josbarRN

In response to "So you spend 40 minutes pushing 2 mg of IV Push Dilaudid?" No, I have never spent 40 minutes giving a med IV Push. I realize it can seem to take forever; fortunately, there are ways to lighten your load: if the patient has maintenance fluids going that are compatible, you *can* administer the IV Push drug through the same access port you would use for an IVPB med and program the pump to deliver 10 mL of fluid, which will take care of your syringe instead of having to stand at the patient's bedside throughout the administration. The patient will get the prescribed dose over a safe amount of time as the med diffuses in the maintenance fluid. I know we nurses are busy and sometimes overburdened and "Chart as you go" is also an unrealistic expectation so we find shortcuts where we can. I would still not give 2 mg of Dilaudid any more quickly than over ten minutes. As far as the flush, remember that a PIV only needs a 3 mL flush, so I don't have to flush a whole 10 mL for a PIV. With a central line that requires a full 10 mL flush, yes, I still flush slowly. By the way, while you are pushing your IV med slowly, this isn't a bad time to *talk* with your patient. We are encouraged to connect with our patients. During this time, I might ask general questions about their life outside the hospital. After all, our goal is to get them out of the hospital to the next phase, whether that be going home or to another facility. Talking with my patient helps keep them focused on today's plan of care: ambulating, procedures, etc. I also take this time to discuss with them risks associated with Opiates, such as Constipation and I discuss mobility, last bowel movement, etc. This is a *great* time for Patient Education and my patients have fewer questions at the end of the shift when I am handing off to the next nurse. My patients understand why we monitor blood pressure, respirations, etc. and they appreciate being well-informed. Being informed also provides your patients with a sense of being part of their treatment instead of feeling everything is being done *to* them. When patients come to the hospital, there is a great deal of control that they give up...this is one way to give that sense of control back to them. I also discuss with my patients that, if they have PO pain medications, why we will want to administer the PO medication when it is available and have the IV medication as a backup for breakthrough pain, since our ultimate goal is to manage their pain with a med they will be able to take at home. Yes, I would *much* rather give them a pain pill which only takes a few seconds...I want to get out of there and get to my next patient, too, but if you are frustrated and impatient, it will show in your mannerisms. I do end up staying after my shift to catch up on charting more often than I care to, but Patient Care comes before charting, in my book.

If you draw up a dose of 4mg/mL Morphine in a syringe, you would have to push 0.25 mL per minute in order to follow the one mg/min recommendation. You would have to guess how much that is if your syringe isn't marked to measure out 0.25 mL increments. If you draw the dose up in a ten mL syringe and have wasted 1 mL of Saline so your total volume is 10 mL, you could then give this medication over four minutes (240 seconds) by pushing 0.5 mL every 12 seconds. Your syringe is marked in such a way as to give this dose accurately. The patient will get the entire 4 mg at a steady rate of 0.2 mg every 12 seconds. This is why it is important to be able to do math in your head, also. This is too much calculation for some nurses. I am "old school" and we had to be able to figure this out in our heads. This is also why there are math problems on the N-Clex. Another example: beer bongs. At keg parties, pouring beer into a person through a funnel quickly gets them drunk and vomiting quickly...and this is a PO route. We are putting drugs directly into the circulatory system. Think about it. Please read the earlier post from a nurse who was getting IV push Dilaudid slammed in quickly and how they felt. We need to take our time and do it right. Every time. And regarding the comment that my instructor wasn't concerned about time demands: it takes less time to do it right than to have to go back and then give nausea medications or give a reversing agent or call an MD to address the symptoms created because you didn't have enough time to give the drugs properly the first time.

And how many times do you give Dilaudid IV Push to see your patient in a slumber five minutes afterwards? I hope you will read my response on why it is important to dilute an IV Push Opiate: these drugs *must* be given slowly to reduce the risks of nausea/vomitting, hypotension, bradycardia or bradypnea: think about how you would feel if you drank a glass of wine or liquor over six seconds vs. over six minutes. Alcohol, like these meds is a Sedative-Hypnotic and the same rules apply. When you dilute with a 10 mL syringe of Saline, you are allowing yourself to more accurately administer the dose over the Morphine "One MG per Minute Rule" and Dilaudid is considered five to seven times more potent than Morphine, so it deserves the same if not greater caution when administering IV Push. Consider that patients on PCA pain therapy receive 0.2 mg of Dilaudid as opposed to 1 mg of Morphine; Dilaudid is at least five times stronger and should be given five times slower than you would give Morphine. I get frustrated with nurses who shove opiates in quickly: we all have had Pharmacology so we should all know better. Then, because I am doing the right thing, I become the "bad nurse", because the patient asks why I am giving their pain med slower than the other nurses did. If we all adhere to the proper procedures, we are consistent and patients can't nitpick at our methods. Sorry for ranting. Obviously, no one told you how to properly administer IV push opiate narcotics.

Your post brings back bad memories: I have worked at two hospitals that informed me that, "as a travel nurse, you can expect to get floated to another unit before a permanent nurse will get floated". At Hospital#1, I was unprepared for how aggravating that rule would become. This particular hospital actually had nurses charting in three, yes *three* separate places: in the computer, on a chart outside the patient room and in a chart at the front desk. This assignment also found me caring for a patient who had meds due every hour and was in Contact Isolation so I had to don gloves and gowns every hour and it made it hard to care for my other four patients. I was assigned this patient for three days straight (which spared the permanent staff). My assignment was changed once his isolation was stopped and his med frequency lessened. Then came the dreaded float day: four hours into my shift, I was getting floated, so I had to catch up my patient care, chart in all three places, give report to an oncoming nurse, go to the next unit and get report on five new patients...and four hours later, you guessed it: I had to catch up on what I was doing, chart, give report to another nurse, float to yet another unit and get report on a new group. I had enough of Hospital #1 and it was the only time I cancelled an assignment before my 13 weeks was completed. Four years later, at Hospital #2, I was again told that I would be first to float as a travel nurse. Over three months, there were only two occasions where I worked back-to-back shifts on the same unit and, at least once every other week, I got floated in mid-shift, usually to replace a nurse who had only picked up an 8-hour shift. Fortunately, all the charting is electronic and peers had shown me "shortcuts" to charting by exception. I have a background in Psych and have learned that "Frustration = Expectations minus Reality". So, keep your expectations low: remember that that if your unit was *the bestest place to work in the entire world", nurses would be flocking to work there and they would not need travel nurses. I keep my expectations realistic so as not to become frustrated with the hospitals. Thirteen weeks can go by very quickly. So decide how you will do three things every shift: 1) Arrive with a smile on your face 2) Make at least three other people smile during your shift and 3) Leave with a smile on your face. Then you will find that you can handle anything they throw your way.

In Nursing School, the rule I was taught was to administer IV Morphine 1 mg per minute. I had to deliver a 10 mg dose and my instructor made sure I knew exactly how I was going to administer the dose. Drawing the dose up in a 10 mL syringe allowed me to give 0.5 mL each 30 seconds (do the math). Furthermore, it is important to flush at the same rate that you administered the drug, so I flush with a 10 mL syringe of Normal Saline at 0.5 mL every 30 seconds. I have worked at hospitals where a nurse gave the IV push medication slowly, then slammed the flush in quickly, which made the patient vomit because all the medication in the IV line was then "shotgunned" into the patient's system. And remember that Dilaudid is considered seven times more potent than Morphine, so we should deliver it *at least* 5 minutes per mg. If a patient complains you are pushing the drug too slowly, the patient is savoring the quick intoxicating effect.

"Second Grade"? I was not driving or parking anything except my bicycle in Second Grade. I believe the term is "second rate". Yes, I know it is "frowned upon" to correct another nurse's grammar on a nursing board blog, but I believe that if we want to stop being treated as "Second Rate" employees, it is important for us to know when we are misusing a term or phrase in such a way as to have others see us as "Second Rate". We all had core classes and our communication should reflect that we are educated beyond being "pill-pushers" and "butt-wipers". I apologize if I have offended anyone. I am personally thankful when someone corrects a mistake that I have been making due to my ignorance, whether it involves grammar, speech or nursing care.

I have read travel nurse forums that recommend setting your overtime pay as $10/hour above the bill rate. Not the hourly pay but the actual *bill rate*. Even so, I have spoken to recruiters who maintain that the OT rate is fixed as 1.5 of the hourly pay and cannot budge from that. I assure them that they can indeed budge from that or there is no incentive for me to work any overtime hours or pick up extra shifts. I am still learning to negotiate.

I have also had an issue with OT pay as a travel nurse. One hospital explained that they could not afford to allow me to pick up OT shifts even though my OT rate was only $30/hr. Once I considered that the agency bills the hospital 1.5 times the bill rate and the standard bill rate is $70/hr, the hospital would then get billed $105/hr and the nurse gets $30 per hr. So, twelve hours of OT would cost the hospital $1260 and I get $360 and the agency gets $900 even though my recruiter was sitting at home watching TV. No, 1.5 of the bill rate is not acceptable as an OT rate.

Thanks, I appreciate having the truth.

As we travel nurses *should* know, one of the main benefits of Travel Nursing is the ability to choose non-taxed travel stipends. We should also know that these stipends are dependent on our status as temporary employees and the good old IRS only considers us temporary if we have been at our location for less than a year. Some travel nurses take a 30 day break and resume work at the same facility after twelve months to continue receiving stipends. I have recently been at a facility more than 12 continuous months as a traveler and I have two agencies giving me two different scenarios (like that has never happened before). Agency #1 states I have to take my next assignment at least 50 miles outside of the city where I have completed my past 12 months of work...starting in a new location will allow me to receive the tax-free stipends...or take 30 days off...without pay. Agency #2 states I can resume work at the same facility I have worked over a year...but with a different agency. Starting a contract with a new employer, even at the same location, will allow me to continue to receive non-taxable stipends as a temporary employee for a new agency...according to Agency #2. Agency #1 disagrees with the logic of Agency #2...and of course, they want to retain my employment, so they are not unbiased. Agency #2 wants to regain my business from Agency #1, so they may not be unbiased. Anyone been in this situation before and care to weigh in on this topic? Thanks in advance.