10 Key Knowledge Principles for Safer Intravenous Therapy
When you master the mathematical basics and you have the skills and knowledge in medicines management, you can go on to the more advanced form of drug administration — intravenous (IV) therapy. Here are ten useful key factors to enable you to administer safe and accurate IV therapy to your patients.
Beginning at the beginning
If you feel a lack of confidence with your mathematical ability and a tendency to shy away from anything to do with math problems in your clinical area, you need to confront this fear head-on and undertake some practice. If you haven’t worked your way through problems for some time and you feel a little rusty trying to recall the decimal units, remember that many drug errors are due to calculations errors so you do need to become conversant with these units again.
Another area you may need to revise is the accepted abbreviations permitted on prescription charts, such as ‘PRN’ (‘as required’), because they can look like a foreign language.
As with any clinical skill, always take your time, never rush the task in hand and if you’re unsure about anything — ask someone!
Knowing the types of medicines
Before administering any medication to a patient, you must have knowledge of medicines management: in other words, know your drug!
Medicines come in many different formats: tablets, liquids for oral ingestion or injection, and topical application. The liquid medications may be administered topically or via different routes, such as subcutaneously, intramuscularly or intravenously. Some medications come as a double whammy — such as codeine phosphate and paracetamol together. Other drugs are classed as smart drugs — releasing their active ingredients over a set period of time, for example ‘modified release’ as in the case of certain drugs administered for Parkinson’s disease.
In order to keep your patients safe, know the doses to be administered, contra-indications and adverse reactions of the medication.
Giving tablets and capsules
Just like the wedding cake at the start of this chapter, you wouldn’t start administering medications with the more advanced skill intravenous therapy. You need to start with oral medications, moving on to the injectables before getting the IVs! You need to start with the basics.
Administering medications to patients is one of the most common nursing tasks, and it isn’t about simply dishing out the drugs — there’s so much more to this skill than that! What’s the drug for (the indications)? What’s its format (tablet or capsule)? What strength does the drug come in? Should the patient even be prescribed this drug (what are the drug’s cautions — prescribers do make mistakes)? As the administrator, you only give the drug when you’re satisfied about all these things.
Then you may have to work out how many pills or capsules the patient requires. This is where the ever-valuable formula comes into its own:
What you want (what’s prescribed) divided by What you’ve got (how the drug is presented)
When administering tablets, you need to know what drugs can be split in half, because some medications are presented in a specialised coating so the pill can’t be cut, as in the case of capsules.
Taking into account the physiological factors
As a nurse, midwife or assistant practitioner, you spend some time during your training looking at the physiological aspects of care, recognising the patient’s norm from the abnormal. In short, drug administration goes hand-in-hand with the patient’s condition, linking it to the physiological factors.
For example, if a patient is pyrexic, you’d speak to a physician to get paracetamol prescribed. Equally, if a patient is suffering from diarrhoea today, you don’t administer the prescribed laxative (PRN).
Whether you’re caring for a newborn baby and need to determine infant feeding requirements, working out calculations to do with body surface or body mass index or a patient’s cardiac output measurements or lung function, you need to know the advance formulae to work out these calculations. Obtaining these calculations enables you to treat the patient holistically (as a whole).
Drug administration is about looking at the facts and using your professional judgement. Two ways in which you can assess patients’ conditions is by obtaining blood samples (venepuncture) and via their vital signs.
Administering intravenous drugs
Not so long ago, preparing IV drugs was regarded as an extended skill, but in today’s healthcare environment it’s seen as a core clinical skill. That doesn’t imply complacency, however. You need to assess factors such as timing considerations, because some medications are to be given over set time limits. You have to reconstitute other medications from powder into a liquid for IV administration, possibly taking into account the displacement factor. The drug may need to be titrated according to the patient’s body weight — one size doesn’t fit all.
You need to assess the whole picture, obtaining patient information by asking questions such as, ‘Has the patient ever had this drug before?’ or ‘Are there any factors that may indicate that the patient shouldn’t receive this medication?’ Preparing the drug also requires an assessment of equipment, such as syringe size for drawing the drug up and the needle type to use. For bolus administration, you may need to know how many millilitres to draw up, which is where the following formula comes into its own:
What you want divided by What you’ve got divided by Volume (of the liquid the drug is presented in)
Dealing with intravenous infusions
When administering IV fluids, knowledge around total body water volume is vital: administering too much fluid can be just as harmful to the patient as administering too little. For this reason, a fluid chart is invaluable, so that the healthcare professional can assess the patient’s fluid balance. You also need to know the type of fluid you’re administering and the compartments of the body you want the fluid to travel to (in, outside or around the body cells).
When working out the drip rates, you have to know what type of pump you’re using and how to set it up with the administration set. Without a pump, the formulae is:
Volume (the prescribed volume in ml) divided by Time in hours (the prescribed time) multiplied by Drops per ml (dependent on the infusate) divided by Minutes per hour (always 60)
Some medications such as heparin and insulin can be administered by continuous infusion, and you need to follow special protocols.
Looking after the IV access device
When administering IV medications through an IV access device, take extreme care with infection control. Whether the device is a peripheral access device or a central line, the drug goes straight into the bloodstream. Any microorganism present during the preparation or administration of the drug therefore enters the patient’s central system, often with devastating consequences.
The Department of Health undertook a campaign to reduce the number of hospital-acquired infections, introducing the Aseptic and Aseptic Non-Touch Technique, starting with hand hygiene. Other national drives have been to reduce the number of sharps injuries, such as needle-stick injuries.
A patient can have an allergic reaction to anything — exposure to an antigen that causes the allergic reaction. Anaphylaxis is the most extreme form of an allergic reaction. As a healthcare professional, you have to know how to recognise this condition and treat it quickly, because adults are more likely to experience an anaphylaxis event due to drug administration.
The first line of defence for an anaphylaxis event is adrenaline (expressed as 1:1,000) administered by intramuscular injection and oxygen, if available. The second line of defence is the prescribed medications: IV fluids, antihistamine and hydrocortisone (to reverse the effects of the allergic response).
Blood transfusion is a highly advanced form of IV therapy and is technically classed as a tissue transplant. Blood transfusion is a skill in four parts, for which nurses and midwives need training:
Obtaining a venous blood sample
Organising receipt of blood products
Collecting blood products
Preparing and administering blood products
Any healthcare support worker taking part in this procedure, even if only collecting the blood product, must have received specialised training.
Caring for the patient in pain
Morphine is a strong opiate and the gold standard of pain management. Intravenous morphine is a highly specialised form of drug therapy for pain management. Healthcare professionals administering this opiate via the IV route need to have an understanding of the dosages prescribed and administered and how to prepare this medication.
They require an awareness of the complications and side effects of opiates, with an understanding of the antidote to be administered if required, and the observations to be undertaken, such as respirations and patient sedation levels.