Download IV Medication Admin Tutorial 2014 LS

Patient Safety and IV
Complications
IV & INFUSION BASICS
Medication Errors
• 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 98,000 Americans
die annually as a result of preventable medical errors
To Err Is Human: Building a Safer Health System (2000). Institute of Medicine (IOM)
• Are given directly into the blood
Intravenous
Medications
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
•
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--when it is a nonvesicant
solution or medication, it is called infiltration; when it is a
vesicant medication, it is called extravasation. Both
infiltration and extravasation can have serious
consequences: the patient may need surgical intervention
resulting in large scars, experience limitation of function,
or even require amputation.
•
Nursing interventions include early recognition,
prevention, and treatment (including the controversial use
of antidotes, and heat and cold therapy).
SAFETYInfiltration vs.
Extravasation
.
Hadaway, L. (2007). Infiltration and extravasation. American
Journal of Nursing. Aug 107(8):64-72.
SAFETY- Incompatibility Interaction 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)
Physical precipitation of Midazolam as a
result of an unfavorable pH medium
IV Administration
THE BASICS
“SAS” Method:
for incompatible meds
•
“SAS” = Saline, agent, 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
• Final saline = Flushes
meds in and prevents
catheter from occluding
• SAS for IV Push (IVP) or IV
Piggy Back (IVPB)
.
Back Priming
The process of back priming or flushing
requires a primary (or flush) bag and a
secondary bag. Here’s the steps to success:
1.
2.
3.
4.
1.
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. Keep bag upright during the
clearing process.
Clamp secondary tubing
Remove old IVPB bag and hang ordered
IVPB medication
Video on back priming is found later in
tutorial
Dilution of Medications for IVP
Some medications must be diluted
•
Decreases phlebitis to the
vessel, required for caustic
medications!
Some nurses dilute all medications
•
Easier calculation and
administration over 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.
Infusion Nursing Standards of Practice. (2011).
Infusion Nurses Society.
.
Process of Dilution for IVP
1. If using a 10 mL prefilled syringe for
2.
3.
4.
5.
dilution, empty out the quantity of
saline that will be replaced by the
medication.
Use the smallest syringe possible to
accurately draw up the medication
from the multidose vial.
Remove the needleless cap from the
10 mL syringe and inject the
medication into the larger syringe.
Replace the needleless cap.
Gently mix the 2 solutions.
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 Rate of Administration: ROA
•
IVPB via pump runs in
mL/hour
• IVPB to Gravity runs in
gtts/min
• IVP is delivered evenly
over the prescribed time
Pump infusion:
mL of solution over
time in hours
Gravity flow:
mL of solution x gtt factor
over time in minutes
IV push rate:
administration rate based on
medication instruction
Syringe Size Guidelines
• Peripheral lines
•
3-5mL syringe size
•
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!!
The Procedure
IV MEDS
IV Administration
Start with the Order & Look the Medication up!
Reliable sources for looking
it up
•
•
•
•
Micromedex
Online resources
Pharmacist
IV med book
Not so reliable
•
•
A fellow student or nurse
Drug insert
Ask yourself…
• Let’s work this through
• Is it IVP or IVPB, how
using the order from
previous page- Lasix)
• Is it a safe dose for my
patient?
• Why is my patient getting
this med?
• Any precautions or side
effects? What do I
monitor before or after
the med is given?
much solution is it diluted
in?
• What IV site does the
patient have? What’s
running through it?
• Compatible or not?
• ROA? mL or gtts/min?
Looking it Up!
Answers…
• Is it a safe dose for my
• Is it IVP or IVPB, how
patient YES
• Why is my patient getting
this med? CHF
• Any precautions or side
effects? ↑ UO, ↓K+, ↓BP
• What do I monitor before
or after the med is given?
UO, K+ and BP
much solution is it diluted
in? IVP, undiluted
• What IV site does the
patient have? What’s
running through it?
Peripheral IV D5NS
• Compatible or not?
Compatible
• ROA? mL or gtts/min?
Dose over 1-2 minutes
Most Common IV Meds
•
pantoprazole (Protonix)
•
ceftriaxone (Rocephin)
•
hydromorphone (Dilaudid)
•
levofloxacin (Levaquin)
•
morphine
•
metronidazole (Flagyl)
•
ondansetron (Zofran)
•
ceftriaxone (Rocephin)
•
promethaine (Phenergan)
•
piperacillin (Zosyn)
•
ketorolac (Toradol)
•
ampicillin (Unasyn)
•
metoprolol (Lopressor)
•
cefaolin (Ancef)
•
vancomycin
•
clindamycin (Cleocin)
Steps to IV Administration
Medications via a Capped Line- IVP
Gather Supplies: Prepared/
labeled syringe with ordered
medication, 2 NS flushes,
Alcohol swab
1.Aseptically, aspirate/flush IV
catheter to verify patency
2.Aseptically administer IV
push medication at
prescribed ROA
3.Flush IV catheter at same
ROA as medication to fully
clear line of all medication
4.When line is cleared,
complete flush at steady rate
http://www.youtube.com/watch?v=xRTTUVNFlgs
&feature=c4overview&list=UUG7a6tFPh1wvF0QDMZ3DarQ
Meds via a Compatible IV Line- IVP
Verify IVP medication is
compatible with the primary
solution
Gather Supplies: prepared /
labeled syringe with ordered
medication, Alcohol swab
1.Using port closest to
patient, aseptically administer
IVP medication at prescribed
ROA
Video link med on IV push (IVP) through a
compatible line
http://www.youtube.com/watch?v=qoG9a
asJzcQ
Medications via a Capped Line- 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- IVPB
Verify IVPB medication is compatible with primary
solution
 Video link on back priming and
setting pump for IVPB below…
Gather Supplies: IVPB with ordered medication
1.Ensure roller clamp on secondary tubing is open
2.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
3.Clamp secondary tubing
4.Remove old IVPB bag and hang ordered IVPB
medication
5.Fully open roller clamp on secondary tubing
6.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.
 http://www.youtube.com/watch?v=9
9LA20UNYgk
Meds via an Incompatible IV line
IVP
IVPB
Verify IVP medication is incompatible with primary
solution
DO NOT INFUSE AN IVPB THRU AN
INCOMPATIBLE MAINLINE INFUSION
Gather Supplies: Prepared / labeled syringe with
ordered medication, 2 NS flushes, Alcohol swab

1.Stop / pause primary infusion
2.Using port closest to patient, aseptically flush IV
line to fully clear tubing of incompatible primary IV
solution
3.Using port closest to patient, aseptically
administer IVP medication at prescribed ROA
4.Flush IV catheter at same ROA as medication to
fully clear line of all medication
5.When line is cleared of medication, complete
flush at steady rate
6.Open roller clamp to re-start infusion of primary
solution
If no other immediate IV access is
available, follow the steps below:
Disconnect incompatible mainline
infusion
2. Using a primary/secondary flush
bag set-up, administer IVPB
3. Following IVPB infusion/flush,
disconnect from patient and reconnect mainline infusion
1.
Practice Scenarios
IV site: peripheral capped line
Order: ondansetron (Zofran) 4 mg IVP now
On hand: ondansetron (Zofran) 2mg/mL (2 mL vial)
Ask….
1.Safe dose?
2.Why is my pt.
getting this?
3.Side effects?
4.What do I need
to monitor for?
5.Dilute?
6.IV solutions?
7.Compatible?
8.ROA?
9.CATS PRRRL
Dosage: Deliver ondansetron (Zofran) 4mg = 2mL
Supplies needed: SAS, alcohol swabs
If diluted
1.
2.
3.
4.
5.
6.
Purge 2mL NS from a 10mL prefilled
syringe
Dilute ondansetron with 8mL of NS
for a total volume of 10 mL
Label syringe
Administer 1st saline using steady
push-pause motion
Deliver medication at 5 mL/min
(10mL / 2min,)
Deliver 1st mL of 2nd saline at same
ROA as Zofran
If undiluted
1.
2.
3.
4.
5.
Draw up 2 mL ondansetron in 3 mL
syringe
Label syringe
Administer 1st saline using steady
push-pause motion
Deliver medication at 1 mL/min (2mL
/ 2 min.)
Deliver 1st mL of 2nd saline at same
ROA as Zofran
Dosage: Deliver famotidine (Pepcid) 20 mg in 100 mL NS
Supplies needed: SAS, primary and secondary flush bag set-up, alcohol swabs
New Set-Up
1.
2.
3.
4.
5.
Prime primary flush bag set-up with
long tubing.
Spike medicated bag with
secondary tubing and back prime to
clear air in the line. Pug in to port
closest to the bag of the primary
line
Confirm IV patency with saline flush
Connect and run at 200 mL/hr (100
mL/30 min.).
Program pump to infuse ~ 30 mL
post flush
Existing Set-Up
1.
2.
3.
4.
5.
Back prime secondary tubing into
old IVPB bag.
Spike IVAB to secondary line
Confirm IV patency with saline flush
Connect and run at 200 mL/hr (100
mL/30 min).
Program pump to infuse ~30 mL
post flush
IV site: Continuous Infusion D5.45 NS @ 100 mL/hr
Order: ondansetron (Zofran) 4 mg IVP now
On hand: ondansetron (Zofran) 2mg/mL (2 mL vial)
Ask….
1.Safe dose?
2.Why is my pt.
getting this?
3.Side effects?
4.What do I need
to monitor for?
5.Dilute?
6.IV solutions?
7.Compatible?
8.ROA?
9.CATS PRRRL
Dosage: Deliver ondansetron (Zofran) 4mg = 2mL
Supplies needed: alcohol swabs
If undiluted
If diluted
Purge 2mL NS from a 10mL prefilled
syringe
2. Dilute ondansetron with 8mL of NS
for a total volume of 10 mL
3. Label syringe
4. Deliver medication at 5 mL/min
(10mL / 2min,)
1.
1.
Draw up 2 mL ondansetron in 3 mL
syringe
2. Label syringe
3. Deliver medication at 1 mL/min (2mL
/ 2 min.)
IV site: Continuous IV D5 .45NS @ 100mL/hour
Order: famotidine (Pepcid) 20 mg IVPB every 12 hours
On hand: famotidine (Pepcid) 20mg/100mL NS prepared and labeled by pharmacy
Ask….
1.Safe dose?
2.Why is my pt.
getting this?
3.Side effects?
4.What do I need
to monitor for?
5.Dilute?
6.IV solutions?
7.Compatible?
8.ROA?
9.CATS PRRRL
Dosage: Deliver famotidine (Pepcid) 20 mg in 100 mL NS
Supplies needed: Secondary tubing, alcohol swabs
New Set-Up
Existing Set-Up
Spike medicated bag with
secondary tubing and back prime to
clear air in the line. Pug in to port
closest to the bag of the primary
line
2. Connect and run at 200 mL/hr for
secondary piggyback (100 mL/30
min.).
1.
1.
Back prime secondary tubing into
old IVPB bag.
2. Spike IVAB to secondary line
3. Connect and run at 200 mL/hr (100
mL/30 min) for secondary
piggyback.
IV site: Continuous Infusion D5.45 NS with 20 mEq KCl@100 mL/hr
Order: methylprednisolone (Solu-Medrol) 125 mg IVP now
On hand: methylprednisolone (Solu-Medrol) 125 mg/2 mL (2 mL vial)
Ask….
1.Safe dose?
2.Why is my pt.
getting this?
3.Side effects?
4.What do I need
to monitor for?
5.Dilute?
6.IV solutions?
7.Compatible?
8.ROA?
9.CATS PRRRL
Dosage: Deliver methylprednisolone (Solu-Medrol) 125 mg IVP
Supplies needed: SAS, alcohol swabs
If diluted
1.
2.
3.
4.
5.
6.
7.
Purge 2mL NS from a 10mL prefilled syringe
Dilute methylprenisolone with 8mL of NS
for a total volume of 10 mL
Label syringe
Stop/pause primary infusion, crimp tubing,
Use the port closest to the patient, flush
tubing with first saline syringe
Administer medication at prescribed ROA:
5 mL/min (10ml/2 min total solution)
Flush at same ROA as medication to clear
line of all medication, then flush remaining
solution
Re-start infusion of primary solution
If undiluted
Draw up 2 mL methylprednisolone
in 3 mL syringe
2. Label syringe
1.
3.
4.
5.
6.
Stop/pause primary infusion, crimp
tubing, Use the port closest to the
patient, flush tubing with first saline
syringe
Administer medication at prescribed
ROA: 1 mL/minute (2mL/2 min)
Flush at same ROA as medication to
clear line of all medication, then flush
remaining solution
Re-start infusion of primary solution
IV site: Continuous Infusion Heparin 1000 u/hr
Order: famotidine (Pepcid) 20 mg IVPB every 12 hours
On hand: famotidine (Pepcid) 20mg/100mL NS prepared and labeled by
pharmacy
Ask….
1.Safe dose?
2.Why is my pt.
getting this?
3.Side effects?
4.What do I need
to monitor for?
5.Dilute?
6.IV solutions?
7.Compatible?
8.ROA?
9.CATS PRRRL
Dosage: Deliver famotidine (Pepcid) 20 mg in 100 mL NS
Supplies needed: Depends….
First Option
1.
Start a 2nd IV site
Second Option
1.
Disconnect incompatible infusion
for the length of the administration
and set up as a capped line; IVPB
infusion using a flush bag.
Documentation
• Sign MAR with initials, date, time, signature and 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.)
FAQ
• How much fluid is needed for the flush before or after a
medication?
•
•
Pre-flush to confirm patency = 3 to 10 mL NS
Post IVP or IVPB: “The minimum volume of flush recommended
is twice the internal volume of the catheter” (Standard 60).
Most times your will see 3-10 mL for IVP and 20-30 mL for IVPB.
Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.
FAQ
• Am I able to use the same syringe for both the pre and
post flush when using SAS?
•
“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.
FAQ
• Do I need to wear gloves when administering an IV
medication?
•
•
“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
Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.
FAQ
 Is it safe to transfer medications from one syringe to
another?


Prefilled saline syringes should not be used for dilution of
medications. Due to risk of serious medication errors, syringe to
syringe drug transfer is not recommended
Drawing up medications in an appropriately sized syringe which
is then diluted into a 10mL syringe of PFSC. Syringe is labeled
before the syringe leaves your hand.
Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.
FAQ
 How long do I need to scrub an IV port with an alcohol
wipe before accessing it?



Most hospital policies say 15-30 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
Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.
FAQ
 What do I do when I have EBP information that is
different than what I see the nurses doing in practice?

1.
2.
3.
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