Skills Lab PDF - Flashing Saline Lock & IV Infusion

SKILLS LAB Ma’am Jennifer Tam | Week 6  All access ports must be disinfected to decrease the Topic Outline: Flashing a saline Lock bacterial load prior to use clean the positive...

SKILLS LAB Ma’am Jennifer Tam | Week 6  All access ports must be disinfected to decrease the Topic Outline: Flashing a saline Lock bacterial load prior to use clean the positive pressure cap Intravenous Infusion for 15 seconds and let dry for 30 seconds. 7. Open clamp on extension tubing. FLASHING A SALINE LOCK  Clamp must be open to flush the saline lock.  Open clamp on the saline lock.  A Saline flush is a mixture of salt and water that is compatible with body’s fluids and tissues. It is used to push any residual 8. If using a prefilled normal saline syringe for flushing, the medication or fluid through the IV line and into your vein. This air must be “purged” from the syringe. To remove air keeps THE PIV line clean and reduces the risk of infection or from a syringe, apply gentle pressure to the syringe occlusion. plunger until a click, snap, or pop sound is heard.  A Saline lock (SL), also known as heparin lock, is a  Purging the air prevents it from being injected into the peripheral intravenous cannula connected to extension tubing patient. with a positive pressure cap. This device allows easy access  Next, remove the sterile dead-ender on the Luer lock end to peripheral vein for intermittent IV fluids or medications. of the syringe, and remove the air by gently pushing the plunger upwards, keeping the syringe vertical.ir should  Saline lock can be used for continuous and intermittent short- never be injected into a patient. term IV therapy. Flushing is performed:  Next, remove the sterile dead-ender on the Luer lock end  Before and after administering IV fluids or medications to of the syringe, and remove the air by gently pushing the assess placement and patency of PIV plunger upwards, keeping the syringe vertical.  After blood sampling  After each infusion to prevent mixing of incompatible 9. Attach NS prefilled Luer lock syringe by twisting the medications and solutions syringe onto the positive pressure cap. Undo clamp on  Every 12 hours when the saline lock is not in use extension tubing. Inject 3 to 5 ml of solution using  A saline lock must be flushed in a specific manner to turbulent stop-start technique. Flush until visibly clear. prevent blood being drawn into the IV catheter and Do not bottom out syringe (leave 0.2 to 0.5 ml in the occluding the device between uses syringe). SAFETY CONSIDERATION  Turbulent stop-start flush ensures full flushing of the catheter.  Poor standard of aseptic techniques is the primary cause of  Bottoming out the saline syringe with the plunger can cause health care infections. reflux of fluid back into the catheter.  Be diligent with disinfecting and sterile technique.  If resistance is felt, do not force flush.  Sterile techniques must be used with all IV procedures.  Flush the saline lock. FLUSHING A SALINE LOCK PROCEDURES 10. Remove syringe from positive pressure cap; THEN clamp the extension tubing. 1. Perform hand hygiene; gather supplies  You will need alcohol swabs, 3 to 5 ml syringe prefilled  Always clamp after removing syringe from the positive with 0.9 % normal saline and clean cloves. pressure cap. Positive displacement occurs when the syringe is disconnected from the positive pressure cap. 2. Compare MAR to patient’s wristband, identify patient  Clamp the extension tubing as close to the IV site as using two identifiers and explain procedure to the possible to prevent negative fluid displacement and patient. accidental aspiration of blood at the catheter tip.  Follow agency policy for proper patient identification. 11. Wipe top of the positive pressure cap with an alcohol 3. Clean work surface with Caviwipes and let dry swab to remove fluid residue.  This prevents the spread of microorganisms.  Moisture promotes the growth of microorganisms. 12. Ensure dressing is dry and intact, and the extension 4. Perform hand hygiene and apply clean gloves. tubing is properly secured with tape.  This prevents and minimizes the spread of microorganisms.  Properly secured extension tubing prevents accidental dislodgement of SL. 5. Assess IV site for signs and symptoms of phlebitis.  Dry and intact dressing.  If IV site is red, tender or swollen, the SL needs to be discontinued; do not flush. 13. Remove gloves; discard supplies and perform hand hygiene. 6. Scrub the top of the Aseptic technique is required for all  Proper disposal of equipment prevents the spread of IV procedures. microorganisms.  Aseptic technique is required for all IV procedure. 1  CONVERTING A SALINE LOCK TO A CONTINUOS IV 12. Initiate IV infusion. INFUSION  Adjust IV infusion rate by gravity or IV pump as per (SAFETY CONSIDERATIONS) physician’s orders. Monitor for factors that may affect flow rate.  If at any time you think a piece of equipment has been contaminated, dispose of it immediately and obtain a new 13. Secure IV tubing to patient with tape. sterile piece.  Properly secured extension tubing prevents accidental  Always assess IV site and flush SL prior to initiating an IV dislodgement of tubing. infusion.  Always follow the safety seven rights x 3 for IV fluids and 14. Document procedure and monitor expected response to medications. IV fluids.  Educate the patient on signs and symptoms of phlebitis and  Chart type of solution, rate, date, and time of infusion as when to call for assistance (unexpected or adverse reactions). per agency policy  IV solutions must be recorded on the in-and-out sheet or patient chart. INTRAVENOUS INFUSION  Patients on continuous IV solutions are at risk for fluid overload, especially patients with renal or cardiac conditions. Objectives Monitor output and input when patients are on a continuous  At the end of the discussion: infusion. 1. The students shall be guided on how to provide a safe and STEP BY STEP PROCEDURE quality nursing care to patients receiving INTRAVENOUS (IV) Therapy. 1. Verify physician orders and collect supplies. 2. The student shall be able to define terms associated with IV therapy.  You will need clean gloves, 3 to 5 ml prefilled 0.9% normal 3. Their knowledge, attitude and skills regarding IV therapy are enhanced. saline syringe, IV solution, IV pump if indicated.  Verify the rate and duration of solution. DEFINITION  Review the rationale/reason for the IV fluids to provide an  An Intravenous (IV) solution is a method of replacing fluid explanation to the patient. lost, or correcting an electrolyte imbalance. Client who are acutely ill, are those on NPO after surgery or have severe 2. Perform hand hygiene and prime IV tubing with IV burns are examples of those who require IV therapy. solution.  Prime IV tubing with correct IV solution as per Checklist 66.  The solution in an IV bag is ordered by the physician Ensure IV tubing and IV solution bag are labelled. according to the client’s needs is changed at least every 24 hours, or as per institution’s policy, to decrease the risk of 3. Enter room and identify patient using two identifiers. infection.  Identifying patient correctly prevents errors and enhances safe practices. ASSESSMENT  Compare MAR with patient’s wristband. 1. Check the physician’s order for the IV solution to be infused and rate of flow to ensure accurate administration. 4. Explain procedure, clean work surface and let dry, and perform hand hygiene. 2. Review information regarding the solution and nursing implications in order to administer the solution safely.  Educate patient about why IV fluids are being initiated. 3. Check all additives in the solution and other medications so  Hand hygiene prevents the spread of microorganisms. that there will be no Incompatibilities of additives with the solution. 5. Apply gloves, scrub the top of the positive pressure cap for 15 seconds, and let dry for 30 seconds. PURPOSES  To supply the body with fluids when the patient is unable to  Appropriately disinfecting the positive pressure cap take adequate amount by mouth. decreases the bacterial count and adheres to the principles  To supply the body with salts of tissue fluids and electrolytes of infection control balance of the body.  Clean the positive pressure cap with alcohol swab.  To supply the body with nutrients.  To reduce body temperature. 6. Open clamp on extension tubing and assess IV site.  To dilute amount of bacteria and toxins.  Open clamp on saline lock EQUIPMENTS:  clamp must be released to flush the extension tubing 1. IV solution in a bag or bottle 2. Infusion set (IV tubing) Refer to steps number 7,8,9 and 10. 3. Medication administration record (MAR) 4. Flow sheet 11. Without breaking sterile technique, remove the cap on the distal end of the IV tubing. Using a twisting motion, PROCEDURES: connect Max Plus end to IV tubing. 1. Check physician’s order for the IV solution.  Do not let the positive pressure cap touch any non-sterile  Rationale: Ensures accurate administration of the solution. surface prior to attaching the IV tubing. If required, place 2. Wash hands. Apply gloves if required by institutional the positive pressure cap on sterile gauze while preparing tubing. policy.  Connect IV tubing to saline lock.  Rationale: Reduces the transmission of microorganisms.  Continuous IV infusion 2  17.Loosen protective cap from the needle oe end of the IV 3. Prepare new bag by removing protective cover from the tubing, open roller clamp and flush tubing with solution. bag or bottle. Priming the IV tubing. Open the roller clamp on the  Rationale: Allows for access to the solution container. tubing to allow the fluid to enter the tube and expel the air. 4. Inspect the bag or bottle for leaks, tears, or cracks.  Rationale: Removes air from tubing. Inspect the fluid for clarity, particulate matter and color. Check expiration date. 18. Close roller clamp and replace cap protector.  Rationale: Prevents infusing contaminated or outdated  Rationale: Prevents fluid from leaking and maintains solution. sterility of needle. 5. Prepare a label for the IV bag or bottle: 19.When ready to initiate infusion, remove the cap protector  On the label, note date, time and your initials. from the tubing. Attach the IV tubing to venipuncture  Attach the label to the bag or bottle. Keeping mind, the bag catheter. Starting the IV. or bottle will be inverted when it is hanging. Make sure the  Rationale: Initiates infusion. label can be read when the IV is hanging.  Rationale: Communicates when the bag was opened. 20. Wash hands Labelling the bag or bottle upside-down makes  Rationale: Reduces the transmission of microorganisms. identification easier when the bottle is hanging. PREPARATION OF THE PATIENT 6. Store the prepared IV solution in the area assigned by the institution.  Check order for solution in Physician’s order sheet and in the Kardex  Keeps the prepared solution readily available for when it is  Assess: Vital signs, Skin turgor, Allergy to tape or iodine, needed. bleeding tendencies and Status of veins to determine appropriate venipuncture site. 7.Remove gloves and dispose of gloves with all used materials. PROCEDURE:  Reduces the transmission of microorganisms.  Prepare the client: Verify the client’s identity, positioning the 8. Wash hands. patient and Introduce yourself. Explain the procedure to the  Rationale: Reduces the transmission of microorganisms. client. A venipuncture can cause discomforts for a few seconds, but there should be no discomfort while the solution 9. Documentation the preparation of the IV solution. is flowing.  Provides a record to ensure continuity of care.  Perform hand hygiene Hanging the Prepared IV  Open and prepare the infusion set. 10. Wash hands  Rationale: Reduces the transmission of microorganisms.  Remove tubing from the container and straighten it out.  Slide the tubing clamp along the tubing until it is just below 11.Obtain the IV solution for the client as ordered. Check the drip chamber to facilitate its access. the label on the IV bag to see that it matches the order.  Close the clamp.  Rationale: Ensures the ordered medication is  Leave the ends of the tubing covered with plastic caps until administered. the infusion is started. 12.Inspect the bag or bottle for leaks, tears, cracks and inspect the fluid for clarity, particulate matter and color.  Spike the solution container.  Rationale: Prevents infusing contaminated solution.  Remove the protective cover from the entry site of the bag.  Remove the cap from the spike, and insert the spike into 13. Check client’s identification bracelet. the insertion site of the bag or bottle. Follow the  Rationale: Ensures IV solution is given to the correct manufacturer’s instructions. patient.  Put a medication label to the solution container, if a 14. Prepares an IV-time tape for the IV bag or bottle: medication was been added.  On the time tape, note the rate at which the solution is to infuse.  Apply a timing label on the solution container.  Mark the approximate infusion intervals.  The timing label may be applied at the time the infusion is  Rationale: Communicates how long before the next IV started. Follow agency’s practice. should be hung.  Hang the solution container on the pole. 15. Make sure the clamp on the tubing is closed. Grasp the  Adjust the pole so that the container is suspended about 1 port of the IV bag with your non-dominant hand, remove m (3 feet) above the client’s head. the plastic tab covering the port, and insert the full length of the spike into the bag’s port.  Partially fill the drip chamber with solution  Rationale: Promotes rapid flow of solution through new  Squeeze the chamber gently until it is half full of solution. tubing without air bubbles.  Prime the tubing. 16. Compress drip chamber to fill halfway.  Remove the protective cap, and hold the tubing over a  Rationale: Filling chamber halfway allows the chamber to container. Maintain the sterility of the end of the tubing and provide a clear measurement of drip rate when the IV is the cap. flowing. 3   Release the clamp, and let the fluid run through the tubing  Unless there is an allergy, a sterile transparent, occlusive until all bubbles are remove. Tap the tubing with your dressing is applied. fingers, if necessary, to help the bubbles move.  Discard the tourniquet. Remove the soiled gloves and  Re-clamp the tubing, and replace the tubing cap, discard them appropriately. maintaining sterile technique.  Loop the tubing, and secure it with tape.  Label the dressing with date and time of insertion, type and  Perform hand hygiene again just prior to client contact. gauge of catheter used, and your initials.  Select the venipuncture site.  Ensure appropriate infusion flow.  Unless contraindicated, use the client’s nondominant hand  Apply a padded board to splint the joint as needed.  Check agency protocol about shaving, if the site is very hairy.  Adjust the infusion rate of flow according to the doctor’s order.  Place a towel or bed protector under the extremity to protect  Label the IV tubing. linens  Label the tubing with the date and time of attachment, and  Dilate the veins. your initials.  Place the extremity in a dependent position.  Document relevant data. Record:  Apply a tourniquet firmly (3-4 inches) above the  The time of the start of the infusion venipuncture site.  The flow rate of the transfusion  If the vein is not sufficiently dilated:  The date and time of the venipuncture  Encourage the client to clench and unclench her fist.  The amount and type of solution used, including any  Lightly tap the vein with your fingertips. additives  If the preceding steps fail to distend the vein so that it is  The type and gauge of the needle or catheter palpable, remove the tourniquet and apply heat compress  The venipuncture sites to the entire extremity for 10-15 minutes.  The client’s general response.  Put on clean gloves, and clean the venipuncture site. COMPLICATIONS OF IV THERAPY  Clean the skin at the site of entry with topical antiseptic swab, 2% chlorhexidine, or alcohol. 1. Infiltration / extravasation  Check for allergies to iodine or shellfish before cleansing 2. Phlebitis / thrombophlebitis skin with betadine or iodine products. 3. Cellulitis  Use a circular motion, moving from the center outward for 4. Septicemia several inches.  Permit the solution to dry on the skin. 1. INFILTRATION/EXTRAVASATION  The most common cause is damage to the wall during  Insert the catheter, and initiate the infusion. insertion or angle of placement.  Use the nondominant hand to pull the skin taut below the entry site.  STOP INFUSION and treat as indicated by Pharmacy,  Holding the over-the-needle catheter at a 15-30 degrees Medication package insert or drug reference book. 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 catheter, or you feel lack of resistance, reduce the angle of the catheter until it is almost parallel with the skin, and advance the catheter until the hub is at the venipuncture site.  Release the tourniquet.  Put pressure on the vein proximal to the catheter to eliminate or reduce blood oozing out of the catheter. Stabilize the hub with the thumb or the index finger of your 2. PHLEBITIS/THROMBOPHLEBITIS non-dominant hand.  Remove the protective cap from the distal end of the tubing,  Chemical and hold it ready to attach to the catheter, maintaining the  Infusate chemically erodes internal layers. Warm sterility of the end. compresses may help while the infusate is  Carefully remove the needle, engage the needle safely stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause device, and attach the end of the infusion tubing to the catheter hub.  Initiate the infusion.  Tape the catheter  Tape the catheter by the ‘’U’’ method.  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 a second strip, sticky-side down, over the catheter hub.  Mechanical  Place a third strip, sticky-side down, over thu tubing hub.  Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears  Dress and label the venipuncture site and tubing according to shortly after insertion. The device may need to be removed agency policy. and warm compresses applied 4  Bacterial 3. HYPOTONIC SOLUTION  Caused by introduction of bacteria into the vein. Remove A solution with a lower salt’s concentration than in normal cells the device immediately and treat w/antibiotics. The arm will of the body and the blood. be painful, red and warm; edema may accompany Ex:  0.45% NaCl 3. CELLULITIS  0.33% NaCl  Inflammation of loose connective tissue around insertion site.  Caused by poor insertion technique  Red swollen area spreads from insertion site outwardly in a diffuse circular pattern  Treated w/antibiotics IV CALCULATIONS IV Flow Rate: mL/h  To regulate an IV volume by electronic infusion pump or controller calibrated in mL/h, calculate:  Order reads: D5W 250 mL IV over the next 2 h by infusion pump Step 1 4. SEPTICEMIA/PULMONARY EDEMA/EMBOLISM  Think. The pump is set by the rate of mL per hour. So, if 250  Septicemia mL is to be infused in two hours, how much will be infused in  Severe infection that occurs to a system or entire body one hour? 125 mL will be infused in one hour. You would set  Most often caused by poor insertion technique or poor site the pump at 125 mL per hour. care Step 2  Discontinue device immediately, culture and treat  Use the formula: appropriately TYPES OF IV SOLUTION 1. ISOTONIC SOLUTION A solution that has the same salt concentration as the normal cells of the body and the blood. Ex: 1. 0.9% NaCl IV Flow Rate: gtts/min. 2. Ringer Lactate 3. Blood Component The Formula method to calculate IV Flow rate for manually 4. D5W regulated IVs ordered in ml/hr or for a prescribed number of minutes is: BLOOD TRANSFUSION 2. HYPERTONIC SOLUTION: A solution with a higher salt’s concentration than in normal cells The giving of blood into the veins. It may direct transfusion in of the body and the blood. which blood is transferred from the veins of one person (donor) Ex: to the veins of another (recipient). 1. D5W in normal Saline solution 2. D5W in half normal Saline 3. D10W 5   Give the blood very slow first and watch patient closely. Stop transfusion immediately if patient develops any adverse reaction and refer to the physician at once.  Remove the needle before the bottle is completely emptied. EQUIPMENT  Bottle of blood  Blood transfusion set  Cotton balls with alcohol Preparation of Equipment:  Same as IV transfusion  Be sure the patient transfusion set has a filter  Typing of patient with the blood. AFTER CARE OF THE PATIENT 1. Place patient in a comfortable position. 2. Place a piece of adhesive tape over the site of puncture. DOCUMENTATION/CHARTING PURPOSE  Time the blood was started and consumed.  Type and amount of blood. 1. To increase the circulating blood volume as in case of shock  Any untoward reactions. due to hemorrhage. 2. To increase red cell volume of hemoglobin content of the WHAT NOT TO DO WHEN TRANSFUSING BLOOD blood as in anemia. 3. To increase WBC content of the blood as in agranulocytosis  Do not store any blood component on a nursing unit or in an and leucopenia. unmonitored refrigerator 4. To increase the quantity of protein in malnutrition, excessive  Do not keep the blood out of the transfusion service loss of protein from burns or vesicular diseases. refrigerator for longer than 30 minutes before starting the transfusion. PHASES OF BLOOD TRANSFUSION  Do not warm the blood in a microwave oven, in an Preparation: unmonitored water bath, under running water or in a sink.  check the physician’s order if being ordered so.  Do not heat blood component to a temperature higher than  secure informed consent from the patient or guardian. 39 degrees centigrade  complete transfusion teaching  Do not transfuse any blood components without using the  take vital signs appropriate blood filter. Standard blood filters have pore sizes of 170-260 microns. Verification:  Do not use the same blood filter longer than 4 hours.  units’ serial number; time of transfusion; ABO and RH with the  Do not transfuse a unit of blood over a period longer than 4 bag’s tag and label hours.  best to have 2 qualified persons to confirm the information.  Do not add drugs/medicine to blood components or infuse  ask the patient, “what is your name?” do not ask, are you Mr. drugs and blood through the same blood administration set. (his name)?  Do not use any solution other than 0.9% (normal saline) to  record the date and time of transfusion prime a blood, to flush the IV line, or to  as well as the staff members who identified the patient  dilute the blood products. Dextrose and water solutions can clump or hemolyze RBC; the calcium in Ringer’s lactate Administration: foster clotting in the bag and in the tubing  Observe for evidence of any adverse reactions, particularly during the first 15 minutes and at least every hour until 1 hour after the transfusion. GENERAL CONSIDERATION  Maintain aseptic technique throughout the procedure.  Check and re-check the labels in identifying the blood (name of patient, name of physician, serial number, blood type and expiration date.  Be sure the blood is properly cross-matched. Check laboratory report on cross-matching.  Watch patient closely for untoward reactions like; chilling, headache, signs of chest oppression, generalized tingling sensation, sudden sharp pain on the lumbar area, urticaria, during and after the procedure.  Follow carefully the pre-transfusion orders for anti-histaminic.  Check patient’s vital signs. 6