Can I bolus this patient? A legal / practice question about sedatives and narcotics

[simvee]

Hi, I'm a new RN in a trauma ICU. We use a LOT of pain drips and sedative drips. Typical patient has Versed and fentanyl on pumps with orders to titrate as needed to maintain sedation (MAAS score of 2-3). Sometimes they use propofol with the same order to titrate. Frequently we have specific orders to maintain, say, the Versed at no more than 6 mg/hr, so we do know when the surgeons or other docs want to limit sedative use. But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.

However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.

My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes and then titrating back down, right? These boluses are delivered slowly, through the pump.

The other contention many nurses have is that if you have to bolus, you probably should be titrating up anyway. But I don't really believe that. Say someone looks comfortable on 3 mg/hr, but when you stimulate them they get agitated and their vitals go nuts. I'd rather bolus then, and then let them rest and return to 3 mg/hr. It's that or jack them up to 5 or 6 mg/hr, doubling their dose indefinitely, even though they don't need it for all 60 minutes of every hour. We're not supposed to be anesthetizing these people anyway!

The problem with my approach is that the trauma team will round and see, from the charting, that the patient was comfortable on 3 mg/hr all night and we could possibly turn the sedation off, when in reality they needed a total of, say, 15 mg of boluses on top of that to keep them comfortable and turning the sedation off will lead to a self-extubation or something.

What do you think? I'd ask the docs but most of them are aware and don't care what the legal aspects are as long as patient care is accomplished. I'm afraid to ask the pharmacy because I don't want to get anyone in trouble.

[meandragonbrett]

To the OP,

First off, it's very evident that you are a new nurse (as you have previously stated) and new to critical care.

People can EASILY divert narcotics and benzos and nobody is none the wiser as to their doings. You will probably be highly surprised with your first experience of finding out that a co-worker...a mentor even...is long longer employed in your unit because of controlled substance diversion. These folks will go to the earth's end to obtain the meds.

Anything you do with controlled substances needs to be VERY carefully documented. You need a paper trail. All it will take is one time of you being investigated and you will understanding exactly what we're trying to tell you and prevent from happening to you.

You can have restrictions placed on your license over 1mg of Midazolam that is unaccounted for.

[meandragonbrett]

It depends on the patient and the team's goals for the patient. Where are we trying to get them in the next 24 hours or so?

One facility I work with uses 1-2mg Ativan IV q15min PRN and a fentanyl gtt.

Another facility I work with...the pulmonologist wants the patients SNOWED. It's nothing to have 30-40mg/hr of Versed, propofol gtt, and fentanyl gtt, and will then have PRN orders for fentanyl, dilaudid, and ativan.

Different strokes for different folks.

[sunnycalifRN]

I agree. We have some docs who start off with 400 of fentanyl and 6 of versed because they don't want their patients to even twitch! Others, will use just propofol and a little fentanyl.

Variety is the spice of life!!

[fiveofpeep]

I have cerner too. Why cant they put in a PRN sliding scale for the drug like for insulin for example and have it q15 or however. Then you can select the med under PRN and then input the amount administered there so you will show what you give on top of everything else.

[zofran]

I feel your pain OP. I am not an ICU nurse but I have the same problem with my morphine/dilaudid gtts for comfort care patients.

We have the same kind of orders you do......For example they go something like.....Morphine gtt-start at 2mg hour and titrate for comfort up to 20mg hour.

The thing is we always have a second order with them for Morphine IV 1-10mg Q1 PRN.

So one day, I was setting up a morphine drip for a dying patient. I didn't want the patient to have to wait 1 hour to get her damn morphine dose. I set up the drip and went back to the med room to grab the vial of 5mg/ml morphine. The most experienced nurse yells out---Why are you wasting your time!!!! Watch this!!!

She grabed a syringe with a needle and stuck it through the port in the tubing. She drew out 5mg/10 ml morphine. Then she took the needle off and gave it to the patient.

We go to chart it and there is NO WAY to chart it. The computer wont LET US.

The OP is not a bad nurse practicing way beyond her scope people. She has a COMPUTER problem.

Good luck OP.

Edited to add---Be careful what you wish for though OP. I am sure if they fix it they will make two nurses come into the room and document that you gave that damn bolus. (or maybe you have to do that with ICU type drips anyway?)

[simvee]

peep and zofran - thanks for understanding my plight. Like I said, there is no way to document these boluses. I already posted the only workaround I could see (volume boluses) which is ridiculous but at least it works. Kinda.

The problem which you guys illustrate is that any solution they come up with is probably going to be stupid. Who dictates that these boluses can only be given Q1H? What if you have to bolus once, it's not enough, and you bolus again? It'll look like you're violating orders, when the ordering physician probably doesn't even know or is too busy to notice that these artificial restrictions were automatically placed on his or her orders.

That's the rub. CPOE is enabling physicians to enter their own orders, which is cool, but it's being designed by nonmedical staff, which is not. The same with eMARs. So you have automatic orderables which sneak in artificial parameters and you have unworkable and impractical charting software that doesn't allow you to reflect what happens in reality.

Like I said, this happens with other drips too. One of the intensivist physicians was asking me how to determine what rate of levophed a patient was on. Charting this is not the easiest thing in the world (especially trying to correlate it to your automatic BP charting, which always seem off by 15 minutes!!), but I realized that there was no easy way to view the titration either!

It's all bad, I know. I'll take some of these suggestions into considerition.

CAVEAT: When I said that other nurses might not chart their boluses, I realize now I was making a grandiose assumption and I need to actually verify this before I go suggesting they're doing something ILLEGAL. Like everyone pointed out, I'm new, and I'm sorry I said that.

[madwife2002, BSN, RN]

A very interesting debate please continue to debate it calmly.

[breeziRN]

Being a Trauma ICU nurse we started off usually with fentanyl and propofol for the obvious reasons of its easier to do a propofol sedation to assess neuro status and prepare for extubation. On the other hand, if its been longer than a week or two the patients goes on Ativan or Versed. If its Propofol I dont really mind going up to the max/hr just because of its short half life. But for Ativan and Versed I go with a lower hourly rate and bolus as needed unless they just have no obvious sedation at a certain rate then yes I go up on the hourly rate. It is so hard to get patients to wake fully after 5 days of Ativan at 5-8 mg/hr.. We used a Ramsey scale and most orders say titrate to Ramsey 2-3, which means opens eyes to verbal commands and otherwise calm...Yeah right...most pts on sedation are 3-4 opens eys to verbal commands or light touch. Bolusing Propofol is illegal so I would be careful as an RN doing that, only the anethesiologist or MD can legally do that...but I know we do it all the time for many legitimate reasons.

[meandragonbrett]

B Bolusing Propofol is illegal so I would be careful as an RN doing that, only the anethesiologist or MD can legally do that

Or Nurse Anesthetist

[Esme12, ASN, BSN, RN]

you are new to nursing and new to an icu. there are many people who have, been there done or seen that, trying desperately to let you know you are on a slippery dangerous slope professionally and legally. it really is not simple. there are strict guidelines for narcotic orders,administration and documentation. there are very good reasons that these rules are there........narcotic diversion is a very real and actively present entity in our profession wether you want to believe it or not. i'll bet flying icu rn has known someone who fell victim to the slippery slope of addiction and watched them self destruct. i know i have......both as watching a co-worker, and freind, fall to the disease of denial.......addiction......and the .........i know better than you syndrome........i know someone who got trapped in the "everybody does it" montra............. and is no longer a nurse anymore. but also as a manager who tried to save someone and follow how they supplied their disease while trying to save them from destruction. we are only trying to gelp you..........and it should have some sort of impact on you that so many nurses find this post alarming. i hear everyone screaming "watch out!" and you refuse to hear.

flying icu rn - i still fail to follow you. how exactly are my coworkers going to abuse a drug that's confined to iv drip bags and the tubing running to the patient? i suppose if you were creative you could angiocath yourself and attach yourself in the patient's room, or you could bolus the line into a paper cup and drink it...? anyway, a properly programmed pump that is properly cleared and accounted for does the same work without the extra syringes and easily stolen glass bottles. isn't it more likely that you would remove a glass bottle of a narcotic and take it home but simply chart you gave it to the patient? it's harder to make the pump lie than it is to falsify charting.

you can draw off iv tubing with a syringe inject the substance into another container (or yourself) to be injected or drank later (yes i said drank) you can draw off the main bag for that matter. do you prime your tubing? another perfect opportunity to feed the addiction. stop being sarcastic and listen to what we are trying to tell you.............we all are very concerned! at your naivety. it will cause you problems. claiming everybody does it or ididn't know won't save you!

emse - i don't recall saying i was wiser than the physicians........and i quote" mdsays start patient on fentanyl and versed, titrate and bolus as needed.this is totally up to the rn. i am fine with this because the rn who has been there for 12 hours typically knows better than the md who can only evaluate the patient for five minutes"

for instance, in our hospital, the physician orders a paralytic agent. we start it using hospital guidelines. we adjust it using hospital guidelines based on our assessment findings. the physician almost never dictates a dose, titration, or bolus. in fact, it's generally assumed (i.e. a head pharmacist said this) that we know more about the intricacies of dosing than the physician does. which is no shame on him or her at all! but regardless of who you think is in charge in this situation, all of our actions are legally covered by (in fact obligated by) the physician's order. there's no such thing as a nurse giving or titrating a paralytic agent without an order.

thank goodnes!!!! but if the md doesn't dictate the dose, titration or bolus..............who does? does the order state "as per protocol"? protocol is an established guideline or order series approvend by the pharmacy and theraputics commities with md's and nursing practice involvement. developed and approved by pharmacy,nursing and the md's. someone has to indicate a dose, how much? how often?

it's simple......... example versed gtt.....start versed gtt bolus with 2.5 mg prior to starting gtt then titrate 2-4 mg q 15 min to achieve maas score of 2-3.

bolus with ......versed 4 mg for breakthrough maas score of 4 q 15 min prn

versed 5 mg for breakthrough maas score of 5 q 15 min prn

to a max 10 mg per hour and so on.........

if bolus needed greater than 2 boluses per hour increase gtt 1-2 mg q 1 hour

to maintain maas score of 2-3.

may give versed 2-4 mg ivp q 15 min prn for agtation not controlled by gtt.

and so on.......... not having this not only inhibits the hospital from seeking reimbursment and it is a jacho requirement.............when was the last survey? the pharmacist better know the appropriate way to administer drugs. when the pharmacist said we .....i think he was refering to other pharmacists:rolleyes:

our use of analgesics and sedatives are governed exactly the same way. the only problem i have is that the hospital guidelines are a bit hazier, i.e. there's no "go up by x amount if the patient is acting y or z." like there is with paralytics or pressors or antihypertensive drips. and my original question was whether boluses are covered by this...... the answer is no....and that's what i wanted input on. i didn't expect the entire concept of rn-led titration would be called into question and that people would call for my license to be revoked!

hospital policy dictates how something is to be done but that actual orders continue to come from the md. the "must be in a designated line.......only in d5w" may only be given in critical care area with pt on monitor is a hospital policy. the how much? how long? how often? is the md order. boluses are only covered only if they are ordered!!!!!!!! rn's titrate by md order only. if it is a bp issue the md writes dopamine 800/250 d5w titrate for map of 62..........or titrate for cpp of 60........how many cc up or down is dictated by the pdr. i have always worked with md's who were not laxy and they would order. dopamine 800/250 d5w to maintain map of 60 or urine out put of 60 cc per hour titrate prn. controlled substance gtts are a completely different animal and are mandated by a completely set of rules including the government.......the dea! no one called for your license to be revoked.......we all told you that what the facility and your peers were engaging in some risky behaviors and your could easily lose your license!!!!!!!!!!!!! forever:eek:

i admit that our charting software is not ideal. in fact, we've had to recently hound some physicians for getting lax about adding the "titrate to sedation" part in the computer. so maybe i will bring up the difficulty of charting boluses and the confusion the rns have over whether boluses are technically covered under that order any longer. maybe it will be fixed? like i said, i chart them as volume boluses, but that doesn't feature as prominently in the charting flowsheet as the dosage titrations do.

if there is truely an order for boluses and there is no way to document them then that is probably a software issue. as far as the software companies not involving medical people is not true....it has become a lucrative field. fyi..........i know of several nurses with 9-5 jobs in the it business.......perhaps you have heard of it........the nursing informatics field. i personally know of 2 md's on easy street for their development of medical software on well known products widely used products...............their greatgreatgreat grandchildren will never work outside the home!!!!!!!!!!!!!! ever!!!!!!

the order "titrate to sedation" .......... is not a "bolus" order! i repeat not........a bolus order. i don't care who rationalized this with you......please hear me out........just because they are given through the same piece of equiptment does not....i repeat.....does not make them the same

titrate: specific dose of drug given in small increments "to effect"

bolus: . a large volume of fluid or dose of a drug given [color=#003399]intravenously and rapidly at one time.

anyway. i do thank you for your concern. i just didn't realize there were so many people who have apparently never heard of rns being delegated (with hospital guidelines and protocols) the titration of medications.

chris

you haven't heard one word anyone has said to you, have you? all of this controversy cannot be supported with ignorant people, who don't have a clue, just to be a pain in your backside! everyone has genuine concern for you and have answered your question countless of times. there is something wrong in what your are saying!!!!!!! no one wants to see a new nurse, fresh in the profession, encounter an epic failure. there are alot of bad habits, lazy md's and burned out staff out there.......we know we've been there done that! a flight nurse has more knowledge than you could possibly have at this young stage in your career. i have no idea why i am so involved in this post with a complete stranger? the original post caught my eye as i could not believe what i was reading. either you are not understanding what is being said here or you have given incomplete or inacurate information. titration of medicines is not an order to bolus.......over the years i have a given a "wiff" here and there to say i have not would be lying. in a critical care area there is a lot of opportunity to make huge mistakes with serious ramifications!!!!!!! no one cares about your license but you! if it comes between the md and you guess who will be sacrificed! md's know how to back stroke..............quickly and they have very selective memories!!!!!

really get malpractice insurance it is cheap and you may need it someday....critical care areas sre high risk just by the very nature of the job and because we are independent decision makers! please take under advisement what has been said here....................call the board and ask a rhetorical question..............you maybe suprised at the answer....and everyone is right a rn cannot "bolus" propofol anymore....thank you dr. murray...:twocents:

[Esme12, ASN, BSN, RN]

I have cerner too. Why cant they put in a PRN sliding scale for the drug like for insulin for example and have it q15 or however. Then you can select the med under PRN and then input the amount administered there so you will show what you give on top of everything else.

That is how it should be ordered!~

[sunnycalifRN]

But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.

However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.

My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes and then titrating back down, right? These boluses are delivered slowly, through the pump.

Well, the "by the book" answer is that you're medicating a patient without an order . . . you can only titrate a drip within the ordered range, and I seriously doubt that the order for versed says 1-30 mg/hr!!! So, you cannot go up to 30 for 10 mins. You can rationalize all you want, but you're illegally medicating your patient.

Now, if you get an order to cover the boluses that you give, then you've covered yourself.

But, I've seen what you describe done before . . .

The thing is, if one of your boluses bottoms out your patient's BP and he codes and dies . . . you're toast!