Medication Mixing: Two Vials in One Syringe PDF

 ͕͔͖             Preparation of medications in one syringe depends on how the medica- tion is supplied. When using a single-dose vial and a multidose vial, air is injected into both vials and the medication in the mult...

 ͕͔͖             Preparation of medications in one syringe depends on how the medica- tion is supplied. When using a single-dose vial and a multidose vial, air is injected into both vials and the medication in the multidose vial is drawn into the syringe first. This prevents the contents of the multidose vial from being contaminated with the medication in the single-dose vial. The CDC recommends that medications packaged as multiuse vials be assigned to a single patient whenever possible (CDC, 2011b). In addition, it is recommended that the top of the vial be cleaned before each entry, and that a new sterile needle and syringe are used before each entry. When considering mixing two medications in one syringe, you must ensure that the two drugs are compatible. Be aware of drug incompat- ibilities when preparing medications in one syringe. Certain medica- tions, such as diazepam (Valium), are incompatible with other drugs in the same syringe. Incompatible drugs may become cloudy or form a precipitate in the syringe. Such medications are discarded and prepared again in separate syringes. Other drugs have limited compatibility and should be administered within 15 minutes of preparation. Mixing more than two drugs in one syringe is not recommended. If it must be done, contact the pharmacist to determine the compatibility of the three drugs, as well as the compatibility of their pH values and the preservatives that may be present in each drug. A drug-compatibility table should be avail- able to nurses who are preparing medications. Insulin, with many types available for use, is an example of a medi- cation that may be combined together in one syringe for injection. Insulins vary in their onset and duration of action and are classified as rapid acting, short acting, intermediate acting, and long acting. Before administering any insulin, be aware of the onset time, peak, and dura- tion of effects, and ensure that proper food is available. Be aware that some insulins, such as Lantus and Levemir, cannot be mixed with other insulins. Refer to a drug reference for a listing of the different types of insulin and action specific to each type. Insulin dosages are calculated in units. The scale commonly used is U100, which is based on 100 units of insulin contained in 1 mL of solution. DELEGATION CONSIDERATIONS The preparation of medication from two vials is not delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP). Depending on the state’s nurse practice act and the organization’s poli- cies and procedures, the preparation of medication from two vials may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient’s needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. 552  ‡†‹ ƒ–‹‘ǣ‹š‹‰™‘‹ƒŽ•‹‡›”‹‰‡ 553 EQUIPMENT The preparation of two types of Antimicrobial swabs insulin in one syringe is used Computer-generated Medica- as the example in the following tion Administration Record procedure. (CMAR) or Medication Two vials of medication Administration Record (insulin in this example) (MAR) Sterile syringe (insulin syringe in this example) ASSESSMENT Determine the compatibility of the two medications. Not all insulin can be mixed together. For example, Lantus and Levemir cannot be mixed with another insulin. Assess the contents of each vial of insulin. It is very important to be familiar with the particular drug’s properties to be able to assess the quality of the medication in the vial before withdrawal. Unmodified preparations of insulin typically appear as clear substances, so they should be without particles or foreign matter. Modified preparations of insulin are typically suspensions, so they do not appear as clear substances. Check the expiration date before administering the medication. Assess the appropriateness of the drug for the patient. Review the assessment and laboratory data that may influence drug administration. Check the patient’s blood glucose level, if appropri- ate, before administering the insulin. Verify patient name, dose, route, and time of administration. NURSING DIAGNOSIS Risk for Infection Deficient Knowledge Risk for Injury OUTCOME IDENTIFICATION AND PLANNING Accurate withdrawal of the medication into a syringe in a sterile manner. Proper dose is prepared. IMPLEMENTATION ACTION RATIONALE 1. Gather equipment. Check This comparison helps to medication order against the identify errors that may have original order in the medical occurred when orders were tran- record, according to facility scribed. The primary care pro- policy. vider’s order is the legal record 554 SKILL 102 ACTION RATIONALE of medication orders for each facility. 2. Know the actions, special This knowledge aids the nurse nursing considerations, safe in evaluating the therapeutic dose ranges, purpose of effect of the medication in rela- administration, and adverse tion to the patient’s disorder and effects of the medications to can also be used to educate the be administered. Consider patient about the medication. the appropriateness of the medication for this patient. 3. Perform hand hygiene. Hand hygiene prevents the spread of microorganisms. 4. Move the medication cart to Organization facilitates error-free the outside of the patient’s administration and saves time. room or prepare for adminis- tration in the medication area. 5. Unlock the medication cart Locking the cart or drawer safe- or drawer. Enter pass code guards each patient’s medication and scan employee identifi- supply. Hospital accrediting cation, if required. organizations require medication carts to be locked when not in use. Entering pass code and scan- ning ID allows only authorized users into the system and identi- fies the user for documentation by the computer. 6. Prepare medications for This prevents errors in medica- one patient at a time. tion administration. 7. Read the CMAR/MAR and This is the first check of the select the proper medica- label. tions from unit stock or the patient’s medication drawer. 8. Compare the labels with This is the second check of the the CMAR/MAR. Check labels. Verify calculations with expiration dates and perform another nurse to ensure safety, if dosage calculations, if neces- necessary. sary. Scan the bar code on the package, if required. 9. If necessary, remove the cap The cap protects the rubber top. that protects the rubber stop- per on each vial.  ‡†‹ ƒ–‹‘ǣ‹š‹‰™‘‹ƒŽ•‹‡›”‹‰‡ 555 ACTION RATIONALE 10. If medication is a suspen- There is controversy regarding sion (e.g., a modified insu- how to mix insulin in suspen- lin, such as NPH insulin), sion. Some sources advise rolling roll and agitate the vial to the vial; others advise shaking mix it well. the vial. Consult facility policy. Regardless of the method used, it is essential that the suspension be mixed well to avoid administer- ing an inconsistent dose. 11. Cleanse the rubber tops Antimicrobial swab removes with antimicrobial swabs. surface bacteria contamination. Allow the top to dry. Allowing the alcohol to dry pre- vents it from entering the vial on the needle. 12. Remove cap from needle by Pulling the cap off in a straight pulling it straight off. Touch manner prevents accidental the plunger only at the knob. needlestick. Handling the plunger Draw back an amount of air only by the knob ensures steril- into the syringe that is equal ity of the shaft of the plunger. to the dose of modified insu- Before fluid is removed, injec- lin to be withdrawn. tion of an equal amount of air is required to prevent the formation of a partial vacuum, because a vial is a sealed container. If not enough air is injected, the nega- tive pressure makes it difficult to withdraw the medication. 13. Hold the modified vial on a Unmodified insulin should never flat surface. Pierce the rub- be contaminated with modified ber stopper in the center with insulin. Placing air in the modi- the needle tip and inject the fied insulin first without allowing measured air into the space the needle to contact the insulin above the solution. Do not ensures that the second vial- inject air into the solution. entered (unmodified) insulin is Withdraw the needle. not contaminated by the medica- tion in the other vial. Air bubbled through the solution could result in withdrawal of an inaccurate amount of medication. 14. Draw back an amount of air A vial is a sealed container. into the syringe that is equal Therefore, injection of an equal to the dose of unmodified amount of air (before fluid is insulin to be withdrawn. removed) is required to prevent the formation of a partial vacuum. If not enough air is 556 SKILL 102 ACTION RATIONALE injected, the negative pressure makes it difficult to withdraw the medication. 15. Hold the unmodified vial on Air bubbled through the solution a flat surface. Pierce the rub- could result in withdrawal of an ber stopper in the center with inaccurate amount of medication. the needle tip and inject the measured air into the space above the solution. Do not inject air into the solution. Keep the needle in the vial. 16. Invert the vial of unmodi- Holding the syringe at eye level fied insulin. Hold the vial in facilitates accurate reading, and one hand and use the other the vertical position allows easy to withdraw the medica- removal of air bubbles from the tion. Touch the plunger syringe. First dose is prepared only at the knob. Draw up and is not contaminated by insu- the prescribed amount of lin that contains modifiers. medication while holding the syringe at eye level and vertically. Turn the vial over and then remove the needle from the vial. 17. Check that there are no air The presence of air in the syringe bubbles in the syringe. would result in an inaccurate dose of medication. 18. Check the amount of medi- Careful measurement ensures cation in the syringe with that correct dose is withdrawn. the medication dose and discard any surplus. 19. Recheck the vial label with This is the third check to ensure the CMAR/MAR. accuracy and to prevent errors. It must be checked now for the first medication in the syringe, as it is not possible to ensure accu- racy once a second drug is in the syringe. 20. Calculate the endpoint on Allows for accurate withdrawal the syringe for the combined of the second dose. insulin amount by adding the number of units for each dose together. 21. Insert the needle into the Previous addition of air elimi- modified vial and invert it, nates need to create positive  ‡†‹ ƒ–‹‘ǣ‹š‹‰™‘‹ƒŽ•‹‡›”‹‰‡ 557 ACTION RATIONALE taking care not to push the pressure. Holding the syringe plunger and inject medica- at eye level facilitates accurate tion from the syringe into the reading. Capping the needle vial. Invert vial of modified prevents contamination and pro- insulin. Hold the vial in one tects the nurse against accidental hand and use the other to needlesticks. A one-handed recap withdraw the medication. method may be used as long as Touch the plunger only care is taken to ensure that the at the knob. Draw up the needle remains sterile. prescribed amount of medication while holding the syringe at eye level and vertically. Take care to withdraw only the pre- scribed amount. Turn the vial over and then remove the needle from the vial. Carefully recap the needle. Carefully replace the cap over the needle. 22. Check the amount of medi- Careful measurement ensures cation in the syringe with that correct dose is withdrawn. the medication dose. 23. Depending on facility policy, This third check ensures accu- the third check of the label racy and helps to prevent errors. may occur at this point. If Note: Many facilities require the so, recheck the label with third check to occur at the bed- the MAR before taking the side, after identifying the patient medications to the patient. and before administration. 24. Label the vials with the Because the vial is sealed, the date and time opened, and medication inside remains sterile store the vials containing and can be used for future injec- the remaining medication tions. Labeling the opened vials according to facility policy. with a date and time limits its use after a specific time period. The CDC recommends that medica- tions packaged as multiuse vials be assigned to a single patient whenever possible (CDC, 2011). 25. Lock medication cart before Locking the cart or drawer safe- leaving it. guards the patient’s medication supply. Hospital accrediting orga- nizations require medication carts to be locked when not in use.