When drawing push meds, do you draw the med first?

[anangelsmommy, ADN, BSN, RN]

ok, I am in my last month of school, and I am trying to clarify something I learned in school. I have tried looking it up and online and I cannot find it. Perhaps I can find either a source here or a consensus among the learned nurses....when you are drawing up your IV push meds that need to be diluted....do you know what the proper what to dilute or can you tell me how you were taught to do it and why? Do you first draw the diluent and then the medication into the syringe? or the medication and then the diluent? for instance 2 mls of lorazepam and then 2 mls normal saline or would you first draw up 2mls of normal saline and then 2 mls of lorazepam? And please explain?

It seems to me that each draw you have the capacity to take in too much of one of solutions, either normal saline or lorazepam. or are you supposed to be pulling back and injecting air so you only take in the amount you need? or are you just drawing back exactly what you need and stopping? I just need to know exactly. I had to dilute medication this week and then was told something very quickly....it didnt make sense and I know I will be asked to discuss next week, I want to make sure for my own and my patients well being that I know everything there is to know about this subject...unfortunately, we dont get a chance to practice this, we just do it in clinical!

thanks for your help!!

angelsmommy!!:uhoh3:

[aura_of_laura]

You should draw up the diluent first. Many times the diluent will come in a multi-dose vial, while the medication is in a single dose vial. If you draw the med up first, you contaminate the diluent vial, and can lose some of the medication.

My practice: Draw up amount of diluent, inject diluent into med vial (if med is powdered, etc.), shake if indicated, draw up total volume from med vial, administer.

In your scenario, draw up the 2 mL saline, and then draw up the lorazepam. Usually lorazepam comes in 1 ml vials, so you would have to draw up two of them.

*Important* the amount of air you inject will not determine the amount of medication that pushes into your syringe! Never assume that just because you put in 1 cc of air, 1 cc of saline will come out. I usually use twice the air as the amount of med I need, so the med comes out easier.

[Work in Progress]

This is how I do it, but I am interested in other replies as well as I have never officially been taught a "right" way, or seen any articles on the topic. This is, however, the way I have seen many, many nurses do it.

In the scenario you describe, I would draw up the lorazepam into a syringe first to ensure the most proper measurement. Then I actually take a prefilled flush, empty it of all but my desired amount of saline. Then I inject the drug into the saline flush. I tape the original container to the flush to keep track of what the medication is. I feel like this works well for me and gives me the most accurate dosing.

[aura_of_laura]

Then I actually take a prefilled flush, empty it of all but my desired amount of saline. Then I inject the drug into the saline flush.

That's interesting! We don't have saline flushes at my hospital (we don't have IVs) - I'd never have thought of that!

[Up2nogood RN, RN]

This is how I do it, but I am interested in other replies as well as I have never officially been taught a "right" way, or seen any articles on the topic. This is, however, the way I have seen many, many nurses do it.

In the scenario you describe, I would draw up the lorazepam into a syringe first to ensure the most proper measurement. Then I actually take a prefilled flush, empty it of all but my desired amount of saline. Then I inject the drug into the saline flush. I tape the original container to the flush to keep track of what the medication is. I feel like this works well for me and gives me the most accurate dosing.

We do this also, we don't even have multidose vials available anymore.

[anangelsmommy, ADN, BSN, RN]

Actually injecting the medication into the saline flush seems like it would be the most efficient and not lose any of the medication. We have to label all medication so i would not need to attache the vial. We label before leaving the med room. I was told to draw up the saline first but what I was concerned with was if I accidentally drew up too much medication, if must be EXACT, or you could be pushing SALINE AND MED back into the med vial - we throw away the vial anyway but I am more concerned with the patient getting the correct dose.

Or when drawing the med in- would it not mix that quickly? or do you just need to be that exact that you just dont draw in too much. I like this method. I will have to review this with my instructor and see if this is acceptable, this seems like not only a much more safe and effecient but quicker!

angelsmommy

[Nursetastic]

I draw up the med first, for accurate measure, then I get a prefilled flush and use the same needle/syringe to draw saline out of the flush. No need to push air into the flush so no risk of losing any of the med. Then either use the flush as part of your push administration or trash it. We don't have multidose saline vials anymore. That is how my preceptor taught me and all the nurses on my unit seem to do it that way.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

I would draw up the medication first for accuracy sake. There's usually more leeway and less danger with the diluent.

As far as air, I stopped injecting it (I know everybody will wince!). I've been sprayed by meds too many times as I remove the needle. Some burn, some really stink. Get sprayed when drawing Thiamine and you'll spend the rest of your shift smelling like a vitamin pill.

I'm open to creative criticism if anyone has a better idea.

[anangelsmommy, ADN, BSN, RN]

As far as the air is concerned, I would think it is probably more of a concern with multidose vials and more meds at least in a hospital are coming in single dose. Right? Now if you work in home care and you are doing patient care with multidose or perhaps some other sort of facility that might use multidose....but the only type of med that I can think of that we use that comes in multidose is our insulin.

I would assume it hasnt been a problem getting medication out or you wouldnt be doing it?

angelsmommy

[anangelsmommy, ADN, BSN, RN]

dthfytr,

what you wrote makes a lot of sense...if you draw up the med first, it doesnt really matter how much diluent you draw up...but that is the opposite of what is being taught. So what is the rational there. or better yet, what is the rational for doing it the other way? I would be concerned about not losing the medication but it doesnt really matter how much diluent you have. I did look on this website previously looking for information on IV push meds and I found that people were using up to 10ccs to dilute their IV push meds becuase they could push 10cc's very slow vs trying to push 1cc slow. But at least while under instruction I have to do it the way I am told, yet this seems to make more sense because if I were to get say an extra ml more than I intended of diluent, well, I would just leave it in the syringe and use it but if I did that with medication what would I do?? start over? right?

angelsmommy

[xstarsfallingx]

I think the biggest hurdle for me to tackle as a new RN was dilution. The truth of it has become, it is more dangerous to underdilute than overdilute. In fact, I often dilute past pharmacy recommendations, especially if I am administering a caustic antibiotic into a PIV...and run very slowly.

Ativan is recommended as a 1:1 dilution, minimum. I will often dilute it further if it is an around-the-clock dose. Now, if it's a stat med for seizing, I would give it 1:1.

We have pre-filled flushes, so I usually draw the Ativan into a 1cc syringe, transfer it into an empty 10cc syringe (our syringe pumps are not compatible with small syringes), and then add my saline with either a needless cannula (it pops right into the top of the syringe) or a female-female connector.

If you only have access to multi-use vials, then yes, I would draw the saline first...but I would probably still use a separate syringe for the Ativan to be sure I measured correctly, and then transfer it into the saline. It is too easy to draw back too much, and once you already have the saline, you aren't wasting the correct amount of med to compensate.

Everyone has their own method...and you'll figure out what works for you. For now, don't get all hung up on the details because it will just drive you crazy. Methods will change from one clinical instructor to another. Just be open to them all and then figure out what you feel most comfortable with.

[Spritenurse1210, BSN, RN]

I always draw up the medicine first and use a pre filled saline flush unless the medicine is not compatable with saline or needs to be re constituted. I prefer accuracy of dosing over contamination of the diluant vials, becayse in my hospital I can always get a fresh bottle if the one I'm using becomes contaminated