as best I can keep the patient and the staff safe and free from injury. Both of these issues should not involve much time. On days I had 6 with an admission by 6, on evenings 8 with the possibility of an admission as days would hold patients I am sure and discharge them just before their shifts end. Nights usually had 9 or 10. They were also responsible for changing the nurses notes as they were done on a daily basis as well as getting people ready for tests and procedures. If you are new you will in time find your own groove so be patient. Your patients will teach you more than any text book so just listen. The med/surg floor I worked was primarily respiratory with some diabetics and strokes. It was an older population and many could not do for themselves so it was a heavy floor in many ways. Some I called lovingly "my repeat offenders" They say that patients become like family but their families do to. I had a brain cancer patient and it was just her and her husband as they did not have any children. Each day she would have on a different color turban. We all had to go in at the beginning of the shift to see what color and style. She would always have a smile no matter how bad she felt. Her husband was a golfer and she had told me that she did not want him there when she went as she wanted him to remember her alive with a smile. Well, one day we all new it was close and he wore knickers like the late Payne Stewart with the knee socks and hat. He had a tee time shortly after my shift began so we all said see ya and he left for his game. Well, I was holding Betty and she took a breath and was gone and that would have just been about the time he got to the golf course. I called my older women mum and the mature fellows pops. I would go in and say I didn't have my hug today and just to see a bit of a smile coming on was payment enough. I think I got more out of the hugs than they did. But you don't do it with someone who is confused. When I started practicing HIV was just becoming something big. Many of my colleagues would triple glove and double gown even after we found out that was not necessary. They would no more go near these patients so I took them. Many times their families had already written them off and it had been a while since they had a real human touch and I was never afraid to give a hug or whatever. I was careful and maintain universal precautions but I did not make the big deal of it as others had. Some would not even shroud there patients as it was up to the techs. Well, whenever I could I would help the techs as if it is someone we have come to know well than it is just as hard on them as it is on us. Sometimes I did it for closure or to diminish the stress in the room. It was my patient just as it was theirs. Remember, in time you will find your own nitch in designing a flexible schedule in order to get things accomplished. Who knows before long there will be another nurse who will need some support. I will to this day and still do it. I say to myself what would Marylou or Nancy do in this situation. Marylou showed me how to do things to get IVs going when I was a clerk in the ER and Nancy was my first head nurse. I would trust them without question. I hope this helps Disabled
May 19, '02We also initiate Heparin, Dobutamine & Cardizem drips and maintain on the floor (oncology) - but we are not supposed to take procanimide or nitro gtts - However that does not keep admitting from trying to send them to us or for physicians to try and order them on the floor. Cardizem and Dobutamine pts are on monitors , though.
As far as pushing ativan/ms04 - I have pushed MS04 up to 20mg, or Dilaudid up to 8mg, or Ativan up to 2mg slow IVP - but I well know my patients tolerance for narcs before I did it and I knew their baselines-they are almost never on monitor. Take into account, recently I had an end stager w/MS04 gtt. at 700mg an hour w/50 mg. bolus q15 minutes for breakthrough, 400mcg Duragesic in place and was getting scheduled po Ativan, Flexeril, Neurotonin & Elavil. The patient was actually ambulating at times, and was alert and fairly oriented, more so than many other patients. And the SPO2 was fine. It is pretty scary at times.
We get kind of used to heavy narc./sed. doses and try not to get blase to them. It's rare that we have a problem, but you still have to be careful. And no, most our patients are not DNRs - one of the local Hospices actually takes Full Code patients. That even scares me.
May 19, '02Sometimes the the patients are more alert than the staff. On night shift we were always accused of sleeping but the work got done some how. I have met a full code patient with 700mcg of Duragesic q 3 days. She is at home and ambulatory, I have left the practice due to a disability and part of it is nonmalignant chronic pain and diabetic neuropathy. I take Pamelor 75hs and25 q am. I am also on Duragesic 75mcg. My highest level was 125 but I asked to reduce it. I also have Percocet for breakthrough. I had stapling and bypass as well as an abdominaldermalipectomy for formaly weighing 425. I did not have the pain then that I do now. It seems that the abdominal adhesions are intertwined with the colon and they say it is too risky to remove them for fear of puncturing the colon and ending up a lot worse. Every time there is peristalsis there is pain. That is also combined with IBS from the surgery but I think I have had it for years but ignored it and just took care of it. I know of patients that have indwelling intrathecal pumps with dilaudid as well as a stack of prns for breakthrough. One in particular is taking Neurotin 3600mg daily. I could never swallow that many pills Hopefully, in time I am able to reduce the Duragesic even more. Note. Do NOT give a pt on Duragesic Nubain. I was in an ER and it happened and from being on the Duragesic I went into immediate withdrawal. It took Ativan 2 mg IV to decrease it. I do not know how addicts do it. I never want to go through it again. Now until I am off the Duragesic or there is something else I say that I am allergic to Nubain.
May 19, '02Thanks for the tip on the Nubain. We don't use it much in ICU but we are seeing more and more patients coming in with pain patches on. Good to know. Thanks!
May 19, '02I don't believe a PRN IV push dose of MS or Ativan needs to be monitored necessarily, unless there are underlying medical conditons that might call for a monitor. An extra set of vitals is always a good idea, IMO, to see how they react. Patients who you may see on cardiac monitors or SPO2's with these drugs: renal insufficiency, COPD, or cardiac problems jump to mind.
I always watch my patient closely with the first dose of any drug like this....ever seen an anaphylactic reaction? I only did once with IV Demerol ....and now I watch 'em like a hawk that 1st IV dose...LOL!
Good points about oncology patients...they often require huge doses of narcotics to obtain pain control. On the other hand, COPD patients may show signs of resp. depression on small doses of narcs and need to be watched closely. Patients with renal or hepatic problems may not metabolize the drugs well and may react more strongly.
Knowing your unit policies and following them are vital.....I know today nurses on the floor are being pushed to titrate drips like Cardizem and Nitro, but it is risky business, IMO. My facility policy is titrating drips (ie turning up and down by vital sign parameters) should be done in an ICU setting, or PCU with a qualified ICU nurse supervising. Continuous bedside cardiac monitoring and VS q 15 minutes are not unusual.
If floors are accepting continuous Nitro and Cardizem IV infusions, even at a steady, slow rate...the nurse should make sure there are policies in place to protect both you and your patients. BP can drop quickly with both these drugs...and Cardizem can cause extreme bradycardia as well.
Many times the docs have no idea the floor nurses have not been trained to titrate Cardizem for SVT, or Nitro for chest pain... or if it is against policy. Sometimes they do know and are trying to sneak one by....
May 20, '02I have never seen an Ativan or alcohol drip in my hospital. We have had insulin drips, Amiodarone infusions, Cardizem drips and dopamine drips on med surg. The dopamine and Cardizem are only allowed if the drips are low dose and are not being titrated.
This weekend one of our IM docs ordered a nitro drip at 10 mcg/min. on a 90 yo. DNR patient. The patient had chronic intermittent angina, and the 10mcg seemed to keep him comfortable. I don't know why the doc didn't just order nitro paste or something else besides the IV nitro. This is the only time I have ever seen nitro on the med surg unit. I really didn't have a problem with it under the circumstances but I hope this particular doc doesn't try to make a habit of it.Last edit by willie2001 on May 20, '02
May 20, '02I work on a telemetry floor, and I have never had an Ativan drip/patient. We have a large population of ETOH and they have IV Ativan ordered and Serax. I have never encountered an ETOH drip, but from what I have read that is an ICU placement. They are asking you to do this on a gen med/surg floor? We operate as a stepdown unit from CCU, we can do IV lopressor, ativan, nitro, and start cardizem drip then they have to be transferred. I can't believe they are expecting you to monitor this on a med/surg floor.
May 21, '02I have never had a nitro drip on the med/surg floor. I think I would be taking vitals every 15 minutes for quite some time. What about the paste? Then again it is intermittent give the pill with different guidelines in particular for a patient of this age.
May 22, '02I work on a mixed medical specialty unit (stroke, neurology, renal, endocrinology) in Australia. We have minimum ratios set by law to 1:4 AM and PM shifts, 1:8 on nights (higher if warranted by patient acuity).
Depending on the stroke protocol, half of them will be on heparin infusions, or none of them. If they're on urokinase or streptokinase they're specialled (1:1) until the infusion's been down for four hours.
We use insulin infusions via syringe driver for DKA - 1/24 checks and hourly rate changes depending on the BSL.
Our migrainoid-withdrawal patients have 10 days of continuous, low-dose lignocaine infusion and have a bedside cardiac monitor.
Lots of our patients have narcotic infusions, and we push IV narcotics, with no special monitoring. If they're being palliated they might also have a midazolam infusion, but that's usually given s/c. The renal patients are sometimes on a frusemide infusion, monitoring ditto.
If they're on GTN or dopamine then they have 1 - 2/24 obs once stable. Amiodarone drips have to go to cardiology or to coronary care.
Hope this helped
May 22, '02I am an LPN. I work on a surgical floor. Some days I feel like I should be working in ICU. We give Ativan IV push. The MD kept on asking me why my patient did not recieve his Ativan right after she ordered it. I communicated it to the RN who was busy with all of her patients. I swapped some tasks with her so she could do all my IV push meds. After this the MD ordered them PO. We also do heparin and insulin drips on our floor. As LPN's we can maintain on a PICC line, but have to get the RN to connect and disconnect them. With a Peripheral line, we just need to keep the RN updated. I am really nervous when I have patients with these drips, but it is not to often. CNA's take the vitals Q2 depending on the patient situation.
May 23, '02Nurse K-bear, in Florida LPNs maintain all perifpheral lines. They do not do any IV pushes or hang blood. Usually the RN hangs and then the LPN who has that patient monitors it. I don't know why this restriction exists because it hampers everyone. I would switch off when I had an LPN on my team. I would take the patient that required IV pushes and she would take one of mne. I know that some LPNs hang blood and sign the form as a second signature or go ahead and give IV pushes. I don't agree with it but I know it happens particularly on a busy floor. Don't give into an RN saying you go ahead and do it. DON'T DO IT or you will be out of a job in no time. It is too risky especially if it is a med that is specialized or if it is not diluted or even the wrong med because it looks similar to what. As I always say no matter what level you are at watch your butt.