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

[simvee]

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 propofol with the same order to titrate. Frequently we have specific orders to maintain, say, the Versed at no more than 6 mg/hr, so we do know when the surgeons or other docs want to limit sedative use. But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.

However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.

My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes and then titrating back down, right? These boluses are delivered slowly, through the pump.

The other contention many nurses have is that if you have to bolus, you probably should be titrating up anyway. But I don't really believe that. Say someone looks comfortable on 3 mg/hr, but when you stimulate them they get agitated and their vitals go nuts. I'd rather bolus then, and then let them rest and return to 3 mg/hr. It's that or jack them up to 5 or 6 mg/hr, doubling their dose indefinitely, even though they don't need it for all 60 minutes of every hour. We're not supposed to be anesthetizing these people anyway!

The problem with my approach is that the trauma team will round and see, from the charting, that the patient was comfortable on 3 mg/hr all night and we could possibly turn the sedation off, when in reality they needed a total of, say, 15 mg of boluses on top of that to keep them comfortable and turning the sedation off will lead to a self-extubation or something.

What do you think? I'd ask the docs but most of them are aware and don't care what the legal aspects are as long as patient care is accomplished. I'm afraid to ask the pharmacy because I don't want to get anyone in trouble.

[RNOTODAY, BSN, RN]

your kidding right? this is rediculous. you think its ok to bolus, not have an order for it, and then on top of it not chart it?

i guess the only thing more idiotic then that, would be to actually chart a bolus that you dont have an order for.... amazing....

[Esme12, ASN, BSN, RN]

This post gives me several concerns. I know that we as nurses, especially critical care nurses, at times take literary license for our patients. I know that there are times while "changing a tubing" or "releasing an air bubble" the patient MAY get bolused with pain meds/sedation. That during transport to and from CT some "additional meds" MAY run in "accidentially". That a "nursing" dose of 1mg of haldol can also be 1cc occurs but is never really admitted to openly, not really openly. But some of the OP's questions are concerning especially concerning narcotics. Bear with me....

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 propofol with the same order to titrate. Frequently we have specific orders to maintain, say, the Versed at no more than 6 mg/hr, so we do know when the surgeons or other docs want to limit sedative use. But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.

While bolusing is common practice with pain/sedation gtts to maintain a certain level of sedation or twitch response when using paralytics, there should be an order for such titration. NO order and you are practicing medicine without a license and can get in real trouble!!!!!!!! If you are busted NOT charting boluses because you are not sure if it is within your scope of practice or orders is professional suicide!!!! Just because everyone else does it does not make it right to your bosses, a court of law, or you state licensing board!!!!! What about the narcotic count? If the order is for X and the total that should be given is XX, you have given XXYZ....but document XX................where is YZ? That is a discrepancy of a controlled substance as well as inconsistant/improper documentation/administration of a controlled substance which can cost you your license.....your career. or you job.

However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.

If you are not sure if this is within your scope of practice you need to look up the policy and nurse practice act because ignorance will not save your license or you career. You must have some gut feeling that something is amiss because you are questioning and that is good. Not charting them will not absolve you.

My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes (how many miligrams were delivered?) and then titrating back down, right? These boluses are delivered slowly, through the pump.

No titrating is the slow/methodical increasing of a gtt to achieve a desired outcome over a peroid of time....not jacking up the gtt quickly to get a desired result. Just because they are both delivered through the pump is splitting hairs and manipulating data to suit the behavior.

The other contention many nurses have is that if you have to bolus, you probably should be titrating up anyway. But I don't really believe that. Say someone looks comfortable on 3 mg/hr, but when you stimulate them they get agitated and their vitals go nuts. I'd rather bolus then, and then let them rest and return to 3 mg/hr. It's that or jack them up to 5 or 6 mg/hr, doubling their dose indefinitely, even though they don't need it for all 60 minutes of every hour. We're not supposed to be anesthetizing these people anyway!

If you are having to "Bolus" frequently........I'd say more than 2 times an hour whether or not the patient is stimulated.........the gtt should be increased. Especially in the setting of trauma maintaining a level of sedation is to allow the patient to heal and to decrease stimulation to the brain to diminish swelling and neurological ramifications.

The problem with my approach is that the trauma team will round and see, from the charting, that the patient was comfortable on 3 mg/hr all night and we could possibly turn the sedation off, when in reality they needed a total of, say, 15 mg of boluses on top of that to keep them comfortable and turning the sedation off will lead to a self-extubation or something.

How can good clinical action plans be formulated when the correct information is not available? Are you not deluding the MD's into a false sense of what the patients needs are? I will admit that there are MD's that even if the patient is swinging for the ceiling with the vent tubing and will not order sedation are around thank god they are not prevalent. I still think they should be made aware of the amount of sedation necessary for the patient so sound medical dedcisions can be made. Or are sedation decisions being made for nursing convenience?

What do you think? I'd ask the docs but most of them are aware and don't care what the legal aspects are as long as patient care is accomplished. I'm afraid to ask the pharmacy because I don't want to get anyone in trouble.

It is my experience that most MD's could care less how you endanger your license as it has absolutely no impact on them at all. Do you really think they care if you are throwing your license out the window? All the responsibility is be taking by the nurses especially if there are no orders!!!! What are you thinking? You need to go to the Clinical specialist, trauma coordinator,pharmacy, or nurse manager with a "Hypothetical" question quickly because I think you are in a dangerous situation. In this case "Usual and customary" practice does not apply because you are acting without orders and are practicing medicine without a license.

Sorry for the long post but the are many alarm bells that went off in my head. Dealing with narcotics is a big deal and I am suprised that someone hasn't caught on by now. If other nurses are telling you not to document then they too know they are doing something wrong.......really wrong. Protect yourself. If you got pulled to HR today for improper documentation of narcotics, got fired and ended up infront of the BON..........Would any of those nurses who told you not to document come to your defense? I think not...........for heavens sake, protect yourself. Ask someone in authority these questions that a friend of yours who workers somewhere else said these things and get the real answer.......GOOD LUCK!

p.s. for GOD"s sake........GET AN ORDER!

[Esme12, ASN, BSN, RN]

Do you have electronic MARS? We have to go in and change of rates every time we change a rate. You should be charting what you are doing. Esp with Fentanyl...I'm not sure about the adult world, but we see chest rigidity with increasing Fent sometimes and I sure as heck wouldn't want it not documented that I upped that gtt and something happen...there'd be some explaining to do, that is for sure!

Bitty, this does not happen in adults as profoundly as it does for babies..... But you're right.....you sure would have some fast talking to do!

[RNOTODAY, BSN, RN]

seriously, it enrages me and humiliates me that an RN, new, old, any kind, would actually do this, and then ask on a message board if its "ok" or "legal"

ummm NOOOOO its not, and frankly, I dont care what anybody says about what I am going to say right now: IF YOU EVEN HAVE TO WONDER ABOUT THE ANSWER TO THIS QUESTION, GO DIRECTLY TO YOUR NURSING BOARD AND HAND IN YOUR LICENSE. YOUR NOT FIT TO GIVE OUT A TYLENOL. PERIOD.

A TRAUMA icu YOU WORK IN?????????

[PostOpPrincess, BSN, RN]

seriously, it enrages me and humiliates me that an RN, new, old, any kind, would actually do this, and then ask on a message board if its "ok" or "legal"

ummm NOOOOO its not, and frankly, I dont care what anybody says about what I am going to say right now: IF YOU EVEN HAVE TO WONDER ABOUT THE ANSWER TO THIS QUESTION, GO DIRECTLY TO YOUR NURSING BOARD AND HAND IN YOUR LICENSE. YOUR NOT FIT TO GIVE OUT A TYLENOL. PERIOD.

A TRAUMA icu YOU WORK IN?????????

Are you a troll?

[fiveofpeep]

Im with brett. If you have to bolus more than once during your shift that is an indicator to me that the patient is not being adequately sedated.

PS, I know that bolusing of propofol causes bradycardia, for example, and Ive seen patients completely bottom out their bp after a bolus. Being a more active titrator sounds safer for all.

[Flying ICU RN]

Controlled substances (expecially in gtts) are like explosives, every single milliliter needs to be accounted for lest it "explode" later down the line.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Completely off topic:

For a while, I thought your user name, Brett, was "Me and dragon Brett". As if you were some guy who had a pet iguana named Brett who hung out on a leash with you. Or perhaps you were a gamer of sorts, into fantasy/Middle Earth/whatever, and you had this alternate reality thing going where you had a companion named Brett who was a dragon.

It completely changes my impression of you, that your user name is actually "mean dragon brett".

Huh? Maybe you're more on topic than you think?

[core0]

We have this problem in our SICU. Our order sets have a bolus dose for Ativan and Versed. There is a drip order and a PRN order. For example Agitation bolus ativan 1 mg and increase ativan drip xx per hour. The problem that we have is with Fentanyl and other drips. Some of the nurses would rather bolus from the pump by running it at 999 for the dose. The problem with this is that it creates a discrepancy on the MAR. When the nurse goes to get a refill on the drip it doesn't match. Since these are controlled substances this creates a whole load of hate and discontent resulting in up to and including corrective action. The bottom line is that if you are bolusing you should have an order (and it should be part of the order set). If you are bolusing from the drip then there should be a way to chart it otherwise the bolus needs to be taken from the pixis.

On the other hand in a true emergency I have ordered bolus from the pump (patient eviscerated and bleeding when both the surgeon and I had our hands in the wound trying to stop the bleeding). In that case I put in an order, wrote a communication order and documented the order for the bolus so that the nurse was protected.

David Carpenter, PA-C

[leslie :-D]

1. op, your colleagues sound like a scary bunch.

2. if you haven't already, get yourself some nsg insurance.

i promise you, at some point, you are going to need legal protection.

leslie

[carolmaccas66, BSN, RN]

I'm no ICU nurse, but I have cared for patients after tramatic surgery (ie: cut fingers off etc). We titrate up after the Drs do their rounds and can see the patient's pain score. I have never titrated a patient down before. Bolusing is different as far as I know. Nothing should be done/given unless it is written down by the treating Dr - you can't just up someone's medication or titrate it down without a written order as far as I know - you would be leaving yourself and the hospital open to litigation. In other words, if there is no written record, it didn't happen/med wasn't given, whatever. How do you keep track of how much pain medication the patient has had?

You sound like you don't want to be the one responsible for reporting this. Do you have a number like we do here in Aus to call anonymously for incident reporting? We don't have to say where we are calling from etc. If not, write a letter or type a letter, to your NM or Director of the Medical Staff maybe.

And not charting what you are giving - in relation to ANYTHING not just meds - is a big no, no. I would refuse to do it. I have actually started my own charts on a shift to document things, to cover myself and I would also be writing in the nursing notes what I have done.

Demand an order to be written up for specific titration variation doses. The Drs have to do this. EVERY medication a patient takes in hospital whether it is a narcotic, mulitvitamin or even simple saline eye drops has to be charted, except for RN initiated PRN meds, and they are written on a separate chart by the RN.

[simvee]

I didn't realize this post would cause so much drama. Or animosity.

To clarify: we certainly do have orders to bolus. The trauma surgeons would be angry if we didn't bolus as needed, or if we called them every time we needed to. The problem is that in our electronic MAR (by Cerner Corp) there is no easy way to enter this order, or to document it. In other words:

1. MD says start patient on fentanyl and Versed, titrate and bolus as needed. There are no starting or bolusing parameters. This is totally up to the RN. I am fine with this because the RN who has been there for 12 hours typically knows better than the MD who can only evaluate the patient for five minutes.

2. Whoever enters the order into the eMAR can only select "titrate for sedation". So this makes it appear only titration, and not boluses, are covered. They also have to pick some random dose, say 1 mg/hr, so then when the RN charts that he or she started at 4 mg/hr it pulls up an alert box that says YOU'RE NOT STARTING AT THE ORDERED DOSE! ARE YOU SURE? So stupid.

3. When the RN charts the ongoing titration, THERE IS NOWHERE TO CHART A BOLUS. The software has nowhere to put it, even if the MD managed to enter "bolus as needed" in the order. You can chart volume boluses, say 5 ml. You cannot chart a 5 mg bolus of Versed. Also stupid.

4. Therefore, THERE IS CONFUSION AMONG THE RNs whether boluses are something we can and should chart. Considering you technically can't chart them with the stupid charting software, it's a gray area. I chart them as volume boluses, which accounts for the dose but looks confusing.

5. But rest assured that any RN who got pulled aside and asked on whose orders they were bolusing the patient would have the full backing of the trauma surgery team.

So like I said, what should I do? I guess I could ask the pharmacy and the practice council. They're not going to be able to change the software, though.

The only problem I have with "reporting" this problem is that any possible solution involves removing the freedom the ICU RN needs to operate. What will probably happen is this: the Versed bolus will be entered separately in the eMAR from the titratable drip. We'll have to open that separately to chart those boluses. And the bolus will need parameters, simply to satisfy the computer, even though the MDs never dictate parameters (appropriately so). What will probably happen is that false parameters will be entered by the pharmacy.

Does that make anything more clear?