Pharmacological and Parenteral Therapies Study Guide for the NCLEX-RN Exam

Parenteral and Intravenous Therapies

Intravenous therapy is used for a variety of reasons. Understand the indications for its use, the differences between the fluids that are used, and the equipment involved. There are four basic types of intravenous therapy: peripheral, central, continuous, and intermittent.

Preparation

Patient education and preparation are needed prior to initiating an intravenous line or therapy. This includes a discussion on potential problems or complications from this type of therapy as well as what certain alarms and signals can mean on any pump equipment that is being used. Patients may receive intermittent infusions at home or facilities with home health nursing, at infusion centers, or in the hospital.

Remember to critically evaluate the indication for and location IV access when selecting a vein. As a general rule, it is preferable to use the largest vein above or below the antecubital area on the patient’s non-dominant hand. Veins in the legs and hands are not ideal for IV use. Do not place an IV on the same side as a patient’s mastectomy, paralysis, or dialysis access. Also avoid veins distal to a previous access site with an infusion and/or phlebitis. Larger veins will be necessary for large bore catheters for trauma patients, to deliver blood products, chemotherapy, or for parenteral nutrition. Smaller veins may be used if the patient only needs IV fluids with or without medications. Always critically evaluate the best vein and location to use based on the patient’s needs and medical condition(s).

Care and Monitoring

Obtaining IV access is only one part of this type of medication administration. Nurses must then know how to calculate the rate of infusions for both medications and fluids.

Drip Rates

Critical thinking skills are required to determine the drip rate for the administration of fluids/medications. In general, the rate of infusion, in gtts/min, can be determined by the total amount of fluid to be delivered divided by time in minutes, multiplied by the drip/drop factor for the IV tubing that is being used. Standard IV tubing comes in different drip/drop rates. There is micro tubing that flows at a rate of 60 gtt/min. There is also macro tubing that flows at rates of either 10, 15, or 20 gtt/min. Drip rates of IV tubing are usually provided in problems related to calculating medication rate.

Infusion Pumps

While infusion pumps allow for convenience and are widely used, manual calculation of medication administration allows for error reduction in incorrect drip rates and pump malfunctions. Check drip rates by actually counting the drops that are given over 1 minute or by calculating the amount of intravenous solution administered in a set period. Both of these numbers should be checked against the manual rate calculations.

Monitoring and Site Care

Care and monitoring of all intravenous lines is done by licensed medical staff. It cannot be delegated to other non-licensed support staff. Since all intravenous lines (peripheral, central, PICC, and venous access devices) are potential sites for infection, fastidious care and monitoring is necessary. Facilities will have protocols in place regarding the care of their IV catheters. Most facilities practice peripheral line dressing changes every 24 hours. Central line changes must be performed with sterile technique, patient masks, and occlusive, preferably transparent, dressings. These dressings may stay in place between 3 and 7 days. All dressings that become non-occlusive, have significant drainage, or have questioned integrity should be changed.

Pharmacological Pain Management

In healthcare, clients are often prescribed PRN or as needed medications for pain management. Some clients may request the medications. Others may need to be encouraged to use them. Nurses must assess their patients’ needs for PRN medication administration. They should also understand any regulations that are associated with the administration of narcotic pain therapy.

Assessment

Each patient will require an assessment of their level of pain. This may be accomplished with various numeric/graphic scales, the PQRST method, and/or standardized pain assessment scales. For those unable to use a pain scale due to disability or age, pain assessment can be completed by monitoring the patient’s nonverbal language and vital signs. Nurses should be aware that pregnant women and children require additional assessments in regard to their pain. Medication administration for these populations can vary significantly from the standard adult population.

Patient assessment for pain management should also include the routes for administering PRN prescriptions. Oral, topical, subcutaneous, IM, and IV medication routes are commonly used in pain management. Determining appropriate medication routes requires critical thinking and understanding of the clients’ abilities and conditions. For example, a client with vomiting and retching due to post-surgical anesthesia should not have pain medications administered orally. If the orders prescribed do not match the client’s abilities or is compatible with specific conditions, the nurse should notify the ordering healthcare provider to prescribe a more appropriate therapy.

Administration

Pharmacologic medicines that have analgesic effect can be broadly grouped into one of two categories: opioid and non-opioid analgesics. In general, opioid medications are indicated for moderate to severe pain and non-opioid are used in mild to moderate pain. Weight-based dosing is generally used for neonates, infants, and young children. Adults generally have a standard dosing schedule. In geriatric patients, medication doses may need to be adjusted due to chronic disease and organ dysfunction (renal, hepatic, etc.), as this may affect metabolism and excretion of the drug.

Documentation

Documentation of the pain assessment findings, medication, dose, and route must be supplied in the patient’s medical record.

Regulatory Guidelines

Due to the illegal diversion of controlled substance medications by healthcare personnel, stringent regulatory guidelines have been developed for all healthcare facilities. Most of the time, an automated system in place counts the medications and keeps careful track of who is accessing them and which patient(s) they are for.

In the event that a facility does not have an electronic narcotic monitoring system, there will be a multi-tiered system in place to prevent diversion. Examples of controlled substance management systems include:

Obtaining a nurse’s signature prior to release of controlled substances from the pharmacy
Delivering controlled substance administration, waste, and count sheets with all controlled medications
Using locked storage containers
Assigning an accountable nurse with single key access to perform controlled substance medication counts at the beginning of every shift
Requiring a secondary nurse to witness and sign documentation of any controlled-substance removal, waste, and administration.

Evaluation

Any time that a pain medication is given, it is imperative to observe and evaluate for its intended therapeutic effect on the patient. Assessment for effectiveness can be completed using the same scales discussed above for assessment of pain. The results of both tests should be documented within the patient’s medical record as well as the patient’s ability to meet the expected outcomes as a result of reduced pain (sleep, ambulation, etc.).

Total Parenteral Nutrition (TPN)

TPN is also known as hyperalimentation. It is nutrition that is provided intravenously to a patient and bypasses the gastrointestinal system. While it is more costly than enteral nutrition, TPN is indicated in certain patient populations. It does, however, also carry its own set of risk factors.

Side Effects

TPN should be administered via a central line (PICC line, port, subclavian venous line, etc.). There is a high risk of peripheral vein thrombosis caused by the solution being high concentration due to the requirement to pack in all the daily nutrients and electrolytes. In the case of any central line, there may be complications with line placement, and conditions such as pneumothorax, hemothorax, or hydrothorax could occur. In relation to the TPN administered, infection, fluid overload, hyperglycemia, hypoglycemia, and air emboli are all potential adverse side effects/complications. Review the signs and symptoms of these complications.

Patient Education

All patients should receive education on why they need TPN and how it will be delivered. They should be informed of all of the potential risks and complications associated with TPN therapy. Patients will also need to understand and be informed on all aspects of the placement, care, and maintenance of the intravenous line (peripheral or central) that will be used to deliver their TPN.

Nursing Skills

The following nursing skills will be applicable and should be used when caring for a patient on or considering TPN:

Assessment—validation of the need for TPN and recording of baseline findings (weight, vitals, glucose, protein, electrolytes, intake, and output)
Nursing diagnoses—actual and potential
Planning—establishment of expected outcomes and client goals for TPN therapy
Evaluating the response to treatment—reassessment of the same criteria evaluated prior to TPN and determination of the effectiveness of treatment

Other applicable skills will include the use of aseptic technique, proper maintenance and changing of tubings, bags, and bottles, maintenance of the catheter insertion site, and mathematical skills to calculate and control the rate of infusion.

Lastly, you must also apply your knowledge of your patient’s pathophysiology to prevent infection, balance the interplay between the dextrose content of the solution and any insulin that is given, and closely monitor intake and output to avoid fluid imbalance.

Administration and Evaluation

Strict sterile procedure must be followed when administering TPN. Direct your patient to bear down, performing a valsalva maneuver, whenever tubing, bags, or bottles are changed to avoid an air embolism. Move quickly, but carefully, during these tasks. Evaluate for the client’s response to the TPN and any changes in the client’s status. Monitor glucose levels, level of consciousness (LOC), and electrolyte levels throughout the duration of TPN therapy.