Intravenous medicine Administration Nursing Aspects

1. Intravenous medicine AdministrationNursing Aspects

2. Risk Assessment • Is the treatment necessary? • Is there a lower risk alternative?

3. Patient assessment • Ask yourself about the patient, are there any conditions you will have to note: • Renal • Fluid restriction • Liver • Fluid restriction • sodium restriction • Diabetes • Dextrose restriction • High serum sodium • Normal values? 135-145 mmol/l

4. Allergies • Does the patient have any allergy • May range from mild itch to full blown anaphylaxis • giving? Do these contain Penicillin? • Amoxicillin? • Co amoxiclav (Augmentin)? • Co-trimoxazole (septrin)? • Tazocin? • Gentamicin?

5. Prior to preparation • Staff trained appropriately • Only those who have completed NHSGG&C’s training programme and maintained their professional knowledge and competence may perform IV medicine administration • 2 people check medicine, prescription and any calculation • Read information (monograph) before preparation • Clean area, wash hands

6. Risk assessment of medicine • What factors should we take in to consideration: • Stability • Special procedure for making up • What else can be drawn up into the vial? • Needle size 23g or use a blunt filter needle • Reconstitution device

7. General Principles for the Preparation of medicines • Prepare medicines immediately before use • Peel wrappers from needles and syringes • Disinfect all vial/ampoule closures/infusion ports with 70% alcohol solution and allow to dry • Do not add any more than one medicine to any solution • No interruptions while prescribing, preparing or administering medicines

8. Recent critical incident • Patient prescribed clarithromicin • Nurse prepared • Interrupted and left syringe with neat clarithromicin on side with chart • FY1 asked to give the medicine • Saw syringe and vial • Gave undiluted medicine to patient Always label a medicine if left unattended If interrupted, and start again.

9. Site Where do you want to give the medicine? • Peripheral • Central

10. Delivery How do you want to give it? • Bolus • Intermittent • Continuous If you are using a pump do you know how it works? If not...ASK and CHECK

11. Important Aspects The Prescription: • Clear, legible and signed • Read carefully • Question any changes The Patient: • Ensure correct patient • Obtain consent from patient • Ascertain allergy history • Know other medication the patient is receiving • Observe response during and after administration – document any reactions

12. Important Aspects Administration of the medicine: • Never administer a medicine prepared by another practitioner when not in their presence • Check that the medicine has not already been administered

13. Flushing • 10ml syringes used for flushing • Flush with sodium chloride 0.9% solution before, between and after administration of each medication unless the medication is not compatible with NaCl • Push pause method • Positive pressure • Flush must be prescribed or covered by a PGD

14. Complications - Speedshock • Rapid administration of a medicine • Toxic levels in the blood • Floods organs rich in blood, i.e heart, liver, brain • Fainting, shock and cardiac arrest

15. Complications -Phlebitis • Irritant medications • Cannula too big • Cannula not secured

16. Documentation • Document administration • Document cannula condition – phlebitis score • Document fluid administered

17. Complications -Infiltration • Leakage of fluid from the vein to the surrounding tissues. • Caused by cannula piercing the vessel wall. • Pain, paraesthesia, cold • Prevention? • Treatment?

18. Complications -Extravasation • Leakage of a vesicant fluid into surrounding tissues. • E.g. cytotoxic, sodium bicarbonate, phenytoin, dopamine, calcium chloride, potassium, amiodarone) • Treatment • Stop infusion • Leave cannula in • Mark area • Seek medical advice

19. Case study • Patient prescribed regular vancomicin • Cannula difficulties mean infusion rarely completed • Medicine signed as given on all occasions • What effect does this have on blood levels?

20. Emergency treatment of anaphylactic reactions See also page 18 of intravenous medicines self-directed learning package (adults)

21. What is … • Anaphylaxis is a severe life threatening, generalized or systemic hypersensitivity reaction. • It is characterised by rapidly developing life threatening airway and/or breathing or circulation problems • There are usually skin and/or mucosal changes

22. What causes anaphylaxis • Stings - 47 • Nuts -32, • Food -13 • Antibiotics – 27 • Anaesthetics drugs – 35 • Other drugs – 15 • Contrast media – 11 • Other – 4 Pumphrey RS suspected triggers for fatal anaphylactic reactions in UK 1992- 2001

23. Recognition and treatment • ABCDE Approach • Treat life threatening problems • Assess effects of treatment • Call for help early 2222 • Diagnosis is not always obvious

24. Airway • Swelling to the throat or tongue • Difficulty breathing and swallowing sensation of throat ‘closing up’ • Hoarse voice • Stridor

25. Breathing • Shortness of breath • Increased respiratory rate • Wheeze • Patient becoming tired • Confusion caused by hypoxia • Cyanosis – a late sign • Respiratory arrest

26. Circulation • Signs of shock – pale, clammy • Tachycardia • Hypotension • Decreased conscious level • Chest pain/ angina • Cardiac arrest • Do not stand the patient up

27. Disability • Sense of impending doom • Anxiety, panic • Decreased conscious level caused by airway, breathing or circulation problem

28. Exposure • Skin changes – often the first feature present in over 80% of anaphylactic reaction. • Erythema – patchy, generalised red rash • Urticaria – hives, nettle rash, weals or welts anywhere on the body. • Angioedema – swelling of deeper tissues e.g eyelids, lips, mouth and/or throat

29. Treatment • A. Establish airway • B. High flow oxygen • C. IV fluid challenge • Monitor – vital signs and responses to treatment • Intra-muscular adrenaline • Chlorphenamine • Hydrocortisone

30. Intra Muscular Adrenaline • IM doses of 1:1000 adrenaline (repeat once after 5 min if no better) • Adult or child more than 12 years: 500 micrograms IM (0.5 mL) • Child 6 -12 years: 300 micrograms IM (0.3 mL) • Child 6 months - 6 years: 150 micrograms IM ( 0.15)

31. Adrenaline • Caution with Intravenous adrenaline • For use only by experts. • For use only on monitored patients

32. Fluids • Once IV access established • 500 –1000mL IV bolus in adult • 20mL/Kg IV bolus in child • Monitor response - give further bolus as necessary • Colloid or crystalloid - 0.9% sodium chloride or Hartmann’s • Avoid colloid, if colloid thought to have • caused reaction

33. Steroids and antihistamines • Hydrocortisone and chlorphenamine • Second line drugs • Use after initial resuscitation started • Do not delay initial ABC treatments

34. Anaphylaxis • •Recognition and early treatment • •ABCDE approach • •Adrenaline • •Investigate • •Specialist follow up • •Education –avoid trigger • •Consider auto-injector

35. Further information on anaphylaxis is available at: www.resus.org.uk