Level 1 IV Orientation [Read-Only]

30/01/2013
Objectives
1. Identify the process for Nursing and Midwifery Staff to attain Canterbury and
West Coast Level 1 IV Certification
2. Show awareness of the key responsibilities of administration of IV therapy
3. Identify the eight key complications of IV therapy administration
4. Identify the timeframe that IV equipment can be safely utilised
5. Describe how risk is minimised in the administration of IV therapy
6. Identify the actions to take following an anaphylaxic reaction
7. Describe how risk is minimised in the administration of blood and blood
products
8. Describe the process of blood product administration
9. Identify actions to take when an adverse blood reaction occurs
Level 1 IV Therapy
Canterbury and the West Coast
Your Logo
Policies
http://www.cdhb.govt.nz/cdhbpolicies
Volume 12
1 The Volume 12
Fluid and
medication
manual can be
located on the
CDHB internet
page
Handouts
2 tHandouts for the
level 1 IV
competency can
be located on the
CDHB
Professional
Development
Website in the IV
Section
To gain your Canterbury/West Coast
Level 1 IV Certificate
Assessment
3 IV Standards are
based on and set
by the Infusing
Nursing New
Zealand
Incorporated
Society.
http://www.ivnnz.co.nz
http://www.cdhb.govt.nz/pdu
To gain your Canterbury/West Coast
Level 1 IV Competency
Assessments
– Clinical calculations Assessment (100%)
– Theory Assessment/s based on Volume 12 (85%)
– IV Practical Checklist (100%)
It is expected that all Registered Nurses, Midwives
and new EN Scope attain their level 1 IV
Competency (unless exempted by workplace eg. Mental Health)
No recertification is required, instead regular clinical audits
occur. Recertification is only required if away from the
organisation for over 12 Months
1. Attend Mandatory IV Lecture
2. Complete all theory and practical sections of the
Canterbury and West Coast IV Assessment
3. Understand the action and reaction of the
medication that you are administering
4. You agree to accept the responsibility for the
administration of the prescribed intravenous
therapy.
Your Level 1 IV Competency is a pre-requisite
for attaining the following competencies
Level 2
IV Competency
Level 2 IV allows a staff member to care for
and access the following IV devices – PICC ,
Hickman and Central Venous lines. Also an
additional portacath Competency can be
attained if required for your area
Venepuncture
Venepuncture, allows a staff member to obtain
blood from a peripheral blood vessel.
IV Peripheral
Cannulation
The Peripheral IV Cannulation competency
allows the staff member to place a peripheral
cannula in a blood vessel
Further information on these competencies is available on the PDU Website
www.cdhb.govt.nz/pdu
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30/01/2013
Key Policies
Transportability
IV Competencies are recognised by the following
St Georges Hospital
All CDHB and WCDHB
Hospitals
Southern Cross Hospital
Pegasus Group and the
Rural Canterbury PHO
Nurse Maude
Oxford Clinic
Double Independent Checking
Double Independent Checking is the key step in the
medication safety process
• Both staff interpret the prescription independently
• Both staff perform calculations independently
• Both Staff perform the patient identification checks at the
patients bedside
• Both staff are present through all stages of preparation,
drawing up and administration of the medication.
Role of the Double Independent Checker
• The Double Independent Checker is just as legally
accountable as the person administering the drug
• They must be present for ALL stages:
Preparation and drawing up
Administration
Bedside checks
Documentation
Includes TWO staff to the bedside
CDHB (2012) Fluid and Medication Checking Procedure
Medications that require Double Independent
Checking
Any Controlled Drug/Infusion
Any Blood or Blood Products
Warfarin and Oral Cytotoxic’s
AND
Any fluid/medication administered by the below routes
Intra muscular
Intra dermal
Subcutaneous
Intravenous
Intrapleural
Intrathecal
Epidural route
Transitioned Enrolled Nurses
Need to Gain the following competencies
1. Independent Medication Administration
Competency. This will enable an enrolled Nurse
to independently administer oral medications, and
undertake independent double checking
responsibilities. This is attained by completing the
clinical calculations and theory components of the
level 1 IV therapy competency.
Please Note: Exceptions only where local policy stipulates - e.g. rural, specialist mental health. For Child Health
and Neonatal Policy please refer to Volume Q
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30/01/2013
Transitioned Enrolled Nurses
Enrolled Nurses who have not transitioned –
and/or do not hold their competencies
2. Level 1 IV Competency (EN Scope)
Must check all Medications and Fluids with their
designated Registered Nurse
May clamp tubing or turn off a pump if an infusion
has completed
Monitor whether an IV infusion is running to time
Perform hourly patient checks when an IV infusion
is in progress
Maintain the patient fluid balance record
Once a transitioned Enrolled Nurse has completed their Level 1 IV
Competency they can;
– Enrolled Nurses can double independent check with another
Enrolled Nurse who has also completed their independent
medication administration competency when their designated
registered health professional is not available
– May Administer IV Saline Flushes as per local policy
– May Administer IV fluids (without additives or Potassium)
– May Administer IV or SC Premixed bags i.e. N/Saline 0.9% or
Dextrose 4% in N/saline 0.18% premixed bags which are running 812 hourly (Adults only)
Verbal Telephone Orders
• Can be initiated by Registered Nurses and Midwives
• For ‘Urgent’ clinical situations when the prescriber is
unavailable to come to the clinical area
• Recorded in Red on the prescription chart
• Repeated by prescriber to second checker (RN/RM/EN but
not student nurse)
• One verbal order for a class A or B drug is acceptable if a
pre-existing order for that drug is present
• Exceptions e.g epidural boluses, blood, paediatrics,
significant renal disease or abortion inducing medications
Complications of IV Therapy
Verbal Orders in an Emergency Situation
The verbal order is given by the Medical Officer
The verbal order is repeated to the medical officer by the nurse
receiving the order and also provides a running total of the
amount of drug the patient has already received
The Medication is then drawn up by the nurse who received the
order
The Verbal order is repeated by the nurse as the medication is
handed to the Medical Officer, and the ampoule is second
checked by the Medical Officer.
The order is documented, and then signed by the Medical
Officer at the conclusion of the Emergency Situation.
Complications of IV Therapy
• Hypersensitivity/Allergy
1.
2.
3.
4.
5.
6.
7.
8.
Hypersensivity
Infiltration
Extravasation
Phlebitis
Infection
Fluid Overload
Air Embolism
Anaphylaxis
• Infiltration - Infiltration occurs when I.V. fluid leaks into
surrounding tissue
Nursing Made Incredibly Easy! (2008) I.V. Essentials: Complications of peripheral I.V. therapy, 6(1). pp 14-17
Intravenous Infusions and Related Tasks [retrieved 23/11/11 from
http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-08_Intravenous_Infusions.html
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30/01/2013
Complications of IV Therapy
Complications of IV Therapy
• Extravasation - the leaking of
vesicant drugs into surrounding
tissue causes tissue necrosis
• Infection.
• Fluid Overload
• Phlebitis - Inflammation of a vein
• Air Embolism
Anaphylaxis
Anaphylaxis and Other Drug Reactions
• Any medication may potentially trigger
anaphylaxis. The most common to do so
include antibiotics, aspirin, ibuprofen, and
other analgesics
Mild
Moderate
Dizziness, tingling, flushing/warmth, puritis
Flushing, urticaria, nasal congestion, sneezing,
lacrimation, angio-oedema, erythema
Severe
Hoarseness, nausea, vomiting, laryngeal
oedema, dyspnoea, abdominal pain/cramps,
substernal pressure
Life
Threatening
Bronchospasm, stridor, syncope, hypotension,
dysrythmias, coma, confusion
http://en.wikipedia.org/wiki/Anaphylaxis
Anaphylaxis Vs Vasovagal
More likely to be tachycardic
More likely to be bradycardic
More likely to be hypotensive
More likely to be normotensive
Less likely to be pale or sweaty
More likely to be pale and to sweat
More likely to have puritis
Never have puritis
May have airway obstruction
Never have airway obstruction
May have uticaria
Never have urticatia
Loss of consciousness usually not
immediate
Loss of consciousness more likely to be
immediate
Less likely to feel better when lying down
Often feel better when lying down
Always follows administration of drug
Sometimes follow painful intervention
Less likely to have tonic-clonic jerks if
unconscious
More likely to have a few topic-clonic jerks
after loss of consciousness
Anaphylaxis: Immediate Management
•
•
•
•
•
•
•
•
A-B-C
– High-flow oxygen.
– Lie patient flat and elevate legs.
ADRENALINE
– 0.5 ml of 1:1000 IM (0.5 mg). Repeat every five minutes if needed.
Antihistamines: promethazine 25-50 mg IM (preferred) or via slow IV push; or cetirizine or
loratadine both 20 mg PO.
Hydrocortisone 200 mg IV (onset of action 4-6 hours).
Intravenous fluids - normal saline to maintain blood pressure.
Nebulised salbutamol 5 mg (bronchospasm).
Nebulised adrenaline 2 ml of 1:1000 (2 mg) diluted to 4 ml in normal saline (stridor).
IV adrenaline is indicated if the situation is life threatening with circulatory collapse, and/or
the patient is unresponsive to the above initial treatment. Cardiovascular monitoring must be
available. Begin with 0.5-1 ml of 1:10,000 (0.05 mg to 0.1 mg) and increase dose
incrementally as required. Very rarely up to 1 mg (10 ml of 1:10,000) may be required every
five minutes.
CDHB (2009) Management Guidelines for Common medical Conditions (13th Edition)
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Infection Prevention and Control
Key Infection Prevention measures
• Hand hygiene
– ‘The 5 Moments for Hand Hygiene’
• Standard Precautions
– Use of non-sterile gloves for Health Care Worker protection
when potential for blood and body fluid exposure
– Other Personal Protective Equipment e.g. mask, apron when
necessary
– Sharps safety practices
• Aseptic non-touch technique (ANTT)
– Asepsis for all invasive procedures
Replacement timeframes
IV Lines
– 72 Hours
But 24 hourly
for Blood/TPN/
and certain
Medications
IV Cannula –72 Hours
Checked at the start of the
shift and at least every eight
hours when not in use
Green IV Line Stickers
Intermittent
Infusion
– Single Use
Only then
discard
IV Cannula placed in an
pre-hospital;
emergency setting – As
soon as the patient is
stable
Aseptic Non-Touch Technique
Always use aseptic non touch
technique (ANTT)
Blood Filters – 8
Hours or 2-4 units
of blood
Phlebitis Score
Visual Phlebitis Score
0 No Symptoms
Observe Cannula
1 Erythraemia at insertion site,
with or without pain
Observe Cannula
Do not contaminate these key parts
Always use luer lock syringes
2 All the above plus oedema
Resite Cannula
3 All the above, plus streak
formation/Palpable Cord
Resite Cannula – Consider
Treatment
4 All the above, plus palpable
venous cord > 1 inch (2.54cm)
and discharge
Resite Cannula – Consider
Treatment
Identify key parts of the equipment
you are using
Always use blunt non coring needle
to access plastic polyamps, drug
bottles and when transferring drugs to
IV bags, and filter needles when
drawing up from glass ampoules
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Sharps Safety Equipment – Single Use Only
Red Cells $253
Blood Transfusions
Platelets
$755
How Precious?
G&S
$45
Cryoprecipitate
$365
WHOLE BLOOD
FFP
$195
Immunoglobulin $156
Albumin 4% & 20% $96
Prothrombinex $266 Intragam P $1058
Why do we give transfusions?
• To correct loss:
- bleeding, destruction, reduced production
- plasma - burns
• To increase Haemaglobin
• To correct clotting deficits – induced by disease
processes or medications
• Neonatal exchange transfusion
• To boost the immune system
Key risks of receiving a blood transfusion
•
•
•
•
HIV – Less than 1 in a million.
Hepatitis C – Less than 1 in a million
Hepatitis B – one in 100,000.
Bacterial Infections – less than 1 in a
100,000.
• Patient given blood that does not match.
STAFF ERROR
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How are blood products prescribed
Blood products are prescribed on the Fluid Prescription
form:
– Number of units
– Rate of transfusion
– Any pre med
– Any diuretic required
– Blood warmer
– Irradiated product
Before getting the blood product
•
•
•
•
•
•
Discuss with the patient and explain the procedure
Obtain Baseline TPR,SpO2, and BP
Record on normal observation chart.
Check IV device – is it patent?
Check consent & prescription
Then…Send blood request form to blood bank, or go
and collect. A Registered Nurse or Midwife needs to
sign as the requester
Medical staff must complete the Blood Bank request form
and not the usual Laboratory form
Blood Collection Points – Christchurch Hospital
Blood Collection Points – Other Hospitals
To collect the blood, you can use the NZ
Blood Service Blood Bank which is on the
lower ground floor of the Parkside block. As
the blood is dispensed by laboratory
scientists it can be obtained/delivered by
As there is no Blood Service onsite, blood is
delivered from the NZBS at Christchurch
Hospital via taxi, ambulance or shuttle. Once it
arrives it is put into the blood fridge in your
location, where it can be collected.
– Orderlies/Hospital Aides
– Nursing and Midwifery Staff
– Sending the request via the Lamson Tube
System (delivered this way as well)
Blood Fridge TPMH
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At the Bedside
When transfusing
Two Nurses/Midwives must check blood details & patient
details at the patients side.
–The Requester must be CDHB IV certified, EN’s must have
their level 1 IV Certification to second check blood
products.
Check the appearance of unit of blood for
– The presence of clots, clumps or abnormal cloudiness
You must check – The patients hospital armband for clarification of
patient identification against the Prescription chart and the blood
request form which is returned with unit of blood.
Filter ?
If it is Fresh, it
needs a Filter
If it comes in a
bottle – no need
to use filter
You can’t mix Blood !
Blood must NOT
be mixed with
any other DRUG
or SOLUTION
other than
Normal Saline.
• Always uses a 20 micron filter
• Change the filter after every 2 bags of blood or 8 hourly –
whichever comes first
• Only one unit of blood is administered at a time.
• Commence the transfusion within 30 minutes of issuing, if you
suspect delay, return the blood to Blood Bank/Blood fridge
immediately
• Complete the transfusion within 4 hours
• Discard tubing and bag, place sticker on the back of the blood
request form and then document the date and time completed
NEVER PUT BLOOD IN A WARD FRIDGE
Observations during the transfusion
Remain with patient for
the first full 15 minutes
15 mins
from
baseline
Hourly until
the infusion is
30 mins
completed
from
baseline
Baseline
Mild Reaction ?
First febrile reaction:
Body core temperature
has increased more than
one degree from their
baseline.
•Stable haemodynamicly
•No respiratory distress
•No other symptoms
Occasional urticarial spots
with no other symptoms
Action !
A. Check the blood bag labels
and patient ID to ensure
the details match
B. Slow transfusion
C. Consider giving an
antipyretic for pyrexia and
antihistamine for urticaria
D. Continue transfusion at a
slower rate with increased
monitoring
If symptoms increase treat as
a moderate reaction.
Moderate or
Severe Reaction ?
Final set of obs
at the
conclusion of
the transfusion
Start again for
each new unit
Action !
A. Stop the transfusion
immediately and review
B. Check the blood bag details
against patient ID to ensure it
is the correct blood product.
C. Disconnect blood & IV set
(keep don’t discard) This will
be sent to the blood bank for
testing
D. Flush cannula to keep patent.
E. Call for medical assistance
Follow NZBS transfusion protocol
management guidelines for
Adverse Transfusion Reactions
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Blood Substitutes
Questions
USED TO FILL FLUID VOLUME AND/OR CARRY OXYGEN
1. Oxygen therapeutics – mimic O2 carrying capacity
- hemopure, Oxygent, PolyHeme
2. Volume Expanders
- Ringers, NS, D5W, Haemacel, Gelofusin
• Allows for all blood types, no need to cross match
• Decreased risk of infection
• Store at room temperature
• Store for longer
References
Canterbury District Health Board (2009) Management Guidelines for Common medical Conditions (13th
Edition), Christchurch, New Zealand: CDHB
THANK YOU!
Harrison's principles of internal medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.;
c2004-2005. Hypovolemia
Harrison's manual of medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005.
Hypo/Hypernatremia
Martin, S. (2003) Intravenous Therapy, Business Nriefing: Long term health care Strategies 2003,
retrieved 23/11/11 from http://www.touchbriefings.com/pdf/14/ACF7977.PDF
Nursing Made Incredibly Easy! (2008) I.V. Essentials: Complications of peripheral I.V. therapy, 6(1). pp
14-17
Brookside Associates (2008) Intravenous Infusions and Related Tasks: Lesson 1: Initiate an Intravenous
Infusion and Manage a Patient With an Intravenous Infusion, retrieved 23/11/11 from
http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-08_Intravenous_Infusions.html
Barts and the London Queen Mary’s School of Medicine & Dentistry (2005) Prescribing Skills - Modules
for self directed learning, retrieved 10/12/12 from http://www.smd.qmul.ac.uk/prescribeskills/
References
New Zealand Blood Service (2008) Transfusion Medicine Handbook , retrieved 10/12/12 from
http://www.nzblood.co.nz/Clinical-information/Transfusion-medicine/Transfusion%20medicine%20handbook
Infusion Nurses Society (2010) Infusion Nursing (Third Edition). USA: Saunders
Popovsky, M.A. (2009) Transfusion – associated circulatory overload: the plot thickens. Transfusion, Vol
49. pp2-3
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