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Thank you, Esme. My supervisors have told me that I am very thorough...I think sometimes overly so....All the more reason why I am beating myself up for not calling about this.

thank you for your response, GrnTea. Is this considered an error? I feel terrible that something could have happened

Thanks for your response, wish_me_luck! Sorry, I should have clarified! I am wondering if I was wrong to give the Tolvaptan (the med to increase the sodium level). I actually called the nephrologist back to confirm that it was really D5W that he wanted given. I guess I am just worried that the tolvaptan shouldn't have been given since he said something to me about it and it can be dangerous to replace sodium too fast...The only reason I can think of that he ordered the D5W was to prevent the sodium from increasing further....116 to 132 in less than 24 hours is a huge increase! I appreciate your responses.

Hi everyone, I have a question related to hyponatremia. I had a patient a few days ago who came in with hyponatremia and her sodium level was 116. They started her on fluids- 0.9% normal saline- and fluid restriction. Around 1 am they rechecked her sodium and it was up to 120. Then, the doctor ordered a sodium level in the morning and it came back at 128. The PA with nephrology saw the patient and ordered a medication called tolvaptan, which I looked up before giving it, and found that it increases the serum sodium levels by increasing water excretion in the body. She may have not seen the sodium level of 128, as it came back at 8:45, and she may have just seen the pt a few minutes prior and based it off of the level of 120 from 1 am. She also ordered the IV fluids and fluid restriction to be discontinued. A sodium level recheck around 2 pm was ordered to be drawn. I gave the medication around 11:30 or 12. The nephrologist came later in the day to see the patient, and asked me if she had received the tolvaptam, and I said yes. He said that she probably hadn't needed it, and asked me to call him with the 2 pm level, which came back at 132, and he told me to start her on D5W. I realize that replacing the sodium level too fast can be dangerous. Was I wrong to have given the medication? Should I have made sure with nephrology to see if they still wanted the medication to be given with the sodium level up to 128? Please help. your advice is much appreciated.

thank you, IVRUS. I appreciate your response!

Hi everyone, I have a question related to hyponatremia. I had a patient a few days ago who came in with hyponatremia and her sodium level was 116. They started her on fluids- 0.9% normal saline- and fluid restriction. Around 1 am they rechecked her sodium and it was up to 120. Then, the doctor ordered a sodium level in the morning and it came back at 128. The PA with nephrology saw the patient and ordered a medication called tolvaptan, which I looked up before giving it, and found that it increases the serum sodium levels by increasing water excretion in the body. She may have not seen the sodium level of 128, as it came back at 8:45, and she may have just seen the pt a few minutes prior and based it off of the level of 120 from 1 am. She also ordered the IV fluids and fluid restriction to be discontinued. A sodium level recheck around 2 pm was ordered to be drawn. I gave the medication around 11:30 or 12. The nephrologist came later in the day to see the patient, and asked me if she had received the tolvaptam, and I said yes. He said that she probably hadn't needed it, and asked me to call him with the 2 pm level, which came back at 132, and he told me to start her on D5W. I realize that replacing the sodium level too fast can be dangerous. Was I wrong to have given the medication? Should I have made sure with nephrology to see if they still wanted the medication to be given with the sodium level up to 128? Please help. your advice is much appreciated.

Thank you, I truly hope so. I know that someone else is now caring for the patient, I just worry that something will have happened to the patient because of me. It has been hard for me to think of anything else but work, even on my days off because I always think of what I should have done differently. Thank you again for your reply :heartbeat

Yes, you're right, I hadn't thought about that! I did not notice any crystallization, but would it usually happen immediately, and would the patient have a reaction immediately? Levaquin is yellow so would the precipitate be white? I guess I was just worried that there could still be some towards the bottom of the tubing or traces of it in the tubing. Other nurses have told me that if two IV meds are incompatible, as long as you flush the whole line with NS then that is sufficient. I definitely hadn't considered that even when the levaquin starts running, it would still need to push all the saline before it got to the patient. Again, I appreciate your response. I hope it won't always be like this where all I can do is sit in front of my computer and stress out about everything...I just can't help but worry about everything I did or didn't do or how the patient is doing even though a new nurse is taking care of the patient now. I will take your advice and run the flushes at a faster rate and a greater volume from now on!

Thank you for your response. Do you think I should be worried? I don't know, I am just stressed out about this and keep looking up things...It's hard for me to leave work at work but now I feel like--what if I did something wrong ? Thank you again for responding.

Hi everyone, Yesterday I had a patient who was on 3 IV antibiotics: zosyn, zyvox, and levaquin. We use micromedex to check compatibility so I found through there that zosyn and zyvox were compatible, so there was no need to change the tubing. I was using normal saline for the primary line to piggyback the antibiotics into. I programmed the normal saline to run for a volume of 10 ml at 10 ml/hr once the piggybacks finished. The levaquin was the third one that I hung, after the normal saline had run through, and I disconnected the previous secondary tubing and hung the levaquin piggyback with the new tubing after the flush had run (with the old piggyback tubing from the zosyn still attached, if that makes sense?). If I remember correctly, the zosyn was the one that was hung before the levaquin, and zosyn and levaquin are not compatible. (So the order was zyvox, NS primary, zosyn, NS primary, levaquin, NS primary). I was wondering if the 10 ml primary was enough to clear the tubing of the medication? Thank you and please let me know your thoughts, I truly appreciate it.

Hi everyone, Yesterday I had a patient who was on 3 IV antibiotics: zosyn, zyvox, and levaquin. We use micromedex to check compatibility so I found through there that zosyn and zyvox were compatible, so there was no need to change the tubing. I was using normal saline for the primary line to piggyback the antibiotics into. I programmed the normal saline to run for a volume of 10 ml at 10 ml/hr once the piggybacks finished. The levaquin was the third one that I hung, after the normal saline had run through, and I disconnected the previous secondary tubing and hung the levaquin piggyback with the new tubing after the flush had run (with the old piggyback tubing from the zosyn still attached, if that makes sense?). If I remember correctly, the zosyn was the one that was hung before the levaquin, and zosyn and levaquin are not compatible. (So the order was zyvox, NS primary, zosyn, NS primary, levaquin, NS primary). I was wondering if the 10 ml primary was enough to clear the tubing of the medication? Thank you and please let me know your thoughts, I truly appreciate it.

Carol- Sorry again for the confusion lol! When we write phone orders or the doctors write orders in the chart, the chart is placed up on a rack at the front desk for the unit clerk to put in the computer. we use the electronic system epic at the hospital. I'm sure the doctor eventually wrote in the progress notes that part of the plan was to do an MRI, but I did forget to write that order in the chart. I did chart the abnormal blood pressures and abnormal rechecks, and let the charge nurse know after I got the order from the PA. The physician's assistant from the patient's cardiology group was on the floor so I told her what was going on and told her I would recheck the pressure again and come back and let her know if it was still high, and since it was, she wrote the order to give the bp meds early. I use a separate sheet for each patient, but I know I need to be more organized with that. I called the PA on call who was a different PA than the one I spoke with in person earlier, right after I had given the bp meds, and she gave me the order to give the patient's other bp meds early, which nightshift gave. Thank you for your advice!!! Beenthere- We have EPIC, so if a doctor is on the floor and writes orders, he puts the chart up front for the clerk to enter the orders. If he gives us telephone orders, then we would still have to write them in the chart to give to the clerk, which was my situation. Thank you, I was worried that it seemed to be getting higher and that the bp meds i had given on my shift weren't working. She did take several and they were pretty high doses. I think it will take some getting used to for me to realize I can't get everything under control on my shift and that nursing is 24 hours. Thank you again for your advice, it is always appreciated :hug:! I hope everyone is having a happy new year!

kelrn215: Sorry I forgot to mention in my original post! I had called the doctor after he left and had written other orders, because the patient pulled out her iv's and was confused. She had a hx of dementia and I wanted to ask if he would like to order a 1:1 sitter since I didn't want her to hurt herself. He wanted an MRI of the brain ordered. I got sidetracked and forgot to write the order in the chart. I called the unit today and felt pretty sheepish...I'd much rather get in trouble and know that the patient is fine/someone is aware of what I forgot to do than have something go wrong! The charge nurse wasn't angry with me and said that the doctor was just rounding now and that she would write it in the chart..I felt like a big airhead though when I had to explain the situation to her. I did realize after I hungg up that I forgot to tell her that he wanted the MRI without contrast...but if I am correct wouldn't she need to verify it with the doctor first since she can't really take a verbal order from me? I'd be frustrated with me lol ! Esme, thank you for the sheets. Every resource is helpful and I want to do whatever I can to be more organized and improve my time management skills. I know that it is not good to be staying late to finish charting. I am trying to be less hard on myself, I just hope I didn't make any mistakes that I am unaware of ...Beating myself up is something I do very well :smackingf...I will try to leave the past and what I cannot change behind me and learn from all of this so that I will be more organized next time. Thank you everyone for caring and for taking the time to reply to my post. I wish you could truly see how much I appreciate all of your advice and constructive feedback as I really do take these things to heart. Thank you for being honest with me. I hope that one day I will be as great a nurse as I know that all of you are :redbeathe.

:redpinkhe

kelRN215: Sorry I forgot to mention in my original post! I had called the doctor after he already left the floor and had written the other orders, because the patient pulled out her iv's and I was wondering if maybe he wanted her to have a sitter as she was confused and had a history of dementia. I did not want her to hurt herself. He didn't want a sitter but wanted to order the MRI and gave me the telephone order. I got sidetracked and forgot to write the order in the chart. I had to call today to tell the charge nurse and she said the doctor was making rounds. I realize I forgot to tell her that he wanted it without contrast but I believe she would have had to ask him again just to verify anyway as she can't really take a verbal order from me if I am correct? I felt sheepish having to call back in to the floor today, but I'd much rather I get in trouble and know that the patient is fine and that someone is aware of what I forgot to do. The charge nurse wasn't angry with me though I felt like a big airhead when I explained the situation. Thank you Esme for the sheets, every resource is helpful! I am trying to be less hard on myself, and I hope I didn't make any other mistakes that I am not aware of I appreciate everyone's words of advice and will do my best to learn from these mistakes, and let go of the past and what I cannot change. Does anyone have any advice on time management? How can I balance emergency situations, which come up often on my unit, and which are the priority, with everything else that I must do? Again I am grateful for all of the feedback and I want to do all that I can to work hard and be better at this. I am thankful that all of you guys care and took the time to respond :redbeathe, and for being honest with me. I truly hope I will become as great a nurse as you all are.