99The infusion administration method is selected and based upon multiple factors including the type of infusion, the frequency of administration, infusion rate requirements, drug stability in solution, patient safety and lifestyle concerns, patient preference, and reimbursement. Patient safety is maximized by teaching the patient and family how to administer the infusion therapy, how to use an infusion pump, how to identify potential problems, and when/whom to call with problems. For patients who require a continuous infusion and are “hooked up” to an infusion pump 24 hours a day, teaching must also address how to manage activities of daily living. Other issues related to infusion administration addressed in this chapter include the administration set and filtration.
After reading this chapter, the reader will be able to:
■ Identify advantages and disadvantages for common infusion administration methods
■ Identify appropriate use of infusion pumps
■ Discuss issues that impact patient selection for any given infusion administration method
■ Identify key points for patient education
100NONINFUSION PUMP METHODS: IV PUSH AND GRAVITY DRIP
IV Push
Direct injection of an intravenous (IV) medication, called “IV push,” is the administration of the medication in a syringe directly into the patient’s vascular access device (VAD) or through the injection port of a continuous infusion. In home care, IV push is used most often for certain antimicrobials, including some in the cephalosporin group (e.g., ceftriaxone, cefazolin, and cefapime). Other examples of medications that may be administered by IV push include antiemetics (e.g., ondansetron) or diuretics (e.g., furosemide).
Advantages to IV push administration include less administration time, cost-effectiveness in terms of supplies, and a relatively simple administration method. However, nurses often administer IV push medications too rapidly (Carter, Gelchion, Saitta, & Clark, 2011; Institute for Safe Medication Practices, 2015). It is important to recognize the risk of “speed shock,” a systemic reaction that occurs when a medication is too rapidly administered into the circulation. Symptoms include dizziness, facial flushing, headache, and medication-specific symptoms that can progress to chest tightness, hypotension, irregular pulse, and anaphylaxis (Phillips & Gorski, 2014). It is critically important to administer IV push medications over the appropriate time frame. The medication syringe should be labeled with the administration time (e.g., “administer over 3 to 5 minutes”).
Fast Facts in a Nutshell
Nurses who administer IV push medications without use of a watch or second hand tend to underestimate the time that has passed and will often administer at a rate faster than recommended. Always use a watch or clock with a second hand or with a digital display of minutes and seconds; use of the timer function on a cell phone is another suggestion. This is also a critical aspect of patient education for patients or caregivers who self-administer (Figure 7.1).
Gravity Drip
Gravity infusion is a common method used to deliver intermittent medications. It is cost-effective, using an infusion container (e.g., mini-bag with antibiotic) and simple IV tubing. An IV pole is required or, 101alternatively, the infusion container can be hung from a home structure such as a drapery rod. For some antibiotics, the medication is contained in a separate compartment with a premeasured drug and diluent that is mixed just prior to administration (Figure 7.2). This method is used for medications that have a limited shelf-life after admixture.
Figure 7.1 Administering an IV push medication. Source: Photograph courtesy of Sherry Lokken, RN.
Note: To reduce the risk of complications associated with rapid administration, always use a watch or other timer device to ensure an appropriate administration rate.
IV, intravenous.
The IV drop rate must be calculated. Necessary information for calculation includes the volume of the infusion, the time frame for infusion in minutes, and the number of drops per milliliter as listed on the container of the IV tubing set. Calculate the IV drop rate as follows:
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Figure 7.2 Use-activated container.
Note: In accordance with the specific manufacturer’s directions for use, the medication container is connected to the port of the solution bag and the medication is mixed with the diluent. It is used for infusions that have a limited shelf-life once admixed (e.g., ertapenem).
A manual flow regulator is often used in lieu of the built-in roller clamp of the IV tubing. The regulator allows the nurse or patient to set the flow rate in milliliters per hour (Figure 7.3). Advantages may include easier regulation, more consistent flow, less drifting of flow compared to using the roller clamp, and less risk of accidental free-flow. However, the accuracy is about the same as the roller clamp (± 10%).
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Figure 7.3 Administration set with manual flow regulator.
Note: It may be used in lieu of the built-in roller clamp of the IV tubing, allowing the nurse or patient to set the flow rate in milliliters per hour.
For patients who require multiple doses per day, the IV tubing is changed every 24 hours as recommended by the Infusion Nurses Society (INS; Gorski et al., 2016). From a procedural standpoint, the infusion is stopped when the infusion container is empty but fluid still remains in the drip chamber. With subsequent infusions within the 24-hour period, a new infusion container is aseptically respiked to the existing tubing.
Patient Selection Considerations: IV Push and Gravity Drip
■ Safety is a concern due to rate management and risk for reactions with IV push.
■ Gravity drip is a more complex procedure as it involves more steps in accordance with attention to infection prevention including maintenance of aseptic technique. Key steps include:
Removing the protective cap from the tubing spike
Inserting the tubing spike into the infusion container
Filling the drip chamber and priming the IV tubing while protecting the male luer end of the tubing from touch contamination
Managing the infusion rate by drop counting
104Fast Facts in a Nutshell
A manual flow regulator is not an equivalent to an infusion pump. The drops should be counted to match the set rate on the dial. Such devices enhance the ease of infusion but do not take away the need to monitor the flow rate whether by the home care nurse or the patient/caregiver.
Fast Facts in a Nutshell
It is critically important that the male luer end of the tubing be protected with a new, sterile cover that is aseptically attached (Gorski et al., 2016). If there is any contamination of the male luer end of the tubing, it should be discarded as it is a source for contamination and it increases the risk for a bloodstream infection.
INFUSION PUMP ADMINISTRATION: ELASTOMERIC BALLOON “PUMPS”
The elastomeric balloon pump is a portable device that consists of an elastomeric reservoir, or balloon (Figure 7.4). Made of a soft rubberized material that is inflated to a predetermined volume, the balloon is encapsulated inside a rigid, transparent container. The balloon exerts positive pressure to administer the medication; control over fluid flow rate is maintained by IV tubing with varying tubing diameters. These devices are used to deliver a variety of infusion therapies, including IV antibiotics, chemotherapy, and analgesics. Volumes range from 50 to 250 mL. Elastomeric pumps can infuse at rates from 0.5 to 500 mL/hr.
Patient Selection Considerations: Elastomeric Balloon Pumps
■ A portable, disposable, nongravity-dependent infusion device that is often ideal for active patients or children who continue to work or go to school
■ Easier to learn compared to gravity infusion as the steps of bag spiking and rate monitoring are eliminated
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Figure 7.4 Elastomeric pump. Source: Photo courtesy of Halyard Health, Alpharetta, Georgia.
Note: These pumps come in a variety of volumes and may be used to administer medications such as antibiotics, chemotherapy, and analgesics.
Fast Facts in a Nutshell
Flow rate at the beginning of the infusion is faster than the rate at the end of the infusion due to variations in pressure within the stretched elastomeric membrane (Skryabina & Dunn, 2006). For patients who are sensitive to the infusion rate, this may be a concern. For example, “red man syndrome” is an adverse reaction of vancomycin associated with the infusion rate (see Chapter 9). Temperature affects performance; when the infusate is cold, the flow rate is slower. Instruct patients to remove the filled device from the refrigerator several hours before the infusion, based on manufacturer’s directions for use and pharmacy instructions.
106ELECTRONIC INFUSION PUMP ADMINISTRATION: SYRINGE, STATIONARY, AND AMBULATORY INFUSION PUMPS
Syringe and Stationary Electronic Pumps
Syringe pumps use a traditional syringe as the solution container, which is filled with prescribed medication and positioned in a special pump designed to hold it. Syringe pumps control the infusion rate by drive speed and syringe size, thus eliminating the variables of the drop rate. In home care, syringe pumps are used for delivery of antibiotics, subcutaneous immune globulin infusions, and small-volume IV therapy. The volume of the syringe pump is limited to the size of the syringe; a 60-mL syringe is often used. However, the syringe can be as small as 5 mL. The tubing usually is a single, uninterrupted length of kink-resistant tubing.
Stationary electronic pumps are mounted on an IV pole. They allow for large infusion volumes and a wide range of infusion rates. They may be less expensive than other pumps. Mobility is an issue and these pumps are usually used for longer, larger intermittent infusions (e.g., amphotericin B, IV immunoglobulin [IVIG] infusions, and continuous infusions in a patient with limited mobility).
Patient Selection Considerations: Syringe and Stationary Electronic Infusion Pumps
■ Must be able to learn the steps of loading the syringe and using the pump correctly
■ Nurse-administered infusions when patient independence is not appropriate due to infusate risks (e.g., IVIG infusion)
Ambulatory Electronic Infusion Devices (EIDs)
Ambulatory EIDs are lightweight and compact infusion pumps that are capable of delivering most infusion therapies including continuous infusions (e.g., chemotherapy and inotropes), intermittent antibiotic therapy, analgesic infusions with patient-controlled analgesia (PCA), and continuous infusions with tapering functions (e.g., parenteral nutrition [PN]). For intermittent antimicrobial infusions, a “keep vein open rate” is programmed to maintain flow between the drug administrations. Features include programmable memory, lock-out functions for safety, and alarms. “Smart pumps” that include drug libraries are available. Ambulatory pumps function on a battery system that requires recharging or replacement of disposable batteries. The pump 107along with the infusion container is placed in a pouch or backpack, providing the patient with full mobility during the infusion.
Patient Selection Considerations: Ambulatory EIDs
■ Patients who require frequent (every 4- to 6-hour) dosing or continuous infusions
■ Those who lack manual dexterity, who have impaired cognitive function, and/or are unwilling or unable to learn the necessary techniques for self-administration, and those who lack a support person at home
Fast Facts in a Nutshell
