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IV MEDICATION
ADMINISTRATION
- PATIENT SAFETY
- IV COMPLICATIONS
- IV & INFUSION BASICS
MEDICATION ERROR
STATISTICS
- 1.3 million people in the United States are injured by medical treatments each year
- Cost of medication errors range from $20-75 billion annually
- National Institute of Health estimates that 98, Americans die annually as a result of preventable medical errors To Err Is Human: Building a Safer Health System (2000). Institute of Medicine (IOM)
IV MEDICATIONS
Be aware that IV Medications
- Are given directly into the blood stream
- Cannot be retrieved if there is an error
- Requires an antidote or dialysis to reverse or remove the medication
- Can cause tissue damage and necrosis if IV infiltrates
- Requires critical thinking and accountability by those who administer them
SAFETY
INFILTRATION VS
EXTRAVASATION
-The Infusion Nurses Society's national standards of practice require that a nurse who administers IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion. -A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter— Getting blood flash does not confirm its in the vein, it could just mean that blood is flowing out into the tissue
1. when it is a nonvesicant solution or medication, it is **called infiltration
- when it is a vesicant** medication, it is called extravasation. VESICANT = blister causing, caustic, antineoplastic agent (to stop cancer) (chemo) blood products -Both infiltration and extravasation can have serious consequences:
- the patient may need surgical intervention resulting in large scars
- experience limitation of function
- may require amputation. TREATMENT
- early recognition, prevention, and treatment
- the controversial use of antidotes
- heat and cold therapy
- dialysis to clean the blood
- stop the infusion
- discontinue the iv site
- apply a sterile dressing
- monitor the site
- start IV in new site or proximally to site
INCOMPATILBILITY
INTERACTION
The Result of 2 meds that don’t mix well in an infusion line Physical and/or chemical incompatibilities can cause:
- Additive or synergistic effect to the one of the medications
- Inactivation effect of one of the medications Always separate incompatible or unknown compatibility drugs with a saline flush (SAS) STEPS
- SAS = S aline injected (flush)
- then A gent (med) injected
- then SAS S aline (flush) injected Physical precipitation of Midazolam as a result of an unfavorable pH medium APPROPRIATE VEINS FOR IV lock -cephalic -accessory cephalic -Basilic (closest to BODY) -dorsal back of hand (more painful) ** start most distal first so you have room to move up the arm if needed HOT/COLD PACKS A warm compress may be applied to the site if small volumes of noncaustic solutions have infiltrated over a long period, or if the solution was isotonic with a normal pH; the affected extremity should be elevated to promote the absorption of fluid. If the infiltration is recent and the solution was hypertonic or had an increased pH, a cold compress may be applied to the area.
IV ADMINISTRATION BASICS “SAS” METHOD FOR INCOMPATIBLE MEDS
“SAS” = Saline, Agent
(medication),Saline
-Technique used to give
incompatible IV meds
(saline block)
SASASASASAS is the
method used to give
multiple meds at same
scheduled time
Initial saline = confirms
patency
Saline in between meds =
creates saline block so that
the meds do not directly
touch
Final saline = Flushes meds
in and prevents catheter
from occluding
SAS for IV push (IVP) or IV
piggyback (IVPB)
BACK PRIMING
the process of priming your secondary tubing backwards With help from gravity , by using the saline you already have hanging, when lowering the secondary bag, this allows saline to flow up into your piggyback medication line - thus priming the line, backwards (“back priming” technique) ****WATCH this video for steps**** https://youtu.be/F5YUXSWdlKY ? list=PLYjGmUqw5Fbsja40XS9lW yFoYxvlwc4FW there is no check valve (one way valve) in the secondary tubing so it allows us to back prime from the primary. There IS a check valve (one way valve) in the primary tubing so fluid will not go back into that bag.
- Set up and prime your primary bag
- set up your IVPB lock/close the clamp
- now unlock clamp, nothing will happen until you lower the IVPB bag. Now back prime the tubing, you will see bubbles coming out of the IVPB drip chamber
- hook up to patient, set up your machine and start BACKPRIME- for a new line BACKPRIME- to clean out the secondary tubing before removing old med and attaching a new med Simply priming your tubing is easy, just spike your bag and allow the solution to flow to the end of your tubing. The process of “back priming” requires a primary (or flush) bag (often normal saline) and a secondary bag (your ordered medication) *Picture is finished product after “back prime” and is ready for infusion (as you see, the IVPB (secondary) is higher so gravity infuses this bag first
DILUTION OF
MEDICATIONS FOR IV
PUSH (IVP)
Some medications must be diluted WHY:
- -Decreases phlebitis to the vessel
- Is required for all caustic medications!
- Some nurses just dilute all medications for safety
- For easier calculation and administration over an allotted time The Institute of Safe Medicine Practices reports that the use of prefilled syringes for medication dilution increases the risk of medication errors. Dilution from a single use vial is always encouraged.
THE PROCESS OF
DILUTION FOR IV PUSH
(IVP)
If drawing a med from a MULTI
- dose vial OR if you are only removing part of the med that is contained in a vial (i.e., I need 1 mg but the bottle contains 2 mg) 1. - If the med requires dilution for safe administration or for ease of administration - using a 10 mL prefilled (flush) syringe for dilution , empty out the quantity of saline that will be replaced by the medication, recap and lay aside. 2. Next, use the smallest syringe possible to accurately draw up the medication from the multidose/partial use vial. 3. Add your med to your flush syringe. Attach the medicated syringe by inserting the attached needle/needleless adapter inject into the larger saline flush syringe. 4. Gently mix the 2 solutions. 5. ACCURATELY LABEL THE SYRINGE BEFORE SETTING IT DOWN TO PREVENT MEDICATION ERRORS. Single Dose Vial: 1. If using a 10 mL prefilled syringe for dilution, empty out the quantity of saline that will be replaced by the medication. 2. Aspirate the entire dose of medication from a single dose vial. 3. Gently mix the 2 solutions. 4. ACCURATELY LABEL THE SYRINGE BEFORE SETTING IT DOWN TO PREVENT MEDICATION ERRORS
DETERMINING THE ROA:
RATE OF
ADMINISTRATION
- IVPB via pump runs in mL/hour
- IVPB to gravity runs in gtts/min
- IVP is delivered evenly over the prescribed time
SYRINGE SIZE GUIDELINES
Peripheral lines
3-5mL syringe size or 10 -The smaller the syringe size the greater the PSI pressure
Central lines
ALWAYS use 10mL syringe size (or larger) -The larger the syringe the lower the PSI pressure -Less risk of catheter rupture *** Remember * Always label all syringes!**
IV MEDS: THE PROCEDURE IV ADMINISTRATION Let’s Practice: ***Start with this medication Order below. Use your resource and Look up Lasix. Reliable sources for referencing the drug
- Micromedex
- Online resources: your Lippincott
- Pharmacist
- IV med book Not so reliable
- A fellow student or nurse
- Drug insert
ASK YOURSELF THESE
QUESTIONS WHEN
RESEARCHING A MEDICATION
- Is it a safe dose for my patient? You will find this info in your resource. Yes 40 is a good start can go up to 80 if no response. Can give safely ever 2 hours so 12 is safe
- Why is my patient getting this med? Connect it to their condition or presentation. For FVO to pee, hyperkalemia, HTN, edema, CHF
- Any precautions or side effects? Common and major concerns when receiving this med. Watch potassium, kidneys must work, are they bed ridden? Think about a catheter/ urine device. BLOOD PRESSURE might tank
- What do I monitor before or after the med is given? Drug associated side, adverse effects, etc. elevated acid, low potassium, low electrolytes,
- Is it ordered as an IVP or IVPB; how much solution is it diluted in? no dilution needed IVP over 1-2 min
- What IV site does the patient have? Is it patent? What’s running through it? peripheral iV good, SAS proves patency, nothing in it now
- Is my med compatible or not? After pausing/stopping the infusion of an incompatible med, use SAS. Rate of administration (ROA)? Am I using a:
- pump = mL or
- gravity = gtts/min ANSWERS
MEDICATIONS VIA A CAPPED
LINE – IV PIGGY BACK (IVPB)
- Gather Supplies: IVPB with ordered medication, NS flush, alcohol swab, normal saline flush bag, long, primary tubing and short, secondary tubing if a new set up
- Ensure roller clamp on secondary tubing is open
- Lower empty IVPB bag below primary bag and “back prime” primary IV solution into IVPB bag until line is cleared of mediation from previous infusion
- Clamp secondary tubing
- Remove old IVPB and hang ordered IVPB medication
- Aseptically, aspirate/flush IV catheter to verify patency
- Aseptically connect primary IV tubing to catheter site
- Fully open roller clamp on secondary tubing
- Regulate IVPB infusion using roller clamp on primary tubing. Determine and run at calculated ROA.
- After IVPB has completely infused, allow primary solution (NS flush bag) to infuse until line is fully cleared of all medication (primary bag will automatically begin infusing after IVPB has emptied)
- Close roller clamp on primary tubing
- Disconnect patient from IV set-up
MEDS VIA A COMPATIBLE
IV LINE IV PIGGY BACK
(IVPB)
Verify IVPB medication is compatible with primary solution. Gather Supplies: IVPB with ordered medication
- Ensure roller clamp on secondary tubing is open
- Lower empty IVPB bag below primary bag and “back prime” primary IV solution into IVPB bag until line is cleared of mediation from previous infusion
- Clamp secondary tubing
- Remove old IVPB bag and hang ordered IVPB medication
- Fully open roller clamp on secondary tubing
- Regulate IVPB infusion using roller clamp on primary tubing. Determine and run at calculated ROA. *Primary solution will automatically begin infusing after IVPB bag has emptied, be sure to return to confirm primary solution is running at prescribed rate.
Video link on back priming
and setting pump for IVPB
below…
http://
www.youtube.com/
watch?v=99LA20UNYgk
MEDS VIA AN
INCOMPATIBLE IV LINE
IVP
Verify IVP medication is incompatible with primary solution Gather Supplies: Prepared / labeled syringe with ordered medication, 2 NS flushes, alcohol swab
- Stop / pause primary infusion
- Using port closest to patient, aseptically flush IV line to fully clear tubing of incompatible primary IV solution
- Using port closest to patient, aseptically administer IVP medication at prescribed ROA
- Flush IV catheter at same ROA as medication to fully clear line of all medication
- When line is cleared of medication, complete flush at steady rate
- Open roller clamp to re-start infusion of primary solution
IVPB
DO NOT INFUSE AN IVPB THRU
AN INCOMPATIBLE MAINLINE
INFUSION
If no other immediate IV access is available, follow the steps below:
- Disconnect incompatible mainline infusion
- Using a primary/secondary flush bag set-up, administer IVPB
- Following IVPB infusion/flush, disconnect from patient and re-connect mainline infusion
PRACTICE SCENARIOS
ORDER # 1
IV site: peripheral capped
line
IV Push Order# 1: -
ondansetron (Zofran) 4 mg
IVP now
On hand: ondansetron
(Zofran) 2mg/mL (2 mL
vial)
Ask….
- Safe dose? yes
- Why is my pt. getting this? For nausea
- Side effects? HA, fatigue
- What do I need to monitor for? has the nausea gone away
- Dilute? no
- IV solutions? Yes mixes with most
- Compatible? yes
- ROA? IVP over 30sec-5 min
- CATS PRRRL- compatibilities, allergies, tubing, site, pump, ROA, release clamps, reassess pt., label meds
ORDER # 3
Already infusing:
Continuous Infusion D5.
NS @ 100 mL/hr
ORDER: IV Push -
ondansetron (Zofran) 4 mg
IVP now
On hand: ondansetron
(Zofran) 2mg/mL (2 mL
vial)
Ask….
- Safe dose? YES
- Why is my pt. getting this? NAUSEA
- Side effects? HA
- What do I need to monitor for?
- Dilute? no
- IV solutions? Is compatible
- Compatible?
- ROA? Give the 2ml IVP Over 2 minutes
- CATS PRRRL Dosage: Deliver ondansetron (Zofran) 4mg = 2mL Supplies needed: alcohol swabs
ORDER # 4
IVPB Order #4: Deliver famotidine (Pepcid) 20 mg in 100 mL NS already running at the IV site: Continuous Infusion D5.45 NS with 20 mEq KCl@100 mL/hr Supplies needed: Secondary tubing, alcohol swabs Is safe For GERD/ ulcers NOT COMPATIBLE W/ KCL
- Either set up a 2nd peripheral IV or turn off primary and turn it back on later. Or wait for KCL to finish Give IVPB at rate of 200ml/hr Order #5: methylprednisolone (Solu- Medrol) 125 mg IVP now On hand: methylprednisolone (Solu-Medrol) 125 mg/2 mL ( mL vial) Already running at the IV site: Continuous Infusion Heparin 1000 u/hr Supplies needed: SAS, alcohol swabs Is safe For: corticosteroid treatment for inflammation Is compatible at y site and as an IVpb Push over 2 minutes
DOCUMENTATION
Sign MAR with:
- Initials
- Date
- Time
- signature
- any other required data Intake/Output:
- Record IVPB medication and flush solution once IV medication is completed.
- IVP medication is not recorded on I/O Narrative note – only needed if an unexpected event occurred (reaction, infiltration, etc.)
FREQUENTLY ASKED
QUESTIONS
#1 -How much fluid is needed
for the flush before or after a medication? Pre-flush to confirm patency = 3 to 10 mL NS. CVAD push 10 Post IVP or IVPB: “The minimum volume of flush recommended is twice the internal volume of the catheter” (Standard 60). Usually 3-10 mL for IVP and 20- 30 mL for IVPB.
#2-Am I able to use the same
syringe for both the pre and post flush when using SAS?
no
“Consider a syringe or needle/catheter contaminated once it has been used to enter or connect to a patient, a patient's solution container, or administration set.” Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.
#3 -Do I need to wear gloves
when administering an IV medication? yes “Standard Precautions are based on the assumption that every person is potentially infected or colonized with an organism that could be transmitted, and that all blood/body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible agents.” If you are going to be in contact with body secretions and/or your patient is infected, gloves should be used.
#4 -How long do I need to scrub
an IV port with an alcohol wipe before accessing it? Most hospital policies say 15- seconds CDC does not offer specific guidelines, follow the institution’s policy Infusion Nursing Standards of Practice enforce the single use of each alcohol wipe
#5 -What do I do when I have
EBP information that is different than what I see the nurses doing in practice? Ask 3 questions…..
- Is patient safety being compromised?
- Is aseptic technique being compromised?
- Is a hospital policy and procedure being compromised? If not….it’s OK…consider it differences in technique
IN CLASS NOTES ALARIS: used at Banner SIGMA: used at honor health MAIN/THE GENERAL - the computer SOLDIER – holds the tubing PRIMARY - has the tubing that goes into the pump. Has Y ports to infuse into. Goes into the soldier and regulates the flow rates SECONDARY- implies were doing IVPB, has a hanger for the primary. Hooks to the port ABOVETHE SOLDIER ASK YOURSELF: is the primary and secondary drugs compatible? If NO then we need a second soldier with a primary or a second soldier with a flush bag. OR you can flush SAS. FLUSH - anything that flushes the line. Usually the 100mL syringe SAS = SALINE, AGENT (drug), SALINE. SASH = add HEPARIN RATE- for pump=ml/hr for gravity = gtt/min for IV push = ml/min,sec PIGGYBACK (IVPB)- any drug spiked with a secondary tubeing that hangs above the primary tubing intermittently or short termtx:
TOOLS FOR SUCCESS
1-Search by GENERIC NAME 2-When hanging a SECONDARY IVPB the machine will prompt you to program the primary first. You need to set it the same at the secondary so that your primary flush is at the same rate (or slower)
IV CRITICAL THINKING
-does the patient even have an IV in? -does the med need to be reconstituted or diluted -does it need to be further diluted so it’s not so thick? Concentration? -what’s the order route? Iv push, IV Infusion, Oral, Enteral, Parenteral, IM -is this a safe dose? -is it compatible with my other drugs? -is it caustic? Risk for extravasation -cardiac drugs = watch the bp & HR -has the patient ever used this drug -patient allergies -is the iv PATENT- check with a flush -is there fluids left in the maintenance iv, do we need to also change this out? -is the tubing good? Do we need to change that? 24-96 hours -is the bed lowered, call light, bed alarm MONITOR IV -look for particulates, color, label, date of tubes, rate, kinks in tube, open clamps MONITOR IV SITE -pain, swelling, redness, heat, induration, edema, leaking, coolness, pallor, intact dressing, bleeding, odor, length of exposed catheter (CVC) Infiltration : swelling, coolness, leakage, pallor edema, pain, decrease in flow rate Extravasation: necrosis, pain, Medications such as vasopressors, potassium and calcium preparations, and chemotherapeutic agents can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. TX:
- STOP infusion
- Notify provider
- Follow agency protocol (antidotes if the IV line should remain in place or be removed before treatment. If antidote prescribed after assessment by the provider, removal of the cannula
- application of warm compresses to sites of extravasation from alkaloids or cold compresses to sites of extravasation from alkylating and antibiotic vesicants.
- The affected extremity should not be used for further cannula placement. Phlebitis: redness, swelling heat, pain, tenderness along the vein (inflammation of vein) can be chemical, mechanical, or bacterial Tx:
- discontinuing the IV line
- restarting it in another site
- applying a warm, moist compress to the affected site INFCTION: abrupt temperature elevation shortly after the infusion is started, backache, headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and shaking, and general malaise. Additional symptoms include erythema, edema, and induration or drainage at the insertion site. In severe sepsis, vascular collapse and septic shock may occur Local infection: redness, warmth, pus, induration, pain, odor Systemic manifestations fever, chills, tachycardia, hypotension FVO : edema in the lungs, HTN, moist crackles on auscultation, cough, restlessness, distended neck veins, edema, weight gain, dyspnea, and rapid, shallow respirations FVO TREATMENT:
- Decrease IV rate
- Sit pt up (high fowlers)
- Monitor AIR EMBOLISM : palpitations, dyspnea, continued coughing, jugular venous distension, wheezing, and cyanosis; hypotension; weak, rapid pulse; altered mental status; and chest, shoulder, and low back pain. Tx: place pt on left side in trendellenverg HEMATOMA: when blood leaks into tissue you see ecchymosis, leaking of blood, swelling tx:
- removing the needle or cannula
- applying light pressure with a sterile, dry dressing
- applying ice for 24 hours to the site to avoid extension of the hematoma
- elevating the extremity to maximize venous return
clotting & obstruction : Blood clots may form
in the IV line as a result of kinked IV tubing, a very slow infusion rate, an empty IV bag, or failure to flush the IV line after intermittent medication or solution administrations. The signs are decreased flow rate and blood backflow into the IV tubing. Tx: discontinue and restart in another site The tubing should not be irrigated or milked. Clotting of the needle or cannula may be prevented by not allowing the IV solution bag to run dry.
WEEK 1 IN CLASS NOTES HALFLIFE- the amount of time for half the drug to be excreted from the body. (20mg half-life 30 min)(30min 10mg, 1 hr. 5 mg 1.5 hour 2.5 mg) FIRST PASS EFFECT- when oral meds pass through the liver they lose potency & bioavailability. Can damage liver DESIRED EFFECT- what we want to drug to do. Intended effect THERAPUTIC RANGE- the concentration of the drug that gives us our desired effect. DOSE- the amount of drug in mg, G, Gm, mcg, or units. (NEVER IN FLUIDS mL, L) POTENCY- the strength of a med 1mg morphine = .5 mg dilauded More potent is dilauded Less potent is morphine EFFICACY- the effect of a drug. Is it working? High efficacy low efficacy SIDE EFFECT- common, expected, not as dangerous ADVERSE EFFECT- more dangerous, not as common EXAMPLE CHEMOTHERAPY SIDE EFFECT= kills cells, lowers immune system, hair loss, dry mouth ADVERSE EFFECT= an infection that now needs ICU and special meds and fluids. Patient can die BOLUS- a large dose over a short period of time. trying to raise drug/fluid in the body. May sometimes be called LOADING DOSE- a higher dose at first to get to therapeutic range / the desired effect TITRATION- adjusting up or down to achieve the desired effect. MAINTENANCE DOSE- the lower amount of drug give to keep the patient in therapeutic range CONCENTRATION- drug to fluid. Particle to solvent 500mg in 250ml Too concentrated = too much drug Not concentrated enough or DILUTE = not enough drug 1:1 DILUTION One drug particle to 1 fluid particle 15mg = 15ml when done STOCK MED : diluent
IV MEDS PRIORITZATION
AND DELEGATION
IV meds work fast , are more effective, don’t have first pass effect, have less patient compliance issues BUT they have higher risks such as they work fast, can be hard on veins, may be caustic and can cause extravasation, can quickly change fluid and electrolyte status, FVO, bacterial growth, and the need for a nurse/hospital to administer them
IV MEDS DELEGATION
CNA Cannot touch pump Cannot turn on/off Can let me know if there are any issues that they notice LPN: same as CNA
LPN W/ CERTIFICATION
NO BLOOD NO HIGH RISK MEDS NO IV PUSH MEDS: all IV push meds are high risk (saline flush ok) -NO IV OPIOIDS CAN push saline only (FLUSH) -can start an IV -can D/C an IV -can FLUSH an IV -can hang NS -can hang non medications (NS, some antibiotics in some places) -can MONITOR the IV HOME HEALTH (class 88 rule) Has different rules -can do most things RN -this is the best person to delegate IV to
