Intravenous medicine

Administration
Nursing Aspects

September 2009

Risk Assessment
Is the treatment necessary?

Is there a lower risk alternative?

February 2009

Patient assessment
Ask yourself about the patient, are there any
conditions you will have to note:
Renal
Fluid restriction
Liver
Fluid restriction
sodium restriction
Diabetes
Dextrose restriction
High serum sodium
Normal values? 135-145 mmol/l
February 2009

Allergies
Does the patient have any allergy
May range from mild itch to full blown
anaphylaxis

giving? Do these contain Penicillin?

Amoxicillin?
Co amoxiclav (Augmentin)?
Co-trimoxazole (septrin)?
Tazocin?
Gentamicin?
February 2009

Prior to preparation
Staff trained appropriately
Only those who have completed NHSGG&Cs training
programme and maintained their professional knowledge
and competence may perform IV medicine administration
2 people check medicine, prescription and any calculation
Read information (monograph) before preparation
Clean area, wash hands

February 2009

Risk assessment of medicine

What factors should we
take in to
consideration:
Stability
Special procedure for
making up
What else can be
drawn up into the vial?
Needle size 23g or
use a blunt filter
needle
Reconstitution device
February 2009

General Principles for the

Preparation of medicines
Prepare medicines immediately before
use
Peel wrappers from needles and syringes
Disinfect all vial/ampoule
closures/infusion ports with 70% alcohol
solution and allow to dry
Do not add any more than one medicine
to any solution
No interruptions while prescribing,
preparing or administering medicines
February 2009

Recent critical incident

Patient prescribed clarithromicin
Nurse prepared
Interrupted and left syringe with neat
clarithromicin on side with chart
FY1 asked to give the medicine
Saw syringe and vial
Gave undiluted medicine to patient
Always label a medicine if left unattended
If interrupted,
February 2009

and start again.

Site
Where do you want to give the medicine?
Peripheral

Central

February 2009

Delivery
How do you want to give it?
Bolus
Intermittent

Continuous

If you are using a pump do you know how it

works? If not...ASK and CHECK
February 2009

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Important Aspects
The Prescription:
Clear, legible and signed
Read carefully
Question any changes

The Patient:

Ensure correct patient

Obtain consent from patient
Ascertain allergy history
Know other medication the patient is
receiving

Observe response during and after

February 2009
11
administration document any reactions

Important Aspects
Administration of the medicine:
Never administer a medicine prepared by
another practitioner when not in their
presence
Check that the medicine has not already
been administered

February 2009

12

Flushing

February 2009

10ml syringes used for flushing

Flush with sodium chloride 0.9%
solution before, between and
after administration of each
medication unless the
medication is not compatible
with NaCl
Push pause method
Positive pressure
Flush must be prescribed or
covered by a PGD
13

Complications - Speedshock
Rapid administration of a
medicine
Toxic levels in the blood
Floods organs rich in blood, i.e
heart, liver, brain
Fainting, shock and cardiac arrest
February 2009

14

Complications -Phlebitis
Irritant
medications
Cannula too big
Cannula not
secured

February 2009

15

Documentation

Document
administration
Document
cannula
condition
phlebitis score
Document fluid
administered
February 2009

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Complications -Infiltration
Leakage of fluid from the vein to
the surrounding tissues.
Caused by cannula piercing the
vessel wall.
Pain, paraesthesia, cold
Prevention?
Treatment?
February 2009

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Complications -Extravasation
Leakage of a
vesicant fluid into
surrounding tissues.
E.g. cytotoxic, sodium
bicarbonate, phenytoin,
dopamine, calcium
chloride, potassium,
amiodarone)
Treatment
Stop infusion
Leave cannula in
Mark area
2009
February
Seek medical
advice

18

Case study
Patient prescribed regular vancomicin
Cannula difficulties mean infusion
rarely completed
Medicine signed as given on all
occasions
What effect does this have on blood
levels?
February 2009

19

Emergency treatment
of anaphylactic
See also page 18 of intravenous
reactions
medicines self-directed learning
package (adults)

February2009

20

What is
Anaphylaxis is a severe life threatening,
generalized or systemic
hypersensitivity reaction.
It is characterised by rapidly developing
life threatening airway and/or breathing
or circulation problems
There are usually skin and/or mucosal
changes
February 2009

21

What causes anaphylaxis

Stings - 47
Nuts -32,
Food -13
Antibiotics 27
Anaesthetics drugs 35
Other drugs 15
Contrast media 11
Other 4
Pumphrey RS suspected triggers for fatal
anaphylactic reactions in UK 1992- 2001

February 2009

22

Recognition and treatment

ABCDE Approach
Treat life threatening problems
Assess effects of treatment
Call for help early 2222
Diagnosis is not always obvious

February 2009

23

Airway
Swelling to the throat or tongue
Difficulty breathing and
swallowing sensation of throat
closing up
Hoarse voice
Stridor
February 2009

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Breathing
Shortness of breath
Increased respiratory rate
Wheeze
Patient becoming tired
Confusion caused by hypoxia
Cyanosis a late sign
Respiratory arrest

February 2009

25

Circulation
Signs of shock pale, clammy
Tachycardia
Hypotension
Decreased conscious level
Chest pain/ angina
Cardiac arrest
Do not stand the patient up
February 2009

26

Disability

Sense of impending doom

Anxiety, panic
Decreased conscious level
caused by airway, breathing or
circulation problem

February 2009

27

Exposure
Skin changes often the first
feature present in over 80% of
anaphylactic reaction.
Erythema patchy, generalised
red rash
Urticaria hives, nettle rash, weals
or welts anywhere on the body.
Angioedema swelling of deeper
tissues e.g eyelids, lips, mouth
and/or throat
February 2009

28

Treatment
A. Establish airway
B. High flow oxygen
C. IV fluid challenge
Monitor vital signs and
responses to treatment
Intra-muscular adrenaline
Chlorphenamine
Hydrocortisone
February 2009

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Intra Muscular Adrenaline

IM doses of 1:1000 adrenaline
(repeat once after 5 min if no
better)
Adult or child more than 12 years:
500 micrograms IM (0.5 mL)
Child 6 -12 years: 300
micrograms IM (0.3 mL)
Child 6 months - 6 years: 150
micrograms IM ( 0.15)
February 2009

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Adrenaline
Caution with Intravenous
adrenaline
For use only by experts.
For use only on monitored
patients

February 2009

31

Fluids

Once IV access established

500 1000mL IV bolus in adult
20mL/Kg IV bolus in child
Monitor response - give further bolus
as necessary
Colloid or crystalloid - 0.9% sodium
chloride or Hartmanns
Avoid colloid, if colloid thought to have
caused reaction

February 2009

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Steroids and antihistamines

Hydrocortisone and
chlorphenamine
Second line drugs
Use after initial resuscitation
started
Do not delay initial ABC
treatments
February 2009

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 Anaphylaxis
Recognition and early treatment
ABCDE approach
Adrenaline
Investigate
Specialist follow up
Education avoid trigger
Consider auto-injector

February 2009

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 Further information on
anaphylaxis is available at:
www.resus.org.uk

February 2009

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