Download GUIDELINES FOR MAINTAINING INFUSION THERAPY PURPOSE

GUIDELINES FOR MAINTAINING INFUSION THERAPY
PURPOSE
Guidelines for assessment and management of infusion therapy.
STANDARDS
A prescriber’s order is required for infusion therapy. The order must specify:
o
Solution to be infused
o
Rate of administration
A “To Keep Vein Open” (TKVO) order will be interpreted as saline/heparin lock unless an immediate need
for IV access is identified or if IV access is required again within 2 hours, in which case the order must
specify a desired rate of infusion. Minimum infusion rates are suggested below but each patient must be
assessed individually and rates adjusted according to patient needs.
“Site to Source” assessment of vascular access site and infusion system to be performed hourly and
when administering IV medications or changing prescription details (e.g. rate/dose change, solution
change) even if patient is asleep.
Infusion system safety checks to be performed when starting or restarting IV therapy and as part of the
bedside safety check at shift assessment, transfers and handovers.
SITE APPLICABILITY
These guidelines are applicable to all areas where infusion therapy is carried out.
PRACTICE LEVEL/COMPETENCIES
The assessment and management of infusion therapy is a foundational level competency for nurses
working in acute care areas at BCCH/SHHC.
PROCEDURE
Rationale
1. At the beginning of each shift and with any order
changes, CHECK prescriber’s order, Kardex,
MAR and/or other appropriate documents for:
a. solution to be infused and amount
b. rate of administration
c. parenteral medications to be
administered
d. date/time tubing change due (ensure
date due label attached to tubing)
2. REFER prescriber to suggested minimum
infusion rates based on patient weight and type
of vascular access:
Facilitates plan for the day.
Patient
Patients under 50 kg – non
critical care
Patients over 50 kg – non
critical care
Critical care patients
Premature neonates
Peripheral IV
2 mL/hr
5 mL/hr
1 mL/hr
1 mL/hr
3. INFORM patient/family that IV site will be
assessed on an hourly basis for signs of
CV.01.01
LastReviewDate
Dec 13, 2013
Disclaimer Message
Refer to online version – Print copy may not be current – Discard after use
Minimum infusion rates required to maintain vein
patency are influenced by many factors (size of
catheter, length of tubing, size of vein, patient
activity level, etc).
Central Venous Line/PICC
4 mL/hr
10 mL/hr
2 mL/hr
2 mL/hr (1 mL/hr if
heparinized solution)
Educates family on importance of performing the
hourly site assessments and engages them in the
BCCH Child & Youth Health Policy and Procedure Manual
Create Date
Jul 01, 1982
Effective Date: Jan 18, 2016
Page 1 of 4
The following information, i.e. guideline/educational material/policy or procedure, has been developed for use only within BC Children's Hospital (BC Children's) and BC Women's Hospital and Health Centre (BC Women's).
Agencies other than BC Children's or BC Women's should use this information as a guideline for reference purposes only. All materials are the property of BC Children's and BC Women's and may only be reprinted in whole or
in part with our expressed permission. Contact [email protected] with questions.
Date/Time Generated
Oct 21, 2016 06:31
Generated By
Anonymous
GUIDELINES FOR MAINTAINING INFUSION THERAPY
complications. REFER to TLC poster to show
process.
patient/family what the hourly check involves.
4. INSTRUCT patient/family to report any pain,
Engages patient/family as partners in patient care.
burning, stinging, swelling, numbness, redness
or bruising at site or if site is wet, firm, hot or
cold to touch. STOP infusion immediately and
assess site to determine appropriate
interventions.
5. PERFORM “site to source” assessment of
Provides thorough assessment of infusion system
vascular access site and infusion system hourly
so complications can be detected early and
and when administering medications or
immediate interventions can be provided in a
changing prescription details.
timely manner.
Site to Source assessment:
a. Assess vascular access site for infiltration and signs of phlebitis by doing the following :
i.
TOUCH: IV site feels soft, warm, pain free and dry to touch
ii.
LOOK: IV site must be uncovered, dry and visible
iii.
COMPARE: IV site is to be without swelling, same size as other side
b. Trace tubing from bag/bottle/syringe to site and assess for kinks, air bubbles, clamps (open or
closed), loose connections, breaks in system, correct solution infusing via correct channels at
correct rates, needless connector present at top of syringe line to close system (except PICU)
c. Ensure restraints or protective devices used are safe and effective (e.g. armboards, surginet
covering)
d. Ensure tubing is secured (not pulling at site) and not posing risk of entanglement (patients at
high risk for tubing entanglement are active children 3 month-3 years of age or
developmentally delayed, with numerous lines or lengthy lines)
e. When administering a medication by secondary infusion, double check that piggyback clamp
is released and you visualize drips before leaving bedside
f. When administering a syringe medication, double check that syringe tubing clamp is released
6. PERFORM infusion system safety check
when starting or restarting IV therapy and as
part of the bedside safety check at shift
assessment, transfers and handovers.
Provides thorough assessment of infusion system
at transition points.
In addition to above site to source assessment:
a. Ensure patient ID number programmed in pump matches patient Medical Record Number
(MRN) on ID band/photo ID
b. Ensure pump has correct pump personality programmed
c. Check solution expiry date and time
d. Check expiry label on tubing for date/time due for change
e. Ensure each infusion module labeled correctly
f. Ensure all lines are labeled correctly below pump proximal to patient
g. Upon arrival to an area, ensure infusion devices are plugged in to electrical outlet or check
battery life
7. For peripheral IV that is saline/heparin locked,
To ensure patency.
ASSESS site hourly and DOCUMENT using the
phlebitis scale. ASSESS:
a. Vascular access site for signs of
phlebitis, leaks by doing the following :
i.
TOUCH: IV site feels soft, warm,
pain free and dry to touch
ii.
LOOK: IV site must be
CV.01.01
LastReviewDate
Dec 13, 2013
Disclaimer Message
Refer to online version – Print copy may not be current – Discard after use
BCCH Child & Youth Health Policy and Procedure Manual
Create Date
Jul 01, 1982
Effective Date: Jan 18, 2016
Page 2 of 4
The following information, i.e. guideline/educational material/policy or procedure, has been developed for use only within BC Children's Hospital (BC Children's) and BC Women's Hospital and Health Centre (BC Women's).
Agencies other than BC Children's or BC Women's should use this information as a guideline for reference purposes only. All materials are the property of BC Children's and BC Women's and may only be reprinted in whole or
in part with our expressed permission. Contact [email protected] with questions.
Date/Time Generated
Oct 21, 2016 06:31
Generated By
Anonymous
GUIDELINES FOR MAINTAINING INFUSION THERAPY
uncovered, dry and visible
COMPARE: IV site is to be
without swelling, same size as
other side
b. Effective, safe restraints (armboards)
c. Presence of blood in tubing or cap (flush
with saline as needed to clear)
d. Document infiltration score when flushing
or after reconnecting to IV infusion
8. STOP infusion at first sign of infiltration or
phlebitis (grades 1 or above). For peripheral IV,
remove catheter and monitor site. For central
line, notify physician immediately for
instructions.
iii.
Prevents further adverse effects.
NOTE: For suspected or confirmed infiltration of
vesicant agents, refer to extravasation protocol
(CV.01.16; CV.01.16B).
NOTE: report all infiltration or phlebitis events in
Patient Safety Learning System (PSLS).
9. RECORD intake as frequently as required for
assessment of patient's fluid balance. CLEAR
volume history at 0400 and 1600, unless
ordered more frequently or per unit standard:
•
PICU, clear volumes at 0600 and 1800
•
Acute peritoneal dialysis patients, clear
volumes at 0600 and 1800
Assessment of fluid balance.
DOCUMENTATION
DOCUMENT on appropriate record(s) (i.e. patient care flowsheet, MAR, nurses notes):
•
shift totals, subtotal, fluid balance, previous day fluid balance
•
medication related fluids
•
hourly site to source checks
•
infusion system safety checks
•
hourly phlebitis and infiltration scale scores
•
medications administered
•
patient response to therapy
If infiltration of vesicant agent is suspected or confirmed, INITIATE the Extravasation Flowsheet.
REPORT all infiltrations/extravasations and phlebitis in PSLS.
REFERENCES
Campbell, T. and Lunn, D. (1997). Intravenous therapy: current practice and nursing concerns. British
Journal of Nursing, 6(21):1218-1228.
Hadaway, L. (2007). Re: tkvo rates via email correspondence. In P DeZorzi, Vancouver.
Hadaway, L. (2004). Closing the case on the keep-vein-open rate. Nursing, 34(8):18.
Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing,
34(1S).
CV.01.01
LastReviewDate
Dec 13, 2013
Disclaimer Message
Refer to online version – Print copy may not be current – Discard after use
BCCH Child & Youth Health Policy and Procedure Manual
Create Date
Jul 01, 1982
Effective Date: Jan 18, 2016
Page 3 of 4
The following information, i.e. guideline/educational material/policy or procedure, has been developed for use only within BC Children's Hospital (BC Children's) and BC Women's Hospital and Health Centre (BC Women's).
Agencies other than BC Children's or BC Women's should use this information as a guideline for reference purposes only. All materials are the property of BC Children's and BC Women's and may only be reprinted in whole or
in part with our expressed permission. Contact [email protected] with questions.
Date/Time Generated
Oct 21, 2016 06:31
Generated By
Anonymous
GUIDELINES FOR MAINTAINING INFUSION THERAPY
Infusion Nurses Society. (2010). Infusion Nursing an Evidence-Based Approach. St. Louis, Missouri:
Saunders Elsevier.
Josephson, D.L. (2004). Intravenous Infusion Therapy for Nurses. Principles & Practice, 2nd edition.
Thomas Learning, Inc. USA.
Macklin, D. and Chernecky, C. (2004). IV Therapy. Missouri: Saunders
Ontario, R. N. A. O. (2005). Care and Maintenance to Reduce Vascular Access Complications (guideline).
Toronto, Canada: Registered Nurses’ Association of Ontario. Retrieved from:
http://www.rnao.org/bestpractices
Sararawala, R. (2000). Confronting the Legal Perils of IV Therapy. Nursing, 30(8):44-47.
Schumacher, D.L., Billings, D. and Kowalski, K. (2005). Do Your CATS PRRR? A Mnemonic Device to
Teach Safety Checks for Administering Intravenous Medications. Journal of Continuing Education in
Nursing 36(3):104-106.
Weinstein, S.M. (2007). Plumer’s Principles & Practice of Intravenous Therapy, 8th edition. Philadelphia:
Lippincott Williams & Wilkins.
CV.01.01
LastReviewDate
Dec 13, 2013
Disclaimer Message
Refer to online version – Print copy may not be current – Discard after use
BCCH Child & Youth Health Policy and Procedure Manual
Create Date
Jul 01, 1982
Effective Date: Jan 18, 2016
Page 4 of 4
The following information, i.e. guideline/educational material/policy or procedure, has been developed for use only within BC Children's Hospital (BC Children's) and BC Women's Hospital and Health Centre (BC Women's).
Agencies other than BC Children's or BC Women's should use this information as a guideline for reference purposes only. All materials are the property of BC Children's and BC Women's and may only be reprinted in whole or
in part with our expressed permission. Contact [email protected] with questions.
Date/Time Generated
Oct 21, 2016 06:31
Generated By
Anonymous