Normal Saline q24 orders

  1. Hi,

    I am a student and we just finished our first clinical, and first semester. I wanted to post this in General Nursing because I need answers from an experienced nurse. The issue I am having is understanding NaCl or/and feeding orders (q 24 hrs (or 10 hrs for that matter). When there is normal saline/feeding infusing when the oncoming nurse comes in, say beginning the 7a shift, and an order says q 24 hrs, but the previous NaCl from the previous 24 hr order, is still infusing due to IVPB interruptions from the previous day or 'overnight', or whatever reason, do you just start a new bag? Or do you let it run? I am not sure I understand this if the pharmacy only supplies a certain amount, then the oncoming nurse has 'to keep track' (if there is no report on the amount infused?) which seems mentally taxing/draining with all the orders he/she is responsible for.

    Another question I had was when the Dr. orders a new 'antibiotic' (piggyback), and the previous old one is still there not infusing, would a nurse use the old one? The nurse I worked with did this, but I don't understand. She did this just in case the dr. orders it again. I didn't understand because it was 3/4 gone. To me it is easier to just get a new one, to save time and nonsense so to say. I am a student not questioning the nurse, so I just wanted to see any responses to this.

    I noticed that the nurses have orders coming in all day with no break (Med-Surg), so I was trying to understand the concept without cutting corners, or violating regulations.

    Thank you.
    Last edit by fibroblast on May 18, '17
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    Joined: Jul '12; Posts: 464; Likes: 487

    7 Comments

  3. by   InArduisFidelis
    Was this a continuous feeding/IV infusion? You might want to look closer at the orders. I have a feeling you are missing something. Just be aware that "q 24 hours" is not a complete order. I see this by itself and I start thinking "Am I supposed to give something once every 24 hours?" or "Am I supposed to be giving something over 24 hours?" If a patient has a continuous feeding or IV infusion ordered you should have a rate ordered with it. (eg 0.9% NS IV Infusion @ 125ml/hr Continuous or Fibersource TF via NG @ 20ml/hr Continuous)

    Now, as for having bags hanging when you come on shift. Let's say your patient has a continuous NS infusion because they are NPO. My facility has a standard of practice that bags of IV fluid are only good for 24 hours and then should be changed. So if you come in and see that the current bag hanging is over 24 hours old (because it was running at a slow rate, or was interrupted because life happens) then you would need to change that bag out and hang a new one. The amount infused into the patient should be tracked somewhere. Look for the I&Os and I bet you will find the nurses recording it there. Hopefully these infusions are running on a pump and you will find that you can track the amount infused from the pump history. Best practice is to look at the volume infused and clear the totals at the start of your shift so you know what you have given.

    If you have a patient receiving piggyback medications it is typically acceptable to reuse the piggyback tubing as long as it is not expired. It would be a waste of time and money if the patient has Q6H IVPB Zosyn ordered, and you threw the tubing out every time. Many nurses leave the empty piggyback hanging on the pole, they pull the old bag off and spike a new one next time the patient is due to be infused. The question to have asked the nurse you were working with is whether that patient only received 3/4 of their antibiotic, or if there was fluid in the bag because it had back flowed up there.

    Hope this helps.

    **Just to clarify it's typically acceptable to reuse piggyback tubing that was used on the same medication. (eg the same tubing for the same antibiotic, not use it for one drug, then use it for a different drug, etc) This is where IV medication compatibility becomes an issue**
    Last edit by InArduisFidelis on May 18, '17 : Reason: Clarify about tubing.
  4. by   YoutubeTheNP
    Your question is missing information. NS or Nacl as you wrote isn't written as q24. You're missing the rate per hour. Same thing for the feeding schedule/volume. Change the bag of NS when it's empty.

    I don't understand what you're asking in regards to the antibiotic. If a new one is ordered should she use the old one? What do you think. Were there multiple abx ordered for the pt? or Did they switch from 1 abx and start a new one? Clarify plz.
  5. by   Purple_roses
    To add onto what's already been said, IV bags and IV tubing each usually have stickers on them that will tell you the date/time the bag/tubing was hung and the date/time that it needs to be changed.
  6. by   ~♪♫ in my ♥~
    I don't completely get your question.

    If something is ordered q24h then it means just that: Every 24 hours do xxx

    Fluids are generally ordered as maintenance infusions to run at a given rate continuously, though sometimes (rarely) they will have a set start and stop time.

    I'm not sure I've ever seen a q24h order but rather qD orders... daily, at a set time.

    Depending on hospital/unit policies, continuous infusions (bags and tubing) are good for 96 hours. Intermittent infusion sets must be replaced every 24 hours.

    To your last example, that sounds wrong. If a medication is scheduled, that med is pulled, prepped, and hung as scheduled. There shouldn't be anything left over (generally) but if there is, it should be thrown away.
  7. by   fibroblast
    Thank you all for answers. I believe I am missing information because it was my first time seeing 2 and 3 antibiotics used during the course of a shift and having to stop one infusion to proceed with another. I've seen one abx used, and then the duration has fully completed (e.g. 10 days, BID PO), but not antibiotics one right after another, and one half used/not completed - IV (maybe dr. stopping one, then adding another?). I was unfamiliar with that, the dr.'s changing/adding orders if that's the case.

    Well, I surely didn't ask the nurse, I just thought maybe she knows what she is doing and I'll figure it out. She was busy working and being gracious enough to teach me so I didn't want to interrupt her routine. Efficient nurse.

    Maybe this MAR is set up to interpret a little differently, I should go back to see if there is a rate (as I thought that is what we are suppose to figure out, as we are taught to calculate, but we are learning that the pumps/pharmacy does a lot of those calculations already, and even had the abx set up, ready to mix). A lot for me to look at. Trying to put the book knowledge, with clinical knowledge.

    Thanks for the info and knowledge.
    Last edit by fibroblast on May 22, '17
  8. by   Here.I.Stand
    Yes, you learn more med math than is typically used in practice. Modern pumps with dose modes are miracles of nursing convenience, and of course are good as a safety measure BUT, it is important to know *how to* do it. There could be a power outage and not enough red outlets, you could work for a medical mission someday, you could work in NICU or peds and have to do lots of wt-based calculations...not to mention PharmD's are human too. I once received a prefilled oral syringe of a med which based on the concentration and ordered dose, contained 2x the correct amount of med.

    But you're correct -- lots of times the eMAR will specify the rate of infusion for an antibiotic.

    Are you asking about atb's which are started prior to shift change but finish after? So say, a dose of Vanco started at 1845, shift change at 1900-1930, and Vanco finished at 2045? Let it finish. There is WAY too much room for error (plus wasteful) to calculate how much infused prior to shift change, and how much of a 2nd bag is needed. The day RN would document that she started the med at 1845, and you would document that the infusion was completed at 2045. Then make sure it's accurately documented on the I&O -- neither undocumented nor double documented.

    If I see that the maintenance fluid is infusing and fluid still in the piggyback bag, I check the orders. Ideally if the MD had d/c'ed the med while a dose was infusing, the prior RN would discard the unused med. That would eliminate any confusion, and be the SAFEST thing if the drug was newly contraindicated (e.g. new evidence of nephrotoxicity, allergic reaction etc.)

    If the pt was to receive it, and assuming the med has not yet expired, I'll finish that bag --
    again to ensure that the pt gets the ordered dose of med. Sometimes a nurse can make a mistake when entering the VTBI, or even forget to open the roller clamp on the secondary tubing.
  9. by   Esme12
    Quote from fibroblast
    Thank you all for answers. I believe I am missing information because it was my first time seeing 2 and 3 antibiotics used during the course of a shift and having to stop one infusion to proceed with another. I've seen one abx used, and then the duration has fully completed (e.g. 10 days, BID PO), but not antibiotics one right after another, and one half used/not completed - IV (maybe dr. stopping one, then adding another?). I was unfamiliar with that, the dr.'s changing/adding orders if that's the case.

    Well, I surely didn't ask the nurse, I just thought maybe she knows what she is doing and I'll figure it out. She was busy working and being gracious enough to teach me so I didn't want to interrupt her routine. Efficient nurse.

    Maybe this MAR is set up to interpret a little differently, I should go back to see if there is a rate (as I thought that is what we are suppose to figure out, as we are taught to calculate, but we are learning that the pumps/pharmacy does a lot of those calculations already, and even had the abx set up, ready to mix). A lot for me to look at. Trying to put the book knowledge, with clinical knowledge.

    Thanks for the info and knowledge.
    This was your first semester so of course you have a ton of questions. It is very difficult to follow what you are saying but yes. Orders are/can be changed every day. They can change in one shift. IV fluids are technically not the "feeding" of the patient. How the fluids are, or not, infused depends on the patient. You will see some fluids that will be kept running while IV antibiotics are run of a different pump.

    The point that I think is important right now is....ask the nurse or your instructor that day. It will help you make more sense. You are in school to learn. Not asking questions and trying to "figure it out" can lead to a dangerous mistake.

    You are the student....ask those questions. (It will get better)

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