I .V.I.'S NURSES RESPONSIBILITY

1.             Checking infusion container for faults.

2.             Checking prescribed fluid goes to correct patient.

3.             Checking I.V. line is patent.

4.             Inspecting entry site is normal-report if not.

5.             Controlling rate of flow as prescribed.

6.             Monitoring condition of patient - reporting changes.

7.             Maintaining appropriate records.

 

ADDITIONAL GUIDE-LINES

1.             Infusion containers should not hang for more than 24 hours (8 hours for blood products).

2.             Administration set must be changed every 24 hours.  (Time it is put up should therefore be recorded).

3.             Regular checking of entry site, inflammation or infiltration.

4.             Sterile dressing covering entry site should be changed daily at time of inspection.

 

FURTHER RECOMMENDATIONS

1.             Use as few connections and stopcocks as possible - keep system closed.

2.             Remind doctors when a cannula has been in place for 48 hours.

3.             Covering dressings should be sterile - entry site is an open wound - Removal should be aseptic.

4.             Ensure cannula stability.

 

 

PRINCIPLES

Asepsis, Safety, Comfort.

 

ADVANTAGES

-               Rapid delivery of drug - therapeutic effect

-               Total absorption of drug - good dose calculated

-               Controlled rate of administration

-               Less pain

-               For drugs which can not be given by other route

 

DISADVANTAGES

-               Inability to recall drug

-               Drugs may be given too rapidly

-               Complications - Microbial contamination

-               Vascular irritation

-               Drug complications or interactions.

 

DHSS      1976 after Breckenridge Report.

 

 

 

Intravenous additives

Administration of a drug directly into the venous circulation over a period of time, usually     diluted in a medium.

May use an I.V.I. bag (a drip) or an infusion pump eg.Graesby.

Not to be confused with I.V. bolus injection.

I.V. access is already established.

 

AS WITH ALL PARENTAL PROCEDURES

Ensure asepsis

Ensure no air enters the circulation

Use bacterial filters for longer term administration

 

 

NURSING OBSERVATION

 

1.             Is there any pain? (local or systemic)

2.             Any oedema swelling developing?  i.e. ensure drug is entering venous flow

3.             Any oedema of the limb developing?

4.             Any systemic oedema developing?

5.             Any signs or symptoms of inflammation/infection/erythema - due to sepsis, chemical or        mechanical irritation?

                -  local    -  redness, pain, red lines, lymph nodes?

                -  systemic               -  malaise, pyrexia, tachycardia?

6.             Is the drug working?

7.             Any drug side effects?

8.             Is the rate of flow constant

 Patient position

 Limb position or venous obstruction

 Administration set

 Cannula

 Know your equipment.

 

9.             Any signs of embolism, air or particle

 BP

 Tachycardia

 Cyanosis

 Unconsciousness

 Temperature

 

P.E. (pulmonary embolism)

Chest pain

Cough

Dyspnoea

 

Avoid glass shards by drawing up with a blue needle.

 

10.  Any allergic reaction, from fluid, additive or drug?

 itching

 rash

 shortness of breath

 

11.  Any sign of Anaphylaxis (please ensure you attend a separate lecture on anaphylaxis)

12.           Circulatory overload is a particular danger when there is cardiac compromise and in                children.

 

 

KNOW YOUR DRUGS

 

I,      S.E.       C.I.     S.P.     Dose

eg.            I.V. Diamorphine

I.              Moderate to severe pain. Pain with anxiety

S.E.          Respiratory depression - Narcan to hand?

                Constipation

                Euphoria

                Nausea and vomiting - give with Metoclopramide

C.I.          Poor respiratory states

S.P.          As above.     History of abuse eg., addiction.  Muchhausens, pregnancy

Dose        Start 5 - 10 mg,    4 - 6 hourly    May increase with tolerance after some weeks of use.

 

KNOW

How many mg per minute and per ml are being given.

 

REMEMBER

Use correct dilutant, (BNF and National Formulary and enclosed literature).

Check prepared fluid for crystalisation or precipitation (crystalisation normal in cold Mannitol)

Check for any precipitation in the giving system.

If in doubt do not give.

When using solutions containing sugars remember to pay attention to blood sugar levels.

Ensure complete homogenous mixing of additives to prevent bolus administration, eg., a high concentration of KCl, (potassium Chloride) can cause cardiac arrest.

Correctly complete label.

Policy is for two nurses to check the drug AND the patient AND the rate of administration eg., 5 mm per hour.

Follow hospital protocol for drug administration.

 

ALL GRAESBY PUMPS

Use 10 ml BD luer lok syringe for heparin infusions and any other infusion requiring small graesby pump.

Draw up to 8 mls  =  48 mm

i.e. heparin 40,000u made up to 8 mls with 4 mls N/Saline over 24 hrs = 2 mm per hour

Insulin 48 units made up to 8 mls = 1 unit/mm.

48 mm = 8 mls.

This is to be standardised all over the hospital.

Please remind Doctors to prescribe this way.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intravenous therapy

 

 

What it is

 

Additives

 

Bolus

 

 

How may iv additives be given

 

 

 

Advantages of giving drugs intravenously

 

By-passes barriers to absorption

 

Avoids first pass metabolism

 

Rapid speed of action

 

Titration of dose

 

Accurate assessment of dose given - total absorption - equal systemic distribution

 

Comfort

 

Some drugs may only be given iv.

 

May be given when nil by mouth

 

Patients may remain mobile

 

Easy to account for variations in half life

 

Control over rate of administration

 

Easy to stop

 

Prevents muscle damage

 

May be patient controlled

 

 

 

Rates of administration

 

Bolus

 

Infusions

 

Consider the dose of drug going into the patient not into the infusion set

 

 

 

 

 

 

Possible complications of intravenous therapy

 

Inability to recall drug

 

Rapid onset of any adverse reactions

 

Speed shock

 

Overdose

 

Allergies and anaphylaxis

 

System disconnection

 

Extravasation

 

Phlebitis

 

Emboli introduction

 

Fluid or drug incompatibility

 

Bacteraemia and septicaemia

 

Particulate introduction

 

Systemic fluid overload

 

Practical considerations

 

Variations in dose

 

Infusion slows down or stops

 

Loading dose

 

Half life

 

Check with two nurses

 

Prevent puncture of infusion bags

 

Ensure all of the dose enters the fluid vehicle

 

Ensure homogenous mixing of drug and vehicle

 

Always use a label with patients name, drug dose time, date and concentration 

 

Checking fluids and drugs

 

Record keeping

 

Changes of containers, giving sets and cannular

 

Maintain cannular sterility and stability

 

 

Stages in the procedure for infusions

Explain the procedure to the patient.

Wash hands.

The drugs to be given and their dilutants are checked according to local protocols.

Check the labelling information to ensure that the preparation may be given by the intravenous route.

Ensuring asepsis, drugs are drawn up into the syringe appropriately to prevent aerosolization.

Solids must be completely dissolved.

When using syringes add the vehicle to the drug to ensure homogeneity

A green needle or smaller is used to draw up preparations from glass vials to prevent injection of glass micro-shards.

Inspect the entry site of the cannula for inflammation, infection and patency.

Flush the cannula through with 0.9% normal saline if required.

Connect the primed system and start to give the drug at an appropriate rate.

Monitor the patient for any local pain, reactions or tissuing.

Monitor the patient for any systemic effects throughout the procedure ie. side effects and adverse reactions.

If more than one drug is to be given, flush the cannular through with normal 0.9% saline after each drug has been administered.

Flush with 0.9% normal saline at the end of the procedure to ensure complete administration of the drug and continued cannula patency.

Close any taps on entry ports.

Safely dispose of all clinical materials used.

Continue to observe the patient for effects, side effects or adverse reactions.

 

Stages in the procedure for bolus injection

Explain the procedure to the patient.

Wash hands.

The drugs to be given and their dilutants are checked according to local protocols.

Check the labelling information to ensure that the preparation may be given by the intravenous route.

Ensuring asepsis, drugs are drawn up into the syringe appropriately to prevent aerosolization. Solids must be completely dissolved.

A green needle or smaller is used to draw up preparations from glass vials to prevent injection of glass micro-shards.

Inspect the entry site of the cannula for inflammation, infection and patency.

Flush the cannula through with 0.9% normal saline if required.

Connect the syringe and start to give the drug at an appropriate rate.

Monitor the patient for any local pain, reactions or tissuing.

Monitor the patient for any systemic effects throughout the procedure ie. side effects and adverse reactions.

If more than one drug is to be given, flush the system through with normal 0.9% saline after each drug has been administered.

Flush with 0.9% normal saline at the end of the procedure to ensure complete administration of the drug and continued cannula patency.

Close any taps on entry ports.

Safely dispose of all clinical materials used.

Continue to observe the patient for effects, side effects or adverse reactions.

 

Practitioner knowledge base

 

Legal and ethical aspects

Scope of Professional Practice      Code of Professional Conduct        Local procedures

 

Practitioner safety

Avoid contact with preparations                  Develop a safe way to open ampoules

Ensure no contact with body fluids  Safe disposal of used clinical materials