IVP pain med safety

[Swellz]

There's an ongoing to push or to hang piggyback issue on our floor. We're telemetry/oncology, but not necessarily all of our patients are on tele. I was told when hired almost two years ago that we don't IVP pain meds, we only IVPB, and never questioned it. There's a rumor going around that our clin spec is saying we can IVP if we are ACLS certified, which doesn't seem right to me. I'm following up with her and my NM, but I wanted to see how it's done elsewhere.

When asking my more experienced coworkers, a few of them IVP'd on other floors/hospitals, and are totally comfortable with it. Others are not comfortable, especially not with a patient off the heart monitor. But according to every order, we have to document a RR q15x2 anyway. So, you're pushing it over a couple minutes and watching your patient, then coming back every 15 min x2... that's pretty close monitoring if you're doing what you're supposed to do. I can't find a policy on any of this, and I'm sure if I call pharmacy they will say how the medication can be administered, not necessarily how it should/could be administered.

When I did an AN search, it looks like everyone is pushing except us, but it isn't specified whether this is on tele-monitored floors or not.

Do you IVP pain medicine? If so, do you do so on non-monitored patients?

[Aurora77]

Yes and yes. It seems weird not to when it's safe to do so. What's the alternative? Leave a bag of dilaudid hanging for anyone to steal?

[Wile E Coyote, ASN, RN]

Cardiac decompensation (enough for one to notice on a busy floor) is a late sign of the respiratory depression we really should be most watchful for when giving narcs.

I'm compelled to ask what a typical narc dose and schedule looks like for your patients? I ask because it's extremely common to give narcs to "non-monitored" inpatients throughout med-surg, ortho, etc. I'm wondering if a typical order for one of your oncology patients is simply a whopper.

[Seaofclouds, BSN, RN]

I've always pushed those IV doses of medications, even for patient's not on a telemetry monitor. The only ones we ever hang are PCAs and Morphine drips in terminal wean patients. When you hang these medications, are you standing there and watching the bag the whole time? Is it secured. No hospital I have ever worked at would be okay with us hanging a narcotic in a bag and leaving it unsecured.

[VANurse2010]

I've pushed a lot of pain meds and never had a reaction that would have been helped by having the patient on telemetry. That line of thinking is flawed.

[Altra, BSN, RN]

There's a rumor going around that our clin spec is saying we can IVP if we are ACLS certified, which doesn't seem right to me. I'm following up with her and my NM, but I wanted to see how it's done elsewhere.

Wouldn't she be surprised to visit a med-surg floor with no tele and find that IVP opioids are pretty routine?

I'm really having a hard time seeing the logic behind "well, you can give opioids IVP *if* your ACLS is current". If a patient has an adverse reaction to the med, most typically respiratory depression, what are you going to do? I'm thinking ambu-bag and attempts to rouse them, get the physician involved, administer Narcan, etc. You don't need ACLS for any of those interventions.

[Here.I.Stand, BSN, RN]

This sounds really strange and completely overkill, to be honest. I've worked in 3 hospitals--2 traditional and one LTACH, and they've never so much had to be on continuous pulse ox to get IVP meds. I have never once in 12 years of nursing, hung an IVPB med. All controlled substances outside of our custody (think PCA/CADD/continuous drip) must be locked up. I'd be way more worried about having unsecured narcs than about suppressing someone's respiratory drive with 0.4 of Dilaudid.

[Here.I.Stand, BSN, RN]

This sounds really strange and completely overkill, to be honest. I've worked in 3 hospitals--2 traditional and one LTACH, and they've never so much had to be on continuous pulse ox to get IVP meds. I have never once in 12 years of nursing, hung an IVPB med. All controlled substances outside of our custody (think PCA/CADD/continuous drip) must be locked up. I'd be way more worried about having unsecured narcs than about suppressing someone's respiratory drive with 0.4 of Dilaudid.

*Clarification: never hung an IVPB pain med. I've hung thousands of IVPB antibiotics, etc.

[ScrappytheCoco]

This is interesting to me! Needing ACLS and monitoring to push pain medication? In the ED we will often top up a pt with IV pain medication just before d/c. Think kidney stone, ovarian cyst, ortho injury etc, stable enough to d/c but still extremely painful. The docs will order 1mg of Dilaudid, we push it, out comes the line and they go home immediately.

[Swellz]

Thanks for all the replies. As it turns out, ACLS was added to the story somewhere along the grapevine, and completely unrelated to our being allowed to do it or not. Silly me for thinking something that didn't make sense could be true! But wait, there's more!

My floor is apparently classified as an intermediate floor, I guess because we're tele and took the critical care course when hired? THAT is the reason we are allowed to push on our floor, per my CNS. So our sister unit that is right next to us, which is not tele/intermediate/whatever, they are NOT allowed to push. We literally share patients and nurses but if I am on that unit like I was today, I have to hang it. But they push who knows how much at the outpatient sickle cell day unit?

My CNS agreed that this is the most ridiculous thing and said she was working on addressing it. Have you ever heard of such an arbitrary rule?!

[Swellz]

And thank you to everyone who brought up the security aspect. I genuinely never thought about that when hanging a narc. Naivete I guess.

Now we're going to have a battle between those who want to push and those who don't want to. Ugh.

[Swellz]

Cardiac decompensation (enough for one to notice on a busy floor) is a late sign of the respiratory depression we really should be most watchful for when giving narcs.

I'm compelled to ask what a typical narc dose and schedule looks like for your patients? I ask because it's extremely common to give narcs to "non-monitored" inpatients throughout med-surg, ortho, etc. I'm wondering if a typical order for one of your oncology patients is simply a whopper.

I don't think our doses are crazy. It's normally 1 or 2mg q4, although of course some people need more.

How much do you push?