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Question: I'm seeing nurses share about routinely diluting intravenous (IV) push medications before giving them to patients. Is this good practice? When should nurses be diluting IV push medications?
This topic has surfaced recently on social media, but it has been studied and discussed for many years. The short answer to the question is no; nurses should not be diluting IV push medications or changing how they are administered.
Yet, nurses have been diluting medication for years. Nurses' reasons for the practice have changed in the past five years concerning the opioid crisis in America. According to the Centers for Disease Control and Prevention (CDC), nearly 841,000 people have died from a drug overdose since 1999; over 70% of those deaths involved an opioid.
Drug overdose deaths now top 100,000 per year, a far greater rate than in the past two decades.
One survey of 1,773 nurses by the Institute for Safe Medication Practices revealed that commonly diluted medications included:
- Antipsychotic medications
Nurses report diluting medications more frequently to improve comfort at the injection site. They also list a high risk of leakage or patients with fragile veins with a higher risk of leakage as a reason.
Yet, the recent discussion on social media speaks to other reasons nurses dilute medications. As we consider what impacts a nurse's decision, this study showed nurses rarely diluted heparin, insulin, or flumazenil (an antidote for benzodiazepine overdose) but did dilute pain medications, antipsychotics, and antiemetics.
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Diluting IV Push Medication Is Risky for the Patient
There are several reasons diluting IV push medication places the patient at risk. Let's consider that pain is a fifth vital sign. When you assess your patient's vital signs, you take their blood pressure, heart rate, temperature, and respiration rate. When that patient can expect to have pain — such as after surgery or in a sickle cell crisis — you also assess their pain level.
After a drug overdose, nurses would not consider diluting Narcan to reverse the drug's effect. It's inconceivable a nurse would give half of a patient's blood pressure medication. Yet, a nurse may dilute pain medication, antipsychotics, or anti-anxiety drugs based on their perception of the patient.
It appears that medications that are more frequently diluted affect symptoms society has stigmatized. Patients with mental health conditions and pain are often marginalized. They may be casually swept under the rug as the issues are not as visible or easily measured as high blood pressure or low respiratory rate.
Independent decisions about a prescribed medication — unless it is to question a potential error — are biased. This can turn your actions into prejudice and discrimination.
Additionally, nurses must administer drugs in a standardized fashion. This allows the results to be accurately evaluated. These are just some of the risks to the patient each time a nurse dilutes a drug.
Risk of Using the Wrong Diluent
Not all drugs can be diluted with normal saline. Some drugs are diluted with lactated ringer solution or sterile water in the pharmacy. One study of patients in the intensive care unit showed that using normal saline to dilute drugs may lead to hypernatremia in patients with compromised kidneys.
One common reason nurses dilute medications is to reduce discomfort during the injection. But pain with the administration of an IV push drug is usually related to an IV that has begun to fail.
The National Coalition for IV Push Safety cautions that the most effective way to reduce discomfort is to ensure that the IV is placed correctly with a good blood return.
Dilution Changes the Pharmacokinetics
IV push medications are delivered to the hospital ready for administration. Adding fluid to a drug, even when it's the right fluid, can change the pharmacokinetics of the medication. This is how the body absorbs, metabolizes, and excretes a medication. In other words, it's what happens to the drug in the body.
When you change the drug's pharmacokinetics by adding fluid to dilute it, you change the outcome of using the drug.
Some pain medications designed to be given IV push are not as effective if the nurse decides to dilute them. Since the outcome is not as effective, the patient may ask for more pain medication quicker.
Dilution Can Lead to Poor Clinical Decisions
Providers make decisions based on data. When the data is skewed, patient care is affected. Consider the situation from the standpoint of antibiotics and not pain medication. Then you can see how changing the administration can affect care.
For example, you may change the time of administration of vancomycin from 60 minutes to 75 minutes to fit your schedule. However, when peak and trough levels are drawn, they will not be accurate. The provider then makes adjustments to the antibiotic based on this data, which is inaccurate.
The same is true with pain medications. Diluted push medications are not as effective. When pain is not effectively controlled, the provider considers other pain treatment methods. Instead, it may have been triggered by how the medication was administered.
The healthcare team may also start labeling patients as "drug-seeking," "frequent flyers," or "needy." These labels can impact how nurses treat the patient, which is not fair to the patient when the nurse may have inadvertently caused the behavior.
Dilution Raises the Risk of Infection
Unnecessary IV dilution on the unit can also increase the risk of infection for patients. All drugs that are not provided to the hospital in manufacturer-prepared syringes must be reconstituted and drawn up under a flow hood in the pharmacy. This setting reduces the risk of contamination of the medication and the introduction of bacteria directly into the patient's blood.
Anything injected into the body or blood must be sterile. Yet, while sterile for flushing an IV, the prefilled normal saline flush syringes are not designed to dilute medications.
They are also not guaranteed to maintain sterility when the plunger is pulled past a certain point.
Understanding the Psychosocial Aspect of Pain
There is also a psychosocial aspect of pain that affects a patient's pain level and how much medication they may need. These factors play a role in controlling chronic pain, acute pain, or acute over chronic pain. The latter describes patients with chronic and consistent pain with intermittent acute pain.
Patients learn to live with chronic pain using medication and other lifestyle strategies. When the pain level exceeds the normal level of chronic pain, it's an acute problem over chronic pain. In this instance, a patient will require more pain medication than they normally use to control their pain.
Medicine has operated under the belief that all pain is a direct result of tissue damage. Yet, several situations demonstrate this model does not explain all pain. For example, phantom limb pain after an amputation or the effect of placebos shows there are other psychological and neurological explanations.
Pain perception is affected by several psychosocial aspects, such as anxiety, depression, fear, and fatigue. Patients with medical trauma may anticipate another bad experience. This, in turn, affects their perception of pain.
It is essential nurses consider each aspect of pain management as they assess their patients and collaborate with the rest of the team. The nurse is the patient's advocate, and when the advocate doesn't champion their patient, the patient loses.
Diluting Medication Puts the Nurse at Risk
Diluting drugs also places the nurse at legal risk. Should the patient sue, the nurse will be asked under oath about how they administered medications. If they diluted the medication without instruction from the pharmacy, they are committing malpractice in the eyes of the law.
The hospital formulary contains manufacturer instructions about how medications should be administered. By law, nurses must follow these instructions as they are the standard of care.
It is crucial to clarify and verify the means of administration before giving medication. The best resource is the pharmacist, whose education is in the chemistry and administration of drugs. Consider consulting the formulary if you can't reach the pharmacist or asking the prescribing provider.
Does Your Patient Truly Have Drug-Seeking Behavior?
There can be several reasons your patient's pain has not been effectively controlled after receiving the right medication, at the right time, over the correct route, and without being diluted. For example, their perception of pain may be heightened because they are scared, don't feel heard, or are highly anxious. The medical condition causing the pain may have progressed, or the medication should be changed.
Nurses must report their concerns to the pain management team. After an evaluation using accurate data, they may find that the patient is seeking more drugs than are necessary to treat their pain level.
It is the responsibility of the pain management team to address issues with drug-seeking behavior and not the nursing staff. Nurses are responsible for assessment, reporting accurate data, collaborating with the team, and administering treatment. Nurses are not responsible for deciding what part of the treatment will be delivered, how, when, and why.
Nurses and other health providers must assess their patients with as little bias and prejudice as possible. It may not be possible to be completely unbiased. But when you recognize that bias may impact your assessment, it is more likely that you can accurately gauge the situation and treat patients with compassion and respect.
- Nurses may decide to dilute medications based on their perception of the patient's behavior. Nurses are more likely to dilute pain, anti-anxiety, and antipsychotic medication rather than heparin, insulin, or antidotes for a drug overdose.
- Diluting IV push medications increases the patient's risk that the medication will not be as effective. Nurses may use the wrong diluent, providers may make poor clinical decisions based on inaccurate data, and dilution increases the risk of infection.
- There are psychosocial aspects to pain that impact how much medication a patient may need to control their pain. This is impacted by fear, fatigue, depression, or anxiety.
- Nurses place their license at risk when they operate outside the standard of care documented in the hospital formulary or advised by the pharmacy.
- Pain management is a specialty. It is the responsibility of the pain management team, psychologist, or therapist to determine if the patient has drug-seeking behavior.
- Nurses can express their concerns while collaborating with the team, but it is vital they assess patients with as little bias and prejudice as possible because this can turn actions into discrimination.
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