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Difficulty: Very hardPharmacological and Parenteral Therapies

A nurse is caring for a critically ill client who is experiencing septic shock and new-onset tonic-clonic seizures. The client has a double-lumen central venous catheter (CVC) in place. Lumen one is infusing continuous total parenteral nutrition (TPN), and lumen two is infusing continuous norepinephrine. The healthcare provider prescribes a stat dose of intravenous (IV) push phenytoin. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral management? (Select all that apply)

  1. Establish a new peripheral intravenous catheter specifically for the administration of the phenytoin.Answer
  2. Flush the intravenous line with 0.9% sodium chloride immediately before and after administering the phenytoin.Answer
  3. C
    Administer the phenytoin IV push through the Y-site of the total parenteral nutrition infusion to expedite delivery.
  4. D
    Direct the unlicensed assistive personnel to evaluate the central venous catheter insertion site for signs of extravasation.
  5. Administer the intravenous push phenytoin at a rate not exceeding 50 mg per minute.Answer
  6. F
    Temporarily pause the norepinephrine infusion to administer the stat phenytoin through the central line.

Answer

The nurse must establish a new peripheral IV line, flush the line with 0.9% sodium chloride before and after administration, and infuse the phenytoin at a maximum rate of 50 mg/min to ensure safe administration without compromising the life-sustaining continuous infusions.
Phenytoin is highly alkaline, irritating to veins, and highly incompatible with dextrose-containing solutions such as total parenteral nutrition (TPN). Therefore, it must always be flushed and administered with 0.9% sodium chloride. Furthermore, TPN requires a dedicated line to prevent infection and chemical incompatibility, and continuous norepinephrine must not be interrupted due to the risk of profound hypotension. Consequently, because both central lumens are occupied by critical infusions, the nurse must establish a new peripheral intravenous access to administer the medication safely. Finally, intravenous phenytoin must be administered slowly, not exceeding 50 mg per minute, as rapid administration can cause severe hypotension and life-threatening cardiac arrhythmias.

Step-by-Step Solution

1
Analyze the current IV access and ongoing continuous infusions.
The client has a double-lumen CVC. One lumen is occupied by TPN (requires a dedicated line) and the other by norepinephrine (a critical, continuous vasopressor).
Identifying existing line usage is essential to prevent adverse drug reactions and maintain life-sustaining therapies.
2
Identify the specific administration requirements for IV push phenytoin.
Phenytoin is highly alkaline, precipitates in dextrose solutions, must be flushed with normal saline, and has a strict maximum administration rate of 50 mg/min.
Knowledge of drug-specific compatibilities and toxicities prevents crystallization in the IV line and cardiovascular collapse.
3
Determine the safest access route and administration protocol.
Because neither CVC lumen can be safely used or paused, a new peripheral IV must be established. The nurse must then use normal saline flushes and administer the medication slowly.
This maintains the ABCs (circulation via norepinephrine), nutritional protocols (dedicated TPN line), and pharmacological safety.
4
Evaluate the distractors against delegation and prioritization principles.
Delegating site assessment to UAP is unsafe, and pausing norepinephrine compromises circulation, ruling out these actions.
Nurses must retain clinical judgment tasks and prioritize hemodynamic stability.

Key Concept

Safe Administration of Intravenous Phenytoin and Central Line Management
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Topics

Pharmacological and Parenteral Therapies

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