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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is preparing to administer an intravenous loading dose of phenytoin to an adult client who was recently admitted for status epilepticus. The client is currently stable but requires the medication to prevent recurrent seizure activity. The client has a continuous peripheral intravenous (IV) infusion of 5% dextrose in water5\% \text{ dextrose in water} (D5WD_5W) running at 75 mL/hr75\text{ mL/hr}. Which of the following nursing actions is essential for the safe administration of this medication?

  1. Stop the primary infusion, flush the line with 0.9% sodium chloride0.9\% \text{ sodium chloride}, and administer the phenytoin at a maximum rate of 50 mg/min50\text{ mg/min}.Answer
  2. B
    Administer the phenytoin via intravenous piggyback directly into the primary 5% dextrose in water5\% \text{ dextrose in water} infusion line.
  3. C
    Administer the medication as a rapid intravenous bolus over 1 to 2 minutes1\text{ to }2\text{ minutes} to maximize central nervous system distribution.
  4. D
    Delegate the task of continuous blood pressure and electrocardiogram monitoring to the unlicensed assistive personnel (UAP).

Answer

Stop the primary infusion, flush the line with 0.9% sodium chloride, and administer the phenytoin at a maximum rate of 50 mg/min.
Phenytoin is physically incompatible with all dextrose solutions and will form a dangerous precipitate if they are mixed. Because the client is receiving a continuous D5WD_5W infusion, the nurse must pause the primary infusion and flush the line completely with normal saline (0.9% sodium chloride0.9\% \text{ sodium chloride}) before and after administration. Furthermore, to prevent severe cardiovascular toxicity including profound hypotension and dysrhythmias, intravenous phenytoin must be administered slowly, never exceeding a rate of 50 mg/min50\text{ mg/min} in adult clients.

Step-by-Step Solution

1
Review the prescribed medication and its compatibility with the current continuous intravenous fluid.
Phenytoin is highly incompatible with dextrose solutions like D5WD_5W and will precipitate.
Verifying IV fluid compatibility is essential to prevent crystallization in the catheter, which could lead to an embolism or loss of IV access.
2
Determine the correct procedure for administration through a line running an incompatible fluid.
The primary D5WD_5W infusion must be paused, and the line must be flushed thoroughly with 0.9% sodium chloride0.9\% \text{ sodium chloride} (normal saline) both before and after giving the drug.
Normal saline is the only compatible IV fluid for flushing and diluting phenytoin.
3
Identify the safe administration rate and necessary patient monitoring.
The medication must be administered at a rate no faster than 50 mg/min50\text{ mg/min} by the registered nurse.
Rapid infusion causes cardiovascular collapse, and the required complex assessments cannot be delegated to a UAP.

Key Concept

Safe administration parameters for intravenous phenytoin
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Topics

Pharmacological and Parenteral Therapies

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