Question:
Dear Nancy,
I work on a 22-bed unit. Six beds are step-down. However, we've been administering Metoprolol piggyback to patients who are not monitored but in a general floor bed. These patients may have taken Metoprolol by mouth but now are NPO and still require the medication, so the physicians have changed the medication to IV piggyback every six hours.
Initially, we were told the patient must be in a step-down monitored bed, but now we are told that if we take the HR and BP, we can hang the med as a piggyback on a patient in a nonmonitored bed. The pharmacy says there isn't anything wrong with hanging the piggyback on the patient.
I think the patient should be on a monitored bed. Am I correct?
Sincerely,
Franki
Nancy Brent replies:
Dear Franki:
Your question did not contain details about the patients who are receiving Metoprolol IV. Have they been admitted to the hospital after acute cardiac problems at home? Have they had surgery? Are they newly diagnosed with a cardiac condition? These and other factors may have an impact on any clinical decision that relates to their care while on the unit.
However, generally speaking, most information reviewed about Metoprolol includes the caveat that when administered IV, the patient should be monitored carefully by EKG, BP readings, and heart rate. Remember that taking a drug orally is very different from having it infused. The patient may be quite tolerant of an oral medication. When it becomes infused, however, it is possible that a different result may occur.
It is important to note that your duty as a nurse is to protect the patient and ensure, insofar as possible, the patient's safety. Also, standards of practice dictate how and under what circumstances IV medications must be administered. The fact that the pharmacist sees no problem hanging the Metoprolol doesn't mean that it's OK not to monitor the patient. The pharmacist simply stated that there was no problem administering this IV medication.
It would be wise to check as many resources as you can concerning the monitoring of a patient with this IV medication. For example, if you have an infusion nurse on the facility's staff, they would be a good resource. If you have a clinical resource nurse/mentor, he or she would be another person with which to consult. Likewise, checking with your risk manager (who might be a nurse attorney or a nurse with a master's degree in health law) would also help.
Remember, though, that if a patient is injured or dies due to non-monitoring, the nurse will be one of the defendants in any subsequent lawsuit. The standard of care for the nurse will be what other ordinary, prudent, and reasonable nurses in the same or similar situation would have done.
Sincerely,
Nancy
