meds

Can I piggyback a sort-of similar question onto your thread?!

What about fluid boluses. How do you know how much to give? Say a 500 cc bolus - do you just learn who can handle this and who can't over time? Is there some sort of formula that I haven't been taught regarding this?

Feeling pretty stupid about this.

Amanda

Boluses: it depends on the pt's weight if peds and general health and need for a bolus for adults. For someone with kidney failure you don't want to give too much of a bolus.

Nurse draws: discard the first 5 mls.

Central vs. heplock: save the central line at all costs because of the proximity to the heart. Use the heplock. For caustic meds you can dilute them in a syringe before pushing them.

Diluting: are you talking about diluting before putting in a piggyback bag? Meds are usually diluted with sterile water before being placed in the appropriate piggyback solution....usually normal saline. I may be wrong but the only med I can think of that NEEDS to be diluted in D5W is nitro, and that is dripped in so slowly that it shouldn't be a factor. Then again, I am an ER nurse and pts on nitro drips are never with me for more than a couple of hours!

Just my thoughts:

1) If I've got a central line, I use it. Dump everything into that big fat turbulent flow. Flush the Heplock q shift per facility protocol to keep it patent. If I had maintenance fluids, that's what I'd probably run in there.

2) I'm trying to think of one that's D5W only. Halperidol? But that can be administered straight. Maybe someone else has an opinion here, but if that's the only way it can be diluted for push, then I'd do it. D5W provides 5 grams of dextrose per 100ml. If you dilute in 10ml D5W, you're supplying 0.5 grams dextrose. There's 4 grams per teaspoon, so... 1/8th teaspoon? They sneak more than that when you're not looking.

3) It really depends. I rely on a couple sources. First, hospital policy. For many IVP medications, my facility has established guidelines on this, including meds that can be pushed by LPN's and those that can only be pushed by RN's, and times for some of them (1,2,5 minutes.) If policy is silent, check with your drug handbook. If you're still not comfortable, call your pharmacy - they're a wealth of information. Use them any time you have concerns about administration, compatibility, etc. They should have the latest information.

4) Again, facility policy will rule. If drawing on a direct stick, just take the blood that comes. If an IV site is used, we discard the first 10ml, take the sample, and then flush with 20ml of NS. If the site has something running in it, stop the infusion for a couple minutes before.

Best regards -

Lee

Central vs. heplock: save the central line at all costs because of the proximity to the heart. Use the heplock. For caustic meds you can dilute them in a syringe before pushing them.

See, now I'm more inclined to use the central line because the more it's being used, the less likely we are to get fibrin growth and occlusion in it. What's the current thinking on this?

Lee

I would definately use the central line. It is there and it is a heck of a better IV than a peripheral IMHO. I would still keep flushing the saline lock/heplock to keep it patent.

What is an IV push med could only be diluted with D5W but the pt was diabetic. What would you do?

I can not think of any IV push meds that HAVE to be diluted with D5W. But I would double check with a drug book or a pharmicist. If something did have to be diluted with D5W, it wouldn't be a very large amount for a push so I would go ahead and use it.

On diluting IV push meds before administering, I go with policy and/or drug book suggestions/guidelines.

If I am sticking a peripheral vein for blood I clean the site and stick and use all the blood I can get. For central lines or VADs/PACs, I follow our hospital's policy (usually 5-6 ccs of blood is what is recommended by our policy).

Fluid boluses: It depends on the patients history. If you have an order for a 500 cc bolus and the patient has no history of cardiac or renal problems, I let it go in as fast as I can get it in, especially if they are hypotensive or bleeding out somewhere. If they have a cardiac or renal history, I would clarify with the MD if it would be ok to give it over an hour or two-most will specify "500 cc bolus over 2 hours".