Sometimes, if the census is low at our clinical site (rehab/LTC), our instructor will not assign us a patient. Instead, we take over "all the CBG/insulins" or "all the blood thinners" for the facility for that shift. Then, we are each given a yellow sticky with a list of patient room #s, names and a drug.
For diabetics, it is more straightforward. Check the sugar, look at the sliding scale and scheduled dose in the MAR and give the insulin.
But today I had Lovenox for a man and it is a higher dose than I've ever given: 70mg BID. Furthermore, the last 3 doses were not recorded on the MAR. We pointed it out to the assigned RN, and I assume they will investigate.
I really didn't understand why his dose was so high and his chart was MIA. He was in the center for rehab from a BKA but the surgical site was healed. The patient was also up in a wheelchair. No diagnosis on the MAR of DVT or PE, which were the only conditions my drug book indicated doses this high for.
My instructor is very nice, but also very passive and never wants to make any waves. So she had me give the injection.
It bothers me because I didn't know why I was giving the med. 30-40mg, OK-- DVT prevention. She didn't have an answer other than "they've been giving this dose for a month, so it must be correct". Well, technically, they didn't give the last 3 doses and he had some bruising, so I was thinking maybe it was held because they were afraid of bleeding--but no note or explanation given in the MAR for the blank fields.
As I thought more about how we were working, it bothers me that I'm just running injections around like a trained monkey and not seeing any kind of big picture, which makes me feel unsafe.
Anyone else have a clinical that works this way? Does it bother you? I'm thinking next time we do this drill I'm going to put my foot down (I make waves) and say that I can't give a med unless I know what the patient's issues are and why they are getting it (and why there are discrepancies, if that is the case).
Jul 16, '13
When we did not have patients, we would do some patient care with one helping and then we would do another activity. My instructor refused to take the floor.
Jul 17, '13
He might have had a heart condition, in which that dose may be acceptable, because it is a 1mg/kg q 12hours. You said the chart was lost, so you may never know. The BKA might have increased his usual dose if he did have a heart problem.
I never have a clinical like this. We always have patients and are required to know them inside and out before even looking at them. It would bother me that they are freely giving injections, but as you said, they cannot make you and you shouldn't without first knowing why.
Even if they did hold the med on purpose, there should be a reason why on the MAR, as you said. I guess I just don't understand the system they are using. Why do you have his MAR sheet but no chart? Do they just take out all of the MARs and pass meds like that? Do all of the meds specifically state what the meds are for on the MAR? Maybe he did have a DVT, but if they don't mark what the med is for on the MAR, you might not know. You would know if he had a PE...
As you, I have some questions of this facility. Maybe next time you go there, ask the RN about the patient information instead of your instructor. But as you said, without any evidence as to why you should be giving a med, don't do it. It will only hurt yourself.
Jul 17, '13
If we had low pt load, we'd either team up 2 students to a patient (and believe me, that pt got hotel-caliber treatment with two students fawning over them!) or we'd have little assignments--like looking up meds and presenting on them in postconf, or reciting how to start an IV. Sometimes we'd get busy work (like checking glucose for everyone, reading through the chart and answering questions, or doing pharmacy runs) but usually it wasn't too bad.
It is a shame that your instructor seems to be taking the "meh. just follow the orders" path. I had an instructor who did that, and I was very upset that whole semester. Early on, I'd be kind of pushy ("but WHY are we giving this med?") but eventually I backed off bcs I realized I was just making myself look bad in her eyes, and it wasn't changing anything. Hopefully you'll have an opportunity to look through this patient's chart in a future clinical? I cannot imagine acting without having reviewed the chart first.
Did the assigned RN have anything to say when you told them?
Jul 17, '13
She seemed embarassed that the MAR was blank and just said she'd look into it
Jul 18, '13
Huh we aren't allowed to give medications unless we have direct supervision from an RN, as in they are eyeballing us doing it.
Jul 18, '13
Yes, my instructor is an RN and she was with me
Jul 18, '13
70 mg of Lovenox seems like a completely reasonable dose to me. The last patient I had on lovenox was a teenage girl and that was her dose. The dose I've typically seen used is 1 mg/kg q 12hr so that's likely what you were seeing here.
Jul 19, '13
you were right to question it. The instructor sounds lazy for not getting to the bottom of it, and making an "assumption". Sorta like the phrase "well, if everyone else jumps off the cliff will you jump too?" The nurse is the patient advocate and that is what you were trying to do. When you are licensed you will remember this incident and make sure the students are aware so everyone learns. Good for you!
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