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Difficulty: HardPharmacological and Parenteral Therapies

A client with a seizure disorder is currently receiving a continuous infusion of 5% dextrose in water (D5W) through a single peripheral IV catheter. The healthcare provider prescribes an immediate dose of intravenous phenytoin. Knowing that phenytoin forms a precipitate when mixed with dextrose solutions, arrange the following nursing actions in the correct chronological sequence to safely deliver the medication.

  1. 1Pause the primary continuous IV infusion pump.
  2. 2Aspirate for a blood return and flush the IV line with 10 mL of 0.9% sodium chloride.
  3. 3Administer the IV phenytoin at a rate not exceeding 50 mg/min.
  4. 4Flush the IV line again with 10 mL of 0.9% sodium chloride at the same rate the medication was administered.
  5. 5Resume the primary continuous IV infusion of 5% dextrose in water.

Answer

The correct sequence is to first pause the incompatible infusion, flush the line with normal saline, administer the phenytoin slowly, flush again with normal saline at the exact same slow rate, and finally resume the continuous infusion.
When administering an IV push medication that is incompatible with a continuous IV infusion, the nurse must utilize the Saline-Administer-Saline method. First, the continuous infusion must be paused to stop the flow of the incompatible fluid. The line is then aspirated and flushed with a compatible solution (normal saline) to clear the existing fluid from the tubing. Next, the medication is administered at its recommended safe rate. Crucially, the subsequent flush must be administered at the exact same rate as the medication to ensure the drug residing in the tubing dead space is not rapidly flushed into the client's circulation. Finally, the primary infusion can be safely resumed.

Step-by-Step Solution

1
Pause the primary continuous IV infusion pump.
The flow of the incompatible D5W solution is completely stopped.
This is the first essential step to prevent the mixing of phenytoin and dextrose, which causes immediate crystallization.
2
Aspirate for a blood return and flush the IV line with 10 mL of 0.9% sodium chloride.
IV patency is confirmed and the tubing is cleared of D5W.
Confirming patency ensures the medication will enter the vein safely. Normal saline is compatible with phenytoin and clears the incompatible fluid.
3
Administer the IV phenytoin at a rate not exceeding 50 mg/min.
The medication is delivered safely into the saline-primed line.
Rapid administration of phenytoin can cause severe hypotension, bradycardia, and cardiovascular collapse.
4
Flush the IV line again with 10 mL of 0.9% sodium chloride at the same rate the medication was administered.
The medication remaining in the dead space of the IV tubing is cleared into the patient.
If the second flush is given rapidly, the patient receives a rapid bolus of the residual phenytoin in the line, leading to adverse cardiovascular effects.
5
Resume the primary continuous IV infusion of 5% dextrose in water.
The client continues to receive their prescribed continuous IV therapy.
The line is now clear of phenytoin, making it safe to reintroduce the dextrose solution.

Key Concept

Administration of an IV push medication incompatible with the primary continuous IV fluid requires pausing the pump and using the Saline-Administer-Saline method, ensuring the final flush is administered at the same rate as the medication to prevent rapid bolusing of residual drug in the dead space.
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Topics

Pharmacological and Parenteral Therapies

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