Post on 14-Mar-2018
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Canterbury and the West Coast
Level 1 IV Therapy
1. Identify the process for Nursing and Midwifery Staff to attain Canterbury and West Coast Level 1 IV Certification
2. Show awareness of the key responsibilities of administration of IV therapy3. Identify the eight key complications of IV therapy administration4. Identify the timeframe that IV equipment can be safely utilised5. Describe how risk is minimised in the administration of IV therapy6. Identify the actions to take following an anaphylaxic reaction7. Describe how risk is minimised in the administration of blood and blood
products8. Describe the process of blood product administration9. Identify actions to take when an adverse blood reaction occurs
Your Logo
Objectives
http://www.cdhb.govt.nz/cdhbpolicies
Policies
tHandouts for the level 1 IV competency can be located on the CDHB Professional Development Website in the IV Section
Handouts
1 1
Volume 12
IV Standards are based on and set by the Infusing Nursing New Zealand Incorporated Society.
Assessment
The Volume 12 Fluid and medication manual can be located on the CDHB internet page
3322
http://www.ivnnz.co.nz
http://www.cdhb.govt.nz/pdu
1. Attend Mandatory IV Lecture2. Complete all theory and practical sections of the
Canterbury and West Coast IV Assessment3. Understand the action and reaction of the
medication that you are administering4. You agree to accept the responsibility for the
administration of the prescribed intravenous therapy.
To gain your Canterbury/West Coast Level 1 IV Certificate
Assessments– Clinical calculations Assessment (100%)– Theory Assessment/s based on Volume 12 (85%)– IV Practical Checklist (100%)
It is expected that all Registered Nurses, Midwives and new EN Scope attain their level 1 IV Competency (unless exempted by workplace eg. Mental Health)
No recertification is required, instead regular clinical audits occur. Recertification is only required if away from the
organisation for over 12 Months
To gain your Canterbury/West Coast Level 1 IV Competency Level 2 IV allows a staff member to care for
and access the following IV devices – PICC , Hickman and Central Venous lines. Also an additional portacath Competency can be attained if required for your area
Venepuncture, allows a staff member to obtain blood from a peripheral blood vessel.
The Peripheral IV Cannulation competency allows the staff member to place a peripheral cannula in a blood vessel
Your Level 1 IV Competency is a pre-requisite for attaining the following competencies
IV Peripheral Cannulation
Venepuncture
Level 2 IV Competency
Further information on these competencies is available on the PDU Website www.cdhb.govt.nz/pdu
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TransportabilityIV Competencies are recognised by the following
Nurse Maude
Southern Cross Hospital
St Georges Hospital
Oxford Clinic
Pegasus Group and the Rural Canterbury PHO
All CDHB and WCDHB Hospitals
Key Policies
Double Independent Checking
Double Independent Checking is the key step in the medication safety process• Both staff interpret the prescription independently
• Both staff perform calculations independently
• Both Staff perform the patient identification checks at the patients bedside
• Both staff are present through all stages of preparation, drawing up and administration of the medication.
CDHB (2012) Fluid and Medication Checking Procedure
Role of the Double Independent Checker
• The Double Independent Checker is just as legally accountable as the person administering the drug
• They must be present for ALL stages:
� Preparation and drawing up
� Administration
� Bedside checks
� Documentation
Includes TWO staff to the bedside
Medications that require Double Independent Checking
� Any Controlled Drug/Infusion� Any Blood or Blood Products� Warfarin and Oral Cytotoxic’sAND Any fluid/medication administered by the below routes
� Intra muscular
� Intra dermal� Subcutaneous
� Intravenous� Intrapleural� Intrathecal
� Epidural routePlease Note: Exceptions only where local policy stipulates - e.g. rural, specialist mental health. For Child Health and Neonatal Policy please refer to Volume Q
Need to Gain the following competencies1. Independent Medication Administration
Competency. This will enable an enrolled Nurse to independently administer oral medications, and undertake independent double checking responsibilities. This is attained by completing the clinical calculations and theory components of the level 1 IV therapy competency.
Transitioned Enrolled Nurses
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2. Level 1 IV Competency (EN Scope)Once a transitioned Enrolled Nurse has completed their Level 1 IV Competency they can;
– Enrolled Nurses can double independent check with another Enrolled Nurse who has also completed their independent medication administration competency when their designated registered health professional is not available
– May Administer IV Saline Flushes as per local policy– May Administer IV fluids (without additives or Potassium)– May Administer IV or SC Premixed bags i.e. N/Saline 0.9% or
Dextrose 4% in N/saline 0.18% premixed bags which are running 8-12 hourly (Adults only)
Transitioned Enrolled Nurses
� Must check all Medications and Fluids with their designated Registered Nurse
� May clamp tubing or turn off a pump if an infusion has completed
� Monitor whether an IV infusion is running to time� Perform hourly patient checks when an IV infusion
is in progress� Maintain the patient fluid balance record
Enrolled Nurses who have not transitioned –and/or do not hold their competencies
• Can be initiated by Registered Nurses and Midwives• For ‘Urgent’ clinical situations when the prescriber is
unavailable to come to the clinical area
• Recorded in Red on the prescription chart
• Repeated by prescriber to second checker (RN/RM/EN but not student nurse)
• One verbal order for a class A or B drug is acceptable if a pre-existing order for that drug is present
• Exceptions e.g epidural boluses, blood, paediatrics, significant renal disease or abortion inducing medications
Verbal Telephone Orders
� The verbal order is given by the Medical Officer� The verbal order is repeated to the medical officer by the nurse
receiving the order and also provides a running total of the amount of drug the patient has already received
� The Medication is then drawn up by the nurse who received the order
� The Verbal order is repeated by the nurse as the medication is handed to the Medical Officer, and the ampoule is second checked by the Medical Officer.
� The order is documented, and then signed by the Medical Officer at the conclusion of the Emergency Situation.
Verbal Orders in an Emergency Situation
1. Hypersensivity2. Infiltration3. Extravasation4. Phlebitis5. Infection6. Fluid Overload7. Air Embolism8. Anaphylaxis
1. Hypersensivity2. Infiltration3. Extravasation4. Phlebitis5. Infection6. Fluid Overload7. Air Embolism8. Anaphylaxis
Complications of IV Therapy
Nursing Made Incredibly Easy! (2008) I.V. Essentials: Complications of peripheral I.V. therapy, 6(1). pp 14-17Intravenous Infusions and Related Tasks [retrieved 23/11/11 from
http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-08_Intravenous_Infusions.html
Complications of IV Therapy
• Hypersensitivity/Allergy
• Infiltration - Infiltration occurs when I.V. fluid leaks into surrounding tissue
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Complications of IV Therapy
• Extravasation - the leaking of vesicant drugs into surrounding tissue causes tissue necrosis
• Phlebitis - Inflammation of a vein
Complications of IV Therapy
• Infection.
• Fluid Overload
• Air Embolism
• Any medication may potentially trigger anaphylaxis. The most common to do so include antibiotics, aspirin, ibuprofen, and other analgesics
Anaphylaxis
http://en.wikipedia.org/wiki/Anaphylaxis
Anaphylaxis and Other Drug Reactions
Mild Dizziness, tingling, flushing/warmth, puritis
Moderate Flushing, urticaria, nasal congestion, sneezing,
lacrimation, angio-oedema, erythema
Severe Hoarseness, nausea, vomiting, laryngeal
oedema, dyspnoea, abdominal pain/cramps,
substernal pressure
Life
Threatening
Bronchospasm, stridor, syncope, hypotension,
dysrythmias, coma, confusion
Anaphylaxis Vs Vasovagal
More likely to be tachycardic More likely to be bradycardic
More likely to be hypotensive More likely to be normotensive
Less likely to be pale or sweaty More likely to be pale and to sweat
More likely to have puritis Never have puritis
May have airway obstruction Never have airway obstruction
May have uticaria Never have urticatia
Loss of consciousness usually not
immediate
Loss of consciousness more likely to be
immediate
Less likely to feel better when lying down Often feel better when lying down
Always follows administration of drug Sometimes follow painful intervention
Less likely to have tonic-clonic jerks if
unconscious
More likely to have a few topic-clonic jerks
after loss of consciousness
•• AA--BB--CC– High-flow oxygen.
– Lie patient flat and elevate legs.
• ADRENALINE– 0.5 ml of 1:1000 IM (0.5 mg). Repeat every five minutes if needed.
• Antihistamines: promethazine 25-50 mg IM (preferred) or via slow IV push; or cetirizine or loratadine both 20 mg PO.
• Hydrocortisone 200 mg IV (onset of action 4-6 hours).
• Intravenous fluids - normal saline to maintain blood pressure.
• Nebulised salbutamol 5 mg (bronchospasm).
• Nebulised adrenaline 2 ml of 1:1000 (2 mg) diluted to 4 ml in normal saline (stridor).
• IV adrenaline is indicated if the situation is life threatening with circulatory collapse, and/or the patient is unresponsive to the above initial treatment. Cardiovascular monitoring must be available. Begin with 0.5-1 ml of 1:10,000 (0.05 mg to 0.1 mg) and increase dose incrementally as required. Very rarely up to 1 mg (10 ml of 1:10,000) may be required every five minutes.
Anaphylaxis: Immediate Management
CDHB (2009) Management Guidelines for Common medical Conditions (13th Edition)
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Infection Prevention and Control
• Hand hygiene – ‘The 5 Moments for Hand Hygiene’
• Standard Precautions– Use of non-sterile gloves for Health Care Worker protection
when potential for blood and body fluid exposure – Other Personal Protective Equipment e.g. mask, apron when
necessary– Sharps safety practices
• Aseptic non-touch technique (ANTT)– Asepsis for all invasive procedures
Key Infection Prevention measures
Replacement timeframes
IV Lines – 72 HoursBut 24 hourly for Blood/TPN/ and certain Medications
IV Cannula –72 HoursChecked at the start of the shift and at least every eight hours when not in use
Intermittent Infusion – Single Use Only then discard
Blood Filters – 8 Hours or 2-4 units of blood
IV Cannula placed in an pre-hospital; emergency setting – As soon as the patient is stable
Green IV Line Stickers
Aseptic Non-Touch Technique
�Always use aseptic non touch technique (ANTT)
�Identify key parts of the equipment you are using
�Do not contaminate these key parts
�Always use luer lock syringes
�Always use blunt non coring needle to access plastic polyamps, drug bottles and when transferring drugs to IV bags, and filter needles when drawing up from glass ampoules
Phlebitis Score
Visual Phlebitis Score
0 No Symptoms Observe Cannula
1 Erythraemia at insertion site,
with or without pain
Observe Cannula
2 All the above plus oedema Resite Cannula
3 All the above, plus streak
formation/Palpable Cord
Resite Cannula – Consider
Treatment
4 All the above, plus palpable
venous cord > 1 inch (2.54cm)
and discharge
Resite Cannula – Consider
Treatment
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Sharps Safety Equipment – Single Use Only
Blood Transfusions How Precious?
WHOLE BLOOD
Red Cells $253Cryoprecipitate
$365
FFP $195
Platelets $755
Albumin 4% & 20% $96
Immunoglobulin $156
Prothrombinex $266 Intragam P $1058
G&S $45
• To correct loss:
- bleeding, destruction, reduced production
- plasma - burns
• To increase Haemaglobin
• To correct clotting deficits – induced by disease processes or medications
• Neonatal exchange transfusion
• To boost the immune system
Why do we give transfusions? Key risks of receiving a blood transfusion
• HIV – Less than 1 in a million.
• Hepatitis C – Less than 1 in a million
• Hepatitis B – one in 100,000.
• Bacterial Infections – less than 1 in a
100,000.
• Patient given blood that does not match.
STAFF ERROR
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Blood products are prescribed on the Fluid Prescription form:
– Number of units
– Rate of transfusion
– Any pre med
– Any diuretic required
– Blood warmer
– Irradiated product
Medical staff must complete the Blood Bank request form
and not the usual Laboratory form
How are blood products prescribed
• Discuss with the patient and explain the procedure
• Obtain Baseline TPR,SpO2, and BP
• Record on normal observation chart.
• Check IV device – is it patent?
• Check consent & prescription
• Then…Send blood request form to blood bank, or go
and collect. A Registered Nurse or Midwife needs to
sign as the requester
Before getting the blood product
To collect the blood, you can use the NZ Blood Service Blood Bank which is on the lower ground floor of the Parkside block. As the blood is dispensed by laboratory scientists it can be obtained/delivered by
– Orderlies/Hospital Aides
– Nursing and Midwifery Staff– Sending the request via the Lamson Tube
System (delivered this way as well)
Blood Collection Points – Christchurch Hospital
As there is no Blood Service onsite, blood is
delivered from the NZBS at Christchurch
Hospital via taxi, ambulance or shuttle. Once it
arrives it is put into the blood fridge in your
location, where it can be collected.
Blood Collection Points – Other Hospitals
Blood Fridge TPMH
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Two Nurses/Midwives must check blood details & patient details at the patients side.
–The Requester must be CDHB IV certified, EN’s must have their level 1 IV Certification to second check blood products.
Check the appearance of unit of blood for
– The presence of clots, clumps or abnormal cloudiness
You must check – The patients hospital armband for clarification of
patient identification against the Prescription chart and the blood
request form which is returned with unit of blood.
At the Bedside
• Always uses a 20 micron filter• Change the filter after every 2 bags of blood or 8 hourly –
whichever comes first• Only one unit of blood is administered at a time.• Commence the transfusion within 30 minutes of issuing, if you
suspect delay, return the blood to Blood Bank/Blood fridge immediately
• Complete the transfusion within 4 hours• Discard tubing and bag, place sticker on the back of the blood
request form and then document the date and time completed
NEVER PUT BLOOD IN A WARD FRIDGE
When transfusing
Blood must NOT
be mixed with
any other DRUG
or SOLUTION
other than
Normal Saline.
You can’t mix Blood !
If it is Fresh, it
needs a Filter
If it comes in a
bottle – no need
to use filter
Filter ? Observations during the transfusion
Baseline
15 minsfrom baseline
30 minsfrom baseline
Hourly until the infusion is completed
Final set of obsat the conclusion of the transfusion
Remain with patient for the first full 15 minutes
Start again for each new unit
A. Check the blood bag labels and patient ID to ensure the details match
B. Slow transfusionC. Consider giving an
antipyretic for pyrexia and antihistamine for urticaria
D. Continue transfusion at a slower rate with increased monitoring
If symptoms increase treat as a moderate reaction.
Action !
First febrile reaction:Body core temperature has increased more than one degree from their baseline. •Stable haemodynamicly•No respiratory distress•No other symptoms
Occasional urticarial spots with no other symptoms
Mild Reaction ?
A. Stop the transfusion immediately and review
B. Check the blood bag details against patient ID to ensure it is the correct blood product.
C. Disconnect blood & IV set (keep don’t discard) This will be sent to the blood bank for testing
D. Flush cannula to keep patent.E. Call for medical assistance
Follow NZBS transfusion protocol management guidelines for
Adverse Transfusion Reactions
Action !Moderate or Severe Reaction ?
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USED TO FILL FLUID VOLUME AND/OR CARRY OXYGEN
1. Oxygen therapeutics – mimic O2 carrying capacity
- hemopure, Oxygent, PolyHeme
2. Volume Expanders
- Ringers, NS, D5W, Haemacel, Gelofusin
• Allows for all blood types, no need to cross match
• Decreased risk of infection
• Store at room temperature
• Store for longer
Blood Substitutes Questions
THANK YOU!Canterbury District Health Board (2009) Management Guidelines for Common medical Conditions (13th
Edition), Christchurch, New Zealand: CDHB
Harrison's principles of internal medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005. Hypovolemia
Harrison's manual of medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005. Hypo/Hypernatremia
Martin, S. (2003) Intravenous Therapy, Business Nriefing: Long term health care Strategies 2003, retrieved 23/11/11 from http://www.touchbriefings.com/pdf/14/ACF7977.PDF
Nursing Made Incredibly Easy! (2008) I.V. Essentials: Complications of peripheral I.V. therapy, 6(1). pp 14-17
Brookside Associates (2008) Intravenous Infusions and Related Tasks: Lesson 1: Initiate an Intravenous Infusion and Manage a Patient With an Intravenous Infusion, retrieved 23/11/11 from http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-08_Intravenous_Infusions.html
Barts and the London Queen Mary’s School of Medicine & Dentistry (2005) Prescribing Skills - Modules for self directed learning, retrieved 10/12/12 from http://www.smd.qmul.ac.uk/prescribeskills/
References
New Zealand Blood Service (2008) Transfusion Medicine Handbook , retrieved 10/12/12 from http://www.nzblood.co.nz/Clinical-information/Transfusion-medicine/Transfusion%20medicine%20handbook
Infusion Nurses Society (2010) Infusion Nursing (Third Edition). USA: Saunders
Popovsky, M.A. (2009) Transfusion – associated circulatory overload: the plot thickens. Transfusion, Vol49. pp2-3
References