Medication administration and IV therapy

Title: Ask a Colleague: Expert Nurses Answer More Than 1,000 Complex Clinical Questions, 1st
Edition
Copyright ©2005 Lippincott Williams & Wilkins
> Table of Contents > 14 - Medication administration and I.V. therapy

14
Medication administration and I.V. therapy
Medication administration
The classic rule in assuring the safest possible administration of drugs is to triple-check drug
labels and drug orders. Safe drug administration requires you to compare the doctor's order as
transcribed on the medication administration record against the drug label three times. (See Say it
three times: Check orders and labels.)
What safety precautions should I observe when administering oral medications?
Say it three times: Check orders and labels
The secret of drug safety is to check, check, and check again. Before giving a drug, carefully
compare the drug's label with each part of the medication administration record, holding the label
next to the administration record to ensure accuracy. The example below walks you through the
steps for administering furosemide (Lasix) 40 mg P.O.
Check drug names
 Read the drug's generic name on the administration record, and compare it to the generic
name on the label. They both should say furosemide.
 Read the trade name on the administration record and compare it to the trade name on the
label. They both should say Lasix.
Check the dosage, route, and record
 Read the dose on the administration record and compare it to the dose on the label. They
both should say 40 mg.
 Read the route specified on the administration record, and note the dose form on the
label. The record should say P.O., and the label should say oral tablet.
 Note any special considerations on the administration record, such as aspiration
precautions (head of bed elevated to 45 degrees for all P.O. intake), “patient is HOH (hard
of hearing), or patient is blind.”
Check orders and labels three times
Follow this routine three times before giving the drug. Do it the first time when you obtain the
drug from floor stock or the patient's supply. Do it the second time before placing the drug in the
medication cup or other administration device. Finally, do it the third time before replacing the
stock drug bottle on the shelf or removing the drug from the unit-dose package at the patient's
bedside.
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The second cardinal rule of medication administration is to be sure you are giving the medication
to the right patient. As part of the National Patient Safety Goals of 2004, several agencies,
including JCAHO, have updated their requirement that medical personnel use two identifiers
before giving any medication or treatment to a patient. In a facility or outpatient setting where
nametags or identification bracelets aren't used, it can appear more difficult to comply with these
rules. Here are some guidelines to help you:
 When the patient is able cognitively and physically, have him verbalize his name.
 When the patient is able cognitively and physically, have him verbalize his date of birth
or address or telephone number. However, don't ask for a room number because it can
change. Some of these items are likely to be readily accessible to you in the patient record
or on a medication administration sheet.
 If the patient has memory deficits or the physical inability to speak adequately, many
agencies will take a picture of the patient and keep it right in the area where medications
are given. The picture should be labeled with the patient's name, date of birth, address
and telephone number, and, possibly, social security or medical record number.
  In settings with stable staff, it's understood by JCAHO that visual recognition is sufficient
for on-going care, but you still need to document the two identifiers you used when
treating any patient new to you.
I've been told that I must verify my patient's identity two ways before giving any medications or
treatments. I work in an assisted living facility where armbands aren't worn. What can I do to
meet this requirement?
Most patients think OTC drugs are harmless, and that prescription drugs are the only ones they
need to worry about for potential side effects or interactions with their other medications. It's
important for you to help your patients realize that OTC drugs can produce varied adverse
reactions, especially if taken with each other or with prescribed drugs, and that overuse of OTC
drugs can cause toxic effects.
Why should I teach my patients about any over-the-counter (OTC) medications they use when I
instruct them on their prescription drugs?
Be sure to review your patient's regular OTC drugs; tell him which active agents they contain,
which adverse reactions they may cause, and how they can interact with his prescribed drugs.
Also make sure your patient knows that OTC drugs sold under different brand names may
contain the same active agents.
Ibuprofen is a simple example. It's available as a brand-name drug (Advil) and in numerous
generic
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and combination products. Most people think of it as a safe and effective drug for headaches,
fever, and musculoskeletal pain—and it is, in general. But it can cause hypersensitivity reactions,
peripheral edema, bleeding risk, tinnitus, bronchospasm, and mental changes in some patients,
particularly if taken in excess. It interacts significantly with common medications (furosemide,
digoxin, prednisone, and warfarin) as well as with the herbs garlic, ginger, red clover, feverfew,
and St. John's wort. Smoking and alcohol use exacerbate the GI risks of taking ibuprofen, and
patients can develop photosensitivity as well.
Your patient who uses ibuprofen needs to be aware of these facts and should be taught to read the
Active Ingredients labels on all OTC products to determine whether a product contains this
medication. As with all patients, teach him to check with his doctor before starting any OTC,
especially if he's taking numerous prescription medications or is at high risk for dangerous side
effects.
Patients taking calcium channel blockers, such as nifedipine (Adalat, Procardia), diltiazem
(Cardizem), or amlodipine besylate (Norvasc), should avoid calcium salts because they reduce
the drug's therapeutic response.
Which OTC preparations should my patient avoid while taking a calcium channel blocker?
Risk factors include advanced age, a small physique, multiple illnesses, multiple drugs, the type
of drugs prescribed, previous adverse drug reactions, living alone, dehydration, and malnutrition.

Age Alert
How can I identify elderly patients at risk for adverse drug reactions?
Keep in mind, however, that all elderly patients are at increased risk for adverse drug reactions.
As a group, they have an increased ratio of fat- to lean-muscle mass. They have decreased gastric
secretion and GI motility, in addition to decreased hepatic and renal function, which slows drug
metabolism and excretion. Elderly patients may require dosage adjustments of some medications.
(See How aging influences drug actions, page 468.)
High doses of vitamin D can result in renal insufficiency, polyuria, hypertension, cardiac
arrhythmias, muscle pain, renal calculi, and conjunctivitis. Other signs of toxicity include nausea,
vomiting, anorexia, headache, weakness, and diarrhea or constipation.
Which toxic symptoms should I monitor in a patient taking a vitamin D supplement?
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How aging influences drug actions

The physiologic changes that come with aging cause changes in how the body absorbs,
distributes, metabolizes, and eliminates drugs. Awareness of these changes can help you better
predict the outcome of your patient's drug therapy.
Action Physiologic change
Absorption  Increased gastric pH
 Slower gastric emptying
 Decreased gastric blood flow and motility
Distribution  More fatty tissue
 Less lean body mass
Metabolism  Decreased total body water
 Smaller liver
 Less liver blood flow and enzymatic activity
 Less air exchange
 Decreased renal mass
Elimination  Decreased nephron function
 Decreased glomerular filtration rate, tubular secretion, and creatinine
clearance and reabsorption
The therapeutic range for warfarin depends on the patient's prothrombin time (PT). Enough
warfarin should be ordered to raise the PT 1.5 to 2 times the normal level. Raising it to 2.5 times
or more above normal usually creates an unacceptable risk of uncontrolled bleeding. Warfarin's
half-life is 36 to 44 hours, and it's shorter if you administer vitamin K.
What's the proper therapeutic range for warfarin, and how long does it stay in the blood?
Spinach is rich in vitamin K, which acts as an antidote to warfarin. Advise any patient receiving
warfarin to avoid spinach and other foods known to contain high vitamin K levels, such as
asparagus, beans, broccoli, brussels sprouts, cabbage, cauliflower, cheeses, collards, fish, milk,
mustard greens, pork, rice, turnips, and yogurt. Avoiding these foods will help the patient
maintain a therapeutic PT.
Why is it necessary to advise patients to avoid eating spinach while taking warfarin?
Rapid discontinuation of a beta-adrenergic blocker may precipitate angina, hypertension,
arrhythmias, or acute myocardial infarction.
What can happen if my patient discontinues beta-adrenergic blocker therapy suddenly?
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Never alter the physical form of any drug that's surrounded by an enteric or protective coating, in
a sustained-action form, in capsule form, or specially formulated for release in the intestine
rather than the stomach.
What kinds of oral drugs should not be chewed, split, or crushed?
Sustained-action drugs are available as plain tablets, coated tablets, and capsules filled with
granules. In many cases, you can identify the drug's sustained action form by its name. For
example, you may find CD, LA, SA, SR, XL, or XR after the name. The drug might also be
labeled as dura-tabs, extentabs, spansules, gyrocaps, or plateau caps. Advise patients to avoid
splitting, crushing, chewing, or emptying these drugs into foods or beverages. Doing so may alter
the absorption rate, cause adverse effects, or result in subtherapeutic levels of activity. When in
doubt, ask the pharmacist whether you can safely take a capsule apart.
No. The patient must swallow the tablet whole because long-acting morphine is in a sustained-
release formula. If you crush the tablet, you'll release the whole dose at once and raise the risk of
overdose. If your patient will be taking these tablets at home, make sure he knows not to break or
crush them.
Can I crush long-acting morphine tablets for easier administration?
I.M. administration will cause the patient severe pain at the injection site. Also, it may increase
serum creatine kinase levels, which complicates assessment of elevated enzymes. Administer
digoxin I.V. over about 5 minutes, and be careful to avoid extravasation, which can cause
irritation or necrosis and sloughing.
Why shouldn't I administer digoxin intramuscularly?
Yes, it may cause contact dermatitis. When you're preparing this type of drug, wear gloves to
keep it away from your skin. And don't forget that your patient may have a hypersensitivity
reaction to antipsychotics as well. Tell your patient to report hives, itching, eczema, sensitivity to
light, rashes, and exfoliative dermatitis.
Is it possible to develop a skin rash from touching an antipsychotic agent?
Definitely not. Erythema around the site of the intradermal injection has nothing to do with the
test results. In fact, you can ignore the red area. Focus instead on the area of induration
(hardening) inside the area of erythema. The size of the induration combined with the patient's
individual risk factors is what determines the test result.
My patient recently had a Mantoux test. Now he shows a marked area of redness around the site
where the purified protein derivative was administered. Can I conclude that he has TB?
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Instilling eye medications

To instill eye drops, first wash your hands and apply gloves. Pull the lower lid down to expose
the conjunctival sac. Have the patient look up and away, then, bracing your hand against the
patient's forehead if needed, squeeze or tap the prescribed number of drops into the sac without
touching the bottle tip to the eye.

Release the patient's eyelid, and instruct him to close his eyes without blinking and apply
pressure to the lacrimal sac for 2 or 3 minutes. Tell the patient to then wipe away any unabsorbed
drops and tears before opening his eyes. Discard your gloves in an appropriate container and
wash your hands. Wait 3 to 5 minutes before adding a second medication to the eye if needed.
To apply an ointment, wash and glove your hands, then gently lay a thin strip of the medication
along the conjunctival sac, from the inner to the outer canthus. Avoid touching the tip of the tube
to the patient's eye. Then release the eyelid, and have the patient roll his eye behind closed lids to
distribute the medication. Instruct the patient to wait 2 to 3 minutes with his eyes closed, and
then wipe away any remaining ointment and tears on the exterior eyelids or lashes before
opening his eyes. Discard your gloves in an appropriate container and wash your hands. Always
instill an ointment last if more than one eye medication is needed.

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Intraocular disks contain pilocarpine for treating glaucoma. You'll use them for a patient who can
benefit from timed-release medication at lower doses. An intraocular disk can remain in the
patient's lower conjunctival sac for up to 1 week, slowly releasing the drug in significantly lower
amounts than eye drops. The disk can be used while wearing contact lenses, swimming, or
playing sports.
When should I use an intraocular disk instead of eye drops? How should I insert the disk?
To prevent such systemic reactions as tachycardia, palpitations, flushing, dry skin, or ataxia and
confusion, follow the procedure outlined in Instilling eye medications. When teaching patients to
self-administer eye medications, be sure to observe their technique. Encourage them to follow
the guidelines about holding the lacrimal sac because this is one of the key steps to preventing
loss of medication and systemic absorption of medications.
Can I do anything to minimize or prevent a systemic reaction to a drug I've placed in a patient's
eye?
You should use caution when handling contact lenses after applying capsaicin to avoid the
irritation and burning that may otherwise occur following lens insertion. Washing your hands
thoroughly or using gloves or an applicator may alleviate this problem. Also tell your patient
with contact lenses about this problem when instructing him on self-administration. Advise your
patient to wait 30 minutes before washing his hands if he's using this medication to treat arthritis
of the hands.
What precautions should I take after administering the topical agent capsaicin?
When you learn that a patient is taking herbal medication (typically during your assessment), ask
why he is taking the herb and how long he has been on it. Find out if his health care provider has
diagnosed the condition he is trying to treat. If so, determine whether he is taking any OTC or
prescription drugs for the condition in addition to the herbal ones. Explain to the patient that
there are many drug-herb interactions that can occur. Teach him to discuss all the medications he
uses—prescription, OTC, and herbal—with his doctor to ensure they work together safely and
effectively to treat his condition. (See Common herb-drug interactions, pages 472 and 473.)
I'm seeing more patients who use herbal medications. What issues does this raise for my nursing
care?
In general, no, because the patient can accidentally take the wrong drug, or take the right drug at
the wrong time or in the wrong amount. In rare circumstances, a doctor may write an order for
you to leave a
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drug like nitroglycerin at the patient's bedside. The goal here is to decrease the patient's anxiety
level—and his chance of anginal attack—by knowing that his medication is within easy reach.
But you'll still want to control the amount of a specific drug available to the patient. In this case,
and any time you leave drugs within reach, make sure the patient understands the drug's purpose
and the proper dose. Ensure that he understands he must report any drugs taken at the bedside
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immediately after taking them. Note: Never leave drugs at the bedside of a very young, elderly,
or mentally impaired patient.
Is it OK to leave drugs at the patient's bedside?
Common herb-drug interactions
Because patients are increasingly using herbs to self-medicate, nurses must be on guard to check
for interactions with other prescribed and over-the-counter medications the patient may be
taking. This chart lists some commonly taken herbs along with their uses. Interacting drugs and
their possible effects (positive or negative) are listed for each herb.
Herb Interacting drug Possible effects
Echinacea stimulates the  Immunosuppressants  May counteract
immune system, prevents  Hepatotoxics effects of drug
colds, and helps treats upper  Warfarin  May increase liver
respiratory infections, toxicity
urinary tract infections, and  May increase
wounds in some people. bleeding time without
increasing
international
normalized ratio
(INR)
Garlic decreases the risk of  Antiplatelets, anticoagulants  Enhances platelet
GI cancers, stroke, and  Insulin, other drugs causing inhibition, increases
myocardial infarction; hypoglycemia anticoagulation
provides some antibiotic  Antihypertensives  May increase serum
and antifungal effects;  Antihyperlipidemics insulin levels
decreases blood pressure;  May increase
and lowers total cholesterol hypotension
and triglycerides while  May have additive
increasing high-density effect
lipoprotein levels.
Green tea helps prevent  Warfarin  Antagonizes drug
cancer, high cholesterol, and
headache; treats GI and skin
disorders; stimulates the
central nervous system; and
provides mild diuresis.
Melatonin treats insomia,  CNS depressants  Increases sedative
jet lag, and tinnitus; effect
decreases depression; and
prevents cluster headache.
St. John's wort treats  Selective serotonin-reuptake  Produces additive
depression and anxiety, and inhibitors (SSRIs), monoamine effects, possible
decreases sciatica and viral oxidase inhibitors (MAOIs), serotonin syndrome
infections. nefazodone, trazodone with SSRIs
 Opioids, alcohol  Increases sedative
 Photosensitizing drugs effect
 Sympathomimetic amines  Increases
(pseudoephedrine) photosensitivity
 Digoxin  Additive effects
 Reserpine  Reduces drug
 Hormonal contraceptives concentration and
 Theophylline efficacy
 Anesthetics  Antagonizes drug
 Cyclosporine  Increases
 Iron breakthrough
 Warfarin bleeding, decreases
 Indinavir; protease inhibitors, efficacy
non-nucloside reverse  May decrease drug
transcriptase inhibitors concentration and
(NNRTIs) efficacy
 May prolong effect of
drugs
 May reduce drug
concentration,
possible organ
rejection
 Reduces absorption
 May reduce INR
 May decrease drug
levels causing
insufficient virologic
response and lead to
resistance to these
drugs
In some situations, such as long-term or personal care settings, a single dose of a medication may
be kept at the bedside; however, an order must be obtained to do so. Keep in mind that you are
responsible for returning to make sure the medication was taken. Some patients are permitted to
retain certain topical or OTC medications at their bedside as well. However, the safety of other
residents who might accidentally take or use bedside medications not ordered for them should be
considered in these decisions.
Only if the doctor writes “NPO except for medications” on the order. For patients who are NPO
because they're scheduled for surgery or another test or procedure, it's a good practice to ask the
doctor about continuing medications. Most doctors will want you to give cardiac or
antihypertensives with sips of water.
If the doctor's orders say that my patient is to receive nothing by mouth (NPO), can I still give
oral drugs?
Generally, it's not a good idea to mix medications in food or fluids; if the child doesn't eat or
drink the entire amount, you can't tell how much of the medication he's consumed. It's better to
direct liquid medications to the side and back of his mouth and to follow unpleasant-tasting
medications with something he likes. This way, you know how much medication he actually
swallowed.
Age Alert
Is it a good idea to mix medications in food or a drink to make them more palatable for an
infant or small child?
First, remember to institute standard precautions when working with this patient. After a
complete physical exam and diagnostic testing, your patient will probably be started on
ciprofloxacin or doxycycline as a prophylactic measure. He will also be given the anthrax
vaccine because this will shorten the length of time he must take the antibiotic. If he is
asymptomatic, provide him with information on signs and symptoms of anthrax complications,
such as lung or skin disorders. The potential exposure must also be reported to the nearest
hazardous material unit for further evaluation and data collection.
A patient in the emergency department reported that he thought he was exposed to anthrax 3 days
ago. Can anything be done now to prevent him from getting it?
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Because these drugs mimic the actions of the sympathetic nervous system, they have an
immediate but short action. So you need a continuous I.V. infusion to maintain them at
therapeutic blood levels. You'll use dopamine, dobutamine, and norepinephrine, primarily in
emergency situations, to support your patient through a crisis. Monitor the patient's
hemodynamic response closely, and titrate the dosage carefully to reach your desired goal.
Dopamine, for example, stimulates the dopamine receptors in the kidneys at low doses (0.5 to 2
mcg/kg/minute), dilating the renal vasculature and improving renal insufficiency. However, at
doses of 2 to 10 mcg/kg/minute, it has significant cardiac actions, improving cardiac output and
supporting blood pressure.
Why are dopamine, dobutamine, and norepinephrine administered by continuous I.V. infusion?
Dilute the vancomycin in 200 ml of normal saline solution or dextrose 5% in water (D 5W) and
infuse it over 60 minutes. Too-rapid infusion puts the patient at increased risk for
thrombophlebitis, hypotension, and “red-neck” syndrome (sudden onset of flushing; a
maculopapular rash on the face, neck, chest, and upper extremities; and severe hypotension).
How should I administer intermittent I.V. vancomycin (Vancocin)?
After administering a code drug through a peripheral line, you need to follow it with a 20- to 30-
ml fluid bolus. This enhances drug delivery to the central circulation or the heart when peripheral
vasoconstriction, which occurs during cardiopulmonary arrest, limits drug delivery to these
areas. When the peripheral site is the antecubital area, elevate the patient's arm in addition to
administering a fluid bolus. Both of these steps will enhance drug delivery to the heart.
Why should I give a fluid bolus following peripheral administration of a drug used during a
code?
Yes. An I.V. catecholamine like norepinephrine may cause necrosis due to its local
vasoconstrictive effects. Consequently, if the patient complains of pain, you should stop the
infusion immediately and infiltrate the site with 10 to 15 ml of normal saline solution containing
5 to 10 mg of phentolamine (Regitine) as prescribed. To save valuable time, you should always
get a standing order for phentolamine whenever norepinephrine is ordered; that way you'll have
it on hand for immediate use in case extravasation occurs. After administering phentolamine, you
should notify the doctor, locate a new insertion site, and monitor the extravasation site closely.

Warning
If my patient receiving I.V. norepinephrine (Levophed) complains of pain at the infusion site, do
I need to do anything besides change the I.V. site?
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Vitamin C, vitamin B complex, cephalothin, tetracycline, heparin, and chloramphenicol are all
incompatible with I.V. erythromycin. Reversible sensorineural hearing loss is a rare but serious
reaction that can occur with I.V. erythromycin use. This reaction is most likely to occur in a
patient with renal failure who is receiving high doses of erythromycin. Establish a hearing
function baseline, and monitor the patient periodically for changes.
What parenteral substances should I avoid mixing with I.V. erythromycin? I've heard that
erythromycin can make a patient deaf, too.
Don't mix phenytoin with D5W or any I.V. solution except 0.9% sodium chloride solution
because the drug will precipitate. Always clear the I.V. line with 10 to 20 ml of normal saline
solution before and after administering phenytoin. Use a 0.22 in-line micron filter and administer
the drug solution at a rate of 50 mg/minute or less to avoid hypotension (the most common
adverse reaction), ventricular fibrillation, bradycardia, and heart block. If giving phenytoin by
I.V. push, administer it slowly into a large vein through a large-gauge needle or I.V. catheter.
What precautions do I need to take when administering phenytoin I.V.?
The mixture of D5W with amrinone results in an 11% to 13% decrease in amrinone activity
within 24 hours. Dilute amrinone in normal saline solution to prevent this decline. The drug can
be pushed I.V. into a running dextrose solution through a Y-connector or directly. Amrinone is
also incompatible with furosemide (Lasix) I.V., immediately forming a precipitate on mixing.

Warning
My nursing supervisor told me not to mix amrinone (Inocor) with D5W for administration. Why?
To help minimize serious adverse reactions associated with I.V. administration of a potassium
preparation, you should always take the following precautions:
 Prevent infusion of an incorrect dose of potassium by following JCAHO guidelines for
high-alert medications: Have the pharmacy prepare the medication whenever possible
(keeps various concentration vials of potassium off the unit), and check the labeled bag
carefully for accuracy per orders. Verify that the infusion is diluted and not in a small-
volume I.V. piggyback system. Check the bag for precipitation, a sign that potassium
phosphate was added to a solution containing calcium or magnesium.
 Never give potassium supplements I.M. or as an I.V. bolus.
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 Administer diluted potassium I.V. infusions slowly; potentially fatal hyperkalemia may
result from a too-rapid infusion. Administer according to your facility's policy.
 Potassium can cause a burning sensation in the veins of some patients despite the
precautions above. Consider asking the doctor to order an anesthetic to be added to the
solution.
 Because potassium can cause phlebitis and necrosis at the insertion site, inspect your
patient's I.V. site regularly for such signs as redness or swelling, and ask the patient about
pain at the site. If symptoms develop, change the I.V. site, notify the doctor, and treat the
affected site as directed.
What precautions, if any, should I take when administering a parenteral potassium preparation?
I.V. therapy
Most experts prefer the hands (several veins are readily accessible and easily secured); the
forearms (vessels found in the upper third are usually the most stable); the upper arm below the
axilla (because the site doesn't interfere with the child's hands and he may leave it alone); the feet
(before walking age); and the scalp (before age 18 months). (See Common pediatric I.V. sites,
page 478.)

Age Alert
Which I.V. sites should be used for children?
No. Apply your tourniquet tightly enough to impede venous flow, but not too tight to impede
arterial flow. That way, blood continues to flow into the extremity, but it meets resistance as it
tries to leave, thus distending the veins.
My colleague says I should tighten the tourniquet if I want to distend my patient's veins more. Is
that true?
Apply the tourniquet snugly, 8″ to 10″ (20 to 25 cm) above the needle insertion site. You should
be able to feel the radial pulse with the tourniquet in place. If you can't, your tourniquet is too
tight.
If the patient's veins won't dilate, even with the tourniquet applied properly, try tapping the vein
gently or flicking the skin over the vein with one or two finger snaps. Ask your patient to open
and close his fist or hang his arm over the side of the bed while you do so. You can also apply a
warm, moist compress prior to cleansing the site to promote vein distention. Leave the compress
in place for 10 to 20 minutes.
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Common pediatric I.V. sites

Here are the most common sites for I.V. therapy in infants and children. Typically, peripheral
hand, wrist, or foot veins are used with older children, whereas scalp veins are used with infants.

The CDC offers these suggestions in its most recent update of Guidelines for the Prevention of
Intravascular Catheter-Related Infections: “Before catheter insertion and dressing changes,
disinfect your patient's skin with an appropriate antiseptic; for anyone over age 2 months, a 2%
chlorhexidine-based solution is preferred; tincture of iodine, iodophor, and 70% alcohol are
acceptable alternatives for all patients.”
Which antimicrobial solution should I use to prepare a patient's skin before I.V. insertion?
Check your facility's policy and procedure manual to determine which solutions are used.
Remember to allow the solution to air-dry before catheter insertion. If you are doing a peripheral
insertion with clean gloves or a dressing change, be sure to maintain aseptic technique by not
touching the site after you have cleaned it.
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If you must use an iodine preparation, first check that the patient isn't allergic to iodine. Then
apply an iodophor (such as povidone-iodine) or tincture of iodine solution, which has the
combined effects of isopropyl alcohol and iodine. Leave the iodophor on the skin for at least 30
seconds or until the area is dry before performing the venipuncture because that's how long it
takes to release free iodine. Make sure that you don't apply alcohol after the iodophor solution
because this will negate the iodophor's effects.
That depends on whom you ask. For now, simply follow your facility's policy. But keep in mind
that many researchers are still working on this question, and authorities are still issuing
somewhat contradictory advice.

Clinical Controversy
Should I use a heparin solution or a saline solution to keep a peripheral I.V. catheter patent?
For example, the Intravenous Nursing Standards of Practice recommends using heparinized
saline solution to maintain the patency of peripheral intermittent devices. In contrast, the
American Society of Hospital Pharmacists recommends using a saline-only flush. (However, the
recommendation doesn't include infants, children, or home care patients because research hasn't
been finished on these groups.)
No matter which flushing solution you use, always maintain positive pressure in the lumen of the
catheter during withdrawal of the syringe. Doing so will prevent a backflow of blood into the
catheter. Also, keep in mind that you can only use preservative-free solutions to flush I.V. devices
in newborns. The benzyl alcohol preservative is toxic to neonatal biochemical systems.
Yes. Don't use a bacteria-retaining 0.2-micron filter when you're administering:
 blood or blood products
 lipid emulsions
 drugs at doses less than 5 mcg/ml
 drugs by I.V. push
 drugs whose pharmacologic properties could be altered by the filter
 drugs that adhere to the filter membrane.
Are there times when I shouldn't use a bacteria-retaining filter?
TPN is a complex admixture of 20% to 70% dextrose, 2.5% to 15% crystalline amino acids, and
10% to 20% fat emulsion. It also includes electrolytes, minerals, micronutrients (trace elements
such as zinc, copper,
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manganese), insulin, and vitamins as ordered. In addition, some solutions have heparin or
hydrocortisone added. Generally, the goal is to supply 2,000 to 2,500 calories to a patient when
other means of intake are blocked for 3 weeks or longer, but are expected to resume.
Are there any special things I should know about giving total parenteral nutrition (TPN)?
You should remember that TPN does require the placement of a central venous catheter, with the
attendant risks of that procedure and subsequent necessary site care. Some patients can develop
metabolic complications (glucose intolerance, electrolyte imbalances) from the hypertonic
solution. TPN can also interfere with immune mechanisms and may be less effective in severely
stressed patients, such as those with sepsis or extensive burns.
To prevent problems, label all TPN solutions and be sure the bag, administration set, and filter
are changed every 24 hours. Always use an infusion pump, and monitor it frequently to be sure
the flow rate is correct. Also monitor the patient's vital signs, physical status, intake and output,
and laboratory tests (serum electrolytes, BUN, creatinine, liver function tests, glucose,
cholesterol, triglycerides, and coagulation studies) regularly per your facility's protocol and
doctor's orders.
No. Although these syringes may look alike—both are thin (holding only 1 ml of fluid) and use a
small gauge (usually 25G) and 5/8″ needle, and are sometimes packaged similarly by
manufacturers—they are not interchangeable, and substituting one for the another can have
disastrous consequences. The Institute for Safe Medication Practices has reported numerous
cases of patient overdose of insulin when a TB syringe was used.

Warning
Can I use a tuberculin (TB) syringe instead of an insulin syringe for my diabetic patient?
Insulin syringes are calibrated not just on the number of milliliters held, but also on the unit
standard of the insulin. The usual rating is U-100, implying that the insulin product you are
administering contains 100 units of insulin per milliliter. Therefore, 0.5 ml would mean 50 units
of insulin.
However, nurses have accidentally misinterpreted the “5” (meaning 0.5 ml) on a TB syringe as 5
units and given the patient 10 times as much insulin as ordered. Always carefully check the
labeling on your syringe package for the designation of TB or insulin and the unit designation for
insulin syringes (U-100, U-50, U-500). Also,
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verify that the syringe inside the package is or isn't labeled with the unit scale.
Polyvinyl chloride (PVC) plastic, which is used in most I.V. bags and tubing, does absorb
nitroglycerin. So there's always some concern about how to administer the drug by this route
without losing efficacy. Here are some tips to avoid problems:
 Administer nitroglycerin with an infusion pump, and titrate the dose to the desired
response.
 Mix infusions in glass bottles, and avoid using I.V. filters because nitroglycerin binds to
plastic, making it necessary to infuse higher doses.
 Obtain special nonabsorbent I.V. tubing from the manufacturer. Regular tubing may
absorb up to 80% of the drug.
 Always use the same type of infusion set when changing I.V. lines.
Because nitroglycerin is absorbed into I.V. equipment, how can I ensure accurate doses?
Start by selecting an appropriate venipuncture site. Avoid flex areas (such as the wrist), areas of
impaired circulation, and sites distal to a recent venipuncture. Before starting the infusion,
confirm the vein's patency with preservative-free 0.9% sodium chloride injection or a similar
flush solution. Check for adequate blood return every 1 to 3 ml during administration, and
monitor the site for signs and symptoms of extravasation, especially if the patient complains of
burning or pain (stop the infusion immediately if extravasation occurs). Before administering any
vesicant, you should know your facility's protocol for treating extravasation and its directive for
choosing an appropriate antidote.
How can I prevent extravasation during peripheral administration of a vesicant? Also, I've heard
that you shouldn't use the antecubital fossa to administer a vesicant, but don't know why.
Use of the antecubital fossa restricts the patient's mobility and raises the risk of extravasation if
the patient moves too much. Extravasation in this area is more difficult to detect early, and could
require extensive corrective surgery if it occurs.
Start by comparing the limb's skin turgor and size with those of the opposite extremity. And
check the infusion site carefully for swelling, coolness, blanching, discoloration, and leakage at
the needle's insertion point. If you still aren't sure, place a tourniquet proximal to the
venipuncture site and make it tight enough to restrict venous flow, but not tight enough to restrict
arterial flow. If the infusion continues without assistance from a mechanical pump device, you've
confirmed infiltration.
How can I detect infiltration in a patient who's highly obese or has pronounced edema at the
venipuncture site?
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You are. Because phlebitis can increase the risk of infection, you should remove the catheter any
time phlebitis occurs and document the condition in your patient's medical record. In fact, at the
first sign of redness or tenderness, you should move the catheter to a different site, preferably on
the opposite extremity. Phlebitis is a common complication of I.V. therapy and may lead to more
serious complications, such as infection. Keep in mind that phlebitis may be influenced by
insertion technique, the vein's condition, the patient's diagnosis and immunocompetency,
compatibility of infusates, osmolarity and pH of drugs and solutions, lack of adequate filtration,
and the catheter's gauge, length, and material.

Best practice
I suspect that my patient has infusion phlebitis. My colleague says I should confirm my suspicion
by leaving the catheter in place and watching to see if the phlebitis worsens. I think I should
remove the catheter. Who's right?
If the patient has a mild infection involving only the exit site, you'll observe localized tenderness,
erythema, and induration. A more serious tunnel or pocket (portal) infection extends deeper than
skin level along the catheter. You'll observe varying degrees of cellulitis accompanied by
tenderness, erythema, induration, or suppurative drainage. The patient may have a fever or an
elevated white blood cell count. An advanced case of systemic line sepsis and catheter-related
bacteremia may cause more acute versions of these symptoms and could be life-threatening;
remove the catheter immediately.
What should I look for when assessing a central catheter-related infection?
JCAHO has worked with other national health care professional groups and the government to
devise yearly National Patient Safety Goals. These goals list the standards of patient care that all
accredited health care organizations must implement. Over the last few years, safety of I.V.
therapy and attention to proper use and care of medical devices have become major focal areas in
the goal of preventing medication errors.

Best practice
JCAHO will be inspecting my facility for “clinical alarms” and “free-flow protection.” What
essential information do I need to know about these two topics if an inspector wants to talk to
me?
Free-flow protection refers to the prevention of intravenous fluids from flowing at an
uncontrolled rate into a patient. JCAHO standards state that each I.V. must have an appropriate
administration set and flow-control device or infusion pump to safeguard the patient from
accidental overinfusion of medication or fluids. These devices can be positive pressure valves on
administration sets, or special locking devices built into
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infusion and PCA pumps that prevent fluid from dripping when the door is open, even when all
clamps are open. You're responsible for ensuring that you're utilizing the proper safety equipment
and have an understanding of how to correctly set up and maintain it.
Clinical alarms refers to the many alarms that are used in various health care settings, such as
those for patient monitoring, infusion pumps, ventilators, and telemetry. You're responsible for
responding quickly and appropriately to all clinical alarms. Bypassing the alarm systems defeats
the safety features of the medical device and is contrary to all standards of care. You're also
responsible for understanding the proper use and maintenance of all equipment required in your
practice area. Your facility or agency should also have a policy describing how medical device
safety alarms are to be tested to verify that they are in order.
Use an intraosseous line. In fact, doctors generally don't spend more than 2 minutes waiting for a
usable peripheral I.V. line in a critically ill child in an emergency. An intraosseous line goes
directly into the bone marrow cavity, an excellent point of entry for fluids, blood products, and
drugs. During intraosseous infusion, the bone marrow serves as a noncollapsible vein. Thus, fluid
infused into the marrow cavity rapidly enters the circulation via an extensive network of venous
sinusoids.
Age Alert
In an emergency, what's the best way to deliver drugs and fluids to a child if I can't start
an I.V. line?
To reduce the risk of infection with an intraosseous line, switch to a conventional vascular access
device within 4 hours, if possible. Other possible complications include extravasation into
subcutaneous tissue from improper needle placement, subperiosteal effusion from failure of the
fluid to enter the marrow space, and clotting in the needle if the intraosseous line is not flushed
or infused right away.
You should suspect that the catheter tip has migrated into the subarachnoid space or an epidural
vein, and take steps to confirm your suspicion. Withhold all epidural drugs until you determine
the catheter's location.
What should I do if I observe clear or blood-tinged fluid around an epidural catheter insertion
site?
Following your facility's policy, use the aspiration technique to assess catheter placement. If you
can aspirate less than 0.5 ml of fluid, the catheter is probably still in the epidural space. But if
you can aspirate more
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than 0.5 ml of fluid—fluid that tests positive for glucose—the catheter has migrated out of the
epidural space. Continue withholding epidural drugs, and notify the doctor.
 Best practice: Confirming needle placement
The Infusion Nursing Standards of Practice require you to confirm correct needle placement in
central venous access ports prior to administering any medication or solution. To confirm a blood
return before each use, attach a 10-ml saline-filled syringe to the end of the tubing and attempt to
aspirate blood back.

The absence of a free-flowing blood return signals a port malfunction. (See Confirming needle
placement.) If you can't withdraw blood or infuse a solution, notify the doctor of the port's
malfunction. If the port is occluded by blood or fibrin, follow the doctor's order and your
facility's thrombolytic protocol, which may include instilling an ordered amount of alteplase
(Activase) into the port.
What should I do when I can't get a blood return from an implanted central venous access port?
Sure you do. The most common reason for extravasation with one of these devices is that the
needle becomes dislodged from the port. To prevent it, make sure you secure the needle
carefully. Support and stabilize it without obstructing your view of the port. In case a needle does
become dislodged, teach the patient to watch for and report any signs of extravasation: edema,
leakage, or a burning sensation at or around the port. Instruct a home care patient to avoid
excessive
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movement, turn off the infusion, and then call the home care nurse.
Do I need to worry about extravasation with an implanted port?
Usually a nurse takes responsibility for accessing an implanted port. However, the patient or a
caregiver can be trained to do so, as long as the doctor agrees. When training the patient or
caregiver, stress the use of sterile technique. Have the patient use a 90-degree noncoring (Huber)
needle because it's easier to secure than a straight needle. Tell him to be sure to access the back
of the port to ensure proper needle placement. Many patients tend to stop short of the back of the
port, leaving the needle bevel in the rubber septum. This makes infusion and flushing difficult.
Can a patient with an implanted central venous access port administer his own infusion?
The catheter probably has a type of thrombotic occlusion called a fibrin tail. In this type of
occlusion, fibrin adheres to the end of the catheter and acts as a one-way valve, permitting
infusion but not withdrawal of fluid from the catheter. There are three other types of thrombotic
occlusion:
 An intraluminal thrombus occurs within the lumen of the catheter, possibly resulting in a
partial or complete occlusion.
 A fibrin sheath forms when fibrin adheres to the external surface of the catheter, and may
resemble a “sock” over the catheter.
 A mural thrombus occurs when fibrin from a vessel wall injury binds to fibrin covering
the catheter surface, leading to a venous thrombus.
My patient has a central venous catheter in place. I was able to infuse fluid into it but couldn't
withdraw fluid or blood from it. What might be causing this problem?
First, let's look at the functional differences between the two systems. PICCs are used for central,
generally long-term I.V. therapy. Midline catheters are used for peripheral, short-term or
intermediate therapy, usually lasting 2 to 4 weeks.
How does a peripherally inserted central catheter (PICC) line differ from a midline catheter?
PICCs are available with one or two lumens. The dual-lumen type has a barrier wall separating
the lumens, which allows you to administer incompatible drugs at the same time. Midline
catheters currently come with only one lumen, which allows you to deliver a single solution or
two or more compatible drugs at the same time.
The physical characteristics of both types of I.V. catheters also differ. PICCs are soft tubes, 16″
to 28″ (40.5 to 71 cm) long and ranging from 28G (small) to 14G. Midline catheters are only 3″
to 8″ (7.5 to 20 cm) long. Both are made from medical-grade, biocompatible materials.

Warning: PICC removal complications

If a portion of the peripherally inserted central catheter (PICC) breaks during removal,
immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of
the catheter piece into the right atrium. Then check the patient's radial pulse. If you don't detect
the radial pulse, the tourniquet is too tight and should be loosened slightly. Keep the tourniquet in
place until an X-ray can be obtained, the doctor is notified, and surgical retrieval is attempted.
What else can happen?
Catheter occlusion is also relatively common. Air embolism, always a potential risk of
venipuncture, poses less danger in PICC therapy. Catheter tip migration may occur with vigorous
flushing. Watch for sudden signs of respiratory distress; arm or chest pain; or new arrhythmia.
Notify the doctor immediately, and obtain a chest X-ray to check catheter status.
Additionally, a PICC is inserted peripherally through an introducer and threaded into the patient's
central venous system. The catheter tip lies in the superior vena cava. After insertion, the catheter
location must be verified with an X-ray before you can use the line. Besides the postinsertion X-
ray, the FDA recommends periodic follow-up films to make sure the tube stays put. Very small
catheters may need a water-soluble contrast medium to verify the tip's position.
In contrast, midline catheters have either an over-the-needle or through-the-needle insertion
procedure. Once inserted, they usually rest in the cephalic, basilic, or axillary veins of the arm.
They don't extend beyond the axillary region.
Note that, because of a PICC line's placement and length, the patient is at risk for certain
complications upon removal of the device. (See PICC removal complications.)
There could be many reasons this route was chosen. For example:
 Only one PICC line is required for the entire course of therapy. This protects the patient's
vascular system.
 You can use a PICC line for continuous or intermittent therapy.
 Complications occur infrequently and usually can be resolved without losing the catheter.
 Compared to traditional central venous access lines, PICC lines have a reduced risk of
infection, infiltration, pneumothorax, hemothorax, and air emboli.
 A PICC line is less costly than conventional central venous access and can be inserted by
a trained nurse.
 A PICC line offers a reliable method for gaining access to the venous system and can
remain in place for 6 months to 1 year.
 PICC lines require minimal nursing care, offer increased patient mobility, and decrease
the length of hospital stays.
Why would my home care patient be given a PICC line instead of a central access device for her
chemotherapy?
Of course, PICC lines aren't perfect. Their disadvantages include the daily care and maintenance
regimen, with its associated costs. The patient must have a chest X-ray after insertion and
periodically thereafter if therapy is very long-term or there is any sign of displacement. The line
may affect the patient's body image and may limit some of her previous activities. The training
process may be lengthy for the clinician and the patient. And catheters with smaller lumens
commonly need a continuous infusion pump and may not meet blood-sampling requirements for
monitoring therapy.
Start by telling him that PICC lines rarely cause complications at all. And if he does encounter
any problems, the likelihood is high that you can solve them without needing to remove the line.
Once he knows that, you can tell him about excessive bleeding at the site, phlebitis, and
complications common to other central lines.
My patient is scheduled to receive a PICC line shortly. What complications should I tell him
about?
It's normal for patients to have a small amount of bleeding at the insertion site because the
through-the-needle insertion technique requires a needle of larger gauge than the external
diameter of the catheter. The insertion site is slightly larger than the line. Most patients have a
spot of blood about the size of a dime on their dressing, but the bleeding should stop within 24
hours. If the patient experiences heavier bleeding, you'll have to assess the problem and intervene
as needed.
If the PICC irritated the vessel during insertion, the patient may develop signs of early-stage
mechanical phlebitis over the following week. Signs include erythema, warmth, inflammation,
edema, pain, and tenderness at the insertion site. Act quickly if these signs arise. Have the patient
rest, elevate the extremity, and apply regulated, continuous heat. You should see improvement
within 24 hours. Continue your interventions until the problem resolves or for a maximum of 72
hours. If the phlebitis doesn't resolve, you'll need to remove the line.
Complications associated with other central venous approaches are possible with PICC lines as
well, including infection, sepsis, thrombosis, catheter emboli, catheter migration, catheter
dysfunction, nerve damage, air emboli, hydrothorax, and cardiac complications.