Intravenous Medication Administration

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Intravenous Medication Administration

Definition

Intravenous (IV) medication administration refers to the process of giving medication directly into a patient's vein. Methods of administering IV medication may include giving the medication by rapid injection (push) into the vein using a syringe, giving the medication intermittently over a specific amount of time using an IV secondary line, or giving the medication continuously mixed in the main IV solution. IV medications are most often given through a peripheral line or saline IV lock, but may also be administered direct IV, through an implanted vascular access port or through a central line.

Purpose

The primary purpose of giving IV medications is to initiate a rapid systemic response to medication. It is one of the fastest ways to deliver medication. The drug is immediately available to the body. It is easier to control the actual amount of drug delivered to the body by using the IV method and it is also easier to maintain drug levels in the blood for therapeutic response. The IV route for medication administration may be used if the medication to be delivered would be destroyed by digestive enzymes, is poorly absorbed by the tissue, or is painful or irritating when given by intra-muscular (IM) or subcutaneous (SQ) injection.

Precautions

Proper IV administration should follow the five "rights" of medication administration to avoid medication errors: be sure it is the right patient, the right drug, the right dose, the right time, and the right route before giving any medication.

The IV line must be intact before any IV medication can be administered. Some IV medications can cause severe tissue damage if injected into the tissue through an infiltrated IV site.

Some IV push medications must be diluted before injection. The health care professional must check the directions for giving the specific drug IV before performing the injection. Administration guidelines for giving IV medications must be followed to avoid serious complications from the drug injection. Most medical settings have an approved IV drug list and instructions for injecting each drug IV. Other resources include the PDR guide, drug administration handbooks, or printed inserts from the pharmaceutical company.

The drug delivery rate is an important factor when administering IV medication. Some IV drugs are meant to be delivered rapidly over several minutes to obtain therapeutic effect. Other drugs are most effective when delivered slowly and intermittently throughout the day. Each drug delivery rate is unique. Administration guidelines for giving IV medications must be followed to achieve the therapeutic effect desired.

IV drugs may not be compatible with certain IV fluids or other drugs. Drug incompatibility is a true risk to the patient because it can cause crystallization of the medication that may at the least clog the IV line or at the worst have an embolus effect on the patient. The health care professional must check compatibility warnings that are included in IV drug administration guidelines. The line must be flushed with saline before and after giving medications IV to avoid contact of incompatible solutions or medications.

The effects of medication appear rapidly after an IV injection. The health care professional must know the indications, actions, and adverse effects of the medication that is to be delivered and must observe the patient closely for adverse medication reactions or allergic reactions and be prepared to respond with supportive therapy or drug reversing agents.

Description

IV push medication techniques deliver a bolus (a dose of medication injected all at once intravenously) of medication directly into a vein or access port to produce an immediate peak drug level in the patient's bloodstream. Large quantities of fluid IV push can cause severe complications; follow the recommendations of the drug administration guidelines. To deliver an IV bolus medication, draw the appropriate amount of medication that has been prepared, diluted, and/or reconstituted according to IV drug administration guidelines into a syringe. A bolus injection is most often given through a peripheral IV line, a saline lock, directly into a vein, or through a vascular access port.

When giving an IV bolus medication through a peripheral line with compatible fluid, the health care professional must shut off the IV line using the control clamp. The Y-port closest to the insertion site is cleaned with an alcohol or povidone-iodine pad to prevent bacterial contamination. The health care professional must then connect the medication needle or needle-less system connector to the port. The medication is injected over the period of time ordered, after which the syringe is disconnected and removed. The IV line is reopened using the control clamp and the IV flow is reset to the appropriate setting. If the peripheral line fluid is not compatible with the IV bolus medication, two syringes with 3cc of normal saline are prepared before giving the medication. The line is flushed before and after the IV medication administration with the prepared saline syringes. The Y-port is quite vulnerable to contamination when switching syringes. After the IV line is flushed the second time, the line can be reopened and the IV flow rate reset to the appropriate setting.

Flow rates for intravenous infusions
Drop factor of tubing (drops/ml)	1000 ml/6 hr (drops/min)	1000 ml/10hr (drops/min)	1000ml/12hr (drops/min)	1000 ml/24hr (drops/min)
Source: Smith-Temple, J. and J.Y. Johnson. Nurses' Guide to Clinical Procedures. 3rd ed. Philadelphia: Lippincott-Raven Pub., 1998.
10	28	17	14	7
15	42	25	21	10
20	56	34	28	14
60	167	100	84	42

A saline (heparin) lock is a peripheral IV device. It is a short IV line that has been locked off to prevent venous fluid from flowing out. It is primarily used to access a vein for intermittent IV drug therapy. A latex cap that can be accessed by a needle or needle-less system connector to deliver drugs or IV fluids intermittently covers the distal tip. When giving an IV bolus medication through a saline lock, prepare two syringes with 3 cc of normal saline as well as the IV bolus medication syringe. (The health care professional should check the medical institution policy because some institutions require the use of heparin to flush IV locks.) The health care professional wipes off the cap of the saline lock with an alcohol or povidone-iodine swab to prevent bacterial contamination. The needle or needle-less system connector is connected to the latex cap of the lock and the patency of the lock is checked by pulling back on the syringe. A flashback of blood into the tubing indicates that the IV catheter or needle is in the vein. If no blood appears, a tourniquet is applied above the IV site for about one minute and then the line is aspirated again. Medication should not be given unless the IV is patent (open and unblocked). To continue, the saline is injected into the lock and the insertion site is examined for signs of leaking or puffiness. If the IV lock appears intact, the saline syringe is removed. The medication syringe is connected to the cap using a needle or needle-less connector and the IV push medication is administered over the amount of time that was ordered. The medication syringe is removed and then the second saline syringe is connected to flush the line. Care is taken not to contaminate the cap when switching syringes. Finally the saline syringe is removed and the saline lock apparatus is left well secured to the patient's skin.

In an emergency when a patient has no IV line in and an IV bolus medication needs to be given, the nurse or physician may elect to insert a temporary butterfly IV apparatus connected to a needle. This is not a common situation. In most cases the staff will attempt to insert a regular IV catheter line to enable them to have a stable line for follow-up infusions of medications or fluids. To insert a temporary butterfly IV apparatus, the health care professional washes his/her hands and puts on gloves. A tourniquet is applied and a large vein is selected. The skin over the vein is swabbed with a povidone-iodine swab and the needle is inserted into the skin and then into the vein. When the IV is in place and a blood flashback is visible in the tubing, the tourniquet is removed and the distal end of the line is connected to a syringe of normal saline. The wings of the apparatus are secured with a piece of tape, and the line is aspirated with a syringe to assure proper line placement. If a blood return occurs, the line is slowly injected with 3 cc of normal saline to flush it. The insertion site is checked for puffiness or signs of leakage. Then the saline syringe is removed and rapidly replaced with the medication syringe. The prepared bolus of medication is given over the amount of time ordered. When the medication administration is complete, the syringe is removed and quickly replaced with another 3cc syringe filled with normal saline. The line is flushed with the saline and the butterfly apparatus is removed from the vein. Pressure is applied to the site using a sterile 2 × 2 gauze pad. This method is not recommended for more than one dose of medication because of the temporary nature of the apparatus. If a patient may require further IV therapy a regular IV catheter should be inserted and connected to an IV line or capped off for use as a saline lock.

IV bolus medication may be given through a vascular access port that has been surgically implanted in the chest. When giving IV medication into an access port follow the procedures for accessing and giving IV medications through the port that are defined by the medical setting. A special needle apparatus is required that will not damage the port or the skin over the port. PICC line and mid-line catheters are not usually used for IV bolus medications because of the length of their tubing. Central lines must be used cautiously when giving IV bolus medication. Since the bolus will be pouring into a large central vein, the effect of the medication will be immediate and can be overwhelming to the patient's body.

IV medication may be given intermittently using a larger amount of fluid to be administered over a longer period of time (such as 50 cc over 20 minutes). Intermittent infusions may be administered through a secondary IV set (piggy back set) using an IV pump or a volume control set using an automatic IV syringe pump. There are many types of tubing and apparatus that can be used to deliver intermittent IV therapy. When administering intermittent IV therapy the instructions as defined on the administration set or in the medical center's IV policies are followed. The basic principles include: ensuring that the IV secondary set (piggy back) is positioned into the correct port on the main IV line and verifying that the pump is set to deliver the IV medication over the correct amount of time that was ordered by the physician. All lines are primed before they are connected to the IV to avoid delivering air through the lines. If the IV medication to be given is not compatible with the IV solution that is hanging, the line is flushed with normal saline before and after running the IV medication. The patient is observed carefully as the medication is delivered for signs of medication reaction or allergic reaction. When the IV medication has run in, the main IV solution is switched back on and the pump is reset for the maintenance rate as ordered by the physician.

Some IV medications, such as potassium chloride, are mixed into the main IV solution bag and run continuously. These medications are injected into the IV bag by the pharmacy or the nurse prior to hanging the IV solution. They run continuously at the rate of flow ordered by the physician.

Preparation

The patient is placed in a comfortable position, the procedure is explained, and the patient is told the name of the drug to be administered. The patient also should be instructed to alert the health care professional immediately if he/she has unusual feelings or discomfort after medication administration. The patency of the IV line is checked to insure that the line is intact and not leaking. The physician's order is reviewed and the five rights of medication administration are checked. The label on the medication is checked to be sure that it is not outdated. (Outdated medication should not be given.) The IV administration guidelines for the specific drug are reviewed, and the health care professional verifies that the drug is approved for IV administration according to the policies of the medical setting. After washing his/her hands, the health care professional calculates and prepares the drug according to drug administration guidelines. Any necessary equipment is assembled and ready access to emergency response equipment (such as contained in a crash cart) is verified.

The health care professional determines the amount of time over which the drug should be delivered according to the physician's order and/or the IV drug administration guidelines. For IV push medications this is calculated in cc to be delivered per minute. This number is calculated by dividing the amount to be delivered (in cc) by the time over which the drug should be delivered (in minutes). For example, if the order is to give 10 mg of drug X over 5 minutes, first determine that 10 mg of drug X comes prepared in 6 cc of liquid. Divide 6 cc by 5 minutes to determine that the rate of IV injection should be 1.2 cc per minute. If the drug must be reconstituted, the rate is calculated using the total amount of drug in cc after reconstitution. For example, give 25 mg of drug Y over 5 minutes. Drug Y is a powder that is reconstituted with 5 cc of sterile water. When reconstituted, the medication has a fluid volume of 6 cc. Divide 6 cc by 5 minutes to determine that the drug should be given at 1.2 cc per minute. Intermittent IV drug doses are usually calculated in cc per hour. They are given in larger amounts of fluid that are usually given with an IV pump and most IV pumps are set in cc per hour, not cc per minute. To calculate the cc per hour rate, the cc per minute rate is multiplied by 60. For example, if the order reads give drug Z in 50 cc of normal saline over 20 minutes, calculate the cc to be delivered per minute by dividing 50 cc by 20 minutes and then multiply times 60 minutes. The rate would be 150 cc per hour to deliver the IV medication in 20 minutes.

Aftercare

After an IV medication has been delivered, the patient is observed for adverse or allergic reactions. Used needles are discarded without recapping them in a puncture proof, contaminated needle container. Used IV tubing, bags, gloves, and disposable supplies are discarded in a plastic bag that can be sealed and discarded in the contaminated trash. The health care professional washes his/her hands and documents that the medication that has been given. If reverting to a primary IV line, the health care professional must be sure to reset the IV flow rate to the correct hourly rate that is ordered for the IV fluids.

Complications

Complications of IV medication administration may include:

infiltration of the IV line when a drug is injected IV bolus
tissue necrosis when drugs are injected into infiltrated IV sites
thrombophlebitis of the vein
injection of air embolism
serious adverse drug reactions such as hypotension, cardiac arrhythmias, and cardiac arrest
allergic reaction to the medication
venous thrombosis
pain at the IV site

Results

When administered according to the physicians orders, following drug administration guidelines, and using the correct technique and IV apparatus, IV medications can have immediate positive therapeutic effects. The effects of the medication will vary depending upon the type of medication given.

Health care team roles

IV medication administration is delegated to registered nurses in most medical settings. Paramedics, LPNs, and IV team technicians who have received special IV training may give certain medications IV according to the policies of some medical settings. Patients and their families can be trained to use IV therapy pumps that automatically deliver IV medications in the home setting. IV nurses visit the home daily or every few days to change the medication cartridge and check the status of the IV line. The settings for the IV pump delivering IV medications are usually locked so that they cannot be accidentally altered. Patients are taught the signs of complications and learn to troubleshoot IV alarms. IV nurses remain on-call to assist the patient and the family 24 hours a day when problems arise.

KEY TERMS

Embolus— An air bubble, blood clot, or foreign matter that lodges in a blood vessel, occluding blood flow.

Necrosis— Tissue destruction or death of tissue cells that is caused by injury, infection, or disease.

Venous thrombosis— A condition in which a vein is clogged off by foreign matter or a blood clot that results in decreased blood flow and oxygen to specific parts of the body.