iv therapy
TRANSCRIPT
Intravenous
By: mplestor,rn,man
Therapy
Definition: Intravenous Therapy
-The insertion of a needle or catheter/cannula into a vein, based on the physician’s written prescription.- The needle or catheter/cannula is attached to a sterile tubing and a fluid container to provide medication and fluids
Objectives: Intravenous Therapy
-
-Recognize the ethico-legal implications of IV Therapy
-Serves as a guide for nurses in providing safe and quality nursing care to patients, relative to IV therapy-Promote the application of principles underlying the administration of IV Therapy
1. Role Definition:
Intravenous Therapy
- The IV nurses are registered nurses committed to ensure the safety of all patients receiving IV therapy
Scope of Practice
Intravenous Therapy
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- Recognition of holistic approach to patient
care
- Thorough knowledge of the vascular system
2. Basis of Practice: - Legal therapeutic prescription of a licensed MD
2. Basis of Practice:
Intravenous Therapy
-
- Networking and linkages with external environment
- Individual profession accountability
- Collaboration with members of health team
2. Basis of Practice:
Intravenous Therapy
- - Utilization of Nursing Process, through: Assessment
Planning Implementation Evaluation
3. Clinical skills:
Intravenous Therapy
- An IV therapy nurse shall be proficient and competent in all clinical aspects of the IV Therapy
Intravenous Therapy4. Procedures: - an IV therapy nurse shall perform procedures that include but not limited to the ff: Carry out MD’s prescription for
IV therapyPerform peripheral venipuncture
(except insertion of subclavian and cut-down catheter)
Prepare, initiate, monitor and terminate IV therapy
Administer Blood and blood components as prescribed by MD
Intravenous Therapy Determine solution and medication
incompatibilities Change IV site, tubings and
dressings, according to IV therapy standards
Establish flow rates of solutions, medications, blood and blood components as prescribed by the MD
Nursing management of patients receiving IV therapy and peripheral/central and parenteral nutrition in various set-ups (hospitals/home/others)
4. Procedures:
Adherence to established infection control practices
Observation and assessment of all adverse reaction related to IV therapy and initiation of appropriate nursing interventions
Appropriate documentation relevant to the preparation, administration and termination of all forms of IV Therapy
Intravenous Therapy4. Procedures:
Intravenous Therapy5. Indications of IV Therapy: To maintain hydration and/or
correct dehydration in patients unable to tolerate sufficient volumes of oral fluids/medications
Parenteral Nutrition
Administration of Drugs
Transfusion of Blood and blood components
Intravenous Therapy6. Contraindications of IV Therapy:
Administration of irritant fluids or drugs
through peripheral access (i.e. highly concentrated, high osmolarity solutions)
7. Communication skills: An Iv therapy nurse shall posses verbal and written communication skills in translating ideas and facts to patients, health care members and others
Intravenous Therapy
An IV therapy nurse have the responsibility of educating patients and significant others on pertinent aspects of IV therapy
Intravenous Therapy8. Client Education
Continuing education and staff development are vital to professional advancement. In this regard, the IV therapy nurse actively participate and share knowledge with other disciplines
Intravenous Therapy9. Continuing Education
Intravenous TherapyStandards of Nursing
Practice 1.Standard policies & procedures: A. Physician’s prescribed treatment
- Patient’s name-Type and amount of solution- Flow rate-Type, dose and frequency of drugs - Others affecting the procedures- MD’s signature
B. Patient Assessments- Clinical status of patient - Type of solution- Patient’s diagnosis - Duration of therapy- Patient’s age- Dominant arm - Condition of vein and skin- Cannula size
Intravenous TherapyStandards of Nursing
Practice 1.Standard policies & procedures:
C. IV set and equipment preparation- Check for expiration date- Check for clarity, sediments, packaging- Check label against doctor’s written prescription- Label for any medication that are added: (date, time, dose and amount; compatibility of drug with the solution)- Functionality of infusion pump, Pt. CA
Intravenous TherapyStandards of Nursing
Practice 1.Standard policies & procedures:
2. Medications 10 GOLDEN RULES FOR DRUG ADMINSTRATION
1. Administer the right drug2. Administer to the right patient3. Administer the right dose4. Administer at the right route5. Administer at the right time
Intravenous TherapyStandards of Nursing
Practice
6. Right documentation7. Teach patient about the drugs he’s
receiving8. Take complete drug history9. Assess for drug allergies10. Be aware of potential drug-drug or
drug-food interactions
10 GOLDEN RULES FOR DRUG ADMINSTRATION
2. Medications
Intravenous TherapyStandards of Nursing
Practice
3. Initiation of IV therapy - Initiation of IV therapy shall be to provide peripheral intravascular access for therapeutic indications- This requires physician’s
prescription
Intravenous TherapyStandards of Nursing
Practice
4. Choices of CannulaFor peripheral infusion:
- Purpose of infusion- Type of infusion- Size and condition of the patient’s
vein- Duration of treatment- Condition of patient
Intravenous TherapyStandards of Nursing
Practice
Needle gauge and color:16 - grey18 – green20 – pink22 – blue24 – yellow26 – violet
4. Choices of Cannula
Intravenous TherapyStandards of Nursing
Practice
Parts of a Cannula
4. Choices of Cannula
Intravenous TherapyStandards of Nursing
Practice
5. Selection of venipuncture siteTake note for:
- Patient’s condition- Patient’s age- The size and vein condition- Type and duration of therapy- Functional utilization of the
hand
Intravenous TherapyStandards of Nursing
Practice
6. Anchoring Cannula & TubingGood anchoring…- Allows normal blood flow- Prevents movement of cannula- Prevents irritation of the vein- Puncture site should not be covered with tape
Intravenous TherapyStandards of Nursing
Practice
7. IV Cannula Removal
- Peripheral IV cannulas and the site are routinely changed aseptically or re-sited every 48-72
hrs or when necessary
Intravenous TherapyStandards of Nursing
Practice
8. Quality Control of IV Solution All IV fluids shall be inspected prior to use:
- Visible sediments
- Turbidity- Leaks/cracks- Expiration date- Damaged caps
Intravenous TherapyStandards of Nursing
Practice
9. Documentation of IV Therapy Proper documentation provides:
- An accurate description of care that can serve as legal protection
- A mechanism for recording and retrieving info
- A record for health insurers and retrieving info documenting the insertion or beginning of therapy.
Intravenous TherapyStandards of Nursing
Practice
The ff. info. of care can serve as legal protection
9. Documentation of IV Therapy
- Size, type and length of cannula/needle- Name of person who inserted the IV
catheter- Date and time of insertion
Intravenous TherapyStandards of Nursing
Practice
The ff. info. Is documented in the patient’s chart:- Location and condition of insertion site- Complications, pt. response & nsg.
Interventions- Pt. teaching and evidence of patient’s
understanding- Nurse’s signature
9. Documentation of IV Therapy
Intravenous TherapyStandards of Nursing
Practice
Policies on Documentation:- Never chart ahead of time- Chart properly- Clearly identify who did the procedure- Don’t leave space on charting- Identify late entries- Don’t criticize personnel on the chart
9. Documentation of IV Therapy
Intravenous TherapyStandards of Nursing
Practice
- Avoid error- Don’t tamper records- Document all reports to the doctor- Chart abbreviations properly- Refusal of meds should be charted- Don’t invent!!!
Policies on Documentation:
9. Documentation of IV Therapy
Intravenous TherapyStandards of Nursing
Practice
10. Infection Control
Intravenous TherapyStandards of Nursing
Practice
The ff. measures reduces patient’s risk:
10. Infection Control
- Wash hands before and after a procedure
- Use an approved antiseptic to clean the client’s skin
- Cut/clip the hair of the venipuincture site. Don’t shave
- Do not re-use catheter or needle
Intravenous TherapyStandards of Nursing
Practice
Center for Disease Control:10. Infection Control
- IV should be change 48-72 hrs- Site prep: tincture of iodine 1-2% (30 sec before
venipuncture- Piggyback tubing should be change after 48 hrs- Tubing should be changed after admin. of blood
products- Between changes of components, the IV system
should be maintained as a closed system as much as possible
Intravenous TherapyStandards of Nursing
Practice
HEMATOMA – a collection of extravasated blood trapped in the tissues of skin or in an organ.
11. Complications in IV therapy
S/S:- Tenderness - Bluish- Bruising around site - Inability to advance catheter- Resistance during flushing
LOCAL COMPLICATIONS
Intravenous TherapyStandards of Nursing
Practice
HEMATOMA
11. Complications in IV therapy
Nsg. Intervention:- Remove IV- Check for
bleeding Prevention:- Choose a good vein- Release torniquet as soon
as insertion is achieved
Intravenous TherapyStandards of Nursing
Practice
THROMBOSIS – an abnormal condition in which a clot (thrombus) develops within a blood
vessel
11. Complications in IV therapy
S/S:- Tenderness- Swollen vein- Reddened - Sluggish
Nsg. Intervention:- D/C IV- Restart new site- Warm compressPrevention:
- Proper venipuncture technique to reduce injury
Intravenous TherapyStandards of Nursing
Practice
PHLEBITIS – inflamed vein
11. Complications in IV therapy
S/S:- Redness- Puffy area- Hard vein on palpation- Increase body temp.
Nsg. Intervention:- Removed IV- Warm compress- Notify MD
Prevention:- Restart at large vein or
use small gauge cannula
Intravenous TherapyStandards of Nursing
Practice
INFILTRATION – a process whereby fluid passes into the tissues
11. Complications in IV therapy
S/S:- Swelling - Discomfort - Tightness at IV site - Blanching at site- Decrease temp at site - Absence of
backflow- Continues fluid infusion even when vein is
occluded although rate may decrease
Intravenous TherapyStandards of Nursing
Practice
INFILTRATION
11. Complications in IV therapyNsg. Intervention:- Removed IV & restart new
site- Warm compress & elevate
limbs- Check for pulse & numbness- Notify MD
Prevention:- Restart at large vein or
use small gauge cannula- Monitor IV site
Intravenous TherapyStandards of Nursing
Practice
LOCAL INFECTION – an infection within a specific area
11. Complications in IV therapyS/S:- Redness and swelling- Presence of exudates- Inc. WBC count
Prevention:- Good aseptic technique
Nsg. Intervention:- D/C- Request for C/S- Apply sterile
dressing- Apply antibiotics
Intravenous TherapyStandards of Nursing
Practice
VENOUS SPASM – a spasmodic constriction of vein
11. Complications in IV therapy
S/S:- Sharp pain at IV site
SYSTEMIC COMPLICATIONS
Prevention:- Check for allergies
Nsg. Intervention:- Warm compress flow
rate- Decrease the flow rate- Restart is spasm is gone
Intravenous TherapyStandards of Nursing
Practice
SPEED SHOCK – a sudden adverse physiologic reaction to IV medications or
drugs that are administered too quickly
11. Complications in IV therapy
S/S:- Dizziness - Headache - Facial flush - Shock- Hypotension - Irregular pulse- Tight feeling in the chest - Loss of consciousness- Cardiac arrest
Intravenous TherapyStandards of Nursing
Practice
SPEED SHOCK
Prevention:- Check for allergies
Nsg. Intervention:- Warm compress flow
rate- Decrease the flow rate- Restart is spasm is gone
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
SEPTICEMIA – systemic infection in which pathogens are present in the circulating blood, having spread
from an infection in any part of the body S/S:
- Fever & Chills - Hypotension- Body malaise - Pain- Contaminated IV site - Nausea
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
SEPTICEMIANsg. Intervention:- Notify MD- Do C/S & Initiate Antibiotic- Monitor V/SPrevention:- Hand hygiene - cover infusion site - follow SOP- Secure all connections - inspect fluids
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
CIRCULATORY OVERLOAD – an elevation in blood pressure caused by an increased
blood volume, as by transfusion. It may lead to heart failure or pulmonary edemaS/S:
- Discomfort - Intake increase- Neck vein engorgement - Decrease
output- Resp. distress- Increse BP
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
CIRCULATORY OVERLOADPrevention:- Use volume control set- Calculate rate- Monitor infusion- Do not “catch-up”
infusion
Nsg. Intervention:- High fowler’s position- Slow flow rate- Admin. Oxygen as
needed- Admin. Furosemide as
ordered
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
CATHETER EMBOLISMS/S:- Sharp sudden pain @ IV site- Rough and uneven catheter noted- Chest pain- Tachycardia
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
Prevention:- Don’t apply pressure- Use radio opaque- Avoid joint flexion- Never re-insert stylet
Nsg. Intervention:- Tourniquet above elbow- Start new site- Inform MD
CATHETER EMBOLISM
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
ALLERGIC REACTION – an unfavorable physiologic response to an
allergen to which a person has previously been exposed and to which a person has developed antibodies
S/S:- Itching - Wheezing- Bronchospasm - Anaphylactic rxn- Urticarial rash - Edema- Bronchospasm
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
ALLERGIC REACTIONPrevention:- Obtain allergic history- Monitor client- Test dosing (slow rate)
Nsg. Intervention:- STOP!!! – Flush w/ PNSS- Notify MD- Admin. Antihistamine as
ordered
11. Complications in IV therapy
Intravenous TherapyStandards of Nursing
Practice
12. Procedural Problems Associated with IV Therapy
Fluctuating flow rate Runaway IV Sluggish IV tubing/ loose connection / disconnection IV line obstruction/kinking of IV tubing Clogged filter Break in aseptic technique leaks due to inappropriate device
Intravenous TherapyStandards of Nursing
Practice
13. Risk associated w/ IV therapy
Infectious organism exposure Needle stick injury Chemical exposure
Intravenous TherapyStandards of Nursing
Practice
14. Outcome Criteria The desired outcome criteria of these
IV Nursing standard shall be to:- To deliver safe and quality IV Therapy care- Protect the patient and the IV nurse
therapist- Protect the IV therapy nurse’s practice
Intravenous TherapyStandards of Nursing
Practice
All nurses are responsible for quality, utilizing IV nursing process of:
- Assessment- Planning- Implementation- Evaluation
Deviation from optimal care in the IV therapy nursing practice requires corrective care
Intravenous TherapyStandards of Nursing
Practice 14. Outcome Criteria
PROCEDURESIntravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV1. Verify doctor’s order & make I.V. label.
- An order requiring the initiation of IV must be made by the physician prior
to the implementation of this procedure.
Intravenous TherapyStandards of Nursing
Practice PROCEDURE I.
2. Observe 10 Rules in Drug Admin.- For legal purposes
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
3. Explain Procedure to Client and secure consent if necessary
- To decrease anxiety and foster cooperation
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
4. Assess client’s vein; choose appropriate vein: location, size, condition.
- Good condition of the vein will facilitate easier insertion of the needles.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
5. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
6. Prepare the necessary materials for procedure - Organization saves nursing
time. - IV tray w/ IV solution - Cotton balls w/ alcohol- Administration set - Plaster and gloves- IV cannula with IV solution - Tourniquet and splints- Forceps soaked in antiseptic solution - Sterile gauze or dressing
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
7. Check the sterility & integrity of the IV
solution, IV set & other devices.
- Break in the integrity of the materials can lead to
infection.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
8. Place IV label on the IV fluid bottle (client’s name, room number, solution, drug incorporation, bottle sequence and duration) - To ensure that the correct client will receive the IVF, and for documentation purposes.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
9. Open the seal of the IV solution and disinfect port with cotton balls with alcohol.
- To reduce number or microorganisms residing in the port.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
10. Open the administration set (IV set) aseptically and close the IV clamp. - Closing the IV clamp prevents the
solution from spilling unintentionally after insertion to the solution bottle.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
11. Spike container aseptically
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
12. Fill drip chamber to at least half and prime the tubing
aseptically.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
13. Remove air bubbles if any and put back the cover to the distal end of the IV tubing (get ready for IV insertion). - To remove air along the tubing
and to prevent air embolism.
A. SETTING-UP an IV
Intravenous TherapyStandards of Nursing
Practice
B. INSERTING IV w/ DUMMY ARM1. Verify doctor’s written prescription for IV therapy, check prepared IVF and other things needed.- An order requiring the
initiation of IV must be made by the physician prior
to the implementation of this procedure.
Intravenous TherapyStandards of Nursing
Practice
2. Observe 10 Rules in Drug Admin.- For legal purposes
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
3. Explain Procedure to Client and secure consent if necessary
- To decrease anxiety and foster cooperation
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
4. Assess client’s vein; choose appropriate vein: location, size, condition.
- Good condition of the vein will facilitate easier insertion of the needles.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
5. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
6. Apply tourniquet 5-12cm (2-6in) above injection site depending on condition of client- To distend the
veins and facilitates easier insertion.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
7. Check for radial pulse below tourniquet.
- To distend the veins and facilitates easier insertion.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
8. Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry. (No touch technique). - To reduce number of microorganisms in
the area and to prevent infection.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
9. Using the appropriate I.V. cannula, pierce skin with needle positioned on a 15-30 degree angle; upon flashback visualization decrease the angle,
advance the catheter and stylet (1/4 inch) into the vein.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
10. Position the I.V. catheter parallel to the skin. Hold stylet stationary the slowly advance the catheter, until the hub is 1mm to the puncture site.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
11. Slip a sterile gauze under the hub. Release the tourniquet, remove the stylet while applying digital pressure over the catheter with one finger about 1-2in. from the tip of the inserted catheter
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
12. Connect the infusion tubing of the prepared IVF aseptically to the catheter.
- To initiate flow of solution into the vein.
B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice
When steel-winged needle (butterfly) is used: A. Connect the I.V. tubing to the steel-winged needle connector & prime the needle with I.V. fluid. B. Using the steel-winged needle, pierce skin with the needle bevel up, positioned on a 5-10 degree angle. C. With steel-winged needle, parallel on the skin, enter the vein directly and advance needle ¼ inch after successful venipuncture. Check for backflow. Remove tourniquet.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
13. Open the clamp, regulate the flow rate and reassure the client.- To initiate flow of solution into the
vein.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
14. Anchor needle firmly w/ the use of:
a. transparent tape/dressing directly
on the puncture site.b. tape (approp. anchoring style).
- To secure the needle in place.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
15. Tape a small loop of I.V. tubing for additional anchoring; apply splint (if needed). - To secure the needle
in place.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
17. Label on I.V. tape near the I.V. site to indicate the date of insertion.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
16. Calibrate the IVF bottle & regulate flow of infusion according to duration. - Improper calibration
can lead to under dosage or over
dosage.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
18. Label with plaster on the I.V. tubing to indicate the date when to change the I.V. tubing.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
19. Observe patient and report any untoward effect.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
20. Document in the patient’s chart and endorse to incoming shift.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
21. Discard sharps and waste according to Health Care Waste Mgt.
Intravenous TherapyStandards of Nursing
Practice B. INSERTING IV w/ DUMMY ARM
1. Verify doctor’s prescription in doctor’s order sheet, countercheck IV label, IV card, infusate sequence, type, amopunt additives (if any) and duration of infusion.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
2. Observe 10 Rules in Drug Admin.- For legal purposes
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
3. Explain Procedure to Client and assess IV site for redness, swelling and pain…
- To decrease anxiety and foster cooperation
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
4. Change Iv tubings & cannula if 48- 72hrs. Has lapsed after IV insertion
- Prolonged used of needle is the primary source of infection in IVF.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
5. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
6. Prepare necessary materials. - To save time and effort
- IV tray - Cotton balls w/ alcohol- New IV bottle w/ IV label - Forceps soaked in antiseptic solution
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
7. Check sterility and integrity of IV solution.
- Break in the integrity of the materials can lead to infection.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
8. Place IV label on the IV bottle
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION9. Calibrate the new IV bottle according to duration of infusion. Place IV label on the IV bottle.
- Improper calibration can lead to underdosage or overdosage.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION10. Open and disinfect rubber port of IV solution to follow
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION11. Close the IV clamp or kink tubing and spike the container aseptically. - Closing the IV clamp prevents the
solution from spilling unintentionally after insertion to the solution bottle.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION12. Regulate the flow rate based on duration of infusion. Remove air bubbles (if any). - Improper calibration can lead to
underdosage or overdosage. Air in the tubings can lead to air embolism.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION13. Reassure client and significant others
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
14. Discard sharps and waste according to Health Care Waste Mgt.
15. Document in the patient’s chart and endorse to incoming shift.
Intravenous TherapyStandards of Nursing
Practice C. CHANGING an IV SOLUTION
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION1. Verify doctor’s order to discontinue IV including IV medications
2. Observe 10 Rules in Drug Admin.- For legal purposes
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION
3. Assess & inform the client of the discontinuation of IV infusion and of any medication.
- Decreases anxiety and foster cooperation.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION
4. Prepare the necessary materials. - Saves time and effort
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION
- IV tray - Cotton balls w/ alcohol- Plaster - Forceps soaked in antiseptic solution-Sterile gauze or dressing - kidney basin
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION5. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION6. Close the clamp of the IV
administration set. - To prevent spilling of
solution.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION7. Moisten adhesive tape around the I.V. catheter with cotton ball with alcohol; remove plaster gently. - It facilitates easier removal of the
plaster.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION8. Use pick-up forceps to get cotton ball with alcohol and without applying pressure, remove needle or IV catheter then immediately apply pressure over the venipuncture site.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION9. Inspect IV catheter for completeness. - Make sure that the entire length of
the catheter is complete. If not, inform the physician immediately.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION10. Place dressing over the venipuncture site
- Make sure that the entire length of the catheter is complete. If not, inform the physician immediately.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION11. Discard sharps and waste according to Health Care Waste Mgt.
Intravenous TherapyStandards of Nursing
Practice D. DISCONTINUING IV INFUSION12. Document
time of discontinuance, status of insertion and integrity of IV catheter and endorse accordingly
A. INCORPORATION INTO IV BOTTLE1. Verify written medication card against MD prescription; observe hospital
policy on drug administration
- To make sure that correct medication will be administered.
Intravenous TherapyStandards of Nursing
Practice PROCEDURE II
A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice
2. Observe 10 Rules in Drug Admin.
- For legal purposes
A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice
3. Explain Procedure (medication & action) and check patency and IV site
- To decrease anxiety and foster cooperation
A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice
4. Verify for skin test of drug for IV incorporation (if skin testing is necessary)
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE5. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE6. Prepare necessary materials needed for the procedure such as: - IV tray - Cotton balls w/ alcohol
- syringes needed - Forceps soaked in antiseptic solution-Sterile gauze or dressing - kidney basin
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE7. Disinfect the injection port of the vial and the ampule before breaking then aspirate the right drug to be incorporated either in vial or ampule.
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE8. Remove the cover of the airway of the administration set, maintain the sterility and incorporate prepared drug into the airway. Recap airway after.
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE*** If the administration set has no airway, put down the bottle, kink the IV tubing, remove the administration set from the bottle aseptically; disinfect the bottle’s rubber stopper; incorporate the right drug to the IVF bottle; return the administration set to IVF bottle aseptically;
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE9. Swirl the IV bottle to mix the drug, with IVF and regulate the flow rate accordingly.
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE10. Observe for 5-10mins for any drug interaction while reassuring the patient; monitor V/S.
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE11. Document in the patient’s chart
Intravenous TherapyStandards of Nursing
Practice A. INCORPORATION INTO IV BOTTLE12. Discard sharps and waste according to Health Care Waste Mgt.
B. IV PUSH THROUGH THE IV PORT1. Verify written medication card against MD prescription; observe hospital
policy on drug administration
- To make sure that correct medication will be administered.
Intravenous TherapyStandards of Nursing
Practice
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
2. Observe 10 Rules in Drug Admin.
- For legal purposes
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
3. Explain Procedure (medication & action) and check patency and IV site
- To decrease anxiety and foster cooperation
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
4. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
5. Check patency and other reactions signs of swelling, redness, phlebitis, etc.. Do not give the drug.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
6. Check for skin test result of drug for IV push, drug-drug, drug IV fluid incompatibility, dosage computation.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
7. Prepare necessary materials needed for the procedure such as: - Right drug - IV tray
- Right diluent - syringes needed- Cotton balls w/ alcohol - etc…..
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
8. Disinfect the injection port of the diluent vial or ampule as appropriate.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
9. Aspirate right amount of diluent for the drug (if drug needs to be diluted.)
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
10. Aspirate the right drug dose; disinfect the Y-injection port of the IV administration set
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
11. Close the roller clamp of the IV tubing from the bottle and push IV drug aseptically and slowly or according to the manufacturer’s recommendation
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
12. Using the same syringe aspirate 1-2cc of IVF to flush the medicine given.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
13. Regulate the rate of IV fluid infusion as prescribed.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
14. Reassure the patient and observe for signs and symptoms of adverse drug reaction.
B. IV PUSH THROUGH THE IV PORT
Intravenous TherapyStandards of Nursing
Practice
15. Discard sharps and waste according to Health Care Waste Mgt.
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
1. Verify written medication card against MD prescription; observe hospital
policy on drug administration
- To make sure that correct medication will be administered.
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
2. Observe 10 Rules in Drug Admin.
- For legal purposes
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
3. Explain Procedure (medication & action) and check patency and IV site.
- To decrease anxiety and foster cooperation
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
4. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
5. Prepare necessary materials needed for the procedure such as: - Right drug and dose - Right diluent
needed- IV injection tray - Syringes and needle
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice 6. Check present IV fluid label, level and the incorporated medicine in the Volumetric chamber or IV bottle if w/ incorporated medicine, check for drug-drug incompatibility and if the on-going IV fluid in the volumetric chamber is to be consumed in 6-8 hrs. Request a prescription for IVF to be used solely for drug administration and keep the whole set sterile.
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
7. Aspirate prepared right drug and with correct dose.
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
8. Add desired IVF diluent into volumetric chamber by opening the sliding clamp from the bottle then close the clamp.
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
9. Disinfect rubber injection port of the volumetric chamber and incorporate the drug. Mix
gently
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
10. Open the clamp of the airway at the volumetric chamber
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
11. Regulate the flow rate of IVF infusion accordingly
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
12. Place IV label on volumetric chamber indicating the drug incorporated and flow rate
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
13. Reassure/monitor client when incorporated medicine is consumed, close airway of VC and IVF and regulate flow rate of main IVF as prescribed
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
14. Discard sharps and waste according to Health Care Waste Mgt.
15. Document in the patient’s chart, IVF sheet and Kardex
C. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
Intravenous TherapyStandards of Nursing
Practice
D. IV PUSH - HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice 1. Verify written medication card against MD prescription; observe hospital
policy on drug administration
- To make sure that correct medication will be administered.
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
2. Observe 10 Rules in Drug Admin.
- For legal purposes
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
3. Explain Procedure (medication & action) and check patency and IV site.
- To decrease anxiety and foster cooperation
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
4. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
5. Prepare necessary materials needed for the procedure such as: - heparin solution - Normal saline
- 2.5cc syringe (3pcs) - tuberculin syringe 1pc)- IV tray - cotton balls with alcohol- etc….
Intravenous TherapyStandards of Nursing
Practice D. IV PUSH – HEPARIN LOCK
6. Prepare medication to be administered e.g. antibiotic and draw it up into a syringe.
Intravenous TherapyStandards of Nursing
Practice D. IV PUSH – HEPARIN LOCK
7. Fill the tuberculin syringe with Heparin solution. (heparin solution is usually prepared with 0.1cc heparin plus 0.9cc Normal saline solution.
Intravenous TherapyStandards of Nursing
Practice D. IV PUSH – HEPARIN LOCK
8. Fill the 2.5cc syringe with Isotonic solution or Normal saline 1cc each
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
9. If using Hep lock device with 3-way stop cock with luer-lock, rotate the stop cock so that the line going to the patient is closed (this will prevent backflow of blood)
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
10. Remove the cover of the injection port aseptically and keep the sterility of the
cover.
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
11. Check the patency, open the IV line, inject NSS to flush Heparin solution
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
12. Close the IV line and remove saline syringe and insert medication syringe into the port.
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
13. Open the IV line & inject medication into the vein, timing the flow rate according to doctor’s order of drug manufacturer’s instructions.
D. IV PUSH – HEPARIN LOCKStandards of Nursing
Practice
Intravenous Therapy
14. Observe client for any adverse reactions and do nursing intervention accordingly
D. IV PUSH – HEPARIN LOCKStandards of Nursing
Practice
Intravenous Therapy
15. Close the IV line & remove medication syringe.
D. IV PUSH – HEPARIN LOCKStandards of Nursing
Practice
Intravenous Therapy
16. Insert the saline syringe, open the line & flush catheter tubing/IV cannula to
flush the line.
D. IV PUSH – HEPARIN LOCKStandards of Nursing
Practice
Intravenous Therapy
17. Close & remove saline syringe.
D. IV PUSH – HEPARIN LOCKStandards of Nursing
Practice
Intravenous Therapy
18. Close the IV saline, remove syringe and return the cover of the injection port aseptically.
D. IV PUSH – HEPARIN LOCKStandards of Nursing
Practice
Intravenous Therapy
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
19. Document in the patient’s chart, IVF sheet and Kardex
D. IV PUSH – HEPARIN LOCK
Intravenous TherapyStandards of Nursing
Practice
20. Discard sharps and waste according to Health Care Waste Mgt.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONType (ABO/Rh)Type (ABO/Rh) Can receive blood from:Can receive blood from:
O+O+ O (+/-)O (+/-)O-O- O (-)O (-)A+A+ A (+/-) A (+/-) oror O (+/-) O (+/-)A-A- A (-) A (-) oror O (-) O (-)B+B+ B (+/-) B (+/-) oror O (+/-) O (+/-)B-B- B (-) B (-) oror O (-) O (-)
AB+AB+ AB, A, B AB, A, B oror O (all+/-) O (all+/-)AB-AB- AB, A, B AB, A, B oror O (all -) O (all -)
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
Whole BloodWhole Blood 1 unit = 450ml1 unit = 450mlContains RBC, Contains RBC, WBC, Platelets WBC, Platelets
and Plasmaand Plasma
Acute massive Acute massive bleeding, open bleeding, open heart surgery, heart surgery, neonatal total neonatal total
exchangeexchange
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
Packed Red Packed Red Blood CellsBlood Cells
Most Plasma Most Plasma removedremoved
1 unit = 250-1 unit = 250-300ml300ml
Replacement in Replacement in chronic and acute chronic and acute
blood loss, GI blood loss, GI bleeding and bleeding and
traumatrauma
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
PlateletsPlatelets 1 “pack” should 1 “pack” should raise count by 5-raise count by 5-
8,000. 8,000. 1 pack = about 1 pack = about
50ml50ml
Active bleeding, Active bleeding, contiguous contiguous petechiae petechiae
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
Leukocyte-poor Leukocyte-poor red cellsred cells
Most WBC Most WBC removed to make removed to make it less antigenicit less antigenic
1 unit = 200-1 unit = 200-250ml250ml
Potential renal Potential renal transplant, transplant,
previous febrile previous febrile transfusion transfusion reaction, reaction, leukemia.leukemia.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
Washed RBCWashed RBC WBC almost WBC almost completely completely removedremoved
1 unit = 300ml1 unit = 300ml
As for leukocyte-As for leukocyte-poor red cells but poor red cells but very expensive very expensive and much more and much more
purifiedpurified
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
Fresh Frozen Fresh Frozen PlasmaPlasma
Contains Factors Contains Factors II, VII, IX, X, XI, II, VII, IX, X, XI, XII, XIII & heat XII, XIII & heat
labile V and VII. labile V and VII. About 1 hr. to About 1 hr. to
thaw. thaw. 1 unit = 150-1 unit = 150-
250ml250ml
Emergency Emergency reversal of reversal of
warfarin warfarin (coumadin), (coumadin), suspected suspected
coagulopathy, coagulopathy, clotting factor clotting factor replacementreplacement
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
5% Albumin or 5% Albumin or 5% Plasma 5% Plasma
Protein FractionProtein Fraction
Precipitate from Precipitate from plasmaplasma
Plasma volume Plasma volume expanders in expanders in
acute blood lossacute blood loss
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONProductProduct DescriptionDescription IndicationsIndications
25 % Albumin25 % Albumin Precipitate from Precipitate from plasmaplasma
Volume Volume expanders, burns, expanders, burns, hypoalbuminemia. hypoalbuminemia.
Draws Draws extravascular fluid extravascular fluid
into circulation.into circulation.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONTRANSFUSION REACTIONS
- Sudden fever - Tachycardia - Backache-Diaphoresis - Hypotension - Shock- Chills - Headache- Hypersensitivity Reactions ( hives, wheezing, pruritus)
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSIONTREATMENT FOR TRANSFUSION
REACTIONS- STOP!!!! The blood product transfusion ASAP!- Keep IV line (PNSS) open and monitor V/S and urine output carefully- Save the blood bag, have the lab verify the type and crossmatch.- In mild febrile transfusion reactions antipyretics can be used- With urticarial reactions dipenhydramine(Benadryl) should be given.- In more sever reaction, prevent acute renal failure.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
1. Verify doctor’s order and make treatment card according to hospital policy
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
2. Observe 10 Rules when preparing and administering any Blood or blood components
- For legal purposes
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
2. Observe 10 Rules in giving blood transfusion
- For legal purposes
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
3. Explain the procedure/rationale for giving blood transfusion to reassure client and significant others and secure consent. Get client’s history regarding previous transfusion.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
4. Explain the importance of the benefits on Voluntary Blood donation (RA 7719 – National Blood Service Act of 1994)
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION5. Request prescribed blood/blood components from blood bank to include blood typing and X-matching and blood result of transmissible dse.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
6. Using a clean lined tray, get compatible blood from hospital blood
bank
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
7. Wrap blood bag with clean towel and keep it at room temp.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION8. Have a doctor and a nurse
assess client’s condition. Countercheck the compatible blood to be transfused against the X-matching sheet noting ABO grouping and RH, serial #, expiry date w/ the blood bag label and other lab. Blood exam as required before transfusion.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
9. Get baseline vital signs and refer to MD accordingly
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
10. Give pre-med 30 mins. before transfusion as prescribed
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
11. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
12. Prepare equip. needed for BT: - IV tray - Compatible blood set
-IV catheter (gauge 18-19) - Plaster- tourniquet - Blood component- Plain NSS - IV set and IV hook- gloves - Sterile gauze or dressing
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with PNSS on another site, anchor catheter properly and regulate drops
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
14. Open compatible blood set aseptically and close roller clamp. Spike blood carefully; fill the drip chamber at lest half full; prime tubing and remove air bubbles (if any). Use gauge 18-19 for adults and 22 for pedia
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
15. Disinfect the Y-injection port of tubing (Plain NSS) and insert the needle from BT administration set and secure w/ adhesive tape.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
16. Open roller clamp of IV fluid of PNSS and regulate to KVO while transfusion is going on.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
17. Transfuse the blood via injection port and regulate @ 10-15gtts initially for 15 mins. And then at prescribed rate.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
18. Observe client for 10-15 mins for any immediate reaction.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
19. Observe client on an on-going basis for any untoward s/s such as:- flushed skin - chills -
inc. temp.- itchiness - urticaria - dyspnea*** if any of these s/s occurs STOP !!! the transfusion, open the roller clamp of the IV line w/ PNSS, and report it to the MD.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
20. Swirl the bag hourly to mix the solid with the plasma
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
21. When blood is consumed, close the roller clamp of BT, and disconnect from IV line then regulate the IVF of PNSS as prescribed
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
22. Continue to observe and monitor patient post transfusion, for delayed reaction could still occur.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
23. Re-check Hgb & Hct, bleeding time, serial platelet count within specified hours as prescribed &/or per institution’s policy.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION
24. Discard blood bag and BT set and sharps accdg. to
Health and Waste Mgt.
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION25. Document the procedure, pertinent observations and Nsg. Intervention and endorse accordingly
Intravenous TherapyStandards of Nursing
Practice BLOOD TRANSFUSION26. Remind the doctor about the administration of Calcium Gluconate if client had several units of Blood transfusion (3-6 units)
The EndThe End