Fentanyl bolus question

Esme12, ASN, BSN, RN · Mar 30, 2013

Ok, now you say your clinical instructor was there...maybe there was an order you didn't know about. Some thing you may not have known about. Using the information you gave us....which is ONLY ONE side.....we gave you the best information based on incomplete facts.

What makes you feel unsafe at clinical? It is that nurses responsibility....it has no bearing on what you do for you know if you don't have an order you don't give it. That nurse isn't responsible for you....your instructor is. Your advisor isn't going to make waves and get you all kicked out of the facility. Unfortunately, nothing is always black and white...take this and know what kind of nurse you won't become. As a student ask questions, keep learning..... but keep your head below the radar.

psu_213, BSN, RN · Mar 30, 2013

This makes me very uneasy to learn that the nurse shouldn't have been doing this in the first place and the instructor choose to ignore it. I know I don't feel safe on clinical now and our group got together to talk with our advisor and we got nowhere.

I think this is a bit melodramatic.

As Esme said, maybe there is a order for breakthough pain. Perhaps there was an order for a bolus, yet it needs to be kept on the "DL" (or whatever the nurse said exactly ) because facility policy is that you bolus narcs via the pump (this is just a theory, but one possibility), yet she drew up a bolus dose and gave it that way. Why would she have done this? Who knows...maybe she thinks she is saving time. Maybe she did it the "right" way before and somehow messed up the setup of the gtt on the pump. She should not have done it in a way that is contrary to facility policy (if this is indeed the case), but it is hardly worth being "scared" over.

Adding to what Esme said: clinical sites can be very hard to come by...often there are more schools that need rotations than there are rotations available in hospitals. It is pretty unlikely that your advisor is going to go to the site with only bits of information about what happened and make a big stink about this situation and risk getting putting the school in a position where they are no longer welcome at this site.

drowningdaily · Mar 30, 2013

DL has been part of the lexicon for as long as I can remember. I am on the east coast, maybe it's a local thing. PRN, ASAP, DL, BON. Isn't it great to learn new things?

Kaysmom8 · Mar 30, 2013

Per policy any bolus dose is to be given via pump. Having an instructor present knowing that the nurse was wrong makes me uncomfortable melodramatic not at all. In our school our patient assignment is our responsibility just as much as the nurses. As for the advisor I didn't mean she was going to make a big stink at the site what I meant was she will probably mention to the clinical teacher what was said about her.

Esme12, ASN, BSN, RN · Mar 30, 2013

But you still really don't "know the whole" story. I'm just saying that ultimately it's the nurse, and your instructor....who both have licenses.... who is responsible. You are not responsible for the meds SHE gives. What I would do is to try to NOT have this nurse again. I find it amazing that she can give that much and if everyone is giving that much and these bags aren't running out early....how the pharmacy accounts for the missing narc to the DEA.

There a thousand variables I would investigate if I was made aware of this....do your clinical try to avoid this nurse. If asked tell your instructor it's none of your business how she (the other nurse) administers meds but you want no part of it. Giving narcs and telling everyone to shush ....... It makes you uncomfortable......Plain and simple.

psu_213, BSN, RN · Mar 31, 2013

In our school our patient assignment is our responsibility just as much as the nurses.

Well, yes and no. The school may "demand" that you are accountable for what happens to your patient. However, in a legal sense, you are 0% responsible for what happens when it is an action done by that facility's RN. Think about it...are your instructor or you mandated to jump across the bed to prevent the assigned RN from doing something against policy? Of course not. This is all on that nurse--not you...no matter what you school might say about your responsibilities.

psu_213, BSN, RN · Mar 31, 2013

Having an instructor present knowing that the nurse was wrong makes me uncomfortable melodramatic not at all.

This is not meant as a criticism...it sound like Yoda wrote the last part of the sentence. :cool:

Perhaps your instructor didn't know the facility's policy? Perhaps she knows the policy, but she does the same thing herself (not that it makes it right, but just may be why she didn't say anything)? Perhaps she didn't want to "dress down" the nurse in front of students, but perhaps she went back later and said something to the nurse?

I think most people on here were disapproving of what the nurse did based on the thought that she gave an unordered bolus dose. In reality, she may have given an ordered bolus does in a manner contrary to the policies of the facility. Still not OK, but, in my mind, far less of an offense than just deciding to practice medicine and decide on her own to give the doses.

LadyFree28, BSN, LPN, RN · Mar 31, 2013

DL has been part of the lexicon for as long as I can remember. I am on the east coast maybe it's a local thing. PRN, ASAP, DL, BON. Isn't it great to learn new things?[/quote']
Along with WT...we can fill in the rest, lol...maybe it's a East Coast thing...

LadyFree28, BSN, LPN, RN · Mar 31, 2013

I think most people on here were disapproving of what the nurse did based on the thought that she gave an unordered bolus dose. In reality, she may have given an ordered bolus does in a manner contrary to the policies of the facility. Still not OK, but, in my mind, far less of an offense than just deciding to practice medicine and decide on her own to give the doses.

^This.

As long as you know what NOT to do in clinical practice and facility policy, that is the more important factor. You will come across nurses in your career that do not always institute the most optimal practice.

For what it's worth, if I reported all the practices I can across from hospitals I rotated in and discussed as a student before clinicals in lecture and in post conference, I could retire in the next 10 years-PN and BSN combined; most were ad nauseum that was repetitive in both programs. I'm not saying this to diminish your valid concern; my point is you will eventually learn to pick and chose your battles.

If it concerned you, was there a way to report anonymously to risk management?? Did you feel as though you didn't want to make waves?? If your group makes a HUGE stink, why would that be punitive results from your instructor??? How does that affect future experiences in that hospital, especially if that may be the ONLY clinical site available to your program???

You will learn how to hone what is best for the patient without compromise...and there are resources when you are practicing professionally.

In the mean time, you know that is NOT what you are going to do once you are a nurse, and to me, that is what matters importantly.

tyvin, BSN, RN · Mar 31, 2013

Well, not to be anal about the whole thing, but keeping it on the down low is when someone is hiding the fact that they're in the closet.

Also; without an order; you knew it would be wrong. Pick your battles wisely as advised previously...there will be many.

MendedHeart · Mar 31, 2013

Well not to be anal about the whole thing, but keeping it on the down low is when someone is hiding the fact that they're in the closet.[/quote']
Actually thats just One use for the word...it its used for more than just that..lol
Its really not a big deal geeshhhhsh

PMFB-RN, RN · Mar 31, 2013

Hello,
Today in clinical a fellow classmates nurse kept taking a syringe and taking fentanyl and drawing some up extra from the iv line and giving it to the patient. She said at one point during the day she had to give the patient 300mcgs. Before the other student left she told her not to tell anyone she had been doing that all day long. Does this go on in the real nursing world or is this completely wrong?

*** Wait, is this a STUDENT doing this!? Not sure if I understood correctly. If I found a STUDENT I was responsible for doing soemthing like that I would make sure she lost her position in school

YES it happens all the time, YES it is completely wrong.

The intentions are usally only the best. The nurse who is at the bedside with her patient understand the patient needs more pain meds. Either she is unable to communicate this clearly to the physician, or the physician doesn't believe her, or for some other reason chooses not to order the addition pain meds. Nurses, trying to relieve our patients suffering end up using a "workaround".

Such situations indicate a systems problem. The bedside nurse SHOULD have much more autonomy in dealing with these situations. IMO it is abserd that the bedside RN has NO decision making roll in the prescrbing process for these situations.

In my hospital the RNs are given very wide latitude when dispecing pain meds or titrating narc drips per protocol. In the ICU and with vented patients this latitude is VERY wide allowing the RN to do a good job controlling pain without haveing to go though the whole call the doctor song and dance. I believe all nurses everywhere should have such decision making within thier power.

FWIW I have had many a physician tell me that all during their residency they though that 0.2mg of Dilaudid, 12mcg of fentanyl, 2mg or morphine, 1 mg of haldol, 0.25mg of ativan were all resonable and effective doses. They thought this since that is what they would write for then they wouldn't hear back from nurses wanting more. They didn't hear back cause the nurse just gave what she knew the patient needed and didn't bother to tell the physician. Of course much of this is the fault of the resident for not coming and assessing their own patients and/or not being approchable to the nursing staff. If the MD makes every communication with them misserable for the nurse then it's even more likely that patients with get "nurses doses".

Better to legaly and officialy put these things into nurses hands.