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Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Take steps to eliminate interruptions and distractions during medication preparation.6
Remember to route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet).6
Many different types of medications are delivered as continuous IV infusions in acute, ambulatory, long-term, home care, and critical care settings.
Medication error is an important topic to consider for all who administer IV medications. These errors, which may have serious negative consequences, can be eliminated or kept to a minimum by standardizing medication nomenclature, concentration, and dosing and by implementing medication safety factors, such as electronic order entry, bar coding, procedures for distraction-free medication administration, protocols for high-risk IV drugs, and the use of smart technologies.
Smart technologies are electronic devices that perform calculations for doses and flow rates after information is entered and programmed by the user. These devices include computers, bedside monitors, and electronic infusion devices. Smart electronic infusion devices have built-in safeguards that identify and correct programming errors before the error reaches the patient by triggering an alarm when drug parameters are too high or too low. They can also detect flow problems, air bubbles in the tubing, and other safety concerns.
The type of administration system used for a continuous IV medication depends on the age and acuity of the patient, the type of medication ordered, the organization’s practice, and the setting. Flow rate devices range from simple mechanical devices using gravity to computerized smart electronic infusion devices. Regardless of the type of administration system used to administer the continuous IV infusion, the goal is controlling the rate of flow. Whether the administration system is simple or complex, it should be viewed as an enhancement to patient care and not a substitution for nursing care.
A continuous IV infusion is an infusion of medication in a solution into the venous system. Continuous IV infusions are often used when the medication needs to be greatly diluted, the drug level in the blood must be tightly controlled, or large volumes of fluids need to be infused.
The metric system is the universally accepted system of measurement for calculating drug dosages (Box 1). The components of calculating a medication dosage include:7
All units of measure used in the formula must be the same when calculations are performed. If they are not, the units of measure must be converted (Box 4) (Box 5).
Choosing which weight to use can be challenging. Distribution of specific medications across fat and fluid body compartments varies, affecting the therapeutic level. Much disagreement and inconsistency exist in the literature as to which weight to use. Thus, the organization’s practice should be followed regarding which of these weights to use: ideal body weight, admitting weight, daily weight, or dry body weight.
Because most drugs are titrated to the patient's response and a desired clinical endpoint, a consistent approach is using the patient's admission weight for initial dose calculations. Titrating is adjusting the dose to attain the desired patient response. Weaning is gradually decreasing the dose when the medication is being discontinued. The clinical pharmacist should be consulted for patients who are obese and for medications that have potentially dangerous toxicities.
Medication dosages based on weight are calculated using kilograms instead of pounds. The universal conversion formula is 1 kg = 2.2 lb.
If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.
Tubing or catheter should be traced from the patient to the point of origin before connecting or reconnecting any device or infusion.6 Tubing should be labeled at the connection site closest to the patient and at the connection site closest to the source when there are different access sites or several bags.6 Labeling reduces the chance of misconnection, especially in circumstances where multiple IV lines or devices are in use. Connections should not be forced, and equipment should only be used for its intended purpose.6 Forced connections or workarounds could indicate that the connection should not be made.
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Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.
Rationale: Some IV medications (e.g., amiodarone) require an inline particulate-retentive filter for administration.
Rationale: Some organizations label the tubing with the date the tubing was hung, and some organizations label the tubing with the date the tubing needs to be changed.
Specific guidelines directing the appropriate technique, disinfectant, or amount of time required to clean various devices have not been determined.
There is moderate quality evidence to support the recommendation to apply mechanical friction for no less than 5 seconds.
Monitor the infusion for flow rate accuracy.
Rationale: Entering the patient's weight, drug name, concentration, and ordered dose ensures the patient's safety and prevents mathematical errors or data entry and programming errors.
Review the organization’s practice regarding medications that must be infused using a smart electronic infusion device.
Rationale: Medications administered by continuous infusions often have potent effects and potentially serious adverse effects. Most medications administered by continuous infusions have a quick onset of action. Frequent monitoring is necessary during the initiation of the infusion.
Reportable conditions: Adverse reactions, hemodynamic instability, cardiac arrhythmias, excessive sedation, respiratory depression, pruritis, urticaria
Reportable condition: Desired response not achieved with current dosage range
Reportable conditions: Extravasation of medication, IV line infiltration, phlebitis
Rationale: Increased risk of contamination exists with an increased number of disconnections and reconnections.
Rationale: Fat emulsions promote bacterial growth and can contribute to infection.
Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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