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Intravenous medicine Administration Nursing Aspects September 2009 1 Risk Assessment • Is the treatment necessary? • Is there a lower risk alternative? February 2009 2 Patient assessment • Ask yourself about the patient, are there any conditions you will have to note: • Renal – Fluid restriction • Liver – Fluid restriction – sodium restriction • Diabetes – Dextrose restriction • High serum sodium – Normal values? 135-145 mmol/l February 2009 3 Allergies • Does the patient have any allergy • May range from mild itch to full blown anaphylaxis • giving? Do these contain Penicillin? – Amoxicillin? – Co amoxiclav (Augmentin)? – Co-trimoxazole (septrin)? – Tazocin? – Gentamicin? February 2009 4 Prior to preparation • Staff trained appropriately – Only those who have completed NHSGG&C’s training programme and maintained their professional knowledge and competence may perform IV medicine administration • 2 people check medicine, prescription and any calculation • Read information (monograph) before preparation 2009 area, wash hands 5 • February Clean Risk assessment of medicine • What factors should we take in to consideration: – Stability – Special procedure for making up • What else can be drawn up into the vial? – Needle size 23g or use a blunt filter needle – Reconstitution device February 2009 6 General Principles for the Preparation of medicines • Prepare medicines immediately before use • Peel wrappers from needles and syringes • Disinfect all vial/ampoule closures/infusion ports with 70% alcohol solution and allow to dry • Do not add any more than one medicine to any solution • No interruptions while prescribing, preparing or administering medicines February 2009 7 Recent critical incident • Patient prescribed clarithromicin • Nurse prepared • Interrupted and left syringe with neat clarithromicin on side with chart • FY1 asked to give the medicine • Saw syringe and vial • Gave undiluted medicine to patient Always label a medicine if left unattended If interrupted, February 2009 and start again. 8 Site Where do you want to give the medicine? • Peripheral • Central February 2009 9 Delivery How do you want to give it? • Bolus • Intermittent • Continuous If you are using a pump do you know how it works? If not...ASK and CHECK February 2009 10 Important Aspects The Prescription: Clear, legible and signed Read carefully Question any changes The Patient: • • • • • Ensure correct patient Obtain consent from patient Ascertain allergy history Know other medication the patient is receiving Observe response during and after administration – document any reactions February 2009 11 Important Aspects Administration of the medicine: • Never administer a medicine prepared by another practitioner when not in their presence • Check that the medicine has not already been administered February 2009 12 Flushing • 10ml syringes used for flushing • Flush with sodium chloride 0.9% solution before, between and after administration of each medication unless the medication is not compatible with NaCl • Push pause method • Positive pressure • Flush must be prescribed or covered by a PGD February 2009 13 Complications - Speedshock • Rapid administration of a medicine • Toxic levels in the blood • Floods organs rich in blood, i.e heart, liver, brain • Fainting, shock and cardiac arrest February 2009 14 Complications -Phlebitis • Irritant medications • Cannula too big • Cannula not secured February 2009 15 Documentation • Document administration • Document cannula condition – phlebitis score • Document fluid administered February 2009 16 Complications -Infiltration • Leakage of fluid from the vein to the surrounding tissues. • Caused by cannula piercing the vessel wall. • Pain, paraesthesia, cold • Prevention? • Treatment? February 2009 17 Complications -Extravasation • Leakage of a vesicant fluid into surrounding tissues. • E.g. cytotoxic, sodium bicarbonate, phenytoin, dopamine, calcium chloride, potassium, amiodarone) • Treatment – Stop infusion – Leave cannula in – Mark area – Seek medical advice February 2009 18 Case study • Patient prescribed regular vancomicin • Cannula difficulties mean infusion rarely completed • Medicine signed as given on all occasions • What effect does this have on blood levels? February 2009 19 Emergency treatment of anaphylactic reactions See also page 18 of intravenous medicines self-directed learning package (adults) February 2009 20 What is … • Anaphylaxis is a severe life threatening, generalized or systemic hypersensitivity reaction. • It is characterised by rapidly developing life threatening airway and/or breathing or circulation problems • There are usually skin and/or mucosal changes February 2009 21 What causes anaphylaxis • • • • • • • • Stings - 47 Nuts -32, Food -13 Antibiotics – 27 Anaesthetics drugs – 35 Other drugs – 15 Contrast media – 11 Other – 4 Pumphrey RS suspected triggers for fatal anaphylactic reactions in UK 1992- 2001 February 2009 22 Recognition and treatment • • • • • ABCDE Approach Treat life threatening problems Assess effects of treatment Call for help early 2222 Diagnosis is not always obvious February 2009 23 Airway • Swelling to the throat or tongue • Difficulty breathing and swallowing sensation of throat ‘closing up’ • Hoarse voice • Stridor February 2009 24 Breathing • • • • • • • Shortness of breath Increased respiratory rate Wheeze Patient becoming tired Confusion caused by hypoxia Cyanosis – a late sign Respiratory arrest February 2009 25 Circulation • • • • • • • Signs of shock – pale, clammy Tachycardia Hypotension Decreased conscious level Chest pain/ angina Cardiac arrest Do not stand the patient up February 2009 26 Disability • Sense of impending doom • Anxiety, panic • Decreased conscious level caused by airway, breathing or circulation problem February 2009 27 Exposure • Skin changes – often the first feature present in over 80% of anaphylactic reaction. • Erythema – patchy, generalised red rash • Urticaria – hives, nettle rash, weals or welts anywhere on the body. • Angioedema – swelling of deeper tissues e.g eyelids, lips, mouth and/or throat February 2009 28 Treatment • • • • A. Establish airway B. High flow oxygen C. IV fluid challenge Monitor – vital signs and responses to treatment • Intra-muscular adrenaline • Chlorphenamine • Hydrocortisone February 2009 29 Intra Muscular Adrenaline • IM doses of 1:1000 adrenaline (repeat once after 5 min if no better) • Adult or child more than 12 years: 500 micrograms IM (0.5 mL) • Child 6 -12 years: 300 micrograms IM (0.3 mL) • Child 6 months - 6 years: 150 micrograms IM ( 0.15) February 2009 30 Adrenaline • Caution with Intravenous adrenaline • For use only by experts. • For use only on monitored patients February 2009 31 Fluids • • • • Once IV access established 500 –1000mL IV bolus in adult 20mL/Kg IV bolus in child Monitor response - give further bolus as necessary • Colloid or crystalloid - 0.9% sodium chloride or Hartmann’s • Avoid colloid, if colloid thought to have • caused reaction February 2009 32 Steroids and antihistamines • • • • Hydrocortisone and chlorphenamine Second line drugs Use after initial resuscitation started Do not delay initial ABC treatments February 2009 33 • • • • • • • • Anaphylaxis •Recognition and early treatment •ABCDE approach •Adrenaline •Investigate •Specialist follow up •Education –avoid trigger •Consider auto-injector February 2009 34 • Further information on anaphylaxis is available at: www.resus.org.uk February 2009 35