Right or wrong? Need some advice - page 4

by Miknsha

4,335 Views | 39 Comments

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... Read More


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    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.
    Miknsha and Liddle Noodnik like this.
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    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.
    Liddle Noodnik likes this.
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    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.
    Liddle Noodnik likes this.
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    Quote from Dafabb
    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.
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    Quote from Miknsha
    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 likes this.
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    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!

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    Quote from Miknsha
    I appreciate everyone's feedback :-)
    I think you are doing a great job holding up under some kinda rough criticism on this thread lol.. I am glad you asked the question, it's helpful for all of us!
    Miknsha likes this.
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    lol thank you :-) a little criticism is great especially from seasoned nurses who have been there done that kinda thing and if I get picked on in the process well.... goes with the territory I s'pose lol was really frustrated the day I posted this ....the issue has now resolved itself I am very happy to say!
    nursel56 likes this.
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    As long as it's less than halfway between doses, it should still be given.
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    Sorry...I had to chuckle or LOL on this response. If I had to call the doc with every late med (In LTC) I should just sit at the desk and forget about passing the meds in the first place.

    The med was a once a day med..two hours wasn't going to hurt. What was the risk of not giving the med? Patients have appts and are always on and off of the floor. Try calling the doc every time a med is late because of this one.






    Quote from morte
    This is why I think the LPN is stuck in LPN/LTC land. In LTC, she would have to call doc and get an order to give it late, so that if the state audited that chart, they wouldn't get a "ding".


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