IVP vs Drip

Guest219794 · Apr 10, 2015

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.

MunoRN, RN · Apr 10, 2015

Putting into a bag doesn't make it a "drip", a drip is a continuous infusion that is usually titrated. It is well within the scope of an RN to use their nursing judgement in managing how an IV is administered, the duration, the flow dynamics, etc and does not have to be specified by the MD. That being said, I don't think putting IV pushes into minibags is generally good nursing judgement as it's just not a good way to infuse an intermittent medication. Are you running it as a secondary? How are you getting all of the medication into the patient? What would make more sense is to still use the minibag and tubing, but put the medication into one of the ports (diluted as indicated) and using the bag and tubing to infuse the medication at the proper rate.

nycsurg · Apr 10, 2015

At a few hospitals that I work at (all the city hospitals), nurses outside of stepdown/sicu are not allowed to push IV medications at all. No BP meds, no pain meds, not even benadryl or ativan.

So I order everything inside a minibag, from labetalol to morphine.

Guest219794 · Apr 11, 2015

Putting into a bag doesn't make it a "drip", a drip is a continuous infusion that is usually titrated. It is well within the scope of an RN to use their nursing judgement in managing how an IV is administered, the duration, the flow dynamics, etc and does not have to be specified by the MD. That being said, I don't think putting IV pushes into minibags is generally good nursing judgement as it's just not a good way to infuse an intermittent medication. Are you running it as a secondary? How are you getting all of the medication into the patient? What would make more sense is to still use the minibag and tubing, but put the medication into one of the ports (diluted as indicated) and using the bag and tubing to infuse the medication at the proper rate.

I often do this as well- draw 1 ml of compazine into a 10 ml syringe. Plug syringe into port. Draw ivf into syringe diluting it. Push all 10 cc's into line. If it is running at 100 ml an hour, it will deliver in 6 minutes. Assuming the volume between the port and pt is 10 MLs.

If I am concerned about leaving it unattended, I can stay in the room, charting, etc, rather than being tied to a syringe for a really slow push. It gives the Benadryl a nice head start, and helps avoid a compazine reaction.

EmergencyRN22 · Apr 11, 2015

I have no prob with diluting some meds in 50ml bags and run them over 5-10 min. I actually prefer diluting 50mg Benadryl iv in 50ml over 10 min ... Saves the pt from the effects from the push (dizzy, lightheaded, nausea, hot flash). When giving Iv reglan and Benadryl, I'll usually mix the reglan in 50ml over 10 min while pushing the Benadryl slow. Normally always dilute phenergan in 50ml over 10 min. I'm surely not going to give 2mg dilaudid IVP to a lil 90yo, 100lb demented hip fx....nope....always dilute and give slow.

Never had doc have issues with it.

MunoRN, RN · Apr 11, 2015

I have no prob with diluting some meds in 50ml bags and run them over 5-10 min. I actually prefer diluting 50mg Benadryl iv in 50ml over 10 min ... Saves the pt from the effects from the push (dizzy, lightheaded, nausea, hot flash). When giving Iv reglan and Benadryl, I'll usually mix the reglan in 50ml over 10 min while pushing the Benadryl slow. Normally always dilute phenergan in 50ml over 10 min. I'm surely not going to give 2mg dilaudid IVP to a lil 90yo, 100lb demented hip fx....nope....always dilute and give slow.
Never had doc have issues with it.

2mg dilaudid is still 2mg of dilaudid whether or not you dilute it. It can be given over 10 minutes either by putting in the line and running it at a rate that infuses it over 10 minutes (diluted for a total 10mls, run the pump at 60/hr. How else are you making sure it all infuses? Are hanging the minimag as a secondary?

Julius Seizure · Apr 11, 2015

I work in pediatrics, and I realize that things are very different in my world when it comes to meds, but some of the answers here surprise me.

For me, if the doc orders "Lasix 7mg IV q12hr", it gets sent to me in a 10mg/ml concentration, pre-drawn up from pharmacy for me (0.7ml).

But I could run this over the pump, as it was sent to me.

Or I could push it slowly by hand (as slow as one can push 0.7ml) into a port of my maintenance fluids.

Or I could dilute it in 2.7ml NS for a total volume of 3ml to make it easier to slow push by hand.

The doctors orders dont specify or preclude any of those. And some of those options change the concentration. I follow lexicomp or whatever guideline that particular hospital uses to appropriately administer the med, within the MD orders. But the MD orders generally dont specify concentration or rate for scheduled intermittent meds - thats what the drug book is for.

Another example, for funsies:

Ativan. Its kinda hard to push without diluting just because its viscous. So if I dilute it in 3ml and slow push, that would be ok, but diluting in 10ml not ok? If appropriate for the patient, why not? And how am I to know how much to dilute it in because the doc is just gonna write "Ativan 2mg IV x1"

I dont know. This is why I dont work adults I guess! :)

EmergencyRN22 · Apr 11, 2015

2mg dilaudid is still 2mg of dilaudid whether or not you dilute it. It can be given over 10 minutes either by putting in the line and running it at a rate that infuses it over 10 minutes (diluted for a total 10mls, run the pump at 60/hr. How else are you making sure it all infuses? Are hanging the minimag as a secondary?

Piggybacked with NS maintaince drip.

MunoRN, RN · Apr 11, 2015

Piggybacked with NS maintaince drip.

Why not just put it in the line ahead of the bag and not mess with need to add a secondary setup?

Anna Flaxis, BSN, RN · Apr 12, 2015

Putting into a bag doesn't make it a "drip", a drip is a continuous infusion that is usually titrated. It is well within the scope of an RN to use their nursing judgement in managing how an IV is administered, the duration, the flow dynamics, etc and does not have to be specified by the MD.

If you want to split hairs, the IVP med put into a minibag isn't a continuous gtt, but technically an intermittent infusion. However, an intermittent infusion does need a concentration and a rate. By mixing the IVP med into a minibag and hanging it by gravity or pump, whether primary or secondary, it is still changing the med from an IV push to an infusion, and thus, requires an order.

Anna Flaxis, BSN, RN · Apr 12, 2015

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.

There is a difference between an IV push and an infusion. They are two different things, requiring two different types of orders.

MunoRN, RN · Apr 13, 2015

If you want to split hairs, the IVP med put into a minibag isn't a continuous gtt, but technically an intermittent infusion. However, an intermittent infusion does need a concentration and a rate. By mixing the IVP med into a minibag and hanging it by gravity or pump, whether primary or secondary, it is still changing the med from an IV push to an infusion, and thus, requires an order.

What requires an order in general is a regulatory issue and in that context there is no difference between and IV push and intermittent infusion, those are different terms for the same thing. Part of what I do is regulatory compliance, and no regulatory body designates a point at which an IVP becomes a "intermittent infusion", they don't differentiate between the two. Whether an IV medication is put into the proximal port to infuse or the distal port to infuse makes no difference in what the order has to say, and putting into a bag is functionally no different than using a more distal port.

From a regulatory standpoint, intermittent infusion orders do not actually require a concentration, that can be, and usually is, up to those interpreting the order, either pharmacy or nursing, to determine based on facility approved resources, which can be the manufacturers IFU, an approved drug guide, etc.