Administering Medications by Intravenous Bolus or Push Through a Medication or Drug-Infusion Lock

Skill 5-11

Administering Medications by Intravenous Bolus or Push Through a Medication or Drug-Infusion Lock

A medication or drug-infusion lock, also known as an intermittent peripheral venous access device or saline lock, is used for patients who require intermittent IV medication, but not a continuous IV infusion. This device consists of a catheter connected to a short length of tubing capped with a sealed injection port. After the catheter is in place in the patient's vein, the catheter and tubing are anchored to the patient's arm so that the catheter remains in place until the patient no longer requires the repeated medication intravenously. Medication administration 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).

The medication or drug-infusion lock is kept patent (working) by flushing with small amounts of saline pushed through the device on a routine basis. The nurse must confirm IV placement before administration of medication. It is important to flush the drug-infusion lock before and after the medication is administered to clear the vein of any medication and to prevent clot formation in the device. If infiltration or phlebitis occurs, the lock is removed and replaced in a new site. Refer to Chapter 16 for a more detailed discussion of intravenous access devices and associated nursing skills.

Delegation Considerations

The administration of medications through an intermittent peripheral venous access device 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 IV 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

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

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 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:

Risk for medication side effect
Knowledge deficiency
Injury risk

Outcome Identification and Planning

The expected outcomes to achieve when administering medication via a medication or drug-infusion lock are that the medication is delivered 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 medication needs to be diluted before bolus administration. Verify the recommended 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. Recommended administration rate 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.	Allows administration of medication.
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).
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 bar code on the patient's identification band, if required (The Joint Commission, 2021) (Figure 1).	Scanning 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 labels 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.	IV medication must be given directly into a vein for safe administration.
22. Put on gloves.	Gloves protect the nurse's hands from contact with the patient's blood.
23. Remove the passive disinfection cap from the needleless connector or access port of the medication lock (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.	Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (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).
24. Uncap the saline flush syringe. Stabilize the port with your nondominant hand and insert the saline flush syringe into the needleless connector or end cap on the access port of the medication lock (Figure 3).	Assessing patency of the venous access device is necessary to ensure IV administration of the medication.
25. Release the clamp on the extension tubing of the medication lock (Figure 4). Pull back on the syringe plunger to aspirate the catheter for positive blood return (Figure 5). If positive, instill the solution over 1 minute or according to facility policy. Observe the insertion site while inserting the saline. 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. Puffiness, pain, or swelling as the site is flushed could indicate infiltration of the catheter.
26. 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).
27. Uncap the medication syringe. Insert the medication syringe into the needleless connector or end cap on the access port of the medication lock. Using a watch or clock with a second-hand to time the rate, inject the medication at the recommended rate (Figure 6). Do not force the injection if resistance is felt.	This delivers the correct amount of medication at the proper interval. Easy installation of medication usually indicates that the lock is still patent and in the vein. If force is used against resistance, a clot may break away and cause a blockage elsewhere in the body.
28. 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).
29. Remove the medication syringe from the access port. 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. Stabilize the port with your nondominant hand. Uncap the second saline flush syringe. Insert the saline flush syringe into the needleless connector or end cap on the access 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).
30. If the medication lock is capped with a positive pressure valve/device, remove the syringe, and then clamp the extension tubing (Figure 7). Alternatively, to gain positive pressure if positive pressure valve/device is not present, clamp the extension tubing as you are still flushing the last of the saline into the medication lock. Remove the syringe.	Positive pressure prevents blood from backing into the catheter and causing the medication lock to clot off.
31. 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 access port of the medication lock (Figure 8).	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).
32. Discard the syringe in the appropriate receptacle.	Proper disposal prevents injury and the spread of microorganisms.
33. Remove gloves and 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.
34. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
35. Evaluate the patient's response to the medication within an 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 delivered via the IV route, the patient has experienced the intended effect of the medication, the patient has 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 and saline flush, including date, time, dose, route of administration, site of administration, and rate of administration on the eMAR/MAR or record using the required format, immediately after administration. 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 the 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 medication lock site before administering the medication, you note that the medication lock has infiltrated: Remove the medication lock from the extremity. Restart the peripheral venous access in a different location. Continue to monitor the new site as the medication is administered.
While you are administering medication, the patient begins to complain of pain at the site: Stop the medication. Assess the medication lock site for signs of infiltration and phlebitis. Flush the medication lock with normal saline again to recheck patency. If the IV site appears within normal limits, resume medication administration at a slower rate. If pain persists, stop, remove the medication lock, and restart in a different location.
As you are attempting to access the lock, the syringe tip touches the patient's arm: Discard the syringe. Prepare a new dose for administration.
No blood return is noted upon aspiration: If the medication lock appears patent, without signs of infiltration, and normal saline fluid infuses without difficulty, proceed with administration. Observe closely for signs and symptoms of infiltration during and after administration.

Special Considerations

General Considerations

Vascular access devices should also be “locked” after completion of the flush solution at each use to decrease the risk of occlusion and catheter-related bloodstream infection (Gorski et al., 2021). According to the guidelines from the INS, vascular access devices are locked with normal saline solution (Gorski et al., 2021). If the device is not in use, periodic flushing according to facility policy is required to keep the catheter patent.
Previously, recommendations suggested routine rotation of insertions sites at various intervals, usually 72 to 96 hours. Current research and guidelines support maintaining peripheral IV access devices until no longer clinically indicated or until a complication develops (Gorski et al., 2021; Weston, 2019). Nurses should use clinical assessment and judgment in deciding when to replace or discontinue a peripheral venous access device.
The clinical need for the IV catheter should be assessed on a daily basis (Gorski et al., 2021). The device insertion site and dressing should be assessed every 4 hours at a minimum (Gorski et al., 2021; Weston, 2019).
A peripheral venous access device that is no longer necessary should not be kept in place just in case it may be needed in a few days (Weston, 2019).
Ongoing assessment is an important part of nursing care to evaluate patient response to administered medications and early detection of adverse 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.

Infant and Child Considerations

The primary method for IV medication administration for infants and children is a mini-infusion (syringe) pump (Kyle & Carman, 2021). Refer to Skill 5-13.
Administration of IV bolus or push medication is usually reserved for emergency situations and when therapeutic blood levels must be reached quickly to achieve the desired effect (Kyle & Carman, 2021).

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 Refer to details in Skill 5-10, Evidence for Practice.

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Skill 5-11

EVIDENCE FOR PRACTICE