IV push failure - how I am failing

[Brandazzle1]

I am new to the hospital environment and brand new to IV meds so when my preceptor said it was a mistake not to pause the heparin drip before doing an IV push dose of morphine I expressed understanding and told her I never knew that. I honestly don't remember learning that in nursing school so she told my boss and now they've added another week of orientation for safety concerns.

I am terrified they're going to fire me. I already had an extra week of training to hone my time management skills and then I do this! I just worry that there are other deficits in my education that will lead me to endanger a patient or get fired and I'm 37 weeks pregnant so I'm about to go on leave without really being on my own. I just feel like I'm failing and the preceptor says I didn't seem to understand how serious this mistake was. She's right. I didn't. I don't know what I don't know, you know? Are there other things specific to IVs that I should be aware of before I kill someone?

[kalycat, BSN, RN]

My hospital has a very accessible database of procedures for dealing with these types of things. I've used it numerous times for procedures to handle multiple drips and high alert meds that are titrated, etc. This is different than micromedex, which we use as well. For example, drawing serial labs on a patient with a heparin drip, it details exactly how long to stop the drip, how much to flush with, how much to waste (central line) etc.

I know this is different from what you were dealing with, but you may want to research your resources. Our database is accessible enough that you can do a quick look before dealing with something you don't see much....chest tubes on certain floors, multiple lines, etc. I know everyone is pressed for time, but my advice is to truly locate your resources and be able to use them independently. Sometimes you get patients that are higher acuity than what you normally see, or who require different sorts of procedures. It's going to be a continual learning curve. Looking things up minimizes the number of times you need to go to your preceptor with questions; also, before performing any task like this for the first time, verbally run through what your plan is with your preceptor. This gives them an idea where you're at, what your thinking is, and shows that you've done your preparation. Hang in there!!

[applewhitern, BSN, RN]

I agree, always flush between push meds, so you don't have to worry if the two drugs are compatible or not. (By the way, both heparin and morphine have a lot of incompatibilities.) I am uneasy about the part where you say you never learned this in school; as the previous poster said, this is basic nursing! I am amazed at how much our new grads don't know, and at how long they have to be on orientation. No offense to you meant, it just seems like we have a ton of new grads at my facility who do not know basic nursing stuff. We also seem to have quite a few who have to take boards several times before they pass. I worry about the quality of the schools.

[Guest219794]

I agree with Nony-

One issue is compatibility, and that is a no brainer. If two drugs are not listed as compatible, they are not.

The issue that is often overlooked is the priming volume. The volume between where you are pushing the med and where the catheter enters the vein. IV extensions can be 1 ml, and the closest port to the pt is usually 1 ml. So- if you are to follow the advice of several here- to flush then push, you would be introducing 2 ml rapidly into the patient. Is this significant? That depends on the med, and that is where your critical thinking comes in.

It is very common for nurses to overlook priming volume. I have seen plenty of nurses push 1 ml very slowly into an IV extension- maybe over 2 minutes. At the end of 2 minutes, none of the med has reached the pt. Then BAM- they flush it in seconds, giving a rapid push.

I gave 10 mg diltiazem to an 80 year old with a SBP of around 85 today. Had I not taken into account the priming volume, I could have really cratered her pressure.

[calivianya, BSN, RN]

I just thought I'd add in that if the patient is on a critical drip (heparin, insulin, pressors, etc.) you should think about having a second line anyway for antibiotics, IV pushes, and anything else that needs to be given so you don't have to stop your drip or bolus it by flushing.

[L♡vER]

I agree with the above poster. I prefer any titrated drip to have a dedicated piv if no central. Throw in another line for your intermittent pushes, abs and what not.

[JustKeepSmiling, ADN, BSN, RN]

Or you could aspirate the high risk drug out to avoid a bolus, give your push, flush then restart the line. Avoid fooling with high risk infusions for pushes if you can avoid it though.

OP - what if it wasn't heparin but say insulin or levophed?

That "bolus" could crash their BG or hype up their BP. Think about what is in your line before you push it faster than the pump.

[Qteapi]

My goodness big ups to you for working up till 37 weeks!

[Sun0408, ASN, RN]

Or you could aspirate the high risk drug out to avoid a bolus, give your push, flush then restart the line. Avoid fooling with high risk infusions for pushes if you can avoid it though.

Please don't do this. You risk clotting the line if it is a PIV. Also you don't want to stop levo or other high risk meds just because. Your pt could

tank very quickly and it can be difficult to get them back. If you have to give IVP meds etc it's best to have a second line. High risk meds are just that, Mess with them cautiously. Hope this helps some. I see you are new to the ICU.

[Brandazzle1]

It's actually just an observation unit, not ICU. ICU would be terrifying now!

[Brandazzle1]

I plan to work until I go into labor. Baby brain isn't helping things though.

[Sun0408, ASN, RN]

Sorry OP I was quoting justkeepsmiling but I didn't do it right 😞.

[Susie2310]

Can you tell us what you were taught about administering IV medications in nursing school? With teaching/learning it is helpful to ascertain what level of knowledge and understanding the person has initially. That was the reason for my earlier question. You asked if there were other things specific to IV's that you should know before you kill someone.