Nursing Dose

[guest449786]

On orientation, at a previous facility, I was told about nursing doses. Normally it involves giving extra narcotic to a person in severe pain. This occurred in a emergent setting where patients would have been ordered Morphine 1mg IV and the dose comes in 2mg vials. The extra 1mg was to be wasted and witnessed. However, if a nurse determined that may not be enough due to the severity of pain, weight, past history, etc., they may decide to give 1.5mg and waste the .5, etc.. I have not heard about it outside the emergent setting, but I'm guessing it occurs in other areas.

Have you ever heard the term "nursing dose"? How do you feel about it? Have you ever given a "nursing dose"?

[Susie2310]

Dranger said:

Yes I have, mostly in the ICU setting with haldol or Ativan in non tubed patients.

Sometimes nurses will run sedation like versed or fentanyl higher for a while as well and drop it back down. Never propofol though.

On the floor it sounds sketchy in the ICU when you want to avoid a 3am call to a sleeping doc it is more common. You can anticipate what they want usually. Is it the correct way? No but it happens

I find this attitude very arrogant, and illegal. If one wants to practice medicine, one should go to medical school.

To avoid a 3 am call to a sleeping doctor, for your own convenience you are willing to practice outside your nursing scope of practice and illegally practice medicine?

Since you are not trained as a physician, how can you or any other nurse possibly know fully why the physician ordered the medication dose as he/she did? Others have pointed out some of the possible consequences for the patient and for the continuation of care of the patient. How can an adverse patient outcome from practicing out of scope of nursing practice in this way be detected and addressed if one has falsely documented that one gave the original dose the physician ordered? Does the nurse who gave the "nurse dose" admit to the physician that he/she exceeded their orders in administering the medication? So, basically, the patient may have an adverse outcome, and the outcome will be attributed to something other than the "nurse dose", and treated as such. This is illegal, unprofessional, and unethical. It is the nurse's duty to obtain appropriate orders for the patient.

[calivianya, BSN, RN]

To my knowledge, I have never worked with anyone who didn't do this. I have never seen anyone actually witness a waste either - except for when we are taking down narc/benzo drips and charting how much was left of the drip. In addition to "nursing dose," I've heard "wasting into the patient."

[AJJKRN]

annie.rn said:

No. Never heard of that expression. I have heard of nurses giving the prescribed dose but then topping it off a little...i.e., if the dose calculation is .85 ml, they'd round it up to 1ml. Like when you add that tiny extra bit of gas to your car to make the price an even dollar amount. This is what I've always been taught was a "AJJKRN" dose but it had more to do with needing to give a small dose in mL's and not having a syringe that was very accurate like a 3cc and you're trying to give 0.25 mL, etc or someone's hulking out and you're just trying to get it close and fast to not get everyone's orifice kicked!

I agree, though, that it's better to bite the bullet and call the doc for an increased dose than to keep chasing your tail trying to give a little extra here and there.

A pet peeve of mine is when nurses give two prn pain meds at the same time. i.e. an IV dose of Dilaudid plus 2 Norco. I was always taught to give one and if on reassessment it has been ineffective, then you give the other. Pts. get upset when I won't do it.

See I was taught to give both, especially when someone's in severe pain because the dilaudid would have a faster onset and wear off quicker and then the PO nor I would hopefully be kicking in in 40+ minutes and be more effective because the Pt's pain wouldn't be so high when they did. How I was taught in pharmacology and it's makes sense to me but I grew up on a surgical trauma floor. I don't see the point in spreading it out and causing more unneeded stress physically and mentally on the Pt's body unless the pain has been reasonably controlled and the norco has been given round the clock and the IVP is just being needed/used every so often for breakthrough. This is why I generally respect the differences in how each individual nurse practices if it happens to be reasonable and within their own comfort, experience, and education and when the Pt ever questions the difference, I don't talk negatively of the other nurse but explain that we all practice somewhat differently.

[AJJKRN]

I did try to break the responses in different paragraphs, guess I didn't pull it off as intended!

[klone, MSN, RN]

calivianya said:

I have never seen anyone actually witness a waste either

Every facility I've worked at, the Pyxis requires a witness in order to waste a narc.

[Kooky Korky, BSN, RN]

Dranger said:

Yes I have, mostly in the ICU setting with haldol or Ativan in non tubed patients.

Sometimes nurses will run sedation like versed or fentanyl higher for a while as well and drop it back down. Never propofol though.

On the floor it sounds sketchy in the ICU when you want to avoid a 3am call to a sleeping doc it is more common. You can anticipate what they want usually. Is it the correct way? No but it happens

do you then get an order at a more decent hour? Or do you all never get an order, thereby practicing medicine without a license? Is your boss or Admin aware of this?

[Kooky Korky, BSN, RN]

I am not saying it's right and I am not saying I do it but the people on this thread that are appalled probably don't work in a intensive care setting where you need to bring people down fast for their safety and healing.

How about the safety of your license?

[Kooky Korky, BSN, RN]

klone said:

Every facility I've worked at, the Pyxis requires a witness in order to waste a narc.

True. But how many of you actually watch a colleague do the actual wasting? A lot of nurses seem to think it's insulting to truly watch their peer really waste something. They just sign that they did, seems like.

[Dranger]

Oh yes all the holier than though nurses are coming out of the woodwork! Instead of using critical thinking skills they go to attacking a license bla blah

Heres an example, sometimes docs write a default order for a fentanyl or Versed drip at 25-50 or 1-10. There are not hard set upper limits for these drugs like Propofol

Docs want patients sedated to a RASS of 0 to -2 usually and if the drip doses in the MAR aren't doing the trick I have see some experienced nurses up them a bit and get the order changed in the AM. If the patient was going nuts of course they would call for for an additional sedative. The patient is on a vent so as long as they are hemodynamically stable and the RASS is goal I have not seen a bad outcome. The goal is to keep patients calm for their own healing then follow up in the AM.

For all those holy and righteous nurses, I am just repeating what I have seen so calm the "arrogance" jiving.

On a side note this is why I went back to Grad school....so I can call the shots and not be stuck in the well you better call the doctor they know what to do world.

[imintrouble, BSN, RN]

I've never heard of it or done it. I've never seen another nurse do it

I'm a very compliant little soldier. I have no interest in wasting my time doing something so flagrantly against the rules.

To put it another way, there's not a single patient I'd put above my license or family, by giving them drugs outside my scope of practice.

All I have to do is call a doc.

There's not single MD I trust enough to cover me if I did.

[calivianya, BSN, RN]

klone said:

Every facility I've worked at, the Pyxis requires a witness in order to waste a narc.

Well, yes, the Pyxis requires a waste, but people just put in their code and peace out. I've never seen anyone stick around or follow anyone else into a room to get proof the waste was really done.

Let me throw out a hypothetical to everyone who would never give additional meds. You have a patient who has been trying to pull out his lines all night despite sedation. You have given everything else you can give and he is asleep most of the time, but occasionally he wakes up and he is nearly able to grab his femoral central line when he does despite wrist restraints. He is currently off the chain, thrashing in the bed and clawing at his gown. You tried to get a safety sitter, but staffing doesn't allow one. You had just called for more drugs and the physician didn't want to give you anything else. You had just given the ordered 0.5mg of Ativan and you might as well have pushed saline. He is on a high-dose heparin drip, so there is a real possibility of him bleeding a lot very quickly if he pulls that central line out. He currently has his hand around the line. You have 1.5mg of Ativan left in that vial, and you can't sit and hold his arms down all night because you have another patient.

Do you let him pull his line and bleed out, or do you give him the Ativan?

[klone, MSN, RN]

Kooky Korky said:

True. But how many of you actually watch a colleague do the actual wasting? A lot of nurses seem to think it's insulting to truly watch their peer really waste something. They just sign that they did, seems like.

Every single time. Besides, how would I put someone else's password or fingerprint into the Pyxis for witnessing?