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Difficulty: Very hardPharmacological and Parenteral Therapies

A nurse is assigned to care for a client who is experiencing recurrent seizures and has a new prescription for an intravenous loading dose of phenytoin. The client currently has a continuous peripheral intravenous infusion of 5% dextrose in water (D5W) running at 100 mL/hr. Which nursing actions are required to safely prepare and administer this medication? (Select all that apply.)

  1. Flush the peripheral intravenous line with 0.9% sodium chloride before and after the phenytoin administration.Answer
  2. Attach a 0.22-micron to 0.52-micron in-line filter to the intravenous tubing prior to initiating the infusion.Answer
  3. Control the administration rate via an electronic infusion pump to ensure it does not exceed 50 mg per minute.Answer
  4. D
    Piggyback the phenytoin infusion into the Y-site of the primary 5% dextrose in water (D5W) line while it is actively running.
  5. E
    Calculate the client's total loading dose by converting their documented body weight from kilograms to pounds.
  6. F
    Delegate the continuous monitoring of the client's electrocardiogram and blood pressure during the infusion to the unlicensed assistive personnel (UAP).

Answer

The correct actions are to flush the line with 0.9% sodium chloride before and after administration, attach a 0.22-micron to 0.52-micron in-line filter, and control the administration rate so it does not exceed 50 mg per minute.
Phenytoin is a highly alkaline medication that rapidly precipitates when mixed with dextrose solutions; therefore, the intravenous line must be flushed with 0.9% sodium chloride before and after administration. An in-line filter (0.22 to 0.52 micron) is essential to trap any microcrystals that may form and prevent them from entering the client's systemic circulation. Additionally, rapid intravenous administration of phenytoin can cause severe cardiovascular collapse, including profound hypotension and arrhythmias, so the rate must strictly never exceed 50 mg per minute.

Step-by-Step Solution

1
Evaluate the current intravenous fluid compatibility.
Identify that the continuous D5W infusion is incompatible with phenytoin.
Phenytoin is highly alkaline and precipitates in dextrose, meaning the line must be completely cleared with a 0.9% sodium chloride flush.
2
Determine the necessary equipment for administration.
Select an in-line 0.22-micron to 0.52-micron filter for the intravenous tubing.
Filters are mandatory for intravenous phenytoin to trap microcrystals that form due to the drug's inherently low solubility.
3
Establish the maximum safe administration rate.
Set the infusion pump to deliver the medication at a rate no faster than 50 mg per minute.
Rapid intravenous infusion of phenytoin directly causes severe cardiovascular collapse, including hypotension and bradycardia.
4
Identify the appropriate nursing scope for client monitoring.
Retain the responsibility for continuous ECG and hemodynamic monitoring.
The RN cannot delegate assessments requiring advanced clinical judgment to unlicensed assistive personnel (UAP).

Key Concept

Intravenous Phenytoin Administration Safety Protocol
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Topics

Pharmacological and Parenteral Therapies

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