What makes IVP meds so scary?

[libran1984, ASN, RN]

So I interviewed today for a PRN position within the hospital network I am currently employed through. This department is going to try using LPNs again after a 9 year hiatus from favoring an all RN staff.

In opening these new LPN spots the department will determine the LPNs scope of practice since the state and hospital scopes are so broad. The major limitation currently thought of is only the RN can give IVP narcotics.

I thought this was highly unusual since just a few miles down the road in the ER I give IVP Dilaudid, morphine, Ativan, fentanyl, on a VERY regular basis. While I understand the med administrations are determined by the individual departments I wonder why one dept vs another would have different rules of medication administration when both are under the same hospital umbrella. In particular the patients in ED are of a much higher acuity!

From my understanding this is not uncommon to restrict LPNs from administering IVP narcotics or even ALL IVP meds. Is IV therapy that scary? While it can be dangerous if done improperly, every ASN and every BSN I have talked to learned IVP times and skills on the job. They all did the same training I did as an LPN in hospital orientation.

Now I am going to be getting ahead of myself, but that is ok. No need to inform me of that fact but do you think after I am hired I could create a formalized and professional report after a little bit of time has passed to discuss the LPN scope of practice in this particular dept (outpatient surgery) and convince them to allow LPNs to give IVP narcotics using hospital policy and evidence from the floor LPNs and ER LPNs as proof of safe IVP administration of narcs by LPNs.

Or how many ppl actually think IVP narcs or even IVP meds in general are just totally out of the question? If so, what (specifically) makes the RN more capable in your state?

For the LPNs that live in states requiring an IV cert, do u give meds IVP or are you simply allowed to start a saline lock, or can u meet half way and hang something as long as its not pushed? Do RNs need an IV cert or is it just on the job training for them?

What does one learn in an IV cert class and what did u manage to take away and how much of it is used in the real world? How long was the class to cert up and how much is a ball park figure?

What about LPNs who are ACLS/PALS... Is that pointless to say your ACLS/PALS if you can't push the med?

Sorry, now I'm just thinking out loud I suppose

[libran1984, ASN, RN]

So to answer some of my own questions...

$450 dollars for the class and 30 hours.

Blah.

Def love the on job training better ^_^

[Fiona59]

I think part of the issue is protectionism by RN associations and hospital boards fear of lawsuits.

Up until about 18 months ago, the only place that an RN could direct push meds were the ICU and ER. If a push was required on the floor then the ordering doctor/resident was required to do it. The rationale being if the patient was that unstable they shouldn't be on the general floors.

Having said that, I've worked with nurses from Ireland and the UK who said they never gave IM narcotics until moving here. The doctors did it.

[begoodlpn]

I work on a med-surg unit and we give IVP narcotics as LPNs. I'm questioning if we're allowed to determine of PRN pain medication is appropriate for us to administer, however. It seems to be a hazy line. Today an RN seemed to reprimand me for giving my patient pain medication without first consulting my RN to get an pain score for herself. I didn't even know what to say to her.

[DeBerham]

To answer some of your questions:

Yes, some IV drugs can be scary if not administered properly in appropriate doses. Maybe it's protection of the RNs, but I strongly suspect more comes from the hospitals own Liability Insurance. As an RN I routinely push narcotics (have actually only hung an IVP of a narcotic once... relatively recently actually) and anoxylitics. The view is probably that the RN has more educational background in med admin than an LPN and SHOULD (do not read into this, it's not necessarily the case) be more cognizant of the risks associated with certain drugs. The RN doesn't make me inherently safer, but for insurance purposes it's probably cheaper to say that only RNs can do it vs RNs and LPNs. To be honest with you, I was an LPN once and I've known some very good LPNs who I would have no issue with having them push IV meds. I've also known two RNs who have killed patients because they were simply incompetent when it came to this stuff. It's too easy to do if you're not careful.

There is no "IV cert" for RN's, it comes with the program that you attend and passing NCLEX-RN is viewed as a general competence to give IV push medications (as scary as that might sound).

I would NEVER discourage an LPN from getting ACLS and PALS, having them does two things: 1) it shows that you are capable of getting through the course which, for many people is, very difficult, and 2) it exposes you to scenarios and information which should make you a more competent provider. Knowing rhythms and being able to predict consequences of said rhythms would probably be the most important take away that an LPN would get from those courses. That being said, you should never be in a position where you are pushing lidocaine or magnesium on a coding patient as an LPN, because simply put, if the outcome isn't good the families lawyer is going to have a field day with you, the doctor, and the facility.

[libran1984, ASN, RN]

That's the thing tho... The hospital allows me to give IVP narcotics I do it multiple times a day in the ER and several floor LPNs do it as well. We are most certainly covered by the hospital and thus my irritation that a Dept would further minimize the scope of LPN practice.

[DeBerham]

I don't know :/

Have you asked your department head about it? We could guess all day as to why they might be doing it, but getting it directly from your leadership would at least give you some insight into what they are actually thinking vs what we assume that they're thinking.

[libran1984, ASN, RN]

If I'm offered the position I'll def be doing so. The response I got in the interview was that they were worried about respiration depression. She asked me if I knew what Dilaudid was and proceeded to educate on how potent a pain killer it is and they only give it in 0.5mg increments due to its intensity.

At first I totally thought she was yanking my chain. I give so much Dilaudid in the ER, some days I think I get a contact buzz (just joking of course). In addition, 0.5mg is small. I don't remember the last time I gave less than 1mg IVP.

Now I understand that there may be a compounding factor with the sedation meds as they wear off and then the Dilaudid Itself. I know how to count respirations, take BP, and judge level of consciousness. It is completely within my license to make a pharmacological nursing intervention when a med is ordered. It is also completely within my license both by the state and hospital to administer IVP narcotics.

I just feel like they're pulling that "assessment" stuff again. You know, like an LPN can't assess, so the LPN should not assess a patients pain level and the appropriate interventions should be determined by the RN since this particular intervention requires a set of vitals before med administration and 30 minutes after administration. Why trust the LPN to interpret acceptable vs unacceptable BP and respiration rate, right?

However, by all means let the LPN determine severity if nausea and determine if the PRN zofran is appropriate!

And never mind that I've been pushing theses meds on patients with a much higher acuity than any of these outpatient surgery pts.

Oh! Then let's just say... Let's just say something like respirations cease. While inconvenient, bagging and narcan, baby! I mean, all of us are ACLS for a reason right? (and of course it would never get to that point without some great oversight)

Ugh.

[libran1984, ASN, RN]

Update: offered job but I think I'm going to counter with "hospital policy and state scope of practice allow me to give IVP narcotics. I have been administering IVP narcotics for 2 years and taking care of a pt load of much higher acuity than here. I would love to accept the job with the stipulation that I am allowed to the full extent of hospital policy"

[dream'n, BSN, RN]

I wouldn't push the issue right now, since you're just starting; creating waves and all. I would give the managers/supervisors a little time to adjust. You said they haven't used LPNs in 9 years? Sounds like they aren't too familiar or comfortable with maximizing a LPNs potential benefit. Work hard and prove to them that LPNs can handle the responsibility. Build up trust and then you will be able to help create a broader scope for the LPNs on that floor.

[brithoover]

Yikes I would not say that at all if you want the job. If pushing IV drugs is that important to you maybe you should look for a job that allows it

[medic9872]

The only thing I can think of is unfamiliarity with the drugs and inexperience. You can have those with an RN or an LPN. Or like in my job, with a paramedic. Good luck with the job. Your experience and confidence will show through.

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