NURSING STUDENT STORY - THE IV MED BOOK

It was the middle of the semester for ten third semester nursing students. Being in the third semester was both exciting and stressful for the students. This was when they were considered in the “RN” portion of the program. The first two semesters were considered the “LPN” portion of the program. So the students were now responsible for giving IV medications. What they learned in pharmacology in the first two semesters would build onto more intensive information they needed to know before administering IV medications. Some of the students were more prepared than others.

The ten students were separated into three different units. There were three on the oncology floor, three on the telemetry floor, and four on the medical-surgical floor. All units had many opportunities to administer IV medications. After checking on the four students on the med-surg unit my pager went off as I walked down the hallway. I looked at the number on the digital screen and knew it was somebody from the telemetry unit. I was close to a hospital phone on the wall and called the extension. The phone rang several times before a female voice answered.

“Telemetry unit. This is Joan,” she answered.

“Hi. This is the nursing instructor. One of my students paged me,” I responded.

“Oh. Okay. I will find out,” said Joan. The phone was then placed on hold. I once again was listening to a female voice telling me what programs were offered at the hospital and why patients chose the facility.
After four rounds of listening to the same woman giving the same speech it was broken by the student who paged me. I did not know if I could stand listening to the same spiel again and again every week.

“Hi. This is Trisha. I have an IV bolus and drip to give,” she said with excitement.
“What med are you giving?” I asked.

“It is Cardizem. First I have to give it IV push and then there is a drip,” said Trisha.
“Okay. You make sure you look it up, give me the class, why you are giving it, side effects, and how you are going to calculate the dose on the IV pump,” I told her.

“I know. I mean. Okay. I will be ready when you get here,” said Trisha. She knew I would question her on medications because it was one of my idiosyncrasies.

“Okay. I will be there in about ten minutes,” I said.

“Okay. Bye,” said Trisha.

Around ten minutes later I walked to the telemetry unit. Trisha was in the medication room with her syringes, needles, and the Cardizem vial ready to go. She had the nurse’s medication book in hand looking up the information. The pharmacy had already mixed the Cardizem drip which was lying next to the syringes and vial. She saw me walk towards her and quickly put her head down to read more about Cardizem.

“Hi. Are you ready?” I asked.

“I think so,” said Trisha.

“Okay. So why are you going to give your patient Cardizem?” I asked.

“Because he is in rapid atrial fibrillation. They want to slow his rate down,” said Trisha.
“Good. What is the classification of Cardizem?” I asked.

“It is a calcium channel blocker,” said Trisha with confidence.

I asked her more questions about side effects, when she would check on her patient, and how fast she administer the IV push. She was prepared for my questions and answered them correctly with her book in hand. I asked to see the orders that were written to double check the doses and rate. Trisha was going to give a 25mg Cardizem bolus followed up with a drip at 10mg/hr.

“Okay. Draw up the IV push,” I said. Trisha had the syringe and the vial in hand. She drew up 25mg of Cardizem without difficulty. She was becoming more confident at drawing up IV medications. I double checked the syringe and vial to make sure it was correct. Trisha was doing well. I looked at the IV bag which contained 125mg of Cardizem in 100ml of normal saline. I knew this resulted in a concentration of 1mg/ml because adding 125mg of Cardizem would add 25mg of solution. I looked at Trisha.

“How fast are you going to run in the drip?” I asked. Trisha looked at me. After several seconds she responded.

“I don’t know. I couldn’t find anything about that in my med book,” she said.

“What was the dose ordered?” I asked.

“Ummm. 10mg an hour,” said Trisha.

“Okay. So to get 10mg an hour, how fast are you going to run it in?” I asked. Trisha looked at me again.

“I don’t know,” she said. I could tell she was stuck.

“Do you have your IV medication book with you?” I asked. I knew there was a simple table in the book to help her figure out how fast she would run in the Cardizem after giving the bolus. She looked at me again. After several seconds she remembered she did bring her book.

“Oh. That book! It’s in my bag,” said Trisha.

“Okay. Go get it and we will figure out how you will set the pump up,” I said. Trisha quickly walked to her backpack which was located underneath one of the desks in the nurse’s station. She returned within a minute.

“I have never opened it,” said Trisha. I looked at her IV med book and saw it was still in the original wrapping. She unwrapped the book and held it in her hands.

“Look up Cardizem,” I told her. She looked in the back of the book for the medication. Quickly she flipped to the page.

“Okay. See that table?” I asked her. She looked at it.

“Look at how much Cardizem is in the normal saline,” I told her. She picked up the bag and looked at the label.

“There is 125mg of Cardizem in 100ml’s,” she responded.

“Find that dose and how fast you will run it on the table,” I told her. She used her finger to find where it said 125mg in 100ml’s. The answer with how fast she was going to run in the drug was right next to it. She did not see it though and was becoming frustrated.

“Look here,” I told her as I pointed to table where the concentration she had was. With my finger I pointed to the answer.

“How fast are you going to run it in to get 10mg in an hour?” I asked. She looked at the table.

“Oh. I will set it at 10ml an hour. Right?” asked Trisha.

“Yes. That is right. You have 1mg/ml. It is a 1:1 ratio,” I told her.

“But there is 125mg in 100ml's. That is not 1:1.

"When you drew up the Cardizem, how much liquid was in 25mg?" I asked. She looked at the bottle.

"Oh. Okay. I see. That wasn’t so bad,” said Trisha. “I never used this book before. I guess I should have looked at it a while ago, huh?”

“It is a good book. A lot of the drips have tables that make it easier for you,” I told her.

Trisha spiked the bag with IV tubing and located an IV pump for the drip. She gave the IV bolus and was comfortable setting the IV pump. After charting what she had done she once again looked confident.
“I guess I need to look at my books more often, huh?” she said after charting.

“It can make your life easier. Don’t lose this book. It will help you with all of your drips,” I told her.

The rest of the day I spent going between the three units and the students who had the opportunity to give IV medications. It was almost 1400 and time for post-conference.

During post-conference the students talked about their day and what they had done. They had their usual complaining about some of the things a few of the nurses had done but overall it was a good day. When it was Trisha’s turn she told her classmates about the book she never opened and how much information was in it to help with the Cardizem drip. She talked about her patient with rapid atrial fibrillation and how the medication helped the heart rate decrease with a couple of hours. Trisha told her classmates how she checked on her patient frequently and watched the monitor from the nurse’s station. She saved a strip from when her patient’s heart rate was rapid and when it came down to normal.

The students were eager to call it a day and start again in the morning. I watched Beth take out her IV medication book still in its original wrapping. She unwrapped it and flipped through the pages. Trisha showed her the table she used for the Cardizem drip. They both were amazed how much information was in the book that was required by the college that remained unused in their backpacks. Tomorrow I expected to see more books unwrapped and looked at during clinical. The students would soon realize how this one IV medication book would help them throughout their careers as registered nurses. But for now all they wanted to do was get through their third semester.