PREPARING MEDICATIONS FROM AMPULES AND VIALS Definition:

Equipment: Special Considerations: 1.

2.

PROCEDURE 1. Wash hands and observe other appropriate infection control procedures. AMPULES 2. Flick the upper stem of the ampule several times with a fingernail or, holding the upper stem of the ampule, make a large circle with the arm extended.

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PROCEDURE 3. Partially file the neck of the ampule if necessary to start a clean break. 4. Place a piece of sterile qauze on the far side of the ampule neck or around the ampule neck, and break off the top by bending it toward the gauze, away from the nurse.

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5. Place the ampule on a flat surface. 6. Disconnect the regular needle, leaving the cap on and attach a filter needle to the syringe. 7. Remove the cap from the filter needle, insert the needle in the ampule, and withdraw the amount of drug required for the dosage. Do not touch the rim of the ampule with the needle tip or shaft. With a single-dose ampule, hold the ampule slightly on its side, if necessary, to obtain all the medication. 8. Replace the filter needle with a regular needle and tighten the cap at the hub of the needle before injecting the client. VIALS 9. Mix the solution, if necessary, by rotating the vial between the palms of the hands, not by shaking. 10. Remove the protective metal cap or clean the rubber cap of a previously opened vial with an antiseptic, such as 70% alcohol on a sterile gauze, by rubbing in a rotary motion.

PROCEDURE 11. Remove the cap from the needle; then draw up into the syringe the amount of air equal to the volume of the medication to be withdrawn, In some agencies, a special filter needle is used to draw up premixed liquid medications from multi-dose vials. The filter needle is then replaced by a regular needle to inject the medication into the client.

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12. Carefully insert the needle into the vial through the center of the rubber cap, maintaining the sterility of the needle. 13. Inject the air into the vial, keeping the bevel of the needle above the surface of the medication. 14. Invert the vial, ensure the needle tip is below the fluid level and hold it at eye level while withdrawing the correct dosage of the drug into the syringe. OR Hold the vial down, move the needle tip so it is below the fluid level and withdraw the medication. Avoid drawing up the last drops of the medication. 15. Withdraw the needle from the vial, and replace the cap over the needle, thus maintaining its sterility. To recap an unused needle, lay the cap on a firm surface and insert the needle carefully, maintaining its sterility. If a filter needle was used to withdraw the medication, replace it with a regular needle before injecting the client.

PROCEDURE Preparing and Using Multidose Vials 16. Read the manufacturers directions. The following are two examples of the preparation of powdered drugs. a. Single-dose vial: Instructions for preparing a single-dose vial direct that 1.5mL of sterile water be added to the sterile dry powder, thus providing a single dose of 2mL. The volume of the drug powder was 0.5mL, therefore the 1.5mL of water plus the 0.5mL of powder results in 2mL of solution does not increase the volume. Therefore, it is important to follow the manufacturers direction. b. Multi-dose vial: A does of 750 mg of a certain drug is ordered for a client. On hand is a 10g multidose vial. The directions for preparation read: Add 8.5mL of sterile water, and each milliliter will contain 1.0g or 1000mg. Thus, after adding the solvent, the nurse will give 750/1000 or mL (0.75mL) of the medication. 17. Withdraw an equivalent amount of air from the vial before adding the solvent, unless otherwise indicated by the directions. 18. Add the amount of sterile water or saline indicated in the directions. 19. If a multidose vial is reconstituted, label the vial with the date, time it was prepared, the amount of drug contained in each milliliter of solution, and your initials.

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20. Once reconstituted, store the medication to the vial in a refrigerator or as recommended by the manufacturer.

MIXING MEDICATIONS IN ONE SYRINGE Equipment: D D D D D D D D D

Special Considerations: 1.

2.

PROCEDURE Mixing Medications from Two Vials 1. Wash hands and observe other appropriate infection control procedures. 2. Inspect the appearance of the medications for clarity. Some medications are normally cloudy. 3. If using insulin, thoroughly mix the solution in each vial prior to administration. Rotate the vials between the palms of the hands and invert the vials. 4. Clean the tops of the vials with disinfectant swabs.

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PROCEDURE 5. Inject a volume of air equal to the volume of medication to be withdrawn into vial A or intothe vial of longer-acting insulin (eg. NPH insulin). 6. Withdraw the needle from vial A, and inject the prescribed amount of air into vial B or into the vial of shorter-acting insulin (e.g. regular or crystalline zinc insulin). 7. Withdraw the required amount of medications from vial B. 8. Using a newly attached sterile needle, withdraw the required amount of medication from vial A. If using a syringe with a fused needle, withdraw the medication from vial A. The syringe now contains a mixture of medications from vials A and B. Mixing Medications from One Vial and One Ampule 9. First prepare and withdraw the medication from the vial. 10. Then withdraw the required amount of medication from the ampule.

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ADDING AN IV MEDICATION TO AN IV BOTTLE OR BAG Definition:

Purpose: Equipment: D D D D D D D

Special Considerations: 1.

2.

PROCEDURE 1. Wash hands and observe other appropriate infection control procedures. 2. Prepare the drug dosage from a vial or ampule.

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PROCEDURE 3. For a glass IV container, remove the metal cap and the rubber disc, if the bottle is vented. Locate the injection port. OR For a plastic container, locate the separate, self-sealing, soft rubber injection port. An injection port may be designated in several ways: by a triangular indentation or by the word add. It is important not to inject medication through the port for the administration spike or through an air vent port if there is an injection port. 4. Clean the injection port with an antiseptic swab. 5. Remove the needle cover from the medication syringe, and inject the medication into the port. 6. Remove the needle. For a glass container, cover the top immediately either with an antiseptic swab with the metal IV cap taped over it or the special sterile cap provided by the manufacturer.

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7. Gently rotate the solution container to mix the drug with the solution. 7. Attach the medication label upside down to the fluid container. Include the name of the client, the dose of medication, the date, time and nurses initials. 8. Clamp the IV tubing. Spike and hang the container, and regulate the flow rate according to the dosage required when the medication is to be administered.

PROCEDURE 9. Document the medication in the appropriate form on the clients record. 10. During the administration, observe the client for signs of an adverse reaction, such as noisy respirations, changes in pulse rate, chills, nausea, or headache. If any adverse sign occurs, follow the agency policy (slow IV rate or stop flow) and notify the physician or nurse in charge. Also monitor the client for signs of the intended action of the medication. Variation for Adding Medications to an Infusing Container 11. Determine that the IV solution in the container is sufficient for adding the medication.

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12. Confirm the desired dilution of the medication, that is, the amount of medication per milliliter of solution. 13. Close the infusion clamp. 14. Clean the medication port with an antiseptic swab.

15. Remove the needle cover from the medication syringe. 16. While supporting and stabilizing the bag with your thumb and fore finger, carefully insert the syringe needle through the port and inject the medication. 17. Gently lift and rotate the container.

PROCEDURE 18. Re-hang the container and regulate the flow rate. 19. Complete the medication label and apply to the IV container. 20. Dispose the equipment and supplies according to agency policy.

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21. Document the medication on the appropriate form in the clients record.

ADMINISTERING INTERMITTENT INTRAVENOUS MEDICATION USING A SECONDARY SET Definition:

Purpose: Equipment: D D D D D D D

Special Considerations: 1.

2. 3.

PROCEDURE 1. Wash hands and observe other appropriate infection control procedures. 2. Provide for client privacy. 3. Prepare the client. Check the clients identification band. If not previously assessed, take appropriate assessment measures necessary for the medication

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PROCEDURE 4. Explain the purpose of the medication and how it will help, using language that the client can understand. 5. Assemble the secondary infusion. Close the clamp on the secondary infusion tubing. 6. Spike the secondary infusion medication infusion bag. 7. Squeeze the drip chamber and fill onethird to one-half full. 8. Hang the secondary container at or above the level of the primary infusion. Use the extension hook to lower the primary infusion if a piggy back setup is required.

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9. Attach the sterile needle or needleless cannula to the tubing, open the clamp to prime the tubing and close the clamp when the tubing is filled with solution. 10. Clean the Y-port on the primary IV line with an antiseptic swab. Clean the primary port (the port furthest from the client) for a piggyback alignment and the secondary port (the port closest to the client) for a tandem set up. 11. If the medication is not compatible with the primary infusion, temporarily discontinue the primary infusion. Flush the primary line with saline solution before attaching the secondary set. To flush the line, wipe the port with an antiseptic swab, clamp the primary line and using a sterile needleless adapter (or needle) and syringe, instill sufficient saline solution through the port to flush any primary fluid out of the infusion tubing.

PROCEDURE 12. Insert the needleless canula of the secondary line into the primary tubing port. 13. Secure needle with tape if using a needle system. 14. Attach appropriate label to the secondary tubing.

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Using a Piggyback Set 15. Ensure the primary line is unclamped if the port has a back-check valve. 16. Open the clamp on the piggyback line and regulate it in accordance with the recommended rate for the medication. Usually, medications are administered in 30 to 60 minutes.

Tandem Infusion 17. Open the clamp on the secondary line and regulate its flow. 18. For continuous infusion, set the secondary solution to the appropriate drip rate for the medication and then adjust the primary solution to achieve the desired total infusion flow. 19. For intermittent infusion, clamp the primary line and adjust the primary drip rate after the secondary solution is completed. 20. Document the time, date, medication, dose,, route and solution, assessments of the IV site, if appropriate; and the clients response. Record the volume of fluid of medication infusion bag on the clients intake and output record.

ADMINISTERING MEDICATION BY IV PUSH Definition:

Indications: 1. 2. 3. 4. 5. 6. 7.

Special Considerations: 1. 2. 3. 4. 5. 6. 7. Equipments: D D D D D D

In addition, for heparin lock: Sterile syringe and a needle with a heparin lush solution Sterile syringe and needle with 4 ml (or amount prescribed by the agency) of normal saline

PROCEDURE 1. Check the physicians order carefully for the medication, dosage, route, and rate of administration.

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2. Wash hands. Gather equipments. 3. Observe the 10 rights in preparing the

medication.

Start

preparing

medication. Label the syringe with the name of the medication and the dosage. 4. In a separate syringe, prepare the heparin solution according to agency practice, if needed. Label syringe.

5. In another syringe, prepare the saline solution. Label the syringe. IV Push into an Existing IV 6. Inspect the injection site for any signs of infiltration, then identify an injection port nearest he client. Some ports have a circle indicating the site for the needle insertion.

7. Clean the port with antiseptic swab. 8. Stop the IV flow by closing the clamp or pinching the tubing above the injection port.

PROCEDURE 9. While holding the port steadily, insert the needle into the port. 10. Draw back on the plunger to withdraw some blood into the IV tubing (not into the syringe). 11. Inject the medication at the ordered rate, withdraw the needle, reopen the clamp, and reestablish the intravenous infusion at the correct rate. 12. If the medication is particularly irritating to the veins, run the IV rapidly for about a minute, and then adjust the rate. IV Push into an Intermittent Set 13. Swab the injection port with an antiseptic swab.

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14. Insert the needle with the normal saline into the port and aspirate for blood return. 15. Inject 2 ml of the normal saline solution (optional, depending on agency policy). 16. Remove the saline-filled syringe, and cap the needle to maintain its sterility.

17. Insert

the

needle

attached

to

the

medication syringe. 18. Inject the medication slowly at the

recommended rate of infusion. 19. Observe the client closely for adverse reactions.

20. Remove the needle and the syringe when all medication is administered.

PROCEDURE 21. Reattach the saline syringe, and inject the recommended amount of saline. 22. Insert the heparin syringe, and inject the heparin slowly into the set. 23. Check the patency of the heparin lock at least every 8 hours or according to agency policy. a. Aspirate for return blood flow. b. Flush the catheter with 2-3 ml of normal saline. c. Refill the heparin lock with the new heparin solution. 24. Check agency times practice for about the

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recommended

changing

heparin lock. Some agencies advocate a change every 48-72 hours. IV Push Directly in Vein 25. Perform venipuncture. 26. Slowly inject the medication into the vein. The rate of to the the order, injection will vary the the according physicians medication, and/or

manufacturers directions. 27. Withdraw the needle, and apply pressure to the site. For All Types of Intravenous Medications 28. Document the medication given, dosage, time, route, all assessments, and your signature. 29. Carefully assess the clients response to the medication in terms of the intended action of the medication, adverse reactions, discomfort, etc.