So I was curious and began reading old threads about narcotics being given IVP vs IVPB. I thought I would get some input on my particular situation.
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.
Where I work I've never seen an MD specify between a push and a piggy back, they're only responsible for specifying the route. Pharmacy and Nursing are responsible for knowing how to properly administer the drug.
So forgive my ignorance, but how does it work when you give something like morphine as a piggy back? Is it given over 5 minutes or an hour? How do you chart when the med was given? (do you chart when you started the infusion or when it finished or somewhere in between? How do you define piggy back (Y'd in to a running line or is it a secondary)? Is the purpose to be able to evaluate the patient after a partial dose?
Wouldn't you need a MD order if you wanted to PB?? I mean, what you can just pick up a bag of NS, mix and give?? I wouldn't do that. IV is IV, not a PB. Just push slow and monitor, unless it is ordered PB or RPh says to do it that way. I wonder if to her it is a short cut. Spike the bag and let it hang and out she goes to the next patient until the machine beeps in 30 minutes. Although that doesn't really seem like a time saver.
It is not specified ever whether it should be IVP or IVPB but if you look on the pharmacy website it states you can either give it IVP over whatever minutes or IVPB in NS or D5. While it would be nice for it to be specified I don't think it NEEDS to be? I mean, IV is a route and whether you give IVP or IVPB it's still being given IV so it's not a med error.
No, I don't think it's being used as a time saver by my preceptor. I think she truly is just uncomfortable giving narcs.
I'm curious to know how much experience your preceptor has. To me it seems more new grads are being precepted by nurses that barely have any experience themselves.
Huh. Interesting. Used to be an onco nurse and have given a bunch of IV narcs. Never once ran them IVPB. The only time we ever ran anything IVPB as a rule was zofran in doses larger than 8mg (or was it 12?, I can't remember for sure) or a dex/zofran pre-med.
But a nurse just can't hang a bag because they want to. If it is stating either, but the MD hasn't specified to hang it with NS, you just can't do it.
For example: Most nurses knows when giving rocephin IM, it is best to reconstitue with lidocaine. However our bottles state it can be mixed with I think sterile water (or NS, cant recall off hand) or lidocaine. So now one must ask the doctor what would he/she like to mix it with. So we get orders for lidocaine right away.
A pharm book is just giving you options as to what is safe to do. It still needs to be physician driven. That's just my 2 cents worth.
I have never given narcotics ivpb ever. Just push slow. What is your hospitals policy? I am curious how to chart. Do you chart time given as when you started or ended the ivpb?
I have a lot of concerns about the practice described of IVPB instead of IVP for pain medications. I think this may have stemmed from an incident in the past and the fear of having this occur again (Need more info). I would first want to explore the "thought process" for why this practice has become the standard for this nurse. I think we need to consider the following:
- Fluid status of the patient---could you be overloading the patient? Is this recorded on I/O? ---think about this from a 24 hour perspective. What if the patient is on a fluid restriction? CHF?
- How do you monitor and reassess the patient? Dilaudid for example is metabolized by the liver.....this can be a slow process for certain patients. Will she be monitoring these patients differently? Pain assessment should be done 1 hour after the medication is given?
-This practice sounds like a nurse-created PCA machine w/o an order. YIKES!--doing it her way...these patients should be on at least a continuous pulse ox monitor.
-The medication should be given based on the rights of medication administration with consideration to the concentration of the medication, how the medication is designed to be administered and within the scope of nursing practice.
-How is the medication kept secured when giving it IVPB
-If the IV infiltrates, how much of the pain medication would have been administered? Wasted? Is there affect of the medication on the tissue?
-How much of the pain medication is left in the IV tubing? Is that the full dose?
-I wonder how much pain control are these "PATIENTS" reporting?
-Why was 50ml and 30 minutes chosen? Why couldn't this be less? more? shorter? longer?
-Is the IV bag labeled? --From Pharmacy? Nurses should not be reconstituting medications at the bedside. This is out of the loop of what Joint Commission requires.
-Is this practice approved by the hospital? Quality? Risk Management? What does the hospital policy state?
-The drug concentration is being altered. The medication is most likely less potent and will not have the same desired affect. These patients may report uncontrolled pain, and then may be perceived as "med seeking" when they aren't being appropriately managed.
-I think the decision to do this maybe out of the scope of practice for nurses. She is now deciding how to administer a medication with concentration, strength, rate, fluid selection, etc.
-When the physician prescribes IV it is meant to given IVP....IVPB is written IVPB (which is usually for medication that are required to be given over a longer period of time or if the concentration is higher).
-If the physician did write for IVP, would she still give it that way?
-Could she be diverting? (Not trying to be funny).
I agree that we should do the best for our patients. I just think that in this situation it may not be the best. I would recommend that you do what you think is best for your patients.
no, i don't think it's being used as a time saver by my preceptor. i think she truly is just uncomfortable giving narcs.
it's really not my style to come off as harsh, but if she has a problem giving narcs, she has no business working in a surgical unit. really, this is a personal problem of hers that needs to be resolved. patients should not have to pay for her discomfort with their own. post op pain can be really severe, especially at first. those patients need pain relief. there are studies out the wazoo showing that patients whose pain is relieved are more likely to walk postop, do their coughing and deep breathing exercises, etc., thus avoiding adverse outcomes than those whose pain medicine is declined by the patient or withheld by either fearful or judgmental doctors and nurses. given correctly, using solid nursing judgment and proper monitoring, there is no reason to fear narcotics like the op's preceptor apparently does. the post asserting how patients can easily od is not accurate in my opinion if a nurse is doing her job properly. and the conrad murray example really doesn't apply. that was not a narcotic, it was a general anesthetic given in a home setting without proper monitoring equipment and lacking adequate supervision. that was an absolutely outrageous deviation from the standard of practice and had nothing to do with proper administration of iv narcotics.
I'm really surprised to see people saying you need an order to piggyback something. I have never seen an order for anything other than "IV." You can dilute things as much as you want as long as it meets the minimum as specified in the policy or instructions from pharmacy. For example if policy is to reconstitute a gram of Vanco with 20 ml SW and you only mix with 5 ml, that's where you're going to run in to problems.
In my facility, nurses on the floor are not allowed to push anything. They must use syringe pumps or piggyback. Nurses in critical care areas (ED, ICU, PACU) however can push everything that RNs are allowed to push per the BON.
Some nurses still use syringe pumps in my department (ED), but I prefer to push almost everything that can be pushed. Of course things like Abx need to go in the syringe pump, but narcotics, lasix, etc all get pushed.
You need to be familiar with your facility's policies. For example one place I work says up to 10 mg Morphine needs to be pushed over a minimum of 2 minutes and the other place says 10 mg should take at least 4-5 minutes.
If my pt has never had IV narcotics before or if it's an elderly person, I will push the first 1/4-1/2 of the dose extra slow to make sure they're tolerating it ok then will push the rest at the speed suggested by pharmacy/policy.
PBI: I work in peds and we push narcs all the time without issue. I work in a critical care area where this is allowed by hospital policy. Our floor nurses are required to use syringe pumps but don't have to slow the administration down by much.
Specializes in Acute care, Community Med, SANE, ASC.
I used to work on a spinal surgery unit where pretty much all I did was give narcs. I have never diluted a narc to give IVPB and have never seen anyone else do it either. Most of our patients were only monitored by pulse ox--very few on heart monitors. I will saying working on the spinal unit straight out of nursing school taught me to be comfortable with narcs.
MunoRN, RN
8,058 Posts
Where I work I've never seen an MD specify between a push and a piggy back, they're only responsible for specifying the route. Pharmacy and Nursing are responsible for knowing how to properly administer the drug.
So forgive my ignorance, but how does it work when you give something like morphine as a piggy back? Is it given over 5 minutes or an hour? How do you chart when the med was given? (do you chart when you started the infusion or when it finished or somewhere in between? How do you define piggy back (Y'd in to a running line or is it a secondary)? Is the purpose to be able to evaluate the patient after a partial dose?