Phenergan & Morphine

Dolce, RN · Nov 4, 2008

i don't think there is anything inherently wrong with phenergan 25 mg iv push. as long as it is diluted well or pushed with iv fluid running there shouldn't be any problem. sounds like you assessed the iv site well while you were giving this drug. i would have been cautious about giving 10 mg morphine iv. i am a little curious how you gave it over 10-20 minutes? did you stand at the bedside that whole time? did you give it in 1 mg increments? when i give this much ms usually i give it in 2 mg increments q 5 minutes or whatever the md ordered. morphine 10 mg iv now implies giving it all at once, not in increments. i'm a little curious how that was ordered. however, in someone who has a high opiate tolerance this would not be a significant amount to give. i agree with you the a diastolic in the 90s 1.5 hours later isn't clinically significant. if his bp was in the 90s when you gave the morphine that would be a problem but it sounds like his bp was fine when you gave it.

i'm sorry you had such a hard time there. it sounds like you are very intelligent and feel confident in your abilities. i know that many experienced nurses feel concerned when they see a high level of confidence among new grads. most new grads are quite tentative about their skills and insecure. usually the first year of nursing is when a person begins to develop skills and experience that leads to confidence--usually its not the other way around. my only suggestion for you is to be receptive to all the input that your more experienced coworkers have for you. many times experienced nurses get frustrated with new grads when they feel that they don't listen to what they have to say.

best wishes to you! :nurse:

HouTx, BSN, MSN, EdD · Nov 4, 2008

sunshineyday,

Our organization does not allow peripheral IV administration of Phenergan - period. We have a policy that addresses this issue. There is too much documentation of risk/harm to patients. Physicians are not permitted to do so either. It doesn't matter whether the nurse is "uncomfortable" talking to the doctor - it is her/his professional responsiblity to do so. If the doc tries to insist, the nurse follows our chain of command and the Chief medical officer will intervene to follow established policy.

We also have very specific policies that address pain management & conscious sedation, including precautions that must be taken when certain dosages are administered - such as the use of pulse ox & frequency of BP monitoring. If the organization had policies related to these issues, you were obligated to follow them. Lacking policies, I agree that it would be difficult to determine what to do.

This was a hard lesson to learn. But you would be better served by engaging self-reflection in order to learn from this experience. The question is not "how can you defend yourself" but to understand that you must learn to listen and accept critical feedback without becoming defensive. More experienced/competent staff are drawing upon skills and knowledge that you do not yet posses - you could learn from them rather than dismissing their insight.

As an educator, it seems to me that you are too confident in your own limited abilities - and this is going to continue to get you into trouble. Please take it down a notch, admit to others and yourself that you are a beginner and have much to learn. Otherwise, I agree with you - a career change is probably the best decision.

sunshineyday · Nov 4, 2008

yes, i was @ the bs the whole time. it was a slow day in the ed. and i actually like hanging around patients. and the pt was talking about their dog and i love dogs :) i cleaned the port with alcohol, attached the syringe and i pushed 2mg about every 5 minutes. i never disconnected the flush from the port until it was all in.

i think i'm more confident than a typical new grad because i started out in a cvi and by my second week i was taking care of aaa's and cabg's. i studied more at home those first few months that i did in nursing school i think. so i think i was forced to progress at a higher pace than a lot of my peers due to the acuity of my first patients.

i don't think there is anything inherently wrong with phenergan 25 mg iv push. as long as it is diluted well or pushed with iv fluid running there shouldn't be any problem. sounds like you assessed the iv site well while you were giving this drug. i would have been cautious about giving 10 mg morphine iv. i am a little curious how you gave it over 10-20 minutes? did you stand at the bedside that whole time? did you give it in 1 mg increments? when i give this much ms usually i give it in 2 mg increments q 5 minutes or whatever the md ordered. morphine 10 mg iv now implies giving it all at once, not in increments. i'm a little curious how that was ordered. however, in someone who has a high opiate tolerance this would not be a significant amount to give. i agree with you the a diastolic in the 90s 1.5 hours later isn't clinically significant. if his bp was in the 90s when you gave the morphine that would be a problem but it sounds like his bp was fine when you gave it.
i'm sorry you had such a hard time there. it sounds like you are very intelligent and feel confident in your abilities. i know that many experienced nurses feel concerned when they see a high level of confidence among new grads. most new grads are quite tentative about their skills and insecure. usually the first year of nursing is when a person begins to develop skills and experience that leads to confidence--usually its not the other way around. my only suggestion for you is to be receptive to all the input that your more experienced coworkers have for you. many times experienced nurses get frustrated with new grads when they feel that they don't listen to what they have to say.
best wishes to you!

allnurses Guide · Nov 4, 2008

We give phenergan IV in our ER and on the floor.

As to the morphine - I don't see a problem with how you gave it and I doubt the bp 1 1/2 hour later had much to do with the morphine but who knows for sure? That systolic wouldn't be a big deal and easily fixed.

I do find some ER cultures to be pretty hard to break into.

You sound like a great nurse - don't take it hard and go find a place where you do "fit".

steph

sunshineyday · Nov 4, 2008

Thank you for your response and I sincerely appreciate your insight. However, I noticed that you have 25 years experience. I know you have a wealth of knowledge far superior to mine but I also notice that nurses with this amount of experience also inflict the most horizontal violence and bias toward new grads.

You said a couple of things that concerned me.

First, you assumed that I dismiss the insight of others. This is incorrect. I constantly gave thanks to nurses who offered constructive feedback and advice, even if I didn't agree with it.

Secondly, you assumed that I didn't follow the chain of command. I notified my preceptor, who notified the physician and charge nurse, and my preceptor ok'd the administration.

You also stated that I was defensive. I did not become defensive until I knew this was an organization I did not want to work at and frankly didn't care. I was taught in nursing school to bring research to the floor to support practice. If that is being defensive so be it. My main point was more that a nurse with limited experience cannot provide a simple rationale without it being viewed as "defensive," when it is a simply a response.

I'm in a Master's program and and just learned a great deal about managed care methodologies (clinical pathways, policies, QI). I think you are correct that my former institution should have had specific policies that staff were on board with (like your organization). I also read in my research that a lot of organizations are removing IV Phenergan from their drug lists. I think that's a smart move.

You just seem like the typical tenured nurse who believes newish grads are all "theory." I hope people can have an open mind and evaluate people individually based on their merits and actions rather than stereotypes and assumptions.

For what it is worth, I was in the ED as a pt in March. An older "seasoned" nurse administered Phenergan without diluting it straight into my AC. People should admit that errors and mistakes happen across the board. From new grads to tenured nurses. We are all human after all.

sunshineyday,
Our organization does not allow peripheral IV administration of Phenergan - period. We have a policy that addresses this issue. There is too much documentation of risk/harm to patients. Physicians are not permitted to do so either. It doesn't matter whether the nurse is "uncomfortable" talking to the doctor - it is her/his professional responsiblity to do so. If the doc tries to insist, the nurse follows our chain of command and the Chief medical officer will intervene to follow established policy.
We also have very specific policies that address pain management & conscious sedation, including precautions that must be taken when certain dosages are administered - such as the use of pulse ox & frequency of BP monitoring. If the organization had policies related to these issues, you were obligated to follow them. Lacking policies, I agree that it would be difficult to determine what to do.
This was a hard lesson to learn. But you would be better served by engaging self-reflection in order to learn from this experience. The question is not "how can you defend yourself" but to understand that you must learn to listen and accept critical feedback without becoming defensive. More experienced/competent staff are drawing upon skills and knowledge that you do not yet posses - you could learn from them rather than dismissing their insight.
As an educator, it seems to me that you are too confident in your own limited abilities - and this is going to continue to get you into trouble. Please take it down a notch, admit to others and yourself that you are a beginner and have much to learn. Otherwise, I agree with you - a career change is probably the best decision.

allnurses Guide · Nov 4, 2008

I like your post :yeahthat:

Just wanted to add that we should follow the policies of our institution and I do find that some nurses have no idea what those policies are.

The P&P Manuals are usually full of the most minute detail about what you are supposed to do at work.

Having been here on allnurses for awhile - I am still constantly amazed at how different we practice across this country. And the phenergan question has been argued for a long long time here.

steph

sunshineyday · Nov 4, 2008

Thanks!

Maybe one day everything will be standardized across the board? LOL! Yeah right... it's a nice thought though.

Where in "the mountains" are you? My sister-in-law works at an ED in Denver...

I like your post :yeahthat:
Just wanted to add that we should follow the policies of our institution and I do find that some nurses have no idea what those policies are.
The P&P Manuals are usually full of the most minute detail about what you are supposed to do at work.
Having been here on allnurses for awhile - I am still constantly amazed at how different we practice across this country. And the phenergan question has been argued for a long long time here.
steph

Dolce, RN · Nov 4, 2008

I am still constantly amazed at how different we practice across this country. And the phenergan question has been argued for a long long time here.

I agree--the Phenergan issue isn't as cut and dried as many would believe. Some hospitals have outlawed it entirely as an IV drug. Others want it pushed through central lines. I cringe every time I give IV and am extremely careful to dilute it generously.

GrumpyRN63, ADN, RN · Nov 4, 2008

To the OP, I think you are in a toxic environment and should get out, not out of the profession, you are intelligent, with good critical thinking skills and common sense, you work for a bunch of wing-nuts. We still give phenergan IV, back in the day we would give 25mg IV q4h atc for post-ops, kept them nicely snowed, never had IV issues, as far as the morphine, 10mg over( what )? 20 minutes is super-conservative in an opioid tolerant pt. we have pts get boluses of that amnt routinely over a minute with no problems, the SBP wouldn't have flustered me either, maybe that's their baseline and they were 120 before being medicated, you need to take your wisdom and talent to someplace that will appreciate you !!

floatRN · Nov 4, 2008

Sorry you are having such a rough time. It doesn't sound like you did anything particularly wrong. The only thing I can suggest is to have a copy of your medication protocol handy in any new place. Every hospital and even different units have differing protocols regarding what can be given IV push vs piggy back and what the max dose allowed is.

cookienay · Nov 5, 2008

Sunshiney, what I would not give to have more new grads like you on my unit!! You are to be commended for knowing your research. Many nurses know there is some controversy with giving Phen IV, but do not know why. You will usually be ok if you are very familiar with your med admin policies. However, it sounds as if you were not going to be ok in this environment regardless of what you did. Furthermore, I must comment that it seems petty that your educator reprimanded you for giving the prescribed dose of a medication. I would have been tempted to ask her where she went to med school. Plus a BP in the 90's that long after Morphine IV is so not an issue. So... that being said here is my two cents- continue on your chosen career path if that is what you want. Find another facility to work for, preferably one that has alot of in-house education or a fellowship for your specialty (we do where I work). Wherever you work- know your stuff!! Familiarize yourself with all P&P as much as possible. And... good luck!!