Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT
Secondary intravenous (IV) infusions are a way to administer smaller volume-controlled amounts of IV solution (25-250 mL). Secondary IV infusions are delivered over longer periods of time than IV push medications, which reduces the risks associated with rapid infusions, such as phlebitis and infiltration. In addition, some antibiotic medications are only stable for a limited time in solution.
The secondary IV medication tubing is connected to the primary macrobore (large internal diameter) IV tubing and is therefore “secondary” to the primary infusion. The secondary solution bag is typically hung higher than the primary infusion bag and is subsequently “piggybacked” on top of the primary IV infusion. This higher position places greater gravitational pressure on the secondary IV solution. As a result, the primary infusion is temporarily paused until the secondary infusion volume has been delivered. This approach ensures that the medication is completely infused due to an immediate return of maintenance IV infusion in the IV line. The secondary IV infusion can be safely delivered when the patient’s fluid volume status permits temporarily pausing the delivery of maintenance fluid and in hypervolemia patients.
This video demonstrates the administration of secondary intermittent IV infusion medications using an infusion pump and using gravity tubing without an infusion pump. This will include a review of acquiring the intermittent secondary IV infusion medication, priming the secondary IV tubing, preparing the patient, calculating the medication administration rate, and setting the secondary IV drip rate.
1. General procedure considerations (review in the room, with the patient).
2. In the medication preparation area, acquire the ordered secondary intermittent infusion and complete the first safety check using the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.
3. Acquire and prime the secondary IV tubing. Refer to step 9.8 for an alternate secondary priming technique.
4. In the medication preparation area, complete the second safety check using the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.
5. Acquire appropriate supplies, including a 10 mL of normal saline flush, alcohol wipes, and the plastic extension arm included in the secondary IV tubing. Discard the waste created during the preparation process.
Administration
6. Upon first entering the patient's room, set the secondary bag, tubing, and additional supplies down on the counter and wash hands, as described in step 1.1.
7. In the patient's room, complete the third and final medication safety check, adhering to the five "rights" of medication administration. Refer to the "Preparing and Administering Oral and Liquid Medications" video.
8. Assess and flush the peripheral IV insertion site. Refer to the "Assessing and Flushing a Peripheral Intravenous Line" video.
9. Hang the secondary intermittent infusion and connect the secondary tubing to the patient's primary IV fluid line.
10. Document the secondary intermittent infusion medication administration in the patient's electronic health record.
11. Discard any waste in the appropriate receptacles.
12. Leave the patient room. Upon exiting the room, wash hands, as describe in step 1.1.
The secondary intravenous infusion is a way to administer volume-controlled amounts of IV medications over longer periods of time compared to IV push medications. This in turn reduces the risks associated with rapid infusions, such as phlebitis and infiltration. The secondary IV medication tubing is connected to the primary intravenous tubing and is therefore “secondary” to the primary infusion.
This video will demonstrate the steps for acquiring secondary IV medication, priming the secondary IV tubing, and setting up the secondary administration assembly and intravenous drip rate.
Before setting up the IV, the nurse will need to perform a few preliminary steps. The first step upon entering a patient’s room is to use standard precautions by using hand sanitizer, or washing your hands vigorously for 20 seconds with soap and warm water.
Next, review the medication procedure with the patient and address any questions the patient might have. At the bedside computer, log in and review the electronic medical record. Make sure that you are aware of the patient’s history, allergies, and admitting diagnosis. Also, validate the type and amount of medication to be administered, and look up the rate of administration in the drug guide. It is important to check compatibility of fluids with any IV medications that are being administered simultaneously.
Leave the patient’s room to gather the supplies and medications as needed and wash your hands upon exiting, as previously described. In the medication preparation area, acquire the ordered IV infusion medication and the secondary IV tubing. Before opening the medication, perform the first safety check by adhering to the five “rights” of safe medication administration.
After obtaining the necessary supplies, the next step is priming the IV tubing. Open the tubing package and slide the roller clamp toward the narrow end before placing it on the counter. Next, pick up the IV infusion medication bag. Remove the pigtail that covers the IV infusion medication bag port and discard. It is important not to contaminate the bag’s opening during this process.
Now, pick up the IV tubing and, using tip of your thumb and index finger, carefully slide the protective cover off the IV tubing spike and discard in a trash receptacle. Again, it is important to avoid contaminating the tubing spike during this process. Next, insert the spike of the tubing into the IV infusion medication bag port with a gentle twisting motion. Now, while holding the IV medication bag near eye-level, gently squeeze the drip chamber until it is 1/3 to ½ full with the IV infusion medication fluid.
To prime the tubing, slightly open the rolling clamp until fluid begins to flow. This allows the medication fluid to flow through the tubing, while ensuring that all air is released without loss of medication. When the fluid has reached the end of the tubing, stop the flow by moving the roller clamp toward the narrow end of the clamp.
Label the medication tubing with the name and dose. The date, time, and nurse initials may also be required by institutional policy. After the medication is prepared, complete the second medication safety check using the five “rights” of medication administration.
You are now ready for the administration of the medication to the patient. Before entering the room, retrieve a 10-mL normal saline flush and alcohol wipes, in addition to the IV medication and IV tubing.
In the patient’s room, set aside the medication and supplies and wash your hands, as described earlier. Now, complete the third and final safety check by following the checklist of the five “rights” of medication administration.
To begin administration, assess the patient’s IV site to ensure that there is no redness or phlebitis occurring. For details on this assessment, see another video in this collection. Once you determine that the IV site is patent, if a primary infusion is running through an infusion pump, temporarily pause the infusion pump. This will prevent unintentional infusion of primary and secondary fluids to the patient.
Now, hang the secondary IV medication onto the IV pole. Next, remove the primary bag from the IV pole and take the plastic extension hook provided in the secondary tubing packaging and attach one side through the hole at the top of the primary bag. Hang the plastic hook off the IV pole, allowing the primary bag to hang lower than the secondary bag. Hanging the primary bag below the secondary one allows the primary bag to take over once the secondary medication has been infused. Closely inspect the secondary tubing for air. If the line has air, follow the instructions under the “Back Flow Priming” section in the text protocol below.
Now, wash hands and don clean gloves. Next, locate the needleless injection port above the pump on the primary tubing and scrub the site with an alcohol wipe for 15 seconds, with friction and intent, while holding the primary tubing needleless injection site with your non-dominant hand. Then, remove the cap from the end of the secondary tubing medication. Subsequently, attach the IV infusion medication tubing to the injection site by pushing it gently and turning the outer portion of the connection port clockwise until secure. Ensure that the needleless hub and the end of the IV tubing do not touch anything but one another in the process.
Now, set the secondary intermittent infusion drip rate. Open the secondary IV tubing roller clamp by sliding the secondary clamp roller toward the larger end of the clamp. To administer, locate the “Secondary” button on the infusion pump to program the secondary infusion rate. The “Secondary” button will allow you to program the rate of administration for the secondary infusion bag. Once the infusion is complete, the pump will automatically resume the primary infusion rate. Push the “Start” button on the infusion pump and verify that the secondary infusion is running by noting drips falling in the drip chamber of the secondary infusion tubing.
In case of gravity tubing, one has to know the drop factor-provided on the IV tubing package-to calculate drops per minute. To calculate the number of drops per minute, multiply the amount of fluid in mL to be administered each hour by the drop factor and then divide that by 60 minutes. Then, to calculate the number of drops per 15 seconds, divide the drops per minute by 4. To administer, while looking at your watch and the drip chamber, adjust the secondary roller clamp so that the number of drops that occur within 15 seconds corresponds to the number of drops previously calculated.
Assess the patient’s IV site for any swelling or leaking. Ask the patient if they are experiencing any pain as the IV medication is infusing. Document the IV infusion medication in the patient’s MAR, including documentation for the time, date, location, and amount of medication that is being administered. Upon completion, leave the patient’s room and wash hands.
“An important step when hanging secondary infusions is to hang secondary solution bags higher than the primary infusion bag, thus “piggybacking” it on top of the primary IV infusion. This higher position places greater gravitational pressure on the secondary IV solution. As a result, the primary infusion is temporarily paused until the secondary infusion volume has been delivered.”
“Another important step is, when priming the secondary line, ensuring that all air bubbles are removed from the tubing. Common errors associated with this procedure include failing to verify compatibility of the maintenance IV fluid with the medication; calculating the drop factor wrong, which would administer the medication at the incorrect rate; and failing to assess the patient for medication reactions.“
You’ve just watched JoVE’s introduction to preparing and administering intermittent secondary infusions. You should now understand the supplies needed, how to prime and back prime IV tubing, and how to adjust the drip rate for both pump and gravity settings. As always, thanks for watching!
This video details the process for administering secondary IV infusion medications using an infusion pump and, alternately, using gravity tubing. As with any IV medication administration, it is always safe practice to double-check the compatibility of solutions prior to administration. Some medications, such as Dilantin, may precipitate within different types of solution containing 5% dextrose (D5); therefore, referencing a compatibility program or nursing drug guide is recommended. Many IV medications can be highly damaging to venous structures. Thus, evaluating the IV patency prior to administration and continually monitoring the IV site of insertion during medication delivery is recommended at least every hour to assess for phlebitis and extravasation. During IV site monitoring, it is also recommended to continually monitor for side effects, hypersensitivity reactions, and anaphylaxis, as these are commonly associated with IV infusions.
Common errors associated with the administration of secondary intermittent IV medication infusions include neglecting to position the secondary IV infusion bag higher than the primary IV infusion bag, failing to open the secondary IV infusion clamp, failing to verify the compatibility of the maintenance IV fluid with the secondary IV infusion medication, and administering the secondary IV infusion medication at the incorrect rate. In addition, phlebitis and extravasation are common; therefore, continual monitoring is appropriate.
The secondary intravenous infusion is a way to administer volume-controlled amounts of IV medications over longer periods of time compared to IV push medications. This in turn reduces the risks associated with rapid infusions, such as phlebitis and infiltration. The secondary IV medication tubing is connected to the primary intravenous tubing and is therefore “secondary” to the primary infusion.
This video will demonstrate the steps for acquiring secondary IV medication, priming the secondary IV tubing, and setting up the secondary administration assembly and intravenous drip rate.
Before setting up the IV, the nurse will need to perform a few preliminary steps. The first step upon entering a patient’s room is to use standard precautions by using hand sanitizer, or washing your hands vigorously for 20 seconds with soap and warm water.
Next, review the medication procedure with the patient and address any questions the patient might have. At the bedside computer, log in and review the electronic medical record. Make sure that you are aware of the patient’s history, allergies, and admitting diagnosis. Also, validate the type and amount of medication to be administered, and look up the rate of administration in the drug guide. It is important to check compatibility of fluids with any IV medications that are being administered simultaneously.
Leave the patient’s room to gather the supplies and medications as needed and wash your hands upon exiting, as previously described. In the medication preparation area, acquire the ordered IV infusion medication and the secondary IV tubing. Before opening the medication, perform the first safety check by adhering to the five “rights” of safe medication administration.
After obtaining the necessary supplies, the next step is priming the IV tubing. Open the tubing package and slide the roller clamp toward the narrow end before placing it on the counter. Next, pick up the IV infusion medication bag. Remove the pigtail that covers the IV infusion medication bag port and discard. It is important not to contaminate the bag’s opening during this process.
Now, pick up the IV tubing and, using tip of your thumb and index finger, carefully slide the protective cover off the IV tubing spike and discard in a trash receptacle. Again, it is important to avoid contaminating the tubing spike during this process. Next, insert the spike of the tubing into the IV infusion medication bag port with a gentle twisting motion. Now, while holding the IV medication bag near eye-level, gently squeeze the drip chamber until it is 1/3 to ½ full with the IV infusion medication fluid.
To prime the tubing, slightly open the rolling clamp until fluid begins to flow. This allows the medication fluid to flow through the tubing, while ensuring that all air is released without loss of medication. When the fluid has reached the end of the tubing, stop the flow by moving the roller clamp toward the narrow end of the clamp.
Label the medication tubing with the name and dose. The date, time, and nurse initials may also be required by institutional policy. After the medication is prepared, complete the second medication safety check using the five “rights” of medication administration.
You are now ready for the administration of the medication to the patient. Before entering the room, retrieve a 10-mL normal saline flush and alcohol wipes, in addition to the IV medication and IV tubing.
In the patient’s room, set aside the medication and supplies and wash your hands, as described earlier. Now, complete the third and final safety check by following the checklist of the five “rights” of medication administration.
To begin administration, assess the patient’s IV site to ensure that there is no redness or phlebitis occurring. For details on this assessment, see another video in this collection. Once you determine that the IV site is patent, if a primary infusion is running through an infusion pump, temporarily pause the infusion pump. This will prevent unintentional infusion of primary and secondary fluids to the patient.
Now, hang the secondary IV medication onto the IV pole. Next, remove the primary bag from the IV pole and take the plastic extension hook provided in the secondary tubing packaging and attach one side through the hole at the top of the primary bag. Hang the plastic hook off the IV pole, allowing the primary bag to hang lower than the secondary bag. Hanging the primary bag below the secondary one allows the primary bag to take over once the secondary medication has been infused. Closely inspect the secondary tubing for air. If the line has air, follow the instructions under the “Back Flow Priming” section in the text protocol below.
Now, wash hands and don clean gloves. Next, locate the needleless injection port above the pump on the primary tubing and scrub the site with an alcohol wipe for 15 seconds, with friction and intent, while holding the primary tubing needleless injection site with your non-dominant hand. Then, remove the cap from the end of the secondary tubing medication. Subsequently, attach the IV infusion medication tubing to the injection site by pushing it gently and turning the outer portion of the connection port clockwise until secure. Ensure that the needleless hub and the end of the IV tubing do not touch anything but one another in the process.
Now, set the secondary intermittent infusion drip rate. Open the secondary IV tubing roller clamp by sliding the secondary clamp roller toward the larger end of the clamp. To administer, locate the “Secondary” button on the infusion pump to program the secondary infusion rate. The “Secondary” button will allow you to program the rate of administration for the secondary infusion bag. Once the infusion is complete, the pump will automatically resume the primary infusion rate. Push the “Start” button on the infusion pump and verify that the secondary infusion is running by noting drips falling in the drip chamber of the secondary infusion tubing.
In case of gravity tubing, one has to know the drop factor-provided on the IV tubing package-to calculate drops per minute. To calculate the number of drops per minute, multiply the amount of fluid in mL to be administered each hour by the drop factor and then divide that by 60 minutes. Then, to calculate the number of drops per 15 seconds, divide the drops per minute by 4. To administer, while looking at your watch and the drip chamber, adjust the secondary roller clamp so that the number of drops that occur within 15 seconds corresponds to the number of drops previously calculated.
Assess the patient’s IV site for any swelling or leaking. Ask the patient if they are experiencing any pain as the IV medication is infusing. Document the IV infusion medication in the patient’s MAR, including documentation for the time, date, location, and amount of medication that is being administered. Upon completion, leave the patient’s room and wash hands.
“An important step when hanging secondary infusions is to hang secondary solution bags higher than the primary infusion bag, thus “piggybacking” it on top of the primary IV infusion. This higher position places greater gravitational pressure on the secondary IV solution. As a result, the primary infusion is temporarily paused until the secondary infusion volume has been delivered.”
“Another important step is, when priming the secondary line, ensuring that all air bubbles are removed from the tubing. Common errors associated with this procedure include failing to verify compatibility of the maintenance IV fluid with the medication; calculating the drop factor wrong, which would administer the medication at the incorrect rate; and failing to assess the patient for medication reactions.”
You’ve just watched JoVE’s introduction to preparing and administering intermittent secondary infusions. You should now understand the supplies needed, how to prime and back prime IV tubing, and how to adjust the drip rate for both pump and gravity settings. As always, thanks for watching!
