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New Nurse - safe practice question

Hi am am a relatively new nurse (less than 6 months) and wanted some feedback from experienced nurses out there regarding a safe practice issue. I was pulled aside by my nurse manager and "counseled" for administering an intermittent infusion of 40 mg protonix in 100cc NS over 15 minutes (400cc an hour) through a working and patent 22 guage IV catheter. Davis Drug guide states intermittent infusion 40 mg in 100 NS over 15 minutes. Hospital policy states a 22 guage catheter is sufficient and preferred for patients recieving intermittent infusions. No other policy exists to contradict this (I am sure many of you are used to doing this IV push iin 10cc over 1-2 minute for an effective rate of 3-600cc an hour... but we are prohibited from pushing most meds as this is a teaching hospital and apparently problems have occurred). I have been told that this was not safe and that no infusions should run faster than 200 cc an hour through a 22 guage, and it is customary to run the protonix over a whole hour. Like I said, I am relatively new, and want to know if I am in error when it comes to what are generally considered standards of the profession. I felt I acted in accordance with policy and recommendations of drug guide literature. I took the crticism as constructive and agreed that I will run it over an hour in the future and limit my infusions to 200cc or less, but I really want to know if what I did is unsafe. Any insight is greatly appreciated.

Scott

Dixielee, BSN, RN

Has 38 years experience. Specializes in ER.

No, what you did was not unsafe practice but sounds like you may not have followed hospital policy. Sometimes I think policies are purely arbitrary and serve to help no one. You just have to learn what is OK in your hospital and what is not.

I worked at a large teaching hospital whose motto was: There is the right way, the wrong way and OUR way. Once you learn their way....no problem.;)

the thing that kills me is that there is no policy at the hospital directly relating to this drug or to IV infusion rates. The 22 guage is mentioned in policy as preferred for this type (intermittent) infusion. We are instructed by policy to refer to a nursing drug book - this max flow rateit is a unit custom - not written anywhere but apparently followed by "everyone". By the book I think I was 100% correct. How the heck is one to know?

Dixielee, BSN, RN

Has 38 years experience. Specializes in ER.

I agree you were 100% correct. Can you ask your nurse manager where the policy can be found or have you already? If you feel uncomfortable asking you might phrase it as you are trying to learn everything as fast as you can, but some things seem to be out of sync with what the drug book and other resources note.

It is not easy being a nurse, and even more difficult being a new nurse. Just go with the flow, try not to let the "pickiness" of others get to you, and know you are doing a good job.

We need more new nurses, somebody needs to be around to take care of us old ones as we fall apart! Thanks for being thorough.

CritterLover, BSN, RN

Has 21 years experience. Specializes in ER, ICU, Infusion, peds, informatics.

we run iv protonix over 15 min. comes labeled from the pharmacy that way, though i think it comes in 50 cc, rather than 100 cc.

as for running it too fast through a 22g, the only problem really would be if the size of the catheter prevented it from going that fast. really, unless you are using a power injector (like they do for some ct scans) or have high pressure limit on your iv pump set way high, the max rate for a particular size iv is self-limiting. that is, if you are trying to infuse something too fast, the iv catheter won't let you. if the rate is too high for the catheter size,l the pump will generate too much pressure in its attempt to infuse, causing the pump to alarm.

hope this makes sense.

i think i'd ask to see a copy of the policy you violated. since you were unable to find it, and it must exist ;) , your supervisor needs to show it to you, and show you where to find it, in case you have questions in the future.

by the way, i work in an outpatient infusion center, and the vast majority of the ivs we start are 22g. i've never seen an 18g (we don't do blood), and a 20 g is rare. we're more likely to do 24s than 20s. we do many infusions that run faster than 200 cc/hr. in fact, the standard mix of vanomycin is in 250 cc ns, and it is usually run over one hour. if we run it through a peripheral line (central line is preferred, but we can do it through a piv for short-term), it is usually through a 22g, since the smaller catheter size allows blood flow aroud the iv catheter, causing better hemodilution of the vanc, and less risk of phlebitis.

so, that max rate on a 22 g may be hospital policy, though i'd doubt it until i saw it in writing. if it really is policy, it really needs to be changed!

Thanks for the encouraging words Dixie. This all comes at a time when I'm starting to discover how backbiting some of the staff can be and how quickly they jump to the conclusions about me and seem to want me to not fit in there (apparently some of the staff is not comfortable that I am comfortable there, I'm a new nurse but have been in hospitals for years). It's unfortunate bacause it is a great hospital. I can deal with all that, but I really took the unsafe practice accusation to heart.

I have emailed the issue to our unit educator for feedback since I am not sure what my manager is thinking.

I understand 100% Critter and thanks for the insight. I knew I wasn't crazy

Dixielee, BSN, RN

Has 38 years experience. Specializes in ER.

I have emailed the issue to our unit educator for feedback since I am not sure what my manager is thinking.

I hate to mention this, but it is a fact of life, but be careful when going "above or around" your nurse manager for information, especially if it may contradict what she may have told you. You do have to look at the politics of the situation, even when there should be none.

You are only looking for clarification on patient care and safe practice, but your manager may see it as going behind her back. Just be careful. Sometimes you have to tip toe around some issues.

It is not like our job is not hard enough, but we also have to be careful not to step on the tender feelings of some around us (I say that with a large degree of sarcasm, but it really is true).

Good luck, and keep on keeping on. Sometimes the price is too high for proving you were right. Knowing it for yourself has to be enough.

annmariern

Has 30 years experience. Specializes in vascular, med surg, home health , rehab,.

fifteen minute infusion

protonix i.v. for injection should be reconstituted with 10 ml of 0.9% sodium chloride injection, usp, and further diluted (admixed) with 100 ml of 5% dextrose injection, usp, 0.9% sodium chloride injection, usp, or lactated ringer’s injection, usp, to a final concentration of approximately 0.4 mg/ml. the reconstituted solution may be stored for up to 2 hours at room temperature prior to further dilution; the admixed solution may be stored for up to 22 hours at room temperature prior to intravenous infusion. both the reconstituted solution and the admixed solution do not need to be protected from light.

i learned something tonight, pharmacy told me to give over 60 mins. personally, wouldn't give it at 200/hr through a 22, learned the hard way, unless its a emergent med, why risk blowing the line? agree with the last post; not worth the confrontation. unless it was written up. if it was you have the right of reply at least. usually though, it just isn't worth the trouble. you didn't harm your patient at all. and you the back up to prove it. sometimes its better to pick your battles carefully because as a new nurse, you need your co-worker's support. hell we all do:sniff:

I understand what you mean by the politics. I actually sent the question to my manager as well and let her know I was seeking furher information from the unit educator because I still didn't understand where to get the info and why I was "wrong".

I guess it does make sense to do it at a slower rate, and I will in the future - I was just distressed by the accusation of unsafe practice

thanks everyone for the insight and advice

Call me crazy, but we are a teaching hospital too, and we push many IV meds - we mix our IV protonix in 10CC and push over 2-3 minutes. Also, some of our higher dose vanco and even some chemo drugs run at up to 500 an hour (uaually they only go for one hour). We use 22s, 20s, and rarely 18s (we do give a lot of blood, but you can give blood through a 20). We also have a lot of central lines, PICCs, ports, etc. I guess I just don't get the connection - what does being a teaching hospital have to do with the IV rate?

nursemary9, BSN, RN

Specializes in Psych, Med/Surg, Home Health, Oncology.

Call me crazy, but we are a teaching hospital too, and we push many IV meds - we mix our IV protonix in 10CC and push over 2-3 minutes. Also, some of our higher dose vanco and even some chemo drugs run at up to 500 an hour (uaually they only go for one hour). We use 22s, 20s, and rarely 18s (we do give a lot of blood, but you can give blood through a 20). We also have a lot of central lines, PICCs, ports, etc. I guess I just don't get the connection - what does being a teaching hospital have to do with the IV rate?

I also work at a Large Teaching hospital--Level 1 trauma Center. we give MANY IV Push drugs, fewer IVPB.

We do most of the vanco over 1 hr.

I am Chemo/Onc/hem. as the above poster said, we give many chemo infusions over 1 hr--large volumes.

Mary Ann

protonix is given IV push where I work

I am told the IV push limitations at the hospital are the result of an intern physician pushing a vasoactive drug on an unmonitored patient and crashing them. The facility just saw it as easier to limit push meds to those that absolutely need to be pushed.

It's more than just a "teaching hospital" - it is a university hospital with a medical school staffed entirely by interns and residents so the policies tend to be very conservative in order to minimize harm even if a mistake is made

In an interesting side note related to my original post. I talked with my manager again today and she brought up that the order actually read to run at 400cc an hour (this was 3 weeks ago so I don't really remember) She has backed down on the "unsafe practice" but is saying I really should have questioned the order as being too fast for the general population of our unit.

I don't mean to offend anyone with this, but Med-surg people are just crazy.... I need to go back into psych : -)

It actually turns out that I am recieving an unsatisfactory six week eval (after 10 weeks on the job)- not over this incident but over a misunderstanding. I was overheard to tell a patient that "nursing sucks". This was apparently overheard by one of the medical interns/residents. It ends up being something we would typically expect of a physician - not listening. The patient was talking about her niece going to nursing school and we were having a candid conversation. She was telling me about the difficulty her neice was having. I told her that nursing school sucks (perhaps I could have chose a better descriptive) and that is is tough. The conversation was really leading into me telling her that despite the difficulty of school, it is all worth it once you move into practice. This somehow turned into me hating nursing. The patient was nervous awaiting a thoracentesis and I was sitting with her and trying to be therapeutic by diverting her from her worrying and focusing on an "everyday conversation" (I've been a psych counselor for the last 5 years and know a thing or two about therapeutic communication). Anyway, turns out that the protonix issue was pretty much part of a witch hunt as my manager was amassing enough to fail my probabtionary period. She changed her mind after we talked and felt the whole situation was misinterpreted. However, because of the physician complaint she is forced to give the unsatisfactory eval.

I am not the type of person who can walk on egg shells with what I say - though I would never say anything inappropriate or anything that would make a patient uncomfortable. I am a better counselor than a nurse - I dare say I am likely a better counselor than my peers are nurses. I am not going to say something to jeopardize the psychological safety of a patient - it just isn't going to happen. I feel like I need to keep my head down, mouth shut, and just do my nursing tasks. That's not a nurse to me though, a robot could do that. I actually do hate the task focus aspect of nursing (prioritizing, etc is necesssary but very dull to me) - it's the human interation that makes it worth while to me

Those of you who might have been in such a position, do you think this is a good time to start looking elsewhere while I am employed there rather than risk the possibility of termination in the future and have to explain myself when looking for another job?

personally?

it sounds like you need to reflect a bit.

keep what is worth keeping and blow the rest away.

self-righteousness will not help you grow in your role as a nurse.

best of luck.

leslie

Earle, wise words no doubt. I take seriously anyone who would quote the wisdom of the dalai lama. I am not trying to be self righteous, I just know my strengths. I think it is fair of me to assert my skills in interpersonal communication. I readily admit my ignorance in nursing.

I guess what I am really seeking is insight into the minds of management. I have basically given a warning and assurance all will be forgiven and forgotten. I'm not sure I should trust that.......

Earle, wise words no doubt. I take seriously anyone who would quote the wisdom of the dalai lama. I am not trying to be self righteous, I just know my strengths. I think it is fair of me to assert my skills in interpersonal communication. I readily admit my ignorance in nursing.

I guess what I am really seeking is insight into the minds of management. I have basically given a warning and assurance all will be forgiven and forgotten. I'm not sure I should trust that.......

you take constructive criticism well. :)

you're talking to an old cynic here, who happens to have been burnt by mgmt.

if someone wants to get rid of you, they will.

as for the motives of your nm, i don't know.

but i would proceed cautiously.

don't be a robot and lose your personality.

but take good notes and as someone advised, pick your battles wisely.

i think it's safe to say with nursing, one has to cover their butt at all times.

leslie

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