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Difficulty: HardPharmacological and Parenteral Therapies

A nurse is preparing to administer an intravenous (IV) push dose of phenytoin to a client. The client has a single peripheral IV line currently infusing 5% dextrose in water (D5W) continuously. Phenytoin is physically incompatible with D5W. The nurse has already verified the client's identity, checked the medication prescription, and donned clean gloves. Arrange the following steps in the correct chronological order to safely administer the medication.

  1. 1Stop the continuous D5W infusion via the electronic infusion pump.
  2. 2Clamp the primary intravenous tubing immediately above the injection port closest to the client.
  3. 3Flush the injection port with 10 mL of 0.9% sodium chloride.
  4. 4Administer the prescribed phenytoin via intravenous push over the recommended time.
  5. 5Flush the injection port again with 10 mL of 0.9% sodium chloride at the same rate as the medication administration.
  6. 6Unclamp the primary tubing and restart the continuous D5W infusion.

Answer

The correct sequence is to first stop the incompatible D5W infusion, clamp the tubing above the port, flush with normal saline to clear the line, administer the phenytoin, flush again with normal saline at the same slow rate, and finally unclamp and restart the D5W infusion.
When administering an IV push medication that is incompatible with the continuous IV fluid, the nurse must create a 'saline lock' environment within the active line. This requires stopping the pump, clamping the line to prevent backflow, and clearing the line with a compatible flush (normal saline) before the medication is introduced. After administration, the line must be flushed again with normal saline to clear the drug from the catheter before the incompatible continuous fluid is resumed. The post-flush must be given at the same rate as the medication to avoid speed shock from the drug remaining in the catheter's dead space.

Step-by-Step Solution

1
Stop the D5W continuous infusion.
The flow of the incompatible fluid is halted.
Prevents the incompatible solution from actively flowing into the line during the medication administration process.
2
Clamp the primary IV tubing above the lowest port.
The fluid pathway back to the IV bag is blocked.
Prevents the normal saline flush and the phenytoin from traveling retrogradely up the IV tubing.
3
Flush the IV line with 10 mL of 0.9% sodium chloride.
Residual D5W is cleared from the lower tubing and catheter.
Phenytoin is highly incompatible with dextrose and will precipitate (crystallize) if they mix, potentially causing an embolus.
4
Administer the IV push phenytoin.
The medication is delivered to the client safely.
The line is now clear and filled with compatible normal saline, allowing safe administration.
5
Flush the line again with 10 mL of 0.9% sodium chloride at the same rate as the medication.
Residual phenytoin is cleared from the catheter into the bloodstream.
Flushing at the same slow rate ensures the remaining medication in the dead space is not rapidly pushed into the client, preventing speed shock.
6
Unclamp the tubing and restart the D5W infusion.
The client's prescribed continuous fluid therapy is resumed.
The medication administration is complete and the line is cleared, allowing safe resumption of the primary fluid.

Key Concept

Safe administration of an IV push medication through a continuous infusion of an incompatible solution using the flush-administer-flush technique.
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Topics

Pharmacological and Parenteral Therapies

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