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Difficulty: Very hardPharmacological and Parenteral Therapies

A nurse is caring for a critically ill client who has a double-lumen peripherally inserted central catheter (PICC). Lumen 1 is infusing continuous norepinephrine, and Lumen 2 is infusing 0.9% sodium chloride at a keep-vein-open rate. The healthcare provider prescribes a continuous infusion of pantoprazole, an intermittent IV piggyback of vancomycin, and a STAT dose of IV push furosemide 40 mg40\text{ mg}. The client's total urine output over the past 2 hours is 25 mL25\text{ mL}. Which of the following nursing actions are appropriate? Select all that apply.

  1. Withhold the vancomycin dose and notify the healthcare provider of the recent urine output.Answer
  2. B
    Administer the IV push furosemide through the injection port on the norepinephrine line.
  3. Flush the designated IV line with 0.9% sodium chloride before and after the furosemide administration.Answer
  4. Administer the 40 mg40\text{ mg} dose of IV push furosemide over a period of at least 2 minutes.Answer
  5. E
    Connect the pantoprazole infusion to the Y-site of the continuous norepinephrine line since both medications are appropriate for central venous administration.
  6. F
    Program the infusion pump to deliver the vancomycin dose over 30 minutes to rapidly achieve therapeutic trough levels.

Answer

The appropriate actions are withholding the vancomycin due to oliguria, flushing the IV line before and after furosemide administration, and pushing the furosemide over at least 2 minutes.
Safe administration of high-risk parenteral therapies requires analyzing multiple client factors simultaneously. Vancomycin is highly nephrotoxic; the client's severe oliguria (12.5 mL/hr12.5\text{ mL/hr}) strongly indicates acute kidney injury, necessitating holding the drug and notifying the provider to prevent irreversible renal failure. Flushing the line before and after furosemide prevents precipitation, as furosemide is chemically incompatible with many medications. Furosemide must be administered no faster than 20 mg/min20\text{ mg/min} to prevent permanent ototoxicity; therefore, a 40 mg40\text{ mg} dose requires at least 2 minutes.

Step-by-Step Solution

1
Analyze the client's clinical data against the prescribed medications.
The client has a urine output of 12.5 mL/hr12.5\text{ mL/hr}, indicating oliguria.
Recognizing oliguria is critical because vancomycin is nephrotoxic and requires dosage adjustment or holding in the presence of acute kidney injury.
2
Evaluate the safety parameters for administering IV push furosemide.
Furosemide must be pushed slowly (20 mg/min20\text{ mg/min}) and requires a cleared IV line.
Rapid administration causes ototoxicity. Furosemide is notoriously incompatible with other drugs, requiring thorough saline flushes before and after.
3
Determine the safety of using the norepinephrine line for other medications.
The norepinephrine line cannot be used for IV pushes, and pantoprazole cannot be empirically Y-sited with it.
Pushing meds through a pressor line delivers a lethal bolus of the pressor. Pantoprazole is incompatible with norepinephrine.
4
Evaluate the standard administration rate for vancomycin.
Vancomycin cannot be administered in 30 minutes.
Rapid infusion of vancomycin causes profound histamine release (vancomycin infusion reaction), requiring a minimum 60-minute infusion time.

Key Concept

Complex multi-medication parenteral therapy requires synthesis of pharmacokinetics (nephrotoxicity, ototoxicity), safe administration rates (preventing infusion reactions), and physical IV line dynamics (preventing pressor bolusing and chemical precipitation).
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Topics

Pharmacological and Parenteral Therapies

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