Week 3

Patient is to receive an IV of 1 Liter Lactated Ringers to infuse over 18 hours. What IV pump settings will the nurse use? Round rate to nearest whole mL

1 Liter Lactated Ringers Infuse over 18hrs 1000 mL/18hrs = 55.5 = 56 mL/h Rate: 56 mL/h Volume to be infused: 1,000 mL

Extension tubing

a length of intravenous tubing added to an intravenous line to allow the patient greater mobility while still keeping the line stable

Leur-lok

a patented, threaded tip of a syringe that can be twisted onto certain ports and needles to create a firm "lock"

Colloid

a plasma expander; a protein-containing fluid infused intravenously to help restore circulating blood volume

Vial

a plastic or glass container in which liquid or powdered medication is packaged in an airtight and sterile environment and sealed with a rubber stopper

Injection port

a small, covered, branched portion of intravenous tubing configured as a place to inject medication or fluid into the infusing fluid

Ampule

a small, sealed, single-use glass or plastic container containing sterile parenteral medications or solutions

Filter needle

a special type of needle required when drawing up certain types of medications to keep small particles of medication or rubber or glass (from a vial or ampule) from entering the syringe and being injected along with the intended solution

Cannula

a tube inserted into a vessel, duct, or cavity

Medication Order: Gentamicin 50 mg IV. Medication is dissolved in 100 mL D5W and is to infuse over 45 minutes. What pump settings will the nurse use? Round rate to whole mL.

100 mL D5W Infuse over 45 minutes. Rate: 133 mL/h Volume to be infused: 100 mL

A patient is to receive 1g ceftriaxone in 100 mL over 30 min. The tubing drip rate is 10 gtt/mL. The nurse should adjust the flow rate to what infusion rate?

33 gtt/min

Medication Order: 1 gram Ampicillin IV. The ampicillin is dissolved in 50 mL D5W and is to infuse over 20 minutes. What pump settings will the nurse use?

50 mL D5W Infuse over 20 minutes Rate: 150 mL/h Volume to be infused: 50 mL

Patient is to receive an IV of 500 mL D5/0.45 NS to infuse over 12 hours. What IV pump settings will the nurse use? Round rate to nearest tenth of a mL.

500 mL D5/0.45 NS Infuse over 12 hrs 500 mL/12 h = 41.66 = 41.7 mL/h Rate: 41.7 mL/h Volume to be infused: 500 mL

A nurse is about to administer an IV medication directly into the vein. The nurse should understand that a disadvantage of parenterally administered medications is that they: A) are irreversible. B) have slow onset. C) bypass the liver. D) have less bioavailability.

A

Right documentation

Accurate documentation must be available before and after a medication is administered to ensure that it is prepared and administered safely. Medication orders should clearly state the patient's first and last name, the name of the medication ordered, the dose, the route, the time the medication is to be administered, and the signature of the prescriber. If any of this information is missing, notify the prescriber before giving the medication. After you give a medication, document it in the MAR per agency policy. Never document that you gave a medication until you've actually given it. Failure to document or incorrect documentation can be considered a medication error in itself and can cause an error as well. If the time of medication administration differs from the prescribed time, note the time on the MAR and explain the reason (e.g., pharmacy states medication will be available in 2 hours) in the nurse's notes. Following the six rights of medication administration and checking the medication label against the MAR three times each time you prepare and administer a medication might seem redundant and unnecessary. However, taking shortcuts and not following procedures greatly increases your chances of making a medication error. Even if your facility uses a barcoding system, the three check system for safe medication administration can be easily incorporated into any workflow.

Order is for 1 Liter Normal Saline to infuse at a rate of 125 mL /h. The IV tubing has a drop factor of 20 gtt/mL. Calculate the drip rate.

Adjust Roller Clamp to deliver 42 drops per minute.

Order is for 1 Liter Normal Saline to infuse over 12 hours using microdrop IV tubing. Calculate the drip rate.

Adjust Roller Clamp to deliver 83 drops per minute.

Doctor's Order: 1 Liter D5W to infuse over 10 hours. IV tubing has drop factor of 15 gtt/mL. Calculate the drip rate.

Adjust roller clamp to deliver 25 gtts/minutes

Prior to starting infusion

Always double-check calculations. Ask another qualified person to check results if your agency policy requires it or if unsure of your results. Remember that errors can & do happen. When assuming care for a pt with an active IV infusion, compare infusing IV solutions with pt's med record. By performing a few simple calculations, you can check accuracy of infusion device, prevent med errors, & ensure optimal pt safety during IV med therapy.

Implantable venous access devices

An implanted venous access device, or port, is surgically implanted in a cutaneous pocket, usually in the chest wall. The incision is closed and no part of the catheter is visible externally which allows for an enhanced body image. The device consists of an internal catheter connected to the patient's venous system, and a reservoir covered by a disc 0.8 to 1.2 in (2 to 3 cm) in diameter and totally implanted under the skin. The disc, or septum, is accessed with a noncoring needle, which allows for repeated accessing without damage to the silicone core. The septum is capable of resealing following de-access. Ports provide venous access for intermittent or continuous infusions while keeping a patient's body image intact when not being accessed. Ports are commonly used for patients requiring long-term IV access, such as those receiving chemotherapy or blood products, and for blood sampling.

Psychosocial & Cultural Considerations

Apply psychosocial considerations and culturally congruent nursing care to all forms of medication administration. Cultural beliefs, attitudes, and social values may differ in areas such as expression of pain, acceptance of "western" medicine, and issues surrounding end-of-life care. The use of IV medications can cause additional anxiety or concern related to fears of addiction or needles. Your awareness and understanding will promote medication compliance and improved patient outcomes.

A nurse administers the first dose of a patient's prescribed antibiotic via IV piggyback. During the first 10 to 15 min of administration of medication, the nurse gives priority to which of the following assessments? A) IV site for redness or swelling B) Patient for systemic allergic reaction C) IV dressing for signs of leakage D) Limb for signs of discomfort

B

A patient was admitted to the hospital for same day surgery and has orders for continuous IV therapy. Before performing a venipuncture, the nurse should: A) Place a cold compress over the vein. B) Inspect the IV solution for fluid color, clarity, and expiration date. C) Apply a tourniquet 1 to 2 in above selected insertion site. D) Secure an armboard to the joint.

B

A nurse is caring for a patient receiving 0.9% sodium chloride (normal saline) at 75 mL/hr through a triple lumen central venous catheter. The pump is alarming that there is an occlusion. Which of the following is the first thing the nurse should do? A) Call the provider who inserted the catheter. B) Flush the line with a 10-mL syringe of heparin. C) Check the line at or above the hub for kinked tubing that is creating a resistance to flow. D) Reposition the patient.

C

A nurse is caring for a patient with a PICC line. Which of the following is true about this type of IV route? A) A PICC line is a short catheter inserted into the jugular vein. B) A PICC line is a catheter that allows for infusion of intravenous fluids without an infusion pump. C) A PICC line is a long catheter inserted through the veins of the antecubital fossa. D) A PICC line is a catheter that is used for emergent or trauma situations.

C

Right patient

Before giving a medication, make sure that you are giving it to the right patient. Check the patient's identification band, name, and identification against the MAR. Ask the patient to state his or her full name. If the patient is confused or unresponsive, your two identifiers can consist of comparing the medical record number and the birth date on the MAR with the information on the patient's identification band. If your patient is a child, ask the parents or legal guardian to identify the patient, in addition to comparing the information on the MAR with the information on the patient's identification band. No matter how long you have been caring for the patient or how well you know the patient, each time you enter the room to administer a medication, you must use a minimum of two identifiers to confirm that you have the right patient. For facilities that use a barcoding system, the scanner may be used at this point by scanning the client's wrist band, the nurse's identification badge, and the medication label just prior to administering the medication. Importantly, these systems do not replace the nurse's responsibility for safe medication administration.

Physical characteristics & Health Status

Body surface area, height, & weight are used to calculate many drug doses, esp for children. Overweight & underweight adults might also require dose adjustments. Problems that can affect IV dose requirements include renal & hepatic impairment & cardiac & pulmonary dysfunction. Knowing your pt's medical history, including current meds, allergies, & intolerances, helps you assess appropriate responses & alerts you to possible adverse effects.

A nurse is caring for a patient who is receiving D5W with 20 mEq of KCL at 75 mL/hr. The provider has prescribed 1g ceftriaxone IV. When preparing to administer this medication by IV piggyback, which of the following data is the highest priority for the nurse to collect? A) The patient's vital signs B) The patient's level of consciousness C) The medication's compatibility with the primary IV solution D) The amount of IV solution in the primary bag

C Rationale The nurse must assess the medication's compatibility with the primary solution prior to administration. If the medication is not compatible with the primary solution, a precipitate can form in the IV tubing, preventing medication administration.

A nurse is assessing a patient receiving IV normal saline at 125 mL/hr. Which of the following must the nurse recognize as a possible complication related to IV therapy? A) Petechiae over the IV site. B) The skin is cool over the IV site. C) Patient reports cough and shortness of breath. D) Patient's blood pressure is lower than normal.

C Rationale: This is a sign of fluid overload. You should slow the IV and notify the provider.

Central Venous Catheters

Central venous catheters are most often placed in the internal jugular or subclavian vein, then advanced into the superior vena cava. They are placed by physicians or advanced practice nurses or other clinicians specially trained in the procedure. The catheter can have two, three, or four lumens spaced along the catheter. Each lumen has a designated purpose, depending on its location along the catheter. Because the distal lumen of the catheter lies nearest the right atrium, information about right-heart filling pressure and right-ventricular function and volume can be estimated when the associated port is connected to a transducer or water-manometer system. Other lumens are used for parenteral nutrition, continuous or intermittent fluid infusions, vasoactive medications, and blood products. The most common complication related to central venous catheters is infection. Assess the insertion site for signs of inflammation or infection at the start of each shift and every 4 to 8 hours or as indicated by the patient's condition. Learn about your role in central-line infection prevention, and follow your agency's policy for site care.

Calculating IV flow rates

Delivery of the correct medication, dose, and volume at the appropriate infusion rate and time is essential for safe and therapeutic intravenous (IV) medication administration. Today's IV infusion pumps can make this process seem simple. They deliver precise volume-controlled infusions, and many can be programmed to calculate dose and flow rates. Despite these conveniences, knowing how to calculate IV flow rates correctly will help you verify equipment accuracy and help prevent adverse events related to medication errors. Knowing how to perform these simple calculations is also helpful when a programmable pump is unavailable, not to mention when calculations are part of pre-employment testing. The first step in determining IV flow-rate calculations is to check the medication label. Compare the label to the medication administration record (MAR) for the correct patient, medication, dose, time, and route. You should perform this comparison a total of three times before you begin the infusion. IV medications are diluted in a variety of concentrations and delivered in a variety of dose rates. Be sure to clarify any questionable orders and use only approved abbreviations to avoid dangerous adverse events. Appropriate IV-medication infusion orders specify the dose to be given over a specific interval and the concentration of the drug in solution. You must calculate the unknown flow rate. There are three factors involved in performing calculations for IV medication infusions. If you know two factors, you can calculate the third by using the basic formula: The concentration of medications is the amount of drug diluted in a given volume of IV solution, usually measured in units, micrograms (mcg), milligrams (mg), or grams (gm). The dose of the medication is the amount of drug ordered for infusion over a specific length of time. Doses have varying units of measurement. The length of time is either by the minute or by the hour. If the medication is dosed by weight, the calculation is made using the patient's weight in kilograms (kg). The flow rate determines how rapidly the infusion is delivered to the patient. On an infusion pump, the flow rate is set using using mL/hr. But you will not always have an infusion pump available, in which case you will have to adjust the rate manually in drops per minute. A basic formula for calculating an IV flow rate in drops per minute without medications is:

Right Med

Determining that you have the right medication involves checking the medication label against the medication administration record (MAR) at least three times before you administer the medication. The exact times you perform these three checks depend on how the medication is stored and your facility's policy, but in most situations you would check as you remove each medication from the storage area, as you prepare each medication, and at the patient's bedside before you administer each medication. In addition to checking the label against the MAR to make sure you have the right medication, check also that you have the right dose, are planning to give it by the right route, and that it is the right time. Verify the medication's expiration date at this time as well.

Pharmacokinetics

Drug distribution relies on blood flow to the intended sites of action, biological barriers, and protein-binding capacity. If the patient has a medical condition that limits blood flow to or perfusion of target tissues, the medication's distribution is likely to be altered. The ability of a medication to pass through an organ's biological barrier depends on the organ and the medication's composition. For example, the blood-brain barrier is selective for fat-soluble medications, while the placenta is nonselective, creating a higher risk of medication-induced fetal complications. Serum proteins such as albumin affect distribution by binding to medications. Low serum protein, as found with malnutrition and advanced age, allows more unbound medication to circulate, creating the potential for increased medication activity or toxicity. Metabolism is primarily the function of the liver, although the kidneys, lungs, intestines, and blood also play a role. Any disease process that impairs the ability of these organs to detoxify and remove biologically active chemicals will affect metabolism. Sites for the excretion of metabolized medications are determined by the chemical composition of the medication. Drugs can be excreted through the kidneys, liver, bowel, lungs, or exocrine glands, including the skin and mammary glands. Evaluate the patient's renal and hepatic function, bowel motility, ventilatory ability, and skin integrity, as these determine the rate of excretion and the potential for prolonging the mediation's actions. Lactation is a special consideration, since there is a risk that a breastfeeding infant will ingest drug metabolites excreted by the mammary glands.

Patient teaching

Evaluate your patient's level of understanding and develop an individual teaching plan. If appropriate, include family members in medication teaching. Pre-administration teaching for IV medications includes the medication's name and dose, desired action, frequency of administration, and possible adverse effects specific to your patient. Also include teaching about IV therapy; instruct patients and family members to report pain or swelling at or distal to the IV catheter's insertion site.

Regulating a gravity drip IV

Flow rate determined by: •Gravity •Drop Factor Regulate rate in drops per minute using roller clamp.

Genetics

Genetic-based differences in drug metabolism are possible & should be considered when pts have unexpected responses to med dosing. Often, genetic-based differences shared by members of same ethnic group, so differences are often categorized that way. Ex: some people of African or Asian decent might be sensitive to the toxic effects of antihypertensive & antipsychotic drugs & might require dose adjustments to provide therapeutic effects. This variation is due to genetic alterations in specific drug-metabolizing enzymes & becomes apparent in individual's response to med.

Nursing responsibilities

IV meds are delivered by three methods: 1) IV bolus (push) 2) Secondary or "piggyback" intermittent infusion 3) Continuous infusion in a large vol of solution. Nursing responsibilities for IV med admin include: - Supporting positive outcomes - Reducing the risk of adverse events - Integrating med admin into pt's plan of care - Providing pt and/or family education

Gender

In general, men & women can respond in different ways to same med. For example, women tend to have a higher % of body fat while men have a higher %of body fluid, thus women might accumulate fat-soluble drugs over time. Other considerations for women are ability of some drugs to cross placenta & that of some drugs to be found in breast milk. When providing any meds to women who are pregnant or may become pregnant or who are breastfeeding, be knowledgeable about safe use during pregnancy and lactation.

Tips for documentation

In your documentation of intravenous medication administration, always include the name of the drug, the dose, the route (including bolus, piggyback), the time, your initials or signature, and any other relevant information. If you withhold a drug or the patient refuses it, indicate this on the medication administration record (MAR) and document the reason in your nurses' notes. Always document the patient's response to the medication or treatment as well as the following information specific to intravenous medication administration. Appearance of the intravenous site before, during, and after administration Amount and type of fluid to which the medication is added Whether it is being infused by an electronic pump or by gravity Period of time during which the medication is infused Flow rate Amount and type of fluid for flushing the intravenous line before and after medication administration

Med Admin via Central Line Catheters

Infusing medication and fluids through a central line is similar to the process used with a PICC. Always follow your agency's policies for asepsis when making connections to the access port. If the port is to be locked following medication administration, it is typical to flush the line with 10 mL of normal saline using the push-pause technique and then to secure the line clamp. Follow your agency's policy for the frequency, solution, and volume to be used to maintain the line's patency.

6 Rights

Learning to prepare and administer medications safely and accurately is an essential component of your nursing practice. It requires that you follow your facility's policies and procedures carefully and always implement the six rights of medication administration: the right medication, the right dose, the right route, the right time, the right patient, and the right documentation.

Drop factors

Macrodrips •10 gtts/mL •15 gtts/mL •20 gtts/mL Microdrip •60 gtts/mL ALWAYS ROUND DROPS TO WHOLE NUMBER CANNOT HAVE FRACTION OF A DROP

Right dose

Many facilities use a unit-dose system to help reduce the risk of medication errors. However, if your facility does not have a unit-dose system or you must prepare a medication from a larger volume or a different strength, you must perform conversions and dosage calculations. When you are new to practice or if you rarely perform calculations or are at all unsure about the dose, have another nurse double-check your work before you give the medication. Although policies differ from facility to facility, many require double-checking of doses of some medications, such as insulin and anticoagulants. When administering oral medications, it is sometimes necessary to give only a portion of a tablet. To break a scored tablet in half, use a cutting device to improve accuracy. If the tablet does not break evenly, discard it, if your facility's policy allows it, and cut another tablet. If it is a controlled substance, follow your facility's policy for discarding these medications. Keep in mind that it is difficult to confirm that you are giving the correct dose after you divide a tablet, so this is a practice best avoided if at all possible. To promote patient safety in inpatient settings, pharmacists split the medication, label and package them, and send them to the unit for dispensing. If a patient is unable to swallow pills, use a crushing device to crush a medication and mix it with food or a beverage before administering it. When mixing the medication, use the smallest amount of food or fluid possible. Because medications can alter the taste of food, avoid mixing it with the patient's favorite foods and beverages as this might diminish the patient's desire to eat or drink them. Whenever you cut or crush a medication, clean the pill cutter or medication crusher before and after use. It is a good practice to check with a pharmacist or a medication guide before cutting or crushing a medication. Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed. Refer to the Institute for Safe Medication Practices (ISMP) website for a "Do Not Crush List".

Med Interactions

Medication interactions result when a medication is used with another medication or substance that modifies the drug's expected action. Medication interactions can develop between food and drugs, between prescribed and over-the-counter drugs including herbal products, and as drug-to-drug interactions. A medication interaction can increase or decrease the drug's effect through changes in absorption, distribution, metabolism, or excretion. Since IV medications have a rapid effect, understanding the concept of medication interactions helps you anticipate the potential results of drug combinations. Synergistic effects develop when the combination of two or more drugs or substances results in a greater effect than that of separate administration would. An example is the combination of opioid analgesics, which are central nervous system (CNS) depressants, and other CNS depressants such as antihistamines or alcohol. Foods that produce pharmacologic activity can also have a synergistic effect on drugs that have a similar action. For example, patients who take monoamine oxidase inhibitors should avoid foods containing tyramines or tryptophan. Each releases catecholamines, and the combined effect can be life-threatening. A potentiating effect results when one drug increases the positive or negative effects of another. Often these drugs are given in combination intentionally; a common example is the drug regimen typically prescribed to treat tuberculosis.

Right time

Medications are usually ordered to be given at certain frequencies, intervals, or times of day (such as "hour of sleep"). Become familiar with the medications you are giving, why they are ordered for certain times, and whether or not the time schedule is flexible. Some medications must be given around-the-clock to maintain a therapeutic blood level. Other medications should be given during the patient's waking hours to allow uninterrupted sleep. Most facilities recommend a time schedule for administering medications ordered at specific intervals (q4h, q6h, q8h). Most facilities also have a policy indicating how soon before or how long after the scheduled time a medication can be administered. For routinely ordered medications, such as antibiotics, 30 minutes before or after the scheduled time is commonly acceptable. For example, if a medication is to be given at 0700, you can give it between 0630 and 0730 and still be administering it at the right time. In certain situations, medications must be administered at times other than those indicated by the facility's time schedule. For example, a preoperative medication might be ordered to be given "stat" (immediately) or "on call" (right before a procedure). When medications are ordered on a PRN (as needed) basis, use your clinical judgment to determine the right time. For example, when a pain medication is ordered q4-6h, assess your patient's pain level to determine whether your patient needs another dose after 4 hours or can comfortably wait longer.

Midline Catheters

Midline catheters are usually used for therapies lasting 1 to 4 weeks. They range from 3 to 8 inches long and may be single or double lumen. They are inserted via the veins in the upper arm, preferably the basilica vein due to its large diameter and straight path. The catheter tip rests no further into the venous network than the ancillary vein. Only nurses with additional education are qualified to insert midline catheters. Those patients that can benefit from midline catheters include: Those with limited peripheral veins Altered peripheral skin integrity Longer term IV antibiotics Heparin infusions for DVT Repeated steroid infusions Midline catheters should not be used for infusions of medication that can cause tissue damage if they infiltrate (causing extravasation). Interventions that should not be conducted on midline catheters include: Parenteral nutrition with low concentrations of dextrose Parenteral nutrition with osmolarity greater than 600 mOsm/L Blood draws Incompatible drug administration via dual lumen catheters

Premedication assessment

Nurses are responsible for knowing implications of IV med admin & applying critical thinking to support positive outcomes & to reduce risk of adverse events. Assessing pt prior to admin any med provides you with info necessary for effective planning & implementation of care, as well as a baseline from which you can evaluate post-admin response. Premedication assessment should include a review of pt's health history, allergies, med data, vitals, physical assessment, psychosocial & cultural considerations, & learning needs.

Basic IV med safety

Nursing responsibilities for safe & effective admin of IV meds begin with standards of practice common to all routes: - Know & perform six rights: right patient, right drug, right dose, right route, right time, right documentation. - Check med at least 3x against MAR prior to admin - as you remove drug from storage area, as you prepare drug, and at pt's bedside just before you admin drug. - Only admin meds you have prepared or those that have been prepared by licensed pharmacist. - Only admin meds that have been labeled appropriately. - Perform accurate dosage calculations. - Remember that, once you have admin'ed an IV med, it enters bloodstream immediately &begins to affect target tissues &organs. - Take diligent care to avoid errors in dosage calculations, preparation, & administration. - Know desired action & SEs of each med prior to admin & antidote if one is available because once an IV med enters bloodstream, begins to act immediately. What medconditions affect how drug is absorbed, distributed, metabolized, &excreted by patient? How does one medication interact with other drugs or IV infusions? Developing a "look it up" habit broadens your knowledge of commonly prescribed IV meds and helps ensure safe delivery of these potent drugs.

Age

Remember liver inactivates & metabolizes most drugs, while kidneys eliminate the byproducts (metabolites) of drugs from body. Important to consider when providing IV med to very young or very old. Young children lack fully developed hepatic and renal function. They metabolize and excrete drugs inefficiently, making children more susceptible to toxic effects. Likewise, diminishing hepatic & renal function prolongs drug action in older adults, who are also more likely to have other conditions affecting drug response such as altered cardiac, pulmonary, & immune function. Older adults are also likely to experience drug-drug interactions due to the treatment of multiple health problems.

Managing med interactions

Obtaining an accurate medication history at the time of a patient's admission is essential for preventing some avoidable drug interactions. Patients often neglect to mention their use of over-the-counter preparations, including vitamin supplements and unregulated herbal or alternative-medicine products that can interact with prescribed drug therapy. They might hesitate to divulge the use of these alternative therapies to "traditional" healthcare providers or be unaware of the significant role these preparations can play in clinical outcomes. When obtaining a family history for significant health risks, ask about any medication reactions in immediate family members. These questions might reveal valuable information about your patient's potential for gene-based drug responses and medication interactions. When administering drugs with dose-based responses, such as opioids or anti-hypertensive drugs, use the least amount of drug to provide the desired effect. Do the same for drugs with synergistic characteristics; "start low, go slow" is a good rule of thumb for administering IV medications safely and effectively. Finally, be sure to document and report all adverse responses to medications to the patient's primary healthcare provider. Document known and newly diagnosed allergies and the reaction on your patient's chart; include them on the medication administration record and the patient's allergy band. Include medication effects in your patient-education plan. Teach patients and their families about the importance of avoiding known intolerances to medications and medication combinations.

Physical assessment & vitals

Ongoing assessment of your patient's physical condition may affect when and how to administer a prescribed or a PRN medication. It also provides a baseline for post-medication evaluation. Patient assessment may include a complete or focused physical exam, vital signs, sedation score, and pain score. The physical assessment can be directed toward a specific system or value. For example, always check your patient's heart rate and blood pressure prior to administering antihypertensive medications or any drugs that decrease or increase the heart rate. The provider may have specified parameters for when to give or withhold those drugs. Also, be aware of medications that are known to cause problems like bronchospasm, rash, flushing, or mental-status changes. Check for these findings before giving the drug so that you can identify any changes after drug administration. Include an assessment of the patient's IV access. Some IV medications cause pain and venous irritation if administered into small peripheral veins, in a concentrated solution, or at too rapid an infusion rate. It might be necessary to access a larger vein, request a dilution more appropriate for peripheral administration, or adjust the IV rate (with the provider's approval). Central IV access should be established for vasoconstrictive medications and for medications and solutions that can cause tissue damage with extravasation. Learn about a medication's implications for administration, and ensure that your patient's venous access line is patent and will accommodate the medication as ordered. Take the patient's vital signs before giving any IV medication. IV medication administration can alter blood pressure, heart rate or rhythm, respiratory rate, or ventilatory function. Be sure to obtain a pain score prior to giving analgesics and a sedation score prior to giving medications that cause mental-status changes. Follow your agency's policy for using any specific scoring or assessment tools.

Admin of meds via implanted venous access device

Only nurses with specialized training should access and de-access an implanted device. Once the device is accessed, the noncoring needle is stabilized and secured to the skin over the septum and a dressing applied according to the agency's policy. The device extension tubing is primed and locked. Medication administration is similar to other venous-access processes: Cleanse the extension tubing port and proceed with the medication-administration procedure. During continuous or intermittent IV infusions, assess the port device for patency and signs of infiltration every 4 hours and as needed. Instill push medications at the rate recommended for the specific medication. Following medication administration, flush the extension tubing with 10 mL of normal saline. As with all central access catheters, avoid using syringes with less than a 10-mL volume for flushing or instilling medication. To ensure patency of the device, follow the saline flush with heparin as specified in your agency's policy.

PICCs

PICCs are especially useful for IV therapy to help manage chronic health problems at home. In acute-care settings, a PICC can provide central access with fewer and less severe complications than can develop with central venous catheters. The most common complications of a PICC are phlebitis, thrombophlebitis, and catheter-related bloodstream infections (CRBSI). PICC lines are ideally inserted percutaneously into the cephalic or basilic anticubital fossa, then advanced into the superior vena cava. PICC lines are available in single, dual, or triple lumen configurations. Some facilities also use PICC lines that can be connected to transducers and used to monitor central venous pressure (CVP). Placement of a PICC is contraindicated for patients who have sclerotic veins and in extremities affected by mastectomy or radial artery surgery, a hemodialysis graft, or an arteriovenous fistula. Patients with PICC lines should not have blood-pressure measurements, venipunctures, or injections in the extremity with the PICC. Specific care of a PICC site is detailed in each agency's policies and procedures, but in general, it is recommended that you assess the insertion site and upper extremity at the start of each shift and every 4 to 8 hours or as indicated by the patient's condition. Look for signs and symptoms of phlebitis, thrombophlebitis, venous occlusion, and infiltration: pain along the vein erythema edema at the puncture site ipsilateral (same-side) swelling of the arm, neck, or face a change in arm circumference of more than 0.8 in (2 cm) from baseline

Pharmacogenetics

Pharmacogenetic research offers new insights about drug interactions and the importance of individualized drug therapy. Because nurses monitor the effects of administered medications, it is important to have a basic understanding of gene-based drug metabolism. Cytochrome P450 (CYP450) enzymes are essential for the metabolism of many medications. More than 50 drug-metabolizing isoenzymes have been found in humans; so far, 10 have been associated with functional polymorphism, a genetic variation in one or more specific isoenzymes. Unlike genetic defects, polymorphisms occur in more than 1% of humans, and CYP450 polymorphism is thought to be present in as many as 20% of specific populations. CYP polymorphism can make a patient more susceptible to the adverse effects of a medication or reduce a medication's therapeutic action. Some drugs, hormones, and chemicals found in foods can inhibit or induce the function of CYP450 enzymes, resulting in significant drug interactions. Because so many drugs and substances have been identified in CYP450 interactions, it is helpful to reference a CYP450 chart. However, there are commonly used drugs associated with CYP450 polymorphism. It is helpful to become familiar with classes of drugs that can have unexpected effects or alter the therapeutic effects of other medications. Common drugs and classifications associated with CYP polymorphism include antidepressants, beta blockers, warfarin, opioids, antiepileptics, azole antibiotics, and statins. Many of these medications are administered intravenously, alone and in multidrug therapy.

Managing drug incompatibility

Planning and implementing the administration of multiple scheduled IV medications require problem-solving and collaboration; drugs must be given at the prescribed frequency to maintain therapeutic drug levels and provide optimal benefits for the patient. However, standard administration times can cause conflict in infusion times and delay of therapy. The patient may have limited intravenous access due to inaccessible extremeties or poor peripheral circulation. These challenges are compounded when coadministration of medications is questionable or prohibited by incompatibility findings. Suggested tools available for solving these problems include the following: Collaborate with other healthcare team members, including pharmacists. Stagger dosing procedures for drug-dose-time management. Check agency policies for staggering charts. Obtain a provider's order for placement of a multilumen central IV access for patients with inaccessible or limited peripheral veins. If coadministration of incompatible agents is unavoidable, infuse the agents as far apart time-wise as possible with a bridge or manifold device (such as using the proximal and distal ports) to allow minimal contact time of the two agents before administering them to the patient. Check your agency's policy for the use of these devices. Ideally, incompatible agents should be replaced with compatible combinations when possible. Consult with the pharmacist and ask the physician for appropriate substitutions that will provide the same desired effect. To minimize the risk of incompatibility of IV bolus (push) medications, be sure to flush before and after each medication with at least 10 mL of sterile normal saline or according to your agency's policy.

Patient teaching

Prior to initiating IV med therapy, assess pt's prior knowledge & ability to participate in education sessions. Explain or reinforce indications & expected response of each med. Instruct patient about reportable symptoms, such as pain, burning, itching, or swelling at IV site, as well as other potential reactions specific to the meds.

Questionable reconstitution

Problem: Reconstituting a medication results in cloudiness, discoloration, or precipitation of the diluent. Possible cause: The wrong diluent was selected for reconstitution. It is also possible that the visible change is appropriate for that medication. Intervention: Never inject a questionable IV medication. If the medication has been reconstituted improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper diluent for a medication. Review the package insert or consult a pharmacist to verify the expected appearance of the reconstituted medication.

Questionable solutions

Problem: The IV fluid in the bag or a pre-mixed medication solution appears cloudy or discolored or has visible precipitate. Possible cause: The solution may be expired or contaminated or might have been stored improperly (exposed to temperature extremes). Intervention: Never administer questionable IV fluids. Discard or return questionable or expired solutions according to your agency's policy. Prevention: Review the package insert or consult a pharmacist to verify the expected appearance of the medication. Always store IV fluids and pre-mixed medication solutions according to the manufacturer's or the pharmacy's guidelines. Remove from stock and dispose of any IV bags that have expired or are not in their original, sealed packaging.

Drug/Fluid Incompatibility

Problem: The IV fluid or solution appears cloudy or has visible precipitate after medication has been added. Possible cause: Incompatibility of the drug to the solution or the drug-to-drug mix Intervention: Never administer questionable IV medications or compounded solutions. If the medication has been mixed improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper solution for piggyback and large-volume medication infusions. Always check and cross-reference medication compatibilities. If your agency's policy permits multiple uses of one secondary line, make sure the current and previous solutions and medications are compatible. Otherwise, set up separate secondary lines and flush between medications.

Inflammation & clot formation

Problem: The IV site is swollen, red, and warm. Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.) Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue. Prevention: Make sure the medication's concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency's policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.

Interrupted IV infusion

Problem: The line or pump occlusion alarm sounds. Possible causes: The IV line is not patent, the IV is in a location that occludes when the patient changes position, the tubing is kinked, the IV loop or line is clamped, the roller clamp is in the off position, or the pump was loaded improperly. Intervention: Begin at the patient, correcting each problem: Check for IV patency, tubing patency, and position; open all occluding clamps; and check the infusion pump settings and setup. If the location of the IV causes flow occlusion when the patient moves, consider restarting the IV line at another site. Make selection below: Nursing responsibilities Premedication assessment Calculating intravenous flow rates IV medication administration troubleshooting IV medication interactions and medication compatibility Introduction to the use of specialized IV access devices Six Rights

Extravasion

Problem: The tissue around the IV site is pale or discolored and cool to the touch. Possible cause: Inadvertent administration of an irritant solution or medication into the surrounding tissue. Vasoconstrictors, calcium, and chemotherapy drugs are examples of drugs known to cause tissue necrosis with extravasation. The area of tissue damage varies with the concentration of the medication, the quantity of extravasated fluid, and the duration of the extravasation process. Assessment: The pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation and could ultimately become necrosed. Blistering and tissue sloughing may not appear for a few days. Intervention: Extravasation is an emergent situation, as it can cause serious tissue necrosis. Stop the IV infusion and discontinue the IV line. Consult your agency's policy or a pharmacist for specific care of the extravasated tissue or use a medication manual to determine the appropriate care (for example, injection of phentolamine within the extravasation border). Follow your agency's policy for proper documentation. Establish new IV access in the opposite extremity if IV therapy must continue. Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. If central access is available, infuse solutions and medications known to cause tissue necrosis via central venous access. Educate the patient about activities and signs and symptoms of infiltration.

Infiltration

Problem: The tissue surrounding the IV insertion site is swollen, pale, and cool to the touch. Possible cause: Unintentional administration of solution or medication into the surrounding tissue Assessment: Leaking from the IV site with slowing or occlusion of fluid flow. The patient reports blanching, burning, tenderness, discomfort, and coolness in the area surrounding the IV insertion site. May also experience fluid leaking from the puncture site. Intervention: Stop the IV infusion and discontinue the IV line. Elevate the extremity. Warm or cold compresses may be used according to the solution infiltrated and the facility policy. Encourage active range of motion, and follow your agency's policy for site care and documentation of infiltrated IVs. Establish new IV access proximal to the original site or in the opposite extremity if IV therapy must continue. Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. Educate the patient about activities and signs and symptoms of infiltration.

Med Error Potential

Problem: The wrong dose was prepared. Intervention: Discard the prepared dose and prepare a new dose correctly. Check your agency's policy for waste procedures and documentation and for crediting the patient's pharmacy account. Prevention: Adhering to the six rights of medication administration is essential for preventing medication errors.

Precipitation during administration

Problem: While administering an IV bolus (push) medication, cloudiness or precipitation forms in the tubing. Possible cause: The line was not flushed properly with normal saline prior to injecting an incompatible medication. Intervention: Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. Follow your agency's protocol for wasting and crediting medication and prepare another dose to administer. Observe the site for signs of venous irritation. Prevention: Follow proper technique for flushing the IV line with normal saline before and after injecting IV medications.

Healthy history

Review the patient's health history for any conditions that might affect IV drug absorption, distribution, metabolism, or excretion. This info will help you assess for the desired action of med & predict any possible adverse effects. Sources for this info include pt's history & physical exam, current lab data, & med & allergy lists.

Electrolyte

a chemical substance that develops an electrical charge and can conduct an electrical current when placed in water, such as sodium and potassium

Drug incompatibility

Some drugs in combination will create a precipitate or discoloration due to chemical changes. Other drug combinations will be less obvious, but chemical changes could have altered the drugs' effects. The designation of incompatible is made when a drug is unable to meet both of the preceding criteria. IV compatibility charts typically provide information about the compatibility of drugs combined in a syringe, combined at the Y-site of injection, if absolute incompatibility exists, or if data are insufficient to administer the drugs together safety. When administering more than two medications in one IV line, determine the compatibility of each medication with the other(s). Most drug reference manuals include compatibility charts listing commonly used IV medications. Often these charts have limited information or unclear data. Many agencies now have computerized tertiary compatibility programs based on the results of published reports from primary drug studies. It is important to access all available resources to determine drug compatibility. If unsure, assume incompatibility.

Introduction to the use of specialized IV access devices

Specialized intravenous (IV) access devices are inserted by a physician or a nurse or other clinician who has had specialized training. These devices include peripherally inserted central catheters (PICCs), implantable venous access devices, and central venous catheters (CVCs). Specialized access devices are most often used for: frequent or recurrent blood sampling for laboratory tests an alternative to poor peripheral venous access delivery of vasoactive medications infusion of total parenteral nutrition (TPN) large-volume or recurrent blood transfusions long-term infusion of medications, such as antibiotics or chemotherapy continuous monitoring of central venous pressure assessment of hypovolemia or hypervolemia placement of a pulmonary artery catheter a transvenous pacemaker

Beyond the basics

The clinical use of specialized intravenous access devices requires focused education and competency training beyond the scope of this module. These advanced skills include patient-safety considerations and infection-control practices, prevention and recognition of unexpected outcomes, and comprehension of hemodynamic values.

IV Push

a concentrated dose of medication injected directly into the systemic circulation via an intravenous (IV) line; also called an IV bolus

Medication

The patient's medication history, including allergies, provides information that guides medication choice and helps achieve optimal patient response. Find out if your patient has taken a drug similar to that prescribed, and if the patient has had any adverse reactions to similar drugs. Check the patient's medication history for prolonged use of medications for a chronic condition, and find out if they must be continued. Check for any medications that could create issues of drug tolerance or drug withdrawal. Review current medications prior to administering any IV medication. You are responsible for knowing as much as possible about each medication you give. This knowledge includes therapeutic intent, possible actions, drug interactions and compatibilities, normal dose ranges, the usual route, side effects, and nursing implications for administration and monitoring. Sources of this information include drug guides, textbooks, medication package inserts, electronic sources, and the agency's pharmacists.

Bolus

a concentrated dose of medication injected directly into the systemic circulation via an intravenous (IV) line; also called an IV push

Right route

The route you will use to administer the medication is indicated on the medication prescription. If this information is missing or the specified route is not the recommended route, notify the prescriber and ask for clarification. When giving an injection, verify that the preparation of the medication is intended for parenteral use. If you inject a preparation not intended for parenteral use, complications can result. Most medication manufacturers label parenteral medications "for injectable use only" to help prevent errors, so check the label carefully.

When you are administering IV medications and must calculate rates, you need the following data:

The unit of measurement used for the drug (units, mg, mcg) The dose to be delivered by unit of measurement (gtts, units, mg, mcg, dose/kg) The volume of the diluent (mL) The time over which each unit of drug is to be delivered (minutes, hours) The patient's weight in kilograms (required for some medications)

Admin of meds via PICC

Unless the PICC line has been placed under fluoroscopy, a chest x-ray must be obtained to indicate that the tip of the catheter resides in the lower superior vena cava before the PICC line can be used for IV infusion. To ensure placement of the catheter in the vascular space, assess for venous blood return and patency before beginning any IV infusion. When performing any task related to a PICC, be sure to adhere to the level of aseptic technique detailed in your agency's policies and procedures. Connect a normal saline-filled 10-mL syringe to the catheter's access port, release the catheter's clamp, and gently aspirate to verify blood return. Flush with up to 10 mL of normal saline using a "push-pause" motion. This technique causes the flush solution to swirl within the catheter, which clears the line and maintains patency. Avoid using syringes with less than a 10-mL volume for flushing or instilling medication. Smaller syringes exert pressure exceeding 40 psi per square inch and may cause catheter rupture or fragmentation with possible embolization. After flushing the line, continue with medication administration or IV infusion. Always cleanse the access port before attaching the infusion tubing or the medication syringe. Adequate flushing after medication administration is the most important factor for preventing the occlusion of a PICC by blood, fibrin, or medication residue. Using a 10-mL syringe filled with normal saline, inject the saline, again using the push-pause motion to create turbulence within the catheter. Your agency's policy and the particular catheter in use determine the frequency of flushing and the solution and volume required to maintain catheter patency. Also, your agency may supply one of many anti-reflux Luer-activated devices designed to keep blood from flowing into the catheter's lumen.

Syringe pump

a device that delivers medications in very small amounts of fluid from standard syringes within a controlled time frame

IV Meds & Plan of Care

When an IV med is prescribed, pt might have unique physical or emotional needs that make IV route preferable or necessary. Nursing process provides framework for assessing need, planning & implementing delivery, & evaluating pt's response to IV meds. Indications for IV meds (or, in some cases, for other routes) include: - Pt who is unwilling or unable to swallow - Drug whose action is adversely affected by digestive secretions - Drug that would irritate the gastrointestinal tract if given orally - GI system that has absorption barriers - Drug used for anesthesia or procedural sedation - Med that is only effective or available in IV form - Need to determine precise, accurate dose (because IV absorption is more complete & predictable than other routes) - A drug that requires monitoring and maintaining therapeutic blood levels - An emergency situation when drug must act rapidly As with all meds, IV drugs prescribed & dosed to treat specific conditions, with additional consideration for pt's medication "profile," which includes genetics, age, gender, current meds, & medical history. Become familiar with your pt's med profile. It provides info essential for planning & implementing effective IV med therapy.

Stopcock

a device use to stop or regulate the flow of fluid through tubing

Diluent

a diluting agent, such as a sterile fluid used to prepare a powdered form of medication for injection

Induration

a hardening or a lump, such as what forms in the skin with a positive reaction to a tuberculin skin test

Drug compatibility

While drug interaction refers to the combined systemic effect of medications, intravenous drug compatibility refers to the chemical stability of two or more medications when administered together. The standardized definition of compatibility is: No visible or electronically detected indication of particulate formation, haze, precipitation, color change, or gas evolution Stable (less than 10% decomposition) for at least 24 hours in admixture or for the entire test period (may be less than 24 hours)

Mini-infusion pump

a battery-powered device that delivers medications in very small amounts of fluid from standard syringes within a controlled time frame

Embolus

a blood clot or a bolus of air developed in or introduced into a blood vessel that moves from its place of origin and is capable of obstructing blood circulation

Saline lock

an intravenous catheter inserted into a vein and left in place for the intermittent administration of medication through its port or as an open line for emergency situations and intermittently flushed with normal saline solution to maintain patency

Volume-control admin

an intravenous infusion apparatus that incorporates a secondary fluid container (such as a volutrol or a buretrol) separate from the primary fluid bottle or bag and connected directly to the primary intravenous line or to separate tubing that inserts into the line; used to limit the volume of fluid administered over a particular time period or to prevent rapid-dose infusion of medications via IV push

Additive

any substance, such as a flavoring agent, preservative, or vitamin, added to another substance (such as a food or drug) that is to be ingested

macrodrip

delivering 15 drops per milliliter of fluid

Microdrip

delivering 60 drops per milliliter of fluid

Electronic infusion pump

device that delivers intravenous fluids via positive pressure at a specific preset rate

Compatibility

harmonious coexistence; used to refer to two or more medications or solutions that can be given simultaneously or mixed without changing the effects of each other or causing any new responses not seen with any of the drugs or solutions administered alone

Osmolarity

the concentration of solutes in body fluids, expressed in osmoles of solute per liter of solution (similar to osmolality, except that osmolality is expressed in osmoles of solute per kilogram of solvent)

Phlebitis

inflammation of a vein

Thrombophlebitis

inflammation of a vein (phlebitis) associated with thrombus (clot) formation

Hyerdermoclysis

introduction into the subcutaneous tissues of fluids, such as normal saline solution, to help correct dehydration from inadequate intake or loss of fluid and sodium

Incompatibility

lack of harmonious coexistence; used to refer to two or more medications or solutions that cannot be given simultaneously or mixed without changing the effects of each other or causing any new responses not seen with any of the drugs or solutions administered alone

Hypertonic

referring to a solution that has a higher osmolarity than body fluids have

Hypotonic

referring to a solution that has a lower osmolarity than body fluids have

Isotonic

referring to a solution that has the same osmolarity as body fluids

Parenteral

referring to administration of solutions or medications outside of the gastrointestinal tract, such as intravenously or intramuscularly

Crystalloid

salt that dissolves readily into true solutions, such as in intravenous solutions

Infiltration

seepage or introduction of fluid, such as intravenous fluid, into the tissues surrounding a blood vessel; similar to extravasation

Extravasion

seepage or introduction of fluid, such as intravenous fluid, into the tissues surrounding a blood vessel; similar to infiltration

Infusion

slow, intentional introduction of fluid into a vein

Drip factor or drop factor

the calibration or number of drops per milliliter of solution delivered for a particular drip chamber

Drip chamber

the portion of an intravenous administration set that lies just below the tubing insertion spike and allows visualization of the individual drops of solution being infused; the portion squeezed and released to begin the flow of solution immediately after insertion of the spike into the solution bag or bottle when preparing an intravenous infusion set

Aspirate

to withdraw or remove, via a syringe or other apparatus; as a noun, the substance or material obtained by aspiration, as in gastric aspirate; also refers to inadvertently inhaling fluid or other substances into the lungs

Intravenous

within or into a vein