IV Therapy Manual - Final 2023 PDF

1|Page Revised: September 2023 For revision on September 2025 and as needed  TABLE OF CONTENTS INTRAVENOUS (IV) THERAPY AND PHLEBOTOMY Intravenous Therapy I. Introduction 5 Aim Lear...

1|Page Revised: September 2023 For revision on September 2025 and as needed  TABLE OF CONTENTS INTRAVENOUS (IV) THERAPY AND PHLEBOTOMY Intravenous Therapy I. Introduction 5 Aim Learning Outcomes II. Anatomy and Physiology 6 Layers of the Vessel III. Definition of Terms 7 IV. Type of Intravenous Fluids 9 Intravenous Infusion Intravenous Flow Rate Calculating Flow Rates V. Types of Vascular Access Device 11 VAD Selection and Management Algorithm VI. Performing Peripheral Intravenous Cannulation 13 Site Selection Site Preparation Cannula Selection Types of Catheters and Cannulas Cannula Placement Improving Venous Access Maintaining Patency of Vascular Access Devices Flushing Indications Heparin Lock Solution for Vascular Access Device Securing the Cannula Device Stabilization Types of Central Venous Catheters VII. Intravenous Therapy Maintenance 22 Monitoring and Assessment Dressing Aseptic Technique Aseptic Non Touch Technique Flushing and Locking Care and Maintenance of Central Catheter Application of Tegaderm Dressing Central Line Associated Blood Stream Infection (CLABSI) Insertion Bundle 2|Page Revised: September 2023 For revision on September 2025 and as needed  Central Line Management Types of Add on Devices for Intravenous Therapy VIII. Complication of Vascular Access Devices 29 Phlebitis Phlebitis Scale Infiltration and Extravasation Infiltration Scale Extravasation Types Nerve Injury Central Venous Access Device Occlusion Classification of Occlusion Infection Catheter – Associated Bloodstream Infection (CABSI) Catheter – Related Blood Stream Infection Central Line – Associated Bloodstream Infection (CLABSI) Catheter Damage (Embolism, Repair, Exchange) Air Embolism Catheter Associated Deep Vein Thrombosis Central Venous Access Device Malposition IX. Documentation of IV Therapy 39 Documentation in ESIHI Histories, Peripheral IV, Central Line and CLABSI Maintenance Bundle Phlebotomy X. Phlebotomy 41 Definition of Terms Guidelines for Phlebotomy Patient Identification Identifying the Conscious/Coherent patient Identifying the Unconscious/Incoherent Patient Patient Preparation Site Selection for Venipuncture Venipuncture Procedure Use of Tourniquet Devices and Materials for Phlebotomy Labeling of Samples Pre-Analytical Variables 3|Page Revised: September 2023 For revision on September 2025 and as needed  Collection of Tube Chart and Order Draw Order of Inversion Blood Culture Collection Devices and Materials for Blood Culture Complication of Blood Collection Handling Specimens Documentation in ESIHI X. References 58 4|Page Revised: September 2023 For revision on September 2025 and as needed  INTRAVENOUS THERAPY I. INTRODUCTION Intravenous Therapy is the infusion of liquid substances directly into a vein. Intravenous (IV) means “within vein” and it is considered as the fastest way to deliver fluids and medications throughout the body. It is for the purpose of fluid administration (such as correcting dehydration), to correct electrolyte imbalances, to deliver medications and for blood transfusions. This therapy is provided in accordance with the laws, rules, and accrediting bodies in all patient care settings as defined and promulgated by the states/country. As a standard of practice, the Nurse inserting devices and or providing infusion therapy should be competent in all clinical aspects of infusion therapy and have validated competency in clinical judgment and practice, thus they will maintain their knowledge and skills. (Collins et.al, 2006; NMC, 2007; Hyde,20058; NMC 2008). AIM The aim of this course is to enhance participants’ knowledge, skills and attitude as responsible practitioner for initiating, monitoring, maintaining, discontinuing the intravenous infusion and for teaching client related to infusion. LEARNING OUTCOMES: At the end of the session, participants will be able to: 1. To recall the anatomy and physiology of vascular vessel. 2. To discuss the maintenance and care of Intravenous Therapy (IVT) 3. To discuss the responsibility on initiation, monitoring and documentation of Intravenous Therapy. 4. Identify available devices for Intravenous Therapy. 5. Identify types and definitions of Vascular Access Device (VAD) 6. To identify complications of Intravenous Therapy. 7. Identify KSUMC policies and practices for maintenance and care for Peripheral and Central Lines. 5|Page Revised: September 2023 For revision on September 2025 and as needed II. ANATOMY AND PHYSIOLOGY The systemic circulation consists of the arterial and the venous systems. The venous system channels blood from the capillary bed back to the vena cava and the right atrium of the heart. The blood travels to the right ventricle of the heart where it is pumped to the lungs, via the pulmonary artery, for oxygenation. The lungs oxygenate the blood and it flows via the left atrium to the left ventricle, which pumps the blood to the aorta and all parts of the body. Arteries are a high-pressure system and a pulse can be palpated. The muscle layer in arteries is stronger and they will not collapse like veins. Arteries are also deeper than veins and are surrounded by nerve endings, making arterial puncture painful. The venous system consists of superficial and deep veins. The superficial or cutaneous veins are those used for venipuncture. Superficial veins and deep veins unite freely in the lower extremities. For example, the small saphenous vein which drains the dorsum of the foot ascends the back of the leg and empties directly into the deep popliteal vein. Because thrombosis of the superficial veins of the lower extremities can easily extend to the deep veins, it is important to avoid the use of these veins. Superficial veins are bluish in color. The pressure within veins is low and therefore a pulse will not be palpated in a vein. Blood in the venous system is moved back to the heart by valves and the action of muscular contraction. Damage to the valves results in stasis of blood and varicosities. Initiation of an IV below a varicosity will result in reduced flow and decreased absorption of added medications, and should be avoided. 6|Page Revised: September 2023 For revision on September 2025 and as needed III. DEFINITION OF TERMS INTRAVENOUS THERAPY  Is giving of liquid substances directly into a vein.  Is an invasive vascular procedure, which means that one of the body’s lines of defense against infection is broken by the entry of a catheter into a vein. CONTINOUS INTRAVENOUS THERAPY  Is an infusion of fluid and other chemical infusates continuously over a prolonged period. 7|Page Revised: September 2023 For revision on September 2025 and as needed INTERMITTENT IV THERAPY  Is an infusion of fluid, I.V. drugs, blood, and blood products at specific intervals for short period. VASCULAR ACCESS DEVICE  Are inserted into veins via peripheral or central vessels for diagnostic or therapeutic reasons, such as blood sampling, central venous pressure readings, administration of medication, fluids, total parenteral nutrition (TPN) and blood transfusions PERIPHERAL LINES  Peripheral intravenous (PIV) line is used on peripheral veins (the veins in the arms, hands, legs and feet). This is the most common type of IV therapy used.  Is the insertion of a catheter or a cannula into a vein based on physicians’ written order. CENTRAL LINES  Catheters that are advanced through a vein and empty into a large central vein (a vein within the torso), usually the superior vena cava, inferior vena cava or even the right atrium of the heart. INTRAVENOUS CANNULATION  Is a clinical or technical skill that is performed by a professional registered nurse and is considered as the simplest invasive procedure. This is the insertion of a flexible cannula / IV catheter inserted in the patient’s vein for therapeutic administration of intravenous fluid and IV medication, TPN, chemotherapy and blood and blood products. CENTRAL VENOUS ACCESS DEVICES (CVAD)  A broad term that includes many types of catheters (thin, flexible hollow tubes) that are inserted into and positioned within a vein in the body to deliver therapies to the bloodstream. VENIPUNCTURE  Procedure to obtain sample of blood for diagnostic purposes. 8|Page Revised: September 2023 For revision on September 2025 and as needed IV. TYPE OF FLUIDS A. INTRAVENOUS (IV) INFUSION 1. INDICATIONS FOR ADMINISTERING AN INTRAVENOUS (IV) INFUSION 1. Dehydration - when oral replacement is inadequate or impossible 2. To replace blood and blood products 3. To maintain or replace electrolytes 4. Administer medications and dilute poisons in the blood 5. To provide a source of nutrients 6. To administer water-soluble vitamins 2. FLUID REPLACEMENT THERAPY 1. Whole Blood 2. Packed Red Blood Cells 3. Fresh Frozen Plasma 4. Colloids – contain protein or other high molecular weight molecules 1. Plasma Protein Fraction 2. Salt-poor albumin 3. Dextran 4. Hetastarch 5. Crystalloids 9|Page Revised: September 2023 For revision on September 2025 and as needed  3. COMMONLY USED INTRAVENOUS SOLUTIONS 3.1 Normal Saline solutions (NSS 0.9% NaCl) Descriptions a. Isotonic Solutions contains same amounts of sodium and chloride that are found in plasma. b. Contains 9 grams of sodium chloride per 1000 ml water. Indications a. Solution of choice to be used in conjunctions with a blood transfusion. b. Indicated for restoring the loss of body fluid. 3.2. Ringer’s Solution or lactated Ringer’s (LR) Description a. An isotonic solution that replaces electrolytes in amounts similarly found in plasma b. Contain sodium chloride, potassium chloride, calcium chloride and sodium lactate. Indications a. Solution of choice for burns. b. Most cases of dehydration c. Supportive treatment for trauma. 3.3. Five Percent Dextrose and Water (D5W) Description a. An isotonic solution b. The glucose is metabolized quickly, leaving a solution of diluted water. c. Contains 5 grams of dextrose per 100 ml of water. Indications a. Provides a source of calorie replacement. b. Solution of choice when glucose is needed for metabolism (hypoglycemia). 10 | P a g e Revised: September 2023 For revision on September 2025 and as needed  B. INFUSION FLOW RATE V. TYPE OF VASCULAR ACCESS DEVICES (VAD) 1. Peripheral Intravenous  Short peripheral venous catheter (< 7.5 cm in length) usually inserted in the veins of the forearm or hand, mainly used for short – term venous access. 2. Midline Catheter  Peripherally inserted catheter that tip is not centrally placed.  Long catheters and it is inserted in the large vein. 3. Central Vascular Access Device  Non – Tunneled  Tunneled  PICC  Implanted Port – venous line that does not have an external connector, instead it has a small reservoir implanted under the skin. 11 | P a g e Revised: September 2023 For revision on September 2025 and as needed  4. Intraosseous (IO) Devices Intraosseous (IO) devices are designed for rapid insertion into the bone marrow where fluids and medications are quickly absorbed. 5. Arterial Catheter  Is a thin catheter inserted into an artery. 12 | P a g e Revised: September 2023 For revision on September 2025 and as needed VI. PERFORMING PERIPHERAL INTRAVENOUS CANNULATION 1. Site Selection  Assessment is a very important part of IV Cannulation. Knowledge of the anatomy and Physiology of a vascular vessel is necessary when choosing an IV site.  Start with distal veins and work proximally.  Starting at the most proximal point can potentially lose several sites you could have below it.  Always use veins in the upper extremity before using lower extremity General Rules in Selecting an IV Site 2. Site Preparation Chlorhexidine: Scrub for 30 sec, wait for 30 secs to dry (Total contact time 1mt) 1% chlorhexidine – for peripheral line 2%chlorhexidne-is preferred for peripheral blood culture& Central venous catheters Chlorhexidine: Recommended in KSUMC 13 | P a g e Revised: September 2023 For revision on September 2025 and as needed  A. Veins commonly used for IV Cannulation 1. Cephalic Vein 2. Basilic Vein 3. Metacarpal Vein B. Veins used for Neonatal Patients 1. Temporal vein (scalp vein) 2. Dorsal venous arch (lower extremities) 3. Lesser and great saphenous vein (lower extremities) 4. Veins of the upper extremities C. Veins to use – (short peripheral IV) 1. Distal veins first 2. Easily palpable veins with good capillary refill 3. Veins on the non-dominant side 4. Veins on the opposite side to surgical procedure. 5. Veins with the largest diameter possible D. Veins to Avoid During IV Cannulation 1. Vein in the lower extremities 2. Point of flexion 3. Veins closed to arteries 4. Median cubital vein which should be reserve for venous sampling 5. Small, visible but impalpable superficial veins 6. Veins that may have been irritated from previous site 7. Fragile and sclerotic veins 8. Areas of lymph edema 9. Infected areas 10. Veins beneath the broken skin 11. Arm with AV fistula 12. Patient with weak arm or loss of sensation Factors to Consider for the Choice of Cannula 1. Condition and history of the patient. 2. Types of infusion 3. Purpose of infusion 4. Duration of the treatment 5. Size and the current condition of the patient. 14 | P a g e Revised: September 2023 For revision on September 2025 and as needed  TYPES OF CATHETERS AND CANNULAS 15 | P a g e Revised: September 2023 For revision on September 2025 and as needed Cannula Placement Before the IV cannulation is performed, the cannula is inspected for product integrity. Skin stabilization is an important element of successful cannulation. Veins are stabilized by applying traction to the sides of the insertion site to prevent the vein from rolling. Strict aseptic technique shall be adhered to. In an emergency, when an IV cannula has been placed without adequate skin preparation, the IV cannula should be removed at the earliest opportunity. A cannula should be secured to stabilize at the insertion site. The type, gauge, length, insertion date, time of insertion, initial of the person who inserted and ward allocation should be written and documented accordingly. Improving Venous Access 1. Application of a tourniquet promotes venous distention and should be applied enough to impede only the venous and not the arterial flow. The act of opening and closing the fist the enables the muscles to force the blood in the veins causing them to distend. 2.Tapping of the vein too hard, the pain may occur and cause vasoconstriction or they may rupture creating hematoma. 3. Warm compress may be applied to the extremity for 10 minutes before the insertion to increase vasodilation and promote venous filling. 4. lowering the extremity below the heart level also improves venous filling. Maintaining the Patency of VADS It is important at all times for the patency of the device to be manifested. Two types of solutions are used to maintain the patency of VADS. (1) Normal Saline Solution - is used to clean internal diameter of the device and of blood and drugs and (2) Heparinized Saline - solution that which is used to prevent the buildup of fibrin. It has been suggested that one of the most important aspects of maintain patency is the method of flushing. When a vascular access device is flushed. 1.) Positive Pressure and 2.) Pulsatile Flushing must be maintained on the lumen of the cannula to prevent a reflux of blood in to the cannula lumen. Positive pressure is maintained by keeping a forward motion on the syringe plunger as the needle from the injection port. Pulsatile Flushing /push pause technique is the use of stop/start flushing technique, to create turbulence in the lumen of the catheter, remove debris, and avoid blockage of the catheter. 16 | P a g e Revised: September 2023 For revision on September 2025 and as needed Flushing Indications 1. Before and after each administration of medication 2. After withdrawal of blood 3. When the cannula is not being used 4. When converting continuous infusion to an intermittent one 5. After administration of blood or blood products 6. When converting a continuous infusion to an intermittent device Securing the Cannula It is important to secure the cannula to prevent mechanical phlebitis. A sterile dressing is applied over the cannula catheter insertion site. A transparent semipermeable membrane is the most commonly used cannula – site dressing. It is water resistant sterile dressing, permeable to air, that enables continual visual inspection and observation of the insertion site. If the device is located over a joint, it should be splinted to prevent movement and possible dislodgement. 17 | P a g e Revised: September 2023 For revision on September 2025 and as needed Device Stabilization Protocols for stabilization of the catheter should be set out in organizational policies and procedures. Products employed to stabilize peripheral cannula, midlines or central venous catheters include transparent film dressings, sutures, engineered stabilization devices and sterile wound closure strips. For stabilization of CVCs, and particularly midlines and PICCs, consider use of an engineered stabilization device (INS, 2021). As use of sutures is associated with needle stick injury, where practicable their use should be avoided for VAD securement. When a specific securement device is used for stabilization, placement should be in accordance with manufacturers’ guidelines (INS, 2021). A catheter which has migrated externally should not be re-advanced prior to re-stabilization. 18 | P a g e Revised: September 2023 For revision on September 2025 and as needed  TYPE OF CENTRAL VENOUS CATHETERS  Non – Tunneled CVC/Short- Term Catheter: also called acute care Central Venous Catheter, is designed for short-term therapy for critically ill patients with an expected duration from several days to three weeks or following failed attempts at the placement of other vascular access devices. This type of CVC can be a single or multi- lumen and inserted at the bedside or in the operating room into the internal jugular, subclavian or femoral vein. 19 | P a g e Revised: September 2023 For revision on September 2025 and as needed   Tunneled CVC / Long Term Catheter:  is surgically placed into a vein in the chest or neck and then passed under the skin. One end of the catheter comes out through the skin so medicines can be given right into the catheter.  Expected duration. from months to years  Peripherally Inserted Central Catheter (PICC):  A catheter that is inserted in the peripheral vein and threaded to the SVC or IVC.  Expected duration – weeks to months. 20 | P a g e Revised: September 2023 For revision on September 2025 and as needed   Implanted Port:  similar to a tunneled catheter, but an implanted port is placed entirely under the skin. Medicines are given by a needle placed through the skin into the catheter. - An implanted port is not as visible as a tunneled catheter, does not require much daily care, and does not get in the way of a patient regular activities as much as PICC line or a tunneled catheter might.  It is the preferred device for frequent or long-term access for children to receive long term therapy. The port body is composed of small metal plastic reservoir that contains silicon rubber septum which is implanted under the skin, allowing the patient’s freedom from any external lumens or connectors.  Expected duration - months to years 21 | P a g e Revised: September 2023 For revision on September 2025 and as needed VII- INTRAVENNOUS THERAPY MAINTENANCE 1. Monitoring and Assessment  The frequency for monitoring peripheral IV sites is determined by prescribed therapy, the condition, age of the patient and practice settings.  IV sites in acute care setting are often monitored at 1-2-hour intervals. The pediatric, geriatric, and critically ill patients require more frequent site assessment.  Avoid disconnection of continuous I.V. administration to prevent infection and delayed in the I.V. therapy. 1.1. Fluid Container The fluid container must be labeled with the date and the time when it was hung. It must have calibration label or tape strip to identify the time the container was hung and should have interval marking indicating the fluid level at a specific time. 1.2. Administration Sets/ Tubing Set Administration set changes are performed routinely based on factors such as type of solution administered, frequency of infusion (continuous versus intermittent) immediately upon suspected contamination, or when the integrity has been compromised.  Primary and Secondary Set Continuous – every 96 hours  TPN and Chemotherapy - Every 24 hours  Primary or secondary Intermittent Infusions- Every 24 hrs.  Propofol Infusions- 6-12 hrs. per manufacturers recommendations  Blood and Blood Components - every 4 hrs. 1.3. Flow Rate Flow rate should identify and compared against the medication order. 1.4. Infusion Pump Use Electronic Control Device (EID) for the administration of infusion therapies that require precise flow control and for patient safety. Monitor flow control devise during administration of infusion therapy to ensure safe and accurate delivery to the prescribed infusion rate and volume. 1.5. IV Devices The nurses must be familiar with the standard colors and gauges of the IV devices. The length of the IV device determines the arm of the patient that requires assessment. 22 | P a g e Revised: September 2023 For revision on September 2025 and as needed 1.6. I.V Site  Peripheral - The insertion site must be assessed for pain, tenderness, and discomfort from the peripheral cannula. The peripheral site must be assessed for any signs of swelling. If the tip of the IV catheter punctures the posterior wall of the vein, leaving the greater part of the cannula in the vessel, a blood return may be obtained, but the fluid could be leaking into the tissues. Blanching is a white, shiny appearance at or above insertion site, which indicates an infiltration or a fluid leak into the tissue. Any IV site from which fluid leaks should be evaluated for signs of cellulitis, which manifests as edema, redness, pain, and irritation that is usually accompanied by weeping skin. Cellulitis is an inflammatory response within the subcutaneous tissue that may be due to irritation, extravasation of irritating medications, lack of aseptic technique during site preparation, and use of contaminated equipment or fluids. Any indications of cellulitis should be reported promptly to the patient’s physician. 2. Dressing FREQUENCY OF DRESSING CVAD site care frequency is based on the type of dressing:  Transparent Semi-Permeable (TSM) Dressing - should be changed every 7 days.  Gauze Dressing - should be changed every 48 hours (2 days) and as needed if the dressing is loose or soiled.  A transparent dressing applied over a gauze dressing is considered a gauze dressing and is changed every 48 hours. If the patient is diaphoretic, a gauze dressing is preferable to a TSM dressing.  If gauze is used to support the veins of a non-coring needle in an implanted port and does not obscure the insertion site, it is not considered as a gauze dressing. A plain transparent dressing is placed over the gauze to completely secure the implanted port.  IV Tegaderm Transparent Dressing – are used to cover and protect the catheter sites and secure devices to the skin. 23 | P a g e Revised: September 2023 For revision on September 2025 and as needed   IV Tegaderm Transparent Dressing with Chlorhexidine Gluconate (CHG) - is the anti-microbial and anti-fungal antiseptic that contained in the gel part of the Tegaderm dressing. It prevents bacteria from growing in the patients’ skin. It protects the catheter sites from outside bacterial and viral contamination It helps stabilize the catheter so it does not move and come out. Reduces skin bacteria, a cause of catheter related blood stream infection. 3. Flushing and Locking  Vascular Access Devices Aare flushed and aspirated for a blood return prior to each infusion to assess catheter function and prevent complications. VADs are flushed after each infusion to clear the infused medication from the catheter lumen, thereby reducing the risk of contact between incompatible medications. Each VAD lumen is locked after completion of the final flush to decrease the risk of intraluminal occlusion, depending on the solution used, to reduce Central Line Associated Blood Stream, Infection (CLABSI). Correct amount of flush and lock should be considered by the practitioner as per guidelines from Infusion Therapy Standards of Practice.  Heparin Lock Solution  Tunneled Catheter:  Permcath Hemodialysis Catheter — should be locked with heparin lock solution 1000 - 5000 international units/ml, as ordered by the physician and manufacturers' instruction.  Apheresis CVAD- Same as with Hemodialysis catheter  Chemotherapy CVAD- Same as with Hemodialysis catheter  Non-Tunneled Catheter:  Non tunneled CVAD- Locked and flushed with normal saline  PICC Line: A heparin lock solution of 10 units/ml is the preferred lock solution used to lock a non-valve PICC. A Non-valve PICC is flushed and locked after each intermittent use and at least every 24 hours when not in use.  Implanted Port: If not being used for more than 24 hours, accessed non- valve implanted ports can be flushed and locked 1-2 times per week using 3-5 24 | P a g e Revised: September 2023 For revision on September 2025 and as needed  mL 100 units/ml heparin, and valve implanted ports can be flushed and locked at least weekly with 3-5 mL 100 units/ml heparin. Otherwise, it should be accessed and flushed every 4-8 weeks to maintain patency.  Saline Use a 10 mL prefilled normal saline syringe to avoid excessive pressure and catheter rupture (syringes smaller than 10 mL can produce higher pressure in the lumen and rupture the catheter). Infusion pressures should never exceed 25 psi because pressures higher than that may also damage blood vessels. Maintain the patency of the device by using the "Pulsatile Flush Technique" using a prefilled and conventional type of syringe to create turbulence within the device lumen. A positive Pressure Technique must be maintained that involves clamping the line while still flushing the last 0.5 mL of saline so that there is no blood reflux into the catheter upon disconnection of the syringe. 25 | P a g e Revised: September 2023 For revision on September 2025 and as needed  26 | P a g e Revised: September 2023 For revision on September 2025 and as needed  TYPES OF ADD ON DEVICES FOR INTRAVENOUS THERAPY 27 | P a g e Revised: September 2023 For revision on September 2025 and as needed   Needleless Connector The needless connector of the central venous catheters is changed in the following situations:  On admission  No more frequently than every 96hrs  After blood draws  Anytime the device is removed for any reason  If there is blood or debris within the needless connectors.  Before drawing a blood culture sample from the catheter  As needed for loose, leaking or damaged connector  Stopcocks It is a valve or turning plug that controls the flow of fluid from a container through a tube. A three-way stopcock can be used on IV tubing to turn off one solution and turn on another.  In-line Filter IV filters strain the solution to remove such contaminants as dissolved impurities (detergents, proteins, and polysaccharides), extraneous salts, microorganism particles, precipitates, and undissolved drug powders. Helps to ensure the purity of the solution.  Port Protector Disinfecting the cap intended for use on needles connectors as a disinfecting cleaner prior to IV access and to act as a cover between line access. The cap will disinfect the needleless connector one (1) minute after application and protect from contamination between access. If not removed ports stay clean and protected for 72hrs.  Joint Stabilization It is a device or a board, such as an arm board or limb or finger splint. It should be padded and used to keep the arm still or to support the area of flexion (fingers, Hand, Arm, and Foot) in order to maintain a functional position. 28 | P a g e Revised: September 2023 For revision on September 2025 and as needed VIII. COMPLICATIONS COMPLICATION OF VASCULAR ACCESS DEVICES. The potential complication is always present in a patient receiving IV therapy. Nurses involved in maintaining vascular access devices must have the knowledge and competency to initiate appropriate nursing intervention if complication occurs. To ensure patient safety, the clinician is competent in the recognition of and appropriate intervention for signs and symptoms of vascular access device (VAD)-related complications during insertion, management, and removal. Prevention, assessment, and management of complications are established in organizational policies, procedures, and/or practice guidelines. 1. PHLEBITIS Inflammation of a vein; may be accompanied by pain, erythema, edema, streak formation and/or palpable cord; rated by a standard scale. 29 | P a g e Revised: September 2023 For revision on September 2025 and as needed Recognize risk factors that can be addressed. A. Chemical Phlebitis - may be related to infusates with dextrose (>10%); extremes of pH or osmolarity; certain medications (depending on dosage and length of infusion) such as potassium chloride, amiodarone, and some antibiotics; particulates in the infusate. B. Mechanical Phlebitis - may be related to vein wall irritation, which can come from too large an outer diameter of a catheter for the vasculature, catheter insertion angle and tip position, catheter movement, insertion trauma, or catheter material and stiffness. Choose the smallest outer diameter of a catheter for therapy, secure catheter with securement technology, avoid areas of flexion, and stabilize joint as needed. C. Infectious Phlebitis - may be related to emergent VAD insertions, poor aseptic technique, and contaminated dressings. Plan to replace a catheter inserted emergently under suboptimal aseptic technique when the patient is stabilized and within 48 hours. D. Post infusion Phlebitis - although rare, occurs after catheter removal through 48 hours due to any of the factors above. If phlebitis is present, determine the possible etiology, such as chemical, mechanical, infectious, or post infusion; apply warm compress; elevate limb; provide analgesics as needed; and consider other pharmacologic interventions such as anti- inflammatory agent 2. INFILTRATION AND EXTRAVASATION A. INFILTRATION - inadvertent administration of a non-vesicant solution or medication into surrounding tissue; rated by a standard scale. The risk of infiltration and extravasation is reduced through careful selection of the most appropriate VAD and insertion site and through establishment of VAD patency prior to and during infusion therapy. Peripheral and CVAD sites are regularly assessed for signs and/or symptoms of infiltration and extravasation before and during each intermittent infusion and on regular intervals during continuous infusions. Appropriate intervention(s) are implemented immediately upon recognition of infiltration/extravasation as determined by the characteristics of the solution or medication escaping from the vein. 30 | P a g e Revised: September 2023 For revision on September 2025 and as needed Practice Recommendations A. Select the most appropriate VAD and insertion site to reduce the risk for infiltration/extravasation. B. Recognize the differences among vesicant, non-vesicant, and irritant solutions and medications. Each organization should reach a consensus on what medication is considered to be a vesicant and irritant based on their internal formularies. C. Identify the vesicant nature of cytotoxic and noncytotoxic medications prior to administration; be prepared to use the correct pharmacologic and nonpharmacologic treatment in the event of extravasation or escalate to a clinician capable of managing these injuries. D. Evaluate for the presence of factors associated with infiltration/extravasation. In the presence of factors that may cause or increase the risk of infiltration/ extravasation, increase the frequency of monitoring and consider alternative vascular access options. 31 | P a g e Revised: September 2023 For revision on September 2025 and as needed  32 | P a g e Revised: September 2023 For revision on September 2025 and as needed  B. EXTRAVASATION - inadvertent infiltration of vesicant solution or medication into surrounding tissue; rated by a standard scale THREE TYPES: A. Extravasation Related to Chemotherapy Drugs B. Extravasation Related to Contrast Media 33 | P a g e Revised: September 2023 For revision on September 2025 and as needed  C. Extravasation Related to Non-Cytotoxic Drug 3. NERVE INJURY Evaluate the nerve injury upon insertion of VAD if the patient complains of unusual presentation pain or discomfort or respiratory difficulty while insertion of central vascular access device. 4. CENTRAL VENOUS ACCESS DEVICE OCCLUSION CVAD patency is routinely assessed, as defined by the ability to flush all catheter lumens without resistance and the ability to yield a blood return. Catheter salvage is preferred over catheter removal for management of CVAD occlusion with choice of clearing agents based on a thorough assessment of potential causes of occlusion. When catheter patency cannot be restored and there is continued need for the device, alternative actions, such as radiographic studies to identify catheter tip location or evaluate catheter flow, are implemented. 34 | P a g e Revised: September 2023 For revision on September 2025 and as needed  Types of Occlusion: a. Mechanical – External or Internal b. Non-Thrombotic – Precipitate, Lipid Accumulation c. Thrombotic – Intraluminal clot, Partial or Total Fibrin Sheath, Mural Thrombus, Fibrin Tail  When a catheter becomes occluded the main goal is to restore function.  The 2011 INS Standard of Practice state that the instillation of low-dose altepase 2 mg is effective in restoring catheter patency in patients. 35 | P a g e Revised: September 2023 For revision on September 2025 and as needed 5. INFECTION Infection prevention measures are implemented with the goal of preventing infusion- and VAD- related infections. 50.2 The patient with a VAD is assessed for signs and/or symptoms of infection and is educated about infection, risks, interventions, and any required follow-up. 36 | P a g e Revised: September 2023 For revision on September 2025 and as needed Catheter-Associated Bloodstream Infection (CABSI): Given variability in international definitions, outcome reporting, and application of the term’s catheter-related bloodstream infection (CR-BSI) and central line-associated bloodstream infection (CLABSI), the INS Standards of Practice Committee is using the terminology Catheter- Associated Bloodstream Infection (CABSI) to refer to bloodstream infections (BSIs) originating from either peripheral intravenous catheters (PIVCs) and/or central vascular access devices (CVADs). Both are equally injurious and can occur from 4 possible sources: 1. During catheter insertion/during catheter dwell time through migration of microbes down the catheter tract. 2. Via the catheter hub/lumen during routine administration and manipulation at the hub/lumen. 3. Due to endogenous microorganisms within the bloodstream. 4. From contaminated infusates. When CABSI is used within a standard, refer to the respective references in that standard to understand the terminology and definitions used in the cited studies. Catheter-Related Bloodstream Infection (CR-BSI): The recognized diagnostic criterion that more accurately confirms the catheter as the source of the infection. It is diagnosed if the same organism is isolated from a blood culture and the tip culture, and the quantity of organisms isolated from the tip is greater than 15 colony forming units (CFUs). Alternatively, differential time to positivity (DTP) requires the same organism to be isolated from a peripheral vein and a catheter lumen blood culture, with growth detected 2 hours sooner (ie, 2 hours less incubation) in the sample drawn from the catheter. Central Line-Associated Bloodstream Infection (CLABSI): This is most commonly reported as a surveillance term; however, it is not an established diagnostic criterion. CLABSI is a primary BSI in a patient who had a central line within the 48- hour period before the development of the BSI and is not related to an infection at another site. However, since some BSIs are secondary to sources other than the central line (eg, pancreatitis, mucositis) and may not be easily recognized, the CLABSI surveillance definition may overestimate the true incidence of CR-BSI 6. CATHETER DAMAGE (EMBOLISM, REPAIR, EXCHANGE) Preventative strategies are implemented to maintain catheter integrity and reduce the risk for catheter damage. Assessment of the individual patient’s risk-to-benefit ratio is performed prior to undertaking catheter repair or exchange. 37 | P a g e Revised: September 2023 For revision on September 2025 and as needed 7. AIR EMBOLISM All infusion connections are of a luer-lock design to ensure a secure connection (eg, IV administration sets, syringes, needleless connectors, extension sets, and any add-on devices). Air is always purged/removed from any administration device (eg, IV administration sets, syringes, needleless connectors, extension sets, and any add-on devices) prior to connection or initiating an infusion. Clinicians, patients, and/or caregivers initiating and managing infusion therapy are instructed in air embolism recognition, prevention, and implementation of critical actions in the event an air embolism is suspected. 8. CATHETER-ASSOCIATED DEEP VEIN THROMBOSIS The clinician identifies risk factors, implements preventive strategies, assesses the patient for sign/symptoms of suspected catheter-associated deep vein thrombosis (CA-DVT), and assesses patient response to treatment. Identify risk factors for CA-DVT in patients who require a VAD. 1. Older age (>60 years), malignancy, diabetes mellitus, obesity, chemotherapy administration, thrombophilia (eg, Factor V Leiden, protein C deficiency, protein S deficiency), critical illness, and history of thrombosis are identified in multiple studies as significant risk factors. 2. Other cited risk factors include presence of adult/ pediatric chronic diseases including inflammatory bowel disease, congenital heart disease, sickle cell disease, end-stage renal failure, surgery/trauma patients, pregnancy, hyperglycemia in nondiabetic children in critical care; history of prior CVADs; repeated PICC insertion in the same arm in pediatric patients. 9. CENTRAL VASCULAR ACCESS DEVICE MALPOSITION 1. Primary intravascular malposition of CVADs occurs during or immediately after the insertion procedure and includes locations in the aorta, lower portion of the right atrium and right ventricle, ipsilateral and contralateral brachiocephalic (innominate) and subclavian veins, ipsilateral and contralateral internal jugular veins, azygous vein, and many other smaller tributary veins. Femoral insertion sites may produce malposition of the catheter in the lumbar, iliolumbar, and common iliac veins. Causes of malposition include: a. Inadequate catheter length and insertion depth. b. Patient position changes (eg, from supine to upright). c. Respiratory movement of the diaphragm and use of mechanical ventilation. 38 | P a g e Revised: September 2023 For revision on September 2025 and as needed  d. Upper extremity and shoulder movement. e. Body habitus (eg, obesity, breast size). f. Congenital venous abnormalities including persistent left superior vena cava and variations of the inferior vena cava, azygous vein, and pulmonary veins. Many of these anatomical variations are undiagnosed until placement of a CVAD is required. Cardiac imaging studies are needed as blood flow into the left atrium and the presence of right- to-left cardiac shunting pose significant risks for air or thrombotic emboli to a variety of anatomical locations (eg, brain, kidney). g. Acquired venous changes including thrombosis, stenosis, and malignant or benign lesions compressing the vein. 2. Secondary intravascular malposition of CVADs, also known as tip migration, occurs any time during the dwell and is related to sporadic changes in intrathoracic pressure (eg, coughing, vomiting); original tip located high in the SVC; DVT; congestive heart failure; neck or arm movement; and positive pressure ventilation. IX. DOCUMENTATION OF INTRAVENOUS THERAPY PROPER DOCUMENTATION:  Provides an accurate description of care that can serve as a legal protection.  A medical record and provides a mechanism to record and retrieve significant data and to give evidence of the nursing process.  Records and documents the insertion of a venipuncture and intravenous cannulation procedures. 1. Insertion of Cannula  Gauge of IV cannula  Site | Location  Name of person who inserted | ward 2. Initiation of IV Therapy  Date of Initiation  Time Started  Time Started  Types of Solutions  Prescribed flow rate/medication 3. IV Therapy Maintenance  Condition of the site  Site care provided  Dressing change  Tubing sets 39 | P a g e Revised: September 2023 For revision on September 2025 and as needed  4. Solution Change 5. Discontinuing IV Therapy and Removal of Vascular Access Device. 6. Date and time when IV fluids and heparin lock were discontinued. 7. Assessment of IV sites before and after vascular access devices.  Document in Peripheral IV (if applicable)  Document in central line (if applicable)  Document in CLABSI Maintenance Bundle Daily (if applicable) 40 | P a g e Revised: September 2023 For revision on September 2025 and as needed  PHLEBOTOMY A. PHLEBOTOMY What is Phlebotomy Phlebotomy/Venesection is the opening of a vein to drain off a quantity of blood via a wide bore needle. Blood analysis is an important part of the diagnosis and treatment of the patient and great care should be taken in ensuring that a suitable specimen is obtained. In order to carry out blood collection safely, the phlebotomist should have a basic knowledge of the following:  The relevant anatomy and physiology.  The criteria for choosing the most suitable vein.  Factors governing sample suitably.  Use of the various blood collection devices.  Procedure for labelling, handling and transporting the sample.  Complications of phlebotomy.  Disposal of used equipment. DEFINITION OF TERMS: Patient: – the person presenting for a phlebotomy procedure regardless of health or status. Phlebotomist: - the person carrying out the phlebotomy procedure, whether a dedicated phlebotomist or a Nurse/Phlebotomist 41 | P a g e Revised: September 2023 For revision on September 2025 and as needed GUIDELINES FOR PHLEBOTOMY Patient presenting for phlebotomy should have a valid request with: 1. Patient full Name 2. MRN Number 3. Date of Birth 4. Date of Test 5. Test Required 6. Location 7. Doctors Name 1. Patient Identification  Identification Requirements 1. Patient Name 2. Hospital Number 3. Date of Birth 4. Address 2. Identifying the Conscious/Coherent patient 2.1 Inpatient 1. Ask the patient to state his/her name 2. Ask the patient to state his/her date of birth 3. Ask the KSUMC Hospital Number on request from with his/her wristband 4. All data is checked with the request from where any detail is incorrect, the nursing/medical staff should correct prior to the procedure 2.2 Outpatient 1. Ask the patient to state his/her name. 2. Ask the patient to state his/her date of birth. 3. Ask the patient to state his/her address. 4. Data is checked with the request form. Where any data is incorrect or unspecific, the phlebotomist must contact the consulting physician to verify the request. 3. Identifying the Unconscious/Incoherent Patient 1. Name, date and KSUMC hospital number on the request form should be checked with the patient wristband. The caregiver, relative or nursing staff should verify details. 42 | P a g e Revised: September 2023 For revision on September 2025 and as needed  2. Phlebotomy should not proceed until the phlebotomist is satisfied as to correct identity of the patient. 4. Patient Preparation Equipment 1. All equipment to be used in the collection of the sample should be prepared in advance. This includes: 2. Gloves/standard precaution equipment. 3. Chlorhexidine 1%. 4. The request forms for the patient/computer generated labels. 5. Tourniquet 6. Safety needles 7. Relevant collection system 8. necessary blood tubes 9. Gauze/s 10. Plaster/tape 11. Punctured resistant bin * All equipment should have expiry dates and sterility seals checked before usage. 5. Site Selection for Venipuncture a. The antecubital area is the preferred site for venipuncture. Here, the median cubital, cephalic, and basilic veins lie close to the surface. This area should be examined first and then the dorsal veins of the hand are considered. The metacarpal veins may be suitable where no other access is available. b. Venipuncture sites to be avoided are:  The anterior veins in the wrist.  Sclerosed or thrombosed veins.  Veins close to the site of infection, bruising or hematoma.  Site of IV therapy.  Affected side of previous mastectomy / axillary clearance, stroke, edema, fracture, burns, amputation and fistula.  Hematoma  Cannula, Fistula, and Vascular Graft * Phlebotomist are restricted to accessing the veins of the arms and dorsal hand veins. Veins in the lower limb and the anterior area of the wrist are not approved sites for access by phlebotomist. 43 | P a g e Revised: September 2023 For revision on September 2025 and as needed  6. Venipuncture Procedure When the patient has been correctly identified: 1. Explain the procedure. 2. The patient’s arm should be supported, kept straight, in a downward position, with the wrist extended. 3. Perform hand hygiene (hand wash/hand rub) 4. Wear gloves. 5. Apply tourniquet and choose the site. 6. Loosen the tourniquet. 7. Clean the skin with a >0.5% Chlorhexidine with a 70@ alcohol swab, in a clockwise direction from within outwards. 8. Assemble equipment and let the skin air dry completely (highly important in decontamination of the site.) 9. Reapply tourniquet for not more than 1 minute. 10. Apply tourniquet around the arm 3 to 4 inches (7.5cm – 10cm) above the blood sampling site. 11. Stretch the sin below the intended site with the free hand to anchor the vein and reduce discomfort. 12. Instruct the patient to close the fist (no-pumping). 13. Expose the needle and inspect. The needle is held at an angle of 15 – 30 degrees to the patient’s arm with the bevel of the needle facing upwards and in line with blood flow direction. 14. Warm the patient appropriately. 44 | P a g e Revised: September 2023 For revision on September 2025 and as needed  15. When the blood flow commences, loosen the tourniquet and instruct patient to open the fist. If flow is inadequate, the tourniquet may be lightly reapplied. 16. The tubes should be filled in a downward position, using correct order of draw, until vacuum is exhausted and blood flow ceases. 17. Ensure maximum fill, to correct ration. 18. If using non-pre-evacuated tube, the required amount is withdrawn by suction. 19. A G21 needle is the recommended size for adult collection. However, a G22 needle or G23 blood collection set may also be used. 20. Avoid changing hands unnecessarily while takin blood as this can displace the needle causing pain and trauma to the patient. 21. When blood has been collected, each tube should be gently mixed by fully inverting accordance of the manufacturer’s instructions and avoid vigorous shaking of the tube. 22. Release the tourniquet fully prior to removing the needle. 23. The last tubes should be removed from the holder before the needle is withdraen from the vein. 24. Place a gauze pad lightly over the site as the needle is withdrawn from the vein. 25. Immediately engage safety device. 26. Pressure should be maintained until the bleeding has stopped. Patient may do this if possible. 27. Sharps are immediately disposed of in puncture resistant bin. 28. Samples are labeled in the presence of the patient. Details should include: a. Patient’s Name b. Hospital Number c. Date of Birth d. Phlebotomist’s Inistials. 29. Place the specimen in leak proof receptacle following any special handling requirement. 30. The arm may be elevated to encourage hemostasis but bending of the arm should be discouraged as it can lead to bruising. 31. Inspect for hemostasis and apple gauze over the puncture site. 32. Wipe the tray with a disinfectant wipe (discard if possible). 33. Remove gloves. Wash hands / hand rub. 34. Place / send specimens in collection area/laboratory. 45 | P a g e Revised: September 2023 For revision on September 2025 and as needed  DEVICES FOR PHLEBOTOMY 46 | P a g e Revised: September 2023 For revision on September 2025 and as needed  LABELING OF SAMPLES 47 | P a g e Revised: September 2023 For revision on September 2025 and as needed  A. PRE-ANALYTICAL VARIABLES: There are number factors that may render the sample of unsuitable for testing, or which h may interfere with accuracy. This are known as pre-analytical variables. They can occur at any time phlebotomy procedures to the testing of the sample. 1. Mixing of Bottle Contents Immediately following blood collection, all tubes should be inserted according to manufacturer’s instructions, at approximately 180 C. for a complete inversion, the air bubble should move from the top to the bottom of the tube. Inverting the tubes will lead to adequate mixing of the blood and the tube addictive’s gives more accurate results. 2. Order of Draw When taking blood, the tubes should be filled in a specific sequence in order to reduce the risk of additives in the bottles contaminating each other and falsifying the results of the test. 48 | P a g e Revised: September 2023 For revision on September 2025 and as needed The recommended order is as follows: 49 | P a g e Revised: September 2023 For revision on September 2025 and as needed  ORDER OF INVERSION 1.Minimum Fill Level  Each evacuated specimen bottle contains a pre- measured amount of vacuum. This allows the tubes to fill a definite point, marked on the bottle with a use of an arrow or a dot. Suction tubes should be filled to the mark.  While it may be possible to test blood at a level below this line, the results will not be as accurate. For this reason, the sample may be unsuitable for testing.  Coagulation tubes which are not filled to the maximum level cannot be processed as the ratio of citrate to blood is incorrect.  Where a butterfly system is used for coagulation sampling, the tubing should be primed with a non-addictive discard tube or a citrate tube. This ensures adequate fill in sample tube. 2. Hemolysis  Hemolysis is the process by which the red blood cells disintegrate and release their pigment. It occurs normally at the end of the life cycle of the cell. This effect is undesirable when testing the blood as it renders the sample unsuitable.  Hemolysis usually occurs for the following reasons: a. Using needle with a small diameter (G23 or smaller) b. Using a small needle with a large evacuated c. Improper mixing of the tubes contents and blood. d. Blood flowing too slowly into the tubes. e. Shaking or vigorous mixing of the specimen tubes. f. Drawing from indwelling lines. g. Drawing from sites of hematoma or bruising. h. Incorrect use of the tourniquet.  If there is difficulty in obtaining the sample, it is desirable that a note should be made of it on the request form. This alerts the laboratory staff to check for micro clots prior to testing. 50 | P a g e Revised: September 2023 For revision on September 2025 and as needed 1. Indwelling Lines, Heparin or Saline Locks, Vascular Access Devices (VADs)  Obtaining blood specimens from indwelling lines or VADs can be potential source of test error due to hemolysis and incomplete flushing of the collection site, resulting in contamination and/or dilution of the specimen, contributing to inaccurate results.  If the blood must be drawn through a VAD, possible heparin contamination and specimen dilution can be avoided by correct flushing of the line.  Maintain careful sterility at all times, both to protect the patient from infection and to avoid compromising specimens drawn for blood cultures.  Because it is normal practice to flush lines with a solution to reduce the risk of thrombosis, lines must be cleared of this fluid before blood specimens can be drawn for diagnostic testing.  An adequate amount of blood must be withdrawn from the line and discarded before drawing a specimen to ensure that the actual specimen is not diluted or contaminated with the flush solution.  Discard volume is dependent on the dead-space volume of the particular line. Discarding two times the dead-space is recommended for non-coagulation testing, and 5 ml or six times the dead-space volume for coagulation tests.  An arm with a fistula should not be used for blood drawing without physician permission. The use of tourniquet may lead to complications.  Drawing blood from an I.V. arm has the potential risk for erroneous and misleading test results. Whenever possible, blood should be drawn from the opposite arm when an IV fluid is being administered.  For distal collection to the I.V. site, apply a tourniquet between I.V. and the venipuncture site.  Ask the permission of the physician to turn off the IV infusion for at least 2 minutes before venipuncture. Care should be taken to ensure that the flow has been completely discontinued.  Collection above proximal to I.V. is not recommended. 1. Improper Tourniquet Use Improper usage of the tourniquet may lead to the falsification of the results of the test. If the tourniquet is placed too tightly on the arm, or remains in situ for too long a period of time, then hemo-concentration or hemolysis may occur. 51 | P a g e Revised: September 2023 For revision on September 2025 and as needed  2. Technique If the overall technique of the phlebotomist is poor, then one or more of the previously mentioned factors may be associated with the unsuitability of a sample 3. Timing Where special instructions, e.g. time of day, fasting, post-prandial, posture, or specified interval following antibiotic or drug levels, are not adhered to, the results may be inaccurate. B. BLOOD CULTURE COLLECTION  Blood culture collection sites require a 30-second friction scrub and disinfection with an appropriate disinfectant. (Chlorhexidine Gluconate or Iodine)  Because of iodine’s effect on the thyroid and liver and the potential for allergic reactions, iodine should be removed from the skin once the procedure is complete.  Manufacturers do not recommend using chlorhexidine gluconate on infant less than two months of age.  Preparing the site typically includes an initial cleansing with 70% isopropyl alcohol, allowing it to air dry, followed by a friction scrub and application of an iodine or chlorhexidine compound.  Strict aseptic technique should be used throughout the procedure.  Bottles are filled directly through a winged collection set attached to a tube holder. Filling bottles directly through a needle/tube-holder assembly is not recommended because of the risk of reflux of the broth media back into the vein and the difficulty of assessing the volume of blood drawn. *** See attached Blood Collection Instruction for Use with BD BACTEC Blood Culture System 52 | P a g e Revised: September 2023 For revision on September 2025 and as needed  DEVICES AND MATERIALS FOR BLOOD CULTURE 53 | P a g e Revised: September 2023 For revision on September 2025 and as needed To diagnose bloodstream infection, at least two sets of blood culture should be obtained. Adults - 2 sets = 4 bottles (2 aerobic, anaerobic) Pedia - 2 sets = 2 bottles Amount of blood to be extracted Adults - 5-10 ml per bottle Pedia – 1-3 ml per bottle If a patient is receiving antibiotic therapy, the best time to obtain blood for culture is before a dose is due. BLOOD CULTURE COLLECTION BY PHERIPHERAL 54 | P a g e Revised: September 2023 For revision on September 2025 and as needed  BLOOD CULTURE TRANSFERRING BY CENTRAL LINE A. COMPLICATION OF BLOOD COLLECTION 55 | P a g e Revised: September 2023 For revision on September 2025 and as needed  B.HANDLING SPECIMEN WHOLE BLOOD, SERUM OR PLASMA COLLECTION  Whole Blood is a blood drawn from the body from which no constituent, such as plasma or platelets, has been removed.  Serum is a clear yellowish fluid that remains from plasma after clotting factors (fibrinogen, prothrombin etc.) that have been used in the formation of a clot has been removed. The cells are usually glued together by the clot formation. In serum separator tubes, the serum stays above the gel while the cells are forced below the gel after centrifugation.  Plasma is a clear yellowish fluid that still contains all the clotting factors and has not been solidified into clot. The cells are also not glued together and can be easily re-suspended by gently rocking the plasma tube from side to side. In plasma separator tubes, the plasma stays above the gel while the cells are forced below the gel after centrifugation.  Please refer to Laboratory Guide for further information. EXTERNAL TRANSPORT  Specialized containers are available to transport samples to outside laboratories.  The phlebotomist should be familiar with local arrangement.  Read the Infection Control Manual regarding:  Hand Hygiene  Standard Precaution  Isolation precautions – Transmission Based Precautions  Management of Needle Stick Injury  Disinfection  Healthcare Waste Management a. Waste Disposal b. Handling, Storage, collection and Transportation, Treatment and Disposal of sharps  Healthcare Personnel Vaccination Recommendations 56 | P a g e Revised: September 2023 For revision on September 2025 and as needed  C.DOCUMENTATION  Check for the order.  Go to ESIHI – Orders – Laboratory - Blood Culture (see sample below)  Go to Schedule Patient Care then print appropriate order to get sticker label.  Chart Done orders in the activities after finishing the collection. (see sample below) 57 | P a g e Revised: September 2023 For revision on September 2025 and as needed XI. REFERENCES 1. King Saud university medical city related Policies and Procedures 2023 2. Infusion Nurses Society 2021 3. WEBSITES:  http://en.wikipedia.org/wiki/Peripheral_venous_catheter  http://archinte.ama-assn.org/cgi/content/full/158/2/151 o  http://archinte.ama-assn.org/cgi/content/full/158/5/473  http://catalog.nucleusinc.com/enlargeexhibit.php?ID=7983&TC=&A =2 o  http://www.cap.org/apps/docs/cap_press/bloodSpecimenBook/Veni puncture.pdf  http://en.wikipedia.org/wiki/Dorsal_digital_veins_of_the_hand  http://www.vein.co.uk/anatomy_page.htm o  http://www.ivtherapy.net 58 | P a g e Revised: September 2023 For revision on September 2025 and as needed