The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [571]
All the points considered when preparing for a continuous infusion should be taken into account here, for example pre-prepared fluids, single additions of drugs, adequate mixing, labelling and monitoring.
Direct intermittent injection
Direct intermittent injection (also known as intravenous push or bolus) involves the injection of a drug from a syringe into the injection port of the administration set or directly into a VAD (Chernecky et al. 2002, Turner and Hankins 2010). Most are administered anywhere from 3 to 10 minutes depending upon the drug (Weinstein and Plumer 2007, Whittington 2008).
A direct injection may be used when:
a maximum concentration of the drug is required to vital organs. This is a ‘bolus’ injection which is given rapidly over seconds, as in an emergency, for example adrenaline
the drug cannot be further diluted for pharmacological or therapeutic reasons or does not require dilution. This is given as a controlled ‘push’ injection over a few minutes
a peak blood level is required and cannot be achieved by small-volume infusion (Turner and Hankins 2010).
Rapid administration could result in toxic levels and an anaphylactic-type reaction. Manufacturer’s recommendations of rates of administration (i.e. millilitres or milligrams per minute) should be adhered to. In the absence of such recommendations, administration should proceed slowly, over 5–10 minutes (Dougherty 2002).
Delivery of the drug by direct injection may be via the cannula through a resealable needle-less injection cap, extension set or via the injection site of an administration set.
If a peripheral device is in situ, the bandage and dressing must be removed to inspect the insertion of the cannula, unless a transparent dressing is in place (Finlay 2008).
Patency of the vein must be confirmed prior to administration and the vein’s ability to accept an extra flow of fluid or irritant chemical must also be checked (Dougherty 2008).
Administration into the injection site of a fast-running drip may be advised if the infusion in progress is compatible in order to dilute the drug further and reduce local chemical irritation (Dougherty 2002). Alternatively, a stop–start procedure may be employed if there is doubt about venous patency. This allows the nurse to constantly check the patency of the vein and detect early signs of extravasation. If the infusion fluid is incompatible with the drug, the administration set may be switched off and a compatible solution may be used as a flush (NPSA 2007d).
If a number of drugs are being administered, 0.9% sodium chloride must be used to flush in between each drug to prevent interactions. In addition, 0.9% sodium chloride should be used at the end of the administration to ensure that all the drug has been delivered. The device should then be flushed to ensure patency is maintained (Dougherty 2008).
The following principles are to be applied throughout preparation and administration.
Asepsis and reducing the risk of infection
Microbes on the hands of healthcare personnel contribute to healthcare-associated infection (Weinstein and Plumer 2007). Therefore aseptic technique must be adhered to throughout all intravenous procedures. The nurse must employ good handwashing and drying techniques using a bactericidal soap or a bactericidal alcohol handrub. If asepsis is not maintained, local infection, septic phlebitis or septicaemia may result (Hart 2008, Pratt et al. 2007, RCN 2010).
The insertion site should be inspected at least once a day for complications such as infiltration, phlebitis or any indication of infection,