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"?

[Susie2310]

calivianya said:

Let me throw out a hypothetical to everyone who would never give additional meds. You have a patient who has been trying to pull out his lines all night despite sedation. You have given everything else you can give and he is asleep most of the time, but occasionally he wakes up and he is nearly able to grab his femoral central line when he does despite wrist restraints. He is currently off the chain, thrashing in the bed and clawing at his gown. You tried to get a safety sitter, but staffing doesn't allow one. You had just called for more drugs and the physician didn't want to give you anything else. You had just given the ordered 0.5mg of Ativan and you might as well have pushed saline. He is on a high-dose heparin drip, so there is a real possibility of him bleeding a lot very quickly if he pulls that central line out. He currently has his hand around the line. You have 1.5mg of Ativan left in that vial, and you can't sit and hold his arms down all night because you have another patient.

Do you let him pull his line and bleed out, or do you give him the Ativan?

How does the physician expect the hypothetical nurse to handle this situation?

Did you use your chain of command (hypothetical nurse)? Who is the next person in the chain to contact to help the nurse obtain appropriate medical orders for the patient?

[annie.rn]

AJJKRN said:

See I was taught to give both, especially when someone's in severe pain because the dilaudid would have a faster onset and wear off quicker and then the PO nor I would hopefully be kicking in in 40+ minutes and be more effective because the Pt's pain wouldn't be so high when they did. How I was taught in pharmacology and it's makes sense to me but I grew up on a surgical trauma floor. I don't see the point in spreading it out and causing more unneeded stress physically and mentally on the Pt's body unless the pain has been reasonably controlled and the norco has been given round the clock and the IVP is just being needed/used every so often for breakthrough. This is why I generally respect the differences in how each individual nurse practices if it happens to be reasonable and within their own comfort, experience, and education and when the Pt ever questions the difference, I don't talk negatively of the other nurse but explain that we all practice somewhat differently.

I understand where you are coming from. I'm more concerned though when the pt. hasn't been given both at the same time before and because the pt.'s pain level is high the nurse gives both. I see that fairly often. The administering nurse has no way of knowing if one or the other would have been effective on its own before doubling up. That's more what my pet peeve is.

Plus, I'd rather give an IV dose of something and see if it works than give both at once b/c if it doesn't work then I still have options to give something else. I guess you could call it breakthrough meds for the other breakthrough meds...ha, ha. ?

Like you said, guess it comes down to a practice preference. I was taught to do it the way I do it. I, too, am very careful never throw the other nurse under the bus.

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

Dranger said:

Oh yes all the holier than though nurses are coming out of the woodwork! Instead of using critical thinking skills they go to attacking a license bla blah

Heres an example, sometimes docs write a default order for a fentanyl or Versed drip at 25-50 or 1-10. There are not hard set upper limits for these drugs like Propofol

Docs want patients sedated to a RASS of 0 to -2 usually and if the drip doses in the MAR aren't doing the trick I have see some experienced nurses up them a bit and get the order changed in the AM. If the patient was going nuts of course they would call for for an additional sedative. The patient is on a vent so as long as they are hemodynamically stable and the RASS is goal I have not seen a bad outcome. The goal is to keep patients calm for their own healing then follow up in the AM.

For all those holy and righteous nurses, I am just repeating what I have seen so calm the "arrogance" jiving.

On a side note this is why I went back to Grad school....so I can call the shots and not be stuck in the well you better call the doctor they know what to do world.

Holier than Thou?

Have you ever observed what happens in a courtroom when the nurse is desperately trying to explain what they did because "everyone does it"? It is extremely humbling to watch. I don't recommend giving a "nurses dose".

I am in Grad school as well, but even that won't let me operate outside the letter of the law once I graduate.

[klone, MSN, RN]

No, it really isn't "holier than thou" to express surprise and consternation that there are nurses admitting that they give more than the ordered dose of a medication rather than getting an order for more meds. It's called breaking the law, it really is a big deal, and you can lose your license. Is it really worth taking that risk? I'm honestly appalled that anyone would think it is.

[klone, MSN, RN]

imintrouble said:

There's not single MD I trust enough to cover me if I did.

And there is the rub. If things went south and TPTB became aware of this practice, I can guarantee you the provider is NOT going to have your back.

[CelticGoddess, BSN, RN]

Kooky Korky said:

True. But how many of you actually watch a colleague do the actual wasting? A lot of nurses seem to think it's insulting to truly watch their peer really waste something. They just sign that they did, seems like.

Everyone I work with on the unit watches the waste. And when you watch a co-worker get escorted out by the local PD, through the main hospital in handcuffs, and 3 other coworkers are fired, you realize how important it is to watch that waste.

[michlynn, BSN, RN]

Um... no. You better be prepared to cover your butt in court if something were to ever happen to that patient. I would love to be a fly on the wall... I just thought I'd give a "nurse dose." Please.

[calivianya, BSN, RN]

Susie2310 said:

How does the physician expect the hypothetical nurse to handle this situation?

Did you use your chain of command (hypothetical nurse)? Who is the next person in the chain to contact to help the nurse obtain appropriate medical orders for the patient?

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.

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

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.

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

[Dranger]

®Nurse said:

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

CAM-ICU doesn't do anything. I don't need a check the box tool to tell if someone has ICU induced delirium. We use it in our complex assessment but I haven't found it that effective.

Simple neuro assessments to keep RASS 0 to -2 suffices

[Dranger]

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.

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.

[kbrn2002, ADN, RN]

klone said:

Nope. Sounds like "practicing medicine without a license" to me. Besides, don't you need a witness to waste? If the order is 1mg, and you CHART 1mg, but you're only wasting 0.5mg, wouldn't that set you up for a diversion accusation? Or, you chart 1.5 mg and then you get nailed for a med error.

This was exactly my question. How on earth would you account for the "missing" narcotic? I am not always a by the book, follow all the rules nurse but I sure wouldn't consider giving a larger dose than ordered. If the ordered dose doesn't cut it, ask the provider for different dosing.