Nursing Dose

allnurses Guide · May 23, 2015

Karou said:
This frustrates me more than anything else. The patient isn't getting the correct treatment. The next nurse suddenly has an agitated or distressed patient in pain, and there appears no reason why the pain or behavior is now uncontrolled. Because the previous nurse was giving higher doses.

You know what . . . .I just remembered! This happened to me as a new nurse. There was a certain nurse who would always overmedicate his patients and then on my shift, the pain would be worse. Very hard to assess what to do . . . .

Wow, I must be getting Early-Onset Alzheimers . . . . . I didn't remember that until just now. Granted, I was a brand new nurse.

Caffeine_IV · May 23, 2015

Yes I've heard of it. I've never had anyone recommend that I do it as that is outside our scope.

I'm sure some nurses do it and they would be wise not to speak of it. I don't think it's good practice. If they truly need more medicine then it is our place to advocate and ask not alter the dose. It really does not benefit a patient to give them your own version of sliding scale medicines.

Long Term Care Columnist / Guide · May 23, 2015

Absolutely not. I've been known to give the highest range dose for a patient in severe pain, but more often I've just called the doc and gotten better pain management. I would NEVER take it upon myself to administer meds without a prescriber's order. I've had to fight a few of them over the years because some are incredibly stingey with pain meds---I mean, plain Tylenol a mere three days after a total knee? I've seen them prescribe exactly that. But again, I wouldn't give something I'm not authorized to give. I worked hard for my license!

twinmommy+2, ADN, BSN, MSN · May 23, 2015

I'm not a fan of nursing doses. In the origional post, the example of 1mg vs 2mg of morphine wouldn't mean a hill of beans to someone having severe pain anyway. They would need a new order for more pain medication (imo).

For those times when it was tempting I just think that if a patient were to get more than prescribed, then the next nurse would come around with another similar dose but suprisingly not as effective, the patient may be upset and rightly so. They should be getting the prescribed dose every time unless their presentation makes a case for less/no medication to be given. Anything other than that is just setting either another nurse, you, or the patient up for problems later. Not to mention you don't have prescription authority.

SubSippi · May 23, 2015

Dranger said:
Yes I have, mostly in the ICU setting with haldol or Ativan in non tubed patients.
Sometimes nurses will run sedation like versed or fentanyl higher for a while as well and drop it back down. Never propofol though.
On the floor it sounds sketchy in the ICU when you want to avoid a 3am call to a sleeping doc it is more common. You can anticipate what they want usually. Is it the correct way? No but it happens

Exactly what you said. Except for where I'm from, it's called a Baptist dose. Not sure why.

Dranger · May 23, 2015

SubSippi said:
Exactly what you said. Except for where I'm from, it's called a Baptist dose. Not sure why.

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.

APRN., DNP, RN, APRN, NP · May 23, 2015

The thought of what could go wrong, is far to great a barrier for me to even attempt such a thing. I've spent too many years working on degrees to risk all of that on something like diversion of narcotics.

I have a lot of experience in the ICU, and you've got to be thinking long term for your patient.

Sure....THIS dose might do the trick, but what about one, two, or three hours from now?

I just don't have that kind of time to be dealing with all that extra covert action. Get the script and get on with taking care of the patient.

Tenebrae, BSN, RN · May 23, 2015

Quote
As hospice, I have parameters with drugs like Morphine Sulfate for pain and/or SOB.
When I worked ER - I had never heard of this "nursing dose".

We often would have meds charted for two things however the dose was still the dose and I would never give more than the charted dose. If the charted dose did not hold the pain I would ring the doc for a stat order

annie.rn · May 23, 2015

No. Never heard of that expression. I have heard of nurses giving the prescribed dose but then topping it off a little...i.e., if the dose calculation is .85 ml, they'd round it up to 1ml. Like when you add that tiny extra bit of gas to your car to make the price an even dollar amount.

I agree, though, that it's better to bite the bullet and call the doc for an increased dose than to keep chasing your tail trying to give a little extra here and there.

A pet peeve of mine is when nurses give two prn pain meds at the same time. i.e. an IV dose of Dilaudid plus 2 Norco. I was always taught to give one and if on reassessment it has been ineffective, then you give the other. Pts. get upset when I won't do it.

klone, MSN, RN · May 23, 2015

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.

Then there should be standing orders with ranges that are up to nurse discretion. This is a systems problem. You should fix the problem, not devise illegal work-arounds.

TiffyRN, BSN, PhD · May 23, 2015

Not in the NICU. Well, on a rare occasion I have known someone to overlook a super minuscule variance in a dose. For example, infant ordered 0.18 mg morphine which comes 2mg/ml. Some might overlook that the syringe amount is slightly above 0.09ml, but not as far as 0.lml.

I've heard that some NICUs would be "generous" in measuring "1/4" of a chloral hydrate suppository. In the context of an intubated infant on full settings.

In the adult world, I used the "nurse dose" when it would be stuff like phenergan 25mg ordered, vial is supposed to be 25mg in 1 ml, total volume: 1ml. But everyone knows those vials tend to be a smidge overfilled. I might give the whole vial which was 1.1-1.2 mls in reality. I would have been willing to do this with narcotic syringes but drug companies always seemed to be very accurate in filling those syringes.

RainMom · May 23, 2015

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.

^^^^^The only time I saw it was not on the floor but on a shift I floated to ICU. I had a pt with confusion, agitation, alcoholism hx & was repeatedly trying to get up although his legs would not support him. No PRN was ordered. Called the doctor & he prescribed ativan 0.5mg q 8hrs prn.

Really? Q8hrs?

I did not have access to the pyxis & another nurse had to pull it for me. She also went ahead & wasted the extra amount with a second nurse but then proceeded to hand me the entire 2 mg "wink, wink, just in case". I was a little dumbfounded. I gave the 0.5, wasted the rest, the pt settled down & we got through the last couple hrs of the shift (I was only there for 4 hrs filling in). Had I been there longer, I no doubt would have been making another call to the doctor (& wouldn't feel bad about that at all since HE was the one giving such a stupid inadequate order the first time).

Nursing Dose

Have you ever given a nursing dose?