Chapter 40. Fluid, Electrolyte, and Acid Base Balance. Procedures Checklist INTRAVENOUS THERAPY. Procedure 40.1: Starting an Intravenous Infusion

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1 Procedures Checklist INTRAVENOUS THERAPY Chapter 40 Fluid, Electrolyte, and Acid Base Balance Procedure 40.1: Starting an Intravenous Infusion Performed Preparation Yes No Mastered Comments 1. Assess: Vital signs for baseline data Skin turgor Allergy to tape or iodine Bleeding tendencies Disease or injury to extremities Status of veins to determine appropriate venipuncture site 2. Consider: How long the patient is likely to have the IV What kinds of fluids will be infused What medications the patient will be receiving or is likely to receive 3. Assemble equipment and supplies: Infusion set Container of sterile parenteral solution IV pole Adhesive or nonallergenic tape Clean gloves Tourniquet Antiseptic swabs Antiseptic ointment, such as povidone-iodine (optional) Intravenous catheter; see Variation at the end of this procedure for use of a butterfly (winged-tip) needle Sterile gauze dressing or transparent occlusive dressing Arm splint, if required Towel or pad Electronic infusion device or pump 4. Unless initiating IV therapy is urgent, provide any scheduled care before establishing the infusion to minimize movement of the affected limb during the procedure.

2 5. Make sure that the client s clothing or gown can be removed over the IV apparatus if necessary. Procedure 1. Explain to the client what you are going to do, why it is necessary, and how she can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Open and prepare the infusion set. Remove tubing from the container and straighten it out. Slide the tubing clamp along the tubing until it is just below the drip chamber to facilitate its access. Close the clamp. Leave the ends of the tubing covered with the plastic caps until the infusion is started. 5. Spike the solution container. Remove the protective cover from the entry site of the bag. Remove the cap from the spike, and insert the spike into the insertion site of the bag or bottle. Follow manufacturer s instructions. 6. Apply a medication label to the solution container if a medication was added. 7. Apply a timing label on the solution container. The timing label may be applied at the time the infusion is started. Follow agency practice. 8. Hang the solution container on the pole. Adjust the pole so that the container is suspended about 1 m (3 ft) above the client s head. 9. Partially fill the drip chamber with solution. Squeeze the chamber gently until it is half full of solution. 10. Prime the tubing. Remove the protective cap, and hold the tubing over a container. Maintain the sterility of the end of the tubing and the cap. Release the clamp, and let the fluid run through the tubing until all bubbles are removed. Tap the tubing with your fingers if necessary to help the bubbles move.

3 Reclamp the tubing, and replace the tubing cap, maintaining sterile technique. For caps with air vents, do not remove the cap when priming this tubing. If an infusion control pump, electronic device, or controller is being used, follow the manufacturer s directions for inserting the tubing and setting the infusion rate. 11. Wash your hands. 12. Select the venipuncture site. Unless contraindicated, use the client s nondominant arm. Check agency protocol about shaving if the site is very hairy. Place a towel or bed protector under the extremity to protect linens. 13. Dilate the vein. Place the extremity in a dependent position. Apply a tourniquet firmly cm (6 8 in) above the venipuncture site. If the vein is not sufficiently dilated: Massage or stroke the vein distal to the site and in the direction of venous flow toward the heart. Encourage the client to clench and unclench the fist. Lightly tap the vein with your fingertips. If the preceding steps fail to distend the vein so that it is palpable, remove the tourniquet and apply heat to the entire extremity for minutes. 14. Don clean gloves and clean the venipuncture site. Clean the skin at the site of entry with a topical antiseptic swab, 2% chlorhexidine, or alcohol. Check for allergies to iodine or shellfish before cleansing skin with Betadine or iodine products. Use a circular motion, moving from the centre outward for several inches. Permit the solution to dry on the skin.

4 15. Insert the catheter, and initiate the infusion. If desired and permitted by policy, inject 0.05 ml of 1% lidocaine intradermally over the site where you plan to insert the IV needle. Allow 5 10 seconds for the anesthetic to take effect. Use the nondominant hand to pull the skin taut below the entry site. Holding the over-the-needle catheter at a 15- to 30-degree angle with the bevel up, insert the catheter through the skin and into the vein in one thrust. Once blood appears in the lumen of the needle or you feel the lack of resistance, reduce the angle of the catheter until it is almost parallel with the skin, and advance the needle and catheter approximately cm (about _ inch) further. Holding the needle portion steady, advance the catheter until the hub is at the venipuncture site. Release the tourniquet. Remove the protective cap from the distal end of the tubing, and hold it ready to attach to the catheter, maintaining the sterility of the end. Carefully remove the needle, engage the needle safety device, and attach the end of the infusion tubing to the catheter hub. Initiate the infusion. 16. Tape the catheter. Tape the catheter by the U method. Using three strips of adhesive tape, each about 7.5 cm (3 in) long: Place one strip, sticky-side up, under the catheter s hub. Fold each end over so that the sticky sides are against the skin. Place second strip, sticky-side down, over catheter hub. Place third strip, sticky-side down, over tubing hub. 17. Dress and label the venipuncture site and tubing according to agency policy. Cover venipuncture site according to policy. Remove soiled gloves and discard appropriately. Loop the tubing and secure it with tape.

5 Label the dressing with the date and time of insertion, type and gauge of needle or catheter used, and your initials. 18. Ensure appropriate infusion flow. Apply a padded arm board to splint the joint, as needed. Adjust the infusion rate of flow according to the order. 19. Label the IV tubing. Label the tubing with the date and time of attachment and your initials. 20. Document relevant data. Record: The time of the start of the infusion The flow rate of the transfusion The date and time of the venipuncture The amount and type of solution used, including any additives The type and gauge of the needle or catheter The venipuncture site The client s general response Variation: Inserting a Butterfly (Winged-Tip) Needle Procedure Hold the needle, pointed in the direction of the blood flow, at a 30- degree angle, with the bevel up, and pierce the skin beside the vein about 1 cm (_ inch) below the site planned for piercing the vein. Once the needle is through the skin, lower the needle so that it is almost parallel with the skin. When blood flows back into the needle tubing, insert the needle to its hub. Release the tourniquet, attach the infusion, and initiate flow as quickly as possible. Securing a Butterfly Needle Tape the butterfly needle securely by the crisscross (chevron) method. Place a small gauze square under the needle, if required.

6 Procedure 40.2: Monitoring a Peripheral Intravenous Infusion Performed Preparation Yes No Mastered Comments 1. Assess: Appearance of infusion site Patency of system Type of fluid being infused Rate of flow Response of the client 2. Determine: The type and sequence of solutions to be infused (from orders prescribed) The rate of flow and infusion schedule Procedure 1. Ensure that the correct solution is being infused. If the solution in incorrect, slow the rate of flow to a minimum to maintain the patency of the catheter. Change the solution to the correct one. Document and report the error according to agency protocol. 2. Observe the rate of flow every hour. Compare the rate of flow regularly for example, every hour against the infusion schedule. If the rate is too fast, slow it so that the infusion will be completed at the planned time. If the rate is too slow, check agency practice. If the rate of flow is 150 ml/h or more, check the rate of flow more frequently for example, every minutes. 3. Inspect the patency of the IV tubing and needle. Observe the position of the solution container. If it is less than 1 m (3 ft) above the IV site, readjust it to the correct height of the pole. Observe the drip chamber. If it is less than half full, squeeze the chamber to allow the correct amount of fluid to flow in. Open the drip regulator, and observe for a rapid flow of fluid from the solution container into the drip chamber. Then partially close the drip regulator to reestablish the prescribed rate of flow.

7 Inspect the tubing for pinches, kinks, or obstructions to flow. Arrange the tubing so that it is lightly coiled and under no pressure. Observe the position of the tubing. If it is dangling below the venipuncture, coil it carefully on the surface of the bed. Lower the solution container below the level of the infusion site, and observe for a return flow of blood from the vein. Determine whether the bevel of the catheter is blocked against the wall of the vein. If there is leakage, locate the source. If the leak is at the catheter connection, tighten the tubing into the catheter. If the leak cannot be stopped, slow the infusion as much as possible without stopping it, and replace the tubing with a new sterile set. Estimate the amount of solution lost, if it was substantial. 4. Inspect the insertion site for fluid infiltration. Assess for infiltration at IV site: Swelling Coolness Pallor Discomfort If an infiltration is present, stop the infusion and remove the catheter. Restart the infusion at another site. Apply a warm compress to the site of the infiltration. 5. If infiltration is not evident but the infusion is not flowing, determine whether the needle is dislodged from the vein. Gently pinch the IV tubing adjacent to the needle site. Use a sterile syringe of saline to withdraw fluid from the port near the venipuncture site. If blood does not return, discontinue the intravenous solution.

8 6. Inspect the insertion site for phlebitis. Inspect and palpate the site at least every 8 hours. If phlebitis is detected, discontinue the infusion, and apply warm compresses to the venipuncture site. Do not use this injured vein for further infusions. 7. Inspect the intravenous site for bleeding. Oozing or bleeding into the surrounding tissues can occur while the infusion is flowing freely, but is more likely to occur after the needle has been removed from the vein. Observation of the venipuncture site is extremely important for clients who bleed readily, such as those receiving anticoagulants. 8. Teach the client ways to maintain the infusion system. For example: Avoid sudden twisting or turning movements of the arm with the needle or catheter. Avoid stretching or placing tension on the tubing. Try to keep the tubing from dangling below the level of the needle. Instruct client to notify a nurse if: The flow rate suddenly changes or the solution stops dripping. The solution container is nearly empty. There is blood in the IV tubing. Discomfort or swelling is experienced at the IV site. 9. Document all relevant information.

9 Procedure 40.3: Changing an Intravenous Container, Tubing, and Dressing Performed Preparation Yes No Mastered Comments 1. Assess: Presence of fluid infiltration, bleeding, or phlebitis at IV site Allergy to tape or iodine Infusion rate and amount absorbed Blockages in IV system Appearance of the dressing for integrity, moisture, and need for change The date and the time of the previous dressing change 2. Determine: Physician s orders for changes in fluid administration 3. Assemble equipment and supplies: Administration set, including sterile tubing and drip chamber Timing label Sterile gauze square for positioning the needle For the Dressing Clean disposable gloves Sterile 2" x 2" or 4" x 4" gauze or transparent dressing Adhesive remover Povidone-iodine swabs Alcohol swabs Optional: Antiseptic ointment (e.g., povidone-iodine or other recommended by the agency) Tape Towel 4. Obtain the correct solution container: Read the label of the new container. Verify that you have the correct solution, correct client, correct additives (if any), and correct dose (number of bags or total volume ordered). Procedure 1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy.

10 4. Set up the intravenous equipment with the new container, and label them. See Procedure 40-1, steps 1 to 8. Apply a timing label to the container. Prime the tubing. Label the tubing. 5. Prepare the IV needle or catheter tape and the dressing equipment. Prepare strips of tape as needed for the type of needle or catheter. Hang the pieces of tape from the edge of a table. Open all equipment: swabs, dressing and adhesive bandage, and ointment. Place a towel under the extremity. Don gloves. 6. Remove the soiled dressing and all tape, except the tape holding the catheter or IV needle in place. Remove tape and gauze from the old dressing one layer at a time. Remove adhesive dressings in the direction of the client s hair growth when possible. Discard the used dressing materials in the appropriate container. 7. Assess the IV site. Inspect the IV site for the presence of infiltration or inflammation. Go to step 8, or discontinue and relocate the IV site if indicated. 8. Disconnect the used tubing. Place a sterile swab under the hub of the catheter. Clamp the tubing. Holding the hub of the catheter with the nondominant hand, loosen the tubing with the dominant hand, using a twisting, pulling motion. Remove the used IV tubing. Place the end of the tubing in the basin or other receptacle. 9. Connect the new tubing, and reestablish the infusion. Continue to hold the catheter, and grasp the new tubing with the dominant hand. Remove the protective tubing cap and, maintaining sterility, insert the tubing end securely into the needle hub. Twist it to secure it. Open the clamp to start the solution flowing. 10. Remove the tape securing the needle or catheter.

11 When removing this tape, stabilize the needle or catheter hub with one hand. 11. Clean the IV site. Start with adhesive remover to remove adhesive residue. Then, using chlorhexidine swabs or alcohol and povidone-iodine swabs, clean the site, beginning at the catheter or needle and cleaning outward in a 5 cm (2 in) diameter. Follow agency protocol about cleaning procedures. 12. Retape the needle or catheter. For a butterfly needle, apply strips of tape to the wings of the butterfly using the crisscross (chevron) method. For a catheter, apply the tape using the U method. 13. Apply antiseptic ointment or solution, if indicated, and apply the dressing. Place povidone-iodine ointment or solution at the entry site, in accordance with agency protocol. Apply a sterile gauze or transparent dressing over the site. Remove gloves. 14. Label the dressing, and secure IV tubing. Place the date and time of the dressing change and your initials either on the label provided or directly over the top of the dressing. Secure IV tubing with additional tape, as required. 15. Regulate the rate of flow of the solution according to the order on the chart. 16. Document all relevant information. Record the change of the solution container, tubing, and/or dressing in the appropriate place on the client s chart. Record the fluid intake, according to agency practice. Record the number of the container if the containers are numbered at the agency. Record your assessments. Procedure 40.4: Discontinuing a Peripheral Intravenous Infusion Performed Preparation Yes No Mastered Comments

12 1. Assess: Appearance of the venipuncture site Any bleeding from the infusion site Amount of fluid infused Appearance of IV catheter 2. Determine: Physician s order to discontinue IV 3. Assemble equipment and supplies: Clean gloves Dry or antiseptic-soaked swabs, according to agency practice Small sterile dressing and tape Procedure 1. Explain to the client what you are going to do, why it is necessary, and how she can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Prepare the equipment. Clamp the infusion tubing. Loosen the tape at the venipuncture site while holding the needle firmly and applying countertraction to the skin. Don clean gloves, and hold sterile gauze above the venipuncture site. 5. Withdraw the needle or catheter from the vein. Withdraw the needle or catheter by pulling it out along the line of the vein. Immediately apply firm pressure to the site, using sterile gauze, for 2 3 minutes. Hold the client s arm or leg above the body if any bleeding persists. 6. Examine the catheter removed from the client. Check the catheter to make sure it is intact. Report a broken catheter to the nurse in charge or physician immediately. If the broken piece can be palpated, apply a tourniquet above the insertion site. 7. Cover the venipuncture site. Apply the sterile dressing. Discard the IV solution container, if infusions are being discontinued, and discard the used supplies appropriately.

13 8. Document all relevant information. Record the amount of fluid infused on the intake and output record and on the chart.

14 Procedure 40.5: Changing a Peripheral Intravenous Catheter to an Intermittent Infusion Lock Performed Preparation Yes No Mastered Comments 1. Assess: Patency of the IV catheter Appearance of the site 2. Assemble equipment and supplies: Intermittent infusion cap or device Clean gloves Sterile 2" x 2" or 4" x 4" gauze Sterile saline for injection (without preservative) or heparin flush solution (10 units/ml or 100 units/ml) in a prefilled syringe, or a 3 ml syringe with a needle-less infusion device Isopropyl alcohol wipe Tape Clean emesis basin Procedure 1. Explain to the client what you are going to do, why it is necessary, and how she can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Assess the IV site (if visible) and determine the patency of the catheter. If the catheter is not fully patent, or if there is evidence of phlebitis or infiltration, discontinue the catheter and establish a new IV site. Expose the IV catheter hub and loosen any tape that is holding the IV tubing in place or that will interfere with insertion of the intermittent infusion plug into the catheter. Clamp the IV tubing to stop the flow of IV fluid. Open the gauze pad and place it under the IV catheter hub. Open the alcohol wipe and intermittent infusion plug, leaving the plug in its sterile package. 4. Remove the IV tubing and insert the intermittent infusion plug into the IV catheter. Don clean gloves.

15 Stabilize the IV catheter with your nondominant hand and use the little finger to place slight pressure on the vein above the end of the catheter. Twist the IV tubing adapter to loosen it from the IV catheter and remove it, placing the end of the tubing in a clean emesis basin. Pick up the intermittent infusion plug from its package and remove the protective sleeve from the male adapter, maintaining its sterility. Insert the plug into the IV catheter, twisting it to seat it firmly or engage the Luer lock. 5. Instill saline or heparin solution per agency policy. 6. Tape the intermittent infusion plug in place using a chevron or U method. 7. Teach the client how to maintain the lock. Avoid manipulating the catheter or infusion plug, and protect it from catching on clothing or bedding. A gauze bandage such as Kerlix or Kling may be wrapped over the plug when it is not in use to protect it. Cover the site with an occlusive dressing when showering; avoid immersing the site. Flush the catheter with saline or heparin solution as directed. Notify the nurse or primary care provider if the plug or catheter comes out, if the site becomes red, inflamed, or painful, or if any drainage or bleeding occurs at the site. 8. Document all relevant information.

16 Procedure 40.6: Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set Performed Preparation Yes No Mastered Comments 1. Assess: Manifestations of hypervolemia Status of infusion site Any unusual symptoms Vital signs for baseline data 2. Determine: That a signed consent form was obtained Any known allergies or previous adverse reactions to blood 3. Assemble equipment and supplies: Unit of whole blood, or packed RBCs Blood administration set 250 ml normal saline for infusion IV pole Venipuncture set containing a #18 or #19 gauge needle or catheter (if one is not already in place) or, if blood is to be administered quickly, a #15 gauge needle or a larger catheter (e.g., #14) Povidone-iodine solution or scrub pad Alcohol swabs Tape Gloves 4. Prepare the client. Instruct the client to report promptly any sudden chills, nausea, itching, rash, dyspnea, back pain, or other unusual symptoms. If the client has an intravenous solution infusing, check whether the needle and solution are appropriate to administer blood. If the client does not have an IV solution infusing, check agency policies. Procedure 1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Obtain the correct blood component for the client.

17 Check the physician s order with the requisition. Check the requisition form and the blood bag label with a laboratory technician, or according to agency policy. Observe the blood for abnormal colour, RBC clumping, gas bubbles, and extraneous material. Return outdated or abnormal blood to the blood bank. With another nurse, compare the laboratory blood record with: The client s name and identification number. The number on the blood bag label. The ABO group and Rh type on the blood bag label. If any of the information does not match exactly, notify the charge nurse and the blood bank. Do not administer blood until discrepancies are corrected or clarified. Sign the appropriate form with the other nurse, according to agency policy. Make sure that the blood is left at room temperature for no more than 30 minutes before starting the transfusion. 5. Verify the client s identity. Ask the client s full name. Check the client s armband for name and ID number. 6. Set up the infusion equipment. Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood components to be transfused. Attach the blood tubing to the blood filter, if necessary. Put on gloves. Close all the clamps on the Y-set: the main flow rate clamp and both Y-line clamps. Using a twisting motion, insert the piercing pin (spike) into a container of 0.9 percent saline solution. Hang the container on the IV pole about 1 m (3 ft) above the planned venipuncture site. 7. Prime the tubing. Open the upper clamp on the normal saline tubing, and squeeze the drip chamber until it covers the filter and one-third of the drip chamber above the filter. Tap the filter chamber to expel any residual air in the filter.

18 Remove the adapter cover at the tip of the blood administration set. Open the main flow rate clamp, and prime the tubing with saline. Close both clamps. 8. Start the saline solution. If an IV solution incompatible with blood is infusing, stop the infusion and discard the solution and tubing, according to agency policy. Attach the blood tubing primed with normal saline to the intravenous catheter. Open the saline and main flow rate clamps and adjust the flow rate. Use only the main flow rate clamp to adjust the rate. Allow a small amount of solution to infuse, to make sure there are no problems with the flow or with the venipuncture site. 9. Prepare the blood bag. Invert the blood bag gently several times to mix the cells with the plasma. Expose the port on the blood bag by pulling back the tabs. Insert the remaining Y-set spike into the blood bag. Suspend the blood bag. Close the upper clamp below the IV saline solution on the Y-set. Open the clamp on the blood arm of the Y-set, and prime the tubing. 10. Establish the blood transfusion. The blood will run into the salinefilled drip chamber. If necessary, squeeze the drip chamber to reestablish the liquid level with drip chamber one-third full. Readjust the flow rate with the main clamp. 11. Observe the client closely for the first 5 10 minutes. Run the blood slowly for the first 15 minutes at 20 drops per minute. Note adverse reactions, such as chilling, nausea, vomiting, skin rash, or tachycardia. Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion. If any of these reactions occur, report these to the nurse in charge, and take appropriate nursing action. 12. Document relevant data. Record:

19 Starting the blood Vital signs Type of blood Blood unit number Sequence number Site of the venipuncture Size of the needle Drip rate 13. Monitor the client. Fifteen minutes after initiating the transfusion, check the vital signs of the client. If there are no signs of a reaction, establish the required flow rate. Do not transfuse a unit of blood for longer than 4 hours. Assess the client, including vital signs, every 30 minutes or more often, depending on the health status, until 1 hour post-transfusion. If the client has a reaction and the blood is discontinued, send the blood bag to the laboratory for investigation of the blood. 14. Terminate the transfusion. Don clean gloves. If no infusion is to follow, clamp the blood tubing and remove the needle. If another transfusion is to follow, clamp the blood tubing and open the saline infusion arm. If the primary IV is to be continued, flush the maintenance line with saline solution. Disconnect the blood tubing system and reestablish the intravenous infusion using new tubing. Adjust the drip to the desired rate. Discard the administration set, according to agency practice. Needles should be placed in a labelled, puncture-resistant container designed for such disposal. Blood bags and administration sets should be bagged and labelled before being sent for decontamination and processing. See agency policy. Remove gloves. Monitor vital signs again. 15. Follow agency protocol for appropriate disposition of the blood bag. On the requisition attached to the blood unit, fill in the time the transfusion was completed and the amount transfused. Attach one copy of the requisition to the client s record and another to the empty blood bag.

20 Return the blood bag and requisition to the blood bank. 16. Document relevant data. Record: Completion of the transfusion. Amount of blood absorbed. The blood unit number. Vital signs. If the primary intravenous infusion was continued, record connecting it. Also record the transfusion on the IV flow sheet and Intake and Output record.