Interpret This Order For Me Please

Dani_Mila, BSN, RN · Jan 29, 2022

On 1/23/2022 at 9:17 AM, SonjaRRN said:

I interpreted the order for : Administer 1000ml bag (available form of IVF is 1000 ml per bag) of D5 1/2 NS (not D5W) at 60 ml/hr x 24 hours. It is clear to me; however, when in doubt, check it out!

This is how I read it as well. I mean 60 mL/hr x 24 hours is very clear. The bag comes in 1000 mL. At my current job, we normally receive orders such as "IV 1000ml D5 1/2 NS 60ml x 24 hours for a total volume of 1440 mL". So basically the patient will have a total volume of 1440 mL of D5 1/2 NS. I would have clarified it with the MD but I would go up to the supervisor first and if they say something say "I clarified it with the supervisor". LOL

guest1143647 · Jan 30, 2022

On 1/28/2022 at 7:32 PM, Been there,done that said:

IV 1000ml D5 1/2 NS 60ml x 24 hours. This order is does not include the hourly rate. Clarification is required.

60ml is the hourly rate

JackSpratsMom · Jan 30, 2022

25 minutes ago, Runsoncoffee99 said:

60ml is the hourly rate

It could technically mean spike a 1L bag of D51/2NS and run 60ml in over 24 hrs ie 2.5ml/hr.
Semantics.

londonflo · Jan 30, 2022

What would you interpret this as?

IV 1000ml D5 1/2 NS 60ml x 24 hours. (1440 ml)

12 minutes ago, Runsoncoffee99 said:

60ml is the hourly rate

And surely a physician will come in during the next 24 hours......

How would you interpret this order?

IV 500 ml D5 1/2 NS 60ml x 24 hours. still 1440 ml

How would you interpret this order?

D5 1/2 NS 60ml.. 1440ml

Bottom line, use your education and experience...patient NPO?, sodium level? Blood sugar level? or at risk for fluid volume overload? Everyone talks about RNs being paid more.....but you gotta use your noggin to move us to a higher salary/respect/professional development ..MD is not going to hold your hand.

Bottom line....

with the original order... run it as written (I am assuming it was written during the day). Don't call in the middle of the night for clarification if it was written less than 24 hours earlier....(Don't figure if your awake..then they should be awake). Ask other RNs how IV orders are written in your institution. What does the Physician order entry require? Even before computer required ordering MDs would write the 1 liter bag but it was meant to continue another liter bag at my institution. The rate was the most important thing unless there was a specific limit for total volume infused.

londonflo · Jan 30, 2022

16 minutes ago, JackSpratsMom said:

It could technically mean spike a 1L bag of D51/2NS and run 60ml in over 24 hrs ie 2.5ml/hr.
Semantics.

It is not semantics. Who runs an IV at 2.5 ml/hr? Does that even keep the line open? 60 ml per hour is CLEARLY stated in the order.

The order is 60 ml/hour. The original question was what to do after the bag runs out, I believe.

PS..Do you know how LITTLE 2.5 ml is? Why not flush the IV with 2.5 ml with the IV solution every hour????

In addition why spike a liter bag??? why not a 250 ml bag, 50 ml or 100 bag? Pharmacy can make them up specially. A liter bag cannot be hung over 24 hours...infection control.

JackSpratsMom · Jan 30, 2022

26 minutes ago, londonflo said:

It is not semantics. Who runs an IV at 2.5 ml/hr? Does that even keep the line open? 60 ml per hour is CLEARLY stated in the order.

The order is 60 ml/hour. The original question was what to do after the bag runs out, I believe.

PS..Do you know how LITTLE 2.5 ml is? Why not flush the IV with 2.5 ml with the IV solution every hour????

In addition why spike a liter bag??? why not a 250 ml bag, 50 ml or 100 bag? Pharmacy can make them up specially. A liter bag cannot be hung over 24 hours...infection control.

Whoa chill the heck out!! You don’t need to patronize people. I have worked in Critical Care for 37 yrs of course I know what 2.5cc/hr is. And the point is….the way the order is written by the original poster is 60ml and not actually 60ml/hr….that is the point that is being made.
I’m saying you can interpret the order a number of different ways….hence this thread is all semantics. I would hope any nurse with an ounce of common sense would clarify with the physician an order that is not clear.

londonflo · Jan 30, 2022

Here is the order as stated by the OP

Quote

IV 1000ml D5 1/2 NS 60ml x 24 hours

18 minutes ago, JackSpratsMom said:

Whoa chill the heck out!!

I don't need to chill. No one has questioned (except you) the hourly rate. The question was the length of time the fluids should be run...beyond the 24 hours such as continuously or a one time 24 hour fluid infusion to be stopped after the 1,000 ml has infused. Sorry if I sounded patronizing but frankly, I could not accept your possible solution.

The area of the US I work in, this order would be interpreted as 60 ml/hr for 24 hours. Then since we would use our common sense and keep it running until we see any MD... in the next 24 hours. I am guilty of assuming this patient is in an acute care hospital bed,. When I moved to this state from another, I was questioning the 1 liter in front of the fluids. The pharmacy needed it that way in the order....I soon learned that the order meant continuously, meaning hanging another bag when the first liter is done. Different medical schools and residencies teach different things...much like different nursing schools.

I was always use to an MD using 'acetaminophen' for a fever. Then a resident ordered 'paracetamol' and continues to use that RX name to this day.

Guest219794 · Jan 30, 2022

8 minutes ago, londonflo said:

I don't need to chill. No one has questioned (except you) the hourly rate.

I do.

"IV 1000ml D5 1/2 NS 60ml x 24 hours"

To be clear- I do not question the intention regarding the rate. That is- assuming the clinical condition of the pt matches the order. But- the rate is not specified. It is a bad order. I interpret it differently than the charge RN in this scenario. An order that two seasoned nurses read differently should be questioned.

From the sounds of it, this nurse does not work in an environment in which they are supported by the docs. "I got written up for calling a doctor about a fall that didn’t result in injury." If a doctor is going to create a hassle for a nurse who is following policy he, or she is creating an environment in which nurses should call to clarify this poorly written order. That doc could just as easily say "Why did you only give one liter?- the order clearly states that it is to run for 24 hours", despite the charge nurse telling the OP to do exactly that. Bottom line is, that the medical staff has not earned the privilege of nurses covering for their shoddy orders.

So- while you can say that nurses should use critical thinking as professionals, the OP does not work in an environment that supports this. I do. I would not have given this a second thought- I would have run this at 60 ml/hr for 24 hours. But- I work in an environment that supports this type of thing. If it been written by a doc who had given me crap for making a mandated call, I absolutely would call for clarification- at 3 AM if that's when the issue arose.

JackSpratsMom · Jan 30, 2022

58 minutes ago, londonflo said:

Here is the order as stated by the OP

I don't need to chill. No one has questioned (except you) the hourly rate. The question was the length of time the fluids should be run...beyond the 24 hours such as continuously or a one time 24 hour fluid infusion to be stopped after the 1,000 ml has infused. Sorry if I sounded patronizing but frankly, I could not accept your possible solution.

The area of the US I work in, this order would be interpreted as 60 ml/hr for 24 hours. Then since we would use our common sense and keep it running until we see any MD... in the next 24 hours. I am guilty of assuming this patient is in an acute care hospital bed,. When I moved to this state from another, I was questioning the 1 liter in front of the fluids. The pharmacy needed it that way in the order....I soon learned that the order meant continuously, meaning hanging another bag when the first liter is done. Different medical schools and residencies teach different things...much like different nursing schools.

I was always use to an MD using 'acetaminophen' for a fever. Then a resident ordered 'paracetamol' and continues to use that RX name to this day.

It has already been pointed out that nowhere does the order actually say 60ml/hr it only says 60ml. My point is that you can make many arguments for what it could mean.
If you don’t understand irony I’m not going to further explain it to you.
I think the majority of people interpret this order as run 60ml/hr for 24 hrs. The volume of the bag is a moot point. I would not consider calling a physician to clarify this order (probably under any circumstance) but particularly not in the middle of the night.

offlabel · Jan 30, 2022

Is 440 ml of D51/2 NS going to be the difference between life and death? Yeah, it's an unclear order, but waking someone up in the middle of the night for that is what makes doctors complain about nurses. Wait until rounds or at least 7 AM for pete's sake....see the 10,000 ft perspective and don't obsess on minutia.

JKL33 · Jan 30, 2022

8 hours ago, hherrn said:

If it been written by a doc who had given me crap for making a mandated call, I absolutely would call for clarification- at 3 AM if that's when the issue arose.

Getting off topic, but if such a call were mandated (which we don't know), that's the first problem.

Choosing not to think because one doctor (we don't even know if it was the same one who wrote this order) was a meanie one time is beyond backward; it's the kind of thing that helps keeps us a "profession" rather than a profession. "I got written up before so going forward I will not be using any common sense" is ridiculous. Another poster has demonstrated the ability to interpret this order absurdly by technicality--not sure how that helps nursing or the patient in question. And some have offered interpretations that are ever-so-slightly more probable, but in the end don't make any sense either.

Admins could not be more pleased that nurses and doctors are still at each other. They make stupid rules that make us each want to tear our hair out. Why we keep being fooled into thinking that we and they are the problem is beyond me. Guess what happens when we (nurse and docs) all run around the yard pecking each other's feathers out? The ADMINS rule the entire roost. I would say that isn't going so well.

8 hours ago, londonflo said:

The question was the length of time the fluids should be run...beyond the 24 hours such as continuously or a one time 24 hour fluid infusion to be stopped after the 1,000 ml has infused.

But it wouldn't be a 24-hour infusion if it were stopped after the 1,000 ml. There would be no point in even including the 24-hour element if it were supposed to be stopped after one liter.

londonflo · Jan 30, 2022

13 hours ago, hherrn said:

But- the rate is not specified.

Yes it is. 60 ml every hour for 24 hours. Uh ohh.. are you thinking I should run a 60 ml bolus every 24 hours? The brain needs glucose to operate so it needs a steady supply...not all at one time.... Rather continuously. I am old. I did not have an internship. Rather I had one day orientation on the floor.The next day "my mentor" called in sick and I was on by myself. Assessment skills were vital.. Assessments. Common machines had yet to be invented. I did not have a device that measure peripheral O2...I used physical assessment to see if they were SOB; what their mucus membranes looked like and if they had dusky peripheral circulation. We called for an ABG. Cardiac monitoring was only done in ICU.

I didn't think a monitor machine is better for my decisions. For example, I went to my pulmonary MD and the nurse who usually does the primary assessment said "Let's hook you up to oxygen. I asked "why" and she said your lips are dusky., I had walked slowly to the exam room... (you betcha my pulse ox was at 80.) This is an example of physical assessment and experience. Off oxygen my numbers were dismal. "Nurse the patient not the machine". Want to be an expert nurse? use all those assessment/observational skills you learned.

Want to be the excellent nurse....stop using machines and learn to use your eyes, ears, and smell to collect data as a source of information and THEN look at a machine. The physical assessment skills are far better than a machine.

Okay I got off topic:

We are on here discussing a 60ml IV order....what are the benefits/detriments? Use your noggin/brain to figure WTH is going to happen with a patient getting 60 ml of the IV solution for a couple of more hours until you see the ordering MD? What if the IV infiltrated and it took an hour or 2 to restart it? Seems like either you can't equate what is really important in the whole realm of things or you just want to complain. I mean it is 60 ML per hour .

I know I sound mean but I worked in a city where nurses used their ability to assess fluid intake. How much fluid had the patient had for the last 24 hours? Was the patient NPO? How much urine produced was actually and measured accurately ?