Safe administration of intravenous fluids and medicines

Chapter 6

Safe administration of intravenous fluids and medicines

Learning outcomes

At the end of this chapter, the practitioner will be able to:

Understand the different methods of delivering intravenous fluids and/or medication

Select the appropriate equipment needed to safely administer intravenous fluid

Understand the step-by-step process in relation to the safe administration of intravenous fluid

Select the appropriate equipment needed to prepare intravenous medication

Understand the step-by-step process in relation to the safe administration of intravenous medication

Demonstrate how to provide appropriate patient monitoring and aftercare.

Introduction

It is important to follow your local healthcare provider’s policy and clinical guidelines when administering intravenous (IV) fluid and/or medications. Some policies provide detailed information, and include step-by-step guidelines, as well as explaining why things are performed in a specific way. In order to administer IV therapy, it is likely that you will need to attend an additional training session and have a period of supervised practice with an appropriately qualified practitioner. Lastly, you will need to be assessed to ensure that you are competent to undertake the procedure.

Understanding different methods of delivery

The method used to deliver IV therapy depends upon numerous factors, such as the drug being used, the patient’s condition and the desired effect of the drug. There are three main methods for delivering IV medication -through a continuous infusion, an intermittent infusion or a bolus method, which is sometimes referred to as an intermittent injection (Dougherty 2002).

Continuous infusion

IV fluid and/or medication can also be delivered in a larger volume of solution. This is known as a continuous infusion method (Boyd 2013). A continuous infusion is typically used to administer IV fluids, or when medication needs to be well diluted (Dougherty 2002). Alternatively, a continuous infusion method may be advocated when the plasma level of the medicine needs to be maintained, or when large volumes of fluid and electrolyte need to be replaced (Dougherty 2002).

An example of a continuous infusion is the administration of 1000mL sodium chloride 0.9%, used as maintenance fluid when the patient has restricted oral intake (e.g. when they are ‘nil by mouth’). However, there are some disadvantages to using a continuous infusion method, such as the risk of fluid overload, or the incompatibility between the infusion and other IV drugs administered through the same peripheral access device (Weinstein & Hagle 20l4).

Intermittent infusion

An intermittent infusion method is used when a medication is added to a small volume of fluid (between 50 and 250mL), and administered over a prescribed period of time, which can vary between 20 minutes and 2 hours (Dougherty 2002). The intermittent infusion method may be used for a specific one-off dose, or alternatively administered at repeated intervals within a 24-hour period (Weinstein & Hagle 2014). Between doses of the medication, the container and the administration set must be discontinued, removed and discarded.

An intermittent infusion method is used when the pharmacology (or make-up) of the medication dictates a specific dilution, or if the medication becomes unstable if delivered and administered in a more dilute volume of fluid. An intermittent infusion may be used, for instance, if the patient is on a restricted fluid intake. Intermittent infusion is also used to administer antibiotics. The disadvantages of this approach include the requirement to use additional equipment, and the risk that an increased concentration of the medication may cause venous irritation (Weinstein & Hagle 2014).

Bolus method

A bolus method (also known as a direct intermittent injection) is the administration of a small volume of medication being pushed into the peripheral vascular access device (PVAD) or central venous catheter (CVC), using a ‘needle-free’ device (in which the syringe can be twisted onto the cap of an access device to provide an administration route).

Medication must be administered slowly using this method, over a time period ranging from a few minutes to 30 minutes, depending upon the medicine (Dougherty 2002). This approach may be used when a rapid dose of the drug is needed (e.g. in an emergency situation) and an immediate response is required, or when the medication cannot be diluted for pharmacological or therapeutic reasons (Dougherty 2002). The main disadvantage of this method is that it can cause a rapid delivery of the medicine, potentially causing a toxic effect or an anaphylactic reaction.

A bolus method is additionally used to administer sodium chloride 0.9% flushes to keep the PVAD patent. When administering a flush, a ‘push pause’ method is advocated, meaning that you must stop and start the administration of the fluid (Boyd 2013). The ‘push pause’ method creates episodes of turbulence, which removes small particles of debris that can build up around the tip of the PVAD (Boyd 2013). Remember that all flushes must be prescribed (or form part of a patient group directive) prior to their administration.

Activity 6.1

Identify a commonly used IV medication that is used in your clinical area. Study the medication in detail – think about how it is mixed, what diluent is used, and the method of administration. Next, identify the side effects of the medication, and consider the effects it may have on the patient’s vein. You may find it useful to create a ‘drug diary’ to list the common IV medications used within your clinical area.

Preparing the patient for administration of IV fluid or medication

Once a patient assessment has been undertaken, and the need for IV therapy has been determined, you need to prepare the patient fully by obtaining their consent and explaining the reason for the IV therapy. Patient education should also include the likely duration of the IV therapy and the possible side effects (Lavery & Ingram 2008). In addition, the patient’s prescription chart and notes should be checked for any other medication that the patient is receiving, to eliminate any possible drug interactions, incompatibilities, known allergies or side effects (Lavery & Ingram 2008).

Points for your practice

Before administering any medication (Boyd 2013):

Explain the steps in the procedure to the patient

Use the ‘5 Rs’ checklist to support your practice (see p. 32)

Ensure you know the identity of the patient you are administering the medicine to

Familiarise yourself with the medication and any contraindications.

Preparing equipment for administration of IV fluid or medication

Preparation of the equipment depends upon the chosen route of IV therapy (i.e. whether the therapy is to be given through a continuous, intermittent or bolus method).

The main points for good practice are as follows:

Check that the patient has appropriate IV access, and that the access device is patent, prior to assembling your equipment or fluid/medication to be infused.

Wash your hands as per aseptic non-touch technique (ANTT) national guidance.

The PVAD must be flushed with 5mL sodium chloride 0.9% (using a 10mL syringe), using a ‘push pause’ technique (Boyd 2013).

Check that the prescription is correct and valid, and that the dose required has not already been administered (NMC 2008).

Always use single use equipment as appropriate (Medical Devices Agency 2000). Check that the equipment is in date, has been stored correctly and is not damaged, to ensure that the product is safe to use (Lavery & Ingram 2008).

Assemble all equipment to reconstitute (draw up) the medication safely, so that there is no delay in administration.

Assess the area for immediate risks, and ensure that it is safe and suitable for medication administration. The area should be clean with sufficient space, light and ventilation to allow the medication to be prepared safely.

Check that you have appropriate equipment to deal with any spillages quickly and effectively.

Always ensure that you wear personal protective equipment; gloves and an apron is a required minimum standard (Loveday et al. 2014). If there is a risk of splashing (e.g. when preparing and mixing medication), you should wear protective eye goggles.

Administering IV fluid via a continuous infusion (without adding a medicine)

Before administering any IV fluid, you will need to ensure that there is a valid prescription in place. A typical prescription will resemble the one shown in Figure 6.1 (below). Make sure that the prescription is accurate (e.g. check that the date, volume and fluid type are correct) and that the prescriber has signed and printed their name on the prescription. If you are in any doubt, or the prescription is incorrect, do NOT administer the IV fluid.

Figure 6.1 A typical prescription slip

In order to administer a continuous infusion of IV fluid, you will need the correct administration set (often called a giving set). A clear fluid administration set delivers 20 drops of fluid per mL. The clear chamber in the middle of the administration set is used to count the drip rate (i.e. how many drops drip through the chamber each minute). This type of administration set needs to be changed every 72 hours (Royal College of Nursing 2010). Fluids must be administered at the prescribed rate, as detailed on the prescription.

If you are using an infusion device to deliver fluid, the device will have its own specific administration set devised by the manufacturer. Again, this administration set will deliver 20 drops of fluid per mL, and will require changing every 72 hours (Royal College of Nursing 2010). It is good practice to label the line with the date and time of commencement, so that other practitioners are aware of when to change infusion lines.

Blood and blood products are typically administered over a 3- to 4-hour period, using a specific blood administration set. Blood administration sets have filters, and deliver 15 drops of fluid per mL (Boyd 2013). The administration set will require changing every 12 hours.

Points for your practice

You will need to calculate the flow rate of an infusion in drops per minute, using the following formula:

Example 6.1

If you wanted to administer 100mL sodium chloride 0.9% over 30 minutes, using a standard giving set, the calculation would be as follows:

Volume of solution = 100mL

Number of drops per mL = 20 (as you are using a standard IV infusion giving set)

Duration of infusion = 30 minutes

Now practise some infusion calculations in Activity 6.2.

Activity 6.2

If 1 litre (1L) 5% glucose is prescribed and to be administered over 8 hours, using a standard giving set delivering 20 drops per mL, what would the infusion rate be in drops per minute?

If 500mL sodium chloride is prescribed and to be administered over 2 hours, using a standard giving set delivering 20 drops per mL, what would the infusion rate be in drops per minute?

If 1 litre (1L) 5% glucose is prescribed and to be administered over 6 hours, using a standard giving set delivering 20 drops per mL, what would the infusion rate be in drops per minute?

(The answers to this activity are in Appendix 4.)

Once you have checked the prescription and determined that it is accurate, gather the fluid and equipment, calculate the flow rate according to the above formula, and ask a second checker to check the fluid and the calculation with you against the patient’s prescription chart. You should go to the patient together to check the fluid against the prescription, and against the correct patient.

Flush the PVAD with 5mL sodium chloride 0.9% (using a 10mL syringe), and set up the fluid ready for administration. Once you have commenced the IV infusion, check the flow rate, dispose of your equipment, and then immediately sign and date the prescription chart, as well as documenting what time the infusion commenced. When the infusion is complete, you can document the completion time. Many healthcare providers require a second checker’s signature on the prescription chart (where appropriate) in addition to the signature of the person administering the fluid.

When a patient has an IV infusion running, they will also need their fluid balance to be recorded. The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in. For example, in human homeostasis, the output must equal the input. It is important that a fluid balance chart is started, so that all fluid input (oral drinks, IV fluids, IV medications, etc.) and all fluid output (urine, vomit, wound drains, etc.) can be documented accurately. This will allow you to work out the patient’s daily fluid balance (or fluid input minus output).

Table 6.1 Key stages in preparing and administering IV fluid using a continuous infusion method, without adding a medication (additive)

What is done

Why it is done

1. Collect all the equipment required (prescribed fluid, suitable IV administration set; 5mL sodium chloride 0.9% flush, prepared in a 10mL syringe).