HLTEN519C Administer and Monitor Intravenous Medications in the Nursing Environment

Mr George Stanford is a 60yr old gentleman who was admitted to the surgical ward you are working on, Mr Stanford has just returned from theatre at 12pm following a right anterior cruciate ligament (ACL) reconstruction. Post operatively - Mr Stanford's doctor has ordered intravenous fluids of Hartman's solution 1000mls over 8 hrs with a drop factor of 20, Mr Stanford also has a patient controlled analgesia (PCA) pump of 100mgs of morphine in 100mls of normal saline (concentration of 1mg/ml) set to deliver 1mg / dose when Mr Stanford presses the patient controller, there is a lockout interval of 5minutes. 

(Mr Stanford is a keen motorcycle enthusiast and while working on his motorbike recently experienced a ACL tear to his right knee when attempting to rescue the motorbike from falling over.)

Often patients who have received a blood transfusion experience no complications or problems.   However, minor to severe problems do occasional occur. Some of the most common complications include fever, allergic reactions, acute immune haemolytic reaction and blood-borne inflections.

Packed red blood cells are administered for excessive blood either due to a surgery or other clinical complexities. Packed red blood cells work by increasing the haemoglobin count and reviving the oxygen supply to the tissues, hence are the first in medical conditions associated with rapidly decreasing haemoglobin count. ("American Red Cross -blood transfusion", 2017). 

Often patients who have received a blood transfusion experience no complications or problems.   However, minor to severe problems do occasional occur. Some of the most common complications include fever, allergic reactions, acute immune haemolytic reaction and blood-borne inflection ("American Red Cross -blood transfusion", 2017). 

Blood transfusion is tricky medical procedure, where a single mistake can harm the patient exponentially. The first responsibility of the nurse is to check the compatibility of the patient to the ordered blood sample via a type and cross match test. The next step in the preparation is obtaining the informed consent from the patient, the nurse is at all times liable to inform the patients about the procedure and the possible side effects (American Red Cross -blood transfusion, 2017). Prior to the transfusion procedure it is also vital that the nurse crosschecks the bag of PRBC with the blood bank form, details of the patient and expiry date. Next set of observations would be checking the temperature of the patient, along with RR, PR and BP. The vitals should be monitored every hour diligently and during the start and finish of each bag. The nurse should take care that the blood bags are taken out from the refrigerator and the nurse should always stay with the patient during the first few minutes of the transfusion (American Red Cross -blood transfusion, 2017). 

1. The mls/hr rateof Mr Stanford’s IV?

Formula : volume in mls           = infusion rate (mls per hr)

                     Time in hrs

1000mls  =    125 mls/hr

8hrs

The drops/min rate of Mr Stanford’s IV? 

Formula : volume in mls         X Drop factor = Drops per min

                    Time in mins

1000mls  =    X 20 =  42 drops/min

8hrs (480mins)   

In isotonic solution cells neither gain nor lose water through osmosis because the concentrations of solutes in the cell are equal to the solutes outside of the selectively permeable membrane. As a result, nothing happens because the concentrations of water solutes outside of the cell are equal to the solutes within the cell. Isotonic solutions are commonly used in medical situations. For example, hospitals use isotonic saline solutions for IVs for patients ("What is an Isotonic solution?", 2017).

Hypertonic Solutions:

Hypertonic solutions are different from isotonic solutions in that cells often lose water. Cells have a water concentration that is greater inside the cell rather than outside of the cell. Furthermore, the solutes outside of the cell are greater than the solutes inside of the cell. When osmosis uses diffusion, cells tend to lose water because the water travels from an area of high concentration (inside of the cell) to an area of lower concentration (outside of the cell) ("What is an Isotonic solution?", 2017)

When this happens, cells can become dehydrated and die. Therefore hospital IV solutions are not hypertonic.

Hypotonic Solutions: 

Hypotonic solutions are the complete opposite of hypertonic solutions. Cells often have a water concentration that is lower than outside of the cell. Following this, the solutes outside of the cell are less than the solutes within the cell ("What is an Isotonic solution?", 2017). As a result of diffusion, cells tend to gain water because the water travels from an area of higher concentration (outside of the cell) to an area of lower concentration (inside of the cell).

When cells gain water, they risk rupturing unless they maintain this balance (through a selectively permeable membrane).

1. What would be your immediatenursing action for Mr Stanford and what is the follow-up reporting that you would carry out

Immediate nursing action for Mr Stanford when he complained about feeling shortness of breath check patient if he appears to show colour of red or blue signs of circulation position him into a semi fowlers or position of comfort. Monitor Obs and oxygen stats also notify Rn and Doctor for assessment. (Medicine.N,D) 

The DR reviewed Mr Stanford and diagnosed fluid overload, what are typical signs of this condition?

Answer: Excessive intravenous fluids, blood transfusions:

• The risk of fluid overload is higher in elderly patients and if there is cardiac or renal impairment, sepsis, major injury or major surgery.

The clinical symptoms of fluid overload or hypervolemia include edema or pitting edema in some cases, distention, bounding pulse and irregular heart beat (Australian medicines handbook, 2017). 

1. Discuss the common indications for use of this particular medicine, highlighting the specific use for this case study

Answer: Furosemide is an effective diuretic that is commonly used in treating breathlessness specifically in the case of pulmonary edema, but also in cases of congestive heart failure, liver and kidney disorders and in case of nephritic syndromes. The mode of action of the drug is escalating excretion of sodium and water with neutralizes the blood pressure within 30 minutes. The rapid action is the reason this drug is used abundantly as IV fluids (Australian injectable drugs handbook, 2017).

1. b) Identify the major medication group the medicine belongs to:

Answer: Diuretic (Australian injectable drugs handbook, 2017).

1. Can you give this drug in this circumstance as an Endorsed ENoutline the reasons for your answer?

Answer: Not all enrolled nurses have the authority to administer IV medications. Enrolled nurses with a notation cannot administer IV medication at all. Enrolled nurses lacking notation can administer IV medication only if they have completed IV administration education or under the supervision of a registered nurse as per the hospital policies (Jacob, Sellick & McKenna, 2012).

1. Using a Mims list the adverse side effects and contraindications for this medication.

Answer: the side effects of furosemide:

• Chest pain
• Coughing
• Fever
• Fatigue
• Headache
• Painful urination (MIMSonline, 2017)

Contraindication of furesomide include acute hyponatremia, hypovolemia and anuria.

1. What are some of the specificnursing considerations of patient care post administration of this medication?

Frusemide is a diuretic that is advised to give with along with potassium supplement so the nurse must take notice that the patient is following potassium rich diet ("Drugs.com | Prescription Drug Information, Interactions & Side Effects", 2017).

The medication has rapid action taking effect only within 30 minutes.

Frusemide increases the frequency of micturition, hence the nurses must inform the patients about the consequences of the medication (Australian medicines handbook, 2017)

The nurse must monitor the vitals of the patient along with his respiratory rates, and if the patient has oedema the limb of the patient must be carefully positioned, along with that the patient needs to be assisted with trips to the washroom if needed (Australian medicines handbook, 2017)

Who is required to check this medication during preparation and when administering

At least two Registered nurses or a registered nurse with enrolled nurses should check the patient bedside monitoring 5 rights checking. The nurses must check right patient, right drug, right dosage, right IV route and right time (Australian medicines handbook, 2017).

1. What documentation is required once this drug has been administered

Informed consent

Completed patient-history chart

Fluid chart

Charting document for begin bag, bolus, rate change, site change and wastage Answer: It can be defined as the catheter that is positioned into a peripheral vein through which any intravenous medication or fluid is administered (Jackson, 2012).

1. What is Phlebitis in relation to IV therapy– also please briefly discuss Bacterial, Mechanical and Chemical Phlebitis

Answer: Phlebitis can be described as a complication that arises with IV therapy including acute inflammation in the inner lining of the vein. Phlebitis causes pain and tenderness in the vein and redness and swelling in the insertion site (Hadaway, 2012).

Bacterial phlebitis: Bacterial phlebitis is usually the precursor of a bacterial infection at the insertion site facilitated by the contamination of the IV solution.

Mechanical Phlebitis: This type of phlebitis occurs when the cannula is larger than what is required for the selected vein that causes inflammation in the vein  (Hadaway, 2012).

Chemical phlebitis: Chemical phlebitis arises due to the irritation caused by the medications or the solution in the endothelial lining of the peripheral vessel wall (Washington & Barrett, 2012).

1. Outline yourcare for a peripheral IVC in general. Discuss what you would be assessing the site for and what, if anything, you would be documenting.

Answer: The peripheral IV site causes the majority of complications in the postoperative care, and it demands the maximum care. The priority of the nursing staff should be periodic and critical observation and monitoring of the peripheral IVC and identification of any abnormalities that may arise (Helm et al., 2015).

The IVC is supposed to be changed every 72 hours, the insertion site is to be cleaned periodically and in situ dry dressing is to be performed and everything should be documented diligently (Helm et al., 2015).

The insertion site should be frequently and critically analyzed for any redness or swelling and the insertion site should be frequently cleaned (Roca et al., 2012).

Answer: Pain and swelling in the knee post operation is a norm in case of ACL tears. Assessment of pain has to be done very critically,

The assessment should begin with the identifying the location of the pain and then the intensity of the pain. The information is vital for nursing intervention as the data will determine the method of pain management. The pain assessment can be performed by taking self report, behavioral assessment or physiological or clinical observations (Dychter et al., 2012). There are different tools available for first two assessment technique, such as visual analogous scale, FACES pain rating scale or FLACC scale. Clinical observation should include patient’s general observation and neurovascular observation.

Answer: Patient controlled analgesia pump or PCA pump consists of a syringe containing pain medication as prescribed by the physician that is connected to the intravenous line of the patient directly (Tran et al., 2012). This computerized pump system is more than just a syringe attached to IV; the PCA machine is adept with a prefixed lockout period that prevents the patient form ever receiving excessive pain medication (Tran et al., 2012).

The indications for use of PCA machine are:

• Post-operative pain relief
• Trauma
• Sickle cell crisis
• Burn (Jackson, 2012).

1. What are the advantages and disadvantages of using a PCA for pain management?

Answer: The advantages of using PCA machines are:

• Providing the  patients control over pain to some degrees
• Immediate and hassle-free pain management procedure
• Extremely helpful for incident pan like physiotherapy
• Improved health care quality and speedy recovery (Tran et al., 2012)

The disadvantages of using PCA pumps are:

• Confusion in correct operation can lead to unnecessary complications
• The risk of overdosing
• The risk with juvenile patients (Chan et al., 2013)
  1. Mr Stanford states that he has not used the PCA as he fears narcotic addiction, what information would you provide to Mr Stanford in regards to the use of a PCA and addition - include the rationale for a lockout period?

Answer: the lack of knowledge in the genera mass about the concept of PCA machines can give rise to apprehension in the patients about the safety in using PCA pumps (Tran et al., 2012). In such cases where the patent rejects the PCA it is necessary to educate the patient about the safety regulation that are strictly followed. The patient needs to be informed about the regulatory dosage that is used in PCA machines and the patient also needs to be educated about the lockout interval (Chan et al., 2013).

Lockout period restricts further dose of morphine despite patient demands to regulate the intake of morphine by the patient. Regular interval of morphine lockout is an interval of 4 minutes. Mr. Stanford can be advised off the safety regulation mentioned above to ease his apprehension to morphine PCA (Tran et al., 2012). Moreover, PCA medication is only used for a limited amount of time and oral medication is started as soon as the patient is able to cope with it.  

Normal saline is the o.9% solution of sodium chloride, which is called physiological or isotonic saline solution. The purpose of this order is to flush the intravenous system of the patient so that no residual medicine is left behind blocking the IV and revive the electrolyte balance in the body (Australian injectable drugs handbook, 2017).

 Prior to administration of this medication the enrolled should check with the mentor or the registered nurse to avoid any complication. 

Answer: There are a lot of complications that can arise with the peripheral IV therapy, some of them are:

Infiltration: IV infiltration is characterized by the medicinal leaking in the surrounding tissue caused by the improperly placed or dislodged catheter. The symptoms of infiltration include swelling, burning and discomfort (Dychter et al., 2012).

Extravasations: Extravasations are caused by the vesicant drugs leaked into the surrounding tissue, inflicting severe damage o the local tissue. Extravasation can lead to delayed recovery, infection, necrosis, mutilation, loss of function and even amputation. The symptoms of extravasation include blanching, discomfort or burning in the IV site (Dychter et al., 2012).

Phlebitis:  Phlebitis is primarily inflamed veins caused by either vein trauma or solutions with high osmolarity. It is characterized by swelling and redness in the insertion site can pave way for more serious infection in the IV site (Hadaway, 2012). 

1. Please state 4 main special precautions you need to be aware of when administering Potassium Chloride via the Intravenous route to ensure patient safety(Please use the Australian Injectable Handbook in the Tafe library for accurate information)

Answer:

• In case of potassium infusion premixed in fusion bags must be used.
• Ampoules need to be diluted prior to administration with a compatible fluid.
• Care should be taken to avoid pooling and the solution concentration must be diluted to a utmost concentration of 40 mmol/L (Australian injectable drugs handbook, 2017).
• Care should also be taken to avoid any chance of infection.

1. Please state 6 signs and symptoms of potassium intoxication:

Answer: potassium intoxication is also known as hyperkalemia and include the following symptoms:

• Stomach cramps
• Diarrhea
• Vomiting
• Irritability
• Fatigue
• Cardiac irregularities (Australian medicines handbook, 2017)

As per catalyst for IV Infusion:  This drug infusion rate is titrated individually to each patient. However it is recommended that to begin the administration a diluted solution at doses of 5 micrograms/kg/min be administered

* How many micrograms per min would this patient be started on (please show your workingout)

Answer: The patient weighs 49 kg

The advised dosage is 5microgram/kg/min

If 5 micrograms are recommended for 1 kg,

For 49 kg the sum would be = 5*49 micrograms

                                             = 245 micrograms

Therefore, the starting dose would be 245 micrograms/min.  

1. Calculate how much the bolus deliverywill be in mLs? 

Answer: 500*50 = 25000

Now bolus delivery: 25000 = 5 mLs

                                  5000

1. Calculate how much the infusion will run at in mls/hr?

Answer: 500 units/hr * 50 Ml = 5 mL/hr in a pump

 What are some precautions and possible side effects of Heparin?

Side effects of Heparin: The side effects of heparin include :

• Blood blisters at the injection site
• Chest pain
• Fever
• Irregular breathing
• Irritation, ulcer or redness at the injection site
• Nausea
• lack of sensation (Australian medicines handbook, 2017)

Precautions of Heparin:

• blood test prior to the administration of the medicine
• Bleeding precautions including restricted movement and avoiding rough food or sharp appliances
• Monitoring bleeding from open orifices (Australian medicines handbook, 2017)

1. Whatcompatibility issues, if any, are there in IV administration of heparin 

Answer: Potassium and calcium.

Calcium as calcium gluconate 10% diluted in water for solubility.

• IV Gentamycin
• IV Frusemide
• IV Morphine 

Answer: IV Gentamycin comes under schedule 4

               IV Frusemide comes under schedule 4

               IV Morphine comes under schedule 8 (Australian injectable drugs handbook, 2017). 

• IV Gentamycin
• IV Fentanyl 

Answer: storage for IV gentamycin: Gentamycin should be stored in a locked medication room with access to only medical staff so that it is not accessible to general public. Special protocols for storing controlled and restricted drugs should be diligently followed in case of storing gentamycin (Australian medicines handbook, 2017).

Storage for IV fentanyl: Fentanyl also belongs to the category of controlled and restricted drugs. It should be stored is a locked containment fastened to a concrete wall with access strictly restricted to only medical staff. This medication should be checked periodically by 2x RN, RN and EN as well (Australian medicines handbook, 2017).  

• Pharmacokinetics
• Pharmacodynamics  
• Toxicology

Answer:

• Pharmacokinetics- pharmacokineticscan be defined as the study of drug absorption in the body.
• Pharmacodynamics- pharmacodynamicson the other hand is the detailed study of the action of the drug in the body
• Toxicology –btoxicologyis tehbstudy of the action of poisonous drugs on the body (Australian medicines handbook, 2017). 

Answer:   The drugs that fall under this discretion are the unscheduled, schedule 2 and 3 drugs or unscheduled drugs (Finn et al., 2012). These medicines are to only to be administered by the registered nurse, enrolled nurse or accredited enrolled nurses. However the nurse initiated medicine administration must be approved by Drug and therapeutic committee of NSW Ministry of Health. Authorized registered nurse with proper medication administration training must obtain the written protocol and sufficient detailed information about the patient before administration of the medication. The facility must also maintain written protocols outlining the procedures that are to be followed by the nurses. Nurse initiated medications, be it oral or transdermal, are for occasional emergencies, for prolonged need the patients must be referred to licensed medical practitioner (APHRA, 2017).

Answer: In case of emergencies, standing orders allow the enrolled nurses to administer or adjust medicinal dosage for a particular individual (Jacob, Sellick & McKenna, 2012). The standing orders facilitate instant medication administration and the patients no longer need to wait for the doctor to arrive. According to the nursing and midwifery board of Australia, only the enrolled nurses who have completed EN medicine administration education can independently carry out medication administration, the nurses who have notation ‘Does not hold Board-approved qualification in administration of medicines’on their registration and mother-craft nurses cannot administer  medication (APHRA, 2017). However medicinal administration without the oversight of a doctor can lead to mistakes that can complicate the situation further. Hence, the enrolled nurses need to be extremely cautious while administering any medication independently.

Reference list: 

APHRA,. (2017). Nursing and Midwifery Board of Australia - Home.       Nursingmidwiferyboard.gov.au. Retrieved 2 March 2017, from http://www.nursingmidwiferyboard.gov.au 

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Australian injectable drugs handbook / [edited by Nicolette Burridge and Danielle Deidum for the SHPA Publications Reference Group]. - Version details. (2017). Trove. Retrieved 14 February 2017, from http://nla.gov.au/anbd.bib-an47686025

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Baker, K. M., DeSanto-Madeya, S., & Banzett, R. B. (2017). Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance. BMC nursing, 16(1), 3.

Chan, E. Y., Fransen, M., Sathappan, S., Chua, N. H., Chan, Y. H., & Chua, N. (2013). Comparing the analgesia effects of single-injection and continuous femoral nerve blocks with patient controlled analgesia after total knee arthroplasty. The Journal of arthroplasty, 28(4), 608-613.

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Finn, J., Rae, A., Gibson, N., Swift, R., Watters, T., & Jacobs, I. (2012). Reducing time to analgesia in the emergency department using a nurse-initiated pain protocol: a before-and-after study. Contemporary nurse, 43(1), 29-37

Hadaway, L. (2012). Short peripheral intravenous catheters and infections.Journal of Infusion Nursing, 35(4), 230-240.

Helm, R. E., Klausner, J. D., Klemperer, J. D., Flint, L. M., & Huang, E. (2015). Accepted but unacceptable: peripheral IV catheter failure. Journal of Infusion Nursing, 38(3), 189-203.

Jackson, A. (2012). Retrospective comparative audit of two peripheral IV securement dressings. British Journal of Nursing, 21(2), 10.

Jacob, E., Sellick, K., & McKenna, L. (2012). Australian registered and enrolled nurses: Is there a difference?. International journal of nursing practice, 18(3), 303-307.

 Mimsonline.com.au. Retrieved 14 February 2017, from https://www.mimsonline.com.au

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Roca, G. M., Bertolo, C. B., Lopez, P. T., Samaranch, G. G., Ramirez, M. C. A., Buqueras, J. C., ... & Martinez, J. A. (2012). Assessing the influence of risk factors on rates and dynamics of peripheral vein phlebitis: an observational cohort study. Medicina clinica, 139(5), 185-191.

Siegel, L., Vandenakker-Albanese, C., & Siegel, D. (2012). Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management.Clinical Journal of Sport Medicine, 22(4), 349-355.

Tran, M., Ciarkowski, S., Wagner, D., & Stevenson, J. G. (2012). A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center. The Joint Commission Journal on Quality and Patient Safety, 38(3), 112-119.

Washington, G. T., & Barrett, R. (2012). Peripheral phlebitis: A point-prevalence study. Journal of Infusion Nursing, 35(4), 252-258.

What is an Isotonic solution?. (2017). Innovateus.net. Retrieved 15 February 2017, from http://www.innovateus.net/health/what-isotonic-solution