IV SETUP

WEAR GLOVES!
1. Verify doctor’s order.
2. Observe 12 rights of medication administration.
3. Introduce self. Explain the procedure and reassure patient or family.
4. Secure consent.
5. Choose appropriate site, location, size, and condition of vein.
6. Prepare necessary materials.
7. Check the integrity of IV solution and other devices. (Expiration date and color)
8. Place IV label on the bottle with the sign of the IV therapy nurse who prepared it.
9. Perform handwashing/hand hygiene.
10. Open IV administration set aseptically, close roller clamp, and spike the infusate container.
11. Fill drip chamber to at least half and open roller clamp.
12. Expel air bubbles and put back cover to distal end of IV set.
IV PUSH MED THROUGH IV PORT
1. Verify doctor’s order.
2. Observe 12 rights of medication administration.
3. Introduce self. Explain the procedure to patient.
4. Perform handwashing/hand hygiene.
5. Check medication labels.
6. Prepare necessary materials.
7. Confirm patency of IV line (Pwede ibaba IV bottle below bed or aspirate sa port)
8. Assess for swelling, redness, phlebitis and other unusual signs. If present, do not give medication.
9. Check for skin test result.
10. Administer medication. Flush and lock IV line. (Wipe port and kink the upper portion of port, give med
then withdraw)
11. Regulate IV flow.
12. Discard sharp and other wastes appropriately.
13. Perform hand hygiene and document procedure.
IV MEDS INCORPORATION
1. Verify doctor’s order.
2. Observe 12 rights of medication administration.
3. Introduce self. Explain the procedure to patient.
4. Assess patient accordingly and prepare necessary materials.
5. Perform hand washing/hygiene.
6. Perform skin testing as prescribed.
7. Check IV fluid label and incorporate drug aseptically.
8. Check patency and regulate IV flow.
9. Observe 5-10 minutes for drug interaction.
10. Discard sharp and other wastes appropriately.
11. Perform hand hygiene and document procedure.
OBTAINING ELECTROCARDIOGRAM
1. Verify doctor’s order.
2. Introduce self and identify the client (check if same name and the ID bracelet)
3. Provide privacy and explain procedure to client.
4. Perform handwashing, wear gloves, face shield and gown if needed.
5. Explain the procedure to patient while setting up machine for 12-lead ECG. (Explain na walang electric
current na papasok sa body and that the test will record heart activity for 5 minutes. Ask if may allergy
sa adhesives to relieve anxiety and gain cooperation)
6. Place ECG machine near patient’s bed and plug cord into outlet. (to save time and proper facilitation)
7. Adjust bed to comfortable working height usually elbow height of caregiver. (this prevents back and
muscle strain)
8. Have the patient lie semi-fowlers in center of bed and arms at side. Raise head of the bed if needed to
provide comfort. Expose patient’s arms and legs then drape correctly. Encourage relaxation. (This will
help ensure na comfortable si patient and minimizes trembling that can cause electrical interference)
9. Select flat, fleshy areas to place electrodes. Avoid muscular and bony areas.
10. If excessive hair is present, clip the hair, do not shave, and clean excess oil or substance from the body
with water and soap then dry. (Shaving skin can cause abrasions, oily can cause electrodes to fail, and
other substances are not recommended for cleaning)
11. Apply limb lead electrodes. Peel contact paper off the electrodes then apply in prepared site. Position
electrodes on legs with lead connection in the pulse site. (Wires are color coded and lettered for easy
identification).
12. Connect limb lead wires to electrodes. Make sure metal parts are clean.
13. Expose patient’s chest and apply precordial lead electrodes.
- VI and V2: 4th intercostal space at left and right sternal border.
- V3: Halfway between V2 and V4.
- V4: 5th intercostal space at left midclavicular
- V5: 5th intercostal space anterior axillary line between V4 and V6.
- V6: 5th intercostal space midaxillary
14. Connect precordial lead wires to electrodes. Make sure metal parts are clean.
15. After application of leads, ensure paper-speed selector is in standard 25 m/second and machine is set to
full voltage.
16. Ask patient to relax, breathe normally, lie still, and not talk.
17. Press auto button and observe tracing quality. The machine will record automatically.
18. When the machine is finished, remove electrodes and clean patient’s skin.
19. After disconnecting lead wires from electrodes, dispose electrodes.
20. Return patient in comfortable position.
21. Observe and practice body mechanics. Show calmness while performing procedure.

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