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Medication Management Policy / Procedure TITLE: INJECTABLE MEDICATIONS Effective Date: NUMBER: 20.10 August 2014 Pages 5 (+ Appendix A) Applies To: Programs, Pharmacy POLICY This policy applies to all patient care areas. However, individual care areas may have unit specific injectable drug policies and protocols that extend beyond limitations set by this policy. This policy defines the various routes of administration of injectable medications and identifies whether or not a nurse may administer the medications by various routes. Before administering an injectable medication a nurse must ensure that he/she is authorized to administer via that route and also ensure that it is a recommended route for the individual drug ordered. DEFINITIONS Continuous Intravenous Infusion: Administration of a medication at a constant rate in a set volume,of intravenous.fluid. Direct Intravenous Injection: Administration of a prescribed medication via a syringe directly into the injection site of intravenous tubing (below the drip chamber), directly into a vein or through an intermittent infusion device [heparin/saline lock].) Intermittent Intravenous Infusion: Administration of a medication infused on a prescribed set schedule. Rapid Direct (IV Push): Administration of a medication by direct intravenous injection over 10 to 60 seconds. Slow Direct: Administration of a medication by direct intravenous injection over more than 60 seconds, but usually over 3 to 5 minutes. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use. Injectable Medications – Policy 20.10 Page 3 of 6 PROTOCOL General Information: Initial calculations for injectable medications administered to neonates and children must be independently checked by a second nurse, physician, or pharmacist. A calculation on the MAR (medication administration record) may be used as a second check for subsequent doses provided the calculation has been checked and signed by Health Care Providers. Calculations on the MAR must include math, concentration of drug used to prepare dose, and initials of each nurse who did initial calculation. Two nurses must sign the medication administration record and check current order, dosage, frequency, route and calculations for each administration of high alert drugs as per Policy 25.05. Intradermal: A nurse may administer all intradermal medications after receiving appropriate instruction and supervision. Intramuscular: A nurse may administer all intramuscular medications. (For recommended volumes per site and needle gauge, see Appendix I) Intra Peritoneal: A nurse may administer intra peritoneal medications following certification in peritoneal dialysis procedures. Intrathecal: A nurse may NOT administer intrathecal medications without having gained certification. Intravenous: General IV Information: Refer to the parenteral drug references: Parenteral Drug Therapy Manual, The Ottawa Hospital (available on adult patient care areas) Pediatric Injectable Drugs, The Teddy Bear Book, Ninth Edition, American Society of Health Systems Pharmacists, Inc. 2014 (available within Children’s Health or on-line edition accessed through IWK Health Services Library) Micromedex (IV Compatibility Section) Compatibility charts available in all areas This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use. Injectable Medications – Policy 20.10 Page 4 of 6 Contact the Pharmacy Department for the following information: - mixing, reconstitution instructions not found on package insert, Pulse or charts - compatibility - dosing (not included in on-line formulary) - stability All intravenous solutions with medication added must be labelled with the IWK IV additive label, with the following information included: o name of patient and room number o date and time medication added o name of medication o concentration or amount of medication added (as appropriate to medication added) o primary solution and volume remaining if medication is added to a bag that is not full o special storage conditions, if applicable eg. Protect From Light o signature and status of person adding medication o signature and status of person checking preparation (if applicable) When injectable medications are prepared on the care area they should be prepared just prior to administration. Preparing doses ahead of time can lead to inadvertent administration of wrong product, wrong dose or wrong patient and also may affect chemical stability and/or sterility. When medications are prepared for infusion in a syringe and a particular final concentration is ordered or desired, add the required amount of medication and q.s (add sufficient quantity to prepare the final volume with the infusion solution. For example, if a medication order reads: Morphine 50 mg/50 mL D5W, this means morphine 50 mg in a TOTAL volume of 50 mL and NOT morphine 50 mg added to 50 mL D5W. This is especially significant when the volume of medication added is large. A nurse may administer heparin lock (10-100 units/mL) or 0.9% NaCl into an intermittent IV cannula between medications to prevent clotting and blockage of the IV cannula. (For volume and frequency of heparin lock, see Heparin Lock Intermittent Infusion Device - Children, Policy 30.26; For 0.9% NaCl, see Saline Lock Intermittent Infusion Devices - Adults and Children, Policy 30.09.) A nurse may not add any medication to blood or blood products. Contact hematologist for approval before mixing any medication with blood products. A nurse may add or increase the concentration of dextrose in intravenous solutions (see Medication Management - 90.04 Appendix IV, Section D and E). A nurse may add any compatible medication to a basic IV solution as ordered. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use. Injectable Medications – Policy 20.10 Page 5 of 6 A nurse may withdraw from the basic IV solution if necessary to prepare solution as ordered. Manufacturer published overfill should be considered when preparing doses. A nurse may NOT add any medication additive to total parenteral nutrition (TPN). This includes the dextrose/amino acid or fat,fish oil or lipid emulsions. Continuous Intravenous Infusion: A nurse may administer a medication by continuous intravenous infusion with the following exceptions: Continuous intravenous administration of magnesium sulfate for pregnancy induced hypertension is only performed by nurses in Birth Unit who have demonstrated competency. (see Policy 30.06) Continuous intravenous administration of oxytocin antenatally, for the purpose of inducing or stimulating labour or for an oxytocin challenge test. Oxytocin antenatally may be administered in Birth Unit by nurses who have demonstrated competency. (see Policy 30.11) Intermittent Intravenous Infusion: A nurse may administer medications to adults and children by intermittent intravenous infusion. A nurse must be supervised until competent in the administration of intermittent intravenous infusions for neonates. Direct Intravenous Injection: Rapid Direct (IV Push) A nurse may only administer medication by rapid IV direct under the following conditions: If rapid direct is a manufacturer labeled method of drug delivery, the nurse has demonstrated competency in rapid direct administration AND the care team approves of nursing administering the drug over this time frame. If a physician is present but unable to give a medication, a nurse may administer the medication rapid direct over 10-60 seconds. WinRho®: by certified nurse. Note: WinRho is a blood product, not a medication. Slow Direct A nurse may administer a medication by slow direct intravenous injection provided that slow direct is a manufacturer labeled method of drug delivery. Electronic Infusion Devices (Pumps) An electronic infusion device shall be used when a patient’s condition is such that consistent medication administration is required, when achieving and/or maintaining This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use. Injectable Medications – Policy 20.10 Page 6 of 6 fluid balance is essential; or at the discretion of the nurse. A smart pump must be used for the infusion of all high alert drugs. Percutaneous Injection: A nurse may NOT administer percutaneous cell mediated skin test antigens. Subcutaneous Injection: A nurse may administer all subcutaneous medications. (For recommended volumes per site, see Appendix I) REFERENCES Potter, A.G. & Perry, P.A. (2010). Clinical nursing skills and techniques (7th Edition) St. Louis: Elsevier Mosby. Parenteral Drug Therapy Manual, 31st Edition, The Ottawa Hospital, General Campus, 2014 Injectable Medicine Administration Guide, Second Edition, Pharmacy Department, University College London Hospitals 2009 Trissel, LA, Handbook of Injectable Drugs, 17th Edition, American Health System Pharmacists, 2012 Pediatric Injectable Drugs, The Teddy Bear Book, Tenth Edition, American Society of Health Systems Pharmacists, Inc 2013 online edition accessed through IWK Health Services Library, Health Professionals, on-line textbooks http://www.iwk.nshealth.ca/index.cfm?objectid=80765B3B-C0B0-5A3A29D3AA1F6471D4D0&category=Electronic%20Textbooks&link_id=723 RELATED DOCUMENTS Policies Medication Management Policy 10.05 - Verbal / Telephone Orders for Medications Medication Management Policy 10.15 - Labeling of Injectable Medications by Outside of Pharmacy Medication Management Policy 20.05 - Administration of Medications Medication Management Policy 25.05 – High Alert Medications - Independent Double Check Medication Management Policy 30.06 - Magnesium Sulfate for Hypertension in Pregnancy Medication Management Policy 30.09 - Saline Lock Intermittent Infusion Devices - Adults & Children Medication Management Policy 30.10 - Drugs & Blood / Blood Products Medication Management Policy 30.11 – Oxytocin Infusion – Birth Unit Medication Management Policy 30.26 – Heparin Lock Intermittent Infusion Device – Children Medication Management Policy 30.35 – Morphine, Continuous Intravenous Infusion for Infants and Children Over Six Months of Age Medication Management Policy 30.45 Paraldehyde Intravenous Medication Management 90.04 Appendix IV – Section D and E Clinical Policy 1520 25 - Connecting stay-safe Extension Tubing to the PD Catheter Clinical Policy 1155 – Maintaining Peripheral IV Therapy Clinical Policy 1810B – TPN – Tubing Change This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use. APPENDIX I - Policy 20.10 SUBCUTANEOUS INJECTIONS AGE SITE OF INJECTION RECOMMENDED MAXIMUM VOLUME (mL) Young Infant all sites 0.2 Older infant & toddler all sites 0.3 Preschooler to young school-age all sites 0.5 Older school age to adolescent all sites 0.75 Older adolescent all sites 1 INTRAMUSCULAR INJECTIONS AGE SITE OF INJECTION NEEDLE GAUGE/LENGTH RECOMMENDED MAXIMUM VOLUME (mL) Birth-18 months vastus lateralis ventrogluteal dorsogluteal deltoid 22-25 g / ⅝ - 1" + not recommended not recommended not recommended 1 not recommended not recommended not recommended 18 months-3 years vastus lateralis ventrogluteal dorsogluteal deltoid 22-25 g / ⅝ - 1" + not recommended* not recommended* not recommended except for immunizations 1 not recommended* not recommended* not recommended except for immunizations 3-6 years vastus lateralis ventrogluteal dorsogluteal deltoid 22-25 g / ⅝ - 1" + 20-25 g / 1 - 1½" not recommended* not recommended except for immunizations 1.5 1.5 not recommended* not recommended except for immunizations 6-15 years vastus lateralis ventrogluteal dorsogluteal deltoid 22-25 g 20-25 g 20-25 g 22-25 g / ⅝ - 1" + / 1 - 1½" / 1 - 1½" / ½ - 1" 2 2 2 0.5 15 years-adult vastus lateralis ventrogluteal dorsogluteal deltoid 22-25 g 20-25 g 20-25 g 22-25 g / ⅝ - 1" + / 1 - 1½" / 1 - 1½" / ½ - 1" 3 3 3 1