Piggy Back IV order with no fluid order?

[Fruit Sucker]

I have a question, and please bear with me as I'm a student. I had a patient who had a PB order, but no order for fluids. My instructor asked if I was ready to give the med, and I said, "I can't give this, because there's not an order for fluids. What do I do?" Well, she got really frustrated with me and said when this happens, you just go get a 50mL bag of NS, run it at KVO, and give the PB med with it. I said, how can I do that when there's no order for the NS? She just said, nurses do this all the time, trust me.

I'm confused. My understanding is that fluids can't be given without an order. I don't like breaking rules because other people "do it all the time." Please give me some guidance.

[klone, MSN, RN]

"she said when this happens, you just go get a 50mL bag of NS, run it at KVO, and give the PB med with it."

What part of what your instructor said above didn't you understand?

Now now, the OP is a student. No need to get snotty. She was clarifying if/why it's okay to do this without an order.

[Here.I.Stand, BSN, RN]

Nurses do it all the time--trust her. Although it was a reasonable question "What do I do"--she didn't need to get annoyed w/ you.

In the ICU where piggybacks are frequent--antibiotics, neuro meds, K+ and MgSO4 bumps...or meds that are run too slowly (like 1 ml/hr) and need a "carrier" to actually get them into the patient, we set up a NS carrier at 10 ml/hr. One way to look at it is if we gave their line a 10 ml NS flush before and after each med and completely unhooked their med line between meds, they'd be getting at least 10 ml per hour in flushes.

Now someone who is in acute CHF, a child, unstable with renal failure, or ANY TIME we're in doubt, we can always run it by the MD.

If it's a once-daily med and/or fluid is a concern, you can still string up a maintenance line, program 20-30 ml as the volume to be infused, and then hang the piggyback. That way the piggyback runs in, some NS flushes the med remaining in the tubing into the pt, and then it alarms rather than infusing extra NS all day.

Another thing you can do is just infuse the piggyback into a primary line. Then when it is finished running, manually flush the line--at the port closest to the bag--with a couple 10 ml NS flushes.

Side note--I say "NS" because that's the most common carrier and easy to type. Always check compatibility. Ampho B's (at least some...if not all) are incompatible w/ NS and needs D5W as a flush.

[Fruit Sucker]

Thanks guys! This is really helpful. Unfortunately, our instructors often do not have time to explain things, so sometimes we're left looking through textbooks and googling to try to understand something.

[ProgressiveActivist, BSN, RN]

It was a good question. Please keep posting.

[AMR21, BSN, RN]

Without the NS order how are you pulling the 50 ml bag from the Pyxis? How are you charging the pt for said bag?

Perhaps where I work is just strict and MDs are understanding. But I would get an order.

[RescueNinjaKy]

From where I am, the bags of ns are in the supply room, easily accessible

[KelRN215, BSN, RN]

Without the NS order how are you pulling the 50 ml bag from the Pyxis? How are you charging the pt for said bag?

Perhaps where I work is just strict and MDs are understanding. But I would get an order.

The only bag of anything that was in our pyxis when I worked in the hospital was Mannitol. All the standard IV fluid bags including 500 mL, 150 mL and 25 mL bags of normal saline, were in boxes in he bedroom for the grabbing. Even if they were in the pyxis, anything in the pyxis was accessible to any patient, all you had to do was override the first screen.

[AMR21, BSN, RN]

I must work at Fort Knox. Everything but saline flushes and sterile water for reconstituting meds like vec is in the Pyxis or comes from pharmacy. And to override anything we need 2 RNs. And once something is an override it pops up as a big purple line or the eMAR until it is linked to an order.

Guess that's why I'm so used to needing an order for EVERYTHING.

[tech1000]

We don't even typically run it with NS if it's just an antibiotic. We just hang the fluids and a handful of CCs go to waste when we finish the infusion. If it's something like potassium, I run the fluids however I feel appropriate and just free text it into my notes when I'm documenting hanging the fluids.

[THELIVINGWORST, ASN, RN]

I must work at Fort Knox. Everything but saline flushes and sterile water for reconstituting meds like vec is in the Pyxis or comes from pharmacy. And to override anything we need 2 RNs. And once something is an override it pops up as a big purple line or the eMAR until it is linked to an order.

Guess that's why I'm so used to needing an order for EVERYTHING.

That doesn't mean we don't have an order for the fluids, it just means we have the fluids stored outside the Pyxis.

[ICURN3020]

Without the NS order how are you pulling the 50 ml bag from the Pyxis? How are you charging the pt for said bag?

Perhaps where I work is just strict and MDs are understanding. But I would get an order.

We can just override it in the Pyxis.

[MunoRN, RN]

We don't even typically run it with NS if it's just an antibiotic. We just hang the fluids and a handful of CCs go to waste when we finish the infusion. If it's something like potassium, I run the fluids however I feel appropriate and just free text it into my notes when I'm documenting hanging the fluids.

It's usually more than just a "handfull of CCs". The tubing itself holds close to 20 mls. With the current ports on IV tubing it's not unusual for another 20 mls to get wasted during priming. That's enough of the antibiotic dose to be a big deal.