Med admin help

squirtle · Dec 14, 2008

Hmmmm, maybe I should have posted my question in another area... Is there a way I can have it moved?

kmoonshine, RN · Dec 15, 2008

hey guys... i have some questions about meds, mainly iv meds, and need some help. these questions seem to arise every time i work and i have asked (i'm on orientation), but seem to be missing something and i never feel 100% comfortable when giving meds. i know these questions may sound silly, but i really need to understand.
1. let's say i have 3 iv meds to give- protonix, dilaudid, and lasix. let's say the pt has a peripheral iv with ns running at 50 ml/hr. can someone tell me the exact method i would use to give these meds? meaning, ovbiously i need to pull each one up in their own syringe... do i need to use a 10 ml syringe and dilute each with ns? do i need to flush in between each med? what is the easiest way to slow push? if the pt's iv is an int how do the rules change?
each time i ask these things i pretty much get "over time you will learn which drugs you need to slow push and which you don't", and with regard to the flush i get different answers.

here's what i'd do: think about what meds you're giving and why. then figure out what should be given first. with the above drugs, i'd probably give dilaudid first (treat their pain), then protonix, then lasix (lasix works pretty quick and if you give it first you might find the pt needs to use the bathroom while you're pushing the last of your meds). if the iv was going at 50ml/hr (0.9%ns), i'd continue to let the pump run (so it flushes the med in for you). i'd push dilaudid slowly over a few minutes, flush with saline, give the protonix over a few minutes, flush with saline, and give the lasix over several minutes (10mg = at least one minute). you can use one prefilled saline flush to flush between your three meds (just use 2ml or so each time).

you do not need to draw up each med in a 10ml syringe, unless that med needs to be further diluted (either for ease of administration, or due to the med causing irritation when given). if i'm giving an irritating med, i'll draw it up in a regular syringe that is closest in size to the volume i need (ie using a 3ml syringe for drawing up 2ml of medication). i'll then take a prefilled saline flush, squirt 2ml out, and inject 2ml of the medication into the flush (and voila, you now have a diluted med). its very inaccurate to draw up small volumes with large syringes (such as drawing up 0.5ml with a 10ml syringe). some meds actually shouldn't be diluted (such as valium, because a precipitate will form).

easiest way to slow push? look at the clock and start to push over the time frame for administration. i'll check the clock, then i push a little med every 15 seconds or so. just keep an eye on the clock and slow down or speed up according to the amount of time that you have left (if you have 1 ml volume to give over 2 minutes, then after 1 minute there should be about 0.5ml left to administer). its not an exact science, but general guidelines. i'll also multi-task and grab vitals at the same time.

i'm not sure what you mean by "if the pt's iv is an int how do the rules change?" i'm assuming you mean a capped line. if thats the case, i usually will dilute the med in 5-10 ml of saline, which helps when giving it slow push. again, it totally depends on the med because some meds shouldnt be diluted.

2. if my patient has a picc line i have been told only to push with a 10ml syringe because anything smaller uses too much pressure going in. so let's say i need to give my pt 25 mcg (0.5 mls) of fentanyl. i have to pull it up from a 100 mcg ampule (2mls). how do i do that correctly using the 10 ml syringe? one nurse told me to "eyeball" it, that's scary! and one pulled it all up in a syringe, diluted with ns and labeled the dosage on the syringe and we used it throughout the day. is that ok?

use a smaller syringe to draw up small volumes (you should have 1ml or even 0.5ml syringes; if you look at some insulin syringes, one side reads "units" and the other side reads "ml"). so, draw the med up in a small syringe and "squirt" it into a 10 ml syringe that is already drawn up with 9 ml of saline. don't forget to label it! and don't draw up the whole med and dilute it unless you're going to use all of it right away - and never give an iv med that someone else drew up (unless you are right next to them when they drew it up, in a code situation, or other similar circumstances). take out the fentnyl, draw up the volume you need, and then waste the rest of the ampule - don't carry it around or leave it lying around (too much room for error, diverting, contamination, and so on).

i understand an ampule might be tricky since you need a filter needle. you could draw up the whole volume into one syringe with the filter needle; then, remove the filter needle and use your "measuring syringe" (ie 0.5ml syringe) and insert the needle into the first syringe to draw up the exact amount you need. then waste the first syringe. this can be quite tedious since smaller syringes tend to be incompatible with needleless iv tubing (so you'll need to "squirt" the med into a compatable syringe, which tends to be larger in volume).

3. if my patient has a triple lumen picc and has insulin, heparin, and kcl going in and i need to give an iv push of a med that is incompatible with each of those, what is the proper way for me to give the med. i am thinking pause the kcl infusion, flush, give the med, flush, then resume the kcl infusion, is that correct?

i'm in the ed and i don't have a whole lot of experience with picc lines. however, i'd probably push the med through the kcl line (i wouldn't use the insulin or heparin line because you'd have to flush the line before and after the med - and if you did that, you'd be giving the pt a bolus of heparin or insulin). i'd do the same as you: pause the kcl infusion, flush the line well, give the med, flush the line well, and resume the kcl infusion.

tip: utilize your pharmacist! they can look up compatibility between meds for you. i carry around a pda with "nursing central" on it (which includes davis's drug guide; http://www.unboundmedicine.com/store/nursing_central_pda_wireless). when i look up a med, it tells you how to administer it (diluted, undiluted, over 5 minutes, rapid push, etc). i once forgot my pda and i felt so lost without it!

squirtle · Dec 16, 2008

Thank you SO very much for taking the time to explain all of that to me. It really cleared some things up. I had bits and pieces of what you said, but it was sort of jumbled up in my mind and I couldn't put it all together... if that makes any sense :bugeyes:

I can't thank you enough!

kmoonshine, RN · Dec 17, 2008

I hope what I wrote made sense! If you have any other questions or if you'd like me to explain anything else, just email or PM me - I'm happy to help!

blondy2061h, MSN, RN · Dec 17, 2008

1. Let's say I have 3 IV meds to give- protonix, dilaudid, and lasix. Let's say the pt has a peripheral IV with NS running at 50 ml/hr. Can someone tell me the exact method I would use to give these meds? Meaning, ovbiously I need to pull each one up in their own syringe... Do I need to use a 10 ml syringe and dilute each with NS? Do I need to flush in between each med? What is the easiest way to slow push? If the pt's IV is an INT how do the rules change?

I'm guessing these would all be IV push (we give all of them IV push). I use the secondary port on the NS. I'll alcohol it, push a flush through, push a med through, another flush (as at 50ml/hr you'd have to wait 8 minutes for a 10cc flush to go through), next med, flush, last med, last flush. If I had IV fluids at a faster volume (some of our patient's immediately post transplant or while getting chemo get NS at like 250ml/hr) I'll skip the saline flushes and just keep the fluids going as the flush. I put all my meds in a 10cc syringe or normal saline. To slow push a med i'll give like 2ml, wait 30 seconds, another 2ml, wait 30 seconds. Etc, etc.

I push most all meds slowly as any narcotic can cause too much of a buzz going in fast, as can benadryl, and Lasix can cause ototoxity going in too fast. Our EMR MARs tell how fast a drug can be pushed over on them, also.

But I don't really do any of this since we have pumps that do almost all of our IV pushes.

2. If my patient has a PICC line I have been told only to push with a 10ml syringe because anything smaller uses too much pressure going in. So let's say I need to give my pt 25 mcg (0.5 mls) of Fentanyl. I have to pull it up from a 100 mcg ampule (2mls). How do I do that correctly using the 10 ml syringe? One nurse told me to "eyeball" it, that's scary! and one pulled it all up in a syringe, diluted with NS and labeled the dosage on the syringe and we used it throughout the day. Is that ok?

I don't give meds I didn't draw up, and it's overall poor practice to do that. I use a 1ml syringe to draw up the med I need to give, waste the rest of the med with another RN, then shoot out 1ml of NS from a 10ml flush syringe, draw back air (just so the med doesn't spray all over, it has someplace to go), put a new needle on the 1ml syringe (if you have a filter needle on it from the ampule), and shoot it into the Flush syringe. I label this syringe, even if I just have that one med I'm giving and know I'll use it all. I always, always, always label my syringes.

3. If my patient has a triple lumen PICC and has insulin, heparin, and KCL going in and I need to give an IV push of a med that is incompatible with each of those, what is the proper way for me to give the med. I am thinking pause the KCL infusion, flush, give the med, flush, then resume the KCL infusion, is that correct?

I pause one of the infusions, disconnect it, cap off the tubing, put the capped tubing aside, and use the lumen to flush/push med/flush, then reconnect the continuous infusion and resume it.

A better practice, however, is to always check compatibilities on all of your meds (we have a software program to do this) and consolidate as much as possible. I don't know compatibilities off the top of my head, but, you can check and see if the heparin and KCl are compatible, and running them each on their own pump, use the secondary port on the tubing (near the patient) to "y" them into each other, leaving one lumen open for pushes and blood draws. This is a life saver.