Professional Documents
Culture Documents
A PRACTICAL APPROACH
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TABLE OF CONTENTS
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.
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COURSE COMPLETION CRITERIA
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.
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.
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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
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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).
*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. 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)
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.
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
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
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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
*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.
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.
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SECTION TWO: TOOLS OF THE TRADE
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.
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OVER-THE-NEEDLE CATHETER
Cover
Hub
Plastic catheter
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.
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
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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.
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2.3 SITE PREPARATION
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
1. Check the doctors order, review standing orders and gather equipment .
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.
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5.Position yourself with the catheter in your dominant hand while palpating the vein with
the other hand
6. Insert the catheter into the chosen vein. Feel for a pop sensation. Watch for
flashback in the chamber.
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7. Advance the catheter a few more millimetres (6-7 mm) as you withdraw the stylet
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.
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.
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
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.
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.
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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.
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:
Answer= 50 gtt/minute
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
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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
When using an infusion pump, the flow rate is set in ml/hr instead of gtt/ minute.
ml/hr = 2000 ml
8h
Answer: 250 ml/hr; set pump @ 250 ml/hr.
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
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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.
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
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6.3 SYSTEMIC COMPLICATIONS
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6.4 TROUBLESHOOTING THE IV INFUSION
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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
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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.
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
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.
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
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.
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Hand hygiene can be done by: waterless, alcohol-based product or an
antibacterial soap and water with adequate rinsing
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)
Medication can be administered directly into the patients systemic circulation through
the following methods:
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)
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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
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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.
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.
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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.
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
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product is to be infused. Orders will vary depending on the situation and the clinical
condition of the client.
10.1: Purpose:
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
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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
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):
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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:
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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
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:
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
1. Viruses
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2. Prions
www.hc-sc.gc.ca/english/diseases/cjd/
3.Massive Transfusion
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.
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REFERENCES
Alberta Occupational Health and Safety Code (2009). Alberta Government. Queens
Printer
Breaky, P. et al. (2003). The Initiation of Intravenous Therapy (fifth edition). Edmonton,
Alberta. Grant MacEwan Community College
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.
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
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