Administer Parenteral Drugs

Transcription

1 Administer Parenteral Drugs Intradermal, subcutaneous, intramuscular, or intravenous. To prepare and administer parenteral medications the nurse must have knowledge of the special equipment, use manual dexterity and sterile technique, and follow Standard Precautions. An injection is an invasive procedure because it breaks the skin barrier. As such, it must be performed using proper aseptic technique to prevent risk of infection. PROCEDURE Withdrawing Medication from an Ampule Equipment Medical administration record (MAR) Ampule of prescribed medication Sterile syringe and needle Sterile gauze or alcohol swab Extra needle of proper gauge and length in accord with site Filter needle Action Rationale 1. Wash your hands. 1. Decreases transmission of microorganisms. 2. Hold the ampule and quickly and lightly tap 2. Moves the fluid trapped above the neck of the top chamber until all fluid flows into the the ampule to the lower chamber of the bottom chamber. ampule. 3. Place a sterile gauze or alcohol wipe around 3. Contains the glass fragments and shields the the neck of the ampule (Figure 29-14). 4. Firmly grasp the neck of the ampule and quickly snap the top off away from your body. Place the ampule on a flat surface. 5. Withdraw the medication from the ampule, maintaining sterile technique. Check connection of needle to syringe by turning barrel to right while holding needle guard. nurse s fingers from the broken ampule. 4. Directs shattered glass fragments away from the nurse s face and fingers. Prevents spillage of medication. 5. Prevents the transmission of microorganisms. Ensures an airtight system. Use a filter needle if recommended. Filters out fine glass particles.

2 Remove needle guard, and hold syringe in dominant hand. With nondominant hand grasp ampule and turn upside down, or stabilize ampule on a flat surface. Insert the needle into the center of the ampule; do not allow the needle tip or shaft to touch the rim of the ampule. Keep needle tip below level of meniscus (Figure 29-15). Promotes dexterity. Provides access to medication. Prevents contamination of needle tip or shaft. Prevents air from entering syringe and fluid from leaking out while the ampule is inverted. A B Figure A. Invert ampule and draw fluid into the syringe. B. Remove filter needle and replace with injection needle. Aspirate the medication by gently pulling on the plunger. If air bubbles are aspirated, remove the Allows medication to enter the syringe.

3 needle from the ampule. Hold syringe with needle pointing up and tap sides of the syringe. Draw back slightly on plunger, and gently push the plunger upward to eject air. Reinsert the needle in the middle of the ampule and continue to withdraw the medication. Prevents loss of medication from the ampule caused from air pressure. Moves air bubbles above the fluid level in the syringe. Pulls medication from needle so only air is ejected from the syringe. 6. Remove excess air from the syringe and check the dosage of medication in the syringe. Recap. 7. Discard any unused portion of the medication, and dispose of the ampule top in a suitable container after comparing with MAR. 8. Change needle and properly discard used needle. Secure needle to syringe by turning the barrel to right while holding the needle guard. 6. Allows for accurate measurement of medication dose. Prevents contamination of the needle and protects the nurse against inadvertent needle sticks. 7. Sterility of a medication is lost in an open ampule. 8. Reduces the risk that the drug will cause irritation to subcutaneous tissue. 9. Wash hands. 9. Prevents spread of microorganisms. NURS I N G T I P Expiration Dates Manufacturers are required by law to put the expiration date on all drugs. The nurse should check the expiration date to ensure that the drug is current. Outdated drugs should be returned to the pharmacy for proper disposal. PROCEDURE 29-3 Withdrawing Medication from a Vial Equipment Medical administration record (MAR) Sterile syringe and needle alcohol swab Sterile needle Vial of medication Action Rationale 1. Wash your hands. 1. Reduces transmission of microorganisms. 2. Prepare the vial. Open the alcohol wipe. New vial, remove metal cap from vial of 2. Provides access to vial. Removes surface contamination. (Note: Manufacturers do not ensure sterility of rubber top.) medicine and cleanse the rubber top of the vial. Used vial, cleanse the rubber top of the vial. 3. Prepare syringe. 3. Ensures a closed system.

4 Choose a syringe of appropriate size to accommodate the volume of medication to be withdrawn. Grasp needle and turn barrel of syringe to the right. Remove the needle cap and pull back on plunger to fill syringe with an amount of air equal to amount of solution to be withdrawn from the vial. 4. Insert the needle into the center of the upright vial and inject air into the vial. 5. Invert vial; keep the vial at eye level and the needle s bevel below the fluid level, and remove the exact amount of medicine while touching only the syringe barrel and plunger tip (Figure 29 17). Ensures withdrawing all the medication at one time. Displaces the solution with air to prevent the formation of a vacuum in the sealed vial. 4. Creates positive pressure inside vial to allow accurate withdrawal of medicine. 5. Prevents contamination of the plunger, barrel, and medicine. Figure Invert the vial, and keep the needle below the fluid level. PROCEDURE 29-4 Mixing Insulins in One Syringe Equipment Medication administration record (MAR) Alcohol swabs Insulin vials Insulin syringe Action Rationale 1. Check with the client and the chart for 1. Prevents occurrence of adverse reactions. known allergies or medical conditions that would contraindicate the use of the drug. 2. Gather necessary equipment. 2. Promotes efficiency. 3. Check the MAR against written health care 3. Ensures accuracy in identification of orders. medication.

5 4. Wash your hands. 4. Reduces transmission of microorganisms. 5. Follow the five rights of medication 5. Ensures correct client. administration. Check the client s identification band. 6. Remove caps from insulin vials (if not 6. Permits access to solution. already off). 7. Slowly rotate each bottle of insulin. Never 7. Ensures complete mixture of suspension. shake. Make sure suspensions are thoroughly Make sure there are no crystals on the bottom mixed. (Cloudy insulin such as NPH should be of the vial. completely mixed.) 8. Clean the rubber stoppers of the vials with 8. Helps remove surface contaminants. an alcohol swab. Angle of Injection The angle of insertion depends on the type of injection. Figure illustrates the angle of insertion for each type of parenteral injection. Intradermal Injection Intradermal (ID) or intracutaneous injections are typically used to diagnose tuberculosis, identify allergens, and administer local anesthetics. The sites commonly used for ID injection are the inner aspect of the forearm (if it is not highly pigmented or covered with hair), upper chest, and upper back beneath the scapula (Figure 29-19). Only small amounts of water-soluble medication should be used for subcutaneous injections. The drug s dosage for an ID injection is usually contained in a small quantity of solution (0.01 to 0.1 ml).

6 A 1-ml tuberculin syringe with a short bevel, 25 to 27 gauge, 3/8- to 1/2-inch needle is used to provide accurate measurement. If repeated doses are ordered, the site should be rotated. ID injections are administered into the epidermis layer by angling the needle 10 to 15 to the skin. See Procedure 29-5 for administering intradermal injections. Subcutaneous Injection Subcutaneous (SC or SQ) injections are commonly used in the administration of medications such as insulin and heparin because these drugs are absorbed slowly, to produce a sustained effect. SC injections place the medication into the subcutaneous tissue, between the dermis and the muscle. Clients who administer frequent subcutaneous injections should rotate sites regularly. The amount of medication given varies but should not exceed 1.0 ml; if repeated drug doses are given, rotate the sites. Subcutaneous tissues are sensitive to irritating medications. Hard painful lumps can develop beneath the skin if the sites are not rotated. PROCEDURE 29-5 Administering an Intradermal Injection Equipment Medication administration record (MAR) Medication Alcohol swab and sterile 2 2 gauze pad Disposable gloves Sterile tuberculin syringe and short bevel, 25 to 27 gauge, 3/8- to 1/2 -inch needle. Action 1. Check with the client and the chart for any known allergies. Rationale 1. Prevents the occurrence of hypersensitivity reactions such as hives,

7 urticaria, or anaphylactic shock. 2. Wash hands. 2. Reduces transmission of microorganisms. 3. Follow the five rights. 3. Promotes client safety. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Take the medication to the client s room and place on a clean surface. 5. Check the client s identification armband. 5. Accurately identifies the client. 6. Explain the procedure to the client. 6. Reduces the client s anxiety and enhances cooperation. 7. Place the client in a comfortable position; 7. Promotes comfort. Promotes absorption provide for privacy. of the medication. Decreases anxiety. 8. Wash hands and don nonsterile gloves. 8. Decreases contact with blood and body 9. Select and clean the site. Assess the client s skin for bruises, redness, or broken tissue. Select an appropriate site using appropriate anatomic landmarks. Cleanse the site with an alcohol wipe using a firm circular motion; cleanse from inside to outside; allow alcohol to dry. 10. Prepare the syringe for injection. Remove the needle guard. Express any air bubbles from the syringe. Check the amount of solution in the syringe. 11. Inject the medication. Hold the syringe in dominant hand. With nondominant hand, grasp the client s dorsal forearm and gently pull the skin taut on ventral forearm(figure 29-20). fluids. 9. Promotes absorption of the drug; reduces trauma to the body s tissue. Aids in the removal of microorganisms on the skin. 10. Ensures correct dosage of medication in the syringe. Taut skin facilitates needle insertion. Figure Spread the skin taut for an intradermal injection. Place the needle close to the skin, bevel side up. Insert the needle at a 10 to 15 angle until resistance is felt, and advance the needle Ensures that medication is injected into the intradermal tissue; initial resistance

8 approximately 3 mm below the skin surface; the needle s tip should be visible under the skin. Administer the medication slowly; observe the development of a bleb (large flaccid vesicle that resembles a mosquito bite). If none appears, withdraw the needle slightly. Withdraw the needle. Pat area gently with a dry 2 2 sterile gauze pad. Do not massage the area after removing the needle. 12. Discard the needle and syringe in a sharps container. 13. Remove gloves, dispose of in appropriate receptacle, and wash hands. indicates the needle s tip is in the subcutaneous region. Indicates that the medication was injected into the dermis. Prevents spreading the medication beyond the point of injection. 12. Prevents needlesticks. 13. Reduces the spread of microorganisms. 14. Observe for signs of an allergic reaction. 14. Ensures client safety. 15. Draw a circle around the perimeter of the bleb 15. Allows for easy recognition and with a ball point pen. observation of the injection site. 16. Document medication and site of injection on the MAR. 16. Provides a written description of the injection site and states the time the medication was administered. Common sites for SC injections are the abdomen, the lateral and anterior aspects of the upper arm or thigh, the scapular area on the back, and upper ventrodorsal gluteal areas (Figure 29-21). The nurse should select a sterile 0.5- to 3-ml syringe with a 25- to 29-gauge, 3/8- to 1/2- inch needle. The medication is administered by angling the needle 45 or 90 to the skin. The client s body weight will influence the angle used for injection. As a general rule, to reach subcutaneous tissue, if you can grasp 2 inches of tissue between two fingers, insert the needle at a 90 angle. If only 1 inch of tissue can be grasped between the fingers, use a 45 angle to administer the medication. The length of the needle may also vary with body weight. Normally for SC injections, a 25-gauge, 5/8-inch needle is used.

9 NURSING ALERT Aspirating the Syringe Do not aspirate on the plunger when giving heparin; doing so may cause tissue damage. PROCEDURE 29-6 Administering a Subcutaneous Injection Equipment 2 alcohol swabs Medication as prescribed Medication administration record (MAR) Sterile syringe and 5/8-inch needle Disposable gloves Action 1. Check with client and the chart for any known allergies. Rationale 1. Prevents the occurrence of hypersensitivity reactions such as hives, urticaria, or anaphylactic shock. 2. Wash your hands. 2. Reduces transmission of microorganisms. 3. Follow the five rights. 3. Promotes client safety. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Take medication to the client s room and place on a clean surface. 5. Check the client s identification armband. 5. Accurately identifies the client. 6. Explain the procedure to the client. 6. Reduces the client s anxiety and enhances cooperation. 7. Place the client in a comfortable position; provide for privacy. 7. Promotes relaxation of the muscles, decreasing discomfort from the injection. 8. Don nonsterile gloves. 8. Decreases contact with blood and body fluids.

10 air bubbles from the syringe; check the dosage in the syringe. With dominant hand, hold the syringe like a dart between your thumb and forefingers. Pinch the subcutaneous tissue between the thumb and forefinger with the nondominant hand. If the client has substantial subcutaneous tissue, spread the tissue taut. 11. Administer the injection. Insert the needle quickly at a 45 or 90 angle. Release the subcutaneous tissue and grasp the barrel of the syringe with nondominant hand. With dominant hand, aspirate by pulling back on the plunger gently, except when administering an anticoagulant injection. If blood appears, remove needle and discard in a sharps container. Inject medication slowly if there is no blood present. Remove the needle quickly and lightly massage area with alcohol swab; do not massage the injection site after the administration of an anticoagulant. Do not recap the needle; discard the needle subcutaneous tissue. Decreases risk for accidental contamination of the needle. Ensures insertion of the needle into the subcutaneous tissue. Quick insertion decreases the client s anxiety and the amount of discomfort. Indicates needle has entered a blood vessel. Prevents the injection of medication into the blood, which causes a faster absorption rate that may be dangerous to the client. Promotes dispersement of medication in the tissues and facilitates absorption. Prevents needle sticks. in a sharps container. 12. Position client for comfort. 13. Remove gloves and wash hands. 13. Reduces the spread of microorganisms. 14. Record on the MAR the route, site, and time of injection. 15. Observe the client for any side or adverse effects and assess the effectiveness of the medication at the appropriate time. 14. Provides documentation that the medication was administered. 15. Alerts the nurse to hypersensitivity reactions; the peak plasma level is dependent on the drug s half-life. Intramuscular Injection The nurse should determine the maximum volume to inject on the basis of the site and the client s muscle development:

11 4 ml for a large muscle (gluteus medius) in a well-developed adult 1 to 2 ml for less developed muscles in children, elderly, and thin clients 0.5 to 1.0 ml for the deltoid muscle When more than 4 ml is ordered, the medication can be divided into two different sites. There are four common sites for administrating IM injections (see the accompanying display). Injection sites are identified by using appropriate anatomic land-marks (Figure 29-22). COMMON INTRAMUSCULAR INJECTION SITES AND MUSCLES Site Muscle Dorsogluteal Gluteus maximus

12 Ventrogluteal Anterolateral aspect of thigh Upper arm Gluteus medius Vastuslateralis Deltoid The primary site for administering an IM injection in clients over 7 months old is the ventrogluteal (VG) site. The gluteus medius is a well-developed muscle, free of major nerves and large blood vessels. Research shows that injuries including fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain have been associated with all the common sites (dorsogluteal, deltoid, and vastuslateralis, for example) except the VG site. The nurse should avoid using the deltoid and dorsogluteal sites in infants and children. There is a risk of striking the sciatic nerve when using the dorsogluteal site. The deltoid muscle is not well developed in infants and children. The nurse will need to decide on the gauge and length of the needle on the basis of the consistency of the solution, the site, and how far the needle must be injected to reach the muscle. A 21- to 23-gauge needle will accommodate the consistency of most drugs and will minimize tissue injury and subcutaneous leakage. The needle s length is determined by the site: 1 1/2 -inch needle, VG site for average-sized adults 1-inch needle, VG site for children 1-inch needle, deltoid or vastus lateralis An obese client usually requires a 2-inch needle to ensure that the needle will reach a large muscle such as the gluteal muscle Z-Track Injection The Z-track (zigzag) technique refers to a method used in administering IM injections (see Procedure 29-7). This technique was traditionally used when administering imferon, an iron preparation, which can cause permanent discoloration in the subcutaneous tissue. Today, the technique is used commonly when administering ventrogluteal and dorsogluteal injections. PROCEDURE 29-7 Administering an Intramuscular Injection

13 Equipment Medication administration report (MAR) Sterile 3-ml syringe and long bevel, 20 to 22 gauge, 1- to 2-inch needle (average-sized, adult client receiving a drug in an aqueous solution) Medication as prescribed Alcohol swab Nonsterile gloves Sterile 2 2 gauze pad Action Rationale 1. Check with client and the chart for any 1. Prevents the occurrence of hypersensitivity known allergies. reactions. 2. Wash hands. 2. Reduces the transmission of microorganisms. 3. Follow the five rights. 3. Promotes client safety. 4. Prepare the medication from an ampule or vial; refer to Procedure 29-2 or 29-3 as appropriate. Add 0.1 to 0.2 ml of air to the syringe. Take medication to the client s room and place on a clean surface. Ensures that all the medication is expelled from the needle s shaft. 5. Check the client s identification armband. 5. Accurately identifies the client. 6. Explain the procedure to the client; provide 6. Reduces the client s anxiety and enhances for privacy. cooperation. 7. Place the client in an appropriate position to 7. Provides access to the site, promotes expose the site. relaxation Deltoid: sitting position. of muscles, and decreases the discomfort from Ventrogluteal: the injection. Side-lying: flex the knee, pivot the leg forward from the hip about 20 so it can rest on the bed. Supine: flex the knee on the injection side. Prone: point toes inward toward each other to internally rotate the femur. 8. Don non sterile gloves. 8. Decreases contact with blood and body fluids. 9. Select and clean the site. 9. Avoids potential problems that may decrease the rate of the drug s absorption. Assess the client s skin for redness, scarring, breaks in the skin, and palpate for lumps or nodules. Select site using the anatomic landmarks. Cleanse the area with an alcohol swab, cleanse from inside outward using friction; wait 30 seconds to allow to dry. Avoids tissue containing large nerves and blood vessels. Removes the surface microorganisms and prevents the introduction of alcohol into subcutaneous tissue to avoid irritation.

14 10. Prepare for the injection. Remove the needle cap by pulling it straight off, and expel any air bubbles from the syringe. Pull the skin down or to one side (Z-track technique) with nondominant hand. 11. Administer the injection. Deltoid: quickly insert the needle with a dartlike motion at a 90 angle (Figure 29-23). Maintains the sterility of the needle; ensures the correct dosage in the syringe. Decreases the risk of medication s leaking into needle track and the subcutaneous tissue; reduces complications and discomfort. 11. Ensures that the needle is injected into the muscle. Figure Administering Intramuscular Injection into the Deltoid Muscle Ventrogluteal: quickly insert the needle using a dartlike motion and steady pressure at a 90 angle to the iliac crest in the middle of the V (Figure 29-24). Aspirate by pulling back on the plunger, and observe for blood. If blood appears, remove the needle and discard. If blood does not appear, inject the medication slowly, about 10 sec/ml. Promotes comfort and allows time for the

15 Wait 10 seconds after the medication has been injected, then smoothly withdraw the needle at the same angle of insertion. Apply gentle pressure at the site with a dry, sterile 2 2 gauze; do not massage the injection site. Swab using gentle pressure. Discard the needle and syringe in a sharps container; do not recap the needle. 12. Position client for comfort; encourage client receiving ventrogluteal injections to perform leg exercises (flexion and extension). tissues to expand and begin absorbing the medication. Allows the medication to diffuse through the muscle. Decreases tissue irritation. Prevents needlesticks. 12. Promotes the absorption of the medication. 13. Remove gloves, wash hands. 13. Prevents transmission of microorganisms. 14. Record on the MAR the dosage, route, site, 14. Provides documentation that the and time. medication 15. Inspect the injection site within 2 to 4 hours and evaluate the client s response to the medication. was administered. 15. Alerts the nurse to hypersensitivity reactions; the peak plasma level is dependent on the drug s half-life. When administering a Z-track injection, the nurse should place the client in the prone position (Figure 29-25A); then pull the skin to one side (Figure 29-25B), insert the needle at a 90 angle and administer the medication (Figure 29-25C). Spreading the skin, a common method formerly used for IM injections, increases the risk that medication will leak into the needle track and the sub- cutaneous tissue The nurse waits 10 seconds and withdraws the needle at the same angle of insertion; the site should not be massaged because massaging could cause tissue irritation. NURS I N G T I P Air Bubble in Syringe The nurse should not draw an air bubble when using a plastic disposable syringe, as doing so can dramatically affect the medication dosage.

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17 Intravenous Injections IV medications are administered by one of the following methods: Intravenous fluid container Volume-control administration set Intermittent infusion by piggyback or partial fill Intravenous push (IVP or bolus) the nurse should assess the condition of the injection site for signs of complications such as infiltration (swelling and discomfort at the IV site) and phlebitis (inflammation of a vein). Before administering any IV medication, the nurse should note the client s allergies, drug or solution incompatibilities, the amount and type of diluent needed to mix the medication, and the client s general condition to establish a baseline for administering medication. The nurse should check for drug compatibilities of drug additives before injecting a medication into an infusion bag. Drug incompatibilities cause an undesired chemical or physical reaction between a drug and a solution, between two drugs, or between a drug and the container or tubing. For example, diazepam (Valium) and chlordiazepoxide hydrochloride (Librium) must not come into contact with a saline solution; insulin should not be added to an infusion bag because the insulin adheres to the inside of the solution bag. Adding Drugs to a Volume-Control Administration Set A volume-control set is used to administer small volumes of IV solution (Figure 29-27). These devices have various names as determined by the manufacturer, such as Soluset, Metriset, VoluTrol, or Buretrol. To administer a drug by this method, the nurse should: Withdraw the prescribed amount of medication into a syringe that is to be injected into the volume-control set. Cleanse the injection port of a partially filled volume-control set with an alcohol swab. Inject the prepared medication into the port of the volume-control set (Figure 29-28). Gently mix the solution in the volume-control chamber.

18 TABLE 29-2 Summary of Intradermal, Subcutaneous, and Intramuscular Injections Type of Purpose Site Needle Size Maximum Angle of Injection Dose Insertion Intradermal Injects medication Inner aspect of forearm; upper Syringe with short bevel; 0.01 to 0.1 ml below the chest; upper 25- to 27- epidermis; drugs are absorbed slowly; typically used for diagnosis of tuberculosis and allergens back gauge; 3/8 to ½ inch Subcutaneous Injects medication between Abdomen; lateral and anterior aspects 25-gauge, 5/8-inch needle ml 45 or 90 dermis and of upper arm (varies by muscle; and thigh; size of absorbed slowly; typically used for insulin and anticoagulants scapular area on back; ventrogluteal area person) Intramuscular Used to promote rapid drug absorption and to provide an alternate route when drug is irritating to SC tissue Ventrogluteal; dorsogluteal; anterolateral aspect of thigh (vastuslateralis); upper arm (deltoid) The gauge and length of needle are selected on the basis of medication volume and viscosity and client s body size Welldeveloped adult: 4 ml in a large muscle; infant and small child: ml; children and elderly: 1 2 ml; deltoid muscle: ml 90

19 After injecting the medication into the volume-control chamber, the nurse should check the infusion rate and adjust as necessary to the prescribed rate of infusion. Administering Medications by Intermittent Infusion A common method of administering IV medications is by using a secondary, or partialfill additive bag, often referred to as an IV piggyback (IVPB). A secondary line is a complete IV set (fluid container and tubing with either a microdrip or a macrodrip system) connected to a Y port of a primary line (see Procedure 29-8). The primary line maintains venous access. The IVPB is used for medication administration. See Chapter 37 for a complete discussion of primary and secondary lines. When the IVPB medication is incompatible with the primary IV solution, the nurse must flush the primary IV tubing with normal saline before and after administering the medication. Intermittent Infusion Devices

20 When the client requires only the administration of IV medications without the infusion of solutions, an intermittent infusion device is inserted into a peripheral needle or catheter in the client s vein (Figure 29-30). This device is commonly referred to as a heparin or saline lock depending on the agency s policy regarding the device s maintenance. A lock provides continuous access to venous circulation, eliminating the need for a continuous IV, and it increases the client s mobility. PROCEDURE 29-8 Administering Medications by IV Piggyback to an Existing IV Equipment Medication administration record (MAR) Prepared and labeled medication 50-ml solution bag from pharmacy Alcohol swab Secondary administration set Needle-less locking cannula Action 1. Gather prepared equipment (medication labeled with the client s name, and time tape for fluids to infuse per hour). Rationale 1. Ensures correct fluids to be administered to the right client at the infusion rate prescribed by the health care practitioner. 2. Wash hands. 2. Decreases risk of transmission of microorganisms. 3. Check the client s armband. 3. Ensures correct client.

21 4. Explain the procedure to the client. 4. Elicits client s support and decreases anxiety. 5. Assess the puncture site 5. Indicates signs of infiltration or infection. Observe for redness and puffiness. Palpate for tenderness. 6. Check patency of infusion site. 6. Verifies patency of IV system with venous Observe fluid infusing. access device in the client s vein. Remove IV container from the pole and lower the container below the level of infusion site. Observe for backflow of blood into the hub of the venous access device. Replace container on IV pole. 7. Secure medication bag prepared and labeled by pharmacy and check health care practitioner s prescription and the MAR. 7. Ensures the correct client, medication, dosage, route, and frequency. 8. Check the client s chart for allergies, and 8. Ensures that the client is not allergic to the check the drug compatibility chart. drug and that the prescribed drug is compatible with the primary IV solution. 9. Hang the secondary bag on IV pole. 9. Provides easy access for preparation. 10. Add the administration set to the secondary bag. 11. Affix a needle-less locking cannula to the end of tubing (Figure 29-29A). 10. Removes the air from the tubing. 11. Reduces risk of exposure to IV needles. Figure 29-29A Administering Medications by IV Piggyback. Connect a needle-free locking cannula to a secondary infusion line. 12. Cleanse needle-less Y site injection port of primary IV tubing closest to infusion site with an alcohol swab; allow to dry. 13. Insert needle-less locking cannula of secondary bag set into Y site injection port of primary set and secure in place with tape (Figure 29-29B). 14. Affix the extension hook to the primary bag on the IV pole so that the primary bag hangs below the level of the secondary bag. 12. Reduces risk of transmission of microorganisms. 13. Provides access for infusion and prevents dislodgement of needle-less locking cannula. 14. Ceases flow of primary solution because of an increased hydrostatic pressure in secondary bag.

22 15. Open clamp of secondary tubing and adjust drip rate to desired infusion rate. Slowly close the regular clamp while observing the drip chamber until the fluid is drip-ping at a slow, steady pace (Figure 29-29C). Count the drops for a 15-second interval and multiply by 4 (e.g., if the drop factor of tubing is 10 drops/ml then the drop rate should be 10 drops/minute to infuse 50 ml in50 minutes). Recount the drop rate in 5 minutes. 15. Allows solution in the secondary bag to infuse at the prescribed drip rate. Determines number of drops falling per minute. Detects changes in rate due to expansion and contraction of tubing Figure 29-29B Connect locking cannula to a Y-site injection port of primary infusion set. Figure 29-29C Monitor the infusion rate. 16. Observe client for any signs of adverse reactions to the medication. 17. When secondary bag and drip chamber are empty, close the clamp on secondary system, read just drip rate of primary solution as indicated, and remove the secondary system. 16. Provides for immediate intervention if client as an adverse reaction 17. Allows the primary solution to infuse at pre scribed drip rate.

23 18. Record medication infusion on the MAR and note any client responses in the nurses notes 18. Documents the nursing intervention. The device can be used to infuse intermittent IVPB or IV push medications, or it can be converted to a primary IV. A major consideration for inserting a heparin lock device is that it provides venous access in case of an emergency. Lock devices are routinely used with cardiac clients. Locks are generally flushed every 8 hours to maintain patency (patency refers to being freely opened). Some agencies require a diluted dose of heparin (100 units/ml) to be injected into the lock; other agencies use normal saline to keep the device patent. See Chapter 37 for a complete discussion of heparin and saline locks. When heparin is used, the devise must be flushed with normal saline solution before and after administration of a medication. Administering IV Push Medications The method of medication administration by IV bolus or IV push injection is determined by the type of IV sys- tem. For example, an IV push medication can be injected into a saline or heparin lock (Figure 29-31) or into a continuous infusion line. When giving an IV push medication into a continuous infusion line, the nurse must stop the fluids in the primary line; the nurse usually pinches the IV tubing closed to inject the drug (see Figure 29-32). This technique is safe and prevents the nurse from having to recalculate the drip rate of the primary infusion line.

24 IV push medications can also be given into a central line or directly into the vessel by venipuncture. The five rights of medication administration are implemented when administering an IV bolus. The nurse must know the specific time interval to inject the medication and the specific reactions of the infused drug. The client must be monitored closely during and after injection for drug reactions.