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

tiggerforhim · Aug 5, 2005

you have to look up compatability of any meds and this also goes with iv meds and iv lines also.

Definitely. Here we have a chart hanging on the wall which abx/meds are compatible with TPN w/lipids and which are not. I have actually seen a shredded central line before by giving rifampin (I think that's what the drug was) which crystalizes; our policy here is to give it through a peripheral. In the case of a med that's incompatible (and yes, there are some abx that are incompatible), we stop the infusion of TPN, run a 10 cc flush, run the med through, and then run another 10 cc flush and restart the TPN. It does make things difficult when you've got vancomycin 4x/day plus the two other meds. It does mean that the TPN is stopped for quite a while sometimes. I don't know that my facility has worked out that kink yet. And I do work in Pediatrics.

angelnurse75951 · Aug 5, 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.

Having taught nursing school it is impossible to cover every possible scenario a student might encounter. That is why we always taught our students to check policies and procedures if dealing with a new treatment. Also one should always check meds for compatability before administering. Basic common sense would dictate that she clarify. I have been practicing nursing for over 20 years and I still ask questions. As we all know there are new drugs and procedures introduced constantly and it is your responsibility to get the right information. We spend way too much time blaming and not being accountable for our own actions.

grannynurse FNP student · Aug 5, 2005

I heard of a nurse in AZ that had a pt that was npo. Doc ordered MOM and the nurse put it through the central line.
I don't know if this is true or just an urban legend type story, but i've met some nurses that I could see doing something like this. SCARY

I don't know about Arizona but I had a new graduate put MOM as a piggyback, in 1975, in a Brooklyn hospital. :nono: :chair: Fortunately, we caught it before any had infused. :eek: And this is not an urban legend, it actually happen and I actually witness it. And the nurse got put back on otientation for three more months. :specs:

Grannynurse :balloons:

DutchgirlRN, ASN, RN · Aug 5, 2005

Whoa is that scary or what !!! It gives me the willey's!

I've been a nurse for 30 years and I look up whatever I'm pushing for first time and jot it down and keep the info. It's a true time saver and whenever anyone asks "does this mix"? I have the quick answer. I have transposed it all on microsoft word and have it printed out and keep it in alphabetized pages in my notebook along with all the protocols in the notebook I keep with me at work. I call it my brain. It's definately a time saver. There are at least 6 of us now who carry our brains around with us at work. We get the looks when someone hears us say "now where did I leave my brain, I've misplaced it again! I use one of those notebooks that has clear plastic on it and put my family and pets pictures in it so I enjoy keeping it around and being able to show off the family.

NoCrumping · Aug 5, 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?

Just an FYI.... when your new, there shouldnt be any "common knowledge". Were you taught in nsg school to always look up a med before giving it, until you know it like the back of your hand and had given it a thousand times??? Just go back to the basics..... never ever give a med, especially an IV, without, right before giving it, knowing exactly what it is compatable with..... they cant teach you every little thing in 3 or 4 years of school..... But they did teach you where and how to get the info you need.

Sunny05 · Aug 8, 2005

Thank all of you for sharing such valuable information with us (the nurse wannabees and newbies). I get the feeling there's a lot of stuff we don't learn in nursing school so it certainly is nice to have some 'one on one' mentoring from those of you who are more experienced and knowledgeable. And they say nurses 'eat their young.' Thank all of you for being nurturers rather than predators. Way to go!!!

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.

beanhead61 · Aug 8, 2005

What we should learn in nursing school is how to think, that we should look things up, that we should never give a med, participate in a procedure, etc without being fully knowledgable what we're doing. I don't expect nursing education to pour things in my head. Just point me in the right direction, let me know who and what my resources are, and give me the opportunity to learn.

Nursing changes so much that training the nursing student to use their own devices to learn things is so much more important than (once again) "pouring information in".

That's what we're not taking the time to teach new nurses... How to be responsible for your own learning and use their common sense to problem solve. because it's not an easy concept to instill in someone"s brain. It's easier just to force them to memorize and then make them think it's their fault if they can't figure things out in the real world.

Oh, too much negative attitude for a Monday morning!

CDRNURSE · Aug 8, 2005

I am actually a student about to enter my last semester and I have read all of the responses with much interest! I completed a nurse "externship" this summer and "absorbed" more than I could ever "learn" under the stern clinical tutelage of a nursing instructor....One thing my (experienced ICU) preceptor taught me which has stayed with me (and was never referred to in school), is that it is very important to flush all lines (that are not currently continuously running) when you first assess your patient at the beginning of your shift. This provides some assurance that, should the patient go "bad" and need IV meds emergently (or urgently) that the lines are patent....this may seem like a "no-brainer" for you expereinced nurses, but I have yet to have an instructor actually encourage this practice. Usually, they just ask whether you completed the "shift" flush. Given the many responses to this particular forum question, and my own limited experince, I would have to agree with all of the advice given about asking, double checking and using references and resources to verify best practices and policies. Truly, there is no substitute for experience. Thanks to you all!

bluesky, BSN, RN · Aug 8, 2005

My Guide to Surviving Your First Year in the ICU:

1. Don't complain about anything. They don't want to hear it and you'll be labeled.

2. Know your unit's standards very well. You are accountable to these.

3. During report, check every line and every pump to make sure it's done right. Trust me on this one.

4. Verify that all the orders you expect for a certain pt type are actually in the chart (i.e. restraints, c-spine precautions, DNR, etc).

5. Spend at least 10 minutes at the beginning of your shift looking through the progress notes and history. Don't assume what you got in report is true. Do this even if it puts you behind in your vitals, etc.

6. If you are even 0.01% uncertain about a med or an IV med interaction, look it up or call the pharmacy before giving.

7. Your patient's family is not your enemy, a nuissance or an inconvenience. Your patient's family is a group of scared, powerless people who may or may not know how to react and behave in this environment. Remember this.

8. If you make a significant mistake, don't cover it up. That's not honorable.

9. All that glitters is not gold and all that smiles is not a friend. (sorry about the cynicism, y'all).

10. All of us have made the following mistakes at one point or other so don't feel bad when it happens to you, just correct it and try not to do it again:

* push too hard into a small bowel feeding tube with a syringe and splash all over ourselves and the patient.

* made a momentary stop cock error and let blood out of an artline or central line for a second.

* fail to assemble the correct equipment for a Swann placement (gloves, introducer, blah blah blah) and get yelled at by a doc.

* been caught feeling like an idiot when not able to answer a seemingly simple question.

* get yelled at for not being perfectly sterile in some dressing change or device insertion by a senior RN and then proceed to observe her doing the same within the next month.

* repeat something in report that you were told by the previous RN only to feel exposed when it turns out what you heard wasn't accurate.

* act like a diva the first time you give report to a floor nurse and proceed to get your a*s kicked.

11. Always have another RN watch you mix high risk IV bags such as vasoactives, not just sign it.

SmilingBluEyes · Aug 8, 2005

My Guide to Surviving Your First Year in the ICU:
1. Don't complain about anything. They don't want to hear it and you'll be labeled.
2. Know your unit's standards very well. You are accountable to these.
3. During report, check every line and every pump to make sure it's done right. Trust me on this one.
4. Verify that all the orders you expect for a certain pt type are actually in the chart (i.e. restraints, c-spine precautions, DNR, etc).
5. Spend at least 10 minutes at the beginning of your shift looking through the progress notes and history. Don't assume what you got in report is true. Do this even if it puts you behind in your vitals, etc.
6. If you are even 0.01% uncertain about a med or an IV med interaction, look it up or call the pharmacy before giving.
7. Your patient's family is not your enemy, a nuissance or an inconvenience. Your patient's family is a group of scared, powerless people who may or may not know how to react and behave in this environment. Remember this.
8. If you make a significant mistake, don't cover it up. That's not honorable.
9. All that glitters is not gold and all that smiles is not a friend. (sorry about the cynicism, y'all).
10. All of us have made the following mistakes at one point or other so don't feel bad when it happens to you, just correct it and try not to do it again:
* push too hard into a small bowel feeding tube with a syringe and splash all over ourselves and the patient.
* made a momentary stop cock error and let blood out of an artline or central line for a second.
* fail to assemble the correct equipment for a Swann placement (gloves, introducer, blah blah blah) and get yelled at by a doc.
* been caught feeling like an idiot when not able to answer a seemingly simple question.
* get yelled at for not being perfectly sterile in some dressing change or device insertion by a senior RN and then proceed to observe her doing the same within the next month.
* repeat something in report that you were told by the previous RN only to feel exposed when it turns out what you heard wasn't accurate.
* act like a diva the first time you give report to a floor nurse and proceed to get your a*s kicked.
11. Always have another RN watch you mix high risk IV bags such as vasoactives, not just sign it.

EXCELLENT post.

SmilingBluEyes · Aug 8, 2005

And I agree w/the poster who said we all are responsible for our own learning to a large extent. I don't want to see this become a nursing instructor-bashing event here.

lady_jezebel · Aug 8, 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?

the information is not correct. it is perfectly ok to run any other drug through the second or third lumens of a central line. also, an embolism is caused by air injected into the line, not a drug. finally, an insulin gtt can be run with tpn/lipids, since it's often added to the actual tpn sometimes anyway.