Please read...New RN question

Kora0880, BSN, RN · Aug 27, 2009

IV means itravenous...it defines where the med is to be administered (into the vein) and not how...it does not imply using a pump, IV medications may be delivered by push, drip by gravity, etc......you will learn as you go.......this case is considered a med error (because of wrong delivery mode-reconstitution whcih caused a precipitate to form) and it should have been reported to your overseeing nurse/preceptor and event report written by her. Just a learning experience that's it. Most important is the condition of the pt and their safety. Besides with that on mind, please make sure there is a preceptor with you when you prepare and administer the meds...for the pts sake and for yours, after all you are learning.

Event reports are not there to point fingers at who did what wrong or punish. They are not a prelude to being reporimended. On the contrary, the event report goes up the chain of command to risk mgmnt so they see what happens in their clinical settings and how things like that can be prevented in the future. Oftentimes if same errors are seen, policies are introduced to eliminate or decrease the chance of someone making the same error in the future. Please always and always check meds with the MEdbook/medguide before giving if you are not familiar with them :) for your sake and the pts. Its a sign of safe and good practice, not of weakness; there are sooo many meds not one nurse knows it all....

Best of luck

K

Tait, MSN, RN · Aug 27, 2009

Diazepam is not compatible with any solution, however the safest and closest you can get is injecting it at the IV port right at the patient.

I do not believe, from what I have read on every site from drugs.com to drug abuser discussion forums that the incompatibility is at all severe enough to warrant a direct vein stick. Primarily you just want to remember it is not a drug you can dilute.

Tait

Oh, and be prepared if giving more than 1-2mg for your patient to potentially go into a drug-induced snooze almost immediately. The most recent time I gave IV Valium was 5mg to a surgical patient and he was out in 30 literal seconds. I looked at his wife, looked at him and called the MD. Freshie MD d/c'd the order pretty quick and the patient was fine in the end.

SweetOldWorld, BSN, RN · Aug 27, 2009

I am still on orientation. The other night at work a seasoned RN gave her pt Valium straight into the vein (like how a drug user shoots up) because Valium was not compat. with NS. I feel werid about it like it was not suppose to be done that way because the order said IV and when I think of IV I think of the IV pump but on the other hand the order said IV and that is into the vein. I guess I have never seen that before and was wondering what would you have done and was that okay to do?
Thank you very much. I am really nervous about being a RN there is so much to learn that wasn't in school!
XOXO,
Jennifer:redbeathe:heartbeat:nurse::typing:saint:

According to Gahart, the nurse did exactly the right thing. She says about diazepam: "Should be given directly into the vein. Inject into IV tubing close to vein site only when direct IV injection is not feasible." I've always injected into the closest port when giving valium, and I've never seen a precipitate.

When in doubt, look up your institution's policy and procedure, and follow that. Congrats on your new job!

Kora0880, BSN, RN · Aug 27, 2009

Hej sorry i did read your message wrong, and the nurse did it right! Now if she did dilute the med in NS prior to IVP that woud be a mistake but its good that you are observing these things, thinking about them and learning in the process.

K

Tait, MSN, RN · Aug 27, 2009

Once again this falls to hospital policy and procedure.

At our hospital we are not allowed to start an IV let alone inject via IV stick. As stated before and as I will support via my quotes below it is not necessary to inject Diazepam via direct vein access and the actual "preferred" method is IM due to the risk of vein damage.

For me this means dilution incompatibilities

"Diazepam is a useful premedication (the I.M. route is preferred) for relief of anxiety and tension in patients who are to undergo surgical procedures."

"Intramuscular: Diazepam Injection, USP should be injected deeply into the muscle.

Intravenous use: (See WARNINGS, particularly for use in children.) The solution should be injected slowly, taking at least one minute for each 5 mg (1 mL) given. Do not use small veins, such as those on the dorsum of the hand or wrist. Extreme care should be taken to avoid intra-arterial administration or extravasation.

Do not mix or dilute diazepam with other solutions or drugs in syringe or infusion flask. If it is not feasible to administer diazepam directly I.V., it may be injected slowly through the infusion tubing as close as possible to the vein insertion.

Once the acute symptomatology has been properly controlled with diazepam injection, the patient may be placed on oral therapy with diazepam if further treatment is required."

http://www.rxlist.com/diazepam-injection-drug.htm

None of the sites listed below listed any severe interaction with small amounts of IV fluids and Diazepam.

http://www.sedationfacts.org/sedation-medication/diazepam-endoscopy

http://www.drugs.com/pdr/diazepam.html

http://en.wikipedia.org/wiki/Diazepam

http://www.rxlist.com/diazepam-injection-drug.htm

Therefore my rationale against directly piercing a vein, though perhaps not considered "wrong", is as follows.

Diazepam and Dilution

Diazepam is insoluble in water. It is lipid-soluble.

Therefore mixing it in water will leave an unhomogenized syringe of part water/part medication.

Diazepam is to be administered slowly to prevent damage to the vein.

Therefore an unhomogenized mixture of water/NS etc and diazepam greatly increases the risk of damage to the vein due to one portion of the syringe having a greater concentration of diazepam to the other and thus allowing a "bolus" of diazepam despite an even and slow IVP.

Second diazepam has the potential to absorb into the plastic tubing of IV's, therefore decreasing the possible intial dose and leaving potentially harmful medication in the IV line if injected further up in the IV system than directly at the closest IV port. However this risk only appeared in one article:

http://www.sedationfacts.org/sedation-medication/diazepam-endoscopy

and was more in reference to slowly diminishing dosages during procedures due to IV tubing uptake of the medication.

Therefore a slim but realistic risk of IV line absorption is in place, making direct venipuncture administration of diazpam preferable to eliminate this marginal risk.

IV vs Venipuncture

Each entry into the body not only introduces potential infection (and rampant risks of MRSA/VRE/ESBL etc) it is also painful and invasive to the patient. In addition repeated accessing of several veins may reduce available veins for phlebotomy use in the necessary and life-saving lab values that need to be drawn.

Therefore weighing the risks of infection/discomfort against the risks of IV line absorption:

IVP > direct vein access

+ add in hospital protocol, procedures and pharmacy recommendations I do not see any reason for a nurse to access a new vein for each dose of diazepam.

Tait