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Difficulty: HardPharmacological and Parenteral Therapies

A critically ill client with septic shock is being managed in the intensive care unit. The client has a double-lumen central venous catheter. The first lumen is dedicated to total parenteral nutrition (TPN). The second lumen is delivering a norepinephrine infusion to maintain the client's mean arterial pressure. Following a focal seizure, the healthcare provider prescribes an intravenous (IV) loading dose of phenytoin. Which of the following is the most appropriate nursing action?

  1. A
    Pause the norepinephrine infusion, flush the line with 0.9% sodium chloride, administer the phenytoin, and resume the vasopressor.
  2. B
    Administer the phenytoin via the lowest Y-site of the total parenteral nutrition (TPN) infusion to ensure central delivery.
  3. Establish a new peripheral intravenous access site and administer the phenytoin exclusively with 0.9% sodium chloride.Answer
  4. D
    Connect the phenytoin to the Y-site of the norepinephrine infusion, ensuring both medications infuse simultaneously.

Answer

The correct action is to establish a new peripheral intravenous access site and administer the phenytoin exclusively with 0.9% sodium chloride.
Phenytoin is highly incompatible with many solutions, especially dextrose (found in TPN), and can easily precipitate. It must be administered exclusively with 0.9% sodium chloride. Furthermore, TPN requires a dedicated line to prevent infection and incompatibilities. The norepinephrine infusion cannot be paused, even briefly, because of its short half-life and the client's dependence on it for hemodynamic stability in septic shock. Therefore, establishing a new IV site is the only safe option.

Step-by-Step Solution

1
Evaluate the current use of the central venous catheter lumens.
The first lumen is dedicated to TPN. The second lumen is infusing a continuous, life-sustaining vasopressor (norepinephrine).
To determine if either existing line can safely accommodate a new intravenous medication.
2
Analyze the pharmacological properties and administration requirements for intravenous phenytoin.
Phenytoin is highly physically incompatible with most solutions and medications, especially dextrose (found in TPN), and must be administered with 0.9% sodium chloride.
To identify compatibility risks and prevent precipitation or crystallization in the IV line.
3
Determine the safest route of administration based on compatibility and patient hemodynamics.
Since the vasopressor cannot be paused without risking cardiovascular collapse, and TPN requires a dedicated line, a new peripheral IV is the only safe option.
To ensure the client safely receives the anticonvulsant without compromising life-sustaining therapies.

Key Concept

Safe administration of incompatible high-alert intravenous medications requires establishing separate vascular access when existing lines are dedicated to life-sustaining continuous infusions.

Alternative Method

If establishing a new peripheral IV is impossible due to severe edema or vascular collapse, an intraosseous (IO) line would be the next appropriate alternative for emergency access.
Estimated Time:1m 30s
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Topics

Pharmacological and Parenteral Therapies

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