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

[Roland]

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?

[suzanne4, RN]

They are made with a concentrated dextrose solution, but the final concentration is usually under 20%. Pay attention to the label and look at all of the other ingredients that are added, including quite a bit of sterile water. You are intersted in the final concentration, not what it was made with. That is what the TPN is calculated on.

[caroladybelle, BSN, RN]

The pharmacy web listed that concentrations of dextrose are available up to 70%, but that after all the additives, electrolytes, co-infusion meds, and amino acids are added that the final product is significant less than 70%. Dextrose 70% is the highest available of many concentrations that TPN is made with. So many solutions will contain much less.

[jeepgirl, LPN, NP]

I've heard of that also. We had a nurse attempt to give a child a dose of motrin suspension via the iv line. Luckily she was caught before actually doing it. :selfbonk:

O

M

G

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[caroladybelle, BSN, RN]

Yet, back to Roland's question:

Quite bluntly, properly done, Nursing eduction teaches one principles. And if one applies those principles through out their Nursing career, I don't think that there are many "blunders" that one could stumble into making. Therefore nursing fundamentals is one's "Nursing for Dummies" as you put it. It was taught there.

This is why you are finding few answers to your question.

As far as the Beta blocker issue. Most MDs include in their orders the appropriate parameters for either BP or Heart rate, or parameters for both under meds. And most nurses attempt to know why the drug is being used, more for rate control, cardiac OP issues, or BP. If the nurse in question, didn't know the purpose for the med and withheld it erroneously with a low BP, that nurse disregarded a Nursing and pharmacology fundamental principle. And if the nurse withheld the med on the basis of the low BP, and did not notify the MD of the excessively elevated heart rate after researching the issue the chart, the nurse has again breached a fundamental/basic nursing principle.

Now at times nurses let their egos or their fears get in the way...they don't feel like calling the MD, they don't want to question the MD, they are afraid of getting yelled at, they think that they have "the answer" to the situation, they are too busy to look in the chart or the the pharmacy book. And that gets them into trouble. But that is still not an issue with a lack in their education. Unless, you consider it the duty of Nursing school to teach people to have initiative, self respect and guts.

It is somewhat like religion. If you obey the principles that underly all of the rules, you will do the right thing..even if it is not easy or pleasant at times. But too many people let their egos, desires, and personal issues get in the way of "doing the right thing"...and they get in trouble.

[Roland]

I don't know about Texas, but I have rarily seen greater than a Dextrose 17% TPN. And I have worked in several states. Given how difficult it is to push a single amp of Dextrose 50% through IV tubing, I would be hard pressed to see how well Dextrose 70% would run.

As far as tapering, in BMT, we half the rate for two hours, half that for two hours, and then stop the infusion with some followup accuchecks. If a TPN bag runs out early, we infuse D10W at the same rate until a new bag is obtained.

The situation which inspired this thread was an order to administer (I think Phenergan although I'm not positive) via IV. Well the nurse only had IV access at the triple lumen port where the TPN was running. She didn't stop (let alone taper) the TPN and the drug seemed to "react" with the TPN, and another nurse seeing what was happening stopped the IV solution from entering the client. The point is how would you taper (which takes time) when you need to administer a medication (or do a blood draw) now. My inclination would be to gain different access, but maybe that's not always possible.

[pricklypear]

At my hospital, we don't taper TPN down. It's just stopped - period. We always taper up, though. We've had plenty of instances where we've needed to stop TPN to administer meds, it's never been a problem.

Caroladybelle is right, principles are taught in nursing school. One of those principles is compatability. I.E. - don't try to mix IV solutions without checking compatibility. Another principle is recognizing precipitation. 2 things that that nurse should have known.

[caroladybelle, BSN, RN]

The tapering is only done when the patient is being taken off completely or for a period of several hours. There is no need to taper if one is just stopping for a couple of minutes to flush, give a IVP, flush and return to TPN.

Thre is some controversy as to exactly how long is too long a period off TPN. Some nurses are reluctant to stop TPN for 1 hour long ABX infusions (with adequate flushing before and after) or such. Some do not worry unless TPN will be off at least 2-4 hours or more. Again, much depends on the facility policy, risk of patient hypoglycemia (such as diabetes and insulin in the TPN mix), comorbidities, and end percentage of dextrose in the concentration.

But an additional factor is that the more times you start and stop and break into the lumen with TPN infusing, the risk of contamination and sepsis increases, given the higher sugar content.

But the end issue in answer to Roland is the same.

If one obeys the fundamentals taught in very basic nursing care, one would examine the contents of the TPN bag, know what kind of access that the patient has and how it works, what facility policies are in place regarding use of the specific device, the issue that many drugs may not be compatible and that must be assessed, that adequate flushing must always done,...if one logically works it out, there are no "I wasn't taught this and I nearly killed someone" moments.

Now if there is a Nursing School that does not teach very basic nursing fundamentals that is accredited and the manages somehow to have it's grads pass the NCLEX without this knowledge, well then there might be issue.

[Roland]

The tapering is only done when the patient is being taken off completely or for a period of several hours. There is no need to taper if one is just stopping for a couple of minutes to flush, give a IVP, flush and return to TPN.

Thre is some controversy as to exactly how long is too long a period off TPN. Some nurses are reluctant to stop TPN for 1 hour long ABX infusions (with adequate flushing before and after) or such. Some do not worry unless TPN will be off at least 2-4 hours or more. Again, much depends on the facility policy, risk of patient hypoglycemia (such as diabetes and insulin in the TPN mix), comorbidities, and end percentage of dextrose in the concentration.

But an additional factor is that the more times you start and stop and break into the lumen with TPN infusing, the risk of contamination and sepsis increases, given the higher sugar content.

But the end issue in answer to Roland is the same.

If one obeys the fundamentals taught in very basic nursing care, one would examine the contents of the TPN bag, know what kind of access that the patient has and how it works, what facility policies are in place regarding use of the specific device, the issue that many drugs may not be compatible and that must be assessed, that adequate flushing must always done,...if one logically works it out, there are no "I wasn't taught this and I nearly killed someone" moments.

Now if there is a Nursing School that does not teach very basic nursing fundamentals that is accredited and the manages somehow to have it's grads pass the NCLEX without this knowledge, well then there might be issue.

Okay, here's a couple more example's (I think) of the sorts of issues that could be easily missed or overlooked by newer nurses:

1. Never giving K via IV push (maybe I shouldn't say never since maybe you would to counteract some sort of acute hypokalemic situation that I cannot imagine right now).

2. Remembering to use an airtight seal for a chest tube that comes lose (such as petrolium jelly), but using a vent bandage (three sides sealed with one side loose) for a penetrating, open pneumothorax type injury.

3. Confusing mls, with units on insulin injections (I think I read a post here or somewhere where that occured).

Okay, I'm looking for about a hundred more things just like this.

[mommatrauma, RN]

Okay, here's a couple more example's (I think) of the sorts of issues that could be easily missed or overlooked by newer nurses:

1. Never giving K via IV push (maybe I shouldn't say never since maybe you would to counteract some sort of acute hypokalemic situation that I cannot imagine right now).

2. Remembering to use an airtight seal for a chest tube that comes lose (such as petrolium jelly), but using a vent bandage (three sides sealed with one side loose) for a penetrating, open pneumothorax type injury.

3. Confusing mls, with units on insulin injections (I think I read a post here or somewhere where that occured).

Okay, I'm looking for about a hundred more things just like this.

All of these things you list here, I learned in nursing school...with the exception of maybe the second part of number 2, which I did learn in my critical care trauma course when I started working in the ER 6 years ago...

[Roland]

All of these things you list here, I learned in nursing school...with the exception of maybe the second part of number 2, which I did learn in my critical care trauma course when I started working in the ER 6 years ago...

Yes, you learned them because you are probably a bright, attentive nursing student with exceptional focus and attention to detail. I'm looking for things that will help the "mentally challenged" like myself who struggle to remember to put the cap back on the toothpaste and to not leave the electric burners on the stove on when they leave the house (okay perhaps I am beyond help, but others who are more borderline might not be).

[beesnest]

I have overheard nurses (while working as a CNA) who were going to hold Beta Blockers on a client because their client's blood pressure was too low (say 90/60).

I too would not have given this med. Been a nurse 15 years and that BP with that heart rate would make me worried about barely compensated shock. I would definitely be looking at the patient's vital signs history, and doing a full assessment before administering any meds.

At about 200bpm the heart has trouble filling completely with each beat, so 110-120 is not where you need to worry about that.

[expatnurse]

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 )

(oh yes CHECK THE HOSPITAL POLICY. as long as you follow that you'll be ok in court.

This is a little off the topic but still involves drugs. During my training we have had NO pharm class! This is the area I am most concerned about because I feel it presents the most possible harm to my client. I understand they can not teach you every drug in nursing school however when you were trained what 'basic' knowledge did you know about drugs. For example were you taught to break it down by classes? Any advice would be helpful since I must teach myself!!! Sorry this is one of my biggest soap boxes. Thanks. I have already started reading a nursing pharm book I just need more guidance.