what is a priority nursing action after administering magnesium sulfate to a pregnant patient?

AHRQ Safety Plan for Perinatal Intendance

Purpose of the tool: This tool describes the fundamental perinatal safety elements with examples for the prophylactic assistants of magnesium sulfate during labor. The key elements are presented within the framework of the Comprehensive Unit-based Prophylactic Program (CUSP).

Who should utilize this tool: Nurses, physicians, midwives, pharmacists, and other labor and commitment (Fifty&D) unit staff responsible for the grooming and assistants of magnesium sulfate during labor.

How to utilise this tool: Review the key perinatal safety elements with 50&D leadership and unit staff to decide how the elements will be implemented on your L&D unit of measurement. Consider any existing facility policies or processes related to magnesium sulfate use. Consider using preprinted orders, standing orders, and staff training to support implementation. A sample of how some of these key perinatal safety elements can be incorporated into a unit arroyo to safe magnesium sulfate assistants is provided in the Appendix of this tool.

Key Perinatal Safety Elements

Standardize When Possible (CUSP Science of Safety)
Fundamental Perinatal Rubber Elements	Examples
Standard criteria established for magnesium sulfate use.	Criteria for use of magnesium sulfate are established. Medical indications for use vary. Several professional organizations, guidelines, and evidence reviews offer examples of maternal and fetal conditions that may be indications for employ of magnesium sulfate.1-7 Absence of contraindications for magnesium sulfate are verified and documented. Contraindications on the manufacturer's drug characterization includeeight— Patients with heart block. Patients with myocardial damage. In addition, the FDA and professional person organizations offer warnings against use of magnesium sulfate longer than 5 to 7 days because of risk of fetal and neonatal bone demineralization and fractures.three,9 Staff with requisite training and supplies bachelor to respond to magnesium-related adverse events, for example respiratory low.x,11
Use uniform and standard drug packaging, preparation, and labeling.12	Unit-established process for using manufacturer's premixed bags or pharmacy-prepared numberless of magnesium sulfate for both loading dose (bolus) and maintenance infusion. Medication errors are more common in unit-prepared bags, so this practice should be avoided.12 Pharmacy and nursing staff should utilise a consistent approach to labeling all magnesium sulfate bags and tubing used to administrate the medication.11
Standardize magnesium sulfate dosing using a calibrated infusion pump with costless-menstruum protection.	Limit the number of different kinds of infusion pumps to maximize staff familiarity with infusion equipment.10 Establish the unit of measurement'southward standard approach for administering a loading dose (bolus). Apply of the maintenance infusion to administer a bolus manually is a high-chance practice that should be avoided. Safe dosing options include— Administering the bolus from the maintenance infusion using a "smart" infusion pump that has the post-obit safety features:10 Pump includes a bolus dose feature that allows programming to automatically switch to the continuous infusion charge per unit at the terminate of the bolus AND staff are trained to utilise this feature. Separate dose limits can exist gear up for bolus doses and maintenance doses. Dose limit alerts are operational at all times. Dose limit alerts are configured as a "difficult stop," requiring pump to exist reprogrammed if dose exceeds limits. If a smart infusion pump with these safety features is not available, then loading dose should be administered via a split up handbag. Premixed or pharmacy-prepared bags (e.g., 4 g/100 ml or viii g/100 ml) should be used unitwide to reduce variability and adventure of error. The same standard preparation either premixed or pharmacy-prepared bags (e.g., 20 one thousand/500-ml bag) unitwide for maintenance infusion.13 Use of a 500-ml bag can assist distinguish the bag from liter bags containing fluids or other medications.11 The smaller book as well reduces the amount of magnesium that can be delivered in the event of an accidental rapid infusion (east.g., pump programming fault or failure). Complete removal of the line from the intravenous (IV) port when magnesium sulfate therapy is discontinued to avert accidental infusion.x,11
Use compatible parameters for maternal and fetal monitoring and provider notification prior to initiation of magnesium sulfate and during infusion.	The utilise of uniform parameters for fetal and maternal monitoring and provider notification before and during magnesium sulfate use minimizes variability across providers and nursing staff in order to reduce the take chances of mistake.
Standardize laboratory reporting of serum magnesium levels.	Hospital policy and procedure for compatible reporting of serum magnesium levels. Magnesium levels can exist reported equally milligrams per deciliter (mg/dL), milliequivalents per liter (mEq/L) and millimoles per liter (mmmol/L), and the same magnesium level would be reported using different numbers depending on the unit of measure out. Bedside staff, providers, and lab personnel should agree on one unit for reporting and communicating magnesium levels to avoid miscommunication and delays in timely care.10
Create Independent Checks (CUSP Science of Prophylactic)
Assess ceremoniousness of magnesium apply in patient by staff other than the ordering provider.	An independent verification of indications and maternal and fetal status per unit-established standard criteria tin minimize medication apply in cases where risk may exceed benefit. These criteria may include— Indications for use (e.g., neuroprotection of fetus during preterm labor, seizure prophylaxis for preeclampsia). Contraindications for apply. Maternal condition prior to initiation. Fetal status prior to initiation.
Use preprinted orders or electronic order entry for magnesium sulfate order.	Unit of measurement process for ordering magnesium using preprinted orders or electronic club entry reduces dosing errors due to wrong dose or illegible orders. Abstention of abbreviations for magnesium sulfate.10,12
Utilise independent verification whenever there is a charge per unit alter or a new magnesium sulfate bag is hung.	A second qualified staff member independently checks that the magnesium bag is clearly labeled, contains the correct dose, and that tubing and pump are ready upwardly correctly whenever a new bag is hung or a rate modify is fabricated.10 This verification is facilitated by tracing the tubing past hand from the IV bag to the pump, and then to the patient.xiv
Use uniform parameters for maternal and fetal monitoring at regular intervals.	Use compatible parameters for maternal and fetal monitoring at regular time intervals per unit-established processes during loading dose and maintenance infusion to identify changes in status. Various clinical references offer parameters for monitoring:3,10,15 Assessment prior to initiation: Vital signs, deep tendon reflexes/clonus, level of consciousness, symptoms such as headache, visual disturbances, nausea/airsickness, epigastric pain, tocography, and fetal heart charge per unit (FHR) (antepartum and intrapartum only). Assessment during infusion: Vital signs, with specific focus on oxygen saturation and respiratory pattern, deep tendon reflexes, fluid intake/output, tocography, signs and symptoms of labor progression, worsening signs/symptoms of preeclampsia, magnesium toxicity, and fluid overload. Typically, a nurse should remain at the bedside during the loading dose to monitor initial response and reassure patient regarding commonly experienced side effects. Use of serum magnesium levels: Regular, routine serum levels practice not e'er correlate with clinical symptoms and are non needed for most patients. Notwithstanding, regular, routine serum levels may be useful for patients with dumb renal role.
Use maternal and fetal parameters for provider notification.	Use of uniform, unit-established parameters for provider notification ensures that signs of potential adverse effects or clinical deterioration are communicated for situational sensation and response if needed. Provider-notification criteria can exist based on patient vital signs, FHR patterns, and signs and symptoms of labor progression, worsening signs/symptoms of preeclampsia, magnesium toxicity, or labor progression. Various clinical reviews and references offer some suggested parameters for notification.10,xv
Have standing orders for nurses to respond to signs and symptoms of magnesium toxicity, with quick admission to antidote.	Employ of uniform, unit-established continuing orders allows nurses to provide initial management in response to suspected magnesium toxicity. Magnesium toxicity is a clinical diagnosis, and serum levels practise not always correlate with clinical signs and symptoms; thus, nurses who monitor patients receiving magnesium sulfate should— Know how to recognize the signs and symptoms of toxicity. Have ready access to the antidote, calcium gluconate, via a kit stored in the patient'south room or hands accessible on the unit of measurement. Know how to temporarily back up ventilation and activate a rapid response for advanced airway back up. Symptoms Magnesium Level (mg/dl) Normal adult values one.seven–two.4 Therapeutic range v-9 Loss of patellar reflexes 8-12 Feelings of warmth, flushing ix-12 Somnolence 10-12 Respiratory difficulty / depression 12-xvi Muscular paralysis 15-17 Altered cardiac conduction >18 Cardiac arrest 30-35 Adapted from Simpson, 2004.10 Standing orders for nurse response for signs and symptoms of magnesium toxicity can include— Activating a rapid response (i.e., call for additional help). Stopping the infusion. Monitoring vital signs, including oxygen saturation and respiratory charge per unit and pattern. Drawing a STAT magnesium blood level. If respiration is depressed, administering oxygen by face mask and administering calcium gluconate to antagonize the effects of excessive magnesium levels. If respiration is arrested, supporting ventilation with bag-valve-mask, administering calcium gluconate, and activating request for avant-garde airway support.
Acquire From Defects (CUSP Module)
Debrief and clarify near misses and adverse events related to magnesium sulfate utilize.	Unit can make up one's mind its arroyo to debriefing events based on seriousness of result, expertise available, and data monitoring and tracking capabilities. Informal debriefings by clinical team immediately following upshot using an approach that does not shame or arraign individuals. This approach allows for understanding of what went well, what could accept gone better, and what could be done differently side by side fourth dimension. Regular forum with a multidisciplinary team can help the unit of measurement learn from defects and sensemaking using the post-obit tools: Discovery form. Root cause analysis. Eindhoven model. Failure mode and effects analysis. Probabilistic gamble assessment. Causal tree worksheet. Interdisciplinary instance reviews.
Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning	Unit tin decide its approach to reviewing cases where magnesium sulfate was used outside of the unit's established criteria for use. This might include an existing medical peer-review process or review past a perinatal safety or quality committee.
Have a process in place to review astringent maternal or neonatal morbidity and mortality events.	Unit can decide its approach to reviewing cases of severe maternal or neonatal morbidity or mortality. This might include an existing medical peer-review procedure or review past a perinatal safety or quality committee. A sample process and forms for a committee review are available at the Council on Patient Safety in Women's Health Care, world wide web.safehealthcareforeverywoman.org. Select "Get SMM Forms."
Use independent verification whenever there is a rate change or a new magnesium sulfate pocketbook is hung.	Sites can decide how often this information will exist shared, how much will be shared, and with whom, and whether this should be specified in a unit policy or handled more informally.
Simulation (Safety Plan for Perinatal Care Signature Element)
Sample Scenarios: Magnesium sulfate toxicity. Preeclampsia/seizure.	Two sample scenarios available through the Rubber Program for Perinatal Care can be used to train teams on the fundamental perinatal safety elements related to magnesium sulfate use. This scenario reinforces teamwork and advice related to— Situational awareness. Power to go additional help rapidly. Timely utilize of continuing orders for managing magnesium sulfate toxicity. Advice with rapid responders. Advice with patient/family. Using of briefings, huddles, and debriefings.
Teamwork Training (TeamSTEPPS®)
Situational awareness during magnesium sulfate utilise.	Situational sensation refers to all staff caring for the patient— Knowing what the patient's plan is through briefings and team direction. Being enlightened of what is going on and what is likely to happen adjacent. Verifying and checking back on data. Providing ongoing updates. In the context of magnesium sulfate use, this includes staff alertness for early signs of abnormal fetal or maternal status, and knowing the plan for a timely response to prevent further deterioration.
Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques.	Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of magnesium sulfate use, these techniques are particularly useful— For communicating a sense of urgency when requesting other unit personnel and provider for aid responding to sudden changes in maternal or fetal status (e.g., seizure, magnesium toxicity, fetal distress). For communicating changes in maternal or fetal status. When giving and receiving new orders to manage sudden changes in maternal or fetal status. When conference new care team members who arrive to support a rapid response. When regrouping to discuss programme of care if patient fails to reply to initial measures.
Communicate during transitions of care.	Utilise of transition communication techniques assures a shared mental model of plan of intendance and perceived risks betwixt shifts, between units. This may include bedside review by nursing team of pump settings, mainline 4 fluids, and written orders for magnesium sulfate.10
High-reliability teams: Anyone can sound an alarm, request assist, or challenge the condition quo. Hierarchy is minimized. Communication is continuous, valued, and expected.	Team members protect each other from work overload and place requests or offers for assistance in the context of patient rubber. Information technology is expected that help will be actively sought and offered. Team members will advocate for the patient when one person'south viewpoint does not coincide with another's. Affirm a corrective action in a firm and respectful way. Use CUS language: "I am concerned. I am uncomfortable. This is a safety upshot." Use the Ii Claiming dominion and repeat the concern and inquire whether business has been heard. Employ a predetermined "stop the line" phrase. Manage conflict using a constructive positive approach to emphasize "what is right, non who is right": D: Describe the specific behavior or situation. Due east: Express how the situation makes you experience or concerns you. S: Advise other alternatives. C: Consequences stated in terms of team goals, not punishment.
Patient and Family Date (CUSP)
Talk over risks and benefits of intrapartum or postpartum magnesium sulfate use.	Employ unit-established process for conveying risks and benefits of magnesium sulfate use to patient and family unit.
Educate patient/family regarding magnesium sulfate use.	Use unit-established approach for nursing-led patient education regarding magnesium sulfate infusion, mobility restrictions, and expected effects. Brainwash patient and family apropos frequency of nursing assessment and monitoring, signs and symptoms to report to nursing staff. Provide instructions for reporting signs and symptoms to nursing staff.

References

1. Doyle LW, Crowther CA, Middleton P, et al. Magnesium sulphate for women at chance of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev 2009 Jan 21;(1):CD004661. Review. PMID: 19160238.
2. Duley L, Gülmezoglu AM, Henderson-Smart DJ, et al. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev 2010 Nov 10;(11):CD000025. doi: 10.1002/14651858.CD000025.pub2. Review. PMID: 21069663.
3. American College of Obstetricians and Gynecologists Commission on Obstetric Practise Society for Maternal-Fetal Medicine. Committee Opinion No. 652: Magnesium sulfate apply in obstetrics. Obstet Gynecol 2016 January;127(1):e52-3. doi: 10.1097.AOG. 0000000000001267. PMID: 26695587.
4. Committee on Obstetric Practice. Committee Opinion no. 514: emergent therapy for acute-onset, astringent hypertension with preeclampsia or eclampsia. Obstet Gynecol 2011 Dec;118(six):1465-eight. doi: 10.1097/AOG.0b013e31823ed1ef. PMID: 22105295.
5. American Higher of Obstetricians and Gynecologists; Committee on Practice Bulletins—Obstetrics. ACOG practice message no. 159: Management of preterm labor. Obstet Gynecol 2016 Jan;127(1):e29-e38. doi: 10.1097/AOG. 0000000000001265. PMID: 26695585.
6. American College of Obstetricians and Gynecologists Committee on Obstetric Do; Society for Maternal-Fetal Medicine. Committee Opinion No. 455: Magnesium sulfate earlier anticipated preterm birth for neuroprotection. Obstet Gynecol 2010 Mar, reaffirmed 2015;115(iii):669-71. doi: 10.1097/AOG.0b013e3181d4ffa5. PMID: 20177305. 7
7. WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia. Geneva: Earth Health Organisation; 2011. PMID: 23741776.
8. Magnesium Sulfate FDA-canonical Drug Label. May 29, 2013. http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/019316s018lbl.pdf. Accessed May ii, 2016. ix
9. Magnesium Sulfate: Drug Safety Communication—Recommendation Against Prolonged Employ in Pre-term Labor. https://www.fda.gov/Drugs/DrugSafety/ucm353333.htm. Issued 5/xxx/2013.
10. Simpson KR, Knox GE. Obstetrical accidents involving intravenous magnesium sulfate: recommendations to promote patient prophylactic. MCN Am J Matern Child Nurs 2004 May-Jun;29(iii):161-9; quiz 170-one. PMID: 15123972.
11. Failure to Set a Book Limit for a Magnesium Bolus Dose Leads to Harm. Astute Care ISMP Medication Safe Alert. June three, 2010.
12. Institute of Medicine (US) Commission on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Homo: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
13. ISMP List of Loftier-Warning Medications in Acute Care Settings. Plant for Safe Medication Practices (ISMP). https://www.ismp.org/tools/institutionalhighAlert.asp Accessed May 2, 2016.
14. Preventing Magnesium Toxicity in Obstetrics. Acute Care ISMP Medication Safety Alert. October twenty, 2005.
15. Simpson KR, Creehan PA. (eds). AWHONN'south Perinatal Nursing 4th ed. Lippincott; 2014.

Appendix

Every effort was made to ensure the accuracy and abyss of this resources. Yet, the U.South. Department of Wellness and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the utilise of information independent within.

SAMPLE Safety Medication Administration Process for Magnesium Sulfate

(References are located in the reference list above.)

Category	Example Process
i. Verifying and documenting indications for use	Verify and document indications and absence of contraindications for use of magnesium sulfate when receiving orders for magnesium sulfate. Indications for employ:1-7 Neuroprotection of fetus before anticipated early preterm delivery (< 32 weeks gestational age). Seizure prophylaxis or treatment in women with preeclampsia or eclampsia. Use as a tocolytic for upwards to 48 hours for short-term prolongation of pregnancy for the administration of antenatal corticosteroids in women betwixt 24 and 34 weeks gestation who are at risk of preterm delivery within 7 days. Contraindications for use:viii Use more than than 5 to 7 days. Patients with middle block. Patients with myocardial harm. Staff with requisite grooming and supplies available to respond to magnesium-related adverse events including respiratory depression.
2. Assessment	Baseline maternal and fetal assessment and periodic cess. Assessment documentation on labor and commitment flowsheet. Cess prior to initiation: Vital signs (temperature, pulse, blood pressure level, respiratory rate and pattern), deep tendon reflexes(DTRs)/clonus, breath sounds, level of consciousness, symptoms such as headache, visual disturbances, nausea/airsickness, epigastric pain, tocography, and fetal heart charge per unit (FHR) pattern (antepartum and intrapartum only). Verify seizure precautions: Oxygen and suction available at the bedside. Bedrails in the upright position. Patient is NPO (nothing past oral cavity). During loading dose: While the loading dose is being administered, the nurse should remain at the bedside to monitor the patient. Periodic nursing assessments: Every xv minutes during beginning hour of infusion, every 30 minutes during second 60 minutes, and hourly thereafter. Assessments should include— Vital signs (claret pressure level, respirations [rate and pattern], pulse, temperature, oxygen saturation level). DTRs and presence or absenteeism of clonus. Fluid inputs and outputs (if a patient cannot ambulate to the bath or utilize a bedpan, an indwelling urine catheter may exist needed). Level of consciousness. Breath sounds. Presence of headaches or visual disturbances (blurred or double vision). Presence or absence of epigastric pain. Presence of extravasation or infiltration at intravenous (IV) site. Signs/symptoms of magnesium toxicity, worsening pre-signs or symptoms of eclampsia, or progression of labor. Periodic urine assessment for poly peptide (if applicable). Vaginal haemorrhage. Tocography and FHR (with antepartum or intrapartum use). Serum magnesium-level monitoring every 6 hours: ___YES (Patients with impaired renal office) ___NO (Patients with normal renal function)
3. Administration	Administrate the mainline fluids and magnesium sulfate using a calibrated infusion pump. Connect the magnesium sulfate medication bag into the mainline 4 tubing past attaching information technology to the lowest port on an extension set or the lowest connector on the Iv tubing set to facilitate immediate disconnection during emergencies. Initiate magnesium sulfate with a loading dose (bolus) using a premixed bag of iv grams per 100 ml. Infuse the bolus dose over a xx- to 30-minute flow. When bolus is complete, initiate a premixed maintenance handbag with a concentration of 20 grams of per 500 ml. Administrate maintenance infusion at a rate of (bank check ane)— ___1 gram/hour (25 ml/hour) ___1.5 grams/hour (38 ml/hour) ___2 grams/60 minutes (l ml/hr) ___Other (split up provider order required for rates other than the to a higher place rates) Characterization the magnesium sulfate line with appropriate medication sticker. Do not infuse other medication into the magnesium sulfate line. 2d nurse must verify pump settings and line hookup whenever there is a rate change or a new pocketbook is hung. When the order for magnesium is discontinued, the pump should be stopped and the bag and 4 tubing promptly disconnected from the patient and discarded.
4. Provider notification parameters and standing orders for responding to suspected magnesium toxicity	Magnesium toxicity is a clinical diagnosis, and serum levels practise not always correlate with clinical signs and symptoms. Symptoms Magnesium Level (mg/dl) Normal adult values 1.7–ii.4 Therapeutic range 5-nine Loss of patellar reflexes 8-12 Feelings of warmth, flushing 9-12 Somnolence 10-12 Respiratory difficulty / depression 12-16 Muscular paralysis 15-17 Altered cardiac conduction >eighteen Cardiac arrest 30-35 Adjusted from Simpson, 2004.10 Standing orders for suspected magnesium sulfate toxicity: Stop the infusion. Activate a rapid response and notify provider. Monitor respiratory rate, design, and monitor oxygen saturation with pulse oximeter. Describe a STAT serum magnesium level. If respiration is depressed, administer oxygen 2L past face mask and administer calcium gluconate 1 gm (10 ml of a 10% solution) over v minutes. If respiration arrests, request advanced airway support and pocketbook-valve-mask to back up respiration.
half-dozen. Patient comfort and education	Discuss risks and benefits of magnesium sulfate with patient and family. Explain the magnesium infusion process, mobility, and dietary restrictions. Explain expected therapeutic furnishings, and discuss likely side furnishings, and symptoms of toxicity that should exist reported immediately. Discuss how patient and family tin request urgent help if nurse is not at bedside. Identify lights in the patient's room on low. Maintain a placidity surroundings. Provide a fan at the bedside for relief from flushing, hot flashes, and sensation of increased body temperature.
7. Communication	Notify pediatrics when antepartum and intrapartum patients are placed on magnesium sulfate. Verify medication bag, pump settings, and IV tubing are correct during change of shifts or other transitions of care squad. Utilize TeamSTEPPS communication techniques to— Asking urgent additional help. Assert and advocate for rubber practices (CUS). Brief new team members, such every bit during a rapid response (SBAR). Acknowledge receipt of orders (airtight-loop communication). Maintain situational sensation by sharing new information with team as it is learned.

Page last reviewed Nov 2018

Folio originally created April 2017

Internet Citation: Safe Medication Administration: Magnesium Sulfate. Content concluding reviewed November 2018. Bureau for Healthcare Research and Quality, Rockville, Md.
https://www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html

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