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Learning Objectives ⬇

After completing this chapter, the reader will be able to:

Glossary ⬆ ⬇

Introduction ⬆ ⬇

Infusion medications may be administered by several routes that are described in this chapter. The IV route is by far the most common. Medications and solutions also may be administered via the subcutaneous (subQ) tissue. SubQ administration is a common way to administer opioid analgesics in the palliative care or hospice patient. A number of other medications and hydration fluids also may be administered subcutaneously. The intraosseous (IO) route is a quick means to vascular access in emergent care for delivery of critical care medications and fluids. The intraspinal route may be used to deliver a variety of anesthetic, analgesic, and other medications for patients in acute care and for those with longer-term needs beyond the hospital setting. There are other less common and very specialized routes used to administer chemotherapy such as the intraperitoneal route and the intra-arterial route for chemotherapy administration directly into an organ (e.g., peritoneal space, liver) (Camp-Sorrell & Matey, 2017). Because they are so specialized, they are not addressed in this text.

Nursing Process ⬆ ⬇

The nursing process is a six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process). The following table focuses on nursing diagnoses, nursing outcomes classification (NOC), and nursing interventions classification (NIC) for patients with medication administration via IV and alternate modalities. Nursing diagnoses should be patient specific and outcomes and interventions individualized. The NOC and NIC presented here are suggested directions for development of specific outcomes and interventions.

Nursing Diagnoses Related to Infusion Medication AdministrationNursing Outcomes Classification (NOC)Nursing Interventions Classification (NIC)
Anxiety (mild, moderate, or severe) related to: Unfamiliar situation, stressors (new equipment technology); role function; environmentAnxiety level, anxiety self-control, copingAnxiety reduction; calming technique; coping enhancement
Impaired physical mobility related to:
Movement limitations due to presence of VAD/infusion administration		Ambulation; mobilityAmbulation; joint mobility; positioning
Injury, risk for related to: Physical barrier (e.g., IV tubing attached to infusion pump/pole)Personal safety behavior
Safe home environment
Knowledge: Fall prevention		Health education; environmental management; fall prevention
Risk for infection related to: Environmental exposure to pathogens; immunosuppression, invasive procedures, altered skin integrity, insufficient knowledge to avoid exposure to pathogensRisk control: Infectious process, immune statusInfection control; infection protection
Deficient knowledge related to:
Lack of exposure; unfamiliar with infusion administration procedures		Knowledge: Treatment procedures; treatment regimenTeaching: Disease process (reasons for infusion therapy, treatment)
Sources: Ackley et al., 2020; Herdman et al., 2021.

Chapter Highlights

Thinking Critically: Case Study

Mrs. Robertson is recovering from an abdominal hysterectomy performed 10 hours ago and is receiving morphine via an epidural catheter. Her vital signs are blood pressure 110/80; respirations 18 per minute, and pulse 82/minute. She is complaining of severe pain, rating it at an 8/10.

Case Study Questions

    1.What additional assessments should be done?

    2.What are potential explanations for her severe pain despite the epidural infusions?

    3.What would you do?

Media Link: Chapter post tests and answers are provided on FADavis.com along with case studies and critical thinking activities.

References ⬆

PROCEDURES DISPLAY 10-1
Administration of Medication by the Direct (IV) Push: Peripheral Catheter

Equipment prepared on a general aseptic field in accordance with ANTT (Chapter 2)

Disinfectant (e.g., 70% alcohol wipes)

Two prefilled syringes of 0.9% sodium chloride

Labeled medication prepared by pharmacy in syringe

Delegation

This procedure cannot be delegated.

ProcedureRationale

    1.Verify the provider's order.

    1.A written order is a legal requirement.

    2.Verify that the patient is not allergic to the prescribed medication.

    2.Patient safety

    3.Introduce yourself to the patient.

    3.Establishes nurse-patient relationship

    4.Verify patient identity using two patient identifiers.

    4.Patient safety

    5.Perform hand hygiene.

    5.Single most important means of infection prevention

    6.Explain procedure to patient and its expected outcome, potential adverse reactions, and signs/symptoms to report.

    6.Prepares patient for procedure

    7.Scan the barcodes on RN identification badge, the patient's wristband, and the drug label (if barcode system is used).

    7.To ensure correct medication administration

    8.Disinfect the needleless connector (intermittent administration) or the injection port of the IV administration set) with antiseptic using a scrubbing for 5-15 seconds and allow to dry.

    Note: If administering medication with a running IV solution, ensure that the medication is compatible with the IV solution.

    8.Disinfects and reduces risk for intraluminal introduction of microbes. A critical step in infection prevention.

    9.Attach syringe of sodium chloride and begin to flush and then slowly aspirate for blood. Slowly flush the solution; disconnect and discard.

    9.Assess patency of catheter and clear the line of any medication. Never forcibly flush catheter.

    10.Repeat Step 8.

    10.Infection prevention

    11.Attach medication syringe and inject slowly over the time indicated on the syringe label or according to pharmacist; disconnect and discard. Use a timer or watch to ensure correct rate of administration.

    11.Slow injection reduces the risk for speed shock and provides time for the nurse to observe the patient for adverse effects. Studies have indicated nurses often administer IV push medications too rapidly.

    12.Repeat Step 8.

    12.Infection prevention

    13.Attach second syringe of sodium chloride and slowly inject the sodium chloride at the same rate as the medication was injected.

    13.To decrease the chance of a “bolus” of medication. To lock the VAD after the intermittent IV push medication, positive pressure must be maintained within the lumen of the catheter during and after administration of a flush solution to prevent reflux of blood into the luer-activated systems. Follow guidelines below.

Note: There are different types of needleless connector devices, so be sure you know which devices are used in your facility.

    14.a. For negative- and neutral displacement devices: Flush all solution into the catheter lumen, maintain force on the syringe plunger as a clamp on the catheter or extension set is closed, and then disconnect the syringe.

b. For positive-displacement device: Flush all solution into the catheter lumen, disconnect the syringe, and then close the catheter clamp.

    15.Assess patient response and any side effects/adverse reactions; ensure plan is in place for ongoing monitoring.

    15.Patient safety

    16.Discard all used supplies per organizational policy.

    17.Perform hygiene.

    18.Document the procedure.

    18.Maintains a legal record

PROCEDURES DISPLAY 10-2
Administration of Continuous Subcutaneous Medication Infusion

Equipment prepared on a General Aseptic Field in accordance with ANTT (Chapter 2)

Transparent semipermeable membrane (TSM) dressing

Prepackaged dedicated subcutaneous set from manufacturer

Antiseptic solution (alcohol-based chlorhexidine preferred)

Sterile 10-mL syringe

Prescribed fluids or prefilled medication container or cassette

Infusion pump (medication infusion)

Delegation

This procedure can be delegated to LPN/LVN as allowed by the nurse practice act.

ProcedureRationale

    1.Verify provider's order.

    1.A written order is a legal requirement.

    2.Verify that the patient is not allergic to the prescribed medication.

    2.Patient safety

    3.Introduce yourself to the patient.

    3.Establishes nurse-patient relationship

    4.Verify the patient's identity using two patient identifiers.

    4.Patient safety

    5.Scan the barcodes on RN identification badge, the patient's wristband, and the drug label (if barcode system is used).

    5.To ensure correct medication administration

    6.Perform hand hygiene.

    6.Single most important means of infection prevention

    7.Explain procedure to patient and its expected outcomes, potential adverse reactions, and signs/symptoms to report.

    7.Prepares patient for procedure.

    8.Assess skin and select insertion site with adequate subcutaneous tissue: a fat fold of at least 1 inch (2.5 cm) when thumb and forefinger are pinched together. Site selection is also based on the patient's anticipated mobility and comfort.

Note: Avoid areas that are scarred, infected, irritated, edematous, bony, or highly vascularized.

    9.Don gloves.

    9.Standard precautions

    10.Prime the administration set and prepare pump per manufacturer's directions.

    11.Perform skin antisepsis and allow to dry. (Note: If skin is visibly dirty, wash with soap and water prior to skin antisepsis.)

    11.Reduces risk for infection.

    12.Follow the manufacturer's labeled use and direction for access device placement; prime subQ set with 0.9% sodium chloride.

    13.Lift the skin up into a small mound between the thumb and index finger.

    14.Insert the primed subcutaneous infusion device into the skin.

    14.Ensures secure entry of the needle into the subcutaneous tissue and not into muscle

    15.Aspirate subcutaneous device using sterile syringe.

    15.Presence of blood may be indicative of entry into blood vessel. Remove and replace device in new site if positive blood aspirate.

    16.Secure subQ device, secure connection junctions, and apply TSM dressing over the site.

    16.Protects the site and stabilizes the catheter or needle to prevent dislocation.

    17.Initiate therapy and adjust the rate per order and medication label.

    17.Accurate medication administration

    18.Discard used equipment and supplies in the appropriate receptacle.

    19.Remove gloves and perform hand hygiene.

    20.Document in the patient's permanent medical record.

    20.Maintains a legal record