Can I bolus this patient? A legal / practice question about sedatives and narcotics - page 5

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... Read More

  1. Visit  aCRNAhopeful profile page
    2
    And yes I realize the seriousness of the situation and that there is the potential for some severe consequences in regards to poorly documented narcotic administration. All the more reason to give some CONSTRUCTIVE advice about how this high risk situation could be changed without completely tying the RN's hands behind their back.
  2. Visit  ChristopherB profile page
    0
    If this is more of a computer issue due to how orders are done in the computer and problems with entering orders for PRN boluses that the doctors want you to give, then you need to take it up with management and get your informatics/computer departments or people involved.
  3. Visit  phoenixfire profile page
    0
    I know that the hospital I work at says NOT to bolus.. but here's the thing: not every patient will respond the same way to the same sedative. Propofol is what we usually use, but some people don't respond well to it. If your patient is requiring several boluses per shift, and pain control is not helping, maybe its time to switch to a different sedative. Look at your patient history: drug user, takes a lot of pain meds at home, has a chronic pain issue, etc. Same for pain control, some people need Demerol because Morphine doesn't work for them (had this fight recently with a surgeon!). Ultimately, it is YOUR patient, YOUR license... don't risk either on 'what if's', 'probably's', and 'that's the way we've always done it's.
  4. Visit  CrabbyPatty profile page
    0
    Quote from phoenixfire
    I know that the hospital I work at says NOT to bolus.. but here's the thing: not every patient will respond the same way to the same sedative. Propofol is what we usually use, but some people don't respond well to it. If your patient is requiring several boluses per shift, and pain control is not helping, maybe its time to switch to a different sedative. Look at your patient history: drug user, takes a lot of pain meds at home, has a chronic pain issue, etc. Same for pain control, some people need Demerol because Morphine doesn't work for them (had this fight recently with a surgeon!). Ultimately, it is YOUR patient, YOUR license... don't risk either on 'what if's', 'probably's', and 'that's the way we've always done it's.

    I've had numerous patients with suicide attempts who were on lots of psych meds prior to their trip to the ICU; and after being intubated, these people required LOTS more sedation than the "average" patient! The nurse needs to communicate these issues to the MD so that appropriate orders can be written for EACH patient, if standard protocol is not working. If it's nightshift there has to be a hospitalist or other MD in the hospital who can write the appropriate orders. If the appropriate protocols don't exist for things like boluses, then they need to be addressed and written! I'd bring this up to my nurse manager.

    Bolusing sedation, paralytics, etc., without an order is illegal. And Bolusing of Propofol can ONLY be done by an CRNA, Anesthesiologist, or MD.

    And something I was taught in nursing school: If you don't chart it, you didn't do it. So if you don't chart those boluses that you gave, then it looks like you're trying to hide them. Chart them somewhere, even if it's in your nursing documentation under "Pain" or Pulmonary or Surigcal., find a place to chart it to cover your butt if there's ever a future audit.

    Or if you bolused them through the pump, why not pull it up in a syringe from your medication administration system (Pyxis or whatever), draw it up into a syringe and let the pump bolus that amount that's ordered? The you don't end up losing volume from your gtt bag; missing volume from the drip bag could appear to be stolen meds and if you were the RN who had meds missing from her patient's IV gtts, it's most likely going to be blamed on you.

    Getting late here, hope this makes sense.
    Last edit by CrabbyPatty on Dec 6, '10
  5. Visit  chudder profile page
    0
    If I have a pt on a versed or fentanyl gtt, in Cerner I will always ensure that I have a titration dose range under my continuous IV infusion orders as well as a PRN order that will cover my boluses. If I give the bolus from the bag then I chart it as a bolus under continuous IV infusions-- yes, you have to chart it as volume delivered instead of dose delivered, which is unfortunate-- and just make sure that my bag boluses are covered by the PRN orders.
  6. Visit  mushrooms4 profile page
    0
    I would have to agree with the previous comments.... If what you have infusing only works when not stimulating the pt, let the MD know and try to get prn orders to cover the linen changes, suctioning, etc. But, of course, during the moment that the pt is going crazy and attempting to extubate himself, if you need to "quickly titrate" your sedation, by all means do so - but NEVER without letting the physician know, bacause as my cohorts have told you, the MD needs to know the exact amount of sedation that pt requires. They cannot make a correct plan of care without all the info.
  7. Visit  MomRN0913 profile page
    0
    It's not legal, but we all know it's done, especailly if a patient is about to pull the tube and you can't calm him, is bucking the vent, so on and so forth.

    If it is a continual problem you need breakthrough orders, not constant boluses. When this happens and we have a patient on Diprivan (our first line) we usually get orders for Ativan for breakthrough agitation.

    Boluses are usually done and not documented. Should not be done excesively. I would rather get the problem taken care of by adding something else on board per MD order.
  8. Visit  Sari2009 profile page
    0
    There is another serious issue at hand here. Any long time ICU nurse is familiar with "nurse dose" of sedation or narcotic. If a lot of nurses are doing this with a particular patient who is requiring a lot of narcotic/sedation and it is not ALL documented and reported on the up and up the MD does not have an accurate feel for total dosing. This can be a HUGE issue when it comes time for weaning. If they are completly underestimating how much sedation/narcotic a patient has requried that patient can look forward to a whole heck of a lot of withdrawl as they will not be properly weaned. So when we think we are helping a patient stay comfortable it may acutally hurt them in the end....not to mention our professional responsibility.
  9. Visit  NtannRN profile page
    0
    Can I just say OMG, OMG, OMG. Propofol has never been legal here to push even prior to MJ. Not even during rapid sequence intubation. MD only! This whole conversation has me wondering about where I work. Thank You. I am now going to look more carefully and really take s look at our policies. We use Baxter pumps. They're not the best for calculating total volume ,but the work. We have to scan bar codes on all our meds. How do you do that if you're bolusing from the bag? How about trying some seroquel or other antipsycotic ? Haldol anyone? Our docs haven't started entering their own orders yet, but we do have already printed order sets. Thanks again for the food for thought.
  10. Visit  IDoNotGiveOut profile page
    6
    I'm wondering if some of the people with the absolutely shocked and horrified responses have ever worked in an ICU???? If so, on what planet was it located? Sarcasm aside, I agree that there is an issue here, but it is an issue of informatics, physician accountability and nurses willing to accept deficiencies in both of the above. The computer people need to make sure there's an easy way for the doctor to order "bolus from infusing bag" which then gives an appropriate dose range and frequency and thus allows the nurse to legally give and document all boluses. The pharmacy people need to not give the doctors grief when they see such orders because they aren't the ones watching the patient bucking the vent, de-satting, dangerously spiking their blood pressure, etc. Nurses need to refuse to accept a situation where everybody knows it happens and that it's not legal, but they're perfectly happy letting the RN risk her license rather than take two seconds to write an order. The real root of this problem is that the people who develop these systems aren't the ones who actually take care of these patients.

    Regarding propofol, the great thing about propofol is its quick onset and short duration. Those of us that work with adult neurosurgery patients on Q1H neuro exams who d/t their brain injury are completely non-directable and who have strict BP parameters lest they bleed more into their brain and/or have ICPs spiking into the 40s and above when they're awake (at which point there is a risk for brain herniation) know that it is necessary to keep them well sedated in the times in between neuro exams, but they can't have long acting narcotics/benzos because this may cloud their neuro exam. You have to turn the propofol off for ten minutes, get your neuro as soon as they are awake which you will know because you will hear the vent alarming like crazy and the monitor red alarming because their vitals are going nuts, and then rapid bolus them back to happy-land. Wait 50 minutes, repeat.

    On non-neuro patients who are truly only getting 1 daily wakeup, there really is no excuse for the frequent bolusing. Turn up their basal rate if it's not working. Get an order for more narcotics. It's not rocket science - there really is no excuse for that. But on vented neuro patients that must be awoken every hour and quickly re-sedated before you kill them, bolusing of propofol is unavoidable. There is no law or guideline stating that propofol cannot be used this way by trained nurses with a physician order on a vented patient in a critical care unit. If the sedation is being used for a procedure, then it is considered a form of anesthesia. Read the insert to a bottle of propofol and you will see that they do state an anesthesiologist must administer propofol when used only for sedation during a surgical procedure and that this physician must be dedicated to the role of anesthesia and not be the one performing the procedure. But they make exception for sedation of vented patients in ICU, in which case trained RNs may administer propofol (with physician order of course). They do not make any statement prohibiting nurses from administering a bolus of propofol if ordered. Again this only applies to trained nurses, in the ICU, when the patient is intubated, and it's not being used solely for a procedure.
    Regardless, you do need to get an order, even though most of us were trained that it is perfectly OK to do it without an order and without charting (which is the way I was trained by multiple different preceptors) and it seems like a ridiculous thing to call a doc to order for you in the middle of the night. Once the docs start getting enough of such calls, though, I guarantee they'll coincidentally start remembering to order that PRN bolus at the same time they order the gtt.
    To summarize, on certain patient populations blousing may be necessary. People with no real life experience caring for these patients, whether these people are nurses or not, really don't have a clue what they're talking about. The real issue here is nurses not standing up for themselves to insist on a system which allows them to legally practice according to the needs of real life patients in the real world.


    CCL RN, esie, mmutk, and 3 others like this.
  11. Visit  MomRN0913 profile page
    1
    IDONOTGIVEOUT- Right on!!! I agree with you 100%. Why not write the order for a PRN bolus? Really! Most of the MD's know the ICU nurses do this...... Just right the damn order. It saves alot of patients from harm. There isn't time to obtain an "order" for a bolus, you need to act according to that situation right then and there.

    I do also believe someone who has never taken care of one of these patients has no idea. Sit there and watch the patient cough out the tube because you can't get a Dr on the phone fast enough for an order to prevent this from happening......
    mmutk likes this.
  12. Visit  silentRN profile page
    0
    I believe Propofol may be a state by state issue. In Arizona, you can lose your nursing license if you bolus propofol.
  13. Visit  ChicagoICUNurse profile page
    0
    @dh07RN---Is this law only for pts in a non-ICU setting? I am an neuro ICU nurse in IL and we use propofol gtts on our intubated pts. We do bolus them and adjust the rate prn per RASS protocol.

    Just curious.....I'm going to look into the Illinois Nurse Practice Act now. thanks!

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