ADMINISTERING METOPROLOL IV

PUSH
WHAT A NURSE NEEDS TO KNOW AT
THE VETERANS ADMINISTRATION
UNIVERSITY OF SAINT MARY
COURSE NU727 CURRICULUM DESIGN & EVALUATION
BY MYRA CASTON, RN-BSN, MARYANNE GLASIER, RN-BSN & ADANIA IVORY, RN-BSN
 NUMBER OF CREDITS
2.5 CNE HOURS
("CALCULATING CE," N.D.).

WE WILL COMPLETE AN APPLICATION DESCRIBING ITS

NURSING SKILLS COMPETENCY COURSE, INCLUDING
CURRICULUM, TEACHING STRATEGIES, INSTRUCTOR
QUALIFICATIONS, LEARNING ENVIRONMENT, AND
SUCCESSFUL COMPLETION CRITERIA (AMERICAN NURSES
CREDENTIALING CENTER [ANCC], 2017, PARA. 1) FOR
APPROVAL OF THE CNES.
 VETERANS ADMINISTRATION
MISSION STATEMENT

TO FULFILL PRESIDENT LINCOLNS PROMISE

TO CARE FOR HIM WHO SHALL HAVE
BORNE THE BATTLE, AND FOR HIS WIDOW,
AND HIS ORPHAN BY SERVING AND
HONORING THE MEN AND WOMEN WHO
ARE AMERICAS VETERANS
(U.S. DEPARTMENT OF VETERANS AFFAIRS, AUGUST 20, 2015, PARA. 1).
 EVIDENCE OF COURSE NECESSARY

THIS PROGRAM IS NECESSARY TO PROVIDE EDUCATION

FOR MEDICAL-SURGICAL NURSES WHO ARE REQUIRED TO
TAKE CARE OF MORE ACUTE PATIENTS WHERE CARDIAC
MEDICATIONS WILL BE REQUIRED. COMPETENCY IN THE
DELIVERY OF METOPROLOL AS AN INTRAVENOUS PUSH
MEDICATION WILL BE OF UTMOST IMPORTANCE WHEN
STABILIZING PATIENTS TO AVOID THE TRANSFER OF PATIENTS
TO A HIGHER ACUITY (ANDERSON, 2010; HSAIO ET AL., 2009; SAETHANG
& KEE, 1998).
 COURSE DESCRIPTION

THIS COURSE WILL PROVIDE THE NURSE THE INDICATION OF METOPROLOLS USE FOR
HYPERTENSION ATRIAL FIBRILLATION, AND SINUS TACHYCARDIA. THE MECHANISM OF ACTION,
ADVERSE REACTIONS, DOSAGE, NURSING CONSIDERATIONS, MONITORING, AND
CONTRAINDICATIONS WILL BE PRESENTED. A REVIEW OF RHYTHM STRIPS WILL BE INCLUDED. IT IS
EXPECTED THAT THE NURSE WILL SHOW ASSESSMENT SKILLS WITH RETURN DEMONSTRATION
AND TO PASS BY 100% ON THE EXAM TO ENSURE COMPETENCY IN IV PUSH METOPROLOL
ADMINISTRATION.
THE MIND IS NOT A VESSEL TO BE FILLED, BUT A FIRE TO BE IGNITED
PLUTARCH (N.D.)

COURSE OUTCOMES

THE NURSE WILL BE ABLE TO IDENTIFY THE CLASSIFICATION OF METOPROLOL.

THE NURSE WILL BE ABLE TO VERBALIZE APPROPRIATE USES AND PURPOSE OF ADMINISTERING METOPROLOL.
THE NURSE WILL VERBALIZE AND DEMONSTRATE THE CORRECT PARAMETERS AND EKG FINDINGS, IDENTIFYING ATRIAL
FIBRILLATION, SINUS TACHYCARDIA, AND HYPERTENSION PRIOR TO ADMINISTRATION OF METOPROLOL VIA IV PUSH.
THE NURSE WILL BE ABLE TO VERBALIZE AND IDENTIFY ANY DRUG CONTRAINDICATIONS AND POSSIBLE PATIENT
ADVERSE REACTIONS TO METOPROLOL, INCLUDING OMINOUS RHYTHMS SUCH AS HEART BLOCKS AND TORSADES.
THE NURSE WILL VERBALIZE AND DEMONSTRATE APPROPRIATE PATIENT MONITORING WHILE RECEIVING METOPROLOL.
THE NURSE WILL BE ABLE TO COMPETENTLY GIVE IV METOPROLOL TO PATIENTS DISPLAYING HYPERTENSION, ATRIAL
FIBRILLATION AND SINUS TACHYCARDIA WITH CORRECT MONITORING AND DOCUMENTATION OF THE PROCEDURE.
(Shastay, 2016).
 ECG VIDEOS TO BE REVIEWED
REASONS FOR METOPROLOL IV PUSH

(Khan Academy Medicine, 2014) (Theriault, 2011)

Atrial Fibrillation Sinus Tachycardia

OMINOUS RHYTHMS TO WATCH FOR

(HippocraTV, 2016) (EMTprep, 2015)

Heart Blocks Torsade de Pointes

 METOPROLOL TARTRATE
INJECTION

MECHANISM OF ACTION
METOPROLOL IS A BETA-BLOCKER. IT AFFECTS THE HEART AND CIRCULATION
OF THE BLOOD THROUGH THE ARTERIES AND VEINS. METOPROLOL IS A
SELECTIVE BETA BLOCKER THAT SELECTIVELY BLOCK THE BETA-ADRENERGIC
RECEPTORS (DRUGS.COM, N.D.).
 INDICATIONS FOR METOPROLOL

HYPERTENSION- DEFINED AS A SYSTOLIC BLOOD PRESSURE >160 OR AS DEFINED BY THE

HEALTHCARE PROVIDER.

ATRIAL FIBRILLATION

SINUS TACHYCARDIA
 ADVERSE REACTIONS

CENTRAL NERVOUS SYSTEM: FATIGUE, DIZZINESS, DEPRESSION, ANXIETY AND NERVOUSNESS

CARDIOVASCULAR: SLOW OR IRREGULAR HEARTBEATS, AV BLOCK, HYPOTENSION, AND HEART
FAILURE
GASTROINTESTINAL: VOMITING AND DIARRHEA
RESPIRATORY: DYSPNEA OR SHORTNESS OF BREATH WITH MILD EXERTION
INTEGUMENTARY: RASH
OTHER SYMPTOMS: IMPOTENCE, DECREASE IN SEX DRIVE OR REACHING ORGASM

(Drugs.com, n.d.)
 DOSAGE
COMES IN A VIAL THAT IS A 1:1 RATIO 5MG/5ML

DOSAGE IS NOT TO EXCEED 5MG EVERY 5 MINUTES

MAXIMUM DOSES X3

RE-EVALUATION OF PATIENT FOR TRANSFER TO HIGHER LEVEL OF

CARE IF PATIENT IS NOT RESPONDING AFTER 3 DOSES.

DOSE MAY BE GIVEN AS A SCHEDULED DOSE FOR PATIENTS WHO

ARE NPO OR UNABLE TO TAKE PO MEDICATION.
 NURSING CONSIDERATIONS FOR IV PUSH
METOPROLOL
PATIENT MUST BE ON A TELEMETRY MONITOR
APICAL HEART RATE MUST >60 BPM
SYSTOLIC BP MUST BE > 100
COMPLETE SET OF VITAL SIGNS MUST BE OBTAINED PRIOR TO ADMINISTRATION
BASELINE TELEMETRY OR EKG READING PRIOR TO MEDICATION BEING GIVEN FOR
COMPARISON
PATIENT MUST BE PLACED ON BEDSIDE MONITOR FOR VISUALIZATION OF EKG AND BLOOD
PRESSURE DURING IV PUSH AND FOR THE NEXT 45 MINUTES AFTER DOSAGE
 MONITORING

VITAL SIGNS EVERY 5 MINUTES

AFTER IV PUSH
EVERY 15 MINUTES X3

NURSE WILL REMAIN WITH

PATIENT IN A 1:1 CAPACITY FOR
ONE HOUR AFTER IV PUSH
 BRADYCARDIA

CONTRAINDICATIONS 2ND OR 3RD DEGREE HEART BLOCK

CARDIOGENIC SHOCK

OVERT CARDIAC FAILURE

RIGHT VENTRICULAR FAILURE WITH SECONDARY PULMONARY HYPERTENSION

 EXAMPLE OF AN ASSIGNMENT WITH LEARNING
OBJECTIVES
ASSIGNMENT LEARNING OBJECTIVES

REVIEW VIDEOS ON SINUS TACHYCARDIA, THE NURSE WILL BE ABLE TO CORRECTLY

ATRIAL FIBRILLATION, 2ND, 3RD DEGREE HEART IDENTIFY EKG STRIPS ON SINUS
BLOCKS AND TORSADES. TACHYCARDIA, ATRIAL FIBRILLATION, 2ND
AND 3RD DEGREE HEART BLOCKS AND
REVIEW RHYTHM STRIPS. TORSADE'S.
PARTICIPATE IN SCENARIO IN SIMULATIONS CORRECTLY IDENTIFY THE CORRECT STEPS
LAB. TO BE TAKEN IN SCENARIO POSED. SEE
SCENARIO.
 SAMPLE SIMULATION SCENARIO
Date 2017 File Name Phillip Arnold Uncontrolled Hypertension Simulator Manikin Needed Diagnostics Available
Discipline RN VA metoprolol IV Push (Course NU727) SimMan 3 G o 12-Lead EKG
Simulation run 25 min Reflection run time 25 min o Labs: CBC, UA, CMP, BMP, LFT, Lipid panel, and
time Troponins
o X-ray/Images CXR
Client Information Psychomotor Skills Required Prior to Simulation Props Documentation Forms
Adm Date 2/13/2017 1. The RN will perform a IV push of metoprolol Patent saline lock Doctors orders
Metoprolol 5 mg IVP now MAR
Name: Phillip Arnold 2. The RN will administer all medications using
the rights. Equipment attached to manikin Equipment available in room
Age 52 DOB 5/14/1964 Gender Male o EKG monitor o Clean gloves
o Patent saline lock o Saline flush
Race Caucasian
o ID band o Dina map
Weight (lbs) 185/83.91kg Pre-pregnancy wt (lbs) n/a
Height (in) 72 inches Cognitive Activities Required Prior to Simulation
Roles/Guidelines for Roles RN Information Needed Prior to Scenario
Allergies NKDA 1. Hinkle, J. L., & Cheever, K. H. (2014).
o Nurse 1 o Has been oriented to simulator
Brunner & Suddarth Textbook of Medical-
o Nurse 2 o Understands guidelines/expectations for scenario
Surgical Nursing (13th Ed.). Philadelphia, o Resource o Has accomplished all pre-simulation requirements
PA. Chapter 31: Assessment and o Fly: medication and skills / o All participants understand assigned roles
management of patients with o Fly: communication o Has been given time frame expectations
hypertension. o Family member/observer
Immunizations Up-to-date 2. Classroom lecture and power point Important Information related to Roles Report RN Will Receive Before Simulation
content on assessment and management Flies are not allowed to talk and help nurse 1 and 2 Col. Arnold is an active duty soldier currently acting as a
of patients receiving metoprolol IV push. Resource person is allowed to talk to both and provide brigade commander to a unit that is deployed. He
information to help steer the student. arrived to the emergency room complaining of a severe
Doctor Jones
headache and changes in his vision. He was admitted to
Past Medical History
Significant Lab Values the telemetry floor for stabilization for his blood
HTN pressure.
History of Present Illness Simulation Learning Objectives
Physician Orders
Col. Arnold is an active duty soldier currently acting as a brigade 1. RN will perform an assessment focusing on
Admit to ED
commander to a unit that is deployed. He arrived to the neuro, cardiac and respiratory. Code status: Full
emergency room complaining of a severe headache and changes 2. RN will perform a detailed history of events. Continuous cardiac monitoring
in his vision. He was admitted to the telemetry floor for 3. RN will prioritize nursing interventions and Titrate oxygen to maximum 4L/min to keep O2sats >92%
stabilization of his blood pressure. You are the nurse responsible implement correctly. VS every 15 min continuous BP monitoring
for his care today. 4. RN will implement all meds according to the 8 Lab: CBC, UA, CMP, BNP, LFTs, lipid panel, Troponins
Social History rights. Place Saline lock
Married with 2 children, 26, and 24 EKG done upon admission
Primary Medical Diagnosis CXR
Uncontrolled HTN Regular diet
Surgeries/Procedures & Dates I&O
None Weight
Metoprolol 5mg IV push for Systolic blood pressure >
Nursing Diagnoses
160mmHg
Ineffective self-health management r/t stress levels and nutrition
Repeat three times if blood pressure is not <160mmHg
Noncompliance r/t lack of understanding regarding importance
Call HCP immediately if no response to three doses of
of controlling HTN
metoprolol, prepare to transfer patient to higher level of
Fidelity care.
Setting/Environment Medications & Fluids References, EVP Guidelines, Protocols, or Algorithms Used for this Scenario (cite source, author, year, page)
o Med-Surg - Telemetry o IV fluids: saline lock Drugs.com. (n.d.). Metoprolol. Retrieved from https://www.drugs.com/pro/metoprolol.html
o Oral Meds: James, P.A., Oparil, S., et al. (2013). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in
o IV Push: Metoprolol 5 mg/ml, 10cc NS flush Adults. Journal of the American Medical Association, 11(5), 507-520.
o IM:
o SQ:
 SIMULATION SCENARIO- CONTINUED
Timing Expected Interventions May use the Following 1. Nurse 1 will ask a 1. I usually eat fast
(approximate) Cues detailed health history food. I do keep
Baseline VS: 179/100, 72, 22, 97.8F, O2 sat 96% RA 1. Nurse 1 will ID pt X 2 1. Pt is A, A & O X 3
Baseline Rhythm: NSR and ask cognitive 2. All assessments are
for this pt. What is protein bars in my
Heart sounds S1, S2 no other abnormalities indicators. wnl except typical diet? Does he office if I get hungry
Lung sounds clear 2. Nurse 1 will complete I really am having a smoke? Does he drink? and just cant get
Bowl sounds active X 4 quads a focused neuro, hard time seeing. Does he get exercise? away. I also drink 6
cardiac and resp My vision is blurry. Does he normally have cans of Pepsi every
assessment. I have a headache
3. Nurse 1 will for 2 days. Nothing HBP? Other day. I work a lot.
communicate high BP I do seems to make comorbidities? What 2. I do not smoke but I
to Nurse 2 requesting it go away. I really meds does he take at will drink 2-3 beers
meds be administered. feel terrible but I home? Has he had every night when I
thought it was
them today? get home just to
because I work so
hard. unwind.
Why is my blood 3. I run once or twice a
pressure so high? week. I usually do
After metoprolol administered, decrease BP 1. Nurse 2 will ID pt X 2, 1. What will this do? 1-2 miles.
to 150/98 and HR to 85. assess allergies. Then Will it help my HA?
4. I was diagnosed
will administer 2. Why would my
metoprolol medication vision be blurry? with high blood
using the 8 rights. pressure 1 year ago,
2. RN will educate I take Lisinopril 40
patient on meds and mg every day
monitor BP & pulse.
You remain A, A & O X 3
Nurse 1 will call HCP using
through this process of correct ISBARR
the meds. reporting BP and labs

After metoprolol administered, continue to

Debriefing/Guided Reflection Questions for this Simulation
monitor vital signs every 5 minute while
giving metoprolol IV push, then every 15 1. How did you feel through the simulation experience?
minutes for the next 45 minutes. Patient will 2. After hearing the nursing report, what are your priority actions?
remain in a 1:1 nurse patient ratio for 1 hour
after giving metoprolol IV push.
3. Why did the physicians orders say to decrease the BP <160 mmHg?
4. What are your thoughts after completing your assessment? What is the patient experiencing?
5. What is Metoprolol? How does it work in the body?
1. Nurse 1 will ask a 1. I usually eat fast
detailed health history food. I do keep 6. What are some other indications for giving metoprolol IV push?
for this pt. What is protein bars in my 7. What adverse reactions are you observing for?
typical diet? Does he office if I get hungry
smoke? Does he drink? and just cant get
8. Flys:
Does he get exercise? away. I also drink 6 a. Communication: What did you observe done correctly? What would you suggest to change in the future?
Does he normally have cans of Pepsi every b. Medications & Skills: What did you observe done correctly? What would you suggest to change in the
HBP? Other day. I work a lot.
comorbidities? What 2. I do not smoke but I future?
meds does he take at will drink 2-3 beers 9. Is there anything else you want to discuss?
home? Has he had every night when I
them today?
Developed by A. Ivory 2017
 EVALUATION
THE VERBALIZATION OF PROPER IV PUSH ADMINISTRATION AND
SIMULATION LAB FOR THE RETURN DEMONSTRATION, MULTIPLE
CHOICE EXAM WILL BE THE PRIMARY EVALUATION METHODS OF THIS
LEARNING MODULE.
THERE WILL BE A RAPID RESPONSE NURSE AVAILABLE FOR THE NURSE
WHO NEEDS EXTRA SUPPORT AS NEEDED TO BUILD CONFIDENCE IN
THIS NEW SKILL.
NURSING EVALUATING NURSES WILL BE AN ONGOING PROCESS
FOR TRAINING RELATIVE INFORMATION WILL BE ASSESSED AS
NEEDED TO KEEP AN EVIDENCE-BASED CURRICULUM.
THE COURSE WILL ALSO HAVE AN EVALUATION OF THE LEARNING
METHODS, AND FACULTY THAT DELIVERS THE LEARNING MODULE SO
THAT IMPROVEMENTS, AND EFFICIENT YET ENGAGING EDUCATIONAL
METHODS ARE EMPLOYED (OBERMANN, 2015).
 COMMUNITY AND EXTERNAL
CLINICAL PARTNERSHIPS CONSTITUENTS ONGOING APPRAISAL

VETERANS ADMINISTRATION NURSE MANAGER YEARLY COMPETENCIES

NURSE EDUCATORS NURSE EDUCATORS QUARTERLY SKILLS FAIRS

SIMULATION LAB PERSONNEL RAPID RESPONSE NURSES

PEERS PEERS
 FACULTY INVOLVEMENT

FLYERS POSTED
EMAILS REMINDERS OF CONFERENCE
PEER LEARNING EXPERIENCES AND ENCOURAGEMENT
 REFERENCES
American Nurses Credentialing Center. (2017). Nursing skills competency program application. Retrieved from
http://www.nursecredentialing.org/NSCP-Application
Anderson, P. (2010, March). Medication errors: Dont let them happen to you. American Nurse Today, 5(3). Retrieved from
https://www.americannursetoday.com/medication-errors-dont-let-them-happen-to-you/
CDC Continuing Education (CE). (n.d.). Retrieved from https://www.cdc.gov/cecredit/calculating-ce.html
Drugs.com. (n.d.). Metoprolol. Retrieved from https://www.drugs.com/pro/metoprolol.html
EMTprep. (2015, December 3). Torsade de Pointes ECG - EMTprep.com [Video file]. Retrieved from
https://www.youtube.com/watch?v=yADrqjbD26A&t=32s
HippocraTV. (2016, April 20). Heart Block Made Easy (feat Taylor Swift) [Video file]. Retrieved from
https://www.youtube.com/watch?v=zqmag9LEHcc&t=1s
Hsaio, G., Chen, I., Yu, S., Wei, I., Fang, Y., & Tang, F. (2009). Nurses knowledge of high-alert medications: Instrument development and
validation. Journal of Advanced Nursing, 66(1), 177-190. http://dx.doi.org/10.1111/j.1365-2648.2009.05164.x
Khan Academy Medicine. (2014, July 8). Atrial fibrillation (Afib) Circulatory System and Disease NCLEX-RN Khan Academy [Video file].
Retrieved from https://www.youtube.com/watch?v=0FufW_MZMa4
Obermann, M. H. (Ed.). (2015). Teaching in nursing and role of the educator: The complete guide to best practice in teaching, evaluation,
and curriculum development. New York, NY: Springer.
Plutarch. (n.d.). The mind is not a vessel to be filled, but a fire to be ignited. Retrieved from http://edgalaxy.com/education-quotes/
Saethang, T., & Kee, C. (1998, March/April). A gaming strategy for teaching the use of critical cardiovascular drugs. The Journal of
Continuing Education in Nursing, 29(2), 61-65. Retrieved from https://search-proquest-
com.stmary.idm.oclc.org/docview/223319678?accountid=45723
Shastay, A. D. (2016, October). Evidence-based safe practice guidelines for I.V. push medications. Nursing2016, 46(10), 38-45.
Retrieved from file:///C:/Users/magla/Downloads/38932%20(1).pdf
Theriault, R. (2011, April 17). ECG: Sinus Tachycardia [Video file]. Retrieved from
https://www.youtube.com/watch?v=K5ol_h_80gw&t=4s
U.S. Department of Veterans Affairs. (August 20, 2015). https://www.va.gov/about_va/mission.asp