2.4: Applying the Nursing Process
Assessments Prior to the Procedure
Prior to administering medication via IV push, the nurse should assess the patient and the IV site to ensure appropriateness of medication administration. Pre-administration patient considerations ensure vital signs, pain level, laboratory results, and other focused assessments related to the medication to be administered are within the appropriate ranges. The skin around the IV access site must be assessed for swelling, erythema, blanching, warmth, coolness, or pain that may indicate the site is compromised or the cannula is not located in the appropriate position within the vein’s inner lumen. Ensure the type of catheter is appropriate for its planned use. For example, if a patient has a peripheral IV ordered prior to a diagnostic procedure using contrast dye, an 18-gauge IV catheter is typically required for this procedure.
To comprehensively examine the IV insertion site following visual observation, the nurse should assess for patency of the cannula by aspirating to check for blood return and infusing 1-2 mL of saline (for adult patients) into the IV site. The site should flush freely, and no significant resistance or pain should be noted. Blood return may not be noted on aspiration, but it should be assessed and documented. [1] If no blood return occurs, the vein may be lightly palpated as the normal saline is injected to feel the fluid travel in a straight line in the vein. While checking the patency of the IV cannula, the nurse should also carefully observe the insertion site for swelling or fluid leakage to confirm the cannula has not dislodged and the solution is properly entering the vein and not leaking into the surrounding tissue. Peripheral sites should be routinely flushed per agency policy, typically once per shift for saline locks.
Additional nursing considerations related to IV push medication administration include measures to decrease potential hazards. Proper hand hygiene, aseptic technique, standard precautions, appropriate personal protective equipment, and sharps safety must always be implemented. The nurse should also review a drug reference guide for medication information related to drug dosage requirements, proper rate for administration of the push, and the appropriateness of the existing infusion site. For example, if the medication requires a central line for administration, a peripheral access site should not be used. The nurse should also be aware of the availability of monitoring equipment required for post-administration assessments, such as a pulse oximeter, blood pressure cuff, cardiac monitoring, or hemodynamic monitoring via an arterial line.
Additional safety principles when preparing for IV push medication administration to protect the safety of the patient and the nurse are described in the following section.
Other Safety Considerations for IV Push Administration
- To reduce the risk of needlestick injuries, use a blunt needle or blunt filter needle when preparing injections from vials or ampules. Use a needleless system when injecting medication into existing IV tubing.
- After preparing the medication, label the medication syringe with two patient identifiers, date, time, medication, dose, your initials, and any diluent added. Never leave the syringe unattended.
- Verify the peripheral IV access is appropriate for administration of the IV push medication.
- Always verify the compatibility of the medication with other running IV fluids and medications.
- Check agency policies for flushing and locking peripheral IV sites prior to administering the medication.
- Check the patient’s medical record for allergies and also verify by asking them if they have any allergies. This is especially important if a new medication has been prescribed.
- Administer the post-administration saline flush at the same rate as the IV push medication rate (based on rate of administration guidelines in a drug reference guide). Know the volume to be flushed based on type of tubing and equipment to ensure the medication is not under-dosed.
- Always assess the patient’s current status and need for the ordered IV medication prior to administration.
- Provide patient education and confirm their understanding of the prescribed medication and potential side effects to report.
Whenever possible, premixed medications should be used to decrease the chance of vial contamination or calculation error with administration.
Review the following table for additional safety principles that should be followed prior to medication administration.
| Principle | Additional Information |
|---|---|
| Verify your qualifications for administration of this medication on this unit. | Are you qualified to administer this type of medication? For example, administration of chemotherapy agents requires specialized training, and many vasoactive medications require cardiac monitoring. |
| Review the route of administration for this medication. | Review a drug reference guide to verify this medication can be given by the IV route. |
| Review preparation and medication administration information. |
Review a drug reference guide for how this medication should be administered by the IV route. For example, does it require dilution or reconstitution? Use less-concentrated solutions whenever possible. If diluting the medication, discard (i.e., waste) the unused portion before going to the bedside.
Review agency policy regarding the frequency of vital signs monitoring before, during, and after administration. |
| Identify when a medication should start to work. | What are the onset, peak, and duration of the medication? |
| Assess the dosage and safe range for this medication. | Is the ordered dose safe for this patient based on their age, kidney function, liver function, etc.? When did the patient last receive this medication? What was the effect of the medication on the patient the previous time they received it? |
| Understand the therapeutic effect. | What is the expected therapeutic effect of this medication for this patient, and when is it anticipated to occur? What assessments should be performed to evaluate the effectiveness of this medication for this patient? |
| Know the adverse effects. | What are the potential adverse effects of the medications? How should severe adverse effects be managed? Is there an antidote for overdose? |
| Know potential incompatibilities. | Are there any potential incompatibilities with existing IV solutions or medications? Is a second peripheral access site required? |
| Know how to complete the procedure. | Is a post-saline lock flush required? If so, what is the amount? The amount can vary based on the size of the tubing and equipment, as well as agency policy. |
| Document the procedure. | Where will you chart the administration of this medication and what will you chart (i.e., Medication Administration Record, intake of IV fluid flush, pre- and post-pain assessment, pre- and post-vital signs, etc.)? |
Additional Administration Considerations
Prior to administering an IV push medication, the nurse should consider whether or not the administration will be given via a saline lock or a primary IV line with infusing fluids and/or medications. Procedural considerations vary depending on the type of access that is available.
If medication is being administered via a primary line, the nurse should first assess the insertion site and then determine the compatibility of the ordered medication with the infusing fluid. If the ordered medication is not compatible with the infusing fluids, a second peripheral IV access site may be required, or it may be possible to first flush the primary line with saline to clear it of incompatible fluids.
If continuous IV fluids are being administered, the IV pump should be paused after noting the current infusion rate of the primary line. The port on the IV tubing closest to the IV insertion site must be identified and cleaned per agency policy. Many agencies require caps on unused ports that are impregnated with alcohol. The tubing should be clamped above this port and the IV site flushed with normal saline before administering the IV push medication. If the IV solution is not compatible with the IV push medication, then the site must be flushed with a minimum of 5 to 10 mL. The IV push medication is then administered according to the correct administration rate and followed by a saline flush with the same rate and volume of saline as the medication that was administered. The nurse may restart the infusing fluids at the rate previously noted if the fluids are compatible with the medication. [3]
If IV push medication is to be administered into a saline lock, the site must be assessed and determined to be in good condition. The port is cleaned, and a saline flush syringe attached. Prior to pushing saline into the lock, the plunger is pulled back gently to check for blood return. The presence of blood return indicates the cannula is appropriately located within the patient’s vein but may not occur. If blood return is not noted, the nurse may proceed to slowly flush a small amount of saline while monitoring for resistance, leaking, pain, or swelling with the first few milliliters of saline flushed into the lock device. If no complications are noted, the flush syringe is removed, the port is cleaned, the medication syringe is attached, and the medication is administered using the recommended administration rate. The timing of the rate of administration begins immediately if a cap is present; otherwise, if a J-loop is present, timing starts after 1 mL of the medication has been instilled. After administration of the medication, the syringe is removed, the port is cleaned, and another saline flush syringe is attached. The saline flush should be administered at the same rate as the medication was administered to ensure that medication still present within the saline lock line is safely administered at the appropriate rate. The connection port should be swabbed with each exchange and attachment of saline and medication syringes.
Clinical Tip: A common acronym for administration of IV push medication into a peripheral IV is SAS (Saline – Administration of medication – Saline). Follow agency policy for maintaining IV patency.Evaluation After the Procedure
Follow agency policies and procedures regarding IV administration guidelines and the type and frequency of monitoring after IV medications are administered. The nurse performs this monitoring and documents the patient’s response to the medication. This includes performing any necessary reassessments. Recall that medications administered via the IV route peak much more quickly than oral medications absorbed through the gastrointestinal tract.
- Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 44 (1S Suppl 1), S1–S224. https://doi.org/10.1097/NAN.0000000000000396 ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵
- Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 44 (1S Suppl 1), S1–S224. https://doi.org/10.1097/NAN.0000000000000396 ↵