How to dilute meds for IVP?

[xmilkncookiesx, RN]

Hello. I am a nursing student. Someone on my last post suggested I move my question to the nurses forum. So I'll give it a shot here

Today we had sim and an order was for 2-4mg of morphine IVP with 0.9% NS.

I got SO confused although my professor showed us a few hours prior to sim.

They said something about, push out the amount of mL you don't need in the NS syringe, then draw up the amount from the morphine vial then push it all out until you get to the mL you need for the patient.

the pt. had burns, was in A LOT of pain, never really had morphine before, so I wanted to start off on 2mg and titrate up if it doesn't improve the first 10min or so (the pts. pain).

The morphine vial said 4mg/mL.

This is how I tried to calculate it, I think I'm overthinking it:

Order: 2-4mg Morphine IVP PRN pain Q 10min in NS over 4-5min

i want 2mg

i have a 10ml flush

i flush out 7ml into the trash or whatever, so I'm now left with 3ml in my saline flush

i draw up 1mL from the morphine vial (4mg/ml)

so now I have a total of 4ml in my saline flush

which I think is 4mg/4ml?

then I flush out 2ml, which leaves me with 2ml in my saline flush

i think that's 2mg/2ml in my saline syringe?

2ml/4min = 0.5ml/min

Did I do this correctly?

[Wandrlust]

It looks right, but I was taught to draw up the Morphine (or whatever medication you will be giving IVP) in a separate syringe- so in your example, I would have drawn up 0.5 ml of Morphine and then injected that into a Saline flush (after discarding approx 6 ml from the saline flush first)..my instructor was super anal and instructed us to do it this way so we didn't accidentally inject the saline into the Morphine bottle before drawing up the amount needed and less guesswork/chance of error.. I always feel like I waste needles and syringes this way though.

Did that amount control the pain?

[xmilkncookiesx, RN]

Ah, im not sure which way would be best. I'm still a little confused either way.

we didn't have enough time to give the sim pt another set of morphine because we were taking too long figuring out the dilutions

[Guest219794]

Lots of ways to do it.

What you did is fine, Really not much calculation to be done. You put 4 mg of ms into a syringe which now has 4 ml total. you know there is 4 mg in the syringe, so waste half and give half.

(You could do the same if you ended up with 6ml, 7.5 ml.etc. But the 4mg in 4 ml works nicely.)

[iluvivt, BSN, RN]

You should never use prefilled normal saline flush for anything other than flushing venous access devices.The IFUS for the product state it is for flushing VADS only.You need to use normal saline from a vial to dilute and reconstitute medications.You will find a ISMP warning for this.If they are teaching you this they are doing you a disservice. As far as the MS is concerned it is safer to draw up the MS and then dilute it.What if you add too much MS to to the NS....yes you can recalculate but what a hassle and can increase risk for med errors.

[BeckyESRN]

You should always draw up the exact amount of medication that you need prior to dilution. You cannot ensure that the amount you wasted was 2mg of morphine, for all you know it could have been 4mg/1ml of morphine and 1ml of NSS or all NSS. You draw up your 4mg/ml morphine, waste 0.5ml, now you have 2mg/0.5ml, add your NSS. Personally, I would use a 3ml syringe. 0.5ml of med. mixed into 2.5ml of NSS.

[NurseGirl525, ASN, RN]

Do lots of places do this? Why do you dilute morphine? It's not a vesicant. You should push the amount of morphine needed, then flush behind with a10mL flush to push it in.

I'm confused on what people think this does. If I say dilute famotidine, which is a vesicant, I draw up the famotidine into a syringe. I then look at my order, which with this particular medication states to dilute with 3mL of NS. Therefore a total of 5mL, in which I use a 5mL syringe. You need to accurately measure the first medication, which is why it is drawn up first, then the NS.

Bit never a flush. There should be a separate vial of NS.

Again, the rationale for diluting morphine?

[NurseGirl525, ASN, RN]

You should also have a separate syringe for waste. You should not draw up 4mL and push 2mL into the cactus, then go administer it. They should be drawn up separately.

[calivianya, BSN, RN]

I just use a 3 cc syringe to draw up the morphine in the first place so I can get the accurate dosing without using NS at all. I only use NS to flush after giving morphine.

[mmc51264, BSN, MSN, RN]

Well now I have to go look at our policy about diluting IV push meds. If a pt has fluids infusing, we just push into a port on the IV line. If a pt is saline locked, we flush, usually dilute the IV morphine, dilaudid (mostly) in a flush, push then flush to clean line. Why no prepackaged NS flush? I will look it up, but I have never been told to use a separate vial of NS. Usually we dilute b/c of pts that want the rush or buzz of an IV push med. they would rather have 0.5 mg of IV dilaudid than 6 mg of PO. I don't understand that.

[chare]

...Why no prepackaged NS flush? I will look it up, but I have never been told to use a separate vial of NS...

It's not so much that you shouldn't use the NS from the prefilled syringe. Rather the concern is using the flush srying, and it either not being labeled, or the label detaching, and it being used as a NS flush.

[NurseGirl525, ASN, RN]

Well now I have to go look at our policy about diluting IV push meds. If a pt has fluids infusing, we just push into a port on the IV line. If a pt is saline locked, we flush, usually dilute the IV morphine, dilaudid (mostly) in a flush, push then flush to clean line. Why no prepackaged NS flush? I will look it up, but I have never been told to use a separate vial of NS. Usually we dilute b/c of pts that want the rush or buzz of an IV push med. they would rather have 0.5 mg of IV dilaudid than 6 mg of PO. I don't understand that.

They still get that. In all actuality, you get a little bit if a fuzzy rush just from pushing in a flush. It's just for a few seconds, but it's there. If you push the flush behind it slowly, the rush is less. It's actually the force of the the flush behind the morphine that can bottom out respiration rates. I think the term diluting is a bad term. By adding NS, you are putting a protective barrier kind out the medication, thus it not burning the vein. The same amount of medication is still going in.

To me, it's not using evidence based practice. Your NS should be in a vial, not a 10mL flush. I can see all kinds of bad things happening with that. And I'm not talking so much about experienced nurses doing it for years necessarily. I'm talking about trying to teach this in Nursing School and then sending new grads out to do this.

I have had plenty of experience with IVs put in me and feeling a flush pushed through. I always just slowly push my flush behind. It doesn't matter how fast the initial morphine gets pushed in all reality as you are generally just pushing a mL and it doesn't get to the vein by itself.

I'm trying to understand how people draw up the morphine, then put it in a flush. Aren't the syringe and flush both lurelock ends as they are both intended to lock into what I call a clave?