Nursing Dose

[guest449786]

On orientation, at a previous facility, I was told about nursing doses. Normally it involves giving extra narcotic to a person in severe pain. This occurred in a emergent setting where patients would have been ordered Morphine 1mg IV and the dose comes in 2mg vials. The extra 1mg was to be wasted and witnessed. However, if a nurse determined that may not be enough due to the severity of pain, weight, past history, etc., they may decide to give 1.5mg and waste the .5, etc.. I have not heard about it outside the emergent setting, but I'm guessing it occurs in other areas.

Have you ever heard the term "nursing dose"? How do you feel about it? Have you ever given a "nursing dose"?

[APRN., DNP, RN, APRN, NP]

Dranger said:

Exactly, I don't think people here fully understand what it's like to stop someone from coughing out their ETT or ripping all their lines out. Nurses don't have time to call a doc covering 5 hospitals for more sedation orders in a tenuous moment and not every floor has a protocol for more.

I want to know what court cases on hemo stable patients involved a nurses bumping Versed from 10 to 15 or fentanyl from 75 to 100. I have never seen nurses pull out meds not ordered but most physicians I have discussed with are surprised when we just didn't bump sedation above the range or give more versed pushes even when it exceeds parameters. Many of the pulm docs just look at the titration range as a guide but not set in stone. They don't understand that we have to go by it technically.

Docs are in the room for 5 min we are there for 13ish hours...it's frustrating.

Now I can see why people get upset when excess morphine or dilaudid is being given to patients on the floor. Usually there is an awake hospitalist and there is no excuse for something like that.

We have a dedicated Intensivist in my CCU. The Hospitalists are not allowed to write orders, because it is a closed ICU.

Delirium assessment tools are Evidence Based Practice. I didn't just dream up the CAM-ICU assessment tool for Delirium. Trial, after trial, after trial, after trial, refutes your claim of their stupidity and uselessness.

You state that you are in a Grad program, so I am going to assume that you are familiar with research, EBP, and the ABCDE Bundle, since you work in ICU.

[Dranger]

®Nurse said:

We have a dedicated Intensivist in my CCU. The Hospitalists are not allowed to write orders, because it is a closed ICU.

Delirium assessment tools are Evidence Based Practice. I didn't just dream up the CAM-ICU assessment tool for Delirium. Trial, after trial, after trial, after trial, refutes your claim of their stupidity and uselessness.

You state that you are in a Grad program, so I am going to assume that you are familiar with research, EBP, and the ABCDE Bundle, since you work in ICU.

I am aware of all those bundles and we implement all of them. A bundle isn't going to stop a patient from getting agitated and trying to buck the vent or pull out lines. So I don't know where you are getting at....Even non delirious patients do that. EBP states that most ICU patients will get delirium if they are vented or in the same environment long enough.

However, like I said I don't need an algorithm to determine delirium. Of course hospitalists do not cover ICU patients but we don't have an intensivist in house. They are on call only at night for admissions and critical issues, covering 5 hospitals. If I had one in my back pocket at all times we wouldn't be discussing this. Must be nice to have that resource.

[SubSippi]

Susie2310 said:

I find this attitude very arrogant, and illegal. If one wants to practice medicine, one should go to medical school.

To avoid a 3 am call to a sleeping doctor, for your own convenience you are willing to practice outside your nursing scope of practice and illegally practice medicine?

Since you are not trained as a physician, how can you or any other nurse possibly know fully why the physician ordered the medication dose as he/she did? Others have pointed out some of the possible consequences for the patient and for the continuation of care of the patient. How can an adverse patient outcome from practicing out of scope of nursing practice in this way be detected and addressed if one has falsely documented that one gave the original dose the physician ordered? Does the nurse who gave the "nurse dose" admit to the physician that he/she exceeded their orders in administering the medication? So, basically, the patient may have an adverse outcome, and the outcome will be attributed to something other than the "nurse dose", and treated as such. This is illegal, unprofessional, and unethical. It is the nurse's duty to obtain appropriate orders for the patient.

Out of curiosity, what area of nursing do you work in?

[calivianya, BSN, RN]

®Nurse said:

We have a dedicated Intensivist in my CCU. The Hospitalists are not allowed to write orders, because it is a closed ICU.

I need to come work with you! Sometimes the intensivists "discharge" our patients way before they get transferred out, and then I just have patients on the hospitalist service that takes 45 minutes to call me back when I page them because they're covering for the whole hospital, while the intensivist is sitting two desks down but I can't talk to him about my patient because he's not consulted anymore... the frustration is unreal. Just so, so stupid.

We assess CAM-ICU qshift and PRN but I have found it more useful in the more stable patients than the critical ones. The ones with a CO2 of 100 who are nearly obtunded but still semiconscious enough to thrash and try to pull masks/ETTs out can't even squeeze my hand when I ask them to, let alone when I say the letter "A" - what exactly am I learning from this?

Besides, we can't give the patients uninterrupted sleep, so all these tricks to minimize delirium are BS. Even the lightly sedated ones end up with delirium because of how much they get messed with. We are waking up every two hours to turn, at least every six hours for a blood sugar (more like every 2 if too low or too high), lab comes around somewhere in the 0300 range if the patient is a stick, CXRs are done around 0400, respiratory comes around 0500 to do ABGs, then there's the ten million IV pumps alarming at all times, the monitor alarming every time the patient rolls over because it thinks the patient is breathing 180 times per minute, tele techs calling to report that "V-tach!" that happened the last time a roll was particularly convincing. I wouldn't even give myself 20 hours as a patient before I started developing those early delirium signs.

[Dranger]

calivianya said:

I need to come work with you! Sometimes the intensivists "discharge" our patients way before they get transferred out, and then I just have patients on the hospitalist service that takes 45 minutes to call me back when I page them because they're covering for the whole hospital, while the intensivist is sitting two desks down but I can't talk to him about my patient because he's not consulted anymore... the frustration is unreal. Just so, so stupid.

We assess CAM-ICU qshift and PRN but I have found it more useful in the more stable patients than the critical ones. The ones with a CO2 of 100 who are nearly obtunded but still semiconscious enough to thrash and try to pull masks/ETTs out can't even squeeze my hand when I ask them to, let alone when I say the letter "A" - what exactly am I learning from this?

Besides, we can't give the patients uninterrupted sleep, so all these tricks to minimize delirium are BS. Even the lightly sedated ones end up with delirium because of how much they get messed with. We are waking up every two hours to turn, at least every six hours for a blood sugar (more like every 2 if too low or too high), lab comes around somewhere in the 0300 range if the patient is a stick, CXRs are done around 0400, respiratory comes around 0500 to do ABGs, then there's the ten million IV pumps alarming at all times, the monitor alarming every time the patient rolls over because it thinks the patient is breathing 180 times per minute, tele techs calling to report that "V-tach!" that happened the last time a roll was particularly convincing. I wouldn't even give myself 20 hours as a patient before I started developing those early delirium signs.

Do you work where I work? hahahahaha

[Kooky Korky, BSN, RN]

calivianya said:

I wish I knew how physicians wanted us to handle these situations... the sedation problem is a continuous one at my job. This is a situation I run into at least twice a week, bare minimum, especially with vent patients. They get ICU delirium, they try to pull everything out, and the physician wants to decrease sedation so the person can get off the ventilator, but when you are decreasing sedation, the patient is more able to pull out lines and tubes. Either you snow them and they stay on the vent forever and never get to go home, or you risk them pulling things out. There's not really a happy medium if the patient is confused, and we all know the soft wrist restraints aren't perfect. Sometimes Precedex helps, but often it does nothing and the patient is still agitated.

I have used my chain of command before but that takes time, which you don't always have if an emergency is happening right then.

Get your bosses involved. If your NM can't make docs do right, Admin can.

It's so convenient for all of them to leave your tail naked in the wind. Don't let them do that to you. You must follow the law. Don't let them try to make you do otherwise.

No one will go down with you when you go. They'll be on the golf course or at the tea party. You'll be in court and then on the bread line.

[Meriwhen, ASN, BSN, MSN, RN]

OP, what you describe is illegal. Involve a controlled substance, and the trouble increases threefold.

IMO, I would not put my license on the line by engaging in this practice, even if it were taught to me by my school. Because I know that such a practice is NOT covered in my nursing scope of practice.

And do NOT think for one minute that the doctor/prescriber/hospital is going to back you up should something happen as a result of this "nursing dose." You'll be hung out to dry--and rightfully so.

[Meriwhen, ASN, BSN, MSN, RN]

Dranger said:

I am not saying it's right and I am not saying I do it but the people on this thread that are appalled probably don't work in a intensive care setting where you need to bring people down fast for their safety and healing.

I do work in such an environment: psychiatric ICU. No, my patients are not likely to die in the next 5 minutes as they might in a medical ICU, but they certainly do require being brought down very fast for the safety of themselves, the other patients and the staff. I've seen other nurses do this "creative" dosing, so it happens here too. But I still can't endorse it.

I leave other nurses to come to their own ethical decision regarding the practice; I'm just not under any delusions about what this is or isn't.

I value my license too much to work outside of my scope, and if doing that puts me in the "holier than thou" category, then I guess I'll get my harp and halo ?

[guest449786]

Meriwhen said:

OP, what you describe is illegal. Involve a controlled substance, and the trouble increases threefold.

IMO, I would not put my license on the line by engaging in this practice, even if it were taught to me by my school. Because I know that such a practice is NOT covered in my nursing scope of practice.

And do NOT think for one minute that the doctor/prescriber/hospital is going to back you up should something happen as a result of this "nursing dose." You'll be hung out to dry--and rightfully so.

I am aware of what is legal, illegal, and what falls within the scope of practice for RNs in the state that I reside and practice in. I did not say that I agree, advocate, or engage in this behavior. When an individual initiates a topic or subject, controversial or not, it does not mean that they engage in this behavior. I never witnessed it and only had the discussion with a co-worker.

There are a lot of commentators on AN who believe they hold onto some secret knowledge, "that's illegal", that only they have access to and "share" it repeatedly. Perhaps this isn't the best place to have open and honest dialogue. I'm aware how easily an account can be traced, and that's part of the reason that "open" and "honest" dialogue can not take place in this type of forum.

My attempt was to have a discussion and not be chastised and accused of something I have never stated or implied that I took part in. I've been in nursing for almost four years now and it's come up several times. I'll be sure to not bring it up again.

Thanks.

[MunoRN, RN]

®Nurse said:

I would like to suggest trialing the CAM-ICU or another similar delirium assessment tool in order to prevent oversedation and delirium.

To be fair, the use of CAM-ICU is not intended to prevent oversedation and delirium, it's only intended to assess for already existing delirium. And while it's more accurate than other delirium screenings, which are notoriously inaccurate, it has yet to be proven particularly useful in changing how we treat patients with delirium.

Aside from a relatively small initial single-center study, the bulk of evidence on the use of CAM-ICU shows it to be fairly inaccurate, rarely achieving greater than 50% sensitivity and specificity in the same study.

When compared to a nurse's ability to recognize delirium without such a tool it's never been established to improve recognition of delirium, and more importantly it's never been shown to improve treatment of delirium. It's only apples to oranges comparisons that suggest a difference; comparing patients that nurses have recognized as being likely to receive medical treatment orders for delirium is compared to patients who are CAM-ICU position does show different rates, but only means something if every patient who is CAM-ICU position tends to be medically treated.

[cree0165, LPN, LVN]

I don't give anything that isn't ordered. Never heard of nursing dose.

[cardiacqueen]

No, this is outside of our scope of practice. Unless you have parameters. One of our surgeons, for example, will put 3 different orders for morphine - eg. 2 mg for mild pain, 4 mg for moderate pain, and 6 mg for severe pain.