DONE ASSESSMENT 1. Reviewed accuracy and completeness of health care provider order, followed Rights of Drug Administration. 2. Performed hand hygiene, identified patient using two identifiers. 3. Applied clean gloves, inspected and palpated skin around IV site, asked patient how IV site feels, assessed VAD for patency and signs of IV-related complications, disposed of gloves, performed hand hygiene. 4. Assessed IV system for patency. 5. Identified patient risk for fluid and electrolyte imbalance. 6. Assessed patient’s knowledge of how positioning of IV affects flow rate. PLANNING 1. Gathered material to calculate flow rate. 2. Checked order for length of infusion, calculated hourly rate if necessary. 3. Checked agency policy regarding Keep Vein Open (KVO) flow rate if needed. 4. Used hourly rate to program EID or to calculate minute flow rate. 5. Knew calibration of infusion set. 6. Selected appropriate formula to calculate minute flow drops based on drop factor of infusion set. IMPLEMENTATION
1.Using gravity flow:
a.Ensured IV container is at an appropriate height (36 inches above IV site). b. Opened roller clamp on tubing until there are drops in drip chamber, counted drip rate for 1 minute, adjusted roller clamp if needed. 2.Using an Electronic Infusion Devices(EID) a.Closed roller clamp on primed IV tubing b. Inserted tubing into chamber of EID control mechanism. c. Secured part of IV tubing through “air in line” alarm system, closed door, turned on power, selected drop rate, closed door and pressed start. If infusing, accessed EID library and set rate and dose limits d. Opened infusion tubing drip regulator completely while EID was in use. e. Monitored infusion rate and IV site for complications. f. Assessed IV system from container to Vascular Access Device(VAD) insertion site when alarm signals 3. Attached label to IV solution container with date and time container changed. 4. Taught patient purpose of EID, purpose of alarms, to avoid raising hand or arm that affects flow rate and to avoid touching clamp. 5. Removed and disposed of used supplies, performed hand hygiene. EVALUATION 1. Observed patient every 1 to 2 hours, noted volume of IV rate infused and rate of infusion. 2. Evaluated patient’s response to therapy. 3. Evaluated patient at established intervals for signs of IV -related complications. 4. Asked patient to explain what causes pump to alarm and what to do when it does. RECORDING AND REPORTING 1. Record IV solution, rate of infusion, and integrity and patency of system in appropriate log. 2. Record use of EID or control device and device ID number. 3. Recorded patient response and unexpected outcomes. 4. Recorded patient’s level of understanding and ability to follow instructions. 5. Reported rate and volume left in infusion to next nurse assigned to care for patient.
Evaluator’s Name and Signature: ______________________________