TITLE:



TITLE: INTRAVENOUS THERAPY – STANDARDS OF PRACTICE AND PROCEDURE

PURPOSE:

To establish an intravenous route for the administration of fluids, medication, blood or blood by-products by placement of an over-the-needle catheter (ONC) into a peripheral vein.

STANDARD OF PRACTICE:

IV therapy must be instituted by an RN or LVN, who has appropriate education in the administration of IV fluids, drugs, and blood/blood by-products and has demonstrated proficiency in insertion of IV catheters to members of the qualifier team (nursing supervisory personnel and anesthesia department members).

Orienting staff nurses will complete proficiency guidelines prior to establishing IV therapy at Mendocino Coast District Hospital.

IV therapy will be established under direct order of the attending physician(s) or, in the event of an emergency, under the order of the physician in attendance (nurse midwives, nurse anesthetists may also order IV’s.)

Equipment

▪ Appropriate fluid for establishment of IV therapy as indicated by physician’s order.

▪ IV tubing (appropriate to situation, i.e., pedi, standard, etc.).

▪ J-Port or T-Port (or equivalent).

▪ IV angio-catheter of appropriate size (20 gauge is appropriate for blood/blood products or if rapid administration of fluid is necessary).

▪ Chlorhexidire skin preparation.

▪ IV pole.

▪ Clippers or scissors.

▪ Transparent dressing and tape.

▪ Infusion Pump.

▪ IV tubing labels, with date and time.

▪ Towel or Chux.

▪ Tourniquet.

▪ Tape.

▪ Medication label (if necessary).

▪ Hand or Arm Board (if necessary for infusion of controlled drugs, hyperal or if otherwise indicated by patient’s age/condition).

▪ Gloves, disposable.

PROCEDURE:

1. If medication is added to the IV bag, place label on IV bag reflecting patient’s name, date, bottle #, and fluid used. Spike IV tubing into IV bag. Close roller clamp and invert IV bag. Fill drip chamber approximately half way. Open roller chamber approximately halfway. Open roller clamp slowly and clear IV tubing of air. Reconfirm MD’s order for fluid and rate. Open IV catheter, prep swab and transparent dressing. Prepare 4 strips of 1” tape in 4” lengths. Wash hands thoroughly. Put on gloves.

NOTE: While the transparent dressing will be the standard, gauze is an acceptable alternative.

2. Explain the procedure to the patient, educate patient in being careful not to disconnect or occlude IV tubing, or dislodge IV catheter. Ask patient to report any discomfort, swelling, redness or warmth at site immediately.

Apply tourniquet and select appropriate vein. Avoid use of patient’s dependent arm if possible and select veins that are prominent, relatively straight, and full to touch (not hard). Avoid, if possible, veins, which are of poor quality or are located near a bony prominence or joints. Consider warm moist compresses if difficult to locate veins. Apply tourniquet and select appropriate vein. Choose a site that will not interfere with client’s activities of daily living or planned procedures. Start peripherally and work centrally. In all cases, avoid the antecubital area unless there is no other alternative. The veins in the back of the hand are preferred in adults. Avoid use of patient’s dependent arm if possible and select a peripheral vein that is prominent, relatively straight, and full to the touch (not hard). If any particular person is unable to start an IV on a patient within two attempts, the most skillful person available should be asked to start the IV.

3. Site chosen for IV insertion should be prepared with the current hospital approved antiseptic with superior antimicrobial activity. Leave the antiseptic to dry on the skin for 30-seconds. It may be wiped off with alcohol 70% if desired. Straight alcohol may be used if patient is sensitive to antiseptic solution.

NOTE: IV site should not be shaved. Remove excess hair with scissors or clippers.

4. Secure vein by placing slight downward traction. Insert IV catheter needle at 20( - 30( angle over vein site and advance ¼ “ to ½ “ into vein until blood is visibly flowing into flashback chamber. Remove tourniquet. Gently slide catheter forward off needle advancing it slowly into vein. Once blood flow is seen from catheter tip, connect IV with J or T-Port to tubing, unless using ONC and clear any blood at site with alcohol. Open roller clamp slowly while securing catheter site with the other hand. Once IV establishment is confirmed, place transparent dressing over catheter site just to end of IV catheter hub. DO NOT PLACE OVER ENTIRE HUB.

5. Secure remaining IV tubing (approximately 6” – 8”) curving around site with tape strips taking care not to kink tubing or interfere with flow. If patient is restless or due to location of site an arm board is necessary, secure with Kerlix or flexnet but leave insertion site visible. Mark site with tape indicating date, time, cath used and initial.

6. IV tubing must be changed every 72 hours. New tubing (from bag to site) must be tagged with date and time of change when due. If IV site is changed due to localized irritation, new tubing must be used.

7. All IV sites will be observed every shift and rotated every 72 hours with the following exceptions:

1) Pediatric IV (i.e., children under 12 years of age require special consideration as follows:

a. Pediatric IV’s can be changed or restarted by the nurse without an order from the doctor if medications are required.

b. If there is any difficulty with starting an IV on an infant/child, the physician should be contacted.

c. Arm or Foot Boards should be used to stabilize an IV site if possible.

d. When the pediatric IV sites have been dressed with an occlusive dressing by the doctor, the doctor will write an order stating how frequently the nurse will check the site by removing the dressing.

2) If the IV must remain in one site for more than 72 hours due to lack of other potential sites, etc., q48 hour dressing changes are recommended. The doctor must be notified and an order given to have the catheter in place.

EXCEPTIONS:

When blood products or fat emulsions are being administered, or infusion related septicemias are occurring in increased numbers, delivery systems should be replaced at least every 24 hours, or after every second unit of blood. For IV Propofol tubing must be changed every 12 hours.

8. Infiltration: An infiltration is indicated by swelling and possible edema, pallor, pain at the insertion, and possible decrease in the flow rate. There may or may not be any blood return. When infiltration occurs, take the following steps:

▪ Infusion must be discontinued and if necessary, reinserted into another extremity.

▪ In the event the infusion includes any medication that may be harmful to the surrounding tissue, (i.e., kcl, dopamine), the pharmacist and/or the attending physician should be immediately contacted for appropriate site care. (Refer to Policy and Procedure “Chemotherapy – Extravasation” for care for extravasations of cytotoxic agents.

▪ If a medication is being infused into a site determined to be infiltrated, the physician should be contacted for clarification if the medication should be re-administered after another site has been started.

New: Revised: 03/09

Approval Signatures:

________________________________ ______________________

Nurse Manager Date

________________________________ ______________________

Chief Clinical Officer Date

________________________________ ______________________

Medical Chief of Staff Date

________________________________ ______________________

Chief Executive Officer Date

________________________________ ______________________

President, Board of Directors Date

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