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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Advanced Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2023.

Nursing Advanced Skills [Internet].

Chapter 2 Administer IV Push Medications

2.1. INTRODUCTION

Learning Objectives

Compare the procedure for administering an IV push medication through a primary IV line versus through a saline lock

In acute care settings, nurses frequently administer medications via the intravenous (IV) route. Medications may be administered through a primary line that is already infusing fluids or through a saline lock inserted into a patient’s vein with direct access to the bloodstream. Medications given via the IV route enter the bloodstream immediately, so extreme caution must be observed while performing this procedure. Administering medications via the IV route requires diligent attention to the rights of medication administration and IV safety. When utilized appropriately, medications administered via IV push can provide rapid symptom resolution and therapeutic effect. There are many advantages and potential disadvantages to using the IV route for administering medications; therefore, a nurse must have a strong understanding of its benefits, risks, and safety implications.

2.2. BASIC CONCEPTS OF IV PUSH MEDICATION

There are several advantages, disadvantages, and potential complications that can occur when administering IV push medication, requiring the nurse to implement many safety considerations.

Advantages

Intravenous push (IV push) is a process of introducing a medication or fluid substance directly into the bloodstream via the venous system. When the medication is administered directly into the bloodstream, it immediately enters the circulatory system and travels to a site of action. Administering the medication directly into the bloodstream reduces the first-pass effect or the action that occurs when a medication must be first metabolized or broken down prior to entering the blood. First-pass effect results in a diminished volume of available circulating drug and a subsequent decrease in therapeutic action.[1] As a result, when utilizing IV push medications, a decreased dosage of medication can be given compared to an oral dosage to achieve the same therapeutic effect.

First-pass metabolism significantly impacts the bioavailability of many medications. For example, larger oral doses of morphine must be provided than intravenous dosages to obtain the same therapeutic pain relief, but the risks of oversedation and respiratory depression are higher with intravenous doses. Nurses who have concerns about an ordered dose of intravenous medication should clarify the dosage with the pharmacist and/or prescribing provider before administering it.

Intravenous medication administration also has a more rapid onset than oral medication. Because the bioavailability of the medication is directly in the circulatory system, the medication is readily transported to the site of action. This is a significant benefit when a rapid response is needed, such as when clients are experiencing severe hemodynamic instability or severe pain.

Let’s consider the following scenario: A nurse on a medical telemetry unit received a direct admission from a cardiac clinic for an 85-year-old male client admitted with an exacerbation of chronic heart failure. The client’s vital signs are heart rate 102, blood pressure 144/88, respiratory rate 24, and pulse oximetry reading of 90% on room air. The nurse listens to the client’s lung sounds and notes crackles in both posterior lungs. The nurse reviews the admitting orders from the provider and sees an order for furosemide 40 mg IV push STAT. Review furosemide’s drug action profile in Table 2.2a and note the different onsets of action for the different routes of furosemide. It is clear that the IV push route of administration will work quickly to remove this client’s excess fluid and positively impact their respiratory status.

Table 2.2a

Furosemide Drug Action Profile[2]

Intravenous medication administration can also be of great benefit when clients are experiencing gastrointestinal issues that may affect absorption, such as impaired swallowing or esophageal, stomach, or intestinal absorption issues. Administering a medication directly into the cardiovascular system allows the substance to freely circulate throughout the body and bypass the breakdown and absorption barriers created by the gastrointestinal tract. See Figure 2.1[3] for an image of a nurse administering IV push medication.

Figure 2.1

Administering IV Push Medication

In addition to rapid onset, some medications are only formulated to administer via the IV route, such as certain vasoactive substances. As a result, many patients who are hospitalized may have an “IV lock” inserted to facilitate rapid IV access if their condition deteriorates. An IV lock (also referred to as a “saline lock”) is an IV cannula that has been inserted into a peripheral vein with a short extension tube that is filled with saline and clamped to keep the cannula patent. This type of IV access may also be referred to as a “peripheral lock” because it is inserted into the peripheral vasculature. Historically, many IV locks were flushed with heparin to keep the line from clotting, so they were referred to as a “heparin lock” or “hep lock.” Although evidence-based practice no longer recommends heparin be used to maintain patency of a peripheral IV access device, the name “hep lock” may still be used in practice. An IV lock is beneficial because it provides rapid access to administering medications in the venous system if needed, but continuous infusion of medication or fluid is not required.

IV push medication can also be a valuable alternative route of administration for clients at risk for fluid volume overload. For example, clients who are experiencing acute renal failure or an acute exacerbation of heart failure may benefit from IV push medications administered with smaller amounts of fluids compared to a typical IV infusion of medication.[4]

One of the most obvious benefits of IV push medication administration from a client’s perspective is that it does not require repeated needlesticks for administering repetitive doses of medications intramuscularly or subcutaneously. As a result, client discomfort is minimized when intravenous access can be maintained.

Disadvantages and Potential Complications

When administering IV push medication, nurses must always proceed with significant caution. Remember that medication administered via IV push cannot be retrieved! For this reason, it is vital for the nurse to perform the rights of medication administration before giving IV push medications. The rights of medication administration are reviewed in the “Safety Concepts” subsection later in this section.

Prior to administration, the nurse must carefully review the client’s current IV solutions and/or medications for incompatibilities with the medication to be administered. Many maintenance fluids (i.e., fluids given intravenously to facilitate hydration status) may include additives like electrolytes that may not be compatible with all medications. Nurses must ensure that all components are compatible with one another to ensure that a precipitate does not form when the substances come into contact with one another. A precipitate is the formation of small crystals as the incompatible substances come in contact with one another. Precipitate can occlude the infusion catheter line, inactivate the medications, or create an embolism, putting the client at significant risk for harm.[5] See Figure 2.2[6] for an example of a client’s existing fluids and medications being infused that must be checked for compatibility before IV push medication is administered in the same line and/or access site.

Figure 2.2

Existing IV Fluids and Medications to Check for Compatibility

An additional potential disadvantage of administering medication via IV push when other fluids and/or medications are infusing is that the infusate can move backwards into the existing IV administration set if not performed correctly and thus reduce the amount of medication that reaches the client. For this reason, the nurse should pinch the existing tubing above the site of the hub in which the IV push medication is being administered.

In addition to leaching, many IV push medications require reconstitution to dissolve the medication powder into a fluid for administration. With reconstitution, there is a potential for nurse error in calculating total volume to be administered so the ordered dose reaches the patient.

The risk of patients experiencing speed shock with IV push medication administration is also a significant potential concern. Speed shock is characterized as an adverse systemic reaction when a foreign substance is introduced into the bloodstream. Speed shock may occur with IV push medication administration when the medication peaks very quickly. This sudden peak increases the risk of significant side effects. When medication is administered in a short period of time (typically in less than one minute), there is little opportunity to stop the medication if the client experiences an allergic response. Signs of speed shock include a systemic reaction such as tightness or pressure in the chest, irregular pulse, flushed skin, headaches, change in the level of consciousness, a feeling of impending doom, or cardiac arrest. Clients who have reduced liver and kidney function or those with cardiac problems are at increased risk of speed shock. If a nurse notes the signs of speed shock during IV push administration, they should immediately stop the infusion, maintain the IV line for emergency access, notify the provider, and begin CPR if indicated.

IV site complications are an additional disadvantage with IV push medication administration. Any time a medication or fluid is given into an IV site, there is increased risk for complications such as infiltration, extravasation, and phlebitis. Review information about these complications in Table 1.3a in the “Peripheral IV Access” section in the “Initiate IV Therapy” chapter.

See Table 2.2b for a summary of common advantages and disadvantages associated with the use of IV push medications.

Table 2.2b

IV Push Medication Advantages and Disadvantages[7]

Safety Concepts

Checking Rights of Medication Administration

When administering IV push medications, it is essential for nurses to vigilantly check the rights of medication administration three times. What began as five rights of mediation administration has been extended to eight rights according to the American Nurses Association. These eight rights include the following[8]:

Right patient: Check that you have the correct patient using two patient identifiers according to agency policy (e.g., name and date of birth).

Right medication: Check that you have the correct medication and that it is appropriate for the client in the current context. Understand the purpose of the medication and why the client is receiving it.

Right dose: Check that the dose is safe for the age, size, and condition of the client. Different dosages may be indicated for different conditions, and pediatric dosages are typically much lower than adult dosages. Be aware of the medication side effects, peak, and onset of action. The peak of the medication administration occurs when the medication is at the highest level in the client’s bloodstream. The onset of medication administration occurs when the action of the medication begins to take effect. It is important for nurses to be aware of both the peak and onset and of IV administration to help assess when client response to medication may start to be observed.

Right route: Check that the route is appropriate for the client’s current condition. Is the medication available to be administered via IV push? Does it require dilution with a substance such as normal saline? Does it require reconstitution? Can it be administered via peripheral access, or does it require central line access into a larger size vein?

Right time: Adhere to the prescribed scheduling of the IV medication. Additionally, the rate of administration of the IV medication and the post-procedure saline flush must be administered according to manufacturer recommendations in a drug reference.

Right documentation: Always verify any unclear or inaccurate documentation prior to administering medications.

Right reason: Verify this medication is being administered to this client at this time for the right reason. If signs and symptoms no longer warrant administration of the prescribed medication, notify the prescribing provider.

Right response: After administering the IV push medication, the nurse must evaluate for expected outcomes with the time frame of expected onset and peak. The nurse must also evaluate for unanticipated adverse outcomes and notify the provider if expected outcomes are not achieved or adverse effects occur.

In addition to checking the eight rights of medication administration, it is important to collect any baseline assessment information and nursing implications for administration. For example, nurses may be required to have certain vital signs monitoring capabilities available when administering certain medications, a certain size vascular access device, or access into the central versus peripheral vascular system.

Additionally, it is important to consider the specific time frame for drug administration. Many IV medications must be infused over a period of time and cannot be pushed into the venous system rapidly due to potential adverse hemodynamic effects. Medications administered by direct IV route are commonly given very slowly per guidelines outlined in a drug reference guide. Nurses must routinely consult drug reference guides when administering IV push medications to check medication and fluid compatibilities and to ensure that medications are given at the correct rate to prevent complications.

Checking for Potential Incompatibilities

When administering medications via the intravenous route, it is also important to consider potential incompatibilities that may exist. Incompatibilities for the IV route are often organized into three different categories, including physical, chemical, and therapeutic issues.

Physical: When one drug is mixed with other drugs or solutions, a product is produced that is unsafe for administration. An example would be mixing oil with a water base.

Chemical: When a drug reacts with other drugs or solutions, resulting in alterations of the integrity and potency of the active ingredient. A cloudy or crystalline precipitate may form.

Therapeutic: When agents are antagonistic to one another, resulting in an undesired pharmacological action in a patient. This is the largest class of incompatibilities.

It is critical that nurses administering IV push medications are aware of available reversal agents for that medication. For example, when administering an opioid such as fentanyl via IV push, the nurse must monitor for oversedation and respiratory depression. The nurse should have naloxone, the reversal agent, readily available and accessible if an adverse reaction occurs.

Checking Current Status of the Client

As with administration of any medication, nurses must ensure that the medication to be given is appropriate based on the client’s current condition. Therefore, associated physical assessment findings, vital signs, pain assessment, and laboratory results must be reviewed before administering IV push medications. For example, if administering morphine via IV push for pain management, the nurse should perform and document a detailed pain assessment prior to administration. Pre-assessment data guides the nurse in determining if morphine is appropriate to administer at this time or if a lower-tier pain medication is more appropriate. It also guides the nurse in determining if a medication should be withheld based on current signs and symptoms and the provider notified. Ultimately, if the medication is administered, the pre-assessment data will be used to compare post-administration data to determine the therapeutic effect of the medication.

The condition and appropriateness of the specific IV site that will be used for administration of IV push medication must be assessed prior to medication administration and monitored for signs of complications. If infiltration of a medication occurs at the site, there may be neutralizing agents that can be given to minimize the impact of the medication on the surrounding tissues. For example, phentolamine mesylate may be injected into the extravasation site of a vasopressor to prevent dermal necrosis. Furthermore, some medications have pH values that must be controlled with a buffering agent to create a more tolerable pH for infusion. Finally, medications that are more viscous may require larger IV cannula sizes to push the medication through the cannula. Medication administered via IV route should never be forced through the IV cannula line. Pushing medication forcefully through a blocked IV cannula may force a clot into the client’s circulatory system.

Select an IV site with a large vein and IV cannula to use for IV push medication administration. Administration of medication through a large cannula allows for greater dilution and minimizes the chance of vascular irritation.

Infection Control

Aseptic technique must be maintained throughout all IV push procedures, including preparing and maintaining equipment and administering IV push medications. Hand hygiene and aseptic non-touch technique (ANTT) must be performed when handling all IV equipment and accessing IV sites. These standards can be reviewed in the “Aseptic Technique” chapter in Open RN Nursing Skills. Cleansing techniques must be followed when accessing an IV site according to agency policy. Additionally, if a syringe becomes contaminated by contact with a nonsterile surface, it should be replaced with a new one to prevent introducing bacteria or other contaminants into the system.

References

Spencer, S., Ipema, H., Hartke, P., Krueger, C., Rodriguez, R., Gross, A. E., & Gabay, M. (2018). Intravenous push administration of antibiotics: Literature and considerations. Hospital Pharmacy , 53(3), 157–169. ↵ 10.1177/0018578718760257. [PMC free article : PMC6102793 ] [PubMed : 30147136 ] [CrossRef]

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 ↵.

2.3. EQUIPMENT

To perform IV push medication administration, nurses must gather basic equipment to perform the task. The main supplies that are required to administer medications via the IV push route include syringes, needles, needleless vial accesses, saline flush syringes, and antiseptic pads (chlorhexidine-based, alcohol, or tincture of iodine). The syringe and needle sizes that are selected to draw out the medication from the medication vial often depend on the characteristics of the fluid and the volume of medication to be given. For example, medications that are more viscous (such as lorazepam) may require a larger bore needle in order to be easily drawn into the syringe.

Additional equipment that will be needed to safely administer medications via the IV push route include gloves, the specific medication ampule or vial, a drug reference guide, and a watch with a second hand so that a nurse can accurately time the rate of administration for the IV push. Common syringe sizes range from 1 mL- to 60 mL-syringes. See Figure 2.3[1] for an image of various sizes of syringes. Most IV push medication for adult patients will be delivered in sizes ranging from 3 mL, 5 mL, or 10 mL using a Luer lock syringe. Luer lock syringes have interlocking threads to hold the connection together. When selecting a syringe, ensure the size will hold the total volume of medication with reconstitution solution. When reading the volume of medication within the syringe, read the volume where the plunger is in contact with the solution being administered.

Figure 2.3

Syringes of Varying Sizes

View a YouTube video[2] on how to read a syringe:

Needles used to withdraw medication from the vial should also be appropriately sized to account for the type of solution being withdrawn. The gauge of a needle is the diameter of the needle. Gauges can vary from very small diameter (25 to 29 gauge) to large diameter (18 to 22 gauge). Note the higher the number of gauge, the smaller the diameter of the needle. A needle will have its gauge and length marked on the outer packaging.[3] See Figure 2.4[4] for images of various needle sizes.

Figure 2.4

Various Needle Sizes (18g, 22g, 25g)

More viscous medications require an 18-gauge or 20-gauge needle to ensure easy withdrawal of the medication from the vial and into the syringe. Smaller gauge needles may bend or break when accessing vial rubber stops, placing a nurse at risk for a needlestick or injury when withdrawing the medication.

There are also many needleless access devices, often referred to as blunt needle devices, available in medical facilities. The “blunt needles” can be used to puncture a vial rubber stop and withdraw medication but should not be used to inject medication into patients. These needleless accesses are commonly made of plastic and reduce the danger of needle puncture. Needleless devices should be utilized whenever possible to reduce the risk of inadvertent needlesticks. Some blunt needle devices also have filters and should be used when withdrawing medication from an ampule.

Ampules, Vials, and Prefilled Syringes

There are various types of parenteral medication containers in which medications may be stored, such as glass ampules, single dose or multi-dose vials, and prefilled syringes.

Ampules are glass containers in 1 mL to 10 mL sizes that hold a single dose of medication in liquid form. They are made of glass and have a scored neck to indicate where to break the ampule. Because there is risk of being cut by glass when opening a glass ampule, the nurse should use an ampule breaker or wrap an alcohol swab package around the neck of the ampule for protection See Figure 2.5[5] for an image of opening an ampule. It is important that the nurse use caution and firmly grasp the ampule neck, breaking the ampule at the neck with firm pressure applied. Nurses should break the ampule away from their hands to help ensure that they do not inadvertently cut themselves in the process of breaking open an ampule. Once the ampule is open, a blunt needle device with a filter must be used when withdrawing medication to prevent glass particles from being drawn up into the syringe. Glass ampule pieces must be disposed of in a sharps containers following medication administration.

Figure 2.5

Opening an Ampule

A vial is a single- or multi-dose plastic container with a rubber seal top, covered by a metal or plastic cap. A single-use vial must be discarded after one use. A multi-dose vial must be labeled with the date it was opened and its “beyond use date” (BUD). Guidelines indicate a multi-dose vial may be used for up to a maximum of 28 days of opening unless there is a specific expiration date labelled by the manufacturer.[6]

Needless caps on vials are dust covers only and are not considered sterile. After removing the vial cap, scrub the diaphragm of the cap using 70% isopropyl alcohol. If using more than one vial, separate alcohol wipes must be used on each vial.[7]

Because a vial is a closed system, air equal to the volume of solution to be withdrawn must first be injected into the vial to permit the removal of the solution. See Figure 2.6[8] for an image of medication being withdrawn from a vial.

Figure 2.6

Withdrawing Medication From a Vial

Prefilled syringes contain prefilled volumes of medication. Many medications used during emergency medication situations are contained in prefilled syringes, such as epinephrine or naloxone. See Figure 2.7[9] for an image of a prefilled syringe. Some prefilled syringes require connection to a syringe device containing a plunger. Prior to administering medication via a prefilled syringe, examine the volume of medication within the syringe, verify the amount with the dose in the medication order, and perform any math calculations required. Remove protective caps from the syringe barrel and medication cartridges and secure the plunger device onto the prefilled syringe by screwing the end of the push device into the plunger barrel. Per manufacturer guidelines, advance the plunger to expel air contained within the device.

Figure 2.7

References

RegisteredNurseRN. (2017, June 12). How to read a syringe 3 mL, 1 mL, insulin, & 5 mL/cc | Reading a syringe plunger [Video]. YouTube. All rights reserved. Video used with permission. https://youtu ​.be/_TnDr8cKums ↵.

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 ↵.

“Needle 18g,” “Needle 22g,” and “Needle 25g” by Chippewa Valley Technical College are 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. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed : 33394637 ] [CrossRef] [CrossRef]

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. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed : 33394637 ] [CrossRef] [CrossRef]

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.

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.

Table 2.4

a IV Push Safety Principles[2]

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.

References

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. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed : 33394637 ] [CrossRef] [CrossRef]

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. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed : 33394637 ] [CrossRef] [CrossRef]

2.5. CHECKLIST: ADMINISTER IV PUSH MEDICATIONS

*Disclaimer: Always follow agency policy and manufacturer recommendations

Checklist: Administer IV Push Medications [1] , [2] , [3] , [4]

Review the patient’s medical record for factors that increase the patient’s risk of adverse reactions and toxicity to the prescribed medication. Check for allergies or any other contraindication to the prescribed medication. Verify when the last dose of this medication was administered, the indication for this medication for this patient, and related pre-administration assessments, vital signs, lab results, or other clinical data.

Gather and prepare the necessary equipment: syringe, medication, saline flush, antiseptic pads, and needle/vial access device.

If medication preparation is required, do so in a designated clean, quiet environment away from sinks using the aseptic non-touch technique (ANTT).[5]

Check the expiration date on the medication. If it’s expired, return it to the pharmacy and obtain new medication. Inspect the medication for discoloration or compromised integrity.

Confirm the following information in a drug reference guide: appropriate dosage, need for dilution or reconstitution, compatibility with running IV fluids and medications, rate of administration, action of medication, potential adverse effects, antidote, and patient education.

Explain the procedure to the patient. Provide education regarding the medication, its purpose, and potential side effects.

Perform necessary pre-administration assessments in accordance with the type of medication being given.

Perform hand hygiene and put on gloves. Adhere to standard aseptic non-touch technique (ANTT) when preparing medication, administering IV push medication, flushing, and locking venous access devices.[6]

If the medication is not in a prefilled syringe and dilution is required, dilute it and draw it up in a syringe using sterile technique. Do not dilute or reconstitute IV push medications by drawing up the contents in a commercially prefilled saline flush syringe.[7] Only dilute medications when recommended by the manufacturer, supported by evidence in peer-reviewed biomedical literature, or in accordance with approved agency guidelines.

Check the rights of medication administration X 3 while preparing the medication. When performing three checks, check against the provider order, check as you are reaching for the medication, and check right before administering the medication.

Prepare one medication syringe at a time. Label all IV push medication syringes unless they are prepared at the bedside and immediately administered. Never pre-label an empty syringe in advance of its use.[8]

If continuous running IV fluid is compatible with the medication, pause the infusion. Trace the IV line from the patient to its point of origin and use the port closest to the patient and clamp the line.

Perform a vigorous mechanical scrub of the needleless connector for at least five seconds using 70% alcohol or an alcohol-based chlorhexidine solution and then allow the connector to dry completely. Do not fan or wave over the site.

Assess the venous access device prior, during, and after administering IV push medication for signs and symptoms of complications, such as pain, infiltration, phlebitis, or extravasation.

Assess for patency using a single-use 10-mL syringe with 0.9% normal saline. While maintaining the sterility of the syringe tip, attach the syringe to the needleless connector port. Slowly aspirate for blood return. Patency is determined by evidence of brisk, bright red blood return, although blood return is not always present. Slowly inject preservative-free normal saline solution into the catheter. Never forcibly flush a venous access catheter. Remove and discard the syringe.[9]

Perform a second vigorous mechanical scrub of the needleless connector with a new swab for at least five seconds and allow it to dry completely.

Maintaining the sterility of the syringe tip, attach the medication syringe to the needleless connector of the venous access device. Administer the medication at the recommended rate of administration according to the MAR, drug reference guide, or manufacturer using a watch or clock with a second hand. Remove and discard the syringe.

Perform a third vigorous mechanical scrub of the needleless connector with a new swab for at least five seconds and allow it to dry completely.

Maintaining the sterility of the syringe tip, attach a prefilled 10-mL syringe containing preservative-free 0.9% normal saline to the needleless connector and flush at the same rate of administration as the medication. The volume of the flush should be twice the internal catheter volume (i.e., a J-loop would be 2 mL and extension tubing would be 4 mL). Continue to flush at a slow, steady pace to clear the line, typically another 2 to 7 mL.[10]

If continuous IV fluids are present, unclamp the tubing and resume the infusion. If locking the venous access device, follow agency policy regarding the sequence of flushing, clamping, and disconnecting the syringe.

Evaluate patient response to the medication and monitor for adverse reactions based on the onset and peak of the prescribed medication. Instruct the patient to call the nurse if feeling any adverse effects.

View a YouTube video[11] showing an instructor demonstration of this skill:

References

Institute for Safe Medication Practices. (2015). Safe practice guidelines for adult IV push medications. https://www ​.ismp.org/guidelines/iv-push ↵.

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. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed : 33394637 ] [CrossRef] [CrossRef]

Institute for Safe Medication Practices. (2015). Safe practice guidelines for adult IV push medications. https://www ​.ismp.org/guidelines/iv-push ↵.

Institute for Safe Medication Practices. (2015). Safe practice guidelines for adult IV push medications. https://www ​.ismp.org/guidelines/iv-push ↵.

Institute for Safe Medication Practices. (2015). Safe practice guidelines for adult IV push medications. https://www ​.ismp.org/guidelines/iv-push ↵.

Institute for Safe Medication Practices. (2015). Safe practice guidelines for adult IV push medications. https://www ​.ismp.org/guidelines/iv-push ↵.

Institute for Safe Medication Practices. (2015). Safe practice guidelines for adult IV push medications. https://www ​.ismp.org/guidelines/iv-push ↵.

Chippewa Valley Technical College. (2023, January 5). Administering IV push medications [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu ​.be/4w9JndX9-uI ↵.

2.6. DOCUMENTATION

When performing IV push medication administration, documentation must include the following components: