heparin flush and giving morphine pulse o2 86%

[puddingpie]

I work in LTC per diem.

I had NO order to flush the peripheral line with heparin and therefore did not and refused to do so.

The nursing supervisor then wrote in the orders "flush line with heparin" "(SASH).

Later, found out that the pt. is also on coumadin.

I asked, where is the policy and procedure book in relation to flushing lines, it was not produced either. I was then told that in LTC this is how we do it, this is not a hospital.

I just want to know, is this right?

Are Peripheral lines flushed with 5ml of (100units/ml) of heparin?????? I thought only PICC and central lines.

Peripheral lines are SHORT TERM not long term and can be maintained with Normal saline, RIGHT?????

I also, witness the nurses writing there own medical orders and later having the MD sign them.

I refuse to do that also, I will only write an order if I received it from the MD even as simple as tylenol or maalox.

I also received an order from a MD to give 1mg of morphine to a pt with pulse O2 of 84-86% room air.

I refused to give that also, when I stated to the unit manger that it woud depress her respirations even more, she disagreed.

They later gave the morphine after I left and the pt. died.

I heard one nurse state that is was for the pain, but the pt. was not in pain and another then said, it was a mercy killing.

So, yesterday, I had a patient on comfort care he denies pain but, I was told to give her Roxanol PRN and they kept saying it, as if I was not going to look it up- IT"S MORPHINE! This is against my morals and values I do not believe in mercy killing although I try to understand the views of others, it is not my place to decide.

[UM Review RN, ASN, RN]

True, a peripheral line can be maintained with a 3 ml NS flush. We don't use heparin for peripheral lines any more.

As for the rest, in good conscience, I would not be able to work there. I would probably have to turn the place in.

[jmgrn65, RN]

i work in ltc per diem.

i had no order to flush the peripheral line with heparin and therefore did not and refused to do so.

the nursing supervisor then wrote in the orders "flush line with heparin" "(sash).

later, found out that the pt. is also on coumadin. flushing a line with heparin generally isn't enough to interfere with coumadin. we used to flush lines with heparin all the time 3 ml. but there should have been order for whatever kind of flush.

i asked, where is the policy and procedure book in relation to flushing lines, it was not produced either. i was then told that in ltc this is how we do it, this is not a hospital.

i just want to know, is this right?

are peripheral lines flushed with 5ml of (100units/ml) of heparin?????? i thought only picc and central lines.

peripheral lines are short term not long term and can be maintained with normal saline, right?????

i also, witness the nurses writing there own medical orders and later having the md sign them.

i refuse to do that also, i will only write an order if i received it from the md even as simple as tylenol or maalox. lots of places do this if they know the md will cover it or doesn't care. i will do for a lot of our docs.

i also received an order from a md to give 1mg of morphine to a pt with pulse o2 of 84-86% room air.

i refused to give that also, when i stated to the unit manger that it woud depress her respirations even more, she disagreed.

they later gave the morphine after i left and the pt. died.

i heard one nurse state that is was for the pain, but the pt. was not in pain and another then said, it was a mercy killing.

this is not necesarrily a mercy killing, the morphine would have relaxed and help the pt breathe easier. 1 mg morphine isn't going to kill someone, i don't think she died because of the morphine. not when patients take 10mg at one time and i have seen alot more than that.

so, yesterday, i had a patient on comfort care he denies pain but, i was told to give her roxanol prn and they kept saying it, as if i was not going to look it up- it"s morphine! this is against my morals and values i do not believe in mercy killing although i try to understand the views of others, it is not my place to decide.

it is important for patients to keep their pain meds on schedule to keep the pain under control. if the patients respirations are ok. but i don't think mercy killing is what their view was, that seems very far fetched. you can't let a patients pain get out of control because it is very difficult to get back under control. that would be why they were telling to give it.

[leslie :-D]

we don't flush peripheral lines w/heparin anymore.

when we did, it was 10u/cc, not 100u/cc.

but even a few hundred units of heparin, are not going to do any damage.

i would like to think there are labs being drawn on this pt.

everyone is different, but i will not write md orders.

i'm painfully familiar w/a nurse friend who did so, and the facility nearly lost their licensing.

mso4 is used for pain and dyspnea.

furthermore, pox's are only an assistive device, and its results can be skewed.

w/ms04 being a vasodilator, i would imagine her sats would have increased w/a bit of morphine.

one needs to look at the big picture when assessing.

and i promise you, the 1mg of morphine, did not kill your pt.

it did virtually nothing....at all.

wishing you the best.

leslie

[Virgo_RN, BSN, RN]

In addition to the excellent points made above, if the patient is on comfort care, controlling their pain takes priority over the possibility of hastening death.

[Alana211]

I work in a subacute rehab unit. We sometimes have patients that have orders to keep a peripheral in X 7 days if patent. If we have that order, we have standing orders protocol to flush the peripheral with heparin. The MD does have to sign the standing order sheet though before we hep flush......Otherwise we usually use the saline. I also agree with the above post that the patient did not die from the morphine. Also, it is very important to stay on top of the pain so it does not get out of control.

[nursemike, ASN, RN]

I remember holding my breath the first time I titrated a morphine drip up to 5mg/hr, and I didn't know whether to cry or puke the first time I turned one up to 10. In both cases, the patient (on comfort care both times) got increased several more times before they passed, and I don't believe the morphine killed either of them. In the latter case, the eventual dose of 15mg/hr may have hastened their passage, but the purpose was to relieve dyspnea, which is not mercy killing.

Not long ago, I kicked myself a little for flushing a PICC with 200 units of heparin when I remembered why I'd been pushing Factor VII through it. (Patient was hemophiliac). That was dumb--but I doubt it had any appreciable effect. If I had called for an order, as I should have, the doc would probably have reminded me that the patient wasn't at high risk for clotting...although hopefully he was more at risk after the Factor VII.

The only time I actually wrote my own order was to give Tylenol instead of Lortab to a pt who'd just gotten scheduled IV dilaudid. The doc later endorsed the order and appreciated not being called at 0300, but it still isn't something I plan to make a habit. My rationale was that I wasn't giving anything that wasn't already ordered--just holding the hydrocodone component. My only concern is that I've seen a nurse with orders for Percocet q4 and Tylenol #3 q4 give percs at 8, 12, and 4 and give the Tylenol 3 at 10, 2, and 6...which gets to be a lot of acetaminophen. But most nurses--including that one, now--know better.

I kinda have to agree with Angie, though. I'd sure be a lot more comfortable at a facility where they cared enough to explain to you what they were doing, and why. No one is born knowing this stuff. When I was in school, our state mandated greater emphasis on end-of-life care, so we were taught some of this stuff pretty thoroughly--but it still isn't quite the same as actually dealing with it in the real world.

It would have been a good thing if some of your co-workers could have shown you the support some of your fellow posters have.

[puddingpie]

thanks everyone.

[EmmaG, RN]

I work in LTC per diem.

I had NO order to flush the peripheral line with heparin and therefore did not and refused to do so.

The nursing supervisor then wrote in the orders "flush line with heparin" "(SASH).

Later, found out that the pt. is also on coumadin.

I asked, where is the policy and procedure book in relation to flushing lines, it was not produced either. I was then told that in LTC this is how we do it, this is not a hospital.

I just want to know, is this right?

Are Peripheral lines flushed with 5ml of (100units/ml) of heparin?????? I thought only PICC and central lines.

Peripheral lines are SHORT TERM not long term and can be maintained with Normal saline, RIGHT?????

That depends upon the policies of the facility. Most are moving away from flushing with heparinized saline.

More important here is you need to understand the difference between a heparin flush and heparin used as a systemic anti-coagulant.

I also, witness the nurses writing there own medical orders and later having the MD sign them.

I refuse to do that also, I will only write an order if I received it from the MD even as simple as tylenol or maalox.

Good for you.

I also received an order from a MD to give 1mg of morphine to a pt with pulse O2 of 84-86% room air.

I refused to give that also, when I stated to the unit manger that it woud depress her respirations even more, she disagreed.

They later gave the morphine after I left and the pt. died.

I heard one nurse state that is was for the pain, but the pt. was not in pain and another then said, it was a mercy killing.

So, yesterday, I had a patient on comfort care he denies pain but, I was told to give her Roxanol PRN and they kept saying it, as if I was not going to look it up- IT"S MORPHINE! This is against my morals and values I do not believe in mercy killing although I try to understand the views of others, it is not my place to decide.

Administering morphine is not 'mercy killing'. Please educate yourself on this subject, as you will no doubt face it again and again throughout your practice.

As Leslie points out, morphine is given for reasons other than pain. A patient with a sat in the mid-80's (if that was indeed accurate) is going to be experiencing air hunger. 1mg of morphine isn't going to 'kill' them, but will help alleviate their sensation that they are suffocating. (IMO, more than 1mg was probably indicated)

Research has shown that morphine given to terminally ill patients does not shorten their lives.

http://www.reuters.com/article/healthNews/idUSKIM44142020070404

In case you missed it, there is a long thread in General on this topic.

https://allnurses.com/forums/f8/morphine-dying-patients-263430.html

[UM Review RN, ASN, RN]

Just a thought: Did I miss something? I never saw where the OP stated that either of the patients who were given Morphine or Roxanol were indeed end-of-life or terminal.

If you give morphine to an opiate-naive patient with a sat of 86%, you will indeed depress the respirations and cause further problems. However, I've had some COPD'ers that "live" at around 86%, so whether I'd give it or not really depends on a few variables.

If the patient is DNR/CMO and terminal, the goal is comfort, so I'd give it.

Depends on the Dx and Prognosis.

As far as the heparin flush goes: It'd make me nervous to give heparin, even a flush, to someone who's not being monitored for HITT, which is why so many of our facilities have gone to using NS flushes. I would think that there would have to be a policy or standing order of some kind regarding IV flushes, even in a LTC. Besides, 5 ml of heparin is overdoing it for a peripheral. Even in the hospitals that required a heparin flush, we used only 2-3 mls, even for a central line. (Ports do require more, per policy.)

But then again, maybe I've been in acute care too long.

[EmmaG, RN]

I kinda have to agree with Angie, though. I'd sure be a lot more comfortable at a facility where they cared enough to explain to you what they were doing, and why. No one is born knowing this stuff. When I was in school, our state mandated greater emphasis on end-of-life care, so we were taught some of this stuff pretty thoroughly--but it still isn't quite the same as actually dealing with it in the real world.

It would have been a good thing if some of your co-workers could have shown you the support some of your fellow posters have.

True, but they are working under their own stressors, and unfortunately often don't have the time to direct these new nurses. I've noticed that when they do try, the new grads (or employees) get mixed messages from the established staff rather than a consistent explanation of policies and practice. They also introduce their own personal beliefs (as evidenced by the first post) that may or may not be accurate. That just serves to further confuse the issue...

Up 'til about 10 years ago, facilities actually employed staff educators and nurse specialists who made sure new (and existing) employees received adequate and consistent orientation and continuing education. Our unit's CNS was the 'go to' person for any and all clinical questions. She was an invaluable resource, keeping up with the latest in research and evidence-based practice to pass on to the staff.

As hospitals and other facilities started to implement cost-cutting, they were one of the first to go. Most at my ex-hospital were transferred into case management; others simply moved on to administrative positions, risk management, etc., or left the hospital altogether.

In my travels, I've seen only one facility that employed CNSs whose sole function was educational and clinical support for the staff. It was at a Federal facility. Even the university hospitals I worked didn't employ these resources.

Go figure...

[EmmaG, RN]

Just a thought: Did I miss something? I never saw where the OP stated that either of the patients who were given Morphine or Roxanol were indeed end-of-life or terminal.

If you give morphine to an opiate-naive patient with a sat of 86%, you will indeed depress the respirations and cause further problems. However, I've had some COPD'ers that "live" at around 86%, so whether I'd give it or not really depends on a few variables.

If the patient is DNR/CMO and terminal, the goal is comfort, so I'd give it.

Depends on the Dx and Prognosis.

As far as the heparin flush goes: It'd make me nervous to give heparin, even a flush, to someone who's not being monitored for HITT, which is why so many of our facilities have gone to using NS flushes. I would think that there would have to be a policy or standing order of some kind regarding IV flushes.

But then again, maybe I've been in acute care too long.

She described her second example as "... a patient on comfort care ..." receiving prn Roxanol.

With the first she didn't specify, but considering the MD order, it sounds as though it was end-of-life care.

I can't remember the last time I saw routine heparin flushes for PIVs. But I suppose it depends on the facility's IV policy.