Right or wrong? Need some advice

Ivanna_Nurse, BSN, RN · Jul 3, 2012

What did the lpn/fellow student propose that you do? Not give it? Ivanna

Miknsha · Jul 3, 2012

It was our first time on that floor and a new pt....we dont get our pts in advance :-/

Ruby Vee, BSN · Jul 3, 2012

i am currently an rn student doing med-surg clinicals (5th quarter). there is a patient who is to receive vanc. through a picc and it is scheduled for 9am. however last week he had an appointment and was gone by 8:30, we were not informed of his impending departure until 8, and by then it was too late to start the infusion as it hadn't been taken out of the fridge yet and is scheduled to run over an hour. the issue i am having is that upon his return at 11:30ish, our instructor said it was ok to give it, even though it was late, and without the dr.'s approval, although she stated that she had spoken to the np who was at the facility and that it was approved, no order was written in the chart. our instructor (who has an msn) gave it anyways. another student and i are arguing on whether or not it was an acceptable thing to do, and we can find nothing in the npa, or the bon websites that will help. was she wrong for doing this? we are considering going to our nursing chair at school, but obviously do not want to look like idiots if this was acceptable. any input would be greatly appreciated.

since you're an "rn student," i assume you're an rn working on a bsn? given that's the case, i don't understand why this is such an issue. the med was due at 9am, and your patient wasn't available at 9am. it was given an hour and a half late (because generally you're given a window of an hour before and after the due time). vancomycin is an antibiotic (i'm assuming that's what you meant by "vanc.") and it's usually given every 12 hours. so you give the next one a little late -- say 10pm. sometimes it's due every 24 or even 48 hours. if either of those was the case, it's really no biggie. would you rather skip the dose? if it was due every four hours, i understand the issue. but vancomycin isn't given that frequently.

i cannot even begin to comprehend why you would go to your nursing chair at school. are you dreaming of reporting your clinical instructor and getting her into trouble? if that's the case, not only are you going to look like idiots, you will actually be idiots. you will also be bullies and backstabbers.

morte, LPN, LVN · Jul 3, 2012

ruby, in a later clarifying post the op said she agreed with what the ci said, it was the class mate that was having a fit. the idea of going to the chair, i am thinking, was to straighten out the classmant.

since you're an "rn student," i assume you're an rn working on a bsn? given that's the case, i don't understand why this is such an issue. the med was due at 9am, and your patient wasn't available at 9am. it was given an hour and a half late (because generally you're given a window of an hour before and after the due time). vancomycin is an antibiotic (i'm assuming that's what you meant by "vanc.") and it's usually given every 12 hours. so you give the next one a little late -- say 10pm. sometimes it's due every 24 or even 48 hours. if either of those was the case, it's really no biggie. would you rather skip the dose? if it was due every four hours, i understand the issue. but vancomycin isn't given that frequently.

i cannot even begin to comprehend why you would go to your nursing chair at school. are you dreaming of reporting your clinical instructor and getting her into trouble? if that's the case, not only are you going to look like idiots, you will actually be idiots. you will also be bullies and backstabbers.

Ruby Vee, BSN · Jul 3, 2012

ruby, in a later clarifying post the op said she agreed with what the ci said, it was the class mate that was having a fit. the idea of going to the chair, i am thinking, was to straighten out the classmant.

going to the nursing chair to "straighten out the classmate" still seems like the move of a bully or a backstabber. why not just let the clinical instructor straighten her out if she needs straightening?

Miknsha · Jul 3, 2012

To straighten everything out lol My classmate was wanting to go to the chair in I am assuming hopes of getting her in trouble, my classmate and I got into a very heated "discussion" about this issue where I was trying to convince her that our instructor did the "right thing" by giving the med even though it was late. I get along great with my instructor however my classmate argues incesently with her :-( there are just a very few of us in the class...ie me and her and I don't want her ignorance to jeapordize me (yes selfish but I'm busting my butt here...as all of you may remember from when you went through nursing school) I have managed to convince her that if she is having a problem with the instructor she needs to go to her first before trying to go above her head. I appreciate everyone's feedback :-)

Dafabb, LPN · Jul 6, 2012

Once you have master the knowledge on Vanc it will be easier. The initial order is written by the Doctor to give Vanc. He might put a dose on it or he might do what most do and give the Pharmacy the control over administration. They have to have his weight and whatever protocol says to send to start the dose. Pharmacy then will have it timed each day. Usual q 24 hr. Of course some cases more often. (Scenario)If you give the first day on time and find something holds the 2rd day up say 4hrs(pending appt). When he returns you give him that dose(late or otherwise)You then call the Pharmacy and inform the Pharmacist that his 2nd dose was late D/t.appt. The pharmacy will then adjust the time of the next dose to be given on the 3rd day along with what time is scheduled for the trough. The trough is usually done 30 min. prior to 3rd dose. If too much time has passed they might also wait until the 4th dose to do trough. You do NOT need a Drs. order for the change. The pharmacy is the controller here and they are the ones you keep informed. If there is any calling to be done the Pharm. will call the Dr. The Pharmacy will also write all consecutive orders if needed. Your instructor gave you the right instructions. That's one headache they have kept us from having to do. Hope this helped.

Dafabb, LPN · Jul 6, 2012

Vanc is one of those meds that has to be timed out correctly. I did write you the protocol for Vac i think on pg 4...)) Your nurse friend was wrong in her statements. Now for any reason that Pharmacy does NOT do the scheduling and dose in your area then you are left to take up the slack and call the Dr and get all orders and inform pharmacy. But I haven't seen that done in 20 yrs. Again your instructor was right. Make a short note to explain the change in time so everyone will not have to wonder or accuse.

canned_bread · Jul 6, 2012

I was taught at nursing school that most meds should be given an hour each way. Some meds (such as insulin) timing is crucial, ie around meals, but most meds it's fine.

The importance is in the HALF LIFE and frequency of dosage.

KelRN215, BSN, RN · Jul 7, 2012

Once you have master the knowledge on Vanc it will be easier. The initial order is written by the Doctor to give Vanc. He might put a dose on it or he might do what most do and give the Pharmacy the control over administration. They have to have his weight and whatever protocol says to send to start the dose. Pharmacy then will have it timed each day. Usual q 24 hr. Of course some cases more often. (Scenario)If you give the first day on time and find something holds the 2rd day up say 4hrs(pending appt). When he returns you give him that dose(late or otherwise)You then call the Pharmacy and inform the Pharmacist that his 2nd dose was late D/t.appt. The pharmacy will then adjust the time of the next dose to be given on the 3rd day along with what time is scheduled for the trough. The trough is usually done 30 min. prior to 3rd dose. If too much time has passed they might also wait until the 4th dose to do trough. You do NOT need a Drs. order for the change. The pharmacy is the controller here and they are the ones you keep informed. If there is any calling to be done the Pharm. will call the Dr. The Pharmacy will also write all consecutive orders if needed. Your instructor gave you the right instructions. That's one headache they have kept us from having to do. Hope this helped.

This is something that varies widely by facilities. When I worked in the hospital, pharmacists didn't write orders and they had no control over the dose of medication that the patient got. Everything was weight based (pediatrics) and the pharmacy could reject an order if it wasn't in a "safe" range but they didn't decide on doses by any means. The MD or the NP had to order the dose.

I've given Vanco as frequently as q 6 hr (usually at this particular facility was q 6 - q 8hr) and as infrequently as q 48 hr (for patients with renal impairment who had ridiculously high trough levels).

The pharmacy also had nothing to do with the timing of the meds after the initial order. Actually, everything was auto timed in the eMAR and it was a nursing responsibility to retime anything. For example, if a med was ordered at 9:52 PM for q 6hrs, the system would automatically time it to 10, 4, 10 and 4. If something was ordered at 9:52, what are the odds the med would be in hand from the pharmacy to give a 10:00 dose? ZERO. It would likely be 12:00 at the earliest that the first dose would be given and nursing would simply retime the med for 12, 6, 12 and 6. Pharmacy would see that it was retimed when they looked at when they had to make the next dose but they wouldn't be involved in this at all.

If the situation the OP described happened at my hospital, I wouldn't have called the doctor or the pharmacy. I would have given the med when the patient returned and retimed the next dose if necessary.

Hay, RN · Jul 7, 2012

We are considering going to our nursing chair at school, but obviously do not want to look like idiots if this was acceptable.

It was acceptable - for all the reasons posters before me have explained.

Liddle Noodnik · Jul 7, 2012

I would give it, write a note in the chart and also the back of the MAR, I would also make sure there were no peak/trough labs in the near future that might be affected by it being given late. Since it's daily I probably would not change the schedule, but I'd pass the info on to the next shift, at which time sometimes a 2nd opinion may be given

edited to add: I appreciate the additional education re Vanco peak/trough/ pharm involvement and it was very helpful, thanks guys!

:)