iv maintenance basics

IV MAINTENANCE BASICS

OBJECTIVES

• Medication Reconstitution

• IM Injections

• IV Reconstitution

• Antibiotic administration

• Basic Drips

• Y Site Compatibility

• Intakes & Outputs

• Hands on Practice

BARRIERS TO SUCCESS

• “The computer figures it out for me.”

• “Pharmacy figures it out for me.”

• “The IV pump figures it out for me.”

• “I’m not good at math.”

• Responsible medical professionals cannot always count on computers and pharmacy to do drug calculations. We must always double check these calculations because if there is an error ultimately it is our license on the line. We are accountable for any medications we administer. We are the last line of defense against a med error and patient safety.

MEDICATION RECONSTITUTION

• Some drugs must be stored in powdered form because they rapidly lose their power once they are mixed into a solution. These drugs will then have to be reconstituted, or mixed with a liquid, called the diluent, before they can be administered.

• Diluent – Product added to a solution, powder, ointment, cream or other product used to reconstitute, dissolve, or dilute another product

• Concentration – How much solute is dissolved in a certain amount of fluid

• Reconstitution – Using the given directions, or recipe, on a prescription label to reconstitute the powder contained inside to a specific concentration

• The process of adding a diluent to a dry ingredient to make it a liquid

RECONSTITUTION MATH BASICS

• What is the Doctor’s order?

• What concentration of medication do you have on hand?

• What is the unit to be administered?

• Is this medication weight based?

1 kilogram (kg) 2.2 pounds (lb)

1 kilogram (kg) 1000 grams (g or gm)

1 gram (g or gm) 1000 milligrams (mg)

1 milligram (mg) 1000 micrograms (mcg)

1 gram (gm) 1 ml (milliliter) (ml)

1 ounce (oz) 30 milliliter

1 teaspoon (tsp) 5 milliliter

1 tablespoon ( T or tbs) 15 milliliter (ml)

3 teaspoons (tsp) 1 tablespoon ( T or tbs)

1 teaspoon (tsp) 75 gtt (drops)

1 milliliter (ml) 15 drops (gtt)

1 liter (L) 1000 ml (milliliter)

MATH CALCULATIONS

EXAMPLE #1

• Your diluent and medication come packaged together in this case.

• How much of the diluent is to be added to the medication?

• How many mLs are to be administered?

• How will this be administered?

For intramuscular injection only (0.5 mL).

MENVEO is supplied in two vials that must be

combined prior to administration: reconstitute the

MenA lyophilized conjugate vaccine component

with the MenCYW-135 liquid conjugate vaccine

component immediately before administration.

This is an active immunization to prevent

invasive meningococcal disease.

ANSWERS

• How much of the diluent is to be added to the medication?

• Whole vial

• How many mLs are to be administered?

• 0.5 ml

• How will this be administered?

• IM

EXAMPLE #2

• What is the diluent?

• How much of the diluent will you need to reconstitute?

• How much medication is in each vial?

• After reconstitution, how much medication is in each mL?

• How many mLs would you administer if your physician order read: Give 250mg of Rocephin IM x1 now.

Order: Give 250mg of

Rocephin IM x1 now.

Set up for Cross multiply

and divide:

Order:

250 mg

-------------- = ---------------

? mLs

Order: On Hand:

250 mg 350 mg

-------------- = ---------------

? mLs 1 mL

250 x 1 / 350 = 0.71 mL

ANSWERS

• What is the diluent?

• Can use 1% lidocaine or sterile water

• How much of the diluent will you need to reconstitute?

• 1 ml

• How much medication is in each vial?

• 500 mg

• After reconstitution, how much medication is in each mL?

• 350 mg/1 ml

• How many mls to administer?

• 0.71 mLs

PEDIATRIC MEDICATION DOSING

• Two of the most common medications ordered for pediatrics are Acetaminophen and Ibuprofen po.

• These usually come in full bottles, so as the nurse giving the medication you may need to set up a dosing equation to figure out how many mLs need drawn up.

• Almost all pediatric medications are weight based.

• Typical dosing for:

• Acetaminophen = 15 mg / kg

• Ibuprofen = 10 mg / kg

Side Note

Order: Give Acetaminophen po per weight.

Patient Weight: 20 lbs

On Hand: Acetaminophen 160mg/5ml bottle

Convert your weight to kg: 20 / 2.2 = 9.09 kg

To figure your dose: 15 mg x 9.09 = 136.36 mg

On Hand Ordered

160 mg 136.36 mg

------------------------ = -------------------------

5 mL ? mL

On Hand Ordered

160 mg 136.36 mg

------------------------ = -------------------------

5 mL ? mL

136.36 x 5 / 160 = 4.26 mL (Round to 4.3)

INTRAMUSCULAR INJECTION OVERVIEW

• Sites: Deltoid, Ventrogluteal, Dorsogluteal, Vastus lateralis, Rectus Femorus

• Sites that are bruised, tender, red, swollen, inflamed or scarred are avoided

• The CDC no longer recommends to aspirate prior to injection of vaccines, however, if you see blood in the syringe when you inject remove needle and start over

• Area may be massaged to help the medication absorb

• To minimize patient discomfort

• May use ice or topical numbing cream (per provider order) to site

• Allow alcohol to dry completely before the injection

• Warm vial of medication but rubbing between palms prior to drawing up dose

INTRAMUSCULAR INJECTION SITES

• Deltoid

• Used for smaller volumes

• Typically no more than 1 mL

• Some sources state 2 mLs can be given here, but this is painful for the patient

• Landmarks: Acromion process

• 2 finger widths below

• Imagine an upside-down triangle

• Injection site is in the center of the triangle


• Ventrogluteal and Dorsogluteal

• Used for larger volumes

• Typically less than 3 mLs

• Some resources state up to 5mLs but this is very painful for the patient

• Ventrogluteal

• The safest site for adults and children older than 7 months

• Deep and not close to any major blood vessels


• Landmarks for Ventrogluteal Site

• Place heel of hand on patient’s hip (greater trochanter) with fingers pointing towards the head

• Position fingers so the thumb points towards the groin and you feel the posterior pelvis under your pinky finger

• Spread your index and middle fingers in a slight V shape (pointing your index finger towards the anterior/superior iliac spine), and inject the needle into the middle of the V


• Dorsogluteal

• No longer site of choice due to potential sciatic nerve injury during injections

• Never used on infants and small children

• Landmarks for Dorsogluteal

• Draw an imaginary line from the posterior superior iliac spine to the greater trochanter

• Inject superior and laterally of line


• Vastus Lateralis & Rectus Femoris

• Larger volumes may be used

• Typically less than 3 mLs

• Some resources state up to 5mLs but this is very painful for the patient

• Landmarks: Vastus Lateralis

• Divide thigh into three equal parts

• Locate the middle of these three sections

• Injection should go into the outer top portion of this section

Z TRACK METHOD• Pulling the skin downwards or sideways at

the site before injection. Must remove needle from injection site prior to releasing the skin because the needle could snap off and remain in the muscle

• After removing the needle the track is closed when the skin is released, preventing leakage of medication into the subQ tissue or even out of the injection site itself

• Can be utilized with all IM injections but must be utilized with caustic medications or medications that will stain the skin

• Caustic – Rocephin and Phenergan

• Discoloration – Vit B12 and Iron

PACKAGE INSERTS AND LEXICOMP

• Always read your package inserts prior to administration

• Check with Lexicomp if you are unsure of how and/or where to administer

• Example #1: Penicillin G Benzathine

INTRAMUSCULAR INJECTION COMPLICATIONS

• Notify your provider if any of the following are noted

• Sever pain at the injection site (mild pain is normal)

• Tingling or numbness

• Redness, swelling, or warmth at the injection site

• Drainage at the injection site

• Prolonged bleeding

• Signs of an allergic reaction, such as difficulty breathing or facial swelling

RECONSTITUTION MATH BASICS

• What is the Doctor’s order?

• What concentration of medication do you have on hand?

• What is the unit to be administered?

• Is this medication weight based?

• Remember all pediatric medications are based on weight

• Other IV medications that are weight based: Heparin & Dopamine

1 kilogram (kg) 2.2 pounds (lb)

1 kilogram (kg) 1000 grams (g or gm)

1 gram (g or gm) 1000 milligrams (mg)

1 milligram (mg) 1000 micrograms (mcg)

1 gram (gm) 1 ml (milliliter) (ml)

1 ounce (oz) 30 milliliter

1 teaspoon (tsp) 5 milliliter

1 tablespoon ( T or tbs) 15 milliliter (ml)

3 teaspoons (tsp) 1 tablespoon ( T or tbs)

1 teaspoon (tsp) 75 gtt (drops)

1 milliliter (ml) 15 drops (gtt)

1 liter (L) 1000 ml (milliliter)

PEDIATRIC IV ADMINISTRATION

• Pediatric medications are usually weight based

• In an emergency situation use Broselow Tapes

• ALWAYS use an infusion pump with infants and children

• ALWAYS use a buretrol with infants and children

• Even if EPIC does not prompt an independent double check, it is still best practice to double check all pediatric medications

TIPS FOR DRIPS

• Examples: Heparin drips, Lasix drips, ect..

• Always have a second nurse perform an independent double check

• Always check the BAG AND THE LABLE!

• Always refer to your Drip Binder or call Pharmacy if any questions

• Lasix

• Always monitor urine output closely

• Heparin

• Always utilize your PTT dosing chart in the EMR

• When in doubt call pharmacy

IV DRUG RECONSTITUTION

• Refer to your Diltiazem (Cardizem) Drug Formulary

• How would you mix a Cardizem drip if pharmacy was not onsite?

• Cardizem vials come in 50mg/10mL

• How would you compound this drip?

• Dr. Order: Give Cardizem 25 mg bolus and initiate Cardizem gtt at 5mg/hr and titrate until converts

ANSWER

Your prep guidelines are telling you to insert 25 mLs of Cardizem into a 100 mL bag

Your Cardizem vials come in 50 mg / 10 mL

So by injecting 25 mLs of Cardizem you will be adding 125 mg of Cardizem

This will give you a final concentration of 1;1

You will have a total of 125 mg in the bag and after injection of 25 mLs of Cardizem, you will have 125

mLs in the bag

? mg 50 mg

------------ = ----------- = 125 mg

25 mL 10 mL

You will then administer your 25 mg bolus (5 mL) over 2 min. Then initiate your drip at 5 mL per hour at

the y site.

IV MED CALCULATION PRACTICE QUESTIONS

Order: Initiate an insulin drip at 13 units per hour

Concentration on hand: Insulin drip 100 units/100 ml

What is your flow rate (mL/hr)?

ANSWER TO INSULIN QUESTION

• Insulin Answer = 13 ml/hr

Set up: 100 units 13 units

----------- = ------------

100 ml X ml

Cross multiply and divide

IV MED CALCULATION PRACTICE QUESTIONS

• Order: Fentanyl 5 mg/hr. The bag is labeled 250 mg in 500 ml of solution.

How fast will the IV need to be infused to give the correct dose?

ANSWER

What do you have on hand?

250mg/500ml

What are you looking for?

5mg per how mL?

On Hand What you are looking for

250 mg 5 mg

---------------------- = ---------------------- = 10 mL

500 ml X

Order: Fentanyl 5 mg/hr. The bag is labeled 250 mg in 500 ml of solution

So 5 mg = 10 mL

So your flow rate will be 10 mL per hour

IV TUBING MAINTENANCE

• IV tubing and dressing for peripheral lines should be changed every 96 hours or prn

• Document time and date when IV tubing was hung on sticker applied to IV tubing.

• All lines to be labeled at the distal end of the tubing (ex. MIV, Neo, Dop)

• Exceptions: for infusion containing fat emulsions – change with each new infusion

• TPN: Tubing changed every 24 hours

• If manufacturer has drug specific recommendations for IV tubing changes, pharmacy will notify nursing

• Secondary Infusions

• Make sure you are watching the drips fall before you walk away. It is very easy to forget to unclamp your secondary and as a result your primary line will be running the whole time

RESOURCES

• https://infuserveamerica.com/116/reconstituting-your-medication/

• https://naturalnewsreference.com/2017-04-11-menveo-meningococcal-groups-a-c-y-and-w-135-oligosaccharide-diphtheria-crm197-conjugate-vaccine-patient-information-prescribing-information-ingredients-manufacturer-adverse-reactions-and-sid.html

• https://www.healthline.com/health/intramuscular-injection#injection-sites

• https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html

• https://www.amsn.org/practice-resources/care-term-reference/medications/question-what-current-practice-for-giving-im

• A-NURSE-Vascular Access Policy

https://infuserveamerica.com/116/reconstituting-your-medication/

https://naturalnewsreference.com/2017-04-11-menveo-meningococcal-groups-a-c-y-and-w-135-oligosaccharide-diphtheria-crm197-conjugate-vaccine-patient-information-prescribing-information-ingredients-manufacturer-adverse-reactions-and-sid.html

https://www.healthline.com/health/intramuscular-injection#injection-sites

https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html

https://www.amsn.org/practice-resources/care-term-reference/medications/question-what-current-practice-for-giving-im

ADDITIONAL MEDICATION CALCULATION PRACTICE PROBLEMS

What type of diluent can be used?


What type of diluent can be used? Answer: Sterile Water


How many mL should be added to the vial for IM use?


How many mL should be added to the vial for IM use? Answer: 2.5 mL


What will your final concentration be after reconstitution in mg/mL?


What will your final concentration be after reconstitution in mg/mL? Answer: 330mg/1mL


To give Ancef 250 mg IM, how much would you draw into the syringe?


To give Ancef 250 mg IM, how much would you draw into the syringe?On Hand Order

330 mg 250 mg

------------- = ------------------ = (250 x 1 / 330) = 0.76 mL

1 mL ? mL


When refrigerated, how long is Ancef stable?

When at room temperature, how long is Ancef stable?


When refrigerated, how long is Ancef stable? Answer: 10 days

When at room temperature, how long is Ancef stable? Answer: 24 hours

iv maintenance basics

Documents