iv therapy

Intravenous

By: mplestor,rn,man

Therapy

Definition: Intravenous Therapy

-The insertion of a needle or catheter/cannula into a vein, based on the physician’s written prescription.- The needle or catheter/cannula is attached to a sterile tubing and a fluid container to provide medication and fluids

Objectives: Intravenous Therapy

-Recognize the ethico-legal implications of IV Therapy

-Serves as a guide for nurses in providing safe and quality nursing care to patients, relative to IV therapy-Promote the application of principles underlying the administration of IV Therapy

1. Role Definition:

Intravenous Therapy

- The IV nurses are registered nurses committed to ensure the safety of all patients receiving IV therapy

Scope of Practice

Intravenous Therapy

- Recognition of holistic approach to patient

- Thorough knowledge of the vascular system

2. Basis of Practice: - Legal therapeutic prescription of a licensed MD

2. Basis of Practice:

Intravenous Therapy

- Networking and linkages with external environment

- Individual profession accountability

- Collaboration with members of health team

2. Basis of Practice:

Intravenous Therapy

- - Utilization of Nursing Process, through: Assessment

Planning Implementation Evaluation

3. Clinical skills:

Intravenous Therapy

- An IV therapy nurse shall be proficient and competent in all clinical aspects of the IV Therapy

Intravenous Therapy4. Procedures: - an IV therapy nurse shall perform procedures that include but not limited to the ff: Carry out MD’s prescription for

IV therapyPerform peripheral venipuncture

(except insertion of subclavian and cut-down catheter)

Prepare, initiate, monitor and terminate IV therapy

Administer Blood and blood components as prescribed by MD

Intravenous Therapy Determine solution and medication

incompatibilities Change IV site, tubings and

dressings, according to IV therapy standards

Establish flow rates of solutions, medications, blood and blood components as prescribed by the MD

Nursing management of patients receiving IV therapy and peripheral/central and parenteral nutrition in various set-ups (hospitals/home/others)

4. Procedures:

Adherence to established infection control practices

Observation and assessment of all adverse reaction related to IV therapy and initiation of appropriate nursing interventions

Appropriate documentation relevant to the preparation, administration and termination of all forms of IV Therapy

Intravenous Therapy4. Procedures:

Intravenous Therapy5. Indications of IV Therapy: To maintain hydration and/or

correct dehydration in patients unable to tolerate sufficient volumes of oral fluids/medications

Parenteral Nutrition

Administration of Drugs

Transfusion of Blood and blood components

Intravenous Therapy6. Contraindications of IV Therapy:

Administration of irritant fluids or drugs

through peripheral access (i.e. highly concentrated, high osmolarity solutions)

7. Communication skills: An Iv therapy nurse shall posses verbal and written communication skills in translating ideas and facts to patients, health care members and others

Intravenous Therapy

An IV therapy nurse have the responsibility of educating patients and significant others on pertinent aspects of IV therapy

Intravenous Therapy8. Client Education

Continuing education and staff development are vital to professional advancement. In this regard, the IV therapy nurse actively participate and share knowledge with other disciplines

Intravenous Therapy9. Continuing Education

Intravenous TherapyStandards of Nursing

Practice 1.Standard policies & procedures: A. Physician’s prescribed treatment

- Patient’s name-Type and amount of solution- Flow rate-Type, dose and frequency of drugs - Others affecting the procedures- MD’s signature

B. Patient Assessments- Clinical status of patient - Type of solution- Patient’s diagnosis - Duration of therapy- Patient’s age- Dominant arm - Condition of vein and skin- Cannula size

Practice 1.Standard policies & procedures:

C. IV set and equipment preparation- Check for expiration date- Check for clarity, sediments, packaging- Check label against doctor’s written prescription- Label for any medication that are added: (date, time, dose and amount; compatibility of drug with the solution)- Functionality of infusion pump, Pt. CA

Practice 1.Standard policies & procedures:

2. Medications 10 GOLDEN RULES FOR DRUG ADMINSTRATION

1. Administer the right drug2. Administer to the right patient3. Administer the right dose4. Administer at the right route5. Administer at the right time

Practice

6. Right documentation7. Teach patient about the drugs he’s

receiving8. Take complete drug history9. Assess for drug allergies10. Be aware of potential drug-drug or

drug-food interactions

10 GOLDEN RULES FOR DRUG ADMINSTRATION

2. Medications

Practice

3. Initiation of IV therapy - Initiation of IV therapy shall be to provide peripheral intravascular access for therapeutic indications- This requires physician’s

prescription

Practice

4. Choices of CannulaFor peripheral infusion:

- Purpose of infusion- Type of infusion- Size and condition of the patient’s

vein- Duration of treatment- Condition of patient

Practice

Needle gauge and color:16 - grey18 – green20 – pink22 – blue24 – yellow26 – violet

4. Choices of Cannula

Practice

Parts of a Cannula

4. Choices of Cannula

Practice

5. Selection of venipuncture siteTake note for:

- Patient’s condition- Patient’s age- The size and vein condition- Type and duration of therapy- Functional utilization of the

Practice

6. Anchoring Cannula & TubingGood anchoring…- Allows normal blood flow- Prevents movement of cannula- Prevents irritation of the vein- Puncture site should not be covered with tape

Practice

7. IV Cannula Removal

- Peripheral IV cannulas and the site are routinely changed aseptically or re-sited every 48-72

hrs or when necessary

Practice

8. Quality Control of IV Solution All IV fluids shall be inspected prior to use:

- Visible sediments

- Turbidity- Leaks/cracks- Expiration date- Damaged caps

Practice

9. Documentation of IV Therapy Proper documentation provides:

- An accurate description of care that can serve as legal protection

- A mechanism for recording and retrieving info

- A record for health insurers and retrieving info documenting the insertion or beginning of therapy.

Practice

The ff. info. of care can serve as legal protection

9. Documentation of IV Therapy

- Size, type and length of cannula/needle- Name of person who inserted the IV

catheter- Date and time of insertion

Practice

The ff. info. Is documented in the patient’s chart:- Location and condition of insertion site- Complications, pt. response & nsg.

Interventions- Pt. teaching and evidence of patient’s

understanding- Nurse’s signature

Practice

Policies on Documentation:- Never chart ahead of time- Chart properly- Clearly identify who did the procedure- Don’t leave space on charting- Identify late entries- Don’t criticize personnel on the chart

Practice

- Avoid error- Don’t tamper records- Document all reports to the doctor- Chart abbreviations properly- Refusal of meds should be charted- Don’t invent!!!

Policies on Documentation:

Practice

10. Infection Control

Practice

The ff. measures reduces patient’s risk:

10. Infection Control

- Wash hands before and after a procedure

- Use an approved antiseptic to clean the client’s skin

- Cut/clip the hair of the venipuincture site. Don’t shave

- Do not re-use catheter or needle

Practice

Center for Disease Control:10. Infection Control

- IV should be change 48-72 hrs- Site prep: tincture of iodine 1-2% (30 sec before

venipuncture- Piggyback tubing should be change after 48 hrs- Tubing should be changed after admin. of blood

products- Between changes of components, the IV system

should be maintained as a closed system as much as possible

Practice

HEMATOMA – a collection of extravasated blood trapped in the tissues of skin or in an organ.

11. Complications in IV therapy

S/S:- Tenderness - Bluish- Bruising around site - Inability to advance catheter- Resistance during flushing

LOCAL COMPLICATIONS

Practice

HEMATOMA

Nsg. Intervention:- Remove IV- Check for

bleeding Prevention:- Choose a good vein- Release torniquet as soon

as insertion is achieved

Practice

THROMBOSIS – an abnormal condition in which a clot (thrombus) develops within a blood

vessel

S/S:- Tenderness- Swollen vein- Reddened - Sluggish

Nsg. Intervention:- D/C IV- Restart new site- Warm compressPrevention:

- Proper venipuncture technique to reduce injury

Practice

PHLEBITIS – inflamed vein

S/S:- Redness- Puffy area- Hard vein on palpation- Increase body temp.

Nsg. Intervention:- Removed IV- Warm compress- Notify MD

Prevention:- Restart at large vein or

use small gauge cannula

Practice

INFILTRATION – a process whereby fluid passes into the tissues

S/S:- Swelling - Discomfort - Tightness at IV site - Blanching at site- Decrease temp at site - Absence of

backflow- Continues fluid infusion even when vein is

occluded although rate may decrease

Practice

INFILTRATION

11. Complications in IV therapyNsg. Intervention:- Removed IV & restart new

site- Warm compress & elevate

limbs- Check for pulse & numbness- Notify MD

Prevention:- Restart at large vein or

use small gauge cannula- Monitor IV site

Practice

LOCAL INFECTION – an infection within a specific area

11. Complications in IV therapyS/S:- Redness and swelling- Presence of exudates- Inc. WBC count

Prevention:- Good aseptic technique

Nsg. Intervention:- D/C- Request for C/S- Apply sterile

dressing- Apply antibiotics

Practice

VENOUS SPASM – a spasmodic constriction of vein

S/S:- Sharp pain at IV site

SYSTEMIC COMPLICATIONS

Prevention:- Check for allergies

Nsg. Intervention:- Warm compress flow

rate- Decrease the flow rate- Restart is spasm is gone

Practice

SPEED SHOCK – a sudden adverse physiologic reaction to IV medications or

drugs that are administered too quickly

S/S:- Dizziness - Headache - Facial flush - Shock- Hypotension - Irregular pulse- Tight feeling in the chest - Loss of consciousness- Cardiac arrest

Practice

SPEED SHOCK

Prevention:- Check for allergies

Nsg. Intervention:- Warm compress flow

rate- Decrease the flow rate- Restart is spasm is gone

Practice

SEPTICEMIA – systemic infection in which pathogens are present in the circulating blood, having spread

from an infection in any part of the body S/S:

- Fever & Chills - Hypotension- Body malaise - Pain- Contaminated IV site - Nausea

Practice

SEPTICEMIANsg. Intervention:- Notify MD- Do C/S & Initiate Antibiotic- Monitor V/SPrevention:- Hand hygiene - cover infusion site - follow SOP- Secure all connections - inspect fluids

Practice

CIRCULATORY OVERLOAD – an elevation in blood pressure caused by an increased

blood volume, as by transfusion. It may lead to heart failure or pulmonary edemaS/S:

- Discomfort - Intake increase- Neck vein engorgement - Decrease

output- Resp. distress- Increse BP

Practice

CIRCULATORY OVERLOADPrevention:- Use volume control set- Calculate rate- Monitor infusion- Do not “catch-up”

infusion

Nsg. Intervention:- High fowler’s position- Slow flow rate- Admin. Oxygen as

needed- Admin. Furosemide as

ordered

Practice

CATHETER EMBOLISMS/S:- Sharp sudden pain @ IV site- Rough and uneven catheter noted- Chest pain- Tachycardia

Practice

Prevention:- Don’t apply pressure- Use radio opaque- Avoid joint flexion- Never re-insert stylet

Nsg. Intervention:- Tourniquet above elbow- Start new site- Inform MD

CATHETER EMBOLISM

Practice

ALLERGIC REACTION – an unfavorable physiologic response to an

allergen to which a person has previously been exposed and to which a person has developed antibodies

S/S:- Itching - Wheezing- Bronchospasm - Anaphylactic rxn- Urticarial rash - Edema- Bronchospasm

Practice

ALLERGIC REACTIONPrevention:- Obtain allergic history- Monitor client- Test dosing (slow rate)

Nsg. Intervention:- STOP!!! – Flush w/ PNSS- Notify MD- Admin. Antihistamine as

ordered

Practice

12. Procedural Problems Associated with IV Therapy

Fluctuating flow rate Runaway IV Sluggish IV tubing/ loose connection / disconnection IV line obstruction/kinking of IV tubing Clogged filter Break in aseptic technique leaks due to inappropriate device

Practice

13. Risk associated w/ IV therapy

Infectious organism exposure Needle stick injury Chemical exposure

Practice

14. Outcome Criteria The desired outcome criteria of these

IV Nursing standard shall be to:- To deliver safe and quality IV Therapy care- Protect the patient and the IV nurse

therapist- Protect the IV therapy nurse’s practice

Practice

All nurses are responsible for quality, utilizing IV nursing process of:

- Assessment- Planning- Implementation- Evaluation

Deviation from optimal care in the IV therapy nursing practice requires corrective care

Practice 14. Outcome Criteria

PROCEDURESIntravenous Therapy

Standards of Nursing Practice

A. SETTING-UP an IV1. Verify doctor’s order & make I.V. label.

- An order requiring the initiation of IV must be made by the physician prior

to the implementation of this procedure.

Practice PROCEDURE I.

2. Observe 10 Rules in Drug Admin.- For legal purposes

A. SETTING-UP an IV

Practice

3. Explain Procedure to Client and secure consent if necessary

- To decrease anxiety and foster cooperation

A. SETTING-UP an IV

Practice

4. Assess client’s vein; choose appropriate vein: location, size, condition.

- Good condition of the vein will facilitate easier insertion of the needles.

A. SETTING-UP an IV

Practice

5. Hand hygiene before and after the procedure

- To reduce transmission of microorganisms and to prevent infection.

A. SETTING-UP an IV

Practice

6. Prepare the necessary materials for procedure - Organization saves nursing

time. - IV tray w/ IV solution - Cotton balls w/ alcohol- Administration set - Plaster and gloves- IV cannula with IV solution - Tourniquet and splints- Forceps soaked in antiseptic solution - Sterile gauze or dressing

A. SETTING-UP an IV

Practice

A. SETTING-UP an IV

Practice

7. Check the sterility & integrity of the IV

solution, IV set & other devices.

- Break in the integrity of the materials can lead to

infection.

A. SETTING-UP an IV

Practice

8. Place IV label on the IV fluid bottle (client’s name, room number, solution, drug incorporation, bottle sequence and duration) - To ensure that the correct client will receive the IVF, and for documentation purposes.

A. SETTING-UP an IV

Practice

9. Open the seal of the IV solution and disinfect port with cotton balls with alcohol.

- To reduce number or microorganisms residing in the port.

A. SETTING-UP an IV

Practice

10. Open the administration set (IV set) aseptically and close the IV clamp. - Closing the IV clamp prevents the

solution from spilling unintentionally after insertion to the solution bottle.

A. SETTING-UP an IV

Practice

11. Spike container aseptically

A. SETTING-UP an IV

Practice

12. Fill drip chamber to at least half and prime the tubing

aseptically.

A. SETTING-UP an IV

Practice

13. Remove air bubbles if any and put back the cover to the distal end of the IV tubing (get ready for IV insertion). - To remove air along the tubing

and to prevent air embolism.

A. SETTING-UP an IV

Practice

B. INSERTING IV w/ DUMMY ARM1. Verify doctor’s written prescription for IV therapy, check prepared IVF and other things needed.- An order requiring the

initiation of IV must be made by the physician prior

to the implementation of this procedure.

Practice

B. INSERTING IV w/ DUMMY ARM

Practice

3. Explain Procedure to Client and secure consent if necessary

Practice

4. Assess client’s vein; choose appropriate vein: location, size, condition.

- Good condition of the vein will facilitate easier insertion of the needles.

Practice

6. Apply tourniquet 5-12cm (2-6in) above injection site depending on condition of client- To distend the

veins and facilitates easier insertion.

Practice

7. Check for radial pulse below tourniquet.

- To distend the veins and facilitates easier insertion.

Practice

8. Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry. (No touch technique). - To reduce number of microorganisms in

the area and to prevent infection.

Practice

9. Using the appropriate I.V. cannula, pierce skin with needle positioned on a 15-30 degree angle; upon flashback visualization decrease the angle,

advance the catheter and stylet (1/4 inch) into the vein.

Practice

10. Position the I.V. catheter parallel to the skin. Hold stylet stationary the slowly advance the catheter, until the hub is 1mm to the puncture site.

Practice

11. Slip a sterile gauze under the hub. Release the tourniquet, remove the stylet while applying digital pressure over the catheter with one finger about 1-2in. from the tip of the inserted catheter

Practice

12. Connect the infusion tubing of the prepared IVF aseptically to the catheter.

- To initiate flow of solution into the vein.

Practice

When steel-winged needle (butterfly) is used: A. Connect the I.V. tubing to the steel-winged needle connector & prime the needle with I.V. fluid. B. Using the steel-winged needle, pierce skin with the needle bevel up, positioned on a 5-10 degree angle. C. With steel-winged needle, parallel on the skin, enter the vein directly and advance needle ¼ inch after successful venipuncture. Check for backflow. Remove tourniquet.

Practice B. INSERTING IV w/ DUMMY ARM

13. Open the clamp, regulate the flow rate and reassure the client.- To initiate flow of solution into the

14. Anchor needle firmly w/ the use of:

a. transparent tape/dressing directly

on the puncture site.b. tape (approp. anchoring style).

- To secure the needle in place.

15. Tape a small loop of I.V. tubing for additional anchoring; apply splint (if needed). - To secure the needle

in place.

17. Label on I.V. tape near the I.V. site to indicate the date of insertion.

16. Calibrate the IVF bottle & regulate flow of infusion according to duration. - Improper calibration

can lead to under dosage or over

dosage.

18. Label with plaster on the I.V. tubing to indicate the date when to change the I.V. tubing.

19. Observe patient and report any untoward effect.

20. Document in the patient’s chart and endorse to incoming shift.

21. Discard sharps and waste according to Health Care Waste Mgt.

1. Verify doctor’s prescription in doctor’s order sheet, countercheck IV label, IV card, infusate sequence, type, amopunt additives (if any) and duration of infusion.

Practice C. CHANGING an IV SOLUTION

3. Explain Procedure to Client and assess IV site for redness, swelling and pain…

4. Change Iv tubings & cannula if 48- 72hrs. Has lapsed after IV insertion

- Prolonged used of needle is the primary source of infection in IVF.

6. Prepare necessary materials. - To save time and effort

- IV tray - Cotton balls w/ alcohol- New IV bottle w/ IV label - Forceps soaked in antiseptic solution

7. Check sterility and integrity of IV solution.

- Break in the integrity of the materials can lead to infection.

8. Place IV label on the IV bottle

Practice C. CHANGING an IV SOLUTION9. Calibrate the new IV bottle according to duration of infusion. Place IV label on the IV bottle.

- Improper calibration can lead to underdosage or overdosage.

Practice C. CHANGING an IV SOLUTION10. Open and disinfect rubber port of IV solution to follow

Practice C. CHANGING an IV SOLUTION11. Close the IV clamp or kink tubing and spike the container aseptically. - Closing the IV clamp prevents the

solution from spilling unintentionally after insertion to the solution bottle.

Practice C. CHANGING an IV SOLUTION12. Regulate the flow rate based on duration of infusion. Remove air bubbles (if any). - Improper calibration can lead to

underdosage or overdosage. Air in the tubings can lead to air embolism.

Practice C. CHANGING an IV SOLUTION13. Reassure client and significant others

15. Document in the patient’s chart and endorse to incoming shift.

Practice D. DISCONTINUING IV INFUSION1. Verify doctor’s order to discontinue IV including IV medications

Practice D. DISCONTINUING IV INFUSION

3. Assess & inform the client of the discontinuation of IV infusion and of any medication.

- Decreases anxiety and foster cooperation.

4. Prepare the necessary materials. - Saves time and effort

- IV tray - Cotton balls w/ alcohol- Plaster - Forceps soaked in antiseptic solution-Sterile gauze or dressing - kidney basin

Practice D. DISCONTINUING IV INFUSION5. Hand hygiene before and after the procedure

Practice D. DISCONTINUING IV INFUSION6. Close the clamp of the IV

administration set. - To prevent spilling of

solution.

Practice D. DISCONTINUING IV INFUSION7. Moisten adhesive tape around the I.V. catheter with cotton ball with alcohol; remove plaster gently. - It facilitates easier removal of the

plaster.

Practice D. DISCONTINUING IV INFUSION8. Use pick-up forceps to get cotton ball with alcohol and without applying pressure, remove needle or IV catheter then immediately apply pressure over the venipuncture site.

Practice D. DISCONTINUING IV INFUSION9. Inspect IV catheter for completeness. - Make sure that the entire length of

the catheter is complete. If not, inform the physician immediately.

Practice D. DISCONTINUING IV INFUSION10. Place dressing over the venipuncture site

- Make sure that the entire length of the catheter is complete. If not, inform the physician immediately.

Practice D. DISCONTINUING IV INFUSION11. Discard sharps and waste according to Health Care Waste Mgt.

Practice D. DISCONTINUING IV INFUSION12. Document

time of discontinuance, status of insertion and integrity of IV catheter and endorse accordingly

A. INCORPORATION INTO IV BOTTLE1. Verify written medication card against MD prescription; observe hospital

policy on drug administration

- To make sure that correct medication will be administered.

Practice PROCEDURE II

A. INCORPORATION INTO IV BOTTLE

Practice

2. Observe 10 Rules in Drug Admin.

- For legal purposes

Practice

3. Explain Procedure (medication & action) and check patency and IV site

Practice

4. Verify for skin test of drug for IV incorporation (if skin testing is necessary)

Practice A. INCORPORATION INTO IV BOTTLE5. Hand hygiene before and after the procedure

Practice A. INCORPORATION INTO IV BOTTLE6. Prepare necessary materials needed for the procedure such as: - IV tray - Cotton balls w/ alcohol

- syringes needed - Forceps soaked in antiseptic solution-Sterile gauze or dressing - kidney basin

Practice A. INCORPORATION INTO IV BOTTLE7. Disinfect the injection port of the vial and the ampule before breaking then aspirate the right drug to be incorporated either in vial or ampule.

Practice A. INCORPORATION INTO IV BOTTLE8. Remove the cover of the airway of the administration set, maintain the sterility and incorporate prepared drug into the airway. Recap airway after.

Practice A. INCORPORATION INTO IV BOTTLE

Practice A. INCORPORATION INTO IV BOTTLE*** If the administration set has no airway, put down the bottle, kink the IV tubing, remove the administration set from the bottle aseptically; disinfect the bottle’s rubber stopper; incorporate the right drug to the IVF bottle; return the administration set to IVF bottle aseptically;

Practice A. INCORPORATION INTO IV BOTTLE9. Swirl the IV bottle to mix the drug, with IVF and regulate the flow rate accordingly.

Practice A. INCORPORATION INTO IV BOTTLE10. Observe for 5-10mins for any drug interaction while reassuring the patient; monitor V/S.

Practice A. INCORPORATION INTO IV BOTTLE11. Document in the patient’s chart

Practice A. INCORPORATION INTO IV BOTTLE12. Discard sharps and waste according to Health Care Waste Mgt.

B. IV PUSH THROUGH THE IV PORT1. Verify written medication card against MD prescription; observe hospital

Practice

B. IV PUSH THROUGH THE IV PORT

Practice

3. Explain Procedure (medication & action) and check patency and IV site

Practice

5. Check patency and other reactions signs of swelling, redness, phlebitis, etc.. Do not give the drug.

Practice

6. Check for skin test result of drug for IV push, drug-drug, drug IV fluid incompatibility, dosage computation.

Practice

7. Prepare necessary materials needed for the procedure such as: - Right drug - IV tray

- Right diluent - syringes needed- Cotton balls w/ alcohol - etc…..

Practice

8. Disinfect the injection port of the diluent vial or ampule as appropriate.

Practice

9. Aspirate right amount of diluent for the drug (if drug needs to be diluted.)

Practice

10. Aspirate the right drug dose; disinfect the Y-injection port of the IV administration set

Practice

11. Close the roller clamp of the IV tubing from the bottle and push IV drug aseptically and slowly or according to the manufacturer’s recommendation

Practice

12. Using the same syringe aspirate 1-2cc of IVF to flush the medicine given.

Practice

13. Regulate the rate of IV fluid infusion as prescribed.

Practice

14. Reassure the patient and observe for signs and symptoms of adverse drug reaction.

Practice

C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER

Practice

1. Verify written medication card against MD prescription; observe hospital

Practice

3. Explain Procedure (medication & action) and check patency and IV site.

Practice

5. Prepare necessary materials needed for the procedure such as: - Right drug and dose - Right diluent

needed- IV injection tray - Syringes and needle

Practice 6. Check present IV fluid label, level and the incorporated medicine in the Volumetric chamber or IV bottle if w/ incorporated medicine, check for drug-drug incompatibility and if the on-going IV fluid in the volumetric chamber is to be consumed in 6-8 hrs. Request a prescription for IVF to be used solely for drug administration and keep the whole set sterile.

Practice

7. Aspirate prepared right drug and with correct dose.

Practice

8. Add desired IVF diluent into volumetric chamber by opening the sliding clamp from the bottle then close the clamp.

Practice

9. Disinfect rubber injection port of the volumetric chamber and incorporate the drug. Mix

gently

Practice

10. Open the clamp of the airway at the volumetric chamber

Practice

11. Regulate the flow rate of IVF infusion accordingly

Practice

12. Place IV label on volumetric chamber indicating the drug incorporated and flow rate

Practice

13. Reassure/monitor client when incorporated medicine is consumed, close airway of VC and IVF and regulate flow rate of main IVF as prescribed

Practice

15. Document in the patient’s chart, IVF sheet and Kardex

Practice

D. IV PUSH - HEPARIN LOCK

Practice 1. Verify written medication card against MD prescription; observe hospital

D. IV PUSH – HEPARIN LOCK

Practice

3. Explain Procedure (medication & action) and check patency and IV site.

Practice

5. Prepare necessary materials needed for the procedure such as: - heparin solution - Normal saline

- 2.5cc syringe (3pcs) - tuberculin syringe 1pc)- IV tray - cotton balls with alcohol- etc….

Practice D. IV PUSH – HEPARIN LOCK

6. Prepare medication to be administered e.g. antibiotic and draw it up into a syringe.

7. Fill the tuberculin syringe with Heparin solution. (heparin solution is usually prepared with 0.1cc heparin plus 0.9cc Normal saline solution.

8. Fill the 2.5cc syringe with Isotonic solution or Normal saline 1cc each

Practice

9. If using Hep lock device with 3-way stop cock with luer-lock, rotate the stop cock so that the line going to the patient is closed (this will prevent backflow of blood)

Practice

10. Remove the cover of the injection port aseptically and keep the sterility of the

cover.

Practice

11. Check the patency, open the IV line, inject NSS to flush Heparin solution

Practice

12. Close the IV line and remove saline syringe and insert medication syringe into the port.

Practice

13. Open the IV line & inject medication into the vein, timing the flow rate according to doctor’s order of drug manufacturer’s instructions.

D. IV PUSH – HEPARIN LOCKStandards of Nursing

Practice

Intravenous Therapy

14. Observe client for any adverse reactions and do nursing intervention accordingly

Practice

Intravenous Therapy

15. Close the IV line & remove medication syringe.

Practice

Intravenous Therapy

16. Insert the saline syringe, open the line & flush catheter tubing/IV cannula to

flush the line.

Practice

Intravenous Therapy

17. Close & remove saline syringe.

Practice

Intravenous Therapy

18. Close the IV saline, remove syringe and return the cover of the injection port aseptically.

Practice

Intravenous Therapy

Practice

19. Document in the patient’s chart, IVF sheet and Kardex

Practice

Practice BLOOD TRANSFUSIONType (ABO/Rh)Type (ABO/Rh) Can receive blood from:Can receive blood from:

O+O+ O (+/-)O (+/-)O-O- O (-)O (-)A+A+ A (+/-) A (+/-) oror O (+/-) O (+/-)A-A- A (-) A (-) oror O (-) O (-)B+B+ B (+/-) B (+/-) oror O (+/-) O (+/-)B-B- B (-) B (-) oror O (-) O (-)

AB+AB+ AB, A, B AB, A, B oror O (all+/-) O (all+/-)AB-AB- AB, A, B AB, A, B oror O (all -) O (all -)

Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications

Whole BloodWhole Blood 1 unit = 450ml1 unit = 450mlContains RBC, Contains RBC, WBC, Platelets WBC, Platelets

and Plasmaand Plasma

Acute massive Acute massive bleeding, open bleeding, open heart surgery, heart surgery, neonatal total neonatal total

exchangeexchange

Packed Red Packed Red Blood CellsBlood Cells

Most Plasma Most Plasma removedremoved

1 unit = 250-1 unit = 250-300ml300ml

Replacement in Replacement in chronic and acute chronic and acute

blood loss, GI blood loss, GI bleeding and bleeding and

traumatrauma

PlateletsPlatelets 1 “pack” should 1 “pack” should raise count by 5-raise count by 5-

8,000. 8,000. 1 pack = about 1 pack = about

50ml50ml

Active bleeding, Active bleeding, contiguous contiguous petechiae petechiae

Leukocyte-poor Leukocyte-poor red cellsred cells

Most WBC Most WBC removed to make removed to make it less antigenicit less antigenic

1 unit = 200-1 unit = 200-250ml250ml

Potential renal Potential renal transplant, transplant,

previous febrile previous febrile transfusion transfusion reaction, reaction, leukemia.leukemia.

Washed RBCWashed RBC WBC almost WBC almost completely completely removedremoved

1 unit = 300ml1 unit = 300ml

As for leukocyte-As for leukocyte-poor red cells but poor red cells but very expensive very expensive and much more and much more

purifiedpurified

Fresh Frozen Fresh Frozen PlasmaPlasma

Contains Factors Contains Factors II, VII, IX, X, XI, II, VII, IX, X, XI, XII, XIII & heat XII, XIII & heat

labile V and VII. labile V and VII. About 1 hr. to About 1 hr. to

thaw. thaw. 1 unit = 150-1 unit = 150-

250ml250ml

Emergency Emergency reversal of reversal of

warfarin warfarin (coumadin), (coumadin), suspected suspected

coagulopathy, coagulopathy, clotting factor clotting factor replacementreplacement

5% Albumin or 5% Albumin or 5% Plasma 5% Plasma

Protein FractionProtein Fraction

Precipitate from Precipitate from plasmaplasma

Plasma volume Plasma volume expanders in expanders in

acute blood lossacute blood loss

25 % Albumin25 % Albumin Precipitate from Precipitate from plasmaplasma

Volume Volume expanders, burns, expanders, burns, hypoalbuminemia. hypoalbuminemia.

Draws Draws extravascular fluid extravascular fluid

into circulation.into circulation.

Practice BLOOD TRANSFUSIONTRANSFUSION REACTIONS

- Sudden fever - Tachycardia - Backache-Diaphoresis - Hypotension - Shock- Chills - Headache- Hypersensitivity Reactions ( hives, wheezing, pruritus)

Practice BLOOD TRANSFUSIONTREATMENT FOR TRANSFUSION

REACTIONS- STOP!!!! The blood product transfusion ASAP!- Keep IV line (PNSS) open and monitor V/S and urine output carefully- Save the blood bag, have the lab verify the type and crossmatch.- In mild febrile transfusion reactions antipyretics can be used- With urticarial reactions dipenhydramine(Benadryl) should be given.- In more sever reaction, prevent acute renal failure.

Practice BLOOD TRANSFUSION

1. Verify doctor’s order and make treatment card according to hospital policy

2. Observe 10 Rules when preparing and administering any Blood or blood components

2. Observe 10 Rules in giving blood transfusion

3. Explain the procedure/rationale for giving blood transfusion to reassure client and significant others and secure consent. Get client’s history regarding previous transfusion.

4. Explain the importance of the benefits on Voluntary Blood donation (RA 7719 – National Blood Service Act of 1994)

Practice BLOOD TRANSFUSION5. Request prescribed blood/blood components from blood bank to include blood typing and X-matching and blood result of transmissible dse.

6. Using a clean lined tray, get compatible blood from hospital blood

7. Wrap blood bag with clean towel and keep it at room temp.

Practice BLOOD TRANSFUSION8. Have a doctor and a nurse

assess client’s condition. Countercheck the compatible blood to be transfused against the X-matching sheet noting ABO grouping and RH, serial #, expiry date w/ the blood bag label and other lab. Blood exam as required before transfusion.

9. Get baseline vital signs and refer to MD accordingly

10. Give pre-med 30 mins. before transfusion as prescribed

12. Prepare equip. needed for BT: - IV tray - Compatible blood set

-IV catheter (gauge 18-19) - Plaster- tourniquet - Blood component- Plain NSS - IV set and IV hook- gloves - Sterile gauze or dressing

13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with PNSS on another site, anchor catheter properly and regulate drops

14. Open compatible blood set aseptically and close roller clamp. Spike blood carefully; fill the drip chamber at lest half full; prime tubing and remove air bubbles (if any). Use gauge 18-19 for adults and 22 for pedia

15. Disinfect the Y-injection port of tubing (Plain NSS) and insert the needle from BT administration set and secure w/ adhesive tape.

16. Open roller clamp of IV fluid of PNSS and regulate to KVO while transfusion is going on.

17. Transfuse the blood via injection port and regulate @ 10-15gtts initially for 15 mins. And then at prescribed rate.

18. Observe client for 10-15 mins for any immediate reaction.

19. Observe client on an on-going basis for any untoward s/s such as:- flushed skin - chills -

inc. temp.- itchiness - urticaria - dyspnea*** if any of these s/s occurs STOP !!! the transfusion, open the roller clamp of the IV line w/ PNSS, and report it to the MD.

20. Swirl the bag hourly to mix the solid with the plasma

21. When blood is consumed, close the roller clamp of BT, and disconnect from IV line then regulate the IVF of PNSS as prescribed

22. Continue to observe and monitor patient post transfusion, for delayed reaction could still occur.

23. Re-check Hgb & Hct, bleeding time, serial platelet count within specified hours as prescribed &/or per institution’s policy.

24. Discard blood bag and BT set and sharps accdg. to

Health and Waste Mgt.

Practice BLOOD TRANSFUSION25. Document the procedure, pertinent observations and Nsg. Intervention and endorse accordingly

Practice BLOOD TRANSFUSION26. Remind the doctor about the administration of Calcium Gluconate if client had several units of Blood transfusion (3-6 units)

The EndThe End

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