I was just reading another thread of someone who got accused of diverting because of diluting morphine in a NS bag to administer.
It reminded me of my rules for handling/administering controlled substances.
1) I always unwrap packets in room, whether IV or PO. I want the pt to have NO QUESTION that I'm giving them the right med. I'll leave the wrappers on the counter until next time I make rounds in case they want to sneak a look.
2) I only do a slow IV push for opiate naive pts. For the seasoned user, a faster push gives them the little rush that assures them they are getting the drug they want/need. I do this to instill confidence in the pt that I'm not stealing their med.
3)I always waste immediately unless it's a dire emergency and time is totally of the essence. I'll still bring the empty original container to temporarily leave on the counter.
In short, I'm not here to change the world. If it's ordered, I give it. Controlled substances are treated by me as radioactive materials that can cause me damage.
We can dilute with a 10ml flush. This makes IVP much easier to push those tiny amounts nice and slow. I do my best to not slam them in.
In my current role I feel like I give PO narcs like they are candy. I do my best to educate, educate, educate. People really do not understand that taking these meds long term can have consequences. I also explain reasonable expectations of pain. You should be somewhat uncomfortable after a major surgery. You shouldn't feel like your normal self. Being 100% pain free is not always a reasonable expectation.
Then there are the patients who are suffering from pain, but refuse anything due to concerns about addiction. Again, I do my best to educate.
I have never seen opiates diluted in a mini bag, ours are given IVP either diluted in a syringe or diluted with the running fluids if compatible.
I just had a very good friend of mine fired from a job and is being investigated for diversion. This RN followed the protocol shown during preceptorship and although apparently other RNs followed the same protocol it was incorrect and now the hammer is dropping. I feel horrible for my friend. Stories on here about diversion accusations and Pyxis screw ups make me nervous, i'll admit. I personally think it would be a great idea to have a camera in the med rooms to cover some of these incidences. I follow waste protocols to the letter, but I still feel like they can ruin you somehow (yeah the stories have made me a smidge paranoid!)
Wanted to add, our push opiates have to be drawn up in the med room per protocol. If there's a waste we have to draw up the entire available amount and squirt out our waste in front of the witnessing RN before even going into the patient's room. We would have our butts handed to us if we drew up these meds in the patients' rooms so there's no way we can draw up in the presence of the patient.
That's a minor pet peeve of mine. I'm constantly having to explain to patients that they are not supposed to feel a rush ....and that if they have been feeling one, that means their medication has been being administered too quickly.
I know I had IV push meds while hemorrhaging from an ectopic pregnancy in the ER, but I can't remember if it was fast, slow, or what. I wasn't screaming (that I remember), but I was in a lot of pain and I remember being treated. I would say this is what matters to someone in severe pain.
We would give narcs diluted in a 10cc flush and put on a syringe driver. If we felt the patient was a tad unstable we might put it in a 50cc bag just to slow it down some. We rarely push narcs because post op open heart patients cannot tolerate it. I've been given IV push narcs in the ED and nearly stopped breathing so it's made me conscious of not doing the same to someone else. Really, it's a nursing judgment call. What happened to allowing us to use our professional nursing judgment?
I always dilute in a 10 cc flush, and if they have a compatible main running i still dilute then push through the main. I also always dispose of vial right after administering it. However that being said, the majority of my patients are usually on a fentanyl drip so IVP push opiates are generally a means of controlling other symptoms.
I know I had IV push meds while hemorrhaging from an ectopic pregnancy in the ER, but I can't remember if it was fast, slow, or what. I wasn't screaming (that I remember), but I was in a lot of pain and I remember being treated. I would say this is what matters to someone in severe pain.
Yeah, you're not the type of patient being discussed here. These patients notice if it's "fast, slow or what" because they're looking for the rush ....sometimes along with pain relief, but often not.
I've had two (over seven years) come back clean and tell me they never had any pain at all- despite setting their alarms for Q3 dilaudid during all of their many hospital visits (one has since relapsed). And these drugs do have safe administration rates, regardless.
Why do so many of you mix it with NS ahead of time? I push a flush behind it to make sure it all goes in, but why would you dilute it ahead of time? We only do that on medications that can be a vesicant. I want to hear the rationale from somebody first. I think I know what people are thinking, but I need to know for sure. I think that rationale is wrong.
To me, unless specifically instructed to mix a med in NS, it is a med error and should not be done. All of our orders specifically state when to mix a med with NS. And how much. And the most we ever mix with is 3mL, not 10mL. That is for vesicants. I will have instructions for reconstructions to mix 10mL.
I think i understand the thought process, but, it's misguided for several reasons.
You can't make somebody a drug addict by administering some fentanyl or hydromorphone for a few days. That's not how it works. You are not contributing to the drug problem by giving meds IVP. We in the medical community especially should grasp addiction better.
Why do so many of you mix it with NS ahead of time? I push a flush behind it to make sure it all goes in, but why would you dilute it ahead of time? We only do that on medications that can be a vesicant. I want to hear the rationale from somebody first. I think I know what people are thinking, but I need to know for sure. I think that rationale is wrong.
To me, unless specifically instructed to mix a med in NS, it is a med error and should not be done. All of our orders specifically state when to mix a med with NS. And how much. And the most we ever mix with is 3mL, not 10mL. That is for vesicants. I will have instructions for reconstructions to mix 10mL.
I think i understand the thought process, but, it's misguided for several reasons.
You can't make somebody a drug addict by administering some fentanyl or hydromorphone for a few days. That's not how it works. You are not contributing to the drug problem by giving meds IVP. We in the medical community especially should grasp addiction better.
In some locations its taught and customary to dilute. The biggest advantage I can think of it that it allows the actual drug to be pushed closer to its safe administration rate. It's difficult to push 0.5ml over three minutes, for example.
There is a segment of the population that can become addicted to these drugs very quickly, although certainly not everybody.
Why do so many of you mix it with NS ahead of time? I push a flush behind it to make sure it all goes in, but why would you dilute it ahead of time? We only do that on medications that can be a vesicant. I want to hear the rationale from somebody first. I think I know what people are thinking, but I need to know for sure. I think that rationale is wrong.
To me, unless specifically instructed to mix a med in NS, it is a med error and should not be done. All of our orders specifically state when to mix a med with NS. And how much. And the most we ever mix with is 3mL, not 10mL. That is for vesicants. I will have instructions for reconstructions to mix 10mL.
I think i understand the thought process, but, it's misguided for several reasons.
You can't make somebody a drug addict by administering some fentanyl or hydromorphone for a few days. That's not how it works. You are not contributing to the drug problem by giving meds IVP. We in the medical community especially should grasp addiction better.
I don't understand the thought process behind why one cannot dilute a medication with NS. For example if i Y site two compatible medications, isn't this technically diluting as well? for example if i have fentanyl running with NS, what is the difference between this and diluting the fentanyl IVP?
Why do so many of you mix it with NS ahead of time? I push a flush behind it to make sure it all goes in, but why would you dilute it ahead of time? We only do that on medications that can be a vesicant. I want to hear the rationale from somebody first. I think I know what people are thinking, but I need to know for sure. I think that rationale is wrong.
To me, unless specifically instructed to mix a med in NS, it is a med error and should not be done. All of our orders specifically state when to mix a med with NS. And how much. And the most we ever mix with is 3mL, not 10mL. That Editis for vesicants. I will have instructions for reconstructions to mix 10mL.
I think i understand the thought process, but, it's misguided for several reasons.
You can't make somebody a drug addict by administering some fentanyl or hydromorphone for a few days. That's not how it works. You are not contributing to the drug problem by giving meds IVP. We in the medical community especially should grasp addiction better.
Many drugs come with suggestions to dilute in solution when giving it IV Push. You don't need an order to do that, and it is certainly not a med error to do so.
Take Morphine for instance:
IV Administration
IV: Solution is colorless; do not administer discolored solution.
IV Push: Diluent: Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection.Concentration: 0.5–5 mg/mL.
Rate: High Alert: Administer 2.5–15 mg over 5 min. Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.
Continuous Infusion: Diluent: May be added to D5W, D10W, 0.9% NaCl, 0.45% NaCl, Ringer's or LR, dextrose/saline solution, or dextrose/Ringer's or LR. Concentration: 0.1–1 mg/mL or greater for continuous infusion.
Rate: Administer via infusion pump to control the rate. Dose should be titrated to ensure adequate pain relief without excessive sedation, respiratory depression, or hypotension. May be administered via patient-controlled analgesia (PCA) pump.
I have accompanied my brother to his pain management appointments and they are always very quick for him, then my education with the doctor begins. I always advocate for pain management for my patient, but I also advocate if a provider uses Dilaudid front line. This PM M.D. has educated me that Dilaudid resets the pain receptors, not only does it increase tolerance, it actually heightens the pain response so initial pain level is higher than pre-Dilaudid. You screw up their pain management for life by giving it. I saw this first hand (how I got the info) when my wife had a high grade fracture that was treated with Dilaudid. Percocet used to be more than enough, now it doesn't touch her.
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loriangel14, RN
6,933 Posts
We use it for pain relief. For me it's mostly post op if they have no PCA.