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

by simvee

19,758 Views | 77 Comments

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... Read More


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    I see frequent boluses like the author mentions in my ICU as well. If that's what you intend to do you better know who is watching you while you do it. I tend to believe those little boluses are not in our scope of practice in our state.
    CrabbyPatty, Esme12, and carolmaccas66 like this.
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    I understand where the OP is coming from. I find "holes" in the system all the time in which I doubt nursing is completely covered by physician orders. The thing about this situation is that I think almost everyone here is doing almost exactly the same thing when it comes to sedating vent patients in the ICU. Everyone here probably gives boluses of some agent to achieve adequate sedation in a short amount of time. The difference is that some systems are better than others. I can honestly say I have NEVER seen a "sliding scale" titration/bolus guidelines, even though I agree they should all be written so thoroughly. So when people say "I hope my family member never gets care in your hospital" or something similar I find it unfair since there is probably ZERO variation in the way the a patient would be treated in another unit that was lucky enough to have very thoroughly written sliding scale orders. Hence the reason the OP came here for some help in how these orders could be better written and software could be better constructed to document the interventions. Try offering suggestions on how to approach the parties responsible for revising the prewritten orders in the CPOE system before abolutely slamming the OP which many people here have done. It's not like he/she is going to call the doc over the phone in the middle of the night and have them give you a telephone order dictating a sliding scale for gtt titration and bolusing when one has probably NEVER been ordered in that hospital or unit before.
    fiveofpeep and simvee like this.
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    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.
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    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.
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    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.
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    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
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    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.
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    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.
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    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.
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    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.


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