To advocate or ignored that this is not happening

[BethulieRN]

Hi,

I am a third semester nursing student who works at an LTC facility.

I have noticed over and over nurses giving IVPB abx without a primary line and using primary set tubing to infuse the abx. By the time they finish priming the tubing only less volume is left of the abx.

For example, last night again, I wathched another attending nurse give 50ml IV Zosyn IVPB over 30 minutes. She first primed the tubing with a primary set tubing; by the time she was done approximately 20 ml of solution was left in the IV bag. Second, she flushed the hep lock with 5 ml of NS and started the infusion. Within 10 minutes the infusion pump beeped. The nurse came, stopped the pump, d/c the IV and flushed the hep lock with another 5 ml of NS.

I asked the nurse if she believed the pt had the right dose of the medication. She reluctantly said yes. She believed the strenght of the medication was so high that even the 20 ml of Zosyn the pt received was enough to cover him and also added that the doctors to not order a primary bag to piggyback the abx. Also this pt was not on fluid restriction.

I thought that, this was a cop out answer. I did not believe this pt was administered the right dose of the medication. Because not only half of the solution was dumped on the trash can during priming, another quater of if was left in the tubing.

As a soon to be nurse, how should I handled a situation like this?

Is this normal practice in the nursing world to have a piggyback to infuse without a primary line?

If it is, what techniques to apply so I do not waste half of the volume to be infused IVPB?

I thought, if there were a primary IV solution that was compatible with Zosyn such as NS, I could back flush it to prime the secondary tubing so that I do not waste any medication.

Am I being too NCLEX oriented and not seing the real nursing world? what suggestion and what step should I take to advocate for this pt ?

[RN1989]

It is not necessary to run a piggyback with IVF. In fact, there are many people who could easily go into CHF by having that extra bit of fluid. It is also not cost-effective to be using bags of saline, extra tubing, etc. Then you also have the issue of explaining to the doctor why you need an order for a mainline IVF because you don't want to give the piggy without it. There is no medical reason for a pt to even have a flush bag - it does not help the antbx work better. Those little flush bags are nicetys to keep your IV line open in case you can't get immediately back to flush your hep/saline lock. IV bags/IVPBs always have a little "extra" in them, to compensate for a small amt left in an IV tubing. And there is this neat thing called GRAVITY that when you take the IVPB off the pump - you can get nearly if not all of the bag down the tubing and into the pt and you won't keep getting that "air" signal along with the beeping. And in LTC - the chances of even having an IV pump is rare. I still remember mainline IVs AND piggys being gravity only unless it was a med. gtt. We went around approx q30 min to check the drip rate with our watches.

Sounds like the nurse needs assist in learning how to prime tubing so as not to waste the med and also how to ensure that the pt gets the med. Unless you really want to pursue this, just make sure that you do things right when you are the nurse. There are going to be a lot of things that irk you - you have to pick and choose your battles or you will be burned out in just a few weeks as a nurse.

[TRAMA1RN]

With iv antibx, I first prime my tubing with the antibx, and then set my pump for 15 cc less than the total bag this leaves antibx in the tubing. I then get a 50 cc bag nss and use that to run an additional 20 cc of nss after antibx through the tubing, patient gets the entire amount of antibx and minimum amt of extra fluid.

[Dolce, RN]

There are several ways to insure that the patient is getting the correct dose.

1. Gravity method: empty the entire bag and primary set IV tubing into the patient by gravity leaving the IV tubing empty. It will then have to be re-primed for the next dose of antibiotics.

2. Hang a 50 cc bag of NS after the ABX are complete. This takes time and wastes supplies. It also is more fluid than necessary for the patient.

3. Use the same tubing for your facility allowed time (usually 72-96 hours) and keep the tubing primed. Give the drug until the ABX are complete and then disconnect the tubing from the patient. The next dose that the patient receives will not "waste" any of the drug.

[Altra, BSN, RN]

From my reading of this, you have a technical question re: IV tubing. Not an ethical/philosophical question about "advocating" vs. "ignoring this is happening."

Perspective is everything.

[lsyorke, RN]

There is always a bit of fluid left in the tubing. This is the norm, and the amount is negligible. A "flush" bag is a waste of money and time. Saline, antibiotic, saline....the standard in administering IV antibiotics through a saline lock.

http://books.google.com/books?id=zJeWi9MaLfgC&pg=PA46&lpg=PA46&dq=medications+through+saline+lock&source=web&ots=6u6KTo3PAO&sig=7ur0UzjaBYWEUXE2cO3AvPw5W3s#PPA49,M1

[bagladyrn, RN]

Unless the person is allowing a HUGE amout to run out of the end of the tubing when priming, nothing like 30cc (you state only @20cc left in bag) would be used up in priming. Even long IV tubing only holds a few ccs. Check the specs on the tubing package or try it yourself with an old empty tubing and a syringe of saline - I think you will find it only takes up about 3.5 ccs. (Good question for a nursing student to research).

[Dolce, RN]

I think primary IV pump tubing takes 27 cc to prime.

[lindarn]

I think primary IV pump tubing takes 27 cc to prime.

We would run 10 cc N/S at the end of the piggy back to flush all of the medication out of the bag/tubing. Worked for us.

Lindarn, BSN, CCRN

Spokane, Washington

[CoffeeRTC, BSN, RN]

I think there are a few things to consider here. RN1989 covered them nicely. This is a LTC setting here. Look at the pt population, their med history, the supplies you have handy etc. I've worked in quite a few LTC in my area and we done it all the same. Primary tubing is used on a pump, no flush bag, prime the tubing carefully trying to not waste any med, put in in the pump let it run. A few times I will see a flush bag hanging and LOL....its normally a nurse new to LTC. You would need an order for this and also need to order it from pharmacy.

The nurse in this senario was wrong in wasting most of the dose. She should have scrapped the IV bag and got another one if she couldn't get it to prime without wasting the med.

I see where the OP was questioning advocating for the pt. Should she tell someone that she wasn't getting the med? You can ask you clinical instructor to show you how to prime a line the right way. I wouldn't approach the nurse directly

[BethulieRN]

From my reading of this, you have a technical question re: IV tubing. Not an ethical/philosophical question about "advocating" vs. "ignoring this is happening."

Perspective is everything.

I thought about ethic because I believed the pt did not get the right dose of medication. I believe, it is ethical and calls for the nurse's moral to make sure that the pt is getting the right dose prescribed. And with abx the right dose and time is critical to kill microorganisms.

Also, it is a technical question because of the waste of almost 3/4 out of the 50 ml solution of abx.

I was just trying to raise these questions, because I have seen these practices by nurses many times, not only with IV meds but also with PO meds.

My hope is that while I am still a student to learn the right way of doing procedures, so that I develop good habits when I am working on the floor as a nurse.

I also understand that there is real world nursing out there where things are done short cut or different than the perfect world of nclex.

But I also know that, it will kill me to know that my pts are not getting the right doses of meds they should have received due to my wrong doings.