What are the nursing considerations for IV push?

Nearly half of all intravenous (IV) medication errors occur during preparation or administration [1.6.4]. Understanding what are the nursing considerations for IV push is critical for patient safety, involving meticulous checks, correct technique, and vigilant monitoring to prevent adverse events.

Quick Summary

Key nursing considerations for IV push include verifying the eight rights of medication administration, assessing patient allergies and IV site patency, knowing the correct administration rate, and monitoring for complications.

Key Points

• Verify the Eight Rights: Always confirm the right patient, medication, dose, route, time, documentation, reason, and response before administration [1.2.1].

• Assess Patient and IV Site: Check for allergies and contraindications, and ensure the IV line is patent and free from signs of infiltration or phlebitis before every push [1.7.5].

• Control the Administration Rate: Administer the medication and the final saline flush at the manufacturer-recommended rate to prevent speed shock and other adverse reactions [1.3.1, 1.4.1].

• Know Your Compatibilities: Verify that the medication is compatible with any running IV fluids to prevent precipitate formation and potential emboli [1.3.4].

• Avoid Unnecessary Dilution: Do not dilute IV push medications, especially in prefilled saline syringes, unless explicitly indicated by the manufacturer or pharmacy [1.2.4].

• Use the S-A-S Method: Employ the Saline-Administer-Saline technique to ensure line patency and delivery of the full medication dose [1.2.5].

• Document Thoroughly: Record all aspects of the administration, including the medication, dose, rate, site, patient response, and any assessments performed [1.9.1].

Understanding IV Push (Bolus) Administration

An intravenous (IV) push, or bolus, is a method of administering a concentrated dose of medication directly into the systemic circulation [1.3.4]. This route provides a rapid onset of action, which is crucial in emergencies. However, because the medication takes effect so quickly, there is a very narrow margin for error, making strict adherence to safety protocols paramount [1.3.4]. The potential for harm is high if mistakes are made in dosage, rate, or compatibility [1.3.3]. Preventable adverse drug events associated with injectable medications impact an estimated 1.2 million hospitalizations annually [1.6.4]. Therefore, nurses must be diligent in every step of the process.

Pre-Administration: The Foundation of Safety

Before a single drop of medication is administered, a series of critical checks and assessments must occur. These steps form the foundation of safe IV push practice.

The Eight Rights of Medication Administration

A cornerstone of safe medication practice is verifying the "eight rights" [1.2.1]:

1. Right Patient: Use at least two patient identifiers (e.g., name and date of birth) [1.2.1].
2. Right Medication: Confirm the medication matches the order and is appropriate for the patient's condition [1.2.1].
3. Right Dose: Check that the dose is safe for the patient's age, weight, and clinical status. High-alert medications often require a double-check with another nurse [1.4.4].
4. Right Route: Ensure the medication is approved for IV push administration. Some drugs require a central line and cannot be given peripherally [1.2.1].
5. Right Time: Adhere to the prescribed schedule [1.2.1].
6. Right Documentation: Ensure the order is clear and accurate before proceeding [1.2.1].
7. Right Reason: Verify the medication is being given for the correct indication [1.2.1].
8. Right Response: Evaluate the patient for the desired effect and any adverse reactions after administration [1.2.1].

Patient and IV Site Assessment

Before administration, a thorough assessment is crucial. This includes reviewing the patient's allergies, medical history (especially cardiac, renal, or liver function), and current vital signs [1.7.1, 1.7.5]. The nurse must also assess the vascular access device (VAD). The IV site should be inspected for signs of complications like redness, swelling, pain, or warmth [1.7.5]. The line's patency must be confirmed by flushing with normal saline to ensure it flows freely without resistance or causing the patient pain [1.4.3]. Using an IV site without confirming patency can lead to serious complications like infiltration or extravasation [1.3.6].

Compatibility and Dilution Checks

IV push medications must be compatible with any concurrently running IV fluids or other medications to prevent the formation of precipitate, which can inactivate the drug or cause an embolism [1.3.4]. Always consult a drug reference guide or pharmacy for compatibility information [1.4.1]. Unnecessary dilution of medications is an unsafe practice and should be avoided unless explicitly recommended by the manufacturer [1.2.4, 1.3.3]. Never use prefilled saline flush syringes to dilute or reconstitute medications, as this is an off-label use and increases the risk of contamination and dosing errors [1.2.4].

During Administration: Technique and Rate Control

Proper technique during the administration phase is critical to prevent complications. Aseptic non-touch technique (ANTT) is mandatory throughout the procedure, including scrubbing the needleless connector for at least five seconds before each access [1.4.3].

The S-A-S Method

The most common procedure for administering an IV push into a saline lock is the Saline-Administer-Saline (S-A-S) method:

1. Saline Flush: First, flush the IV line with normal saline (typically 3-5 mL) to confirm patency [1.2.5].
2. Administer Medication: Administer the medication at the prescribed rate. This is one of the most critical steps.
3. Saline Flush: Flush the line again with normal saline (using the same volume as the first flush) to ensure the entire dose of medication is cleared from the tubing and enters the bloodstream. This final flush should be administered at the same rate as the medication to avoid inadvertently bolusing the remaining drug in the line [1.4.1].

The Importance of Rate

Administering a medication too quickly, known as "speed shock," can cause symptoms like a flushed face, headache, tightness in the chest, irregular pulse, and even cardiac arrest [1.3.1, 1.3.4]. Always use a watch or clock with a second hand to time the push according to the manufacturer's or a drug reference guide's recommendation [1.4.6]. For a drug that needs to be pushed over 2 minutes, for example, a nurse might administer 1/4 of the syringe volume every 30 seconds.

IV Push vs. IV Piggyback (IVPB)

Nurses must understand the differences between IV push and IV piggyback (IVPB) to apply the correct method.

Feature	IV Push (Bolus)	IV Piggyback (IVPB)
Administration Time	Fast (typically 1-5 minutes) [1.5.2]	Slower (typically 15-60+ minutes) [1.9.2]
Volume	Small, concentrated volume of medication	Medication is diluted in a larger volume of fluid (e.g., 50-250 mL) [1.5.5]
Onset of Action	Rapid, almost immediate [1.3.4]	Gradual onset as the medication infuses over time
Primary Use	Emergency situations, rapid effect needed, fluid-restricted patients	Routine intermittent medication delivery (e.g., antibiotics) [1.5.3]
Risk Profile	Higher risk of speed shock and acute adverse reactions [1.3.4]	Lower risk of speed shock; infusion can be stopped if a reaction occurs [1.5.4]
Resource Usage	Fewer supplies (syringes, needles) [1.5.2]	Requires an infusion bag, secondary tubing, and often an infusion pump

Post-Administration: Monitoring and Documentation

The nurse's responsibility does not end when the flush is complete. Continuous monitoring is essential to evaluate the drug's therapeutic effect and watch for adverse reactions [1.2.1].

Key documentation for an IV push medication includes [1.9.1, 1.9.3]:

• Date and time of administration
• Name of medication, dose, and route
• IV access site location
• Rate of administration
• Patient's response to the medication (both therapeutic and adverse)
• Any patient education provided
• Pre- and post-administration assessments (e.g., pain level, vital signs)

Conclusion

Safe IV push administration is a high-level nursing skill that demands knowledge, precision, and critical thinking. From meticulous pre-administration checks and patient assessment to controlled administration and diligent post-procedure monitoring, every step is vital for patient safety. By strictly adhering to the eight rights, understanding medication-specific guidelines, and recognizing potential complications, nurses can effectively minimize the significant risks associated with this essential route of medication delivery.

---

For more in-depth guidelines, nurses can refer to resources from the Infusion Nurses Society (INS).

Frequently Asked Questions

What is speed shock and how can it be prevented?

Speed shock is a systemic reaction caused by rapidly injecting a medication into the circulation. Symptoms include a flushed face, headache, chest tightness, irregular pulse, and potentially cardiac arrest. It is prevented by administering IV push medications slowly, at the rate recommended by the manufacturer or a drug reference guide [1.3.1, 1.3.4].

Why is it important to flush the IV line after an IV push?

Flushing the IV line with normal saline after the medication is administered ensures that the entire dose is cleared from the IV tubing and delivered to the patient's bloodstream. This flush should be given at the same rate as the medication to prevent an accidental bolus of any remaining drug [1.4.1].

Can all medications be given via IV push?

No, not all medications are suitable for IV push administration. Some drugs are too irritating to the veins (vesicants), require slow dilution via an infusion to be safe, or must be given via a larger central line. Always check a drug reference guide to confirm the approved route of administration [1.2.1].

What is the difference between infiltration and extravasation?

Infiltration is the leakage of a non-vesicant (non-irritating) IV fluid or medication into the surrounding tissue. Extravasation is the leakage of a vesicant (a substance that can cause tissue damage) into the surrounding tissue. Extravasation is more serious and can lead to tissue necrosis [1.3.6].

Why shouldn't I dilute medication in a prefilled saline syringe?

Diluting medication in a prefilled saline flush syringe is an unsafe, off-label practice. It increases the risk of contamination, inaccurate dosing, and labeling errors. Prefilled flush syringes are classified as devices, not drug containers, and their use in this manner has not been tested for safety [1.2.4, 1.2.6].

What are the 'eight rights' of medication administration?

The eight rights are a safety checklist for nurses: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation, Right Reason, and Right Response. Verifying all eight rights before administration helps prevent medication errors [1.2.1].

How do you check an IV for patency before giving a medication?

To check for patency, you perform a saline flush by slowly injecting 3-5 mL of 0.9% normal saline into the IV port. You should feel no resistance, and the patient should report no pain. You should also visually inspect the site for any swelling, which would indicate infiltration [1.4.3].