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Difficulty: HardPharmacological and Parenteral Therapies

A healthcare provider orders a stat intravenous bolus of phenytoin 400 mg for a hospitalized client experiencing seizure activity. The client's only current venous access is a 20-gauge peripheral catheter through which 5% dextrose in water (D5W) is actively infusing at 100 mL/hr. Which of the following actions represents the safest method for the nurse to administer this medication?

  1. Flush the peripheral IV line with 0.9% sodium chloride, administer the phenytoin over at least 8 minutes, and flush again with 0.9% sodium chloride.Answer
  2. B
    Pause the D5W infusion, administer the phenytoin dose steadily over 4 minutes, and immediately restart the primary continuous infusion.
  3. C
    Dilute the phenytoin in a 50 mL bag of 5% dextrose in water (D5W) and administer it as a secondary piggyback infusion over 30 minutes.
  4. D
    Delay the administration of the medication and notify the healthcare provider to insert a central venous catheter to prevent peripheral tissue necrosis.

Answer

Flush the peripheral IV line with 0.9% sodium chloride, administer the phenytoin over at least 8 minutes, and flush again with 0.9% sodium chloride.
The correct action ensures both chemical compatibility and physiological safety. Phenytoin is highly alkaline and precipitates in dextrose; therefore, the IV line must be cleared with 0.9% sodium chloride before and after the push. Additionally, the maximum safe rate for IV phenytoin in adults is 50 mg/min to prevent cardiovascular toxicity. Calculating the rate for a 400 mg dose (400÷50=8400 \div 50 = 8) confirms that an administration time of at least 8 minutes is required.

Step-by-Step Solution

1
Identify medication incompatibilities based on the current continuous infusion.
Recognize that phenytoin precipitates when mixed with dextrose solutions (D5W), requiring a normal saline flush to clear the line.
To prevent crystal formation in the intravenous line, which could cause a life-threatening embolism or occlude the catheter.
2
Determine the safe intravenous administration rate for the prescribed dosage.
Calculate that a 400 mg dose at a maximum rate of 50 mg/min requires at least 8 minutes (400÷50=8400 \div 50 = 8).
To prevent severe cardiovascular adverse effects, such as profound hypotension and arrhythmias, which are associated with rapid phenytoin administration.
3
Formulate the procedural administration plan.
Select the method that flushes out the incompatible fluid with normal saline, delivers the medication slowly at the calculated safe rate, and flushes again before restarting the primary fluid.
To ensure complete, safe delivery of the prescribed dose without compromising the IV access or patient hemodynamics.

Key Concept

Safe intravenous administration of phenytoin requires strict adherence to rate limits (maximum 50 mg/min) and flushing with 0.9% sodium chloride due to severe incompatibility with dextrose solutions.
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Topics

Pharmacological and Parenteral Therapies

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