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Difficulty: HardPharmacological and Parenteral Therapies

A nurse is preparing to administer a prescribed dose of intravenous phenytoin by direct injection (IV push). The client has a single peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) continuously. Knowing that phenytoin is incompatible with dextrose solutions, arrange the following nursing actions in the correct sequence to safely administer the medication.

  1. 1Pause the continuous intravenous infusion of 5% dextrose in water.
  2. 2Cleanse the access port and flush the intravenous line with 10 mL of 0.9% sodium chloride.
  3. 3Administer the intravenous phenytoin by direct injection at a maximum rate of 50 mg/minute.
  4. 4Flush the intravenous line with 10 mL of 0.9% sodium chloride at the same rate the medication was administered.
  5. 5Resume the continuous intravenous infusion of 5% dextrose in water.

Answer

The correct sequence is to first stop the incompatible dextrose infusion, flush the line with normal saline, administer the phenytoin slowly, flush the line again with normal saline at the same slow rate, and finally resume the dextrose infusion.
When administering an intravenous push medication through a line infusing an incompatible solution, the nurse must ensure the two fluids never mix in the tubing. The strict sequence must be: stop the incompatible fluid, flush with a compatible fluid (0.9% sodium chloride) to clear the line, administer the medication, flush again with the compatible fluid to clear the medication from the line, and finally restart the continuous infusion. Crucially, the post-medication flush must be administered at the same slow rate as the medication to avoid inadvertently pushing a bolus of the medication remaining in the tubing into the client's circulation.

Step-by-Step Solution

1
Pause the continuous infusion of D5W.
The flow of the incompatible fluid is stopped.
Prevents the mixing of phenytoin and dextrose in the IV tubing, which would cause immediate crystallization.
2
Flush the IV line with 0.9% sodium chloride.
The IV tubing is cleared of dextrose.
Normal saline is compatible with phenytoin and creates a safe, clear environment in the tubing for the medication to pass through.
3
Administer the IV push phenytoin slowly.
The medication is delivered safely into the bloodstream.
Slow administration (maximum 50 mg/min) prevents severe hypotension and cardiac arrhythmias associated with rapid phenytoin delivery.
4
Flush the line again with 0.9% sodium chloride at the same slow rate.
Phenytoin is completely cleared from the tubing dead space.
Ensures the entire dose reaches the patient and prevents precipitation when D5W is resumed. Flushing slowly prevents the remaining drug from being delivered as a rapid bolus.
5
Restart the D5W infusion.
Continuous intravenous fluids are resumed.
Maintains the client's prescribed hydration and glucose support after the medication has been safely delivered.

Key Concept

Safe administration of intravenous medications via a line with an incompatible continuous infusion requires the 'flush-administer-flush' technique using a compatible solution to prevent drug precipitation.

Alternative Method

If the client requires uninterrupted dextrose infusion (e.g., for severe hypoglycemia), the nurse should establish a second peripheral intravenous site specifically for the phenytoin administration rather than interrupting the primary line.
Estimated Time:2m 0s
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Topics

Pharmacological and Parenteral Therapies

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