Dr's order or nurse's decision

PJMommy · Jan 24, 2004

#1 - Yes. Call doctor as he'll have to put in a central line if he/she really wants TPN. You can only go up to 10% glucose on a peripheral and TPN tends to run more like 50% (I think).

#2 - Dopamine (again, doctors orders) because it has good vasoconstrictive properties...will return more blood to the heart and give inotropic support. Atropine is used more for bradyarrythmias or asystole.

#3 - Hmmm? I'd have to agree with you on this one. But I think it's a sterile procedure also so...? Tricky question!

#4 - I'd go with infection on this one. It can kill a person fast if not caught. Hyperglycemia can be identified and managed easier relative to a massive sepsis. I look at it this way...I come into the room and pt is lethargic, poor response...etc. Am I going to grab a blood sugar on him first? No...I'm going to check hr, bp, temp, resp. I'll check blood sugar after I've assessed vitals.

**canoehead, BSN, RN** · Jan 24, 2004

I agree, and I also think the last two questions were awfully hard, even if you know your stuff. I'd have to check/do both options.

doingourbest · Jul 14, 2007

my nursing school was like that too, but so were the boards. The best answer will always depend upon a the particular patient and the particular situation. The test questions don't have a whole lot to do with how well you will function as a nurse. When you are a new nurse, it is helpful if you are unsure if you should have called the physician to let them know that you are new. Some of them will be much more understanding. Others will yell at you whether it is something they had to be called for or not. You can always ask a coworker what the particular physicians preferences are. It sounds like you have the general knowledge. But it is not cut and dried. Every facility, physician, situation, and patient is different. You just have to trust your judgement.

al7139, ASN, RN · Jul 14, 2007

Here's my two cents:

First q: yes call MD and get order for a peripheral IV. NOTHING can be given with TPN, EVER! Hopefully, most real MDs would not write an order like that...

The other questions:

1. Only PPN can go via PIV, due to the low(10%) glucose.

2. Dopamine, definitely. Has inotropic, vasoconstrictive effects. With cardiogenic shock, epi is also given in some cases.

3. A huber is essential to draw from a mediport. I agree with previous responses though, I would use sterile technique as well.

4. Definitely infection. TPN is so high in glucose, that it is an infection waiting to happen. This is why the bag and tubing are changed every 24 hrs (at least in my hospital). At room temp, even one little bacterium in a bag can trigger a huge problem. BG is important, hyperglycemia is easily treated, infection is not.

Hope you do weel on your tests.

Amy

Roy Fokker, BSN, RN · Jul 14, 2007

Ex. Pt has TPN infusing in a single lumen port and Dr. orders Digoxin IVP. Do we start a peripheral IV or do we call the Dr. to see if he would want to order it by another route or make an order for an peripheral IV?

Depends.

If it is something like Reglan or Compazine, I might call the Doc and ask if s/he wants it PO/PR. If it is something like Cardizem or Dig, I don't bother calling the Doc - I start a new peripheral line.

Of course, if patient is a very hard stick or some other contingency - it changes things a bit :) There are no "hard and fast" rules.

1. Pt has an order for TPN. Only has a peripheral IV. Should we call Dr? Am I right by saying that if it is TPN that it needs to go in a central line b/c TPN is a hypertonic solution?

PPN can be given through peripheral IV (Can't remember but conc. has to be less than 1000? Or something?)

2. Pt is in Cardiogenic Shock would want to give Atropin for it's anti-cholenergic effect or Dopamine? (We haven't studied these drugs but we were suppose to look them up ourself so I'm not positive I understand everything in this area).

Dopamine is drug of choice (unless contraindicated). As long as heart is still beating, I don't usually think/consider Atropine.

3. If you were drawing blood from a port what item would be essential to have: a Huber needle or sterile gloves? I chose Huber needle b/c you would not be able to even withdraw blood with out it.

You're on the money here - Huber Needle is more "essential" than sterile gloves.

4. Pt is recieving TPN what nursing assessment would be highest priority? S/S of infection or blood glucose levels as ordered. I know from what I have learned the reason pt's die from TPN is b/c of infection due to the high glucose level that will grow bacteria so easily. But the high glucose level they also run the risk of getting hyperglycemic.

Infection is harder to treat (and sometimes to detect!) than Hyperglycemia (and while we are at it, I'd rather have someone in hyperglycemia than hypo...)

Hence, I'd prioritize on "infection control".

I get very irritated that I know my info and I am an excelent student (all A's so far). I am not bragging on myself, but I do try very hard. Anyway I am not sure that having do decide b/t answer' s that are so very close I will make me that much better of a nurse.

It's called "critical thinking" and "exercising good clinical judgment".

And it is certainly, by far, the most difficult nursing "skill" to acquire!

Nursing school preps you for the basics - it's the "putting it all together" that's hard.

You pose good questions - which at least tells me that you're thinking about the process. That's always a good sign :)

cheers,

PS: Anyone who walks out of nursing school thinking they know 'it all', is delusional. If anything, nursing school and the NCLEX should teach you - it is how little we really know when we start out...

Tweety, BSN, RN · Jul 14, 2007

In the real world, I'm not going to expose a person to the risks of periperal IVs when they have a perfectly good central line. I'm going to stop the TPN for two minutes, flush the line good and give the meds, flush and resume the TPN. It's not going to harm the patient to stop the TPN for a few minutes. The meds are instantly put into the circulation system (the heart is usually pumping 60-100 beats per minute) so the Dig and the TPN aren't going to mix. Usually our TPN patients have a triple lumen cath and there are ports for meds. Single lumens, then you run a risk by interrupting. So I'm going to judge according to how often the dig is going to be given.

You're experienced patients aren't going to let you start a periperal on them anyway.

That of course is not how your going to answer the question in school so don't listen to me.

UM Review RN, ASN, RN · Jul 14, 2007

I'm a 3rd semester nursing student. I find that I sometimes don't know what a nurse needs to get an order for or can go ahead and do.
Test Question--
Ex. Pt has TPN infusing in a single lumen port and Dr. orders Digoxin IVP. Do we start a peripheral IV or do we call the Dr. to see if he would want to order it by another route or make an order for an peripheral IV?

First off, I haven't read all the answers, so if these have all been answered correctly and discussed, my apologies.

Here's what I would do:

Get a peripheral. You don't need an order for it.

I'll give the rest of the questions a try, but it's been a long time since I took NCLEX and I agree, these questions can be tricky.

Also I have a couple of other questions if someone wouldn't mind helping me out. I took a test today and won't be until next week until I find out what I made. I felt like I was splitting hairs all the way through the test. Some questions the answers were both so right--that I had trouble choosing.
1. Pt has an order for TPN. Only has a peripheral IV. Should we call Dr? Am I right by saying that if it is TPN that it needs to go in a central line b/c TPN is a hypertonic solution?

That's correct, TPN must go into a central line. Doctor needs to give an order, patient needs to sign consent.

2. Pt is in Cardiogenic Shock would want to give Atropin for it's anti-cholenergic effect or Dopamine? (We haven't studied these drugs but we were suppose to look them up ourself so I'm not positive I understand everything in this area).

Just looking at this question makes me think that one of those drugs is directly contraindicated for cardiogenic shock. So I would look them both up under the contraindications.

http://www.theksbwchannel.com/hearthealth/6859569/detail.html

This website says it's dopamine.

3. If you were drawing blood from a port what item would be essential to have: a Huber needle or sterile gloves? I chose Huber needle b/c you would not be able to even withdraw blood with out it.

Accessing a port is a sterile procedure and would require sterile gloves, but I agree, without the Huber needle you cannot access the port.

4. Pt is recieving TPN what nursing assessment would be highest priority? S/S of infection or blood glucose levels as ordered. I know from what I have learned the reason pt's die from TPN is b/c of infection due to the high glucose level that will grow bacteria so easily. But the high glucose level they also run the risk of getting hyperglycemic.

I'd probably do the accuchecks first.

I get very irritated that I know my info and I am an excelent student (all A's so far). I am not bragging on myself, but I do try very hard. Anyway I am not sure that having do decide b/t answer' s that are so very close I will make me that much better of a nurse. I don't know if all nursing schools are like this or not. Sorry my post is so long. Thanks ahead for any input

Your school is trying to prepare you for the NCLEX. However, I don't like a couple of the questions here either. But you'll get through it. Let us know how it's going, OK?

UM Review RN, ASN, RN · Jul 14, 2007

OK, so now that I've read all the answers, and the consensus is against me, I'll give you my "real-world" take on that last question (which I don't like because we do accuchecks and routinely check for infection so seamlessly it's hard to go back and say which is done as a priority.)

The accuchecks would keep the patient in a euglycemic state, which would help prevent infection in the first place.

Checking for infection is a little more time-consuming. Checking the site, the line, the dressings, then looking over the vitals signs trends is how I check for infection.

To me, both are important and either could become a priority if something suspicious was found.

Now you know why I am not good at these type of questions. :)