cardiacqueen

Just gave this today for strep! Very painful for the poor patient. to answer your question about giving it iv - no, it can't be given IV because it can cause severe neurovascular damage

Interesting...what do you mean by one order with a range? I know that our docs have been criticized, for example, by pharmacy for putting in range orders such as "1-2 tabs for pain." Not sure if this is what you meant though. I have had that thought that specified doses for certain levels of pain has some issues. Mainly related to patients having different pain tolerances and perception, as well as varying tolerances for certain medications. But what is the alternative? Say for example I have a patient who is 2 hours post op, not tolerating PO intake, and says they are beginning to have pain, 4/10. I have orders for Percocet and Morphine. I am concerned about giving a larger dose of morphine (say 6 mg is my only order option) to patient who is drowsy and whose pain is at a level in which the risks may outweigh the benefits. Sorry for the long post! Just curious as to what you guys think!

While we're ranting, here's what frustrates me... Why does lab, radiology, and pharmacy call nurses to ask questions about DOCTORS orders? "Dr. X ordered this but did he really want it?" I am not the doctor and I didn't place the orders. I may be able to give you some insight on the patient, but when you call, I now have to call the doctor, relay your concerns and call you back. I just don't get it! You could get your answer faster if you asked for him directly when you called the unit.

No, this is outside of our scope of practice. Unless you have parameters. One of our surgeons, for example, will put 3 different orders for morphine - eg. 2 mg for mild pain, 4 mg for moderate pain, and 6 mg for severe pain.

If the blood was pulsing strongly up the tubing, then I would feel pretty certain yes, you hit an artery. I have had an inadvertent arterial puncture once, in a patient with a very thin arm, while aiming for the basilic v. I didn't even get to the point of flushing it...as soon as I removed the needle from the angiocath I could tell the blood flow from the hub was pulsatile - and strong! Both the patient and I were wide-eyed! Removed the line, applied pressure and started over. I have noticed that sometimes with a particularly patent IV that a small amount of blood (maybe a few inches max) has backed up into the tubing if the IV is infusing at a really slow rate, or if I stop the pump for a few minutes to take a blood pressure or something. In this case, the pressure in the vein is greater than the pressure being exerted by the fluid in the tubing (especially if you have a BP cuff squeezing the arm :)). Bottom line, if you suspect arterial puncture I would err on the side of caution and remove the catheter. Part of your medication "rights" is "right route."

Thanks. I did read about the ostomy cones but I haven't been able to find them in our facility. Back at work tonight a few days later and the patient is improving without signs of perf, so thankfully looks like no harm came of using the regular enema. But, good to know for future reference.

I have another one. I once had a patient tell me he had "tickly-itis" (diverticulitis) when I was taking his health history. Still makes me laugh!

thanks!

MeTOprolol, NOOOOT meTROprolol

I had a patient admitted last night with an old RLQ stoma - either an ileostomy or colostomy (look to me based on the location like an ileostomy). The patient needed a CT abd but radiology would not scan the patient because he had residual Barium from a previous study in his bowel. Therefore, the physician ordered a warm tap water enema - when I asked for clarification, he said yes - through the stoma. I have never given an enema through a stoma before, so I asked our supervisor. I was told to just give the enema like a normal rectal enema except obviously, through the stoma. I used a soap suds enema kit sans the soap (the one with the plastic tubing + irrigation bag) and inserted the end of the enema only about 1-2 inches, no resistance. Due to the poor sphincter control of the stoma most of the water immediately drained out and the rest after I removed the enema tube. After completing the procedure I decided to go home and read up on the current literature regarding ostomy irrigation. I now have 2 huge concerns. #1 - For the enema, was it Ok for me to use a normal enema tip? I'm reading that these can potentially cause bowel perforations? It seems hard for me to believe that a gently placed plastic tube can rip through the bowel...do I need to worry if I didn't "hit a wall" or insert the tube far? I am panicking! I have read that foley catheters can be used for irrigation as well. This seems similar to the plastic enema tubes. #2 - Not sure if the patient had a colostomy or illeostomy, but illeostomy irrigation is not recommended due to risk of dehydration, but this patient needed cleared out for CT. Do you think giving an enema through an ileostomy was OK in this case? I know I was following Drs. orders, but after doing some extensive research I am second-guessing my actions...please help!

On a side note...have you ever had a patient think that your 1mg dilaudid + 5 cc NS is ALL concentrated dilaudid?

Like most posters here, I dilute all iv narcotics as well...unless it is an extremely small dose and the patient has fluid running.

KelRN, do drug companies manufacture a different syringe device for peds...like one with a smaller needle and appropriately smaller doses? Or do you draw your Lovenox up from a vial and give in a short sub-q needle? Just curious.

thanks so much! Makes sense!

So we've all been there...you have a 30-some kilo very ill lady to whom you need to administer Lovenox.. This seems like a dumb question, but is it possible to puncture/damage the intestines or other underlying organs of a very emaciated patient by administering Lovenox at the recommended 90-degree angle? I know the needle is only 1/2 inch...but it scares me because pinching up the skin on these patients is just that, only skin. Doing that would result in an intradermal injection and likely a needle stick for the me. I want to give these injections properly in the proper tissue but I also don't want to put myself at high risk for needle stick injuries...I have tried introducing the needle only about half way into the tissue (without pinching skin) to prevent the medication from being injected too deep and hitting musculature. Several of my coworkers say that hitting organs is impossible and it's actually not necessary to pinch up fat as the needle is so short. I have heard of a few rare cases of muscular hematomas resulting from lovenox but never any organ damage? What do you guys think? Any tips for giving Lovenox to very very emaciated patients? This has always bothered me.