The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [570]
Any nurse administering intravenous drugs must be competent in all aspects of intravenous therapy and act in accordance with The Code (NMC 2008b), that is, to maintain knowledge and skills (Hyde 2008, RCN 2010). Training and assessment should comprise both theoretical and practical components and include legal and professional issues, fluid balance, pharmacology, drug administration, local and systemic complications, infection control issues, use of equipment and risk management (Hyde 2008, RCN 2010).
The nurse’s responsibilities in relation to intravenous drug administration include the following.
Knowing the therapeutic use of the drug or solution, its normal dosage, side-effects, precautions and contraindications.
Preparing the drug aseptically and safely, checking the container and drug for faults, using the correct diluent and only preparing it immediately prior to administration.
Identifying the patient and checking allergy status.
Checking the prescription chart.
Checking and maintaining patency of the VAD.
Inspecting the site of the VAD and managing/reporting complications where appropriate.
Controlling the flow rate of infusion and/or speed of injection.
Monitoring the condition of the patient and reporting changes.
Making clear and immediate records of all drugs administered (Finlay 2008, NMC 2008a, NMC 2008b, RCN 2010).
Evidence-based approaches
Methods of administering intravenous drugs
There are three methods of administering intravenous drugs: continuous infusion, intermittent infusion and direct intermittent injection.
Continuous infusion
Continuous infusion may be defined as the intravenous delivery of a medication or fluid at a constant rate over a prescribed time period, ranging from several hours to several days to achieve a controlled therapeutic response (Turner and Hankins 2010). The greater dilution also helps to reduce venous irritation (Weinstein and Plumer 2007, Whittington 2008).
A continuous infusion may be used when:
the drugs to be administered must be highly diluted
a maintenance of steady blood levels of the drug is required (Turner and Hankins 2010).
Pre-prepared infusion fluids with additives such as those containing potassium chloride should be used whenever possible. This reduces the risk of extrinsic contamination, which can occur during the mixing of drugs (Weinstein and Plumer 2007). Only one addition should be made to each bottle or bag of fluid after the compatibility has been ascertained. More additions can increase the risk of incompatibility occurring, for example precipitation (Weinstein and Plumer 2007, Whittington 2008). The additive and fluid must be mixed well to prevent a layering effect which can occur with some drugs (Whittington 2008). The danger is that a bolus injection of the drug may be delivered. To safeguard against this, any additions should be made to the infusion fluid and the container inverted a number of times to ensure mixing of the drug, before the fluid is hung on the infusion stand (NPSA 2007d). The infusion container should be labelled clearly after the addition has been made. Constant monitoring of the infusion fluid mixture (Weinstein and Plumer 2007, Whittington 2008) for cloudiness or presence of particles should occur, as well as checking the patient’s condition and intravenous site for patency, extravasation or infiltration (Downie et al. 2003).
Intermittent infusion
Intermittent infusion is the administration of a small-volume infusion, that is, 25–250 mL, over a period of between 15 minutes and 2 hours (Turner and Hankins 2010). This may be given as a specific dose at one time or at repeated intervals during 24 hours (Pickstone 1999).
An intermittent infusion may be used when:
a peak plasma level is required therapeutically
the pharmacology of the drug dictates this specific dilution
the drug will not remain stable for the time required to administer a more dilute volume
the patient is on a restricted intake of fluids (Whittington 2008).
Delivery of the