Tuesday, August 9, 2011
Check, check, checking out
So it was SO FREAKING BUSY the other night. The back was stuffed full of sick people and new ones were coming in the door so fast we had two nurses out double-triaging for almost 2 hours. The theme of the night seemed to be chest pains or lacerations secondary to kicking glass/tables/sports equipment.
There were the usual WTF visits, like the mom who ABSOLUTELY had to get her kid "tested" for celiac disease in the middle of the night. At the ER. Where people were practically hanging from the rafters in the waiting room. The urgency? Well, she Googled a new diet and wanted to start him on it the next morning... "Can't I just see the doctor real quick?"
"No. I'm sure the other 25 people in the waiting room would like to see the doctor 'real quick', too." Then, after lipping off the triage nurse, she stormed out. Bye...
There were the usual WTF visits, like the mom who ABSOLUTELY had to get her kid "tested" for celiac disease in the middle of the night. At the ER. Where people were practically hanging from the rafters in the waiting room. The urgency? Well, she Googled a new diet and wanted to start him on it the next morning... "Can't I just see the doctor real quick?"
"No. I'm sure the other 25 people in the waiting room would like to see the doctor 'real quick', too." Then, after lipping off the triage nurse, she stormed out. Bye...
Anyway, I had a patient who was recovering from an infected cat bite**. She was on IV therapy q daily and this was to be her last dose.
I pick up the order - Gentamicin 480 mg IV and a PO dose of Cipro.
Go to Pyxis. Look up Gent. Go to withdraw vial.....
.....wait, we only have Gent vials that come in 80 mg/2 mL concentrations?
I check the order again. Yes, 480 mg.
Now, the nurse's cardinal rule in pharmacotherapy is that if you need more than one vial for ANYTHING you're probably doing it wrong. You know, the "thou shalt not overdose the patient into serious complications and probable death" idea. The manufacturers pre-package them in the normal dosages as one step of the safety chain.
I do a quick calc and see that I'd need..... six..... vials of Gent to make the ordered concentration.
I re-check the order and the vial about 500 times. I get an RN to check it. She laughs and says, "Yeah, that's normal for Gent. Don't worry about it!"
Easier said than done. I get to work drawing up the vials and mixing them up in N/S.
Then I go to the patient and start programming the smart pump. Smart pumps have "guardrails" on certain drugs to prevent nurses from accidentally giving unsafe dosages or infusion rates.
So the guardrail pops up with the amount of Gent that I'm planning to infuse. It also pops up with the rate I want to set. The smart pump actually wants me to infuse the 100 mL bag in 30 minutes. I'm all like "screw that, Alaris, you'll run it over an hour!". It's weird that the guardrail cautioned me running the med longer than the time allowed. Usually it's running it too fast that causes phlebitis. But I digress.
So after bypassing 3 red flag safety checks, I was feeling pretty unnerved by the whole experience. I mean, it was only 480 mg of an IV antibiotic, not 48 grams. I was pretty confident that I was giving a safe dosage, and I cleared it with 2 RNs during prep and administration. I also checked my drug guide to verify it was a safe dosage.
Seriously, manufacturers of Gentamicin and Alaris, put guardrails where you need 'em, cuz you just about gave this nursing student apoplexy!
** Who'd've thunk it, but cat bites are among the most common reasons I've seen for people to get cellulitis. Those things just get NASTY! Swelled limbs and purulent drainage. And they usually happen to the nicest people (cat people are usually nice, or nice-crazy, IME). Cute cuddly kitties need to come with a disclaimer.
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4 comments:
Cat bites and human bites are the worst. I once saw an arm so infected edematous....they almost lost it...from a human bite.
I hear you about the abx. It used to be when I first started nursing that our abx doses were so small....compared to now.
Also the practice of once a day dosing (rather than the tid we used to give eons ago) for Gent was found to be less damaging to the kidneys while still killing the bacteria....however...the ototoxicity is where the danger lies...
Wow - that is some picture. The moral of the story is: watch out for bites of kittie AND human kind. You did well to check to be safe about the treatment you made. You are sounding more and more professional. :-)
It good to be extra careful and CYA when you are not sure about giving meds. I always call the pharmacy when I have a question.
How scary, I would have been right there with you, sweating bullets. Sounds like you did everything right. Always good to double and triple check like you did!!!
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Thanks for your thoughts :)