Dilute Lasix before giving IV?

[guest1139088]

When I give Lasix, I mix it in a 50ml bag of NS, and hang it over 2 minutes. If the patient already has some NS running I just push it over 2 minutes. Good practice?

[LovingLife123]

Do you guys not realize that even oxygen is considered a medication and that you can’t apply or titrate without an order? Do you realize you can’t ambulate a patient without an order?

While many of these are covered by basic floor orders, you still have to have an order. My standard icu orders cover a lot of things, oxygen, IV insertion, SCDs, ambulation, blood pressure parameters, heart rate parameters.... I still have to have an order for all of it.

You cannot decide how to dilute medications. Is it 5mL, 10mL, or 50mL. The OP is even deciding how fast to run it. How are they deciding that? How fast it too fast? We are told in our orders how fast to push a med, is that what the Op is using? Are they deciding that with it diluted? Does that affect how fast it can go in?

It boggles my mind that you all think you are pharmacists and it’s ok to just randomly dilute meds on your own.

[MunoRN, RN]

9 minutes ago, LovingLife123 said:

Yes. Because that’s what my policy tells me to do. To dilute with 15mL of sterile water, then flush with 15mL sterile water. If it’s potassium or miralax, it tells me exactly how much to dilute with as well.

TJC will tell you the same thing.

First, the TJC has no purview over nursing practice. The TJC is a company that can be contracted for CMS accreditation, which means they can interpret and indirectly enforce federal regulations and only federal regulations. Nursing practice is the sole purview of the states, not the federal government. This doesn't mean that TJC surveyors don't act outside of their scope and make comments on nursing practice, but their views are no different than the expressed views of some random person off the sidewalk expressing their views.

There are CMS regulations on order interpretation, which even by the JC's interpretation is that there must be a "common understanding of how the order will be interpreted". This does not require the amount that the amount of dilution be specifically defined in the order or even by policy. If the common understanding of how the order will be interpreted is that the nurse will use commonly accepted practices to determine the amount of dilution required for the crushed medication then that is all that is required by regulations.

There is typically a reasonable expectation by prescribing physicians that the person interpreting the order has some knowledge of the basic practices associated with administering the medication and doesn't have to have someone, or a policy, hold their hand throughout the process.

12 minutes ago, LovingLife123 said:

Do you guys not realize that even oxygen is considered a medication and that you can’t apply or titrate without an order? Do you realize you can’t ambulate a patient without an order?

While many of these are covered by basic floor orders, you still have to have an order. My standard icu orders cover a lot of things, oxygen, IV insertion, SCDs, ambulation, blood pressure parameters, heart rate parameters.... I still have to have an order for all of it.

You cannot decide how to dilute medications. Is it 5mL, 10mL, or 50mL. The OP is even deciding how fast to run it. How are they deciding that? How fast it too fast? We are told in our orders how fast to push a med, is that what the Op is using? Are they deciding that with it diluted? Does that affect how fast it can go in?

It boggles my mind that you all think you are pharmacists and it’s ok to just randomly dilute meds on your own.

That's wildly inaccurate, by your description you're failing to meet the scope of your license.

[JKL33]

2 hours ago, LovingLife123 said:

You cannot decide how to dilute medications. Is it 5mL, 10mL, or 50mL. The OP is even deciding how fast to run it. How are they deciding that? How fast it too fast? We are told in our orders how fast to push a med, is that what the Op is using? Are they deciding that with it diluted? Does that affect how fast it can go in?

The OP example (random lasix piggy-back) is not a good one; it's an example of not using available information.

But there is reasonable information available; typically there has always been a vetted/accepted source of such information for nurses to use in decision-making. It used to be hard copy IV drug handbooks and manufacturer leaflets; now that information is available integrated w/in EMR usually.

There is typically enough info to gauge safe parameters for administering the med. For example, a medication reference might note that the med is not to be given at a concentration stronger than X, or not to be administered at a rate faster than Y.

For example: Here is manufacturer information regarding preparation/administration of levetiracetam loading dose infusion:

Source: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/021872s005lbl.pdf

That contains the information necessary in order to prepare the medication for infusion.

Usually within manufacturer information one can find acceptable diluents and special instructions such as maximum concentration or instructions "do not exceed [specific rate of administration]."

[Horseshoe, BSN, RN]

We are told in our orders how fast to push a med, is that what the Op is using?

I have never in 24 years of nursing had a doctor order a med and direct over what time frame it should be pushed. This is something that a nurse is required to know or to find out if she doesn't know. Just as mentioned in an earlier post, I always look up IVP drugs to make sure I know exactly how fast (or slowly) to give it. Not once did I ever receive an order "give over 2 minutes" or the like. Nor did the nurses call the docs for that information. It was expected that as educated professionals, we would not need to be spoon fed how to practice nursing. If I ever had a doubt, I called the pharmacist, but I can't imagine calling a doc and telling him I can't give the ordered med without an order specifying over what time period to push it. They would probably be highly irritated by that.

[Subee2, BSN, MSN, CRNA]

Nursing judgement...isn't that why we have to take a board exam. Doctor's , with a few exceptions, do not administer the meds. That's OUR job to administer prescribed meds accurately. Good grief. We'd have no ability to manage the patients if someone else HAD to micromanage us just doing our jobs. And, BTW, dilauded is given in PACU's every day IVP. If anyone is too worried to do that, put a 25 g. needle on the syringe and then you have to push really hard to give it too quickly. No IV bags, tubing or other expensive items required.