Administering an Intermittent Intravenous Infusion of Medication Via a Mini-Infusion Pump

Skill 5-13

Administering an Intermittent Intravenous Infusion of Medication via a Mini-Infusion Pump

Medications can be administered by intermittent IV infusion. The mini-infusion pump (syringe pump) for intermittent infusion is battery- or electrical-operated; medication mixed in a syringe is connected to the primary line and delivered by mechanical pressure applied to the syringe plunger and provides a highly precise rate of infusion (Kyle & Carman, 2021). Mini-infusion pumps may use a smart pump design; smart (computerized) pumps are increasingly being used by many facilities for IV infusions, including intermittent infusions. Smart pumps require programming of infusion rates by the nurse, but also are able to identify dosing limits and practice guidelines to aid in safe administration (ISMP, 2020). These smart IV pumps use computerized dose error-reduction software with IV drug therapy libraries that calculates infusion rates and provides an alert to the user when infusion rate limits are exceeded (Giuliano et al., 2018). Because manufacturers' designs vary, it is important to check the directions carefully for the systems used in the facility.

Delegation Considerations

The administration of medications by intermittent IV infusion 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

Medication prepared in labeled syringe
Mini-infusion pump and tubing
Needleless connector, if required, based on facility system
Antimicrobial swab
Date label for tubing
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)
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 compatibility of the ordered medication, diluent, and the infusing 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/family's/caregiver's knowledge of the medication. If the patient/family/caregiver 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. Verify patient name, dose, route, and time of administration. Assess the patient's knowledge of the medication.

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
Risk for adverse medication interaction
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve 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.	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.
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. Assess the compatibility of the ordered medication, diluent, and the infusing IV fluid.	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. Compatibility of medication and solutions prevents complications.
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 read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates. Confirm the prescribed or appropriate infusion rate. 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. Infusing medication at appropriate rate prevents injury.
9. 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, read the label and 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.
10. 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.
11. Transport medications 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.
12. 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.
13. 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.
14. 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.
15. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
16. 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/family/caregiver.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, and reduces anxiety.
17. Scan the bar code on the patient's identification band, if required (The Joint Commission, 2021).	This provides an additional check to ensure that the medication is given to the right patient.
18. Based on facility policy, the third check of the label may occur at this point. If so, read the label and 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.
19. 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.
20. Using aseptic technique, remove the cap on the administration tubing and the cap on the medication syringe, taking care not to contaminate either end.	Maintaining sterility of the tubing and medication port prevents contamination.
21. Attach the administration tubing to the syringe, taking care not to contaminate either end.	Maintaining sterility of the tubing and medication port prevents contamination.
22. Place a label on the tubing with the current date.	The label identifies the date of the first use of the tubing. Most facilities allow the reuse of tubing, reducing the risk for contamination. The frequency of administration set tubing changes varies. Refer to Box 16-3 in Skill 16-3 for recommended administration set change guidelines. Intermittent administration sets disconnected after use should be replaced every 24 hours; repeated disconnection and reconnection increases risk of contamination at the spike end, catheter hub, needleless connector, and the end of the administration set, potentially increasing the risk for catheter-related bloodstream infection (Gorski et al., 2021).
23. Fill the administration tubing (priming) with medication and purge the air from the tubing by applying gentle pressure to the syringe plunger (Kyle & Carman, 2021). Place the needleless connector on the end of the tubing, if required, using sterile technique.	This removes air from the tubing and maintains sterility.
24. Insert the syringe into the mini-infusion pump according to the manufacturer's directions (Figure 1).	The syringe must fit securely in the pump apparatus for proper operation.
25. Remove the passive disinfection cap from the needleless connector or end cap on the access port on the primary IV infusion tubing, closest to the IV insertion site (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 access port or stopcock above the roller clamp on the primary IV infusion tubing, usually the port closest to the IV insertion site.	The 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).
26. Connect the secondary infusion to the primary infusion at the access port (Figure 3).	This allows for delivery of the medication.
27. Program the mini-infusion pump to the appropriate rate and begin infusion (Figure 4). Set the alarm if recommended by the manufacturer.	The pump delivers medication at a controlled rate. The alarm is recommended for use with medication or a drug-infusion lock.
28. When the infusion is completed, flush the syringe pump tubing, according to facility policy and procedure (Kyle & Carman, 2021).	Flushing the syringe pump tubing delivers any medication remaining in the tubing (Kyle & Carman, 2021).
29. Clamp the tubing on the syringe pump tubing.	Most facilities allow the reuse of tubing, reducing the risk for contamination. The frequency of administration set tubing changes varies. Refer to Box 16-3 in Skill 16-3 for recommended administration set change guidelines.
30. Check the rate of the primary infusion.	Administration of a secondary infusion may interfere with the primary infusion rate.
31. Remove 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.
32. Document the administration of the medication immediately after administration. See Documentation section below. Document the volume of fluid administered on the intake and output record, if necessary.	Timely documentation helps to ensure patient safety.
33. Evaluate the patient's response to the medication within the appropriate time frame. Monitor the IV site at periodic intervals.	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 experienced no adverse effects, and the patient has verbalized an understanding of and engaged 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. Document the volume of fluid administered on the intake and output record, if necessary.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Upon assessing the IV site before administering medication, you note that the IV has infiltrated: Stop the IV fluid and remove the IV from the 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 the IV from flowing and stop administering the medication to prevent precipitate from entering the patient's circulation. Clamp the IV at the site nearest to the patient. Replace the tubing on primary and secondary infusions. Check a drug resource or consult a pharmacist regarding compatibility of medication and IV fluid before continuing with administration. The medication infusion may require a second IV site or flushing of tubing before and after administration.
While you are administering medication, the patient begins to complain of pain at the IV site: Stop the medication. Assess the IV site for any signs of complications. 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 and continue to monitor.

Special Considerations

General Considerations

If the medication is delivered via intermittently through a medication or drug-infusion lock, flush the peripheral IV access device before and after medication administration as outlined in Skill 5-11. Once the post-infusion flush is completed, attach a passive disinfection cap to the needleless connector or end cap on the access port of the medication lock, based on facility policy.
Intermittent administration sets disconnected after use should be replaced every 24 hours; repeated disconnection and reconnection increases the risk of contamination at the spike end, catheter hub, needleless connector, and the end of the administration set, potentially increasing the risk for catheter-related bloodstream infection (Gorski et al., 2021)
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.

Infant and Child Considerations

The primary method for IV medication administration for infants and children is a mini-infusion (syringe) pump (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.

section name header

Skill 5-13

EVIDENCE FOR PRACTICE