Right or wrong? Need some advice

[Miknsha]

I am currently an RN student doing med-surg clinicals (5th quarter). There is a patient who is to receive Vanc. through a PICC and it is scheduled for 9am. However last week he had an appointment and was gone by 8:30, we were not informed of his impending departure until 8, and by then it was too late to start the infusion as it hadn't been taken out of the fridge yet and is scheduled to run over an hour. The issue I am having is that upon his return at 11:30ish, our instructor said it was OK to give it, even though it was late, and without the Dr.'s approval, although she stated that she had spoken to the NP who was at the facility and that it was approved, no order was written in the chart. Our instructor (who has an MSN) gave it anyways. Another student and I are arguing on whether or not it was an acceptable thing to do, and we can find nothing in the NPA, or the BON websites that will help. Was she wrong for doing this? We are considering going to our nursing chair at school, but obviously do not want to look like idiots if this was acceptable. Any input would be greatly appreciated.

[KelRN215, BSN, RN]

What would you have preferred to have been done? The patient needed the medication, there was no other practical time to give it to him. If patients are delayed because of procedures, appointments, what have you or if the medication doesn't arrive from the pharmacy until 2 hours after it's due (which happens), you give it as soon as you can. Your instructor did exactly as I would have done.

[Sun0408, ASN, RN]

Why would you need an MD order to give a late med ?? Your instructor did the correct thing. Meds are given late for various reasons, this being one of them. Pharmacy, time of first dose or hospital policies regulates medication times. If it is only scheduled for once a day, the pt needs that medication.

[Miknsha]

Please let me clarify my post before roasting me on an open fire.....I was trying to find information on why it was RIGHT for the nurse to give the med, as this other student (who constantly states she's been an LPN for 3 yrs so she knows more than me) was saying no matter what it was wrong because of the wrong time, no Dr order etc.... I on the other hand have passed medication for 6 yrs and have many many times given medication at unscheduled times due to appointments, meds being late, unavailable etc....I was just looking for verification to back up my argument since she doesn't want to listen to the instructor. I just didn't want to write a book at the onset to explain everything how I should have. Thank you for your input it has been helpful in my argument with her.

[Silverlight2010]

I'd give it. Vanco is generally once a day. I'd just note in my chart that the patient was away from the floor at time med was due and make further note of when it was administered.

Alternatives could include starting the infusion before departure and the patient goes to the appointment with the infusion running, set to switch to a mainline infusion at say 10-20 cc/h when the vanco was finished. I'd have done this if the vanco was a 1 time dose intended as a prophylactic prior to a procedure, knowing the RN in the procedure room would manage the infusion (and would expect to see it running). Also have to add as long as they are tolerating it well.

For 2.5 hours late I likely wouldn't reschedule a UID med, but if it were many hours late I'd check to see if the MD wants the schedule changed but would probably still give it. They are on it for a reason. Just think about the number of antibiotic resistant organisms we have because of incorrect use of antibiotics.

My quick mental check list for giving late or held meds

Is the order still current? (not changed, discontinued or put on "hold" by the MD on rounds)

What is the med and what is it for?

How many times per day are we giving it?

How late is it and how close is it to the next scheduled dose? (think onset of action, peak times, duration)

Is the patient condition appropriate for this med?

For example a patient fasting pre-procedure has the morning metformin held. They come back, it's lunch time and their next scheduled metformin is due in about 4 hours or so. I'm about half way between scheduled dose times. In this case I don't give it. If the patient has insulin coverage orders, even better. I can cover a high accu until we get their diabetic meds on track.

I wouldn't take it to the nursing chair. This happens unfortunately in nursing practice and meds are not given in the acceptable time frame for many legitimate reasons. In this case, "patient not available". Great topic for a nursing post-conference if your group does that. Just chalk it up to another experience that will build your nursing judgement skills.

[Silverlight2010]

I was trying to find information on why it was RIGHT for the nurse to give the med, as this other student (who constantly states she's been an LPN for 3 yrs so she knows more than me) was saying no matter what it was wrong because of the wrong time, no Dr order etc....

Wow. Giving the med is the right thing unless the patient isn't tolerating it or the order has changed.

[Sun0408, ASN, RN]

If you thought the nursing instructor was "right", why would you go to the nursing chair about the issue with the other student? Please see your second to last sentence in the original post.

[Miknsha]

Sorry it was a typo....I did type "we" I meant "she"

[amoLucia]

Using your critical thinking skills, you need to think this one out. Antibiotics are time-scheduled to provide and maintain a maximum, constant and steady-state of medication for effective infection-fighting therapy. If even one dose is missed (and in this scenario, the ONE daily vanco dose), the vanco peak & trough titre levels (also known as evidence-based rationale) will most likely be sub-therapeutic. Your pt then experiences a negative outcome (sub-therapeutic medication) that could delay his recovery. Medication dosages will then probably have to be adjusted based on altered vanco levels and renal lab values (all of which have been affected by the omitted vanco dose. Also, another negative possibility would have been to jiggle the appt and transport, etc. (Not a good idea!)

Using nsg's rule of thumb of the 1 HOUR window for med admin --- giving an 8am vanco at 9am and running it for 2 hours pushes it to what...11am? And you were starting at 11:30 - 12N ish??? You're talking about a very minimal delay versus omission (with possible negative sequella).

The only issue I see here is that your instructor should've/could've written an order from the NP that would cover the delayed admin OR a nsg entry on the MAR of nsg notes could explain the delayed admin action.

Even with your 2nd post, I don't see your reasoning for "going to your nursing chair" as you say --- you had the oppt'y to have a good discussion with your instructor to clear up any issues FIRST. (Of course unless that was the other student's doing.) You sound like you have enough experience to know to go thru your proper chain of command and you've dealt with problematic med admin in your past. As a student, be careful who you listen to - be an independent, not a follower. This is your discourse for your student colleague (I don't think she's quite a peer).

[KelRN215, BSN, RN]

Please let me clarify my post before roasting me on an open fire.....I was trying to find information on why it was RIGHT for the nurse to give the med, as this other student (who constantly states she's been an LPN for 3 yrs so she knows more than me) was saying no matter what it was wrong because of the wrong time, no Dr order etc.... I on the other hand have passed medication for 6 yrs and have many many times given medication at unscheduled times due to appointments, meds being late, unavailable etc....I was just looking for verification to back up my argument since she doesn't want to listen to the instructor. I just didn't want to write a book at the onset to explain everything how I should have. Thank you for your input it has been helpful in my argument with her.

It's the right time after you reschedule the dose. You have a doctor's order, how else would you know you had to give this medication?

Whether this was a daily dose or a q 6hr dose, I would still give it as soon as the patient returned. If it was a q 6hr dose, then you reschedule all subsequent doses to get back to the right schedule. (I.e. give this dose now at 11am, the next dose is moved to 5pm, 11pm then 5am.)

[JZ_RN]

Better to have it a little late rather than not at all, unless it was closer to the next dose than it was to how late it was (if that makes any sense). You can always have the order changed to reschedule.

[jtmarcy12, BSN, RN]

If I was you I would not go making "waves: against the instructor. The patient went for a procedure, when the patient returned the medication was given. She was RIGHT to give the medication when the patient returned. You are a student, go over this with your instructor if you are not sure and tell her/him your rationale for giving or not giving the medication as soon as possible.