I'm in 3rd semester nursing and I'm having trouble determing what we need to get a physician order for or what a nurse can do on her own. I had test a Friday and this was 2 questions that I had missed.
1. Pt has TPN infusing single lumen port and Dr. orders say to give Digoxin IVP now. I can always get it down the 2 Possible choices 1. start peripheral line 2. call Dr. The answer was to start line, but I thought I would need to get an order for this.
2. Pt is in shock (I think it was hypovolemic) Dr. orders Lactated Ringers. Do you: 1. call Dr. for rate or 2. start the lactated ringer. I put to start it. I prob. read to much into the question b/c I was thinking I was just started but not fast while I was calling Dr. b/c this poor guy needs some volume.
Is there any unwriten rules that I need to know when making these judgement calls in nursing and for nursing school test!!!
Personally I would have shut off the TPN and pushed the digoxin
From what I have learned in school if someone is getting TPN you never use that port for anything else due to the high glucose content and the extremely high risk for infection. You don't want to open it for any additional reasons than just to change out the bag. Of course I know what we learn at school is sometimes different than real life so I am not doubting what you say. Although knowing the high risk for infection I would prob try to stay away from the TPN port.:)
Thanks everyone for all of your helpful information and you taking the time to answer my post.
What you learned in school is absolutely correct. In fact you use any central line as little as possible because each and every time you open it, it's a risk of infection, whether it is TPN or not. I would have done what the above nurse did, stop the infusion, because in my reality, when IV dig is due, there is much time to stop and start an IV when I've got a full assignment.
I know you're a student, so you go by the book and don't listen to me. But don't be so horrified at us old nurses when you get out there. We have to juggle at lot, prioritize, etc. You hold on to what you've learned and how you've learned them.
I know TPN has a high glucose level, but can you clarify why that precludes us using the port? (Remember I'm old, and open to learn. Thanks.)
Technically, given the MD's order, you should have drawn it up in a syringe with a needle and injected it in a vein--just like heroin
you should never main-line any medication - esp not dig....if you are giving an iv med - you need to have access to counteract that med and/or attend to any side effects it may cause....in dig's case they could easily brady down, heart block etc... i would advise that you NEVER main line any medication as a nurse.
If, in the institution where you are going to school, doing your clinicals, etc. has a policy or standing order ... and that is the "protocol" under which you have been taught, then starting the IV on your own is the proper thing to do. If there is no policy, written protocol, or standing order, then calling the doc to get one is the correct thing to do
this is correct....and check - most hospitals have a policy that pt's on the floor need to have an iv....and i agree w/ the previous poster that if a pt has an iv dig order they should be monitored and should therefore have peripheral access.
I would most definiatly argue both of those questions!!!!!!!!They were vague questions with very poor options to answering them!
And they were so poor they would never make the boards!!!! The instructor who wrote them needs to be challenged.. Without a facility protocol in place you can not make a descion when you dont have all the facts!.
IV Dig Is not an emergency drug, period. as long as you check an apical and follow protocol it is a standard med. The patient is on tpn for a reason, gut rest, inability to swallow so,on. The only time you would need to moniter is if you were cardioverting! basically for nursing school you need an order. In the real world (unit dependent) Once you have been out a while and have a good relationship with the mds use your judgement. always clue the doc in .They always always always miss something in the orders. and we are there to clean it up. make the choice and fill them in. when in doubt call the md
In the case of the shock you are covered under emergency regs. Shock no brainer t berg fluids wide open and warm them up. call md stat.or take verbals from him right there.you did not have enough info provided to you in your questions.they should be thrown out.
The high glucose content in TPN is the reason why you cannot use blood from this line to do a glucose reading, always do a capillary stick. Your pt will not be happy about this as they of course would prefer not to be stuck. Just an FYI to skip that reading when reviewing pt labs, don't panic, give insulin & call the MD. He will NOT be impressed especially @ 3 in the morning !! LOL
Yes I got to see the tail end of this conversation with a Doc & a new nurse...The things they fail to tell us in nursing school.
I suggest always get an order unless nursing measure such as oxygen for sob or something like that better to just me on the safe side let the doc make the call that's what they get the big bucks for:)
you should never main-line any medication - esp not dig....if you are giving an iv med - you need to have access to counteract that med and/or attend to any side effects it may cause....in dig's case they could easily brady down, heart block etc... i would advise that you NEVER main line any medication as a nurse.
this is correct....and check - most hospitals have a policy that pt's on the floor need to have an iv....and i agree w/ the previous poster that if a pt has an iv dig order they should be monitored and should therefore have peripheral access.
Thank you Athomas..I read about the mainlining of Dig and thought WTH!!! That is something I would never do..not even IF the MD told me to mainline it!! Too risky! Beings as I have pretty much either worked with Central lines in home infusion and Oncology or in the ED where pretty much everyone has an IV..I never really thought about the Dr ord er for the PIV..If I had a pt in the ED that the MD said give Dig IV and I said do you want me to start a line? I can only imagine what sort of snide comment I would get... this would be the doc!!
Tweety, BSN, RN
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