Can I bolus this patient? A legal / practice question about sedatives and narcotics - page 6

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  Esme12 profile page
    0
    Quote from ChicagoICUNurse
    @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!
    I beleive the restriction is bolusing propofol is mandated for patients to be on a vent and the bolus administered through a pump only and only in a critical care setting. The "bolus" restricted for use by non trained personel is the IV push "bolus" if not in the ICU setting. Most states allow nurses "specially certified" in certain situations to give IV boluses (IV push) only if patient 1:1 monitored with MD IN THE ROOM......like in endoscopy in doses consistant with "conscious sedation" and anesthesia "stand by". Hospitals are notorious for saying something is illegal when it is forbidden by their facility.

    So still check your states guidelines and regulations.......
  2. Visit  mmutk profile page
    1
    I agree with the WHAT PLANET ARE YOU FROM if you do not give an occasional bolus or quick temp titration for your drips when your patient needs it. As long as you have a titration orders it's not a big deal.

    If someone was taking care of my mom I would hope if she needs a quick fent dose prior to a bath or something she could get it.
    CCL RN likes this.
  3. Visit  Esme12 profile page
    0
    Quote from mmutk
    I agree with the WHAT PLANET ARE YOU FROM if you do not give an occasional bolus or quick temp titration for your drips when your patient needs it. As long as you have a titration orders it's not a big deal.

    If someone was taking care of my mom I would hope if she needs a quick fent dose prior to a bath or something she could get it.
    I agree, Of course we have all given that brief wiff of med to ease through a tough spot...... but at some point a descrepancy will occur then how do you account for the lost narcotic. Titration orders are not bolus orders......I know what is done but just the same. The practice here from the OP's statement gave me an impression of excessive use and negligent documentaion which for me accumulated in narcotic descrepancy.
  4. Visit  armyicurn profile page
    0
    Quote from Esme12
    Ok it sounded harsh...............but I really mean this from the bottom and top of my heart........this practice is not good......please call you BON and ask that rhetorical question...........thanks

    Well....NO. It was NOT harsh. Your post (#27) was proper and basically meant to open the OP's eyes.

    There are clearly some serious and very dangerous issues in that ICU/hospital. The manager of that unit needs to get fired for sitting on their ass and not spot checking his/her unit. Seems like there is not a chart audit/PI program in place.

    I would have blown a gasket if my coworkers told me not to chart the narcotic boluses! WTH/W*T*F* are these idiots thinking???

    I've worked too damn hard to get my license and I have promised myself that when I die, I will be taking it to the grave with me.

    The OP needs to get management involved to include IT. If that crappy software can't let you add customized fields, then get rid off it and get a better program. And get the director involved as well. Never trust a doc. Just b/c they bring you breakfast everyday, does not mean they will cover your ass. They will sell you as fast as you can blink.

    Good luck.
  5. Visit  picurn1972 profile page
    0
    dont you have to do totals every hour? Any doc sees the volume which is off the pump and knows how much the pt got. At least all our SICU attendings did. second in peds yes you chart the time of the bolus, but in adults you chart the score of the scale you used to bolus then a post assessment. How would you defend yourself in court without record of the symptoms/scores on which you based your bolus's. That is why you bolus and titrate up. Pts are stimulated every hour or two. Do you want to be intubated and be awake or appropriately sedated?
  6. Visit  RW23RN profile page
    0
    Interesting debate. I had the same problems with Cerner-maybe the bolus should be a seperate PRN order so we can chart them appropriately. At my new hospital, all of our patients on narcotic drips have PCA pumps, if they are on a vent and sedated (usually with propofol here), they have a basal and a bolus order with no demand settings. That way all of our boluses are recorded and accounted for on the PCA. Its a very small oncology ICU though and its not feasible to do that on a large scale. But it has made me more conscious of my boluses. Although, I've seen nurses accidently type in 1000 mcgs of Fentanyl instead of 100...just CYA whatever you're doing cause no one else is going to do it for you!
  7. Visit  CCL RN profile page
    2
    Quote from IDoNotGiveOut
    .
    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.
    ]

    I've worked in a few different ICUs, in 2 different states, and bolusing from the bag; without charting, and without orders (other than titration) is *always* how its been done. By all the nurses. In all the hospitals.

    A quick 25 mcgs of fent prior to suctioning, or a quick versed bolus before a trip to CT is perfectly fine. If it's due to a need for increased sedation then they get a bolus along with a rate increase. Ive done it in front of the MD, pharmacy, my nurse manager...in fact, we worked with pharmacy and our smart pumps to set bolus limits on the pumps.


    Everyone needs to chill: Good-freaking-grief!!
    Last edit by CCL RN on Oct 8, '11
    MomRN0913 and mmutk like this.
  8. Visit  mmutk profile page
    0
    I have never heard of Propofol on a PCA?! Does anyone else do that?
  9. Visit  Esme12 profile page
    0
    Quote from mmutk

    I have never heard of Propofol on a PCA?! Does anyone else do that?

    There are some facilities that are placing these meds on PCA pumps to regulate and account for these high abuse meds. The pumps are NOT used by the patient. They are set at a basal rate with the "boluses" administered by the staff at a pre-set amount to end the casual "just a touch" for suctioning. The patient does not self administer....they are for narcotic control on usage and waste.
  10. Visit  FCMike11 profile page
    1
    Just an example. Nurses in my icu will bolus 3 ml or so of propofol for an agitated situation like you described an in front of the pulmonologist at some point mentioned she had to "give the patient some love". End result physician freaked an now no longer will allow propofol drips on his intubated patients(its hell).

    Of course its wrong, dont do it, ive seen in surgery the CRNA wouldnt (cant? Idk) push the propofol, was passed to the anesthesiologist to push.
    Esme12 likes this.
  11. Visit  aCRNAhopeful profile page
    1
    Quote from FCMike11
    Of course its wrong, dont do it, ive seen in surgery the CRNA wouldnt (cant? Idk) push the propofol, was passed to the anesthesiologist to push.
    That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it just needs someone with advanced airway management skills to push it in a non-intubated patient (something that a CRNA, Anesthesiologist, or AA all possess).
    Esme12 likes this.
  12. Visit  FCMike11 profile page
    0
    Quote from aCRNAhopeful
    That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it just needs someone with advanced airway management skills to push it in a non-intubated patient (something that a CRNA, Anesthesiologist, or AA all possess).
    Right exactly why I tried not to assume much, maybe I wasn't looking that specifically and the MD just happened to be closer to the iv site. Main reason I noticed he walked in at the beginning of the case, pushed propofol then immediately left.
  13. Visit  Esme12 profile page
    0
    Quote from aCRNAhopeful
    That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it that a CRNA, Anesthesiologist, or AA all possess).
    I agree.......sounds like someone got caught with their hand in the cookie jar......


Nursing Jobs in every specialty and state. Visit today and find your dream job.

Top
close
close