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INTRAVENOUS THERAPY:

A PRACTICAL APPROACH

AN INDEPENDENT LEARNING MODULE FOR HEALTH PROFESSIONALS

(Queen Elizabeth II Hospital)

Revised January 2010


DEVELOPED SEPTEMBER 2004

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TABLE OF CONTENTS

Section One: Introduction

1.1 Purposes of IV Therapy ..................................................................................................................................................... 4


1.2 Crystalloids/Colloids ........................................................................................................................................................... 5
1.3 Administration sets/ accessories ....................................................................................................................................... 6
1.4 Add on devices ................................................................................................................................................................... 6
1.5 Blood vessel anatomy ........................................................................................................................................................ 7
1.6 IV site selection .................................................................................................................................................................. 9

Section Two: Tools of the Trade

2.1 Equipment selection ......................................................................................................................................................... 10


2.2 Vein Dilation techniques ................................................................................................................................................... 11
2.3 Site Preparation ................................................................................................................................................................ 14
2.4 The IV dressing ................................................................................................................................................................. 14

Section Three: Initiating an IV

3.1 The procedure.................................................................................................................................................................... 15


3.2 A few helpful hints for insertion ......................................................................................................................................... 19
3.3 Butterfly needle insertion ................................................................................................................................................... 20
3.4 IV dressing ........................................................................................................................................................................ 21
3.5 Troubleshooting ............................................................................................................................................................... 21

Section Four: Therapy Set-up

4.1 Priming the IV line............................................................................................................................................................. 22


4.2 Glass and plastic IV systems ........................................................................................................................................... 22

Section Five: Flow Rates

5.1 One-step method .............................................................................................................................................................. 23


5.2 Two-step method .............................................................................................................................................................. 23
5.3 An order in ml/hour ........................................................................................................................................................... 24
5.4 Factors affecting gravity flow rates .................................................................................................................................. 24
5.5 Flow rates and electronic infusion pumps ....................................................................................................................... 24

Section Six: Client Care

6.1 Assessment and site maintenance .................................................................................................................................. 25


6.2 Local complications .......................................................................................................................................................... 26
6.3 Systemic complications .................................................................................................................................................... 27
6.4 Troubleshooting an IV infusion......................................................................................................................................... 28

Section Seven: Discontinuing IV Therapy

7.1 Discontinuing an IV ........................................................................................................................................................... 29

Section Eight: Infection Control Guidelines

8.1 CINA guidelines ................................................................................................................................................................ 32


8.2 Patient safety and infection control .................................................................................................................................. 32

Section Nine: IV Medications .......................................................................................................................................... 32-36


Section Ten: Blood and Blood Products ....................................................................................................................... 36-43

Module Development: Carol Anne Doll RN, Clinical Leader, Peace Country Health
Photos by: Gerry Whyburd RN, Inservice Coordinator, Peace Country Health
Revised by: Karen MacKay and Sandra Trubyk, RN BN Clinical Educators

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Intravenous (IV) therapy is the administration of fluid and electrolytes directly into
the clients circulatory system through a vein. An IV catheter may be placed in a
peripheral or a central vein. Factors determining IV placement location include, the
length of therapy, type of medication or nutritional solution and physician preference.
This module focuses on the initiation and maintenance of peripheral IV therapies.

IV initiation, monitoring of established IVs and blood administration are required


competencies for many healthcare professionals in Alberta Health Services (AHS). IV
competencies may be utilized by members of the Interdisciplinary (ID) team at different
times, in a variety of practice settings, throughout the region. The environment, desired
client outcomes and system efficiencies are all considerations when deciding which ID
team member is most the appropriate to deliver IV therapy. For example, it may be
reasonable to have the LPN independently perform all components of IV therapy in one
practice setting and to work in collaboration with other members of the ID team in other
settings.

Once it has been determined who is responsible for IV therapy, it is each


professionals individual responsibility to practice in accordance with the legislation and
standards that govern their practice. Each member of the ID team must be clear about
the role and responsibilities they have in ensuring safe and desired outcomes for the
client. Each member of the ID team is solely responsible to ensure they have the
required skill, knowledge, attitude and judgement to practice safely in the initiation and
management of peripheral intravenous lines. If the professional requires further
assistance and support to practice safely and ensure the desired outcomes are achieved
for the client, they are expected to identify this need to the rest of the team and to refrain
from performing the activity. It is expected that if the competency is within the
professionals defined scope of practice and is a competency requirement within their
role, in their practice setting, the ID team member will ensure they are competent to
practice to both regional and college standards. AHS is dedicated to providing the
support and resources to enable the successful implementation of each ID team
members scope of practice. This independent learning module is designed to support
AHS ID team members in basic IV therapy and initiation competencies.

The independent learning module includes theory for self-study, followed by


practical component, performed in the clinical setting with an instructor or mentor. After
the module review and written examination has been successfully completed,
participants will be monitored on three IV initiations. Each ID team member must decide
upon completion of the module, exam and practical whether they feel competent to
perform the competency independently or if they require further assistance to ensure
they are able to deliver safe and desired care. If additional support is required, this must
be communicated to the Manager immediately, to ensure the support is offered in a
timely fashion ,thus supporting the team to achieve the program and service goals.

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COURSE COMPLETION CRITERIA

Review of the self study module


80% on the written examination
3 supervised successful starts, signed by the instructor/mentor.

SECTION ONE: INTRODUCTION

1.1 PURPOSES OF IV THERAPY:

The physician will order IV therapy and the order must include, the type of access
(i.e.: IV, venipuncture, venous access; terminology may vary), the required solution
and a flow rate and length of therapy if appropriate.

Restoration/ maintenance of fluid and electrolyte balance


Administration of regular intermittent, continuous and emergency
medications
Administration of blood/ blood products
To gain venous access for emergencies
Administration of diagnostic reagents
Administration of general anaesthesia or procedural sedation

Orders may indicate heparin or saline lock. AHS utilizes the saline lock system
and heparin is used when ordered specifically by the physician.

Standing orders may be in place in some clinical settings; you are responsible to
be familiar with the practice in your area.

1.2 INTRAVENOUS SOLUTIONS:

IV solutions can be divided into COLLOIDS or CRYSTALLOIDS. They are


distinguished by their solution properties and the osmolarity.

Table A-Solution Properties


COLLOID CRYSTALLOID
Definition Solutions that contain Solutions that contain completely
suspended substance dissolved substance particles in
particles in water. water.
The particles do not dissolve Readily passes through a semi-
completely permeable membrane
does not pass through a
semi-permeable membrane
Examples Blood and blood products such Electrolyte solutions can be classified
as albumin into isotonic, hypotonic and hypertonic
solutions
Uses Plasma expanders used to To expand intracellular or extra cellular
replace circulating blood volume fluid volumes and replace electrolytes.
Choice of solution depends on desired
outcome

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Osmolarity (Tonicity)
Categories that further divide crystalloid solutions are based upon comparing
the osmolarity of the IV solution to normal blood serum osmolarity. Osmolarity is
defined as: the amount of osmotic pressure exerted by the particles in a
solution(Chernecky, Macklin, Murphy, 2001.p.224) Normal blood serum osmolarity
is 290 mOsm/L. Osmolarity influences the osmotic pressure, which has a direct
impact on osmosis (movement of fluids and solutes between a semi permeable
membrane). This is pertinent in IV therapy because choice of IV solution can
create very different clinical outcomes based on the osmolarity. This is explained
further in Table B.

Table B: Tonicity

OSMOLARITY INDICATIONS PRECAUTIONS SOLUTION


ISOTONIC Between 270- No net increase in Excessive amounts D5W*
340 mOsm/L cell size can lead to 0.9% N/S
Increases the circulatory overload Lactated
volume of and pulmonary Ringers
intravascular edema 3.3%
Does not change Monitor dextrose
the electrolyte electrolytes; 0,3%
concentration of alterations can sodium
plasma occur depending on chloride
Replaces water solution used and
losses the amount
Treatment of Use with caution in
dehydration and clients with CHF,
fluid replacement renal impairment
and cardiac
insufficiency
HYPOTONIC Less than 290 Fluid moves Contraindicated in D5.45 N/S
mOsm/L into the cells increased intra- 0.45 N/S
Used for cranial pressure 0.33 NaCl
cellular re- (ICP) and
hydration hypovolemia
Monitor for water
intoxication
HYPERTONIC Greater than 290 Shifts into Cellular 5%NaCl
mOsm/L intravascular dehydration Mannitol
spaces from the Fluid overload 10-20%
cells D5LR
Restores
electrolytes and
nutrients
Often used as a
diuretic

*Dextrose is rapidly metabolized in IV solutions. Dextrose-only solutions become


hypotonic in the body once all the dextrose is metabolized. Close monitoring for
water intoxication is therefore indicated.

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1.3 ADMINISTRATION SETS/ ACCESSORIES

The drop factor (how many gtts/ mL) will be indicated on the infusion set packaging
used at the AHS- Queen Elizabeth II Hospital (QEII).

A. Macrodrip: 10-20 gtt/mL


B. Microdrip: 60 gtt/mL
C. Blood Sets: 10-15 gtt/mL
D. Needleless saline lock(Clave): Priming volume; 0.2 mL
E. Needleless extension set(Clave): Priming volume;0.4 mL
F. Trifurcated Adapter (Medex): Priming volume 0. 4 mL/port

*It is important to know which drop factor is required for the rate and types of therapy
you are providing. Standard is the 10-20 gtts/ml, however, you are responsible to
know the standards in your practice setting.

1.4 ADD-ON DEVICES

1. 0.22 micron filter: This device is added on to filter out particulate matter in certain
IV solutions/ medications. The addition of such a device is recommended by the
manufacturers of the medications and can be found in the pharmacy manual on the
intranet or on the package inserts for the medications themselves. Their purpose is
to prevent potential damage to the pulmonary and or circulatory systems.
Filters may eliminate the following:
Particulate matter
Medication precipitates
Residue
Glass splinters
Metal
Rubber
Air
Fungi
Bacteria
Endotoxins produced by gram-negative organisms (Centers of Disease
Control and Prevention (CDC), 2002)

Examples for use:


Mannitol infusions
Dilantin infusions
Digoxin infusions
Amiodarone infusions

Filters will not remove pyrogens or viruses.

2. Stopcocks: for use in specific care areas where intermittent access to the closed
system is required.
3. Extension sets: often used with specific pieces of equipment such as the blood
warmer. Can also be used as the lock for the saline lock
Note: these devices increase the potential for infection due to increased
manipulation or risk of separation. Use should be limited to practice care-setting
protocols.

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Saline locks: The saline lock is used to keep a site viable for use for intermittent or
emergency medication administration. The Clave needleless system is used in AHS
QEII Hospital. All peripheral IVs are to be flushed with normal saline for injection using
the positive pressure technique. Heparin injected into the lock requires a specific
physicians order.

1.5 ANATOMY OF ARTERIES AND VEINS

It is important to understand the anatomy of the peripheral blood vessels so the


clinical provider can choose the appropriate vessel for venipuncture and avoid
inserting IV devices into arteries. Table C provides you with a comparison
between the physiological differences between arteries and veins. Each
professional is accountable to have a clear understanding of the physiology and
anatomy of the circulatory system as part of the competency.

TABLE C
ARTERIES VEINS

Pulsatile Non-pulsatile

High pressure system carries oxygenated blood from Low pressure system carries de-oxygenated blood

the heart to the rest of the body back to the heart for re-oxygenation

Commonly located deep in tissue Commonly more superficial on arms and legs

Elastic and thick walled Thin-walled and flaccid

Generally not visible on arms and legs Visible on limbs, bluish in color

Blood in vessels appears very red Blood in vessels appears very dark

Do not collapse Collapse easily

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DIAGRAM 1
BLOOD VESSEL ANATOMY

Tunica intima: The internal layer of arteries and veins. It is made of endothelial tissue
and consists of a single layer of cells. This layer allows for free flow of cells and platelets
through the vessels. This lining forms the valves in veins that assist them in returning the
blood back to the heart. Valves prevent blood from flowing backwards as it journeys
towards the heart.

Tunica media: The central layer of blood vessels. Tunica media is composed of
muscle, nerve and elastic tissue. This layer provides structure and support to the vessels
and is more tensile in arteries.

Tunica adventitia: The outer layer of the blood vessels. The tunica adventi provides a
barrier and support to the vessels and is notably stronger on arteries because of the
pressure exerted on these vessels.

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DIAGRAM 2
VEINS OF THE UPPER EXTREMITY
Median cubital: Branches off the basilic
vein and joins the cephalic vein below
the antecubital area.

Cephalic
Basilic

Basilic: Flows upward along the ulnar


Cephalic: Flows upward along surface of the forearm and joins the
radial aspect of the forearm. median cubital above the elbow.

Antebrachial: Branches off the basilic


vein @ the ulnar aspect of the anterior
forearm.

Dorsal metacarpal: Formed by the


union of the digital veins below. (Not
shown)

*Note: Digital veins have limited blood flow and should only be used as a last resort. Metacarpal
veins are best utilized for those with an adequate amount of subcutaneous tissue. This tissue
tends to decrease with advanced age.

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1.6 IV SITE SELECTION

The goal in choosing a site to start the IV in is to choose a vein that is visible, palpable,
soft, straight and has evidence of good blood flow. It is best to choose the most distal
site to prevent damaging the sites above that may be required later on in therapy.

There are many things to consider when selecting an IV therapy site:

Purpose of IV initiation. Example: If starting an IV to administer sedation for a


short procedure, one may consider starting a small gauge IV with an attached
saline lock. Similarly, if starting a line for blood administration, one may need to
consider a larger gauge catheter in a large vessel.
Length of IV therapy. Example: Long-term antibiotic therapy may require a large
vessel and larger catheter.
Dominant hand: Example: Choose the non-dominant side when initiating an IV
on an upper extremity (if possible). Always consider patient comfort.
Condition of the patients veins. Example: IV drug users may have very
damaged veins and site selection may be limited. Geriatric patients have very
fragile veins and a smaller catheter is required. (Avoid metacarpal veins in the
elderly due to the lack of fatty tissue and the increasing fragility of veins in the
elderly.)

Avoid:
Operative site when surgery is on that extremity.
Flexion point such as the wrist- wrist flexion can obstruct flow- use shorter
catheters or use arm boards to immobilize*.
Joints such as the elbow- this can cause discomfort to the patient and obstruct IV
flow. Arm boards can be used if this site is necessary. *
Valves. Valves are often visible or palpated as small depressible knots along
the length of the vein. Use of shorter catheters can help in avoiding them.
Bruised or traumatized veins or areas below traumatized tissue.
Limbs with reduced sensation- the patient cannot report any unusual sensations
that can alert the staff to potential complications.
The area below an existing phlebitis.
Extremities with impaired circulation
AV shunts, grafts or fistulas.
One consideration may be the circulation of lymph fluid and blood. It must be
adequate on the side of the body the IV is being initiated on, For example ,post
mastectomy clients may have impaired lymphatic circulation ,so you would
choose the other side.

* If splinting devices are used, the immobilized joint should be positioned in a


position of slight flexion and range of motion exercises should be performed
periodically when assessing the IV site.

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SECTION TWO: TOOLS OF THE TRADE

2.1 EQUIPMENT SELECTION

A. Over- the-needle catheter(ONC): Most commonly used for initiating IVS, the
ONC consists of a metal stylet, which is used to pierce the skin. Over this lies a
Teflon, plastic or silicone catheter that is threaded into the vein and left in place
for the infusion. The metal stylet is removed and discarded. These flexible
catheters cause less trauma to the actual veins when compared to the older style
metal needles and the plastic catheter is less apt to become detached. At the
distal end of the stylet, a flashback chamber is attached. This collects a small
amount of blood to let the clinician know the IV is indeed located in the vein.
B. The butterfly device: Named for its plastic wings, the butterfly is a stainless
steel needle that is attached to plastic wings to help secure it and an extension
tubing that ranges from 7.5-30 cm in length (GMCC IV initiation module, 5 th
edition.p.31) These devices are commonly used for short-term infusions, patients
with smaller veins or for babies during scalp vein infusions. There is a greater
potential for an IV to infiltrate due to increased risk of venous puncture from the
hard needle.
C. Intraosseous device: This device is generally used in a pre-hospital setting
when IV access is not possible and emergency access is required. It involves
using a bone marrow aspiration device to access the venous plexus in an
appropriate bony site. Most commonly used in children, this procedure requires
advanced skill and will not be covered at this time, an advanced skill section will
be added to this module at a later date.

14 gauge: Large gauge; used for life saving


emergencies
16 gauge: Trauma, GI bleeding; use for
conditions where rapid infusion of large
volumes of blood/ fluids is required
18 gauge: Infusion of blood/ fluids
20 gauge: Less traumatic to veins; most
common size started on adults for medication
administration
22 gauge: Pediatric clients, adults with fragile
veins
24 gauge: Neonates, pediatrics, adults with
fragile veins
* the higher the number the smaller the needle

Always insert the smallest gauge with the


shortest needle that can be used to treat
your patient effectively

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OVER-THE-NEEDLE CATHETER

Cover

Metal Stylet- Flashback


(not visible) chamber

Flow control plug


Bevel

Hub

Plastic catheter

THE BUTTERFLY DEVICE

Extension tubing

Hub

Butterfly Grip

Metal needle

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2.2 VEIN DILATION TECHNIQUES

The tourniquet: Used to dilate the vein for most clients. Restricting blood flow for a short time (2-3
minutes) causes venous dilation and increased blood volume. This makes the vein more visible. If
patients have hypertension or fragile veins, tourniquet use may not be necessary. Place the
tourniquet 10-15 cm above the insertion site. Placing it above the antecubital area gives
visualization of the entire arm. A new tourniquet should be used for each client and never use the
same tourniquet from client to client.

The blood pressure cuff: Cuff inflation should not exceed the clients diastolic pressure so the
arterial circulation is not impaired. A radial pulse should still be palpable when inflated.

Gravity, heat and relaxation: Dangling the arm below the level of the heart helps to dilate the veins.
Heat naturally assists in venous dilation. Ensure first that your client is warm and comfortable. Help
relax the client by explaining the procedure; assist them to practice deep breathing if particularly
nervous. A warm blanket can be wrapped around the arm (have the client check the temperature first;
it should not feel too hot or uncomfortable in any way.) Applied heat is usually effective within 10
minutes. Re-examine the veins using a BP cuff or tourniquet following.

Do Not Tap or Slap: chosen vein once your tourniquet is applied, this only hurts the client.

PROCEDURE FOR APPLICATION OF A TOURNIQUET

Please note: All procedures where a clinician is exposed to blood and or body fluids
requires that clinician to wear personal protective equipment. This procedure requires all
clinicians to wear gloves. Increasingly, healthcare personnel have been identified as
being at high risk for latex allergy. Non-latex products are available as needed for the
clinician and patient alike.

1. Have the patient lying in a position of comfort. Lay the tourniquet under the arm.

Tourniquet Arm

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2.Pull the tourniquet straight up until it is taut

3.Cross the right side of the tourniquet over the left side

.
4. Push the right side of the tourniquet up under the left. It should form a loop.

This technique ensures that one-handed release of the tourniquet is possible once the
IV has been established. Leave the tourniquet in place no longer than 2-3 minutes. If
no radial pulse is palpable, the tourniquet is too tight. Tourniquets are generally made
of latex and are actually Penrose drains.

Tourniquets are a source of cross contamination. Ideally, single use is


recommended.
Discard after use or decontaminate (Canadian Intravenous Nurses Association,
1999)

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2.3 SITE PREPARATION

Correct preparation of the IV site is important to help reduce the chance


of infection. It is vital to cleanse an area larger than the outer size of the
dressing. Site preparation must start at the insertion site and move
outwards(concentric circle).

The following antiseptics are appropriate for site preparation:


Chlorhexidine:
2%chlorhexidne-based preparation is preferred (CDC,2008)
0.5% in 70% alcohol is widely used in Canada

Alcohol:
70 % is the most common
Requires a one-minute friction rub
Allow to dry

Iodophors:
Providone iodine requires a two-minute friction rub
Allow to dry
Do not remove

If gross contamination is visible, have the patient wash the area with warm water
and soap before starting the procedure.

Patients with excessive body hair that makes it difficult to visualize the vein or to
apply tape should have hair clipped with clippers or cut with scissors. Shaving is
not recommended due to the potential for injury to the skin, thus increasing
infection risk.

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SECTION THREE: INITIATING AN IV

3.1 THE PROCEDURE

1. Check the doctors order, review standing orders and gather equipment .

Sample; may also need IV solution and tubing


*You may wish to bring various catheter sizes as you gather equipment. Your selection may be based on not
only the intention for the IV therapy, but the anatomy of the patients veins

2. Prepare the patient in a position of comfort that facilitates starting an IV. Explain the
procedure. Apply the tourniquet as described in chapter two and identify an appropriate
vein.

If no veins visible/palpable, remove tourniquet and apply heat for 5-10 minutes
*Check both arms; choose the non-dominant arm if possible. Avoid limbs with decreased
sensation. Consider the purpose for this IV.

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3.Have equipment at the ready once you have determined catheter size and site.
Always check the catheter for manufacturers defects such as barbs, cracks and so on.

* Have your IV solution, tubing, and IV pump at the ready. Ensure it is all functioning; check expiration
. dates on IV fluids.

4. Swab site with alcohol for 30 seconds and allow to dry for one minute

*You may wish to have the patient clench and unclench the fist to assist in venous
dilation.

* If skin is grossly contaminated, wash with soap and water.


Note that gloves are worn in all pictures!!!

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5.Position yourself with the catheter in your dominant hand while palpating the vein with
the other hand

* Catheter should be inserted in the bevel up position. Apply traction to


the skin either above or below to stabilize the vein.

6. Insert the catheter into the chosen vein. Feel for a pop sensation. Watch for
flashback in the chamber.

* Successful initiation of IVS takes a great deal of practice. Feeling that


pop may take several attempts.

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7. Advance the catheter a few more millimetres (6-7 mm) as you withdraw the stylet

* Never re-insert the stylet; this could cause shearing of the


catheter and an embolus to your patient.

8. Occlude blood flow above the catheter site, release the tourniquet and attach the luer
connector of the IV tubing, extension set or saline lock.

* Apply a transparent dressing just to the edge of the hub and secure the tubing above and
below with tape. Change IV dressings with site rotation or when integrity is compromised.

9. Always have a sharps container close to your work area and dispose of the stylet as
soon as it is removed from the catheter. The sharps container should be puncture proof,
tamper-proof and marked with a biohazardous waste symbol.

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Never recap your stylet or place it on a bed or floor. It is illegal to recap used
needles. Alberta Occupational Health and Safety Code, Part 35, Item 527,
2003.

3.2 A FEW HELPFUL HINTS FOR INSERTION

Apply either one of two techniques: The indirect or the direct method.
Indirect: use for smaller veins, fragile veins (those that tend to collapse) or those
that are extremely mobile when palpated. This technique is accomplished by
insertion of the catheter into the skin below the point that the vein is visible and
entry into the vein.
Direct: use for all other veins as required. Enter the vein directly on top at a 15-
20-degree angle. Decrease the angle to 5 degrees for more superficial veins
Once blood flashback is seen in the stylet, drop the device so that it lies almost
parallel to the skin and advance another 6-7 millimetres.
If using metacarpal veins, hold and splint the clients hand with your non-
dominant hand. This technique further assists in stabilizing the vessel as you
insert the catheter.
Always start your IV in the most distal position that is appropriate. This assures
the integrity of the vessels above should your first attempt be unsuccessful.
It is appropriate to ask for assistance after two unsuccessful attempts- this is in
no way a reflection on your skill; rather, an attempt to acknowledge that often all
that is needed is a fresh pair of eyes.
Always put your client first.

3.3 BUTTERFLY NEEDLE INSERTION

While wearing gloves, prepare the client, IV device/ medication as for the over-the-
needle catheter technique.
Identify the vein that is to be used by performing the vein dilation techniques that
have been described previously; anchor the vein; grasp hold of the plastic wings
with the thumb and forefinger of your dominant hand.
Insert as per the direct insertion method with the bevel up at a 30-45 degree
angle.
Once skin is punctured, lower the angle and insert metal needle fully into vein.
Release the tourniquet.
Watch for blood flashback into the extension tubing; remove cap and let blood
from the vein flush the air out (you may also flush the device with normal saline
for injection prior to insertion).
Connect appropriate IV device; give medication as required and secure with a
transparent or gauze dressing.

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3.4 THE IV DRESSING

IV dressings are required to provide stabilization and protection of the catheter and
insertion site (CINA, 1999). Because the insertion of the IV breaks the skin integrity it is
important that dressings are sterile to help protect this portal from contamination. In
PCH a transparent dressing such as IV 3000 or Tegaderm is preferred so that the
site can be visualized. Some clients and circumstances require the use of different
dressing techniques; you will need to assess each situation for the type of dressing that
is appropriate. There are some principles to IV dressing that must be adhered to:
The dressing should not be tight and should be comfortable for the client.
Dressings should be changed when loose or soiled and as per policy.
Dressings are not a replacement for thorough IV site care and assessment.

3.5 TROUBLESHOOTING
PROBLEM SYMPTOMS SUGGESTED CAUSES SOLUTION
IV not in vein No flashback Catheter missed the vein Place bevel directly
Swelling with Poor body alignment on top of the vein
infusion Poor lighting Reposition yourself or
IV will not Vein movement client
infuse Reposition the vein
and stabilize
Ensure adequate
dilation.
Traumatic insertion Rapidly filling Vein trauma Decrease insertion
causing haematoma pocket of blood Excessive force applied angle
at the insertion Failure to reduce angle of Reduce amount of
site device force used
Poor condition of veins Reduce angle on
Catheter too large device immediately
Poor technique when after flash is noted
separating the stylet from Use a smaller
the catheter catheter
Smooth gentle
separation of stylet
from catheter
test stylet movement
in catheter prior to
insertion.
Unable to advance Skin may Damaged vein (IV drug Choose a different
catheter into the vein pucker as use, damage from vesicant vein
threading is medications) If on a valve- pull
attempted Resistance from a valve stylet back slightly
Catheter will Poor angle and attempt to
not slide Wrong catheter size advance with IV
evenly into the Stylet removed to early. solution flowing
vein slowly
To correct angle, pull
back on the entire
device, lower the
angle and advance.
Maintain the catheter
and stylet as a unit
until you determine it
is actually in the vein.

* Never re-introduce the stylet once it has been withdrawn from the catheter.

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SECTION FOUR : THERAPY SET-UP

4.1 PRIMING INTRAVENOUS LINES

IV therapy provides a direct route for pathogens to enter the bloodstream. It is because
of this that aseptic technique must be maintained when handling the equipment and
opening the system. Always start this and every procedure with good hand washing.
Application of gloves is no substitute for good hand washing.

1. Check the doctors order and obtain the appropriate IV solution and
administration set.
2. Remove the solution bag from protective packaging. Inspect the bag for apparent
leaks; gently squeeze the bag. Look for particulate matter, clouding and check
expiry date. Make sure the sterile cap is on the sterile end
3. Hang the bag on the IV pole.
4. Remove IV tubing from package- check for any visible damage; ensure sterile
covers are on the ends. Check expiry date on tubing package.
5. Close all clamps.
6. Remove protective cover from IV bag port.
7. Remove cover from spike on IV tubing and with a twisting motion, insert it into
the IV bag port. CAUTION: The spike from this port is very sharp and can
potentially cut through the side of the IV bag. Avoid contaminating the spike with
your fingers or the outside of bag.
8. Fill the drip chamber by squeezing it until it is half full.
9. Flush the line by opening the clamp; invert back-check valves and infusion ports
to remove air. Gently tap the infusion/injection ports to remove air. There should
be no air/visible bubbles
10. Close the clamp.
11. Replace the end with a sterile cover until it is ready to be used.

Caution: There should be no air left in an IV line. It is not known what is a


safe amount of air and as little as 10 ml of air could be fatal to a critically ill
patient.

4.2 GLASS AND PLASTIC IV SYSTEMS

Glass IV bottles are used for specific medications that will either degrade in plastic bags
or become adsorbed by the plastic and become less effective The clinician must
know all possible reactions/ side effects when giving medications intravenously. This
information is available from the manufacturer, the Compendium of Pharmaceuticals
and Specialties (CPS), current drug books available at your site or on AHS intranet.

The glass system contains a partial vacuum and will not infuse unless it is vented.
Venting is accomplished by using a specific vented tubing, or some tubing has both
vented and non-vented features accomplished simply by opening a port at the top of
the drip chamber.

Plastic: These bags are flexible and considered a true closed system. There is no
vacuum in a plastic bag and it collapses as its contents are administered. Non-
vented tubing is used with the collapsible plastic IV bag.

22
Buretrol/ Volutrol: This device is added to the IV system just below the IV bag to act as
a volume control device. It can be used with macrodrip or microdrip tubing. Since it
holds a maximum fluid volume of 150 ml, it is used in patients such as the neonate,
pediatric patient or those with certain medications to safeguard against fluid overload
or accidental infusion of certain medications.

SECTION FIVE: IV FLOW RATES

5.1 ONE-STEP METHOD

gtt/min= volume of solution in ml x drop factor


total time in minutes

Example: The doctor has ordered 1200 ml of fluid to be given over 4 hours. Using a
macrodrip set (10/gtt/ml), the infusion shall be run as follows:

gtt/minute= 1200 ml x 10 gtt/ml


240 minutes (4 hrs)

Answer= 50 gtt/minute

5.2 TWO-STEP METHOD

1. Determine the ml/hour.


ml/hour = total volume of solution to be infused
total number of hours

2. Then use this formula:


gtt/min= ml/hr x drop factor
60 minutes

Example: The doctor has ordered 1200 ml of fluid to be given over 4 hours. Using a
macrodrip set (10gtt/ml) the infusion shall be run as follows:

ml/hr = 1200 ml
4 hours
Answer =300ml/hr

gtt/min = 300 ml/hr x 10 gtt/ml


60 minutes
Answer: 50 gtt/minute

5.3 CALCULATING WHEN THE ORDER IS IN ML/HOUR

The most common order a clinician will see is written in ml/hour.


Example: The doctor orders normal saline to be run at 100 ml/hour. A macrodrip set is
used. The package indicates it is a 15 gtt/ml set.

gtt/min = 100 ml/hr x 15 gtt/ml


60 min
Answer: 25 gtt/min

23
5.4 FACTORS AFFECTING GRAVITY FLOW RATES

Container must be suspended at least one meter above the IV site. This
is known as ideal head pressure.
Catheter gauge and length
Insertion site and tip location
Stabilization technique
Patient mobility/movement/ position of extremity
Viscosity of fluid
Temperature of fluid
Catheter patency
Integrity of tubing/filters/air vents
Length of administration set and any add-on devices

5.5 FLOW RATES AND ELECTRONIC INFUSION PUMPS

When using an infusion pump, the flow rate is set in ml/hr instead of gtt/ minute.

ml/hr = total volume to be administered


total number of hours

Example: Administer 2 litre of Ringers Lactate over 8 hours.

ml/hr = 2000 ml
8h
Answer: 250 ml/hr; set pump @ 250 ml/hr.

SECTION SIX: CLIENT CARE

6.1 ASSESSMENT OF THE IV SITE/SYTEM MAINTENANCE:

There are common interventions that must be delivered as part of the care for clients
receiving IV therapy. These interventions are outlined below:

1. Inspect the IV site for phlebitis, infiltration and infection q 4 h and prn

2. Check infusion rate q 1 h and prn. Record intravenous intake a minimum of q 4 h


on the intake and output sheet.
3. Change IV bags every 24 hours
4. Change administration sets every 72 hours; change the IV bag at the same time.
(There exceptions to this rule, for example, TPN tubing which is changed every
24 hours)
5. Change sets being used intermittently every 24 hours.
6. If infusing IV medications as frequently as q 6h or less, change the secondary set
every 24 hours as well.
7. Re-site the catheter every 72 hours if possible. (This depends on availability of
veins, length of therapy and patient condition). This action helps reduce the
incidence of phlebitis and infection.

24
8. Label tubing with date and time of change.
9. If the IV is not running adequately:
Check the tubing for kinks and obstructions
Check the infusion pump
Remove dressing and assess the site
If the IV continues to run poorly, change the IV site
DO NOT IRRIGATE. THIS MAY FORCE BLOOD CLOTS INTO THE
PATIENTS CIRCULATORY SYSTEM
10. Avoid unnecessary manipulation of tubing and needle.
11. Clearly label the container with medication label as needed.

6.2 LOCAL COMPLICATIONS

INFILTRATION* PHLEBITIS
Definition: An accumulation of fluids in the Definition: Inflammation of the vein
subcutaneous tissue that can occur when caused by trauma or chemical irritation
the catheter has come out of the vein. Signs and symptoms: Warmth,
Signs and Symptoms: Pain, burning, tenderness or pain at IV site, redness,
itching, swelling, blanching at insertion site, streaking along vein, palpable cord-like
inability to palpate the tip of the IV catheter, vein, area of hardness, edema (with
cool skin, wet site, continued infusion, even thrombophlebitis)
when manually occluded. Treatment: Discontinue IV, apply warm
Treatment: Discontinue the IV, elevate the moist compresses to site as necessary.
limb, and apply warm moist compresses
prn.

INFECTION HEMATOMA
Definition: Invasion of the insertion site by Definition: Infusion of blood into
bacteria. subcutaneous spaces
Signs and symptoms: Generalized redness and Symptoms: Discoloration, swelling,
heat to the IV site, may involve redness tenderness
progressing up the arm, purulent drainage may Treatment: Remove IV, rest affected limb,
be present, fever. Apply pressure over the IV site
Treatment: discontinue the IV; notify the
physician, antibiotics and a swab of any
drainage may be required. Monitor the site and
patient closely for spread of infection and signs
of systemic infection such as fever and general
malaise. If restarting IV, do so in the other arm

*NOTE: Do not lower the IV container to


check for infiltration; this action may dislodge
blood clots that have formed at the site.

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6.3 SYSTEMIC COMPLICATIONS

SEPTICEMIA CATHETER EMBOLISM


Definition: Systemic infection resulting from invasion of Definition: Catheter fragment in the bloodstream.
the bloodstream by pathogenic bacteria Symptoms: Chest pain, signs of shock, shortness of
Symptoms: Chills, fever, headache, disorientation, signs breath, evidence of missing catheter fragment after
of shock, nausea and or vomiting IV removal.
Treatment: Discontinue IV, culture site if drainage Treatment: Apply tourniquet proximal to the site,
apparent, culture tip of catheter, Notify physician- may consider the ABCS- provide care to support
need blood cultures, antibiotics as required. this.i.e. Oxygen. Notify the physician, Fluoroscopy
may be required-catheters are radiopaque.

PULMONARY EMBOLUS AIR EMBOLISM


Definition: the pulmonary artery becomes blocked when Definition: a significant amount of air introduced into the
a blood clot is dislodged into the circulation from circulatory system causing blockage of the pulmonary
another part of the body. capillaries.
Symptoms: Chest pain, shortness of breath, Symptoms: Anxiety, chest pain, shortness of breath,
haemoptysis, signs of shock signs of shock
Treatment: Remember ABCS, , supportive therapy- Treatment: Stop infusion, check for air in system, turn
may require a VQ scan patient to left side with head down to trap air in right
atrium. Remember ABCS- administer oxygen. Notify
physician.

INADVERTENT ARTERIAL CANNULATION CIRCULATORY OVERLOAD


Definition: accidental insertion of an IV catheter Definition: Excessive fluid in the alveoli of the lungs.
into an artery Also known as pulmonary edema; prevalent among
Symptoms: Bright red flashback, pulsation of those who have received excessive IV fluids.
Symptoms: Dyspnea, cyanosis, increased work of
blood in tubing, IV will not infuse
breathing, tachycardia, frothy pink sputum, distended
Treatment: Remove catheter immediately, apply neck veins.
firm pressure for 5 minutes, and observe for Treatment: Semi-fowlers position, remember ABCS-
continued bleeding. administer oxygen, notify physician, supportive
therapy as required.

26
6.4 TROUBLESHOOTING THE IV INFUSION

PROBLEM POSSIBLE CAUSES PREVENTION TREATMENT


IV not infusing Tubing pinched Check for pinches If no visible pinches,
remove dressing and
check catheter and
site.
IV catheter bent Stabilize and Re-secure catheter
secure catheter or re-start IV if
with each IV start required
Apply arm board
Catheter tip against Avoid insertion over Gently reposition the
vein wall site of flexion catheter slightly
Re-tape if
repositioning
successful
IV clotted Ensure continuous Disconnect IV
flow of solution tubing; directly
Use of infusion connect a 3-5ml
pumps prevent IVS syringe, gently
from running dry attempt to aspirate
the clot. NEVER
irrigate the catheter
Blood back-up with Maintain or Adjust the height of
ambulation increase ideal head IV pole.
pressure
Blocked in-line filter Prime filters Inspect filters;
or air-lock in filter correctly replace if needed
Phlebitis Change site per Remove IV. Apply
protocol, monitor warm, moist
site and client compresses
closely
Venous spasm as Trauma Use slow, gentle, Apply warm
evidenced by pain @ fluid insertion compresses to the
site techniques, insert area
bevel-up Slower rate of
May use a smaller infusion
catheter and a Use blood warmer if
large vein if appropriate
appropriate
Chemical Slow IV rate or
irritation dilute if not
contraindicated
Viscous fluids Dilute if not
contraindicated
Cold IV fluids Use fluid warmer
Rapid infusion Slow IV rate if not
contraindicated
Air in line Incorrect priming of Prime the line as Close the roller
the IV tubing described on page clamp below the air,
22, pay attention to loop the tubing
y- ports, back around a pen, guide
check valves and air towards drip
filtering devices. chamber
Gently tap the IV
tubing below the air
bubbles to force air
into drip chamber.
Lock a syringe onto
the medication port

27
below the air
bubbles and gently
aspirate the air
Remove the tubing
from the catheter
and run the air out of
the line.
Failure to close Always close Remove air if
clamps when clamps before required using one of
changing IV bags removing an the techniques
existing IV bag to described above.
replace with a new
one.
IV solution runs out. Check IV infusion Close roller clamp
hourly. Ensure adequate
Use infusion solution levels
pump. Remove air as
required

Painful IV site Phlebitis Change site per Remove IV and


protocol, monitor apply warm, moist
site & client closely compresses
Chemical irritation See phlebitis Increase dilution as
indicated
Reduce flow rate
Flush vein
Add an inline filter
Discontinue and
apply compresses
Catheter inserted Do not insert Loosen tape and pull
too far beyond 2 mm of catheter back and
the hub of the re-tape
catheter
Check with the
patient re: comfort
Infection Follow proper C&S swab, remove
insertion protocol. IV, restart other arm.
Monitor client and Apply warm
IV site closely compresses & notify
physician
Infiltration Follow proper Remove IV. Apply
insertion protocol. warm, moist
Monitor client and compresses
IV site closely
Catheter too large Use the smallest Remove the IV and
for vein gauge possible for select a smaller
purpose of the IV catheter
Consider patient
anatomy
IV catheter against Select IV site Remove the IV
a nerve carefully Assess for motor or
Be familiar with sensory impair ment
anatomy ability to move
hand or limb, burning
or numbness &
tingling, continued
pain despite removal
of the IV are all signs
of this
Record and inform
physician

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SECTION SEVEN: DISCONTINUING IV THERAPY

7.1 DISCONTINUING AN IV

An intravenous may need to be discontinued for many reasons- the site may not be
healthy, the doctor may have ordered it be removed or it may be being discontinued based
on a single time use standing order (i.e.: used only to inject dye for a diagnostic
procedure).

Whatever the case, safe removal of the existing IV is essential to protect the patient and
the health care provider.
1. Wash hands and gather equipment
2. Ensure that the device is in fact a peripheral IV and that it is safe to be removed
(peripheral line vs. central line)
3. Clamp off IV tubing. Remove tape securing tubing to the patient.
4. Don gloves
5. Examine insertion site for complications.i.e: purulent discharge, swelling or
inflammation.
a. If purulent discharge is noted, milk the vein toward the site immediately
after catheter removal and obtain a swab for C&S.
b. If phlebitis or infiltration apparent; apply warm compresses.
6. Hold sterile gauze lightly over the insertion site and gently remove the catheter
keeping it level with the skin.
7. Apply firm pressure with gauze and elevate the limb. Maintain pressure until
bleeding stops.
8. Examine the catheter to ensure it is intact. If uncertain or visible missing fragment,
follow procedure.
9. Apply small bandage if required.
10. Document IV removal as per protocol.

7.2 Procedure for applying a saline lock:


Establish the IV as described earlier in this module
Flush the extension set or lock with normal saline for injection as per flush
volumes on page 6
Luer lock the device to the catheter; ensure tourniquet is removed
Inject 2 ml of normal saline for injection using the luer connection between
the syringe and the lock in a slow, steady stream
When you are at the last 0.5 ml of saline, slowly clamp the extension set as
you continue to inject the flush or begin to twist the syringe off the luer
connection as you continue to inject into a plain clave lock. This procedure
is called applying positive pressure. (Positive pressure works to keep
blood from flowing back into the catheter and forming a clot.
Watch to ensure the catheter is in the vein (infiltration will be seen as
swelling as fluid is injected)
Secure the device.
The saline lock must be flushed with 2 ml of normal saline every 12 hours
when not in use.

Positive Pressure: While gently flushing the IV line with 2 ml of normal saline, begin to
clamp and remove the luer lock syringe once you have reached the last 0.5 ml of fluid.
(extension set). If using a lock with no clamp, inject slowly and evenly to the last 0.5 ml and
begin to twist the syringe off the lock as you continue to inject the fluid.

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SECTION EIGHT: INFECTION CONTROL GUIDELINES

8.1 GUIDELINES (CDC2002, 2008)

Hand washing is a primary infection control measure and prevents cross contamination.
Vigorously wash hands with an antimicrobial agent before and after all clinical
procedures.

Standard [universal] precautions must be utilized with all patients/[clients].


The potential for coming into contact with a patients blood while starting an IV is
high and increases with the inexperience of the operator. Gloves must be worn
while starting an IV and where risk of blood spatter is high, such as an agitated
patient, the operator should consider eye protection as well as a gownonce
removed from the [plastic] sheath, IV catheters should either go into the patient or
an appropriate sharps containerRecapping of needles is one of the most
common causes of preventable needle stick injuries in health care workers.
(Department of emergency medicine, University of Ottawa, 2003)

Protective Clothing:
Gloves are required with all invasive procedures
Gown, mask, goggles are required when procedure may generate droplets
or splashing of blood/ body fluids

Assembly of Equipment:
Prepare equipment using aseptic technique
Assemble and open equipment immediately prior to use

Disposal:
Utilize a mechanism for safe disposal of all sharp items
Container must be non-permeable, tamperproof and [accessible] to prevent
cross-contamination and /or accidental needle-stick injury
A mechanism must be in place to dispose of gowns/ masks soiled with blood/
body fluids

8.2 PATIENT/CLIENT SAFETY AND INFECTION CONTROL

It is important to adhere to the basic principles of hand washing and aseptic technique to
protect the safety of the clients we serve. The potential for infectious complications
increases in a healthcare setting, especially when skin integrity is broken to administer
peripheral IV therapy.

Good hand washing before catheter insertion or maintenance, combined with aseptic
technique during catheter manipulation, provides protection against infection CDC
(2002, 2008)

Equipment that has been contaminated should never come into contact with the
clients central circulation been contaminated should never come into contact
with the clients central circulation.

30
Hand hygiene can be done by: waterless, alcohol-based product or an
antibacterial soap and water with adequate rinsing

Gloves are required by Occupational Safety and Health as standard precautions


for the prevention of blood-borne pathogen exposure.

An aseptic technique does not necessarily require sterile gloves; disposable non-
sterile gloves can be used with a no-touch technique for the insertion of
peripheral venous catheters. (CD, 2002, 2008)

Consider use of further isolation techniques when dealing with an immuno-


suppressed client or those who have been diagnosed with a highly
communicable disease. If uncertain in these complex situations, you may contact
the regional Infection control office.

Section Nine: IV Medications:

After completing this section of the module participants will:


Recognize the advantages/disadvantages of IV medication administration
Know responsibilities associated with giving IV medications
Know where to find specific drug information on dosages, rates, compatibility,
possible side effects

Medication can be administered directly into the patients systemic circulation through
the following methods:

IV Push- involves administration of a medication directly into a patients vein, into an IV


injection port, or through an IV lock device over a short period of time (usually 2-5
minutes but varies with the medication)

Intermittent IV infusion- involved administration of a medication diluted in compatible


fluid over a longer period of time (30-60-90 minutes), usually at specified intervals.

Continuous IV infusion- the continuous administration of medication through an IV


system (eg insulin, potassium)

Medications administered through central lines require specific knowledge of central


lines and their maintenance, however the basic medication information required is the
same.

Advantages of IV administration:
Offers direct access to the systemic circulation so medications have a faster
onset of action (they do not have to go through any periods of dissolution or
absorption)
Medications are 100% bioavailable (medications given orally can have erratic
absorption and are subject to first pass metabolism by the liver before reaching
the systemic circulation)

31
Can be used when patients cannot tolerate oral therapy, absorb oral medication,
or are on strict NPO orders prior to procedures
Is less painful (once IV is situated) than IM injections so drugs that are irritating
or required more frequently can be administered this way.
Can give large volumes of medication if needed
Can be abruptly discontinued if needed

Disadvantages of IV administration:
Immediate onset of action and also of problems (eg allergic reactions, sudden
hypotension)
Medication and dose must be correct as this is hard to rectify once medication
has hit systemic circulation
Risk of local/systemic complications at IV site
Speed shock- significant hypotension can result from too rapid administration of
certain agents
Phlebitis-some drugs, and some drugs at high concentrations, can be very
irritating and painful on injection
Extravasation-drugs which can cause direct tissue damage (including necrosis)
should they inadvertently go into interstitial spaces eg dopamine, norepinephrine
Venous spasm-can be caused by rapid infusion, cold fluids, viscous solutions or
irritating solutions.
Cost- IV preparations are usually more expensive, plus costs associated with
tubing, needles, flushes, preparation time and administration time have to be
factored in
IV access poses some challenges in pediatric patients, agitated patients, addicts

Nursing Responsibilities:
Patient education
Thorough knowledge of the medication, including indication, dosage range, side
effects, maximum rate, maximum concentration, dilution instructions, frequency,
method of elimination, contraindications, client responses that would necessitate
a change.
Proper labelling and documentation
Assessment of client and response to therapy

Drug Information:
Specific drug information can be found on the intranet under interdisciplinary and
then drug information. Information is also available in the Compendium of
Pharmaceuticals and Specialties (CPS), product monographs, Alberta Cancer Board
Parenteral Drug Manual, various manufacturers websites and from the pharmacy
department.
Prior to giving any medication the diagnosis, usual dosage range, allergies,
contraindications, maximum rate, frequency, dilution instructions if needed, side effects
and route of elimination should be considered. Any discrepancies should be clarified
before giving the medication.

Some medications pose special risks to patients and should be considered high alert
medications that require additional vigilance. Adverse events are not more common with
these agents, but when they occur consequences can have devastating effects
(including death). These medications include potassium and other concentrated

32
electrolyte solutions, heparin, insulin, and antineoplastic agents. The Institute for Safe
Medication Practices has listed 30 drugs and drug categories as high alert agents and
special care should be taken when administering any of these agents.
Peace Country Health has a policy restricting the use of certain medications (usually
high alert preparations) to specially trained nurses (OR/ICU/ER/NICU) or certain
locations due to increased monitoring requirements. This policy can be accessed on the
intranet under Drug Information- interdisciplinary page or Policies and Procedures
when updated.

Special considerations:
Allergic reactions: Patients may have immediate or delayed allergic reactions to
medications and careful history is essential to minimize risk. Allergic reactions can
range from itchy rash, runny nose to full blown anaphylactic reactions with airway
compromise and cardiovascular collapse. Assess ABCs (airway, breathing, circulation)
and treat with epinephrine and diphenhydramine (Benadryl) (located on the crash cart)
if indicated. Patients may also have anaphylactoid type reactions- reaction to a large
molecule or protein to which drug is complexed (eg iron dextran) even if they have never
been exposed to the agent previously.

Narcotics/Benzodiazepines: because these agents act much more quickly when given
through IV sites careful patient monitoring is required and rapid intervention if needed.
IV doses are usually much smaller (1/10 to ) than oral doses. Naloxone (Narcan )
counteracts the effects of opioids, both on the pain and respiratory receptors. Onset of
action is very rapid but can wear off quickly requiring more doses. Flumazenil
(Anexate) reverses the effects of benzodiazepines but is also very rapid acting.

Labelling/Storage: All products should be labelled appropriately with date (including


time), medication added, concentration, expiry and initials. Multidose vials (like insulin,
heparin and dexamethasone) should be labelled with an expiry date and kept for a
maximum of 30 days in the refrigerator once opened. Products prepared in pharmacy
should always be double checked to ensure label matches solution and patient order.
Certain preparations (like ampicillin, erythromycin and primaxin) require immediate
refrigeration if not being hung immediately as they rapidly (within 1-2 hours) lose their
potency at room temperature.

Scheduling: For ease of scheduling IV medications (so pharmacy can prepare them
and have them on the units on time) q6h orders are assumed to be 0600,1200,1800,
and 2400; q8h orders are 0600, 1400 and 2200; q12h orders are 0900 and 2100 and
daily orders are 0800 (exception: extended interval aminoglycosides (gentamicin and
tobramycin) are given on a daily basis but are given 24 hours after first dose (so indicate
time needed on the order).
When therapy involves more than one agent compatibility and drug interactions must be
considered eg. penicillins should be given prior to aminoglycosides (separated by an
hour) as penicillins can directly bind aminoglycosides (if given through same lines) but
penicillins also make bacterial cell walls more sensitive to the aminoglycosides leading
to a synergistic action.

Therapeutic Drug Monitoring:


If drug or electrolyte levels are ordered try to make sure lab work is drawn from the
opposing limb to where the infusion is running as this may lead to artificially high levels.

33
Most drugs will have distributed throughout the body within 30 minutes so levels can be
done any time after that (exception digoxin takes a long time for tissue concentrations
to equalize with plasma concentration so levels should be drawn 6-8 hours after dose).
If critical results are obtained further doses should be withheld until communication with
the physician has taken place.

Filtering:
Drugs which come in ampoules, drugs which have a low solubility (eg phenytoin,
mannitol), and drugs which cannot be viewed because they are an emulsion (eg TPN,
should all have filters, unless specifically contraindicated, attached before entering the
patients systemic circulation to ensure no particulate matter gets through.

Product Integrity:
All agents should be visually inspected for particulate matter, haziness, leaks, tampering,
and expiry before use. Some agents require the use of glass containers and non-PVC
tubing to prevent adsorption to the plastic and loss of potency.

Pooling:
Medications should be gently inverted prior to hanging to ensure standard mixing
throughout the solution (eg potassium solutions, TPN) so that any concentration
differences are minimized. In addition, IV bags that are made of more than one
compartment (eg TPN solutions) need to have the inner seal broken so that the solutions
have the opportunity to mix properly.

Calculations:
Again, because of the immediate action of agents that are administered directly into the
patients systemic circulation it is of vital importance to ensure the dose calculations, rate,
duration of therapy are correct prior to starting.

Documentation:
Complete documentation of all medication administered should occur immediately after
administration.

Patient Safety:
Patients need to be involved in their care and have education and consent to any
treatment. Adverse events that are preventable account for almost 7% of hospital
injuries. It is your responsibility to know about the medication you are administering and
communicate that information to your patients. If you consider the medication, route or
dose unsafe, or not in your patients best interest, it is your responsibility to advocate for
that patient.

Section Ten: Administration of Blood and Blood Products:

Administration of the various blood and blood products will be reviewed here. All blood
products are not the same and significant knowledge is required when giving these
products to our clients. Please keep in mind that a physician must order blood and blood
products. This order shall include the precise product to be given, the amount, that a
cross- match is required (if applicable) and oftentimes, the length of time in which the

34
product is to be infused. Orders will vary depending on the situation and the clinical
condition of the client.

10.1: Purpose:

Hypovolemia due to blood loss


Acute/ chronic anemia (hgb < 70 g/L)
Coagulopathies
Emergency reversal of Warfarin therapy
Protein administration
To boost immune response

10.2 Blood Regulation/ Collection in Canada

FYI:
Health Canada regulates blood collection and testing
Canadian Blood Services (CBS) collects blood in all provinces and territories
except Quebec
Hma-Qubec in Quebec
Donor unit testing is done on all products as follows:
o ABO and Rh (D) type
o RBC alloantibodies
o HIV 1 and 2-antibody, HIV nucleic acid testing
o Hepatitis B- Hepatitis B surface antigen
o Hepatitis C- antibody and HCV nucleic acid
o HTLV I and II- antibody testing
o West Nile virus (WNV)- WNV nucleic acid testing
o Syphilis

10.3 Selected Products:

A. Packed Red Blood Cells: Most common form of blood transfusion.

Used to restore blood volume loss, and treat anemias


Must be transfused through a 170-260 micron blood filter
Compatible ONLY with normal saline
Volume is generally about 280 mL
To be stored in a temperature-controlled refrigerator with continuous temperature
monitoring by the transfusion service (blood bank/ lab staff)
Freezing or over-heating can damage cells and harm the client
Initiate transfusion within 30 minutes of removing product from the fridge
Monitoring:
o Stay with the client during the 1st 5-15 minutes.
o Transfuse slowly for the 1st 15 minutes (50 ml/hr)
o Vital signs (T, P, R AND BP) should be checked at: THE START, EVERY 15
MINUTES (until stable) AND EVERY 30 MINUTES UNTIL TRANSFUSION
IS COMPLETE
Transfuse:
o During daytime hours in the non-urgent/ non-bleeding patient
o One unit at a time, unless massive blood loss indicates otherwise
o Within 4 hours maximum, but 2 hours is usual

35
o With warming devices approved for doing this, especially in the case of
massive transfusions
o By gravity or using an infusion pump approved for this purpose
B. Platelets:

Used for platelet dysfunction, thrombocytopenias, marked bleeding, pre and post
operatively (prophylaxis)
Must be transfused through a 170-260 micron blood filter
3 forms available: Random donor (from whole blood)-most common, single
donor, HLA (human leukocyte antigen) matched single donor (for patients with
HLA-alloimmunization and refractory to random donor platelets)
Compatible ONLY with normal saline
Volume is generally about 40-70 mL per unit
1 unit is given for each 10 kg of body weight
In adults, random donor platelets are transfused in groups of 5 units
Stored at 20-24 C with constant mixing to preserve platelet function (do not
refrigerate)
Monitoring:
o Monitor and run platelets as you would for the packed red blood cells
(PRBCS)
o Vital signs are to be done as per the procedure for PRBCS
Transfuse:
o Recommended infusion time is 60 minutes per dose
o Maximum infusion time is 4 hours

C. Fresh Frozen Plasma (FFP):

Used for emergency reversal of warfarin therapy, Active bleeding; major surgery
with PT/PTT more than 1.5 times normal, microvascular bleeding or massive
transfusion, Liver disease-related coagulopathies for certain invasive procedures
Can be derived from random donors (most common) or an apheresis donation
(250 mL vs. 500 mL)
Must be transfused using a 170-260 micron blood filter
Compatible ONLY with normal saline
Volume is generally about 200-250 mL per unit
Doses run from about 3 units for a small adult and 4 units for a larger adult
May be kept frozen for up to one year
Must be stored at -18 C or colder
Monitoring:
o Monitor and run FFP as you would for PRBCS
o Vital signs are to be done as you would for PRBCS
Transfuse:
o Recommended infusion time is 30-120 minutes
o Maximum infusion time is 4 hours

D.Cryoprecipitate (CRYO):

Used for treatment of microvascular or massive bleeding in clients with low


fibrinogen concentration, Von Willebrands disease, Hemophilia A only when
factor concentrates are not available and DDAVP is unavailable or ineffective.
Contains factor VIII (8), fibrinogen, and von Willebrands factor

36
Obtained from multiple pooled donors
Must be transfused through a 170-260 micron blood filter
Compatible ONLY with normal saline
Volume is generally about 5-20 mL per unit
Doses are given based on 1 unit per 10 kg of body weight; small adult average
dose would be about 8 units; a large adult, about 12 units
Must be stored at -18 C or colder
May be stored for up to one year
Monitoring:
o Monitor as you would for PRBCS; rates are generally ordered by the
physician; usually @ a rate of 10-15 mL/ minute for adults
o Vital signs are to be done as you would for PRBCS
o Maximum 6 units in 30-40 minutes
Transfuse:
o Recommended infusion time is 10-30 minutes
o Maximum infusion time is 4 hours

E. Albumin:
Albumin is a plasma protein synthesized by the liver and catabolized by the
endothelium
Used to increase the circulating blood volume by increasing the intravascular
oncotic pressure
Manufactured from a pool of approximately 10,000 blood donors
Comes in concentrations of 5 and 25%*
Glass bottles come in 50-100mLs
No crossmatch is required
Use regular IV tubing
Compatible with all IV solutions
Document lot number and volume administered on patient chart
Monitoring:
o Monitor as you would for PRBCS; start at a rate of 0.2-0.4 ml/minute
o Max rate for 5% is 5mls/min Max rate for 25% is 2mls/min
o Vital signs are to be done as you would for PRBCS
Caution:
o Administering 25% albumin instead of 5% in error can result in circulatory
overload
o 25 g of albumin= 500 mL of 5% albumin results in a 750 ml increase in
intravascular volume (250 mL from interstitial pool)
o 25 g of albumin=100 mL of 25% albumin results in a 450 ml increase in
intravascular volume (350 mL from interstitial pool)

For further information about these blood products and those not listed here, go
to: www.bloodservices.ca/

10.4 Equipment:

Appropriate blood administration set


Normal Saline IV solution
Alcohol wipes
Disposable, clean gloves
Tape

37
BP cuff and stethoscope
Thermometer
Patent IV. 22 g and larger can be used safely without damaging blood cells
Appropriate flow sheet to chart vital signs
May Need:
Rapid infusion pump/ blood warmer
Infusion pump
Leukocyte depleting filter (specific patients require this; the lab will supply this
and let you know if it is required)
Pressure bag

10.5 Procedure for Administration:

1. The appropriate clinician must identify the client for the lab staff at the time of the
drawing of the blood for cross match.
2. The client will be identified with the typenex at the time the cross match sample is
obtained
3. Generally, one unit of product is obtained at a time from the lab
4. The blood bank staff and the messenger check the blood product and compare
the clients name, date of birth, blood bank number, blood unit number,
blood type and Rh factor and the clients chart number
5. The lab will issue a pink sheet with each unit, it is signed by the lab person
releasing the unit and co-signed by the messenger.
6. The patient is then identified at the bedside by two appropriate clinicians and the
highlighted information is checked again.
7. If the two parties verify the information correct, both sign the lab sheet.
8. The appropriate clinician may then initiate the blood using the appropriate
infusion device
9. Blood unit tab (if applicable) is to be signed and dated on initiation.
10. Administer the blood product by gravity or through an infusion pump as required.
11. The transfusion must be started within 30 minutes of the blood product being
removed from the refrigerator (except in the case of FFP; it must be thawed for
30 minutes prior to initiation).
12. Check and record vital signs at the start, every 15 minutes until stable and
every 30 minutes until transfusion is complete.
13. Monitor the client closely for the first 15 minutes and transfuse slowly; generally
no faster than 50 mL/ hr for the 1 st 15 minutes
14. Filtered administration sets must be changed every 4 hours. If there is visible
debris or sluggish flow, the filter may need changing more frequently.
15. All empty blood containers are to be saved with tags filled out, sampling site
coupler attached to the blood bag, placed in a plastic bag and returned to the lab.
16. Chart on client care notes:
Blood bag number ( if applicable)
Amount and type of product given
Time commenced
Vital signs
Any signs of reaction
Time product discontinued or completed
17. The appropriate clinician may discontinue the administration of blood products
and change tubing as required and necessary.

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10.6 Transfusion Reactions:

A. Febrile: > 1 C increase in temperature AND temperature > 38 C during transfusion


or within 4 hours of the end of the infusion.
Possible Causes: Bacterial sepsis, acute hemolytic transfusion reaction, febrile non-
hemolytic transfusion reaction

B. Allergic reaction/anaphylactic reaction: A transfusion reaction that may be associated


with urticaria, facial edema, airway edema, lower respiratory tract symptoms (wheezing),
hypotension (> 30 mmHg drop in systolic or diastolic blood pressure), signs and
symptoms of shock.

C. Hemolytic Reaction: Break down of RBCS caused by ABO incompatibility (error in pt


identification or clerical error), presence of alloantibodies, medical-device related, over-
heating, freezing, RBCS given under pressure with a small bore needle (< 22 g)(Perry
and Potter, 2002) outdated product, use of hypotonic IV solutions with the blood product.
Patients often present with fever and chills, hemoglobinuria, chest pain, hypotension,
nausea and vomiting, dyspnea, renal failure, disseminated intravascular coagulation
(DIC).

Procedure for Suspected Blood Transfusion Reaction:

1. Stop the transfusion. Keep normal saline infusing at 30-50 mL/ hour
2. Consider A, B, CS, administer oxygen as required
3. Implement q 5-15 minute vital signs as client condition warrants
4. Notify the physician
5. Stay with the client until stable
6. Complete the transfusion reaction form and send it to the lab as soon as possible
7. Save the remainder of the transfusion for the lab for testing
8. As soon as possible, obtain a urine specimen for hemoglobinuria
9. Repeat urine in 2 to 3 hours
10. Following a transfusion reaction, no further blood should be administered until
the investigation is complete. In an emergency situation when more blood is
required immediately, the physician must contact the blood bank

Blood-Borne Pathogens and Other Complications:

1. Viruses

Risk per Donor Exposure (i.e.: 1 unit of RBCS)


HIV 1 in 4.7 million
Hepatitis C 1 in 3.1 million
Hepatitis B 1 in 85,000
Human T-cell 1 in 3 million
lymphotropic
virus
West Nile Virus Unknown
Callum, J., Pinkerton, P., 2003

39
2. Prions

Variant Creutzfeldt-Jakob Disease (vCJD)

There is no clinical evidence to support the existence of transfusion-


transmitted vCJD in humans (or classis CJD)
At present, high risk donors are deferred in Canada

For more information on CJD, refer to the following website:

www.hc-sc.gc.ca/english/diseases/cjd/

3.Massive Transfusion

Defined as a transfusion of more than 10 units of RBCS or transfusion of more than


the blood volume of a client in a 24-hour period.

Massive transfusion puts the client at risk for multi-organ failure. Complicatons are
dependent upon the number of units transfused, rapidity of transfusion and individual
client factors.

Complications of massive transfusion:


Dilutional Coagulopathy- 33% of massively transfused clients have
thrombocytopenia with a low platelet count
Hypothermia- rapid infusion of cold blood can result in cardiac arrhythmias
(prolonged PR, QRS, QT; T-wave inversion, development of J (Osborne)
waves, platelet dysfunction, reduced citrate clearance, decreased cardiac
output, hypotension. Studies have shown that mortality after massive
transfusion is inversely proportional to core temperature:
o < 34 C-40%
o < 33 C-69%
o < 32 C-100%
Callum J., Pinkerton, P., 2003
Citrate Toxicity- citrate is the anti-coagulant used in blood products; the liver
usually metabolizes it rapidly. With massive transfusion the livers capacity to
metabolize citrate may be overwhelmed. Citrate binds to calcium and
magnesium, creating a functional hypocalcemia and hypomagnesemia in the
body. Bicarbonate is a metabolite of citrate and can cause metabolic acidosis
Clinical symptoms include:hypotension, narrow pulse pressure, elevated
pulmonary artery pressure, tetany, paresthesia and arrhythmias.

Hyperkalemia- Potassium from stored RBCS is released with increased


storage time. RBCS can be stored for a maximum of 42 days under proper
refrigeration. A cross match in PCH is valid for 21 daysthe client must have
a repeat cross match after this time if there is blood to be transfused. If the
client has received a unit of blood, the remaining units must be transfused
within 72 hours or the client must be re-cross matched.

40
REFERENCES

Alberta Occupational Health and Safety Code (2009). Alberta Government. Queens
Printer

Alberta Association of Registered Nurses. (2009). Bylaws. Edmonton, AB: Author

Breaky, P. et al. (2003). The Initiation of Intravenous Therapy (fifth edition). Edmonton,
Alberta. Grant MacEwan Community College

Callum,J., Pinkerton, P.,(2003)Bloody Easy; Blood Transfusions, Blood Alternatives and


Transfusion Reactions.Sunnybrook and Womens College Health Sciences
Center

Cherneky,C., Macklin, D. & Murphy-Ende, K. (2002). Fluids & Electrolytes.


Philadelphia. W.B. Saunders.

Center for Diseases Control and Prevention: website:


http://www.cdc.gov/mmwr/preview/mmwrhtml/rr511al.htm

The Journal of Intravenous Nursing. (1998).Revised Intravenous Nursing Standards of


Practice.( January/ February. Volume 21, Number 1S)

Institute for Safe Medication Practices. Website:


http://www. ismp.org

Le Mone, P., Lillis, C., Taylor, C. (1997). Fundamentals of Nursing: The Art and Science
of Nursing Care. (third edition). p.617, pp. 1413-1425. Philadelphia. Lippincott-
Raven.

Medication Administration by IV Push. Grant MacEwan Community College, 1997.


Edmonton, Alberta.

Perry, A., Potter, P., (2002). Clinical Nursing Skills and Techniques.(fifth edition).pp.
560-578. St. Louis, Missouri. Mosby.

Pipa, D. Pharmacists Administering Drugs by Injection (2002). A report prepared for the
Alberta College of Pharmacists. Appendix II- Competencies for pharmacists
administering parenteral medications. Edmonton, Alberta

Registered Nurses Association of Ontario (RNAO) 2010 website:


http://rnao.ca

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