1. NUR 141: SKILL 22-6 ADMINISTERING INTRAVENOUS MEDICATION BY PIGGYBACK INTERMITTENT INFUSION SETS AND MINI-INFUSION PUMPS

2. INTRODUCTION
One method of administering intravenous medications uses small volumes (25 to 250 mL) of compatible IV fluids infused over a desired period of time. This method reduces the risk for rapid dose infusion and provides independence for patients.
Patients must have an established IV line that is kept patent by either a continuous infusion or intermittent flushes of normal saline.
You can administer intermittent infusion of medication with any of the following methods:
1. Piggyback
2. Volume-Control Administration
3. Mini-Infusion Pump

3. Introduction – cont’d PIGGYBACK:
A piggyback is a small (25 to 250 mL) IV bag or bottle connected to a short tubing line that connects to the upper Y-Port of a primary infusion line or to an intermittent venous access such as a saline lock.
The IV container that holds the medication is labeled following the IV piggyback medication format of the Institute for Safe Medication Practices.
The piggyback tubing is a micro-drip or macro-drip system.

4. Introduction- cont’d PIGGYBACK – CONT’D
The set is called a piggyback because the small bag or bottle is set higher than the primary infusion bag or bottle.
In the piggyback setup the main line does not infuse when a compatible piggybacked medication is infusion. The port of the primary IV line contains a back-check valve that automatically stops the flow of the primary infusion once the piggyback infusion flows.
After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion starts to flow again.

5. PIGGYBACK PUMP

6. INTRODUCTION – CONT’D
VOLUME-CONTROL ADMINISTRATION:
Volume-control administration sets: (e.g., Volutrol, Buretrol, Pediatrol) are small (50 to 150 mL) containers that attach just below the primary infusion bag or bottle. The set is attached and filled in a manner similar to that used with regular IV infusion. However, the primary filling of the set is different, depending on the type of filter (floating valve or membrane) within the set. Follow package directions for priming sets.
MINI-INFUISON PUMP:
Mini-Infusion Pump: The mini-infus8ion pump is battery operated and delivers medication in very small amounts of fluid (5 to 60 mL) within controlled infusion times using standard syringes.

7. ASSESSMENT
1. Check accuracy and completeness of each MAR or computer printout with prescriber’s written medication order. Check patient’s name, medication name, and dosage, route of administration, and time of administration. Recopy or reprint any portion of MAR that is difficult to read.
2. Assess patient’s medical and medication history.
3. Assess patient’s history of allergies; known type of allergens and normal allergic reaction.
4. Review medication reference information for medication action, purpose, normal dose, side effects, time and peak of onset, how slowly to give medication, and nursing implication (e.g., need to dilute medication, administer through filter).

8. Assessment – cont’d
5. If you give medication through existing IV line, determine compatibility of medication with IV fluids and any additional additives within IV solution.
6. Assess patency and placement of patient’s existing IV infusion line or saline lock.
7. Assess patient’s symptoms before initiating medication therapy.
8. Assess patient’s knowledge of medication.
Clinical Decision Point: Never Administer IV medication tubing that is infusing blood, blood products, or parenteral nutrition solutions.
Clinical Decision Point: If patient’s IV site is saline locked, clean the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile sodium chloride.

9. planning 1. Expected outcomes following completion of the procedure:
Patient experiences no adverse reactions.
Medication was administered safely with desired therapeutic effect.
Medication infuses within desired time frame
IV line remains patent.
IV site remains intact without signs of swelling, inflammation or symptoms of tenderness at site.
Fluid infuses into vein, not tissues.
Patient explains medication purposes, action, side effects, and dosage – this Demonstrates Learning.

10. IMPLEMENTATION
1. Prepare medications for one patient at a time using aseptic technique. Check label of medication carefully with MAR or computer printout 2 times when preparing medication. Pharmacy prepares piggyback and prefilled syringes. You will prepare medication for Volutrol.
2. Take medication(s) to patient at correct time. Medications that require exact timing include stat, first time or loading doses, and one time doses.
3. Close room curtain or door. Perform hand hygiene and apply clean gloves.
4. Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy.
5. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if they have any allergies.

11. IMPLEMENTATION – CONT’D
6. Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions. Explain that you will give medication through existing IV line. Encourage patient to report symptoms of discomfort at site.
7. Administer Infusion:
A. PIGGYBACK INFUSION:
Connect infusion tubing to medication bag (see Chapter 28). Fill tubing by opening regulator flow clamp. Once tubing is full, close clamp and cap end of tubing.
2. Hang piggyback medication bag above level of primary fluid bag. (Use hook to lower main bag).
3. Connect tubing of piggyback infusion to appropriate connector on upper Y-Port of primary infusion line:
A. Needleless system: Wipe off needleless port of main IV line with alcohol swab, allow to dry, and insert cannula tip of piggyback infusion tubing.

12. Implementation – cont’d
4. Option: Normal saline lock: Follow Steps 9a (1) through 9b (6) in Skill 22-5 to flush and prepare lock. Wipe off port with alcohol swab, let dry, and insert tip of piggyback infusion tubing via needleless access.
5. Regulate flow rate of medication solution by adjusting regulator clamp or IV pump infusion rate. Infusion times vary. Refer to medication reference or agency policy for safe flow rate.
6. Once medication has infused:
A. Continuous infusion: Check flow rate of primary infusion. Primary infusion automatically begins after piggyback solution is empty.
B. Normal saline lock: disconnect tubing, clean port with alcohol, and flush IV line with 2 to 3 mL of sterile 0.9% sodium chloride. Maintain sterility of IV tubing between intermittent infusions.

13. Implementation – cont’d
7. Regulate continuous main infusion line to ordered rate.
8. Leave IV piggyback and tubing in place for future drug administration (see agency policy) or discard in puncture and leak proof container.
B. VOLUME-CONTROL ADMINISTRATION SET (E.G., VOLUTROL):
1. Fill Volutrol with desired amount of IV fluid (50 to 100 mL) by opening clamp between Volutrol and main IV bag.
2. Close clamp and check to be sure that clamp on air vent Volutrol chamber is open.
3. Clean injection port on top of Volutrol with antiseptic swab.

14. Implementation – cont’d
4. Remove needle cap or sheath and insert needleless syringe or syringe needle through port and inject medication. Gently rotate Volutrol between hands.
5. Regulate IV infusion rate to allow medication to infuse in time recommended by agency policy, pharmacist, or medication reference manual.
6. Label Volutrol with name of medication; dosage, total volume, including diluent; and time of administration following ISMP (2011) safe medication label format.
7. If patient is receiving continuous IV infusion, check infusion rate after Volutrol infusion is complete.
8. Dispose of uncapped needle or needle enclose in safety shield and syringe in puncture and leak proof container. Discard supplies in appropriate container. Perform hand hygiene.

15. Implementation – cont’d
C. MINI-INFUSION ADMINISTRATION:
1. Connect prefilled syringe to mini-infusion tubing; remove end cap of tubing.
2. Carefully apply pressure to syringe plunger, allowing tubing to fill with medication.
3. Place syringe into mini-infusion pump (follow product directions) and hang on IV pole. Be sure that syringe is secured.
4. Connect end of mini-infusion tubing to main IV line or saline lock:
A. Existing IV line: Wipe off needleless port on main IV line with alcohol swab, allow to dry, and insert tip of mini-infusion tubing through center of port.
B. Normal Saline lock: Follow Steps 9a (1) through 9b (6) in Skill 22-5 to flush and prepare lock. Wipe off port with alcohol swab, allow to dry, and insert tip of mini-infusion tubing.

16. Implementation – cont’d
5. Set pump to deliver medication within time recommended by agency policy, pharmacist, or medication reference manual. Press button on pump to begin infusion.
6. Once medication has infused:
A. Main IV infusion: Check flow rate. Infusion automatically begins to flow once pump stops. Regulate infusion to desired rate as needed.
B. Normal Saline Lock: Disconnect tubing, clean port with alcohol, and flush IV line with 2 to 3 mL of sterile 0.9% sodium chloride. Maintain sterility of IV tubing between intermittent infusions.

17. Implementation – cont’d
8. Dispose of supplies in puncture and leak proof container.
9. Remove gloves and perform hand hygiene.
10. Stay with patient for several minutes and observe for any allergic reactions.

18. evaluation
1. Observe patient for signs or symptoms of adverse reaction.
2. During infusion periodically check infusion rate and condition of IV site.
3. Ask patient to explain purpose and side effects of medication.

19. Unexpected outcomes Stop medication infusion immediately.
1. Patient develops adverse or allergic reaction to medication.
Stop medication infusion immediately.
Follow agency policy or guidelines for appropriate response to allergic reaction (e.g., administration of antihistamine such as diphenhydramine {Benadryl} or epinephrine) and reporting of adverse medication reactions.
Notify patient’s health care provider of adverse effects immediately.
Add allergic information to patient record per agency policy.
2. Medication does not infuse over established time frame.
Determine reason (e.g., improper calculation of flow rate, poor positioning of IV needle at insertion site, infiltration).
Take corrective action as indicated.

20. Unexpected outcomes – cont’d
3. IV site shows signs of infiltration or phlebitis (see Chapter 28).
Stop IV infusion and discontinue access device.
Treat IV site as indicated by agency policy.
Insert new IV catheter if therapy continue.
For infiltration determine how harmful IV medication is to subcutaneous tissue. Provide IV extravasation care (e.g., injecting phentolamine {Regitine} around IV infiltration site) as indicated by agency policy or consult pharmacist to determine appropriate follow-up care.

21. Recording and reporting
Immediately record medication, dose, route, infusion rate, and date and time administered on MAR or computer printout. Include initials or signature.
Record volume of fluid in medication bag or Volutrol on intake and output (I&O) form.
Report any adverse reactions to patient’s health care provider.
SPECIAL CONSIDERATION:
Teaching:
Review all IV medications with patient and significant others, including why patient is receiving the medication and potential adverse effects, including allergic responses.
Teach patient and/or significant others not to alter the ordered rate of infusion without consulting the prescriber. IV medications need to be infused at a specified rate to achieve their desired effect and avoid adverse effects.
Teach patient and/or significant others to report any adverse effects immediately.

22. END OF SKILL This is the end of the skill.
Your book has not provided a video for this skill.
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IV PIGGYBACK:
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