Skill 5-10

Administering Medications by Intravenous Bolus or Push Through an Intravenous Infusion

A medication can be administered via the intravenous (IV) route as an IV bolus or push through a venous access device being used for continuous infusion of fluid. This involves a single injection of a concentrated solution directly into an IV access. Drugs given by IV push are used for intermittent dosing or to treat emergencies. The drug is administered at the rate recommended by the manufacturer, supported by evidence for practice, or in accordance with approved institutional guidelines (Institute for Safe Medication Practices, 2015, p. 13).

Confirm exact administration times by consulting a drug reference, package insert, or a pharmacist. Appropriately label all clinician-prepared syringes of IV push medications or solutions, unless the medication or solution is prepared at the patient's bedside and is immediately administered to the patient

(ISMP, 2015, p. 12).

Delegation Considerations

The administration of medications by intravenous bolus is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the administration of specified intravenous medications in some settings may be delegated to licensed practical/vocational nurses (LPN/LVNs) who have received appropriate training. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Antimicrobial swab
Watch or clock with second hand
Gloves
Additional PPE, as indicated
Prescribed medication
Two normal saline flushes prepared in a syringe (3 to 10 mL) according to facility policy
Passive disinfection caps (based on facility policy)
Syringe with a needleless device or 23- to 25-gauge, 1-inch needle (follow facility policy)
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Check the expiration date. Assess the compatibility of the ordered medication and the IV fluid. Assess the patient's IV site for signs of any complications. (Refer to Fundamentals Review 16-3 and Box 16-2 in Chapter 16 on pages 1005 and 1021.) Assess the patient's knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication. If the medication may affect the patient's vital signs, assess them before administration. If the medication is for pain relief, assess the patient's pain before and after administration. Verify the patient's name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Injury risk
Risk for adverse medication interaction
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve are that the medication is given safely via the IV route, and the patient experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient experiences no adverse effects, and the patient verbalizes an understanding of and engages with the medication regimen.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies. Check a drug resource to clarify whether the medication needs to be diluted before administration. Check the administration rate.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies. Compatibility of medication and solution prevents complications. Delivers the correct dose of medication as prescribed.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and select the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. If necessary, withdraw the medication from an ampule or vial as described in Skills 5-3 and 5-4.
10. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
11. Label the syringe with the medication's name, dose, and amount (The Joint Commission, 2021).	Unlabeled syringes are unidentifiable and may lead to a medication administration error (The Joint Commission, 2021). Appropriately label all clinician-prepared syringes of IV push medications or solutions, unless the medication or solution is prepared at the patient's bedside and is immediately administered to the patient (ISMP, 2015, p. 12).
12. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
13. Transport medications and equipment to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications. Having equipment available saves time and facilitates performance of the task.
14. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
15. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
16. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
17. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
18. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of the medication to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, and reduces anxiety.
19. Scan the patient's bar code on the identification band, if required (The Joint Commission, 2021).	This provides an additional check to ensure that the medication is given to the right patient.
20. Based on facility policy, the third check of the label may occur at this point. If so, recheck the label with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
21. Assess the IV site for the presence of inflammation or infiltration or other signs of complications.	IV medication must be given directly into a vein for safe administration.
22. If the IV infusion is being administered via an infusion pump, pause the pump.	Pausing prevents infusion of fluid during bolus administration and activation of pump occlusion alarms.
23. Put on gloves.	Gloves prevent contact with blood and body fluids.
24. Select the injection port on the administration set that is closest to the patient. Close the clamp on the administration set immediately above the injection port (Figure 1). Do not disconnect the administration set from the venous access device hub (Gorski et al., 2021).	Using the port closest to the needle insertion site minimizes dilution of the medication. Closing the clamp immediately above the access port ensures the medication is administered to the patient and prevents the medication from backing up the tubing.
25. Remove the passive disinfection cap from the needleless connector or end cap on the infusion set injection port (Figure 2). Alternatively, if a passive disinfection cap is not in place, use an antimicrobial swab to vigorously disinfect the connection surface and sides of the needleless connector or end cap on the injection port and allow it to dry.	The passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads, and provides continuous disinfection of the needleless connection versus intermittent disinfection when using antimicrobial wipes (Barton, 2019; Casey et al., 2018). Venous access device entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent venous access device-related infection (Flynn et al., 2019; Gorski et al., 2021). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness (Gorski et al., 2021; Slater et al., 2018).
26. Uncap the saline flush syringe. Insert the saline flush syringe into the needleless connector or end cap on the injection port on the administration tubing (Figure 3).	Assessing patency of the venous access device is necessary to ensure IV administration of the medication.
27. Pull back on the syringe plunger to aspirate the catheter for positive blood return (Figure 4). If positive, instill the solution over 1 minute or according to facility policy. Remove the syringe.	Positive blood return confirms patency before administration of medications and solutions (Gorski et al., 2021). Flushing without incident ensures patency of the IV line and administration of the medication into the bloodstream.
28. Use an antimicrobial swab to vigorously disinfect the connection surface and sides of the needleless connector or end cap on the injection port and allow it to dry.	Venous access device entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent venous access device-related infection (Flynn et al., 2019; Gorski et al., 2021). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness (Gorski et al., 2021; Slater et al., 2018).
29. Uncap the medication syringe. Insert the medication syringe into the needleless connector or end cap on the injection port. Using a watch or clock with a second-hand to time the rate, inject the medication at the recommended rate (Figure 5).	This delivers the correct amount of medication at the proper interval.
30. While administering the medication, observe the infusion site and assess the patient for any adverse reaction. If signs of adverse reaction occur, stop the infusion immediately and notify the health care team.	Signs of adverse reaction, such as peripheral IV infiltration, rash or itching, or pain at the infusion site, necessitate stopping administration of the drug (Gorski et al., 2021).
31. Detach the medication syringe. Use a new antimicrobial swab to vigorously disinfect the connection surface and sides of the needleless connector or end cap on the injection port and allow it to dry. Uncap the second saline flush syringe. Insert the saline flush syringe into the needleless connector or end cap on the injection port. Instill the flush solution at the same rate as the administered medication (Gorski et al., 2021).	Venous access device entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent venous access device-related infection (Flynn et al., 2019; Gorski et al., 2021). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness (Gorski et al., 2021; Slater et al., 2018). Flushing after medication administration ensures the entire drug dose has been cleared from the extension tubing on the venous access device or from the infusion system and prevents precipitation due to solution/medication incompatibility (Gorski et al., 2021).
32. Remove the flush syringe. Unclamp the administration set above the injection port.	Clamping prevents air from entering the extension set on a capped venous access device. Unclamping the administration set allows for resumption of the continuous IV infusion.
33. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of the needleless connector or end cap on the injection port and allow it to dry. Attach a passive disinfection cap to the needleless connector or end cap on the extension tubing or the injection port on the administration set (Figure 6).	Venous access device entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent venous access device-related infection (Flynn et al., 2019; Gorski et al., 2021). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness (Gorski et al., 2021; Slater et al., 2018). Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protect the hub from contamination by touch or airborne sources (Barton, 2019; Casey et al., 2018).
34. Remove gloves and perform hand hygiene. Restart the infusion pump and check IV fluid infusion rate.	Removing gloves and performing hand hygiene prevents the spread of microorganisms. Restarting the infusion pump resumes the prescribed continuous infusion of fluid. Checking the IV fluid infusion rate assures accuracy in administration.
35. Discard the syringe in the appropriate receptacle.	Proper disposal prevents injury and spread of microorganisms.
36. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
37. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
38. Evaluate the patient's response to the medication within the appropriate time frame.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the medication was administered safely via the IV route, the patient has experienced the intended effect of the medication, the patient experienced no adverse effects, and the patient has verbalized an understanding of and engages with the medication regimen.

Documentation

Guidelines

Document the administration of the medication immediately after administration, including date, time, dose, route of administration, site of administration, and rate of administration on the eMAR/MAR or record using the required format. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team as appropriate. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Upon assessing the IV site before administering medication, no blood return is visible upon aspiration: If the IV appears patent, without signs of infiltration, and IV fluid infuses without difficulty, proceed with administration. Observe closely for signs and symptoms of infiltration during and after administration.
Upon assessing the patient's IV site before administering medication, you note that IV has infiltrated: Stop the IV fluid and remove the IV from the patient's extremity. Restart the IV in a different location. Continue to monitor the new IV site as medication is administered.
While administering medication, you note a cloudy, white substance forming in the IV tubing: Stop administering the medication. Clamp the IV at the site nearest to the patient. Change the administration tubing and restart the infusion. Check a drug resource or consult a pharmacist regarding compatibility of the medication and IV fluid before continuing with administration. Medication infusion may require a second IV site.
While you are administering the medication, the patient begins to complain of pain at the IV site: Stop the medication. Assess the IV site for any signs of infiltration or phlebitis. Flush the IV with normal saline to check for patency. If the IV site appears within normal limits, resume medication administration at a slower rate.

Special Considerations

Do not withdraw IV push medications from commercially available, cartridge-type syringes into another syringe for administration. Using the cartridge as a vial can lead to contamination and/or dosing errors, drug mix-ups, and other medication errors (ISMP, 2015, p. 11).
Do not dilute or reconstitute IV push medications by drawing up the contents into a commercially available, prefilled flush syringe of 0.9% sodium chloride. These devices have been approved for flushing of vascular access devices, but have not been approved for the reconstitution, dilution, and/or subsequent administration of IV push medications (ISMP, 2015, p. 11).
Appropriately label all clinician-prepared syringes of IV push medications or solutions, unless the medication or solution is prepared at the patient's bedside and is immediately administered to the patient (ISMP, 2015, p. 12).
If the IV is a small gauge (22 to 24 gauge) placed in a small vein, a blood return may not occur even if the IV is intact. Also, the patient may report stinging and pain at the site while medication is being administered due to irritation of the vein. Slowing the rate of administration may relieve discomfort.
Ongoing assessment is an important part of nursing care for both evaluation of patient response to administered medications and early detection of adverse drug reactions. If an adverse effect is suspected, withhold further medication doses and notify the health care team. Additional intervention is based on type of reaction and patient assessment.

EVIDENCE FOR PRACTICE

Infusion Nursing Standards of Practice

Infusion Nurses Society (INS). (2021). Infusion therapy. Standards of practice. Journal of Infusion Nursing, 44(Suppl 1), S1-S224. https://doi.org/10.1097/NAN.0000000000000396

The Infusion Nurses Society is recognized as the global authority in infusion therapy. The Infusion Nursing Standards of Practice is an evidence-based document, providing guidelines for nurses related to infusion therapy for use in all patient settings and addressing all patient populations.

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Skill 5-10

EVIDENCE FOR PRACTICE