Policy: - IEMSA



Policy: Pediatric IV Therapy

A. It is the policy of _________________________to ensure the safe, uniform administration of intravenous therapy to pediatric patients. Definition: a pediatric patient is defined as a person 12 years of age or less.

B. The special guidelines and considerations for IV therapy to pediatric patients will be in addition to and in accordance with _____________________currently existing policies for IV insertion, maintenance, discontinuance of IV therapy and use of infusion pumps.

C. The provider monitoring infusion therapy for pediatric patients shall have clinical knowledge with respect to children 12 years of age and less.

D. All pediatric IVs shall be placed on an infusion pump. 60 drop per milliliter tubing should be utilized on all pediatric patients.

E. For all patients less than 5 years of age, a volume control device (Buretrol) shall be used.

F. Maximum fluid volume to be placed in the Buretrol is (2) times the amount ordered per hour, plus an additional 5-10ml.

G. Lower leg/foot veins may only be used as venipuncture site on children less than 2 years of age when other sites are not available.

H. Scalp veins may only be used as a venipuncture site on infants less than 1 year of age.

I. Only qualified personnel shall perform pediatric venipuncture. Example: Paramedics, Anesthetists, or any other RN with prior experience in pediatric venipuncture.

J. All IV rates ordered for a pediatric patient shall be written in terms of “ml per hour”. No “To Keep Open” (TKO) rate orders are to be accepted without the exact ml per hour specified.

K. The pediatric patient’s IV site shall be monitored/observed every 1 hour for any signs/ symptoms of complications.

L. When an armboard is used, circulation checks shall be performed every 2 hours on the extremity in which the IV is present.

M. All pediatric patients receiving IV therapy shall be intake and output.

N. Leave all peripheral venous catheters in place in children until IV therapy is completed unless complications (e.g., phlebitis and infiltration occur).

Equipment:

A. IV cannula – the cannula chosen should be the smallest size possible to administer the prescribed fluid/medication.

B. Prescribed IV solution

C. Microdrip volume control device (Buretrol)

D. 60 drop per milliliter IV tubing (microdrip tubing)

E. Baxter IV connector loop

F. Transparent semi permeable membrane (TSM).

G. IV infusion pump

H. Pediatric arm board (optional)

I. Flat bed sheet (optional) – if needed to papoose/mummy restrain the child during IV insertion.

J. Large rubber band. If scalp vein site is selected, a large rubber band may be used as a tourniquet by being placed around the top of the infant’s head.

Procedure:

A. Gather together all necessary equipment.

B. Explain procedure to patient/parent.

C. Prepare equipment.

1. Select correct size container of IV fluid

a. For infants 12 months of age or less, the IV fluid container should contain no more than 250ml of fluid.

b. For pediatric patients 1-12 years of age, the IV fluid container should contain no more than 500 ml of fluid.

2. Prime microdrip IV tubing and volume control device tubing (Buretrol). Fill the Buretrol with enough fluid to prime the tubing, plus fluid for a maximum of 2 hours (maximum volume to be placed in the Buretrol is (2) times the amount ordered per hour, plus an additional 5-10ml). This extra 5-10ml prevents the fluid in the Buretrol from emptying completely, thus allowing air to enter the IV tubing. Set infusion pump volume to be infused for 2 hour maximum.

3. Prime Baxter IV connector loop.

4. Cut any tape that will be used to secure IV site in desired width/length.

D. Select venipuncture site. Preferred sites for pediatric venipuncture include: hands, arms, feet, lower legs and scalp.

1. Lower leg/foot veins may be used on children less than 2 years of age.

2. Scalp veins may be used on infants less than 1 year of age.

3. When choosing a site in the patient’s upper extremities, every effort should be

made to choose a site in the patient’s non-dominant hand.

4. If possible, veins in the lower extremities of an ambulatory child should be avoided in order to prevent restricting his freedom to roam about as he/she pleases.

E. Restrain child (only as needed, in order to perform the procedure safely).

1. Whenever possible, if they desire to do so, the parents shall be allowed to actively participate in comforting the child before, during and after the procedure, but should not be forced to do so if they are uncomfortable about it.

2. Papoose/mummy restraint shall be used on the child if needed to perform the procedure safely. Use flat bed sheet as restraint sheet.

3. Assess the child’s status frequently throughout the procedure for any signs/ symptoms of distress.

F. Select IV cannula to be used for venipuncture.

1. Preferred cannula sizes for pediatric patients are #20, #22, or #24 IV catheters (over the needle cannula).

2. For very small infants, or difficult stick patients, a #23, or #25 butterfly (scalp vein) needle may be used.

3. The cannula chosen should always be the smallest size possible to administer the prescribed fluid/medication.

G. Apply tourniquet

1. If scalp vein site is selected, a large rubber band may be used as a tourniquet by being placed around the top of the infant’s head.

2. In some pediatric patients, the use of a tourniquet is discouraged, as the veins may be so fragile that it can cause an increased amount of pressure, causing the vessel to rupture.

H. Prepare chosen site for venipuncture.

1. Cleanse skin with alcohol. Begin at the center of the insertion site, and work outward in a circular pathway.

2. Allow skin to dry completely prior to penetration of skin.

3. If scalp vein is to be used, clip excess hair as needed. Shaving is not recommended as it can cause micro-abrasions. Removing excess hair decreases the chances for contamination and allows for less painful removal of tape when discontinuing the IV.

I. Perform venipuncture

1. Wash hands with antiseptic soap or disinfect hands with waterless alcohol-based gel.

2. Don gloves.

3. If the child’s vessel is small in relation to the size of the cannula, the cannula may be advanced with the bevel down in order to avoid penetration of the vessel’s opposite wall.

4. Scalp veins may be cannulated in either direction, as they have no valves.

J. Release tourniquet/rubber band.

K. Attach Baxter IV connector loop between cannula and IV tubing. Use of the IV connector loop helps to decrease the chances of IV cannula dislodgement if IV tubings need to be changed, or if continuous IV is converted over to saline lock.

L. Observe for signs/symptoms of patency/complications.

M. Secure IV site.

1. Apply skin prep to 2” X 3” area and allow to dry.

2. Apply transparent transpermeable membrane (TSM) dressing directly over the insertion site and hub of needle. Do not place TSM over the IV tubing.

3. Place tape on IV connector loop tubing along patient’s extremity so that pulling point is away from the IV cannula itself. Double backed tape should be used whenever possible to promote minimal contact of tape with the skin.

4. An arm board may be used when cannula is in an area of flexion. When applying an armboard, consideration should be given to the preservation of circulatory flow, ability to easily monitor the infusion site, and the potential for nerve and/or muscle damage. If an armboard is used, circulation motion and sensation (CMS) checks shall be performed every 2 hours on the affected extremity.

5. Use of roller type bandages (Kling) is not recommended on an extremity where an IV cannula is placed. Roller bandages obstruct visualization of the site, and may impair circulatory flow.

6. If a scalp vein has been utilized, a plastic medication cup, cut to fit over the IV cannula, may be used to protect the IV site. Pad the cut edges of the med cup with gauze/tape to avoid possible injury due to the rough edges.

N. Begin prescribed intravenous therapy.

O. Monitor/observe IV site every 1-hour for any signs/symptoms of complications. The pediatric patient is at greater risk for potential complications related to IV therapy, and thus requires more frequently monitoring.

1. Discoloration, erythema

2. Localized swelling/edema

3. Drainage

4. Leakage of infusate

5. Tenderness

6. Change in sensation, tingling, pain

7. Device dislocation or malposition

8. Loss of dressing integrity

9. Frequent alarming of infusion pump.

P. Change IV cannula site and tubing according to the recommendations for adult patients in the adult IV therapy policy.

Documentation:

A. IV Flow Sheet

1. Date and time of insertion

2. Type of infusion/fluid and amount up in the bag/Buretrol

3. Flow rate in terms of “ml per hour”

4. Gauge and type of IV device used

5. Location of IV site

6. Signature/initials

7. Flow rate checks and site checks shall be done on pediatric patients every 1 hour and documented on the IV flow sheet or nurses notes.

B. Flow Record

1. Number of attempts at IV start

2. Any complications encountered during either the insertion or the duration of the time that the patient is receiving IV therapy

3. Patient’s tolerance to the procedure

4. Circulation motion sensation (CMS) checks.

C. Graphic sheet

1. Record the patient’s I&O on the graphic sheet.

2. If daily weights are ordered by the physician, these should also be recorded on the graphic.

Key Words for Cross-References:

1. Pediatric

2. Intravenous

Reference(s):

A. Family Centered Nursing Care of Children, 2nd Edition; Cecily Lynn Betz, Mabel Metzger

Hunsberger, Stephanie Wright, W.B. Saunders’ Company, 1994, page 827.

B. Intravenous Infusion Therapy for Nurses, Principles and Practice, Diane L. Josephson, Delmar Publishes, 1999, pages 381-388.

C. Medical Surgical Unit Policy and Procedure Manual – Version 2, Medical Consultants Network Inc., 2000, pages 745.

D. Journal of Intravenous Nursing, Infusion Nursing Standards of Practice, Volume 23- Number 6S, Intravenous Nurses Society, Lippincott, Williams and Wilkins, Inc., November/December 2000, pages S19, S21-S22, S32-S33, S39.

E. Policies & Procedures for Infusion Nursing – 2002 – Infusion Nurses Society.

F. Guidelines for the Prevention of Intravascular Catheter-Related Infections, CDC,

August 9, 2002.

Attachment(s): N/A

Originator(s):

___________________________

Signature(s):

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