30/01/2013 Objectives 1. Identify the process for Nursing and - - PDF document

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Canterbury and the West Coast

Level 1 IV Therapy

• 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

Your Logo

Objectives

http://www.cdhb.govt.nz/cdhbpolicies

Policies

tHandouts for the level 1 IV competency can be located on the CDHB Professional Development Website in the IV Section

Handouts

1 1

Volume 12

IV Standards are based on and set by the Infusing Nursing New Zealand Incorporated Society.

Assessment

The Volume 12 Fluid and medication manual can be located on the CDHB internet page 3 2 http://www.ivnnz.co.nz

http://www.cdhb.govt.nz/pdu

• 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.

To gain your Canterbury/West Coast Level 1 IV Certificate

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

• ccur. Recertification is only required if away from the
• rganisation for over 12 Months

To gain your Canterbury/West Coast Level 1 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, allows a staff member to obtain blood from a peripheral blood vessel. The Peripheral IV Cannulation competency allows the staff member to place a peripheral cannula in a blood vessel

Your Level 1 IV Competency is a pre-requisite for attaining the following competencies

IV Peripheral Cannulation Venepuncture Level 2 IV Competency

Further information on these competencies is available on the PDU Website www.cdhb.govt.nz/pdu

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Transportability

IV Competencies are recognised by the following

Nurse Maude Southern Cross Hospital St Georges Hospital Oxford Clinic Pegasus Group and the Rural Canterbury PHO All CDHB and WCDHB Hospitals

Key Policies 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.

CDHB (2012) Fluid and Medication Checking Procedure

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 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

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

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.

Transitioned Enrolled Nurses

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• 2. Level 1 IV Competency (EN Scope)

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 8- 12 hourly (Adults only)

Transitioned Enrolled Nurses

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

Enrolled Nurses who have not transitioned – and/or do not hold their competencies

• 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

Verbal Telephone Orders

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

• rder

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.

Verbal Orders in an Emergency Situation

• 1. Hypersensivity
• 2. Infiltration
• 3. Extravasation
• 4. Phlebitis
• 5. Infection
• 6. Fluid Overload
• 7. Air Embolism
• 8. Anaphylaxis
• 1. Hypersensivity
• 2. Infiltration
• 3. Extravasation
• 4. Phlebitis
• 5. Infection
• 6. Fluid Overload
• 7. Air Embolism
• 8. Anaphylaxis

Complications of IV Therapy

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

Complications of IV Therapy

• Hypersensitivity/Allergy
• Infiltration - Infiltration occurs when I.V. fluid leaks into

surrounding tissue

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Complications of IV Therapy

• Extravasation - the leaking of

vesicant drugs into surrounding tissue causes tissue necrosis

• Phlebitis - Inflammation of a vein

Complications of IV Therapy

• Infection.
• Fluid Overload
• Air Embolism
• Any medication may potentially trigger
• anaphylaxis. The most common to do so

include antibiotics, aspirin, ibuprofen, and

• ther analgesics

Anaphylaxis

http://en.wikipedia.org/wiki/Anaphylaxis

Anaphylaxis and Other Drug Reactions

Mild Dizziness, tingling, flushing/warmth, puritis Moderate Flushing, urticaria, nasal congestion, sneezing, lacrimation, angio-oedema, erythema Severe Hoarseness, nausea, vomiting, laryngeal

• edema, dyspnoea, abdominal pain/cramps,

substernal pressure Life Threatening Bronchospasm, stridor, syncope, hypotension, dysrythmias, coma, confusion

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

• 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.

Anaphylaxis: Immediate Management

CDHB (2009) Management Guidelines for Common medical Conditions (13th Edition)

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Infection Prevention and Control

• 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

Key Infection Prevention measures 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 Intermittent Infusion – Single Use Only then discard Blood Filters – 8 Hours or 2-4 units

• f blood

IV Cannula placed in an pre-hospital; emergency setting – As soon as the patient is stable

Green IV Line Stickers Aseptic Non-Touch Technique

Always use aseptic non touch technique (ANTT) Identify key parts of the equipment you are using Do not contaminate these key parts Always use luer lock syringes 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

Phlebitis Score

Visual Phlebitis Score No Symptoms Observe Cannula 1 Erythraemia at insertion site, with or without pain Observe Cannula 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

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Sharps Safety Equipment – Single Use Only Blood Transfusions How Precious?

WHOLE BLOOD

Red Cells $253 Cryoprecipitate $365 FFP $195 Platelets $755 Albumin 4% & 20% $96 Immunoglobulin $156 Prothrombinex $266 Intragam P $1058 G&S $45

• 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

Why do we give transfusions? 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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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

Medical staff must complete the Blood Bank request form and not the usual Laboratory form

How are blood products prescribed

• 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

Before getting the blood product

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

– Orderlies/Hospital Aides – Nursing and Midwifery Staff – Sending the request via the Lamson Tube System (delivered this way as well)

Blood Collection Points – Christchurch Hospital

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.

Blood Collection Points – Other Hospitals

Blood Fridge TPMH

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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.

At the Bedside

• 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

When transfusing

Blood must NOT be mixed with any other DRUG

• r SOLUTION
• ther than

Normal Saline.

You can’t mix Blood !

If it is Fresh, it needs a Filter If it comes in a bottle – no need to use filter

Filter ?

Observations during the transfusion

Baseline 15 mins from baseline 30 mins from baseline Hourly until the infusion is completed Final set of obs at the conclusion of the transfusion

Remain with patient for the first full 15 minutes Start again for each new unit

• 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. Action !

First febrile reaction: Body core temperature has increased more than

• ne degree from their

baseline.

• Stable haemodynamicly
• No respiratory distress
• No other symptoms

Occasional urticarial spots with no other symptoms

Mild Reaction ?

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

Action !

Moderate or Severe Reaction ?

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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

Blood Substitutes Questions

THANK YOU!

Canterbury District Health Board (2009) Management Guidelines for Common medical Conditions (13th Edition), Christchurch, New Zealand: CDHB 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

References