ADMINISTERING INTERMITTENT INTRAVENOUSMEDICATION USING A SECONDARY SET

Definition: An intermittent infusion is a method of administering a medication mixed in a small amount of IV solution,

such as 50 ml or 100 ml. The drug is administered at regular intervals, such as every 4 hours, with the drug being infused for a short period of time such as 30 to 60 minutes.Purpose:

To administer small amounts of drug at regular intervalsEquipment:

MAR or computer printout 50- to 250- ml infusion bag with medication Secondary administration set Antiseptic swabs Disposable clean gloves Tape Sterile needle or needleless adapter, syringe and saline, if medication is incompatible with primary infusion.

Special Considerations:1. Check the medication administration order (MAR).

Check the label of the ampule carefully against the MAR to make sure the correct medication is being prepared.

Ensure medication compatibility with primary infusion.2. Organize the equipment.3. Remove medication bag from refrigerator 30 minutes before administration, if appropriate.

PROCEDURE RATIONALEWash hands and observe other appropriate infection control procedures.

Reduces transmission of infection

Provide for client privacy.Prepare the client.Check the client’s identification band.

If not previously assessed, take appropriate assessment measures necessary for the medication

This ensures the right client receives the right medication.

Explain the purpose of the medication and how it will help, using language that the client can understand.

Information facilitates acceptance of and compliance with the therapy.

Assemble the secondary infusion. Close the clamp on the secondary infusion tubing.Spike the secondary infusion medication infusion bag.Squeeze the drip chamber and fill one-third to one-half full.Hang the secondary container at or above the level of the primary infusion. Use the extension hook to lower the primary infusion if a piggy back setup is required.Attach the sterile needle or needleless cannula to the tubing, open the clamp to prime the tubing and close the clamp when the tubing is filled with solution.

The tubing is primed to prevent introduction of air into the client.

Clean the Y-port on the primary IV line with an antiseptic swab. Clean the primary port (the port

To prevent introduction of microorganisms into the port

furthest from the client) for a piggyback alignment and the secondary port (the port closest to the client) for a tandem set up.If the medication is not compatible with the primary infusion, temporarily discontinue the primary infusion. Flush the primary line with saline solution before attaching the secondary set. To flush the line, wipe the port with an antiseptic swab, clamp the primary line and using a sterile needleless adapter (or needle) and syringe, instill sufficient saline solution through the port to flush any primary fluid out of the infusion tubing.

Flushing prevents mixing of the two solutions.

Insert the needleless canula of the secondary line into the primary tubing port.Secure needle with tape if using a needle system.

Tape prevents needle dislodgement.

Attach appropriate label to the secondary tubing. Secondary tubing is usually changed every 48 hours.Using a Piggyback SetEnsure the primary line is unclamped if the port has a back-check valve.

The valve automatically stops the flow of the primary infusion while the secondary set infuses and automatically starts running after the piggyback solution has been administered.

Open the clamp on the piggyback line and regulate it in accordance with the recommended rate for the medication. Usually, medications are administered in 30 to 60 minutes.Tandem InfusionOpen the clamp on the secondary line and regulate its flow.For continuous infusion, set the secondary solution to the appropriate drip rate for the medication and then adjust the primary solution to achieve the desired total infusion flow.For intermittent infusion, clamp the primary line and adjust the primary drip rate after the secondary solution is completed.Document the time, date, medication, dose,, route and solution, assessments of the IV site, if appropriate; and the client’s response. Record the volume of fluid of medication infusion bag on the client’s intake and output record.

ADMINISTERING MEDICATION BY IV PUSH

Definition:Intravenous “push” (or “IV bolus”) refers to the administration of a medication from a syringe and needle

directly into an ongoing IV infusion. It may also be given directly into a vein or heparin lock.

Indications:For emergency administration of cardiopulmonary resuscitative procedures, allowing rapid concentration of a medication in the patient’s bloodstream.When quicker response to medication is required (e.g., furosemide [Lasix], digoxin [Lanoxin]).To administer “loading” doses of a drug that will be continued via infusion (e.g., heparin [Heparin]).To reduce patient discomfort by limiting need for IM injection.To avoid incompatibility problems that may occur when several medications are mixed in one bottle.

To deliver drugs to patients unable to take them by mouth (e.g., coma) or IM (e.g., coagulation disorder).Cost-effective method-no need for extra tubing or syringe pump.

Special Considerations:Before the administration of medication:Determine that the medication matches the order.Dilute the drug as indicated by pharmacy references. Many medications are irritating to veins and require sufficient dilution.Determine the correct (safest) rate of administration.If IV push is to be given with an ongoing IV infusion or to follow another IV push medication, check pharmacy to possible incompatibility. It is always wise to flush the IV tubing before and after administration of drugs.Assess patient’s condition and ability to tolerate the drug.Assess the patency of IV line by presence of blood return.Ascertain dwell time of catheter. For infusion of vesicants (some chemotherapeutic agents), a catheter placement of 24 hours or less is advisable.Maintain sterility of the IV and medication equipment.Inspect the infusion site for signs of infiltration.Watch patient’s reaction to drug.Be alert of major side effects, such as anaphylaxis, respiratory distress, tachycardia, bradycardia, or seizures. Assess for minor side effects such as nausea, flushing, skin rash, of confusion.Vesicants are always given through the side port of a running IV infusion.Be familiar with the hospital policies and guidelines regarding how, where, and by whom IV push medications can be given.

Equipments:Physician’s order or medication cardCorrect sterile medicationSterile syringe (appropriate size)Sterile needle (appropriate size)Alcohol swabIV trayIn addition, for heparin lock:Sterile syringe and a needle with a heparin lush solutionSterile syringe and needle with 4 ml (or amount prescribed by the agency) of normal saline

PROCEDURE RATIONALECheck the physician’s order carefully for the medication, dosage, route, and rate of administration.

A medication that is injected too rapidly can create concentrations in the blood plasma that are toxic.

Wash hands. Gather equipments. pevents spread of microorganisms.

Observe the 10 rights in preparing medication. Start preparing the medication. Label the syringe with the name of the medication and the dosage.

to avoid errors.

In a separate syringe, prepare the heparin solution according to agency practice, if needed. Label syringe.

In another syringe, prepare the saline solution. Label the syringe.

IV Push into an Existing IVInspect the injection site for any signs of infiltration, then identify an injection port nearest he client. Some ports have a circle indicating the site for the needle insertion.

An injection port must be used because it is self-sealing. Any puncture to the plastic tubing will leak.

Clean the port with antiseptic swab. for asepsis.

Stop the IV flow by closing the clamp or pinching the tubing above the injection port.

prevents the medication from going up into the bottle.

PROCEDURE RATIONALEWhile holding the port steadily, insert the needle into the port.

Draw back on the plunger to withdraw some blood into the IV tubing (not into the syringe).

This shows that the needle or catheter is in the vein.

Inject the medication at the ordered rate, withdraw the needle, reopen the clamp, and reestablish the intravenous infusion at the correct rate.

to maintain the prescribed rate of IV infusion

If the medication is particularly irritating to the veins, run the IV rapidly for about a minute, and then adjust the rate.

to dilute the medication

IV Push into an Intermittent SetSwab the injection port with an antiseptic swab. prevents introduction of microorganism into the

vein.Insert the needle with the normal saline into the port and aspirate for blood return.

this ensures that the heparin lock catheter is in the vein. In some situations blood will not return even though the heparin lock is patent.

Inject 2 ml of the normal saline solution (optional, depending on agency policy).

this is done to flush the heparin from the catheter and to verify patency of the vein.

Remove the saline-filled syringe, and cap the needle to maintain its sterility.

this syringe is used again, so it must be kept sterile.

Insert the needle attached to the medication syringe.

Inject the medication slowly at the recommended rate of infusion.

some medications may irritate the vein if given faster.

Observe the client closely for adverse reactions.

Remove the needle and the syringe when all medication is administered.

PROCEDURE RATIONALEReattach the saline syringe, and inject the recommended amount of saline.

the saline injection flushes the medication through the catheter and prepares the lock for the heparin. Heparin is incompatible with many medications.

Insert the heparin syringe, and inject the heparin slowly into the set.

prevents clotting formation into the set.

Check the patency of the heparin lock at least every 8 hours or according to agency policy.Aspirate for return blood flow.Flush the catheter with 2-3 ml of normal saline.Refill the heparin lock with the new heparin solution.

to ensure the patency of set is maintained.

Check agency practice about recommended times for changing the heparin lock. Some agencies advocate a change every 48-72 hours.

IV Push Directly in VeinPerform venipuncture.

Many medications are injected slowly over a period of several minutes and are diluted in the syringe to decrease the concentration in the client.

Slowly inject the medication into the vein. The rate of the injection will vary according to the medication, the physician’s order, and/or the manufacturer’s directions.

Withdraw the needle, and apply pressure to the site.

to prevent bleeding.

For All Types of Intravenous MedicationsDocument the medication given, dosage, time, route, all assessments, and your signature.

Carefully assess the client’s response to the medication in terms of the intended action of the medication, adverse reactions, discomfort, etc.

MONITORING AN INTRAVENOUS INFUSION

Definition:An important nursing responsibility is to monitor an IV infusion so that the flow of the correct solution is

maintained at the correct rate.

Indications:To maintain prescribed flow rate.To prevent complications associated with IV therapy.

Assessment FocusAppearance of infusion site; patency of system.Type of fluid being infused and rate of flow.Response of the client.

special consideration:Assess the whole infusion system at least every hour to ascertain problems.Maintain asepsis.Ensure that the correct type and amount of fluid is infused within the specified time period.Prevent or identify early:fluid infiltrationphlebitiscirculatory overloadbleeding at the venipuncture siteblockage of the infusion flow

PROCEDURE RATIONALEFrom the physician’s order determine he type and sequence of solutions to be used.

IV infusion should only be performed with support of a physician’s order.

Determine the rate of flow and infusion schedule.

Ensure that the correct solution is being infused. If the solution is incorrect, slow the rate of flow to a minimum to maintain the patency of the catheter.

Stopping the infusion may allow a thrombus to form in the IV catheter. If this occurs, the catheter must be removed and another venipuncture should be performed before the infusion can be resumed

Change the solution to correct one. Document and report the error according to agency protocol.

PROCEDURE RATIONALEObserve the rate of flow every hour. Compare the rate of flow regularly.

If the rate is too fast, slow it so that the infusion will be completed at the planned time.

Infusions that are off schedule can be harmful to a client.

Assess the client for the manifestations of hypervolemia and its complications, including dyspnea; rapid, labored breathing; cough; crackles in the lungs bases; tachycardia; and bounding pulses.

Check if the rate is too slow.

Inspect the patency of the tubing and needle. solution administered to quickly may cause a significant increase in circulating blood volume. Hypervolemia may result in pulmonary edema and cardiac failure.

Observe the position of the solution container. If it is less than 1 m (3ft) above the IV site, readjust it to the correct height of the pole.

Observe the drip chamber. If it is less than half if the container is too low, the solution may not

full, squeeze the chamber to correct amount of fluid to flow in.

flow into the vein because there is insufficient gravitational pressure to overcome the pressure of the blood within the vein.

Open the drip regulator and observe for a rapid flow of fluid from the solution container into the drip chamber. Then partially close the drip regulator to reestablish the prescribed rate of flow.

Inspect tubing for pinches or kinks or obstructions to flow. Arrange the tubing so that it is lightly coiled and under no pressure. If it is dangling below the venipuncture, coil it carefully on the surface of the bed.

Rapid flow of fluid into the drip chamber indicates patency of the IV line. Closing the drip regulator to the prescribed rate of flow prevents fluid overload.

PROCEDURE RATIONALELower the solution container below the level of the infusion site and observe for a return flow of blood from the vein.

The solution may not flow upward into the vein against the force of gravity.

Check for leakage. Locate the source. If the leak is at the catheter connection, tighten the tubing into the catheter.

If the leak cannot be stopped, slow the infusion as much as possible without stopping it, and replace the tubing with a new sterile set.

Absence of blood return may indicate that the needle is no longer in the vein or the tip of the catheter is partially obstructed.

Inspect the infusion site for fluid infiltrationPalpate the surrounding tissue for edema.

Feel the surrounding skin for changes in temperature

If the tubing does not have a backcheck valve, lower the infusion bottle below the venipuncture site.

Use a sterile syringe of saline to withdraw fluid from the rubber at the end of the tubing near the venipuncture site. Discontinue the IV infusion if blood does not return.

Try to stop the flow by applying a tourniquet 10-15 cm (4-6 in.) above the insertion site and opening the roller clamp.

To ascertain the presence of infiltration

to see if blood returns. Blood may indicate that the IV needle is still in the vein.

Inspect for the presence of phlebitis. The clinical signs are redness, warmth, and swelling at the IV site and burning pain along the course of a vein.

a new venipuncture site is usually selected, and he injured vein is not used for further infusions.

PROCEDURE RATIONALEBe alert to signs of circulatory overload. circulatory overload means that the circulatory

system contains more fluid than normal.

Inspect for bleeding at the IV site. Bleeding into the surrounding tissues can occur while the infusion is freely flowing.

If the client is able, teach him or her when to call for assistance, e.g., if the solution stops dripping or the venipuncture site becomes swollen.

EVALUATION FOCUS

Amount of fluid infused according to the schedule.Intactness of IV system.Appearance of IV site.Urinary output compared to urinary intake.Tissue turgor; specific gravity of urine.Vital signs and lung sounds compared to baseline data.

CHANGING AN INTRAVENOUS CONTAINER AND TUBING

Indications:1. To maintain the flow of required fluids.To maintain sterility of the IV system and decrease the incidence of phlebitis and infection.To maintain patency of the IV tubing.To prevent infection at the IV site and the introduction of microorganisms into the bloodstream.

Assessment Focus:Presence of fluid infiltration, bleeding, or phlebitis at IV site.Allergy to tapeInfusion rate and amount absorbedAppearance of the dressing for integrity, moisture, and need for change.The date and time of the previous dressing change.

Special Considerations:Intravenous solution container are changed when only a small solution of the fluid remains in the neck of the container and fluid still remains in the drip chamber. However, all IV bags should be changed every 24 hours, regardless of how much solution remains, to minimize the risk of contamination. IV tubing is changed every 48 to 96 hours, depending on agency protocol, as is the site dressing.Determine allergies to tape or iodine.Select the correct solution.Prime the tubing before attaching it to the IV needle.Wear gloves when there is possibility of contact with the body secretions.Prevent needle dislodgement when disconnecting and connecting the IV tubing and when cleaning the venipuncture site.Make sure the IV system is intact and the correct flow rate is established.Inspect and clean the venipuncture site appropriately.Secure the needle appropriately with the tape and apply an appropriate dressing.Label the container, tubing, and dressing appropriately.

Patient Education:Teach the client ways to maintain the infusion system, like:

Avoid sudden twisting or turning movements of the arm with the needle.Avoid stretching or placing tension on the tubing.Try to keep the tubing from dangling below the level of the needle.Notify a nurse ifThe flow rate suddenly changes or the solution stops dripping.The solution container is nearly empty.There is blood in the IV tubing.Discomfort or swelling is experienced at the IV site.Equipments:Container with the correct kind and amount of sterile solutionAdministration set, including sterile tubing and drip chamberTiming labelSterile gauge square for positioning the needleAlcohol swabClean gloveTape

PROCEDURE RATIONALEChanging IV ContainerReview physician’s order for changes in fluid administration.

Obtain the correct solution container and make sure it is properly labeled. Check for sterility and integrity.

to prevent medication error

Prepare to change solution when it only remains in the neck of the bottle and make sure the drip chamber is half full.

prevents air from entering tubing

Wash hands.

-reduces transmission of microorganisms

Verify the physician’s order. Prepare all necessary materials for changing IV solution and place it on an IV tray.

for faster, organized and smooth change

Identify the patient and explain what you are going to do, why is it necessary, and how he can cooperate.

ensures correct client undergoes procedure.

Move the roller clamp to reduce flow rate. prevent solution remaining in drip chamber from emptying while changing the solution.

Remove the protective cover from the entry site of the new IVF bottle and disinfect rubber port with cotton and alcohol.

to maintain sterility of the solution.

PROCEDURE RATIONALERemove old solution from IV pole. brings work to eye level.

Quickly remove spike from old IV solution, and without touching tip, spike it to the new solution bottle while kinking the tubing below the drip chamber.

prevent solution inside the drip from running dry and maintain sterility.

Invert the IV bottle and hang to IV pole. allows gravity to assist with the delivery of fluid into the drip chamber then to the tubing.

Check the tubing for air. If with air, remove air from the tubing.

prevent air embolism

Regulate IV to prescribed rate. maintain measures to restore fluid balance

Observe system for patency and the response of the client to the therapy.

provides ongoing evaluation of response to therapy

Changing IV TubingDetermine the need to change the IV tubing.tubing should be changed 48-96 hours, depending on agency protocol.

puncture of infusion tubing.

Contamination of tubing.

Occlusion of tubing.

tubing should be changed according to agency protocol.

results in leakage of fluid.

can allow entry of bacteria into bloodstream.

Assemble the equipment. ensures efficient and safe procedure.

Explain the procedure to the patient. promotes cooperation and prevents movement of extremity, which could dislodge needle or catheter.

Do hand washing. reduces transmission of microorganisms.

Open the administration set and attach it to the container, using sterile technique.

provides nurse with ready access to new infusion set and maintains sterility of infusion set.

PROCEDURE RATIONALETighten the clamp and hang the container on the pole if it is not already hung.

to avoid spillage of fluid as tubing is removed.

Remove the protective cap from the end of the tubing, and prime the tubing. Clamp the tubing and replace the cap.

replacing the cap maintains the sterility of the end of the tubing.

Don gloves. Remove the tape and the dressing carefully from around the needle. Take care not to dislodge the needle from the vein.

Place a sterile swab under the hub of the catheter to absorb any leakage that might occur when the tubing is disconnected. Clamp the old tubing.

While holding the hub of the needle with the fingers of one hand, remove the tubing with the other hand, using a twisting, pulling motion. Place the end of the tubing in the kidney basin or other receptacle.

holding the needle firmly but gently maintains its position in the vein.

Continue to hold the needle, and grasp the new tubing with the other hand. Remove the protective cap, and maintain sterility, insert the tubing end tightly into the needle hub.

attaches new, primed infusion tubing to hub of angiocatheter.

Open the clamp to start the solution flowing. permits the solution to enter catheter or tubing.

Clean the venipuncture site, working from the insertion point outward in a circular manner.

minimize spread of microorganisms.

PROCEDURE RATIONALEApply a sterile dressing over the site and tape the needle in place. Apply a labeled tape over the dressing. The label should include the date and time the dressing is applied; the original date and time of the venipuncture; the size of the catheter or needle; and your initials, as the nurse who changed the dressing.

Tape a label on the new tubing with the date and time of the change and your initials.

Regulate the flow of the solution according to the order on the chart.

maintains infusion flow at prescribed rate.

Record the change of the tubing in the appropriate place on the client’s chart.

EVALUATION FOCUS

Status of IV site.Patency of IV system.Accuracy of flow.

DISCONTINUING AN INTRAVENOUS INFUSION

Definition:When an IV infusion is no longer necessary to maintain the client’s fluid intake or to provide a route for

medication administration, the infusion is discontinued.

Indications:To discontinue an intravenous infusion when the therapy is complete or when the client’s oral fluid intake and hydration status are satisfactory.The medications administered via IV route are no longer necessary.There is a problem with the infusion that cannot be fixed (e.g. thrombophlebitis, etc.).

Assessment Focus:Appearance of IV catheter.Amount of fluid infused.Any bleeding from infusion site.Appearance of the venipuncture site.

SPECIAL CONSIDERATIONS:Maintain asepsis.Prevent discomfort to the client.Prevent bleeding and hematoma formation.Make sure a catheter is removed intact.Wear gloves to prevent contamination by the client’s body secretions.

Equipment:Clean gloveWaste receptacle trayDry or antiseptic-soaked swabsPlasterSterile dressing

PROCEDURE RATIONALEVerify written doctor’s order to discontinue IV infusion.

Wash hands. reduces anxiety and promotes cooperation

Prepare all necessary equipments. reduces transmission of microorganisms

Close the roller clamp of the IV administration set.

PROCEDURE RATIONALEPut on the clean glove. clamping the tubing prevents the fluid from

flowing out of the needle onto the client or bed

Moisten adhesive tapes around the IV catheter using cotton balls with alcohol; remove plaster gently while holding the needle firmly and applying counteraction to the skin.

prevents direct contact with patient’ blood

Gently remove the needle or catheter by pulling movement of the needle can injure the vein and

it out along the line of the vein. cause discomfort to the client. Counteraction prevents pulling the skin and causing discomfort

Immediately apply pressure to the site, using the cotton swab, for 2 to 3 minutes.

pulling it out in line with the vein avoids injury to the vein

Hold the client’s arm or leg above the body if any bleeding persists.

pressure stops bleeding and prevents hematoma formation.

Inspect the catheter for completeness. raising the limb decreases blood flow to the area.

Report a broken catheter to the nurse in charge immediately.

if a piece of tubing remains in the client’s vein it could move centrally (toward the heart or lungs) and cause serious problems.

If a broken piece can be palpated, apply a tourniquet above the insertion site.

Cover the venipuncture site by applying a sterile dressing.

application of tourniquet decreases the possibility of a piece moving until a physician is notified.

Discard the IV solution container, if infusions are being discontinued, and discard the used supplies appropriately.

the dressing continues the pressure and covers the open area in the skin, preventing infection.

PROCEDURE RATIONALEDocument all relevant informationthe amount of fluid infusedtype of solutioncontainer numbertime of discontinuancethe client’s response to the procedure

EVALUATION FOCUS

Appearance of the venipuncture site.The pulseRespirations, skin color, edema, sputum, cough and urine output.And how the client feels physically and psychologically.

STARTING AN INTRAVENOUS INFUSION

Definition:It is one of the commonest invasive procedure in hospitals and is administered either by the peripheral or central route.

It is the aseptic instillation of fluids, electrolytes, nutrients, or medications through a needle into a vein.

Indications:To supply fluid when clients are unable to take in an adequate volume of fluids by mouth.To provide salts needed to maintain electrolyte balance.To provide glucose (dextrose), the main fuel for metabolism.To provide water-soluble vitamins and medications.To establish a lifeline for rapidly needed medications.To provide nutrition while resting the gastrointestinal tract.To monitor central venous pressure.To restore acid-base balance.To restore volume of blood components. Patient Education:

Educating the patient is one of the best complication prevention measures that can be done!!!All procedures should be explained to the patient with regard to why, what, complications, and signs and

symptoms about which to call a nurse.

Preparation Of Patient:Explain procedure and answer all questions to decrease anxiety.Describe the patient’s participation and the importance of holding still during the procedure.Assist in positioning the patient in a comfortable position that allows easy access to the desired site.Show the patient the equipment.Touch the patient to assess the skin.Anxiety can cause vasoconstriction.If site selected is hairy, clip or shave.Ensure patient is not allergic to skin prep agent.

Special Considerations:Maintain asepsis.Select the correct solution.Prime the tubing.Label the container appropriately.Label the IV tubing with the date and time of attachment.

Types of Solutions:Isotonic solution- A solution that exert the same osmotic pressure as that found in plasma.It has no effect on the cell/expand intravascular compartments only.Ex. 0.9% NaCl (normal saline), Lactated Ringer’s (a balanced electrolyte solution), D5W (5% dextrose in water), Blood components.Hypotonic solution- A solution that exert less osmotic pressure than that of blood plasma.Cell size increases and extracellular fluid (ECF) volume decreases; fluid and electrolytes shift out of intravascular compartment, hydrating intracellular and interstitial compartment.Ex. 0.45% NaCl, 0.2% NaCl, 0.33 NaCl, 2.5% Dextrose.Hypertonic solutionA solution that exert higher osmotic pressure than that of blood –plasma.Cell size decreases and ECF volume increases; fluid and electrolytes are drawn into intravascular compartment, dehydrating intracellular and interstitial compartments.Ex. D5NS (5% dextrose in normal saline), D5 1/2NS (5% dextrose in 0.45% NaCl), D5LR (5% dextrose in lactated ringer’s), D10W, D20W.

Kinds of Needles and CathetersButterfly Needles (Wing-tipped needle)Used in short-term IV therapyEasy to insert, infiltrate easilyOver-the-needle Cannula (Angiocatheter)Most commonCannula is over needle: allows ease of insertionInside-the-needle CatheterCatheter of 14- to 19-gauge inside the needleRarely used because of advances in midline and central cathetersShearing of catheter is a major risk

Site Selection Guidelines:(Take into account available vein condition, patient comfort, and type and duration of IV therapy)

Start distally and move proximally. Use lower extremities as a last resort.Use the client’s non dominant arm whenever possible to increase patient mobility.Use smallest catheter that accomplishes the purpose.Dorsal metacarpal veins of the hand provide the most comfortable insertion site (skin on back of the hand is less sensitive).Select a vein that isEasily palpated and feels soft and fullNaturally splinted by bonesLarge enough to allow adequate circulation around the catheter

Avoid using veins that areIn areas of flexion/joints ( e.g. the antecubital fossa)Highly visible, because they tend to roll away from the needleDamaged by previous use, phlebitis, infiltration, or sclerosisContinually distended with blood, or knotted or tortuousIn a surgically compromised or injured extremity, because of possible impaired circulation and discomfort for the client.The median basilica and cephalic veins are not recommended for chemotherapy administration due to potential for extravasation and poor healing resulting in impaired joint movement.

Age-Related Considerations:PEDIATRICDorsal surfaces of hands and feet are most frequently used.

Dorsal vein of hand allows child the greatest mobility.Always select site that will require the least restraint.Scalp veins are very fragile and require protection so they are not infiltrated easily (used for neonates and infants)Foot, scalp and antecubital sites are most commonly used in infant through toddler age-group.

GERIATRICSkin becomes paper-thin. Anchor catheters carefully to avoid tears and infiltrations.Insert catheter without a tourniquet if skin is fragile and veins are palpable and visible.Vascular disease, obesity, and dehydration may limit venous access.

Equipments:Infusion set as orderedIntravenous solution as prescribed by physicianIntravenous catheterIV poleIV tray containing

- Adhesive or nonallergic tape- Clean glove

- Tourniquet- Antiseptic swab- Sterile gauge dressing or transparent occlusive dressing- Arm splint, if required- Towel or pad

PROCEDURE RATIONALEVerify the physician order for type and amount of solution to use and the flow rate.

Serious errors can be avoided by careful checking.

Observe the 10 rights in preparing and administering medications.

IV solutions are medications and should be doubled checked to reduce risk of error.

Identify client and explain the procedure, secure consent if necessary.

to facilitate cooperation and alleviate client’s anxiety.

Do hand washing. reduces transmission of microorganisms.

Prepare necessary materials for the procedure. to avoid delay

Check the sterility and integrity of the IV solution, IV set and other devices.

Crack or leak would indicate contamination.

Place IV label on IVF bottle duly signed by RN who prepared it.patient’s nameroom numberIV solutiondrug incorporation (if any)bottle sequencedrop ratetime starteddate started

For proper documentation.

Open and prepare the infusion set.Remove the tubing from the container and straighten it out. Slide the roller clamp along the tubing until it is just below the drip chamber.

Move roller clamp to off position.

Leave the ends of the tubing covered with the plastic caps until the infusion is started.

Close proximity of roller clamp to drip chamber allows more accurate regulation of flow rate.

To prevent spillage of fluid.

This will maintain sterility of the ends of the tubing.

PROCEDURE RATIONALESpike the solution containerRemove the protective cover from the entry site of the IVF bottle and disinfect rubber port with cotton and alcohol.

Remove the cap from the spike and insert the spike into the insertion site of the IVF bottle.

To maintain sterility of the solution.

Invert the IV bottle and hang to IV pole. Adjust the pole so that the container is suspended about 1 m (3 ft.) above the client’s head.

Height is needed to enable gravity to overcome venous pressure and facilitate flow of the solution to the vein.

Fill the drip chamber with solution. Squeeze the chamber gently until it is half full of solution.

creates suction effect; fluid enters drip chamber.

Prime the tubing. Remove the protective cap and release the roller clamp to allow the fluid to travel from drip chamber through the tubing until all the bubbles are removed. Tap the tubing if necessary with your fingers to help the bubbles move.

Tubing is primed to prevent the introduction of air into the client which can act as emboli.

Reclamp the tubing and replace the tubing cap, maintaining sterile technique.

To maintain system sterility.

Then prepare to assist the IV therapist in IV insertion.

BLOOD TRANSFUSION

Definition:Blood transfusion is the introduction of whole blood or blood components (such as serum, plasma, platelets, or erythrocytes) into the venous circulation.

Indications:To restore blood volume after severe hemorrhage.To combat infection due to decreased or defective white cells or antibodies.To restore the capacity of the blood to carry oxygen.To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet concentrates, which prevents or treat bleeding.

Special Considerations:Confirm that there is a physician’s order and assigned consent from the client.Have two health care professionals confirm that the client name and ID #, and crossmatching result are correct.Maintain asepsis.Keep blood cold until ready for use.Blood should be stored in the blood bank and not in the nurse’s station.Do not use blood if released from blood bank for more than 30 minutes.Give pre-med 30 minutes before transfusion as prescribed.Don’t use blood with bubbles and has been discolored.Wear gloves before performing venipuncture, transfusing the blood, and when terminating blood and disposing of equipment.Administer all blood products through the correct filter for prevention of emboli.Monitor patient carefully throughout blood transfusion.Crystalloid solutions other than 0.9% saline and all medications are incompatible with blood products. They may cause agglutination and or hemolysis.Do not transfuse a unit of blood more than 4 hours.Assess the client closely for transfusion reactions.

Types Of Transfusion Reactions:Hemolytic reaction: incompatibility between client’s blood and donor’s blood.Febrile reaction: sensitivity of the client’s blood to white blood cells, platelets or plasma proteins.Allergic reactions (mild): sensitivity to infused plasma proteins.Allergic reaction (severe): antibody-antigen reaction.Circulatory overload: blood administered faster than the circulation can accommodate.Sepsis: contaminated blood administered.

Blood Products For Transfusion:Whole blood - Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors.Red blood cells – Used to increase the oxygen-carrying capacity of blood in anemias surgery, disorders with slow bleeding. One unit raises hematocrit by approximately 4%.Autologos red blood cells – Used for blood replacement following planned elective surgery. Client donates blood for autologos transfusion 4-5 weeks prior to surgery.Platelets – replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets most effective.Fresh frozen plasma – Expands blood volume and provides clotting factors. Does not need to be typed and crossmatched (contains no RBC).Albumin and plasma protein fraction – Blood volume expander; provides plasma protein.Clotting factors and cryoprecipitate – Used for clients with clotting factor deficiencies. Each provides different factors involved in the clotting pathway; cryoprecipitate also contain fibrinogen.

Assessment Focus:Clinical signs of reaction (sudden chills, fever, nausea, itchiness, low back pain, dyspnea).Manifestations of hypervolemia.Status of infusion site.Any unusual symptoms.

Equipments:Unit of blood that has been correctly crossmatchedBlood administration set500 ml or 250 ml of normal saline solution for infusionIV pole# 18 or # 19-guage needle or catheter (if one is not already in place)Alcohol swabPlasterClean gloveTourniquet

PROCEDURE RATIONALEVerify doctor’s written order for blood transfusion.

Serious errors can be avoided by careful checking.

Obtain client’s consent before the transfusion. Informed consent involves explaining medical indications for transfusion, benefits, risks, and alternatives.

basis for legal purposes.

PROCEDURE RATIONALEExplain the procedure and its purpose to the patient. Instruct the client to re[port promptly any sudden chills, nausea, itching, rash, dyspnea, backpain, or other unusual symptoms.

reduces anxiety and promotes cooperation.

If the client has an IV solution infusing, check whether the needle and solution are appropriate to administer blood. The needle should be gauge # 18 or # 19, and the solution must be normal saline.

to achieve maximal flow rate. Normal saline is isotonic and reduces hemolysis.

If the client does not have an IV solution infusing, you will need to perform a venipuncture on a suitable vein and start an IV infusion of normal saline.

Request prescribed blood/blood component from the blood bank to include blood typing and X-matching result, the expiration of he blood and blood result of transmissible disease.

safe storage of the blood is only limited to 35 days after extraction from he donor since the BC deteriorates after this time causing in allergic reaction when given.

Using a clean tray, get the compatible blood from the laboratory or blood bank.

With another nurse, compare the laboratory blood record withThe client’s name and identification number.The serial # on the blood bag label.The ABO group and Rh type on the blood bag label or check crossmatching form.

to check for correct blood to infuse.

Check blood bag for bubbles, cloudiness, dark color or sediments.

these signs indicate bacterial contamination.

Wrap blood with clean towel and keep it at room temperature for no more than 30 minutes before starting the transfusion.

RBCs deteriorate and lose their effectiveness after 2 hours at room temperature. Lysis of RBCs releases potassium into the bloodstream, causing hyperkalemia.

PROCEDURE RATIONALEVerify the client’s identity by asking the full name and/or checking the arm band for name and ID number.

to make sure you are doing the procedure to the correct patient.

Get the baseline V/S: BP, RR, Temperature before transfusion and refer to M.D accordingly.

to establish baseline data. V/S beyond normal may result to the postponement of the transfusion.

Give pre-med 30 minutes before transfusion as prescribed.

prevents allergic reaction.

Do hand hygiene before ad after the procedure. prevents spread of microorganism.

Prepare equipment needed for the procedure. for efficiency of work and accessibility of needed materials.

Set up the transfusion equipment.Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood components to be transfused.

Blood filters have a surface area large enough to allow the blood components through easily but are designed to trap clots.

If the main line is with dextrose 5% initiate an IV line with appropriate IV catheter with plain NSS on another site, anchor catheter properly and allow a small amount of solution to infuse to make sure there are no problems with the flow or the venipuncture site.

Infusing a normal saline before initiating the transfusion also clears the IV catheter of incompatible solutions or medications.

Prepare the blood bag. Invert the blood bag gently several times to mix the cells with the plasma.

Rough handling can damage the cells.

Expose the port on the blood bag by pulling back the tabs.

Spike blood bag port carefully and hang the unit. Be sure blood clamp is closed.

PROCEDURE RATIONALEGently squeeze the flexible sides of the drip chamber to reestablish the liquid level with drip chamber one-third full. Make sure filter is submerged in the blood.

Open the clamp and prime tubing and remove air bubbles if any. Use needle G 18 or G 19 for side drip (for adults) or G 22 (for pediatrics).

tubing is primed to prevent the introduction of air into the client which can act as emboli.

Disinfect the Y-injection port of IV tubing (PNSS) and insert the needle from BT administration and secure with adhesive tape.

Shut off the primary IV and begin the blood transfusion.

allows passage of blood components into the vein.

Run the blood slowly for the first 15 minutes at 20 gtts/min. Note adverse reactions, such as chilling, nausea, vomiting, skin rash, or tachycardia.

the earlier the transfusion occurs, the more severe it tends to be. Identifying such reactions promptly helps to minimize the consequences.

Observe the client for the first 5 to 10 minutes of transfusion.

early identification of reaction facilitates prompt intervention.

Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion.

Document relevant data. Record time blood was started, V/S, type of blood, blood serial #, sequence # (e.g. #1 of three ordered units), site of the venipuncture, size of the needle, and drip rate.

for documentation of relevant information and future reference for legal purposes.

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

Check the V/S of the client 15 minutes after initiating transfusion. If there are no signs of reaction, establish the required flow rate.

Most adults can tolerate receiving one unit of blood in 1 & ½ hours. Do not transfuse blood more than 4 hours.

PROCEDURE RATIONALEAssess the client every 30 minutes or more often, depending on the health status, until 1 hour post-transfusion.

If any untoward reaction or signs occur, stop the transfusion immediately and notify the physician ASAP.

When blood is consumed, don glove, close the roller clamp of BT set and disconnect from IV line. Flush the line with saline solution by opening the mainline and adjust the drip to desired rate.

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

to check the effect of the blood transfusion.

Discard the administration set according to agency practice. Needles should be placed in a labeled puncture-resistant container designed for such disposal. Blood bags and administration sets should be bagged and labeled before being sent for decontamination and processing.

Remove glove.

Document the procedure, pertinent observations and nursing intervention and endorse accordingly.

documentation of relevant information and serves as future reference for legal purposes.

Remind the doctor about the administration of Calcium Gluconate if patient had several units of blood transfusion 93-6 or more units of blood).

to maintain cardiac function and prevent hypocalcaemia that may lead to citrate toxicity.

EVALUATION FOCUS

Changes in vital signs or health status.Presence of chills, nausea, vomiting, or skin rash.