IVP vs IVPB

stephenfnielsen · Dec 14, 2011

Not so much for inpatient, but outpatient reimbursement for IVPB is greater than IVP. This is why you see a lot of Onc, and pain clinics giving pain and nausea meds IVPB (more money!).

Go to any drug book, Micromedex or online equivalent and you will find that IVP narcs are common and safe if you are reasonably monitoring the patient's VS, (my tongue and cheek deal I make with my patients is, "hear's the deal, if you keep breathing I'll keep giving you pain meds, if you stop breathing I can't give you anymore").

Seems like a waste of time and supplies to give all narcs IVPB... unless of course that is the way the order is written.

Sun0408, ASN, RN · Dec 14, 2011

I have only heard of giving IV meds in a piggyback if its phenergan because it can do some nasty stuff. However, I give all IV meds IVP. Phenergan, I will dilute in 2 10cc NS flushes and then a straight flush but everything else, I just give straight and slow.. I take that back, I will dilute ativan too.

If most RN's do IVPB at your facility; what does policy say ??

mindlor · Dec 14, 2011

If pt is in severe pain, push it, just dosing to stay ahead of previuosly controlled pain....titrate via IVPB.....

I am a student so pls correct me if need be....

oh yeah, if order specifies, do it that way :) And always assess repsiratory status and LBM/COCA prior to administering opiods :)

mindlor · Dec 14, 2011

Also as someone who was victimized, please please push benadryl SLOWLY

DennRN · Dec 14, 2011

It depends upon dosage and if the pt is opiate naive.

I would address the Rights of Medication, if you need clarification, go straight to the source and ask for clarification from the prescribing physician, to do otherwise is like waiting to see if you get hit by a car to judge if it's safe to cross the street. The order is probably for IV on purpose so that you can use your nursing judgement, but better safe than sorry if you have concerns.

Personally I have never encountered an IV dosage of an opiate that made me question if I needed to administer it over 30 minutes, and if I did, that would mean I would have to pace out my rounding/charting to allow me to check on my pt every few minutes until peak efficacy, which would start at 30 minutes and last for an 1.5-2 hours after the 30 min IVPB ends for dilaudid for instance.

Then comes the problem of clearance time for the opiate, with the tail end of, say, q2 dilaudid still circulating when the next dose is administered. Since IV dilaudid peaks can last 2 hours when pushed, subtract 30 min from that and you can see that the next dose will be available to the pt before the client has metabolized half of the first dose. Check the peak times, you need to be in the room when the normal stated peak is and tack on the 30 min delay for the infusion to run. Then address the problem of what if my pt wants another dose within the clearance time.

The medication is there to relieve pain! If it is infusing slowly, it takes longer to bring the pain down, meanwhile the pain is not under control and will need a higher dose to be effective.

Lastly IV opiates have a short half-life, and are fast acting. Personally I feel safer pushing it because I know I'm in the room observing the pt when it starts to kick in and will return while it's fresh on my mind. Narcan won't do anything if I have left the room and forgotten about them.

In short I would say if the prescribing physician says use your judgement, do what you are comfortable with and get a baseline RR. Peek in every once in a while to see if there is a significant change, and factor in some extra time if you are using IVPB.

krista312 · Dec 14, 2011

I had the same issue during my recent orientation at my current hospital. your facility should have a policy for each IV drug you are given. Where I work we have a pharmacy web page that you can search the particular drug and it will tell you how you can give it, ivp or ivpb, if there are limits to what you can and can't push, if you need to dilute the med and what to dilute it in...and so on...you should ask your preceptor about any resources such as this, and of course you can always call that pharmacy, the bottom line is you need to follow your facilities policies, its probably ok to do either and this is your preceptors preference in that case follow her lead till you are on your own...as far as other threads posting they would never hang a med ivpb and leave it there so unsafely, I offer the question what do you do when you have a Sickel cell pt who is getting 10mg iv dialudid q 2 hours???? no, a pca is not going to be ordered...eveywhere you go you will find people leaving narcs running unlocked, another good example is morphine drips which you will find many places do not secure...just food for thought....

Horseshoe, BSN, RN · Dec 14, 2011

i just started on a surgical unit and a lot of our patients are on iv narcotics, usually q3 or q4. the order is just "iv" so no specification on whether is should be ivp or ivpb. my preceptor puts all narcotics in a 50 ml bag of ns and runs it over 30 minutes. she says she doesn't feel comfortable pushing them. we do leave while they are infusing, which is something a lot of people mention as a big no-no. i assume a lot of other nurses do the same (ivpb) because there is usually an empty bag with tubing hanging in the room. we just switch out the new bag for the empty bag. now, after reading i see that this is not the norm. most rns (on here anyway) give narcotics slowly, sometimes diluted ivp.
should i say something to my preceptor? i don't want to go against her but at the same time i want to be doing what is best for the patient and my license.
thanks! :)

as a blanket policy, that's just crazy. if she's not "comfortable pushing them," she has a problem- ivp drugs appropriately ordered at the proper dose and with consideration given to patient diagnosis, pain level, respiratory status, neurological status, etc. are quite safe. is this a pedi unit?

because i worked icu and stepdown icu (high acuity non vented pts. at 3:1 ratio), all of our patients were monitored, so it was easier to feel comfortable giving narcotics ivp. i understand that not having that kind of constant feedback could give one pause, but refusing to give any pain meds ivp is not the answer. post op pain can be extremely painful, and it seems your preceptor's method could easily result in completely ineffective pain control.

also, i agree that all meds should be very specific with regard to route. just "iv" would not have cut it in my unit, and that doctor would be called every time for clarification.

PediLove2147, BSN, RN · Dec 14, 2011

I had the same issue during my recent orientation at my current hospital. your facility should have a policy for each IV drug you are given. Where I work we have a pharmacy web page that you can search the particular drug and it will tell you how you can give it, ivp or ivpb, if there are limits to what you can and can't push, if you need to dilute the med and what to dilute it in...and so on...you should ask your preceptor about any resources such as this, and of course you can always call that pharmacy, the bottom line is you need to follow your facilities policies, its probably ok to do either and this is your preceptors preference in that case follow her lead till you are on your own...as far as other threads posting they would never hang a med ivpb and leave it there so unsafely, I offer the question what do you do when you have a Sickel cell pt who is getting 10mg iv dialudid q 2 hours???? no, a pca is not going to be ordered...eveywhere you go you will find people leaving narcs running unlocked, another good example is morphine drips which you will find many places do not secure...just food for thought....

We do have a pharmacy website and I am quite familiar with it. The website gives you how you CAN give it, not how you SHOULD. To be honest I didn't even think there was a problem with leaving the med unattended until I read it on here. Sometimes AN makes me even more nervous than I was before.

I think I might ask around to other nurses, see how they do it. Once I am off orientation I can make my own decisions regarding IVP vs IVPB. Thanks all!

nurseprnRN, BSN, RN · Dec 14, 2011

maybe, maybe not. as one poster says, "iv" for a med that can be given more than one way calls for clarification from the provider, not your choice. for example, i would not be happy if i found my chf patient got extra fluids in the amount of a couple of hundred cc/day. your instructor should upgrade her skills, not engage in making those decisions which have their own serious consequences (as noted-- with a push med you can be there if anything happens). . :twocents:

wooh, BSN, RN · Dec 14, 2011

Is this a peds unit? Peds nurses can be really paranoid giving narcs.

I tend to give narcs over a couple minutes. I dilute only to make it easier to push slowly.

Isabelle49 · Dec 14, 2011

If the physician want the drug given IVPB he must order it as such. If pain meds are ordered IV, it is understood to be IVPush. You should not leave a narcotic hanging around in a bag anywhere on the unit, you must monitor the medication to make sure it doesn't stray (if you know what I mean). The only IVPB narcotics I know of are given via a pain pump, where the bag containing solution and medication is locked inside the pump and a password code is needed to adjust dosage. This prevents tampering.