They didn't teach me this in nursing school and I could have killed someone!

SharonH, RN · Jul 28, 2005

What things "didn't" you learn in nursing school or during orientation that could have resulted in a patient being harmed? I knew a person who said that she was never taught that certain (any?) IV medications cannot be given during a TPN feeding in the same PICC line. She had a situation where she was going to push a med using a free lumen on the same double lumen PICC line while TPN was running, and was stopped at the last second by another nurse who just happened to come into the room. I cannot remember the med, but she was told that it would have likely caused an embolism had she proceeded. This caused me to ponder what other sort of "common knowledge" that is sometimes missed in school and on orientation, but that could result in real client harm. What would your "top three" things be that fall into this category?

That's interesting. I have never heard of such a thing and I've been at this for over 14 years. I sure would like to know what med that was. Oh and you can give meds through a free lumen on a PICC line while Hyperal is running, it's lipids you have to be careful about.

Oh and your friend is responsible for looking up medication interactions, contraindications and correct route, etc. before giving it, THAT is what she should have learned in school, not necessarily which meds in particular you cannot push in what fluid.

caroladybelle, BSN, RN · Jul 28, 2005

Actually, your friend should have known to check compatibility of meds before pushing or hanging any meds into a line, not specifically TPN. That is part of basic nursing care (nursing 101/fundamentals).

Though one thing not generally taught. TPN components in most facilities are changed everyday in response to lab work changes. Just because a drug is compatible with the solution one day does not mean that it will be compatible the next, because solution components may have been changed. And connecting anything into a TPN line increases risk of line infection, even if compatible. As such, nothing should be given through TPN. They should also be marked so that blood draws are not done off the TPN line, as lyte panels may be altered. Also TPN should not be abruptly stopped and started, as it can make the patient hypoglycemic - it needs to be titrated off.

As to use other lumens for incompatible solutions, policy varies depending on the central access. Some midlines and PICCs are inappropriate and some lines are. Most facilities have polcies based on research and their experience dealing with is in use in the facility.

Mulan · Jul 28, 2005

What things "didn't" you learn in nursing school or during orientation that could have resulted in a patient being harmed? I knew a person who said that she was never taught that certain (any?) IV medications cannot be given during a TPN feeding in the same PICC line. She had a situation where she was going to push a med using a free lumen on the same double lumen PICC line while TPN was running, and was stopped at the last second by another nurse who just happened to come into the room. I cannot remember the med, but she was told that it would have likely caused an embolism had she proceeded. This caused me to ponder what other sort of "common knowledge" that is sometimes missed in school and on orientation, but that could result in real client harm. What would your "top three" things be that fall into this category?

What drug was it?, and was the information verified with a reliable source? I wouldn't take what you've posted here at face value, unless you have specific information regarding the actual drug. Why would it have caused an embolism?

suzanne4, RN · Jul 28, 2005

Never heard of a drug being pushed thru a PICC line causing an embolism. :rolleyes:

TPN runs continuously in most facilities 24 hours per day.................

There is usually a second port so that you can give other medications, that is the whole reason for them. So that is not considered the same line.

pricklypear · Jul 28, 2005

Our policy is never to run anything with TPN (we usually have lipids piggybacked into it anyway) in the same line. Compatibility should not be an issue with multiple ports of any central line or PICC. Unless it is a single lumen with a pigtail attached.

suzanne4, RN · Jul 28, 2005

The OP was speaking of a "free" lumen on a PICC line, so I would assume that it was a double lumen to begin with.

NICU does it all of the time, sometimes the TPN is stopped long enough to run the meds thru.

pricklypear · Jul 28, 2005

The OP was speaking of a "free" lumen on a PICC line, so I would assume that it was a double lumen to begin with.
NICU does it all of the time, sometimes the TPN is stopped long enough to run the meds thru.

Yes. I agree, we will also sometimes have to stop the TPN long enough to run meds if we have only a single lumen and no other access. Never had a problem doing that.

gwenith, BSN, RN · Jul 28, 2005

We will run insulin with TPN but it is the only thing we will run.

There WAS a case here in Australia where a newly registered nurse was working as an agency and managed to give oral dilantin IV - claimed that this was not taught during hiw undergraduate studies,

I will try to find a link to the legal transcripts of the case because it is a fascinating one (if tragic all the way around) Unfortunately so far I have had little luck in finding a transcript - I do remember it happened in New South Wales.

Roland · Jul 28, 2005

Unfortunately, the story was told to me about four months ago (first hand) and I've just gotten around to posting the subject. I do not know if mixing the medications would have actually caused an embolism or some other negative reaction. I only know that the person who related the incident said that she was told that it could/would have caused an embolism. When she told me this story I remember thinking "that could be me" because I was also unaware of the procedures regarding TPN/ IV piggybacks/drugs. Furthermore, just to clarify I was told that it was a double lumen PICC and that she didn't stop the TPN (and obviously didn't flush). I realize that in theory you should read the compatibility of all medications multiple times carefully before administration. However, in talking to many nurses who "work in the real world" sometimes with five or more clients each on many medications, this doesn't always happen and even when nurses do check for contraindications et. things are still missed (obviously if something goes wrong their licenses are in grave peril). Stated still another way if I were the "academic curriculum tsar" to a major undergraduate nursing program and had the ability to emphasize several commonly overlooked aspects of clinical skills (which can cause negative client outcomes) what might they be? For example I have read that a common error for new doctors/residents is to give too high an Oxygen flow rate to patients with long standing COPD spectrum disorders. Because, people with COPD often rely upon a state of perpetual hypoxgenination (hypoxic rather than hypercapnic drive) to stimulate breathing, giving too much oxygen can cause problems. Well, I am looking for nursing versions of this type of "newbie" error/scenario.

Ms.RN · Jul 28, 2005

what things "didn't" you learn in nursing school or during orientation that could have resulted in a patient being harmed? i knew a person who said that she was never taught that certain (any?) iv medications cannot be given during a tpn feeding in the same picc line. she had a situation where she was going to push a med using a free lumen on the same double lumen picc line while tpn was running, and was stopped at the last second by another nurse who just happened to come into the room. i cannot remember the med, but she was told that it would have likely caused an embolism had she proceeded. this caused me to ponder what other sort of "common knowledge" that is sometimes missed in school and on orientation, but that could result in real client harm. what would your "top three" things be that fall into this category?

this is very interesting and educational. so if a nurse have to give a medicine through central line while tpn is running, is it safer to just stop the tpn with every medicine and give medicine through second lumen? how long do they have to stop the tpn before they can push a med?

gizelda196 · Jul 28, 2005

this is very interesting and educational. so if a nurse have to give a medicine through central line while tpn is running, is it safer to just stop the tpn with every medicine and give medicine through second lumen? how long do they have to stop the tpn before they can push a med?

in the icu access becomes an issue. sometimes i have a patient with 3 triple lumens,and it is still an issue. you always roll your eyes and say yes doctor when the doc says "don't forget to save a port for tpn" (btw it is an infection issue ,tpn should be on a filter and spiked with air preventing tubing)

as long as your follow aseptic technique,flush before and after with 10cc saline you can use the line. just remember with every break you open up a risk of contamination. but that is true with every line.tpn dextrose content just increases the risk.

but a dual lumen, hmmmn, no problem it is central access with 2 lumens in a large vein,the med is diluted with the blood and quickly moves it along.

just remember to always look your meds up sometimes they are not compatible in the same syringe but you are able to use a y site port,sometimes the dextrose in like d51/2ns is not compatible with iv antibx. and if you still are unsure call the pharmacy .if you need more call the clinical nurse specialist. remember you are responsible for your practice. like a previous posted noted nusing school teaches you to check out when in doubt. it cant teach you all the meds. {school would be 15 years long then :eek: )

(oh yes check the hospital policy. as long as you follow that you'll be ok in court.