IVP vs Drip

I personally would never walk away and leave narcotics in a BD pump or as a piggy back. I have used a BD pump for lasix when I don't want to stand at the bedside to do IVP and if lasix dose is >40 mg of lasix.

Good point about the narcotics. Didn't think of it that way. But for other meds, maybe like Benadryl or reglan or compazine it would be okay? And this wouldn't be considered changing the order?

It would be changing the order, because infusion orders must contain a concentration and a rate. By mixing the drug in a minibag you would not be following the order.

For example, your typical IVP Reglan order looks like:

Reglan 10mg Intravenous x1 now

An order for an infusion of Reglan would look like:

Reglan 10mg in 50mL 0.9% NS Intravenous @ 100mL/hr x1 now

Also, it is not best practice to mix your own medications- routinely prescribed medications should be pre-mixed, in order to prevent contamination and medication errors.

I feel it is just easier to push the reglan, morphine, Zofran, or etc. We do not have syringe pumps and do not have 50cc bags of saline on the units either.

My unit uses pumps and primary tubing cassettes where it is possible to screw on a syringe and program that into the secondary line on the pump like you would an IV bag. In fact, some of our antibiotics like Ancef come in a prefilled syringe that we are told by pharmacy to put on the pump like a secondary bag. If the med is not a narcotic, I am okay with programming the diluted syringe on the pump and walking away. If it is Phenergan, a narcotic, or something like IV Valium, I screw on the syringe and let the pump run it while I am opening other pill packets or working on part of my head to toe assessment. It lets me multitask.

It would take longer to set up the bag, get tubing, and set the pump, than to do a two minute push, so I don't see any benefit.

The only time I use a pump for an IV push is for a large dose of IV lasix, and only if I have a pump that I can hook a syringe to. Otherwise, I just relax and enjoy whatever TV show my patient is watching.

1.) You're altering the concentration of the drug

2.) You're giving it over 10 min. vs. over 2 min.

3.) Controlled substances must be secured. We have see-through plastic lock boxes to put Ativan drips in, because the pharmacy mixes them in a bag, vs. coming in a CADD cassette.

4.) It's going to take you way more than two minutes to mix the drug, prime the tubing, get a lock box from the equipment people, lock up the drug, program it into the pump, connect it to the patient, and then flush the line (so they're not getting the Rx'ed dose minus the amount left in the tubing.)

Why wouldn't you just push it?

If you wanted something to save time, perhaps you can start an initiative on your unit where all pumps are issued with a lock box and syringe pump, so all you'd have to do is lock and load.

I still think it would take longer than just pushing it to start with.

I wouldn't want to infuse benzos or opioids unattended anyway. Antibiotics are one thing, but I prefer to be present when some drugs are infusing.

It would be changing the order, because infusion orders must contain a concentration and a rate. By mixing the drug in a minibag you would not be following the order.

For example, your typical IVP Reglan order looks like:

Reglan 10mg Intravenous x1 now

An order for an infusion of Reglan would look like:

Reglan 10mg in 50mL 0.9% NS Intravenous @ 100mL/hr x1 now

Also, it is not best practice to mix your own medications- routinely prescribed medications should be pre-mixed, in order to prevent contamination and medication errors.

I am going to disagree with couple of posters.

I can't remember ever getting an order that included the concentration. There are plenty of drugs that come in multiple concentrations, and the docs have no idea what they are.

The docs I work with also have no idea how long various IVPB drugs need to run for.

As an example: Let's say I have an order for regular insulin, 3 units IV. My total volume here is 3/100 of an ML. I don't know the residual volume in the barrel of a syringe, but it could put a heck of a dent in 3/100 of a ml. And, even a minute leak when attaching the syringe.

What I do is carefully measure in units, then put it into a 10 ml flush, using the insulin needle in the flush barrel. Then, push slowly. If I lose 1/100 of a cc, it is 1/1000 of my dose, rather than 1/3.

If the doc for some weird reason wrote an order specifying volume, I would ask to change it.

Another example- IV phenergan. Probably will come to a shock for some but this is not universally forbidden. And, if you think about it, we give many vesicants, and all need to be given carefully. And, like phenergan, none should be given in an artery.

I have no problem giving IV phenergan, but put it into a bag of 50 ml. Having never gotten an order specifying rate and concentration, I see no problem.

I would say that unless the doc specifies a rate and volume, those parameters fall into the nursing judgement zone.

As an example: Let's say I have an order for regular insulin, 3 units IV. My total volume here is 3/100 of an ML. I don't know the residual volume in the barrel of a syringe, but it could put a heck of a dent in 3/100 of a ml. And, even a minute leak when attaching the syringe.

What I do is carefully measure in units, then put it into a 10 ml flush, using the insulin needle in the flush barrel. Then, push slowly. If I lose 1/100 of a cc, it is 1/1000 of my dose, rather than 1/3.

This is a bad example, because you're still giving the insulin IV push. Simply diluting it in a flush does not change that. If you were to mix the insulin into a minibag and thus change it into an IV drip, then yes, you would need an order for that.

If the doc for some weird reason wrote an order specifying volume, I would ask to change it.

Why? Docs write orders that specify volume (and rate) all the time, such as 1 Liter of 0.9% Sodium Chloride intravenous at 250mL/hr.

Another example- IV phenergan. Probably will come to a shock for some but this is not universally forbidden. And, if you think about it, we give many vesicants, and all need to be given carefully. And, like phenergan, none should be given in an artery.

I have no problem giving IV phenergan, but put it into a bag of 50 ml. Having never gotten an order specifying rate and concentration, I see no problem.

Not shocking to me at all. Until recently, my facility still allowed Phenergan IVP. What you seem to be missing is the difference between an IV push medication and an IV drip. When you mix the med into a mini bag and hang it to infuse either by gravity or on a pump, it is no longer IV push. It is a drip. Orders for IV drips need to include a concentration and a rate.

I would say that unless the doc specifies a rate and volume, those parameters fall into the nursing judgement zone.

Again, the different methods of administration require different orders. There is a difference between IV push and a gtt. Would you say that changing a PO dose of Zofran to IV push falls into the nursing judgment zone?

This is a bad example, because you're still giving the insulin IV push. Simply diluting it in a flush does not change that. If you were to mix the insulin into a minibag and thus change it into an IV drip, then yes, you would need an order for that.

Why? Docs write orders that specify volume (and rate) all the time, such as 1 Liter of 0.9% Sodium Chloride intravenous at 250mL/hr.

Not shocking to me at all. Until recently, my facility still allowed Phenergan IVP. What you seem to be missing is the difference between an IV push medication and an IV drip. When you mix the med into a mini bag and hang it to infuse either by gravity or on a pump, it is no longer IV push. It is a drip. Orders for IV drips need to include a concentration and a rate.

Again, the different methods of administration require different orders. There is a difference between IV push and a gtt. Would you say that changing a PO dose of Zofran to IV push falls into the nursing judgment zone?

Anna-

I have a pretty good understanding of the difference between a push and a drip. And, if a drug was ordered as a push, I would give it as a push, or have the doc correct the order, then give it in the safest way I know.

And you are right- fluid orders have volumes and rates. And, every now and again, an order for something else might include a rate- but that is unusual where I work. As far as: "Orders for IV drips need to include a concentration and a rate". I get orders for IV drips without concentrations or rates all the time. Our docs trust nurses and pharmacy to take care of that. They do not know the concentrations or rates.

I work in the ER, have also worked ICU. In my experience, many orders have neither rates nor volumes.

So- back to phenergan- If I got an order for phenergan, it would be: phenergan, 25 mg iv. No rate or volume specified. I have worked in one ICU and 8 ERs, and have never had a rate or volume specified. I would not give this po or IM, as it is ordered IV. But, since it is a potential vesicant, I would use some nursing judgement. If I personally had placed an 18 in an AC, I might push it slowly into a running IV. Alternately, as the OP asked, I might put it in a bag of 50 ML ns, and run it piggyback.

Either way, I am giving phenergan, 25 mg iv. All 5 rights covered.

Most of the experienced nurses I work with would do the same, and none of our docs would question this. I really only know ICU and ER, maybe your work environment is different.