23. Principles of drug administration
intravenous drug administration
CHAPTER CONTENTS
Intermittent infusion164
Administration using a syringe driver165
Patient-controlled analgesia166
Role and responsibilities of the midwife166
Summary166
Self-assessment exercises166
References167
LEARNING OUTCOMES
Having read this chapter the reader should be able to:
• describe each of the different ways that drugs can be administered intravenously
• discuss the role and responsibilities of the midwife when undertaking intravenous drug administration
• calculate the infusion rate when using a syringe driver.
The midwife should be trained properly to administer drugs intravenously (I.V.), recognising that in some areas it is an extended role. Updating is often required (according to local protocol) to maintain competence. Antibiotics are the most common drugs administered I.V., but many preparations can be administered in this way. This chapter considers the administration of medicines intravenously, as bolus or ‘push’ administration, or intermittent infusion, concluding with continuous administration of drugs using a syringe driver and patient-controlled analgesia. Maximum understanding will be gained from this chapter if it is read in conjunction with Chapters 18, 47 and 48.
Drugs given intravenously act quickly: an advantage if a rapid response is required; a disadvantage if allergy occurs. The potential for medication errors, especially drug incompatibility, should be considered particularly when multiple drug infusions are required at the same time and drugs are mixed (Nemec et al 2008). This includes bacterial or particulate contamination as well as physicochemical incompatibilities of intravenous solutions, and steps should be taken to reduce the risk of these occurring (Bertsche et al 2008). Cousins et al (2005) found that errors with drug administration centred around four areas: (1) unlabelled prepared drugs that were left for short periods were being administered to the wrong patient; (2) using the wrong diluent to prepare the drug, resulting in the powder not dissolving properly or being inactivated; (3) bolus drug administration being undertaken too quickly, which can cause phlebitis; and (4) loss of cannula patency and inadherence to aseptic procedures.
As for the administration of all medicines, the woman’s details are thoroughly checked, as are the medicine administration chart and drug (and diluent if required) to be administered. Note that the use of medical devices, particularly syringe drivers, features highly in the reported work of the Medicines and Healthcare Products Regulatory Agency (MHRA). It is essential that midwives have a thorough working knowledge of the equipment that they use and its correct maintenance (Murray & Glenister 2001).
The cannulation site should always be checked for patency prior to the administration of intravenous drugs. Signs of infiltration (and, if indicated, extravasation) should be looked for (see Chapter 47) and if present the cannula will require re-siting. Infiltration occurs when the cannula is no longer in the vein or only the tip remains and any drugs injected will therefore infiltrate the surrounding subcutaneous tissues (Dougherty 2008). The site should be flushed with 2–5 mL of normal saline before and after the administration of drugs; if more than one drug is given, the cannula should be flushed between drugs to avoid drug incompatibilities (RCN 2007).
The procedure follows the principles of asepsis as the risk of introducing microorganisms directly into the circulation is real (see Chapter 10). The midwife must also protect her hands from contact with the drug constituents, thus gloves should be worn whilst drawing up and administering the drug. These do not need to be sterile (unless the situation requires this), but should be well fitting and the midwife should use a non-touch technique.
Bolus administration
A bolus administration of a drug produces a high drug concentration without fluid overload but the high concentration can also cause a chemical phlebitis (Scales 2008).
PROCEDURE: bolus or ‘push’ administration
• A patent cannula should be available with an injection port.
• Gather equipment:
○ the drug, including correct solution (often water for injection) if it is to be diluted, and the woman’s medicine administration chart
○ appropriately sized sterile syringe and needles
○ hand rub
○ non-sterile gloves
○ 10 mL sodium chloride 0.9%, needle and syringe for flushing (or locally approved flushing solution)
○ clean injection tray
○ 70% alcohol-impregnated swab
○ disposable sheet
○ portable sharps box.
• Wash hands and put on non-sterile gloves.
• Prepare and draw up the drug according to the manufacturer’s instructions, with a second midwife checking the dosages and expiry dates.
• Gently resheath the needle using a non-touch technique and place the prepared syringe on the tray, retaining the ampoule (if not using a needle free port the needle should be changed).
• Draw up the normal saline (if unable to differentiate between the syringes, place on a separate tray and label).
• Confirm the woman’s identity then place her arm on the disposable sheet.
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