Table of Contents - Halton and St Helens PCT

Intravenous Therapy Workbook 

For Cheshire and Merseyside NHS North West 

Intravenous Access Care and Maintenance 

in Hospital and Home 

Developed by 

Collaborative Intravenous Nursing Service 

(CINS) 

Version 8.7 Adult 

September 2007

Intravenous Access Care and Maintenance in Hospital and Home 

The aim of this programme is to develop a uniform approach towards training and 

assessment for IV access, care and maintenance therefore developing a standardised 

approach to practice and reducing the need for repeated assessment when 

practitioners move between health care organisations. 

While this workbook may initially appear intimidating, on closer inspection you will 

notice that it consists of a lot of reference material to aid you in your future practice. By 

completing this workbook and the programme of learning you will gain a solid 

foundation of knowledge and have a personal record of your skill expansion to aid you 

in your career development. 

Good Luck 

CINS Group 

Acknowledgements 

Substantial sections of this workbook have been developed by the following on behalf 

of the CINS group 

• Mid Cheshire Hospital Trust 

• The Royal Liverpool and Broadgreen University Hospitals NHS Trust 

• Liverpool Primary Care Trust 

Special thanks also to all those within and outside of the CINS group who have 

contributed their time and effort to reviewing this workbook. 

The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 

CINS workbook draft 8.7 (adult) complete 3

Table of Contents 

Page 

Introduction to workbook and assessment strategy 2 

Introduction to Intravenous therapy 10 

1. Legal, professional and ethical issues 14 

2. Anatomy and physiology 21 

3. Vascular access devices 29 

4. Medical infusion devices best practice guidelines 48 

5. Drug calculations 51 

6. Pharmacology and pharmacotherapeutics related to 

reconstitution and administration of IV medication 57 

7. Local and systemic complications 65 

8. Infection control issues 73 

9. Home Intravenous Therapy 80 

10. References and further reading 84 

11. Appendices 88 

Annotated careplan for peripheral cannula care 89 

Clinical Competency Frameworks& documentation 92 


CINS workbook draft 8.7 (adult) complete 

1

INTRODUCTION TO WORKBOOK AND ASSESSMENT STRATEGY 

This intravenous (IV) access workbook has been created to assist practitioners to 

become competent and confident in the safe administration of IV medication It has 

been developed to complement the IV training day held at your local organisation and 

support you in your practice. The Collaborative Intravenous Nursing Service (CINS) 

project has produced these educational resources in order to support the guidelines 

for best practice, ensure uniformity of approach and set a high standard of care in IV 

therapy. All practitioners have a responsibility to deliver care based on current 

evidence, best practice and, where applicable, validated research when it is available. 

It is recommended that practitioners managing IV therapy will have undergone 

theoretical and practical training (RCN 2005). This workbook contains theoretical 

elements of the course. It is important that you read, reflect and perform the required 

exercises to help you better understand the concepts which will be developed and 

tested on the study day. Please bring the completed workbook and any remaining 

queries with you to the study day. It is imperative that you collect this workbook at 

least 2 weeks prior to the study day so that you can complete this pre-course material. 

Failure to collect the workbook will cancel your place in the course. In order to meet 

the recommended training (NPSA 2003, NICE 2003, RCN 2005) this pack will include: 

‣ Legal, professional and ethical issues 

‣ Anatomy and physiology 

‣ Vascular access devices – advantages, disadvantages & care 

‣ Medical infusion devices best practice guidelines 

‣ Possible complications –risk management / Health and Safety 

‣ Drug preparation and administration 

‣ Calculations 

‣ Home Intravenous therapy 



Learning Outcomes 

It is hoped that by completing all the elements in this book and the theoretical and 

practical assessments that you will meet the following learning outcomes: 

Discuss the importance of legal and professional issues 

Analyse the principles of relevant anatomy and physiology for IV therapy e.g 

fluid and electrolyte balance 

Identify the indications for Intravenous drug / fluid administration 

Analyse the range of IV access devices suitable for IV therapy 

Analyse possible risks of IV therapy and take appropriate measures to limit 

them 

Identify the infection control measures that need to be instigated when 

undertaking IV therapy 

Demonstrate safe and effective practice when preparing, administering and 

managing IV therapy in accordance with CINS guidelines 

Calculate drug dosages correctly 

Demonstrate competence in relation to standards in the CINS guidelines and 

Trust policy 

To achieve competence in the skills of IV therapy the candidate must: 

• Successfully complete both the theoretical and practical assessments 

• Keep up to date with any change in practice 

• Seek an update session from practice educators/skills lab if the skill is not 

carried out in 6 months 

The practical elements of the course are: 

• Safe management of vascular access devices 

• Preparation and administration of IV medications via different vascular access 

devices 

• Use of most common infusion devices for IV therapy 

The following are the underpinning knowledge, psychomotor and affective 

competencies you need to achieve to be deemed competent and safe in the 

administration of IV medications: 



• Demonstrate the ability to use and validate the correctness of the prescription 

sheet. 

• Demonstrate knowledge on the therapeutic use of medicines to be administered 

including normal dosage, side effects, precautions and contraindications. 

• Demonstrate the ability to prepare and use appropriate equipment. 

• Undertake the administration of IV medications following the 5 rights (5R’s) in 

medication administration. 

• Ensure that patients are informed and that they understand the reason for the 

medication in relation to the plan of care. 

• Accept any limitations in knowledge and skills and takes measures to remedy 

them. 

• Make good and proper use of local and national clinical guidelines on IV 

administration of medications and identify how to access further information 

• Demonstrate the ability to use and care for venous access devices. 

• Demonstrate compliance with standard precautions in the control and 

prevention of infection. 

• Identify clinical and safety risks and takes actions to avoid potential 

complications. 

• Demonstrate knowledge of medical devices best practice guidelines and uses 

the devices correctly. 

• Demonstrate professional behaviour in accordance with the NMC Code of 

Professional Conduct. 

IV Therapy and the NMC 

‘To practice competently you must possess the knowledge, skills and abilities required 

for lawful, safe and effective practice without direct supervision and acknowledge the 

limitations of your professional competence (NMC, 2004). In addition, the NMC (2004) 

states that ‘the administration of medicines is not solely a mechanical task to be 

performed in strict compliance with the written prescription of a medical practitioner; it 

requires thought and the exercise of professional judgement’. 

In order to develop and assess this, it is important to have validated competency in 

clinical judgement and practice. This workbook will help to provide the knowledge 



needed to underpin this professional clinical judgement. The explanation and diagrams 

on the next few pages are intended to provide you with further guidance on the 

assessment processes. 

Becoming Competent in IV Therapy and in 5 Easy Steps 

Step 1 – Get support from your manager 

Ensure that your manager would like you to learn this skill. 

It’s hoped that this will be done at your individual performance review / appraisal 

where both you and your manager will have had time to reflect upon those skills and 

experiences you have acquired and those that you need to develop for your role. 

Upon completion of the learning programme your manager will be required to sign the 

competency checklist to demonstrate their support for you in undertaking this skill and 

that it is needed in developing you for your job. 

Step 2 – Getting help to learn 

If you haven’t done so already book yourself on a IV therapy training course. 

You will also need to identify a suitable practice supervisor within your work area who 

can guide and support you in acquiring the skill. 

You may find you will need more than one practice supervisor in-order to have some 

one present when the skill needs to be performed. 

The person you choose must meet the following criteria; 

• Be competent in the skill of IV therapy for which you are being assessed 

• Be familiar and practice in accordance with the CINS guidelines 

• Have practised the skill for at least 6months on a regular basis within the 

Trust 

• Hold a relevant teaching and assessing qualification eg; City & Guilds, 

ENB998, Mentorship in Clinical Practice 



Step 3 – Undertake the learning programme 

Next you need to complete the “Reflective practice” contained within this learning 

package prior to attending the training course. Failure to do this may lead to your 

place being cancelled. The study day will consist of an assessment of skills using 

simulated scenarios and post course theoretical exam. 

When you pass mark these assessments you can progress to supervised practice. 

Supervised practice must be completed within 3 months. These should be logged on 

the “Supervised practice assessment sheet” 

You need a minimum of 3 supervised practices but the number supervisions may vary 

between individuals and work areas so you may need more. Spare forms can be 

obtained from the training department. 

When you feel confident with the procedure contact a member of the learning & 

development team or specialist nurse practitioner to come and assess you. 

They will assess you using the “final assessment of practice” record sheet. 

When they sign you off as competent complete the “competency checklist” and make 

3 copies; 

• Copy 1 – To be sent to the Learning & Development team, upon receipt you will be 

issued with a certificate. 

• Copy 2 – To be held by your manager as a record of competency 

• Copy 3 – To be retained by you for your professional portfolio and KSF 

Only when you receive a certificate from the learning & development team will 

you then be able to practise the skill unsupervised. 

Step 4 – Independent practice 

Ensure you have accessed, read and understood your health care organisation’s 

guidelines and policies relating to IV therapy, the CINS guidelines and any specific 

guidelines that have been adopted for your area. 



It is up to you to maintain your clinical competency. Don’t lose all the effort you put 

into the learning the skill. Continue to update your knowledge and keep practising. 

Step 5 – Seeking advice 

Don’t be frightened to ask for help if you need it. 

If you have any questions contact a member of your learning and development team 

and they should be able to help you overcome any issues you may have. 

More details regarding the assessment process can be found under the clinical 

competency framework in the appendix 



Training pathway for registered practitioners in the extended role of 

IV medication administration 

Newly qualified nurses signed off for single nurse drug administration 

Nominated by line manager for IV therapy training 

Book place with local training department 

Collect workbook 2 weeks prior to course date and complete 

Attend course 

(will include skills assessment using simulated scenarios on use of venous access devices, use of 

infusion devices, reconstitution of drugs ) 

Post course written test (theoretical assessment) 

Pass 

Part 1 – score of 100% 



Fail written test 

Re-take written test within 2 weeks 

Work- based assessment 

With qualified assessor 


Remedial session within 1 week 

Signed off 

Part A& B and 

Statement of Intent Copy 3 sent to Trust register Retake written test within 2 

weeks 

Statement of Intent Copy 2 sent to line manager 

Statement of Intent Copy 1 kept in professional portfolio 


Referred to line manager. Trust 

Capability Policy or KSF review will 

apply. 



Training pathway for registered nurses with previous experience in 

IV medication administration 

Evidence of IV training and has practiced skill in 

last 6 months 

Yes 

Yes 

Trained according to 

CINS guidelines 

No 

Follow training pathway for 

registered practitioners in the 

extended role of IV administration 

No 

Collect workbook and 

complete within 2 

Sit written test 

Pass 

Part 1 – Pass mark 100% 



Fail Written test 

Book a drop in session for clinical skills 

session in the lab (1 hour) 

Will include skills assessment including simulated 

scenarios on use of venous access devices, use of infusion 

devices and reconstitution of drugs. 

No 

Pass 

Retake within 2 

weeks 

Fail 

Remedial session 

within 1 week 

Work based assessment with qualified 

assessor 

3 rd 

Fail 

Fail 

Pass 

Yes 

Pass 

Retake within 2 

weeks 

Sign off 

Send Part A & B statement of intent to; 

• Copy 3 - skills lab 

• Copy 2 – line manager 

• Copy 1 – For your professional portfolio 

Fail 

Refer to line Manager. 

Trust capability policy 

/ KSF appraisal will 

apply 



INTRODUCTION TO INTRAVENOUS THERAPY 

IV therapy and haemodynamic monitoring via vascular access devices e.g. central 

lines, is commonplace in clinical practice. Use of the IV route for fluids or medication is 

a decision made by the prescribing practitioner, based upon patient condition. If the 

intravenous route is required, account should be taken of how long the treatment is 

intended to last, whether the drugs / infusates are vesicant, how frequently and what 

volumes are to be infused (RCN 2005). Many of these patients are distributed across 

both hospital and community settings. 

IV therapy presents a potential risk to patient safety, with associated risks varying 

from minor complications to death. The number of patients who require IV therapy is 

increasing, because more patients are being recognised as acutely ill and also 

because of changes in prescribing patterns. It is important therefore to ensure that 

best practice is evidence based and that those involved in the management of IV 

therapy have sufficient knowledge, skills and competence within their professional 

scope of practice to optimise care. 

Advantages and Disadvantages of the Intravenous Route. 

The risks and costs associated with the IV route should be considered before a drug is 

administered intravenously. If the oral route is available and therapeutically practical, 

it should be used. Subcutaneous, intramuscular, transdermal, enteral, rectal, buccal 

and sublingual routes may offer advantages in some situations. The intravenous route 

should be considered for the following reasons: 

1. Facilitates a rapid, predictable response providing an immediate therapeutic effect 

2. Allows administration of fluid and drugs when other routes are unavailable. 

3. Affords 100% bioavailability. If drugs are administered orally, not all the dose may 

be absorbed from the gastrointestinal tract; some may even be destroyed in the 

gut. 100% of the administered dose of an injection or infusion enters the circulation. 



4. Some drugs are not active orally e.g. heparin, insulin and naloxone can only be 

administered parenterally. 

5. Less painful than IM, less trauma particularly if cachexic 

6. More acceptable to patients than the rectal route. 

7. To achieve constant plasma levels and allow fine control over the rate 

administration of drugs. Prolonged action can be provided by administering a dilute 

infusion intermittently or over a prolonged period of time. 

However the intravenous route also presents the following disadvantages. 

1. Time 

o Time taken for administration or potential for reduced mobility of patient 

2. Infection risk 

o Every time the skin is pierced, the potential to introduce micro-organisms 

exists. In addition, infection can be introduced through the bag or giving set. 

Bags made on the ward have a higher risk of contamination and patients who 

are frail or immunocompromised may be at higher risk of infection. 

3. Stability and compatibility problems 

o Once a drug is reconstituted, its rate of breakdown increases rapidly. The 

presence of other drugs or fluids in the same bag, syringe, or line may result 

in compatibility problems. 

4. Thrombophlebitis and embolism risks 

o Most drugs are irritant to the veins, but some, for example clarithromycin, are 

especially so. Some drugs must be administered through an in-line filter to 

reduce particles such as infusions of phenytoin. 

5. Toxicity 



o Some drugs may cause toxicity if adequate therapeutic drug monitoring 

(TDM) is not in place to check levels e.g. aminophylline, gentamicin. 

6. Adverse effects 

o Some drugs given intravenously can cause adverse effects not normally 

associated with the drug especially if not used according to manufacturer’s 

instructions e.g. vancomycin can cause "red man" syndrome and furosemide 

can cause deafness if administered too quickly. 

7. Fluid balance problems 

o A patient receiving several intravenous doses may also receive substantial 

volumes of fluid. This may be clinically important in fluid restricted and 

paediatric patients. 

8. Hypersensitivity 

o This is also a problem with other routes but may develop faster or more 

aggressively following an intravenous injection. Anaphylaxis may develop 

following penicillin or cephalosporin administration. This can happen after any 

number of doses. 

9. Speed shock 

o Insufficient control may lead to speed shock from too rapid a rise in serum 

concentration of the drug or circulatory overload. 

10. Extravasation and infiltration risks 

o The potential for patient discomfort from the IV access device. This is most 

commonly caused by a poorly sited or inserted cannula. Any drug with a too 

high or low osmolality or pH may also cause this problem, e.g. aciclovir 

11. Cost 

o Drug- injections are more expensive than oral medication. E.g. ciprofloxacin - 

16p per 250 mg tablet. £22 for 200mg injection. In a similar manner, a 500mg 

twice daily regime of clarithromycin costs £22.92 for the drug alone before 

bags or CIVAS costs, much more expensive than oral erythromycin. (British 



Medical Association & the Royal Pharmaceutical Society of Great Britain , 

2007). 

o Staff time - even if CIVAS bags are prepared in pharmacy, there is still a staff 

cost which must be borne by the Trust. 

o Equipment - needles, syringes, bags, lines etc. 

12. Inability to recall the drug, reversal agents may not exist. 

13. Psychological considerations 

o Altered body image, especially with central venous access devices & needle 

phobia. 

The CINS guidelines and supplementary care plans have been developed as an 

evidence based guide to minimise the potential disadvantages and risk of 

complications. The guidelines should be read in conjunction with the workbook and 

competency framework. Before commencing IV therapy, it is important that the 

professional is aware of the potential risks and how to minimise them, their 

professional and legal responsibilities. 



1. LEGAL, PROFESSIONAL AND ETHICAL ISSUES 

Professional guidance in care delivery 

Healthcare professionals have a duty of care to provide safe and competent care to 

their patients and clients. In addition to this the Nursing and Midwifery Council [NMC] 

Code of professional Conduct (2004) states that : 

• You are personally accountable for your practice. This means that you are 

answerable for your actions and omissions, regardless of advice or directions from 

another professional. 

• You must keep your knowledge and skills up-to-date throughout your working life. 

In particular, you should take part regularly in learning activities that develop your 

competence and performance. 

• To practice competently, you must possess the knowledge, skills and abilities 

required for lawful, safe and effective practice without direct supervision. You must 

acknowledge the limits of your professional competence and only undertake 

practice and accept responsibilities for those activities in which you are competent. 

• If an aspect of practice is beyond your level of competence or outside your area of 

registration, you must obtain help and supervision from a competent practitioner 

until you and your employer consider that you have acquired the requisite 

knowledge and skill. 

The workbook is a resource to use to protect both professional and public interests. 

Reflection activity 1.1 

Think about situations in relation to IV therapy when each of these bullet points will 

guide your actions 



The law and accountability in relation to IV drug administration 

The law requires that medicines be given to the right person, in the correct form, using 

the correct dose and via the correct route. It is essential that administration practice be 

informed both in relation to the law and each area of accountability: The legal 

framework protects patients from the harmful effects of medicines whilst allowing them 

to benefit from their therapeutic properties by drawing together four separate areas of 

accountability. 

1. To the public, via criminal law 

2. To the patient, via civil law 

3. To the employer, via contractual law 

4. To the profession, via the regulating professional body 

Criminal law: Usually seeks to establish guilt and determine punishment and will 

follow if a criminal act has taken place e.g. The Beverly Allitt case. 

Civil law: May be pursued by an individual or relative if negligence is implicated in the 

death or injury of a patient. Civil law usually seeks to establish accountability and 

award damages. 

Contractual law: Based upon practitioners contract of employment, and the terms 

within it. Failure to comply with terms and conditions of contract may result in 

disciplinary action against the employee. 

Professional Accountability: Through registration with the professional regulating 

body. Following successful prosecution of a civil or criminal law suit the professional 

body will review possible misconduct charges and any action, which should be taken. 

In exercising your professional accountability during administration of IV therapy in the 

best interests of your patients, you must: 

• Ensure patient consent is obtained for treatment 

• Know the therapeutic uses of the medicine to be administered, its normal dosage, 

side effects, precautions and contra-indications. 



• Be certain of the identity of the patient to whom the medicine is to be 

administered by checking against the patient name band their name, unit 

number, date of birth. The details must be confirmed whenever possible by the 

patient. 

• Be aware of the patient's care plan in relation to the medication/s being 

administered and take reasonable steps to ensure the patient is informed, and 

understands the reasons for the medication in relation to the plan of care. 

• Ensure that the prescription, and label on the medication, are clearly written, 

are unambiguous and accurately match the prescription. 

• Have considered the dosage, method of administration, route and timing of the 

administration in the context of the condition of the patient and co-existent 

therapies. Remember the 5R’s i.e right patient, right drug, right dose, right route 

and right time 

• Check [where appropriate] the expiry date of the medicine to be administered. 

• Check that the patient is not allergic to medication before administering it 

• Accept any limitations in your knowledge and skills and take measures to 

remedy them. 

• Make good and proper use of the clinical guidelines and local policies in your 

practice. 

• Contact the prescriber or another authorised prescriber without delay where 

contraindications to the prescribed medication are discovered, where the 

patient develops a reaction to the medicine or where the assessment of the 

patient indicates that the medicine is no longer suitable. 

• Make a clear, accurate and immediate record of all medicine administered, 

intentionally withheld or refused by the patient/client ensuring that any written 

entry and the signature are clear and legible. It is your responsibility to ensure 

that a record is made when delegating the task of administering medication. 

• Clearly countersign the signature of any student who is being supervised in the 

administration of medicines 

(NMC, 2006) 



Legal requirements in relation to transfusion of blood products 

Blood Transfusion: European Directive (2002/98/EC) and the UK Blood Safety 

regulations 2005 came into force in November 2005. Vein- to-vein traceability of all 

blood products shall be maintained for the Trust to be compliant with this law. 

The transfusion of blood and blood products remains a highly effective and potentially 

life saving treatment for many patients. However, blood is a living tissue and it’s 

transfusion, from one individual to another, is not without risk. One of the most 

common is the potential for human error that may then lead to the transfusion of 

incorrect blood products (Higgins, 2000). The decision to transfuse a patient with blood 

or blood products should only be considered following careful examination of the 

patient, the patient’s condition and the patient’s blood results i.e. full blood count. The 

doctor should take careful consideration and gain the patients verbal consent where 

possible before requesting blood or blood products. 

Any blood transfusion incidents shall be reported to the Transfusion Practitioner or the 

Blood Transfusion laboratory, to be reported to the appropriate authorities. 

Responsibilities: 

Collection of Blood Products (Providing they have been previously shown how): 

Registered nurse, Healthcare Assistant, Operating Department Practitioner or Student 

Nurse –. 

1 st Checker: RGN/M, ODP, Medic 

2 nd Checker: RGN/M, ODP, 2 nd / 3 rd Year Student 

Please contact the Transfusion Practitioner for more details or training in relation to 

Trust policy. 

Vicarious Liability 

When a practitioner works for an employer within the policies, procedures and 

guidelines laid down by that employer, the practitioner will be covered by the Trust via 

vicarious liability. Should the employee act outside of these guidelines / protocols then 

they are liable themselves. If Mr A is receiving IV therapy the practitioners involved 



have a duty of care to provide that therapy to a reasonable standard. See example 

below; 

Case Study Example 

If Mr A is receiving IV therapy:- During the administration of an IV drug, he complains 

of pain. The nurse stops the administration of both the drug and the IV fluids, 

reassesses the venous access removes the device and arranges for another to be 

inserted. Mr A wants to sue because of his painful arm. 

If documented at the time, subsequent inquiry will demonstrate that there was no 

breach in the duty of care because the practitioner took appropriate action as soon as 

the pain was known (Scales 1996). 

Although the subject of Law seems daunting, it is essential to have an awareness of 

the implications for practice. If any patient or relative is dissatisfied with his/her care, 

they can sue for negligence. For this action to be successful, there are three main 

criteria, which must be established: 

• A duty of care must be proven between the health authority or individual 

professional and patient 

• A breach in the duty of care must be proven 

• There must be evidence of damage caused by that breach. This may be physical, 

psychological or financial. 

You must keep clear records of drugs that you have given or withheld, the time 

administered and document any deviations. Well-written records do not simply convey 

information but they provide evidence of your actions and can protect you from liability. 

• It is your responsibility when administering medication to be aware of all areas of 

accountability and that these are met. 

• It is your responsibility to ensure that the patient has taken medication given by 

you to them. 



Suggested Readings 1 

NMC (2006) guidance on medicines management is available on line at 

http://www.nmc-uk.org 

Medicines Management documents available on the hospital intranet 

Activity 1 

1. 1 

Look at prescription charts. On top of the front sheet, there are boxes and spaces that 

need to be completed. Any observations Are they all filled up with the necessary 

information 

Answer: _______________________________________________________ 

____________________________________________________________ 

1.2 

Why is the following information necessary 

Height ________________________________________________________ 

Weight ________________________________________________________ 

Drug Sensitivity _________________________________________________ 

Hospital number ________________________________________________ 



1.3 

List 5 IV medications that your ward uses frequently and identify its indication, 

contraindications, side-effects, dose, route and nursing actions. 

Drug name Indications Contraindications 

nursing 

Side effects Dose, route and 

actions 



2. ANATOMY AND PHYSIOLOGY 

It is important that you have a good understanding of the anatomy & physiology 

involved in IV drug administration in order that you can be aware of complications that 

may arise due to cannula placement or incorrect prescription of fluids. In this chapter 

we will consider the venous system, the importance of fluid management in 

maintaining homeostasis and the role electrolytes play. 

Figure 2.1 Diagram of the arteries and veins 



Above is an illustration of the vascular system and some potential vascular access 

points. The most suitable vein should be chosen for IV therapy, taking into account the 

patient condition, type of fluid needed and how long fluid is to continue for. 

Documentation is an important aspect of IV care and it is important to correctly identify 

line sites to ensure continuity of care and accurate documentation. 

Figure 2.2 Detailed view of the arm veins 

R. Subclavian 

vein 

R. Cephalic 

vein 

R. Axillary 

vein 

R. Brachial 

vein 

R. Median 

vein 

R. Basilic 

vein 

R. Cephalic 

vein 

R. median 

vein 

Dorsum of the hand 

Digital veins 

Reflection & Activity 2 

2.1 

In the illustrations of the vascular system (see above), identify the blood vessels that 

are most commonly used for the administration of IV medications. Do this by 

encircling the label/name. 

2.2 

Identify and briefly describe the 3 layers of a vein. 

a. 

b. 

c. 



Clinical application 

Phlebitis 

Phlebitis is defined as inflammation of the walls of a vein and is not uncommon as a 

side effect of IV therapy. For this reason all patients with an intravenous access 

device in place must have the IV site checked for signs of infusion phlebitis. The Visual 

Infusion Phlebitis Score (VIP Score) is a helpful tool to use to make this assessment. 

The subsequent score and action(s) taken (if any) should be documented as evidence 

that assessment has taken place and appropriate treatment has been given. 

Site appears healthy 

One of the following is evident: 

• Slight pain near IV site or 

• Slight discolouration near IV site 

0 

1 

No signs of phlebitis 

Observe cannula 

Possibly the first signs of 

phlebitis 

OBSERVE CANNULA 

Two of the following are evident: 

• Pain at IV site 

• Erythema / discolouration 

• Swelling 

2 

Early Stage of phlebitis 

RESITE CANNULA 

All of the following signs are 

evident: 

Pain along path of cannula 


• Induration 

3 

Medium stage of Phlebitis 


CONSIDER TREATMENT 


evident and extensive; 

• Pain along path of cannula 



• Palpable venous cord 

4 

Advanced stage of phlebitis or 

the stage of thrombophlebitis 


CONSIDER TREATMENT 


evident and extensive: 

• Pain along path of cannula 



• Palpable venous cord 

• Pyrexia 

5 

Advanced stage Thrombophlembitis 

INITIATE TREATMENT 


Figure 2.3 Visual Infusion Phlebitis (VIP) score 



The cannula site must be observed: 

• When bolus injections are administered 

• IV flow rates are checked or altered 

• When solution containers are changed 

The incidence of infusion phlebitis varies but the following good practice points may 

assist in reducing the incidence of infusion phlebitis: 

• Observe cannula site at least daily and in accordance with local 

guidelines 

• Secure cannula with a proven intravenous dressing 

• Replace loose and contaminated dressings 

• Cannula must be inserted away from joints whenever possible 

• Aseptic technique must be followed 

• Consider re-siting the cannula every 48 - 72 hours 

• Plan and document continuing care 

• Use the smallest gauge cannula most suitable for the patients need 

•Document VIP score according to local guidelines and replace the 

cannula at the first indication of infusion phlebitis (Stage 2 on VIP score) 

RCN: Standards for Infusion Therapy (2005) 

Homeostasis and the Importance of Fluid Balance 

Homeostasis is defined as a state of body equilibrium which maintains a stable internal 

environment in the body. In order to ensure that the body has the right amount of fluid 

and the correct concentrations of electrolytes (e.g. sodium and potassium), many 

internal physiological feedback mechanisms take place causing constant movement of 

water and electrolytes in and out of cells. If this delicate balance is altered cellular 

metabolism can be severely impaired which may ultimately result in death if 

unchecked (Finlay, 2004). 



Table 2.1 Sources of fluid intake and fluid loss 

Fluid intake is derived from three 

main sources: 

Ingested fluids 

Water in food 

Metabolic water resulting from 

oxidation of food amounts 

Water is lost from the body in three 

main ways: 

Urine output 

Evaporation (Via lungs & skin) 

Alimentary tract 

(Sheppard & Wright 2002). 

Disturbances in the balance of fluid intake and output can cause significant problems 

for patients. Situations where fluid loss (output) exceeds fluid gain are evidenced on 

the fluid balance chart as a negative fluid balance and represent possible dehydration 

(hypovolaemia) especially if the patient is unable to take oral fluids. Clinical situations 

which may result in the need for IV fluids include: excessive vomiting or diarrhoea; 

excessive insensible losses (e.g. sweating); periopertaive hydration problems; severe 

burns and reduced input due to reduced consciousness level or mobility. Relative loss 

of fluid can also occur as it moves from the intravascular space into the interstitial and 

intracellular spaces e.g. in sepsis, internal bleeding, heart failure. 

All fluid losses and gains need to be recorded on a fluid balance chart to provide a 

comprehensive record of fluid balance over a period of time. The time of day, volume 

and nature and sources of loss and gain need to be clearly identified (Sheppard & 

Wright 2000). It is critically important within the field of paediatrics that this is accurate 

as the risks of fluid dehydration or fluid overload are high with relatively small volumes 

of fluid. All patients requiring intravenous fluids should have an accurate fluid balance 

chart recorded to help to recognise and prevent the complications of fluid overload and 

dehydration. 



Table 2.2 The consequences of fluid dehydration / overload 

System Signs of fluid loss Signs of fluid gain Nursing 

observation 

Increased heart rate 

Increased heart rate BP Pulse 

Cardiovascular 

CVP 

BP 

Irregular thready pulse 

Neck vein distension CVP readings. 

Reduced BP & CVP 

may be evident. 

Respiratory 

Increased respiratory rate 

Hyperventilation 

Increased rate 

Dyspnoea 

and 

Nature 

frequency 

& 

of 

pulmonary 

oedema 

respirations 

may be evident 

Oxygenation 

status – skin 

colour 

Saturation (pulse 

oximetry, 

Blood 

gases) 

Urinary 

Urine output decreased (increased 

in diabetes insipidus) 

Output may be 

increased or decreased 

Volume of urine / 

24 hrs. 

depending 

on 

underlying cause and 

renal function 

General 

Apprehension 

Confusion 

General 

orientation / 

Restlessness 

Irritability 

orientation status 

behaviour 

Skin 

Dry and Lax. Under – perfusion of 

Dependent generalised 

General 

tissues and reduced vascularity 

and / or pitting oedema 

appearance / 

leads to skin colour change, dry 

Skin may be warm 

hydration status 

mucous membranes and evidence 

of thirst. 

Excessive 

perspiration 

accompanies increased body 

temperature. 

moist and swollen with 

the appearance of 

being tight and shiny. 

Colour 

Temperature 

Condition 

mucous 

membranes. 

of 

(Sheppard an Wright, 2002) 



Electrolytes – A Brief Overview 

Nurses have a professional and legal responsibility to understand the rationale for the 

use of specific prescribed fluids and the desired and untoward effects of 

administration. Safe administration requires knowledge of the role of electrolytes and 

water, as well as the various solutions available for administration (Hand 2001). 

Sodium: Is the main positive ion found in fluid outside of the cells (extra cellular fluid) 

and in chemical terms is noted as Na+. It plays a vital role in regulating the 

concentration and volume of extra cellular fluid. It is also important for normal nerve 

and muscle function. Serum Sodium should normally be between 135-145 mmol/l. 

Potassium: Is the main positive ion found in fluid inside cells (intracellular fluid). 

Potassium is lost from the body through the kidneys, GI tract and skin. High levels may 

have an adverse effect on heart muscle and can cause cardiac arrhythmias. Signs of 

high potassium (Hyperkaleamia) are: tingling and numbness. Signs of Low potassium 

(Hypokalaemia) are: Malaise, muscular cramps and postural hypotension. The normal 

potassium level is between 3.5-5.0mmol/l. 

Calcium: Combines with phosphorous to form mineral salts of the bones and teeth. 

Calcium has important intracellular functions including electrical nerve conduction and 

contraction of muscles especially in the heart. 

Magnesium: Has an important role in enzyme activity, contributing to the metabolism 

of carbohydrates and proteins. 

Bicarbonate: Is a negatively charged ion which acts as a buffer in the blood so it can 

maintain its normal level of pH. Blood acidity is effected by the function of the kidneys 

and the respiratory system (carbon dioxide is carried as carbonic acid in the blood). 

Bicarbonate is expressed as HCO3- and has a normal range of 22-30 mmol/L 

Chloride: Is a negatively charged ion found in blood. It has a role to play in fluid 

regulation in the body and chloride deficiency may lead to a deficiency of potassium 

and vice versa (Hand, 2001). 



Types of Fluid 

It is important to monitor the serum concentrations of electrolytes in the blood if a 

patient is receiving IV fluids. There are many different types of IV fluids but the 

indications and contraindications of some common ones are outlined below. 

Table 2.3 Indications and contraindications for crystalloid solutions 

Solution Indications/actions Contraindications 

0.9% 

sodium 

chloride 

(Normal 

Saline) 

Extra cellular sodium, chloride and 

water deficits. 

Hypovolaemia 

Because of sodium content, potential risk 

of fluid retention and circulatory overload. 

5% 

Dextrose 

Dehydration with no electrolyte 

imbalances. 

When in the vascular system, 

dextrose is metabolised leaving 

water, which is distributed evenly 

throughout the body. 

Used to replace deficits in total body 

water. 

Hyperglycaemia 

Should not be used in large volumes in 

patients with high ADH (anti diuretic 

hormone) activity, or to replace fluids in 

hypovolaemic patients. (Metheny 1996) 

Hartmans 

Solution. 

Hypovolaemia, burns and fluid loss 

in bile or diarrhoea (Methany 1996) 

Treating mild metabolic acidosis 

Risk of lactic acidosis particularly with poor tissue 

perfusion and impaired liver function. 

Risk of fluid retention and circulatory overload due 

to sodium content. 

Understanding the anatomy and physiology will also help when considering not only 

what type of fluid but also which type of IV access device is most appropriate 



3. VASCULAR ACCESS DEVICES 

It is vital that you are familiar with the different devices available in the Trust to 

enable the selection of the most appropriate venous access device for your patient. 

This could save the patient’s blood vessels from very frequent cannulation and also 

your time and the cost to the department. 

It is equally important that you know how to use and manage venous access 

devices as it is one of the major competencies required for safe and competent 

practice. 

Considerations when selecting a venous access device 

Duration of treatment: Will the chosen access device last the length of treatment 

Medical history and current clinical stability of the patient: Is the patient able to 

lie flat 

Venous anatomy and availability: Is ultra sound guidance needed to identify 

peripheral veins Has the patient had venous access devices in the past Are all 

veins patent Is a venogram needed 

Potential therapies: Is the patient requiring more that one therapy Would a dual 

or multi lumen line be more appropriate What is the inflammatory potential of the 

therapy 

Potential community use: Is the proposed venous access device safe for 

community use 

Needle phobia and body image: Implantable port is often inappropriate for needle 

phobic patients. 



Selecting an Appropriate device 

The Vascular Matrix (below) provides guidance on selecting the most appropriate 

venous access device for your patient. The following sections will then give a brief 

overview on the venous access devices identified and the relevant care plan: 

1. Peripheral cannula 

2. Peripheral Midline catheter (PMC) 

3. Peripherally Inserted Central Catheter (PICC) 

4. Non tunnelled/noncuffed central line 

5. Tunneled Cuffed Line e.g. Hickman 

6. Implantable port e.g. Port-O-Cath 



A -Assessment of patient 

· Diagnosis/prognosis 

· Previous IV devices 

· Patient lifestyle 

·Care setting eg community 

B-Duration of therapy, consider 

·Length of time required 

·Likelihood of extension or added therapy. 

C-Infusate criteria for peripheral administration 

·Ph between 5-8. 

·not an irritant or vesicant for continuous infusion. 

·Osmolarity

1. Peripheral Cannulae 

Peripheral cannulae are the most common type of IV access device used in clinical 

practice. Although it is technically relative simple to place a peripheral catheter within a 

suitable vessel, it is important to evaluate whether this is the most appropriate device for 

the therapy that is required. The vascular access matrix above may be a useful guide for 

the practitioners involved in IV care. The use of peripheral veins for IV access implies 

the use of the veins in the hand or forearm although those in the feet and lower limbs 

can be used. Peripheral venous access it intended for short term therapy (hours to 

days).Common indications for using peripheral access include: 

• Fluid replacement 

• Blood transfusion 

• Short term drug administration 

Advantages 

• Can usually be inserted quickly and effectively with minimal complications 

• Peripheral cannulae come in a range of sizes so that the smallest cannula possible 

can be used to deliver the IV fluids/drugs to minimise complications 

• There is no need to expose the patient to X-ray radiation to confirm positioning 

• There are many suitable sites and most allow easy visibility of insertion site 

• Ported devices allow administration of drugs without stopping infusion 

• Easily secured to the patient promoting comfort and minimising mechanical phlebitis 

if site chosen carefully 

Disadvantages 

• Normally site rotation is required after 72hours 

• Phlebitis (chemical or mechanical) not uncommon 

• May not be appropriate for IV therapy involving irritant drugs as insufficient dilution 

occurs in peripheral veins thus increasing phlebitis risk 

• Ported cannulae increase the risk of contamination 


32

2. Peripheral Midline Catheter 

Peripheral midline catheters are inserted either into the basilic or cephalic vein at the 

antecubital fossa. Peripheral midlines are made of polyurethane or silicone and can be 

single or double lumen. They range in length with an average length of 20cm so that 

once inserted, they do not extend past the axilla (INS 2000). They are consequently still 

classed as a type of peripheral cannula and have advantages over peripheral cannulae 

discussed above without some of the disadvantages of Central Venous Access Devices 

(CVADs) which will be discussed later. They can be inserted using a small gauge 

cannula for example, 22gauge. Peripheral midline catheters have been associated with 

lower rates of phlebitis than short peripheral catheters with lower rates of infection than 

CVADs (Mermel et al 2001). The duration of the peripheral midline catheter is 

approximately 2 – 6 weeks, however they have been shown to last up to 12 weeks in 

the community setting. They provide a timely, safe and efficient method for 

administering intravenous therapy and nutrition. 

Advantages of peripheral midline catheters 

•Timely, safe and efficient method for administering IV therapy and nutrition 

•They can be used in hospital or community 

•No need for x-ray to confirm the position of the tip 

•Avoids repeated peripheral cannulation 

•Reduction in the risks from using central venous access devices for the same therapy 

Disadvantages of peripheral midline catheters 

•Requires a good vein 

•Cannot be used for blood sampling as the catheter has a very small lumen 

•Cannot measure an accurate CVP 

•Easily blocked due to the small lumen size – must be flushed 

•Phlebitis–mechanical or chemical 

•Specific contraindications exist 

a) Poor peripheral venous access 

b) Confused patients. 

c) Oedema of the arms. 


33

Central Venous Access Devices (CVADs) 

The term CVAD refers to any intravenous catheter whose tip lies in a large central vein, 

giving what is termed, central access. The tip of the catheter should be placed in the 

superior vena cava, just above the right atrium where the blood flow around the catheter 

is far greater than in a peripheral vein. This means that irritant drugs or fluids can be 

easily infused without damaging the vein wall. Many different types exist but please 

refer to vascular access matrix , CINS guidelines (2007) and specific care plans for 

detailed care in the prevention of infection and other complications. Most Central 

Venous Access Devices (CVADs) come in different sizes with single or multiple lumen. 

With multiple lumen lines, each lumen provides independent access to the venous 

circulation. This allows two incompatible drugs or fluids to be infused simultaneously. As 

a general principle, the lumen diameter and number of lumens should be kept to a 

minimum as larger bore catheters and multiple lumens are associated with higher risks 

of infection and thrombosis. Most central lines are open ended i.e. they have no valve 

within the line to prevent backflow of blood up the line however some are closed with the 

theory being that it might reduce occlusion from blood clotting in the line. 

General Indications for Central Venous Access Devices 

Indications for the use of CVADs include: 

• Drug and fluid administration especially vesicant, cytotoxic or longer term IV drug 

therapy as allows for rapid haemodilution of thrombophlebogenic agents 

• Nutrition and other hyperosmolar solutions 

• Central Venous Pressure (CVP) monitoring 

• Cardiac pacing 

• Lack of peripheral access 

• Multiple infusions 

• To avoid predictable problems with future peripheral cannulation if inserted early 

General complications associated with CVADs 

Due to the increased invasive nature of central as opposed to peripheral lines there are 

many potential complications associated with their insertion and general care. Insertion 

risks include: 

• Infection 


34

• Haemorrhage 

• Air embolism 

• Pneumothorax 

• Cardiac arrhythmias 

• Cardiac tamponade 

• Misplacement 

Infection, thrombosis, air embolism , bleeding and migration remain as potential risks 

during the duration of the line placement and you should access the care plans to 

check how to minimize these risks. These are available in the guidelines for 

peripherally inserted central cathers (PICCs), Non tunnelled central venous access 

device, tunnelled and cuffed central venous access device e.g Hickman lines and 

implantable ports e.g. Port-O-Caths. 

3. Peripherally Inserted Central Catheter (PICCs) 

Peripherally Inserted Central Catheters (PICC) provides a safe and effective delivery of 

fluids, drugs, parental nutrition, chemotherapy and irritant drugs with a high osmolality or 

non physiological pH. PICCs are useful alternatives to peripheral lines when frequent IV 

access is required and distal, peripheral vasculature is unsuitable. The Peripherally 

Inserted Central Catheter has, in some clinical situations, become a preferred device to 

other central venous access devices, as it is associated with far fewer complications, 

particularly during insertion (Goodwin and Carlson 1993). 

The PICC is an IV device usually manufactured from silicone or polyurethane. It is 50- 

60cm in length, with diameters ranging from 2French to 5French. PICCs are either openended 

or have a valve incorporated in their tip (closed catheters) to minimise reflux of 

blood up the line. Venous access for PICC placement is obtained through the veins of 

the antecubital fossa, usually the basilic or cephalic vein (Todd 1998). The tip of the line 

must lie within the Superior Vena Cava just above the right atrium and requires 

radiological confirmation prior to use, as with all central lines. It is recommended that 

conventional peripheral cannulae be replaced approximately every 72 hours dependent 

on the therapy being infused (Maki , Ringer & Alvarado 1991) whereas the dwell time for 


35

a PICC is currently unknown; consideration may be made to leaving a PICC in place for 

up to one year (INS, 2000). 

Figure 3.1 PICC line in relation to underlying vasculature 

PICC advantages 

•PICCs provide cost-effective, reliable and comfortable venous access 

• Appropriate for placement and management in all health care settings with financial 

and resource benefits. 

•Avoids frequent peripheral cannulation avoiding pain unnecessary vessel damage 

•Useful in patients with a needle phobia 

•Administration of irritant infusates, vesicant chemotherapy, or drugs capable of causing 

tissue necrosis if infiltrates or extravasated. 


36

•Elimination of risks associated with the chest or neck approach to central venous 

cannulation such as pneumothorax and haemothorax 

•Lower overall complication rates in relation to other CVADs 

•infection, phlebitis and device malfunction are low 

•There are fewer colony-forming units (CFUs) of skin flora on the arm than the 

chest. This may partly explain the reported low rate of infection in PICC lines - less 

than 1% in the immunocompetent patient (Goodwin and Carlson 1993). 

•Insertion does not require patient to lie flat and anaesthesia and surgical treatment are 

not required therefore easily replaced 

•Well tolerated generally 

PICC disadvantages 

• Chest X-ray to confirm position and exclude pneumothorax 

• Mechanical phlebitis not uncommon 

• Can’ kink’ if placed low in antecubital fossa 

• Risk of air embolism if open ended catheter 

• Lumen may be too small to aspirate blood from 

• Need a specially trained, skilled professional for PICC placement 

• Specific contraindications include: 

o Unpalpable peripheral veins and no ultrasound guidance available 

o Patient has anatomical distortions e.g. axillary node problems, lymphoedema, 

burns or infection at insertion site 

o Patient non compliance 

4. Non-Tunnelled Central Venous Catheters 

Non-tunnelled Central venous catheters are often inserted in emergency situations for 

immediate vascular access. These can be inserted in the subclavian, femoral or jugular 

veins by experienced personnel. The National Institute of Clinical Excellence (NICE) 

guidelines advocate that central venous access devices should be inserted using ultra 

sound imaging to reduce the incidence of complications related to insertion. Most non 


37

tunnelled Central Venous Catheters are open ended with no valve within the lumen. 

They may have single or multiple lumens. Multiple lumen catheters are advantageous in 

patients undergoing multiple regular infusions such as patients is high dependency or 

critical care areas however EPIC 2 guidelines confirm that there is an increased risk of 

infection related to the number of lumens the catheter has so the benefits need to be 

weighed against the risks in catheter selection. 

Advantages of non tunnelled central venous catheters 

•Useful for multiple access 

•Familiarity 

•Quick insertion 

•Central venous pressure 

monitoring 

•Antimicrobial lines available 

•Specialised lines e.g for 

haemofiltration 

Figure 3.2 Diagram of subclavian and jugular venous insertion sites for non tunnelled 

central venous catheter 

Disadvantages of non tunnelled CVADs 

•Chest X-ray needed to confirm placement 

•High risk of catheter related blood stream Infections (CRBSIs) 

•Site specific risk as identified below 


38

Subclavian line placement 

•Problem with secretions infecting exit site 

•Hair increasing risks of infection 

•More skin flora on the chest than arm 

•Higher risk of pnemothorax /complications on insertion 

•Jugular line Placement 

•Increased risk of infection 

•Increased risk of catheter malposition 

•difficult to secure increasing likelihood of mechanical phlebitis 

•Restricts neck movement 

•Occlusion from ‘kinking’. 

•Contamination from oral secretions 

•Femoral line placement 

•High risk of infection from localised flora 

•Difficult to access using aseptic technique 

•Unable to secure dressings 

•Occlusion 

•Limited mobility 

• Unable to monitor CVP 

•Increased risk of deep vein thrombosis compared to jugular or subclavian sites 


39

5. Skin tunnelled catheters 

Skin tunnelled catheters (including Hickman, Broviac, Groshong and Quinton) 

commonly are used to provide vascular access to patients requiring prolonged 

intravenous therapy i.e. months to years. Skin-tunnelled catheters can be either openended 

or closed (with a valve at the end of the line). The catheter is inserted in either 

the internal jugular vein or the subclavian vein with the tip of the line entering the central 

venous system at the lower third of the Superior Vena Cava. These catheters have a 

tunnelled portion exiting the skin and a Dacron cuff inside the tunnel. The cuff inhibits 

migration of organisms into the catheter tract by stimulating growth of surrounding 

tissue, thus sealing the catheter tract and providing a natural anchor for the catheter. In 

general, the rates of infections reported with the use of tunnelled catheters have been 

significantly lower than those reported with the use of non-tunnelled central venous 

catheters. 

Skin tunnelled catheter placement can be done under general or local anaesthetic, in an 

X-ray department or theatre. The skin-tunnelled catheter can have more than one lumen 

and are available in single, double or triple lumen ranges. The number of lumens is 

dependant upon patient needs. They are excellent for long-term continuous therapy or 

intermittent therapy and may last for months or years. This can include chemotherapy, 

long-term antibiotics and TPN. 

A skin tunnelled catheter enables blood sampling, avoiding peripheral sampling which is 

particularly important to patients requiring frequent blood monitoring and preferred by 

patients who are needle phobic. In order to prevent any risk of infection, the skintunnelled 

catheter requires regular external site care with an appropriate intravenous 

dressing e.g. mepilex border. Additionally it requires routine flushing with 0.9% Normal 

Saline followed by 5mls Hepsal (if open ended) at least weekly when not in use. 


40

Figure 3.3. Skin tunnelled central venous catheter in relation to underlying vasculature 

Skin Tunnelled Catheter advantages 

• Skin tunnelled catheters provide a reliable and comfortable venous access. 

• Inpatient, outpatient and community use. 

• The incidence of central vein thrombosis and catheter embolization is low 

• Elimination of pain and discomfort associated with frequent peripheral venepuncture 

• Decreased cost of therapy. 

• Secured without sutures if cuffed 

Disadvantages of skin tunnelled catheters 

• Anaesthesia and surgical treatment may be required for insertion and removal. 

• Need specially trained and skilled professionals for line placement 

• Contraindicated if 

• anatomical distortions, burns, infection or oedema 

• uncorrected coagulopathy 


41

6. Implantable Ports 

Implantable ports have been shown to have the lowest reported rates of catheter-related 

blood stream infections compared to either tunnelled or non-tunnelled central venous 

access devices. Most ports tend to be single lumen however dual lumen port are 

available. An implantable port is placed completely under the skin, usually on the chest 

or arm. It is used for the administration of medications and fluids via a simple injection 

through the skin. It can remain in place for months or years. 

It consists of two components: 

(1) A reservoir encased in silicone. The area of silicone which covers the hollow 

of the reservoir is termed the septum. The self sealing membrane is pierced in 

order to administer medications, fluids or feed and to take blood samples. 

(2) A silicone catheter, which is introduced into the vein with the tip ending in the 

superior vena cava. 

The implantable port is accessed using special non coring needles which prevent any 

damage occurring to the port. Under no circumstance should an ordinary needle be 

used to access a port as it can cause damage. 

Advantages 

• Only require 1 monthly flushing with 0.9% Normal Saline followed by 5mls Heparin 

(100units/ml) 

• No dressing 

• Less risk of infection 

• Good for positive body image 

• Ability to continue with sports (swimming/bathing) 

Disadvantages 

• Requires specially trained staff for insertion under anaesthesia 

• Specialist equipment – expensive to purchase device and needles 

• Still requires a needle which may cause discomfort during access 

• Requires surgical removal and can leave a large scar 


42

General Line Management Issues 

All of the careplans for the above lines are found in the CINS guidelines and there are 

detailed competencies in the appendices of this book to help you with some more 

specific aspects of IV care. Also in the appendices is one annotated example of the 

careplan for a peripheral IV cannula which may help to illustrate some of the points 

below. Some key points have been highlighted here to emphasise management issues 

to optimise good cannula care. 

Infections can be minimized by good cannula care 

•Document the site, date and time of cannula placement including reason for siting the 

cannula and by who on the care plan, reviewing daily the clinical need for intravenous 

therapy. 

•Dressings should be highly permeable and allow visibility at entry site (e.g.mepelex 

border, IV 3000). 

•Change the cannula dressing when not intact or when moisture collects at the site 

using an aseptic technique 

•Dressings should be changed on a weekly basis or when dressing is dirty or loose to 

prevent extrinsic contamination of the site. 

•Securely anchored lines help to prevent phlebitis. 

•Assess the cannula using the visual infusion phlebitis (VIP) scale (fig 2.5) for 

assessment and record the patient’s score 8hourly. 

•Clean the cannula hub with 2% alcoholic chlorhexidine before accessing the system. 

Preventing cannula thrombosis and maintaining cannula patency will minimize 

opportunity for infection 

•Peripheral cannula should be flushed with an appropriate volume of normal saline prior 

to administering IV therapy and immediately after therapy is complete 

• Syringe sizes smaller than 10ml may damage the catheter (Hadaway, 1998). 

•Use a pulsated push/pause action to create turbulence in the lumen and prevent debris 

build upon internal catheter wall (Todd, 1998) 


43

•Positive pressure within the lumen of the catheter should be maintained to prevent 

reflux of blood. 

•Peripheral cannula should be flushed every 8 hours when not is use. 

•There is an increased risk of infection and occlusion when withdrawing blood via a 

central venous catheter (RCN, 2005). 

•There is no requirement to routinely withdraw blood and discard it prior to flushing 

(except prior to blood sampling) although the first sample can be used for blood cultures 

(RCN, 2005). 

•To ensure that the a peripheral IV cannula, and close-ended peripheral midline or PICC 

is patent before giving any iv medication and kept patent after, just remember SAS: 

S – Saline flush (push/pause action) 

A – Administer IV medication as prescribed 

S – Saline flush again 

•For tunnelled, non-tunnelled and open ended Peripheral Midline and PICC lines, flush 

with saline and lock with an appropriate volumes of heparinised saline (10 iu/ml) i.e. 

equivalent to 50 iu of heparin. If the lumens on a line are being used at least once a 

day, they do not need to be heparin locked. The heparin dosage for implantable venous 

access devices (e.g. portacath) is 100iu/ml and dialysis lines may differ. Remember this 

technique: 

A – Aspirate 3 to 5 ml of blood with an empty syringe if hep locked 

S – Saline flush 

A – Administer iv medication as prescribed 

S – Saline flush again 

H – Heparin lock 

Changing IV giving sets appropriately 

•Document the date and time of each administration line change on the care plan and 

by use of a sticker applied to the line itself. 

•Do not add 3 way taps to the end of peripheral cannula - use of needle free extension 

sets is preferable. 

o Needle-free system should be used for every lumen of a venous access device. 


44

o Change every 7 days or as per manufacturer’s guidelines 

o Do not attach directly to a peripheral IV cannula. Use an extension tubing 

(octopus) with a needle-free system. 

•Use an aseptic non touch technique to manipulate administration sets 

•Change the administration sets every 72 hours 

•Administration sets used for total parenteral nutrition (TPN) infusions should be 

changed every 24 hours 

•Administration sets for blood and blood components should be changed when the 

transfusion episode is complete or every 12 hours (whichever is sooner). 

Catheter Removal 

General principles apply to all IV access devices in that they should be removed as 

soon as no longer needed to minimise the risk of infection and other complications. If 

the VIP score indicates that complications are already developing, the appropriate 

action must be taken and removal/replacement is likely if IV therapy is still required. If 

there is evidence of infection/pus at the insertion site, the IV access device must be 

removed, a tip sent for culture and recorded on the care plan. Potential complications 

from removal of IV access devices include: Haemorrhage, air embolus and septic 

shower. Practitioners should not undertake this procedure unless they are 

competent to do so and have consulted the clinical team responsible for the line 

who have agreed that it is appropriate to do so. 

Peripheral line 

•Recommended removal after 72 hours unless specified otherwise. 

•Can be removed at bedside 

Midline/PICC Removal 

• Can be removed at bedside in accordance with local policy 

• Remove slowly. Do not use excessive force. 

• If resistance felt, stop removal. Apply warm compress and wait 20-30 minutes. 

• Resume removal procedure. 

• Send tip for culture 


45

Non Tunnelled Central Venous Catheter 

•Refer to local hospital policy regarding removal. 

•Can be removed at patients’ bedside by staff trained and competent staff. 

•Send tip for culture 

Skin tunnelled catheter removal 

• Requires a skilled experience practitioner 

• Surgical removal of dacron cuff 

Implantable Port removal 

•Requires surgical removal 

Reading 3 

Read the following before undertaking Activity 3 

The Collaborative Intravenous Nursing Services (CINS) guidelines are the Trust 

approved procedures in the management of venous access devices. 

The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6 th edition is 

available on the hospital intranet. It is recommended that you read relevant topics in 

Chapter 44 

Reflection and Activity 3 

3.1 

What are the different venous access devices that you have seen in your clinical area 

List them down and also mention what they were for (i.e. indication). 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 


46

3.2 

Look at the care plans in the CINS guidelines for the devices listed in this chapter. What 

do you think are the advantages of using these 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

3.3 

Observe a colleague flush a cannula or any venous access device. Describe how 

he/she does it. 

____________________________________________________________ 

____________________________________________________________ 

3.4 

Ask your colleagues on the ward this question – “Do we have a needle-free system on 

the wards and do we use it” What was their reply 

□ Yes □ No □ I’m not sure 


47

4. MEDICAL INFUSION DEVICES BEST PRACTICE GUIDELINES 

All relevant staff should ensure that they are conversant with Medical Device, 

Equipment and Decontamination Policy & Procedures. It is the policy of the Trust 

that staff comply with this policy in order that whenever a single-use or reusable 

medical device is purchased due regard is made to standardisation, safety, training, 

cost and consumable issues, and that when the device is used it is suitable for its 

intended purpose, properly understood by users and maintained in a safe and 

reliable condition, to ensure the safety of patients and staff 

• If formal training is required for a device that you are about to use and you 

haven’t been registered as a “competent user” – Don’t use it! 

• All professional users and end-users should have access to the manufacturer's 

instructions for all medical devices and users sign statements to the effect that 

they have received instructions on the safe use of devices or equipment and after 

use are filed so all others users can gain access to them 

Before you use any infusion device, ask yourself: 

• Do I know what the pump does 

• Do I know how to use it 

• Are the leads, administration set, bags, cassettes or syringes in good 

working order and properly assembled/loaded 

Before pressing the start button: 

• Is the displayed rate and volume to be infused correct 

• Is the displayed syringe size and type the same as the one being used 

• Are drops already flowing in the burette 


48

During the infusion at specified intervals: 

• Does the position of the plunger or level of fluid in the bag correspond with the 

delivered volume displayed on the pump 

• Have I recorded the observation time 

• Have I checked the infusion site 

• Do I need to take any action 

What should you do when an infusion system malfunctions 

• Stop the infusion – make sure all clamps on the giving set are closed. 

• Take all steps necessary for the well being of the patient. 

• Do not unload the giving set or syringe. 

• Do not touch the pump – except the OFF button. 

• Note details, if possible, of all medical equipment attached to the patient - type, 

make, model and serial numbers. 

• Note setting of controls and audible/ visible alarms. 

• Note the volume of the contents remaining in the set or the syringe. 

• Leave any fluids in the infusion system. 

• Inform the sister/nurse in charge. 

• Retain packaging and details of consumables. 

• All Incidents should be reported immediately, using the Trust’s current Incident 

reporting system 

After use 

• Clean the device as per manufactures recommendations 

• It is vitally important that the pumps are cleaned thoroughly in between EVERY 

PATIENT and before returning to storage 

Any device involved in, or suspected of having an involvement in an incident or 

near miss must be: 

1. Removed from service, 

2. Labelled 

3. Quarantined along with any accessories and/or disposables. 


49

4. It is important to record the exact error message or error code displayed. Write 

down any settings on the equipment e.g. rate/volume. 

5. Finally, report any device involved immediately to Medical Engineering giving an 

accurate description of the failure not just ‘faulty’. 

6. Routine calibration by medical engineering must occur regularly to ensure the 

pump is operating within set standards. 

Reading 4 

Go on to the hospital intranet and read the following: 

Medical Device, Equipment and Decontamination Policy & Procedures 

Medical devices for single use only should only be used as stated. If not, there are 

severe implications and consequences of re-use. It is considered as an offence to reuse 

single use devices. 

Reflection and Activity 4 

List the names (Make and Model) of the infusion pumps and syringe drivers that you use 

on the wards. Do you feel competent to use the machine 

Yes No 

_________________________________________ 

_________________________________________ 

_________________________________________ 

_________________________________________ 

_________________________________________ 

_________________________________________ 


50

5. DRUG CALCULATIONS 

It is important that you can calculate drug doses and volumes accurately if you are to 

administer medications. Remember, you are accountable for decisions you make in 

practice, including checking (or deciding not to check) doses, volumes and infusion 

rates. Each time you are required to calculate for a dose, you have do the calculation on 

your own and then with someone else - both of you should undertake the calculation 

and then cross-check answers rather than one person relying on the other’s working. 

There is always a risk of deferring to the other person’s answer when it is perceived that 

the other person is right because of their status, authority or experience. This is not 

necessarily the case. Both of you must agree the answer having both undertaken the 

calculation separately and then compared results. Otherwise, do not give the 

medication – seek assistance! 

Practical Tips 

• Use calculators, information and other aids. 

• Take time, avoid interruptions and re-check answers. 

• Do not show off mental arithmetic skills 

• If unsure of the calculation or answer, do not give the drug. 

• Answers that look wrong are usually wrong. 

• Be careful: With some drugs, the dosage is based on the patient’s weight in 

kilograms. With others, the dosage is based on body surface area (BSA). 

Percentage 

This is the number of grams of drug in 100g or 100mL of product. 

1% solution of drug X means there is 1 g of X in 100mL. 

5% powder of drug X means there is 5g in 100g. 

Conversions 

1 kilogram = 1000 grams 

1 gram = 1000 milligrams 

1 milligram = 1000 micrograms 

1 microgram = 1000 nanograms 


51

Ratios 

This is a different way of expressing concentration or dilution. An example of this would 

be adrenaline (epinephrine)which is often expressed as 1:1000 which means 1g in 

1000ml or 1mg in 1ml 

Manually Controlled Drips 

To set up a manually controlled drip accurately by eye, you need to be able to count the 

number of drops per minute. To achieve the rate (drops/minute), the formula below may 

be used. The drop factor (DF), which is the number of drops in a milliliter (ml), is 

normally indicated in the packaging of the “IV giving set.” The time in hours (T) is the 

number of hours prescribed for the fluid to run. The number “60” is constant as it is the 

number of minutes in an hour. 

Rate (drops/minute) = Total volume of fluid in ml (TVF) x drop factor (DF) 

Time in hours (T) x 60 min 

For example, how many drops/minute should 500 ml of normal saline be regulated if it is 

to run for 8 hours The giving set indicates that the drop factor is 20 drops/min. 

Rate = 500 ml x 20 

8 x 60 

Rate = 10000 

480 

Rate = 20.8 

Rate = 21 drops/min 

Answer: The infusion will be regulated at 21 drops/min 

Electronically controlled drips 

The given equation works for intravenous prescriptions for manually controlled 

administration equipment and also for electronically controlled drip counters which are 

set as a rate of ml per hour. 


52

For example, at what rate should the infusion pump be set at if you are to infuse 1 litre 

of normal saline with 40 mmol of KCl over 8 hours 

Rate (ml/hour) = Total volume of fluid in ml (TVF) 

Time in hours 

ml/hour = 1000 

8 

Rate = 125 ml/hour 

For liquid and injectable medications 

Volume or dose required (ml) = Strength or dose Required x Stock volume (ml) 

Stock strength 

The strength or dose required is the amount of drug prescribed. The stock strength is 

the amount of drug in the container (vial, ampoule, etc.). The dilution is the amount of 

volume of the ready-diluted infusion or the solution (saline or water for injection) used to 

dilute the stock dose. 

The following examples are hypothetical examples only and may not reflect the actual 

practice in the clinical areas. 

Example 1. 

The prescribed medication is aciclovir 650mg IV. It is available in 500mg vials which 

your ward normally dilutes with 20 ml of water for injection. How many ml will you give 

to your patient 

Volume or dose in ml = 650 x 20 

500 

Volume or dose in ml = 26 

Answer: The amount to be given is 26 ml 


53

Example 2. 

Your patient is prescribed gentamicin 120mg. The drug comes in 80mg/2ml ampoules. 

How many mls would constitute the required dose 

Volume or dose in ml = 120 x 2 ml 

80 

Volume or dose in ml = 

120 ml 

40 

Volume or dose in ml = 3 

Answer: The amount to be given is 3ml. 

Occasionally the stock strength makes the volume of drug required very small. When 

attempting to draw up very small volumes especially in paediatric medicine, the error 

margin may be large and could lead to unnecessary risks from toxicity. Consider the 

following example. 

Example 3 

Your patient requires 2.5mg increments of IV morphine over a short period of time to 

control chest pain. The vials normally contain 10mg in 1ml. How many mls would you 

administer for a 2.5 mg bolus 

Volume of dose in mls = 2.5 x 1 

10 

Volume of dose in mls = 0.25 

However, the margin for error is too high and subsequent doses may be required so the 

10 mg is initially diluted further using 9ml of fluid to make a new concentration of 10mg 

in 10ml. The new calculation is now: 

Volume of dose in ml = 2.5 x 10 

10 


54

Volume of dose in mls = 2.5 

Answer = 2.5ml of a 10mg/10ml dilution 

If there was a stock problem and the only stock available to you was a 30mg/ml vial of 

IV morphine. How could you dilute this to give 2.5ml increments safely 

Undiluted the volume of the dose would be too small for accuracy i.e 

Volume of dose (ml) = 2.5 x 1 = 0.08ml 

30 

Even a dilution to 15ml might be more feasible with a 20ml syringe. 

Volume of dose (ml) = 

2.5 x 15 = 1.25ml 

30 

Otherwise a further dilution would be necessary using a larger syringe. Whatever the 

chosen dilution, it is important that you know how many mls of the drug you need to give 

the correct dose. There are drug calculations in your IV assessment paper and it is 

essential to answer them all correctly so get your calculator out and try some examples 

below. 

Activity 5 

5. 1 

Magnesium sulphate 50% comes in 2ml ampoules. How many mls would be needed to 

give 4g dose 

Calculation: 

Answer: ________ 


55

5.2 

The doctor prescribes 7.5mg diazepam by injection. The stock dose is 10mg/2ml. How 

many mls would you administer 

Calculation: 

Answer: __________ 

5.3 

If a litre of 0.9% sodium chloride solution is required to be administered over 8 hours, 

how many ml/hr would you set the infusion pump at 

Calculation 

Answer 

If a subsequent 1 litre bag of 5% glucose is prescribed for over 12 hours,how many 

ml/hr will the infusion pump be set at 

Calculation 

Answer 


56

6. PHARMACOLOGY & PHARMACOTHERAPEUTICS RELATED TO 

RECONSTITUTION & ADMINISTRATION OF IV MEDICATION 

Different methods of intravenous drug administration 

1. Slow IV bolus Injection 

Slow IV bolus injection involves the injection of a drug over several minutes 

(normally 3-5 minutes depending upon the drug) via an indwelling catheter, 

This is indicated when a rapid serum concentration of a drug is required e.g. 

adenosine or when a drug cannot be diluted for pharmacological or 

therapeutic reasons. Rapid administration of most drugs could result in toxic 

levels and an anaphylactic reaction Some injections may be given over less 

time in an emergency e.g adrenaline (epinephrine) while most have to be 

given over a minimum time period e.g. cyclizine should be give over 3-5 

minutes 

The cannula should be flushed with Sodium Chloride 0.9% for injection 

before and after each drug has been administered in accordance with CINS 

guidelines. 

Advantages 

Disadvantages 

• Rapid response 

• Quick to administer 

• Low equipment cost 

• Fewer stability/compatibility 

problems 

• Decreased infection risk 

• Sometimes from CIVAS e.g 

cefuroxime syringe 

• Drug irrecoverable 

• Irritant to veins 

• Potential toxicity due 

to rapid administration 


57

2. Intermittent IV Infusion 

The drug may be added to a small bag of intravenous fluid (50-250mL) and 

given as a specified dose at repeated intervals (Dougherty & Lister, 2004) 

over 20 minutes to 2 hours. (e.g. ceftriaxone). Intermittent IV infusion is 

indicated when peak blood concentration is required at periodic levels, the 

pharmacology of the drug dictates this specific dilution, the drug will not 

remain stable for the time required to administer a more dilute volume or the 

patient is on a restricted fluid intake. Potential disadvantages include the fact 

that additional equipment is required and increased concentrations may cause 

venous irritation. Some drugs such as clarithromycin and vancomycin need 

larger volumes of fluid, (250-500mL) to reduce the risk of adverse drug 

reactions, e.g. thrombophlebitis or other toxicities. There are many drugs that 

need IV infusion which are already pre-diluted e.g. ciprofloxacin. 

Advantages 

Disadvantages 

• Less irritant than slow IV • Stability/compatibility 

• Available from CIVAS 

problems 

• Reduced risk of toxicity 

• Microbial contamination 

due to slower 

• Fluid overload 

administration rate 

• Increased staff time 

(e.g. furosemide, 

ranitidine, vancomycin) 

• Restricted patient 

mobility 

• Equipment costs 

3. Continuous IV infusion 

Continuous IV infusion is defined as IV delivery of a medication or fluid at a 

constant rate over a prescribed time period ranging from 24 hours to days to 

achieve a controlled therapeutic response (Dougherty & Lister, 2004). It is 

indicated when the drug to be administered needs to be highly diluted, a 

constant plasma concentration is required or when large amounts of fluid and 

electrolytes need to be replaced. If additives are used, there should generally 


58

only be one per bag after compatibility established. The bag should be well 

mixed and clearly labelled. These are used for drugs such as aminophylline 

and dopamine, where a steady blood level is important. Some drugs may be 

given in a syringe driver to prevent fluid overload or to prevent absorption of 

the drug onto a P.V.C. bag e.g. insulin and glyceryl tri nitrate (GTN). 

Advantages 

Disadvantages 

• Steady blood levels for 

drugs with narrow 

therapeutic window 

• Useful for drugs with 

short half-life e.g. heparin 

• Can titrate against 

response e.g. insulin, 

nitrates, etc. 

• Rapid switch off 

• Fluid overload 

• Stability 

• Micro biological 

contamination 

• Staff time 

• Restricted patient mobility 

• Equipment costs 

• Incompatability if other 

drugs administered 

through the same port 

Issues of Compatibility and Stability 

1. Visual signs of incompatibility 

Cloudy appearance, precipitation, or colour change may occur, e.g. a 

precipitate forms within 1 hour with erythromycin and heparin. Calcium 

gluconate and dobutamine form a deep pink colour after 24 hours. Some 

drugs may harmlessly change colour e.g. amoxycillin clear→yellow. 


59

2. Physical and Chemical Properties 

Properties 

pH 

Drug-drug reactions 

Drug-fluid reactions 

Drug-container reactions 

Examples 

Amphotericin is unstable in acidic 

environments 

Cefuroxime/gentamicin 

Amiodarone is incompatible with 

sodium chloride 

Insulin, diazepam and P.V.C. 

bags and lines 

3. Factors affecting stability 

Some of these factors can be controlled: 

• Temperature 

• Light 

• Time 

• Concentration 

• Bacterial contamination initially in bag 

• Stock rotation 

4. Microbiological factors 

It is impossible to avoid some contamination. Use bags made on ward 

immediately and use CIVAS before expiry date (stored in fridge where 

indicated prior to use) to minimise the consequences of possible 

contamination. National Patient Safety Agency (NPSA) guidelines suggest 

that any drugs made on the ward must be discarded after a maximum of 24 

hours. 


60

5. Labelling 

All syringes and bags should be clearly labelled with their contents and time of 

reconstitution in case the drugs reduce effectiveness over time e.g primaxin is stable for 

only 3 hours once reconstituted at room temperature. 

6. Displacement values 

If 3mL of diluent is added to a vial, the final volume may be more than 3 ml of product. 

Normally this is not important, since the contents of the whole vial are usually given in 

adult medicine however this is critical in paediatric drug administration. Where the dose 

of a drug is less than the complete vial and the vial requires reconstitution, it is essential 

to take account of the displacement value. 

Another consideration when preparing infusions is if the volume of medicine solution to 

be added is more than 10% of the initial volume of the diluent (i.e. more than 50ml 

needs to be added to 500ml or more than 100ml to a litre). If this is the case, an 

equivalent volume must first be removed with a syringe and needle (NPSA, 2007) 

7. Sources of assistance 

Further information is available from your ward IV resource file, ward pharmacist and 

from the medicines information centre. Outside normal working hours help is available 

from the on-call resident pharmacist. Never do anything YOU are not sure is safe. 

If in difficulty, the advice and assistance of nursing colleagues and managers can be 

sought day and night. NMC guidance describes the need to be competent in a 

procedure before it can be carried out clinically by a member of staff. In addition, certain 

other services are provided by the pharmacy to assist and protect you, your patients 

and the Trust. 


61

Centralised Intravenous Additive Service (CIVAS) 

Centralised Intra-Venous Additive Service (CIVAS) products are available from 

the pharmacy for many common intravenous drugs. The product is made under 

aseptic conditions and is guaranteed to be chemically and physically stable and 

aseptic until the stated date when kept in a refrigerator. 

Therapeutic Drug Monitoring (TDM) 

Therapeutic Drug Monitoring (TDM) is carried out to obtain blood levels of a small 

number of drugs with a narrow therapeutic range e.g. phenytoin, theophylline, and 

digoxin. Some intravenous antibiotics need monitoring e.g. gentamicin and related 

drugs. TDM must be carried out to reduce the likelihood of adverse effects and to 

ensure therapeutic efficacy, e.g. gentamicin can cause renal toxicity. It is unsafe 

to continue to administer any drug that needs TDM without appropriate 

monitoring. 

Adverse Drug Reaction (ADR) 

If you suspect that a patient might have suffered an Adverse Drug Reaction (ADR), 

you should inform a doctor and senior nurse immediately. In addition, you should 

use the system in your local Trust to record this e.g. ADR cards. IR1 forms. You do 

not have to be certain which drug, if any, is the cause; clinical pharmacists and 

pharmacologists will decide. 

Activity 6 

You need to refer to the British National Formulary or to the ward IV drug 

resource pack to be able to answer the following questions. 


62

6.1 

A patient cannot receive IM injections. How would you administer diclofenac if 

the patient is vomiting 

Answer: ________________________________________________ 

6.2 

How would you administer IV ranitidine Describe the diluent, volume and rate of 

administration. 

Answer: ________________________________________________ 

6.3 

How would you administer a 750 mg loading does of IV phenytoin Describe the 

diluent, volume, rate of administration and any monitoring 

There are 2 methods. 

Answer: ________________________________________________ 

________________________________________________ 

6.4 

Can you mix: 

a. benzylpenicillin and gentamicin Answer: ________ 

b. metronidazole and cefuroxime Answer: ________ 


63

6.5 

What problem can occur when adding potassium chloride to an infusion bag 

containing glucose or saline solution 

Answer: _______________________________________________ 

6.6 

How would you prepare a 500 mg does of clarithromycin 

Answer: ________________________________________________ 

6.7 

How would you administer 80 mg of IV furosemide 

Answer: ________________________________________________ 

6.8 

Can you put 50 mg of glyceryl trinitrate (GTN) into a 500 ml bag of sodium 

chloride 0.9% What alternatives do you have 

Answer: ________________________________________________ 


64

7. LOCAL AND SYSTEMIC COMPLICATIONS 

Catheter related complications can quickly escalate into far more serious 

complications for the patient (Dougherty & Lister, 2004) so it is vital that health 

care professional regularly observes for any complications and acts at an early 

stage in order to resolve them. 

Infusion slows or stops 

Check the patient and cannula. Look for the following: 

•Has bandage been placed around the site If so this may be causing occlusion 

•Is the cannula sited in a position prone to obstruction on movement e.g. over a joint, if 

so instruct the patient on how to rest arm in order to promote flow. The cannula may be 

lying against the vein wall, consider re-siting 

•Check the height of the drip (IV) stand. Lack of gravity is often the cause of infusions 

slowing or stopping. 

•Is the giving set kinked Is the patient occluding the line by accident 

•Check the infusion container. If it’s a rigid container it may require an air inlet. 

Catheter occlusion 

Always check patient position first and be aware of the amount of pressure required on 

a syringe to administer a bolus injection (white finger nail pressure is a good guide). 

Familiarise your self with the varying pressures in the different size cannula, the smaller 

the cannula the greater the pressure required. To flush any venous access device, 

CINS recommends 10 ml syringe as the smallest syringe size to be used. If a cannula 

is difficult to flush (administer a bolus through) it is undoubtedly occluded. Do not 

continue. Re-site the cannula. 

For central venous access device occlusion refer to the RCN algorithm for persistent 

withdrawal occlusion cited in the CINS guidelines. Either total occlusion or withdrawal 

occlusion indicates catheter occlusion. 


65

Table 7.1 – Causes of catheter occlusion 

CAUSE 

Blood Clot 

MANAGEMENT 

Instil urokinase into lumen and leave 

for the recommended time (normally 

1hour). Attempt to withdraw urokinase 

before flushing the line. 

Must be prescribed. 

Seek advice from pharmacy 

Kinked catheter 

Check patient position. Change 

dressing and straighten device 

Tip malposition 

Replace device 

Fibrin Sheath 

Urokinase infusion 40,000 units per 

hour for six hours. 

N.B. not for haematology patients. 

Must be prescribed. 

Seek advice from pharmacy 

The most effective means of preventing thrombotic occlusions is observance of 

proper flushing techniques and protocols. 

Cannula displacement 

A cannula which is partially out of the insertion site will increase potential for 

development of infection and must be removed. If the patient is difficult to cannulate, 

contact the medical staff or IV nurse specialist if available for advice as soon as 

possible. Catheter migration is indicated by excess catheter visible at exit site. This 

can occur if the dressing is not secure or because of patient movement. X-ray 

should verify the tip position if this occurs with a central venous access device. The 


66

line should then be secured and IV therapy modified depending upon the catheter tip 

position. 

Cannula entering surrounding tissues 

Sometimes referred to as “tissued”, this can create a serious hazard to the patient and 

good observation skills around IV therapy are imperative to prevent serious tissue 

damage. To help prevent this occurring always flush a cannula before use to establish 

its position. If the cannula is in the tissues a fluid build up at the exit point will be visible 

or palpable (depending on the amount of fluid which has entered the tissues) and skin in 

this area will blanch if pressed and will feel cool to the touch. If this is the case take the 

following action: 

• Remove the cannula immediately, as it will serve no useful purpose, and if used may 

harm the patient. 

• If the patient reports that the site that was used feels uncomfortable a warm 

compress may alleviate the discomfort. 

• If tissue damage has occurred consider filling in an incident form. 

See trouble shooting guidelines for extravasation/infiltration in CINS guidelines. 

Phlebitis, thrombophlebitis and cellulitis 

Phlebitis is a progressive disorder which, if the cannula is left in, will continue to 

deteriorate. The cannula should be removed and when necessary re-sited into a 

different vein at the first signs of phlebitis developing (2 on the Visual Infusion Phlebitis 

Score). A cool compress may alleviate any discomfort a patient feels, but ideally leave 

the site exposed once haemostasis has occurred. Monitor the site and the patient’s 

temperature for signs of infection and follow the trouble shooting guide for exit site 

inflammation/phlebitis in the CINS guidelines. 

Thrombophlebitis or thrombosis can be caused by caused by injury to the venous intima 

by traumatic insertion of the access device, an abnormal coagulation profile or if the IV 

access device is malpositioned in smaller veins (James, Bledshoe & Hadaway, 1993). 

Signs include pain, redness, venous cord, induration and swelling. The device should 

then be replaced. Phlebitis or thrombophlebitis can develop into cellulitis. Thrombosis 

may need fibrinolytic and anticoagulant therapy. 


67

Mechanical phlebitis in PICC/PMC devices 

Sterile mechanical phlebitis usually occurs within the first 24-72 hours of catheter 

placement. It is not an infectious process but rather represents the body as response to 

the presence of a foreign material within the vascular space. The incidence of 

mechanical phlebitis in PICC catheters has been reported as being 1.2-23% (Goodwin 

and Carlson 1993). Any occurrence of mechanical phlebitis is usually evident within 

seven days of PICC insertion (Goodwin and Carlson 1993). Signs include pain, redness, 

warmth, venous cord (a hard, palpable thrombosed vein), induration and swelling. 

Conservation measures include the application of warm, moist compresses to the arm 

for 20 minutes four times a day, elevation of the extremity and mild exercise or the 

application of a 5mg GTN patch placed distal to exit site. As a last resort, the 

PICC/midline should be removed however this should not be done without prior 

consultation with the clinical team responsible for the line. 

Infective phlebitis in PICC/PMC devices 

The literature reports an incidence of infective phlebitis of less than 1% in the nonimmunosuppressed 

patient (Todd 1998). Maki et al (1991) report that this is due to the 

presence of fewer CFU's of bacteria on the skin of the arm than on the chest. 

Additionally the skin on the arm is exposed to less perspiration than the chest and is 

less exposed to expired air and secretion from the mouth and nose. Infective phlebitis is 

caused by poor aseptic technique during Midline/PICC placement or when accessing 

the device. Signs include inflammation, swelling and exudate at catheter exit site. The 

site should be cleaned with 2% chlorhexidine in 70% alcohol (Maki et al 1991). A swab 

should be taken for culture from the exit site and phlebitis treated with an appropriate 

systemic antibiotic. The Midline/PICC should only be removed when the patient is 

acutely unwell with bacteraemia or the infection fails to respond to antibacterial therapy. 

Infection 

Routine replacement of non tunnelled CVADs should not be a method used for 

preventing catheter related infection. Guidewire assisted catheter exchange to replace a 

malfunctioning catheter is acceptable if there is no evidence of infection. However, if 

infection is suspected, the existing catheter should be removed and a new catheter 

inserted at a different site. 


68

Signs of Infection 

The patient may have a temperature above 38 ° C on two separate occasions 2 hours 

apart, a raised WCC, raised CRP or show signs of fever for example, flu like symptoms, 

or rigors (shiver and shaking for no apparent reason). 

1) A catheter related blood stream infection is defined as at least two blood cultures 

positive with the same organism, obtained from at least two separate sites. 

2) An exit site infection presents with erythema, tenderness and occasionally a 

discharge at the insertion site. 

3) A tunnel infection is characterised by pain and induration along the track of the 

catheter. 

If a catheter related infection is suspected an attempt to obtain a sample of blood from 

all catheter lumens is required for culture and sensitivity. In addition a blood culture 

sample is needed from a peripheral vein and also a swab taken from the exit site of the 

venous access device should be obtained and sent for culture and sensitivity. The 

medical microbiology department should be consulted for advice before. Broad 

spectrum antibiotics are given prior to culture results. 

Bacteraemia and septicaemia 

Bacteraemia is the presence of bacteria in the bloodstream. Septicaemia is the 

multiplication of these microorganisms in the blood steam which could imply systemic 

infection and the severe consequences of sepsis. The maintenance of strict aseptic 

technique is essential when handing equipment in the preparing and administration of 

medication. Equally important is the proper care of venous access devices and 

systemic infection trouble shooting guide as identified in the CINS guidelines to prevent 

and manage this. 

Pain at the insertion site 

As well as a sign of cannula displacement into the tissues or phlebitis, pain can often 

occur during use. This is usually as a result of pressure applied to the cannula itself 

during bolus administration. Ask the patient to identify the site at which he/she feels 

discomfort you may find this is often at the site were the wings of the cannula meet with 


69

the patients skin. This is not an indication for cannula replacement, use may continue if 

efforts are made to alleviate the discomfort during use. 

Itching or irritation at the site 

Consider the possibility of the patient being allergic to the dressing or tape used. 

If confirmed, document in patient notes and care plan. 

Catheter damage 

Signs include fluid leaking from the catheter or exit site on infusion, which may be 

caused by accidental puncture of the catheter, excessive syringe pressure or poor 

catheter care. The catheter should be repaired where possible, using the correct repair 

kits, by an experienced practitioner. If unable to repair, then it should be replaced. 

Air embolism 

This is the introduction of air into the bloodstream and this could be fatal. Ensure 

that all connections are secure on IV access devices and that positioning is 

appropriate for insertion and removal of CVADs to minimise the risk of air 

embolism 

Speed shock 

This is a sudden severe systemic reaction to IV medications administered too 

rapidly by either bolus or infusion, or in excessive amounts. 

Pulmonary oedema and circulatory overload 

This could be attributed to the excessive administration of IV fluids especially to 

paediatric patients or adults with renal or cardiac problems. See table 2.2 for 

signs and symptoms of circulatory overload. 

Anaphylaxis 

This is the most dangerous complication of intravenous therapy. Anaphylaxis is a 

rapid, generalised reaction to a substance (an antigen) to which an individual has 

become sensitised. It is rare, but it can be life threatening, so when it does occur 

rapid recognition and treatment is vital. The signs and symptoms are: 


70

Table 7.2 Signs and symptoms of anaphylaxis 

General • Faintness 

• “Aura” of impending doom 

Skin • Itching 

• Rash (urticaria/erythema) 

• Facial oedema 

Respiratory • Breathlessness 

• Cough 

• Stridor 

• Wheeze 

• Cyanosis 

Gastrointestinal • Diarrhoea 

• Nausea/vomiting 

• Stomach cramps 

Cardiovascular • Tachycardia 

• Hypotension 

• Circulatory collapse 

Note: All complications must be documented and reported accordingly. 


71

Activity 7 

7.1 

To avoid anaphylaxis, what should you do before administering any medication or 

treatment to your patient 

Answer: _________________________________________________ 

_________________________________________________ 

_________________________________________________ 

7.2 

In the event of anaphylaxis, list the nursing actions that you would perform. 

Answer: ________________________________________________ 

_______________________________________________ 

_______________________________________________ 


72

8. INFECTION CONTROL ISSUES 

Reducing the Infection Risk. 

Good infection control practice relating to the care and management of devices such as: 

IV access devices consists of basic advice: 

• Invasive devices will only be used when there is no suitable alternative and then 

kept in for as short a time as possible. 

• Devices will be inserted and removed by appropriately trained staff using aseptic 

technique 

• Manufacturer’s guidelines will be adhered to 

• All IV care will be performed to the standard required in the CINS guidelines 

• Appropriate personal protective equipment will be worn. Hands will be adequately 

decontaminated before and after devices are handled 

Adequate hand washing and hand decontamination is a pre-requisite to an effective 

aseptic technique and crucial to infection control measures in IV care. The Ayliffe 

technique (see below) is the recommended way to thoroughly wash your hands and 

should be used each time 


73

Figure 8.1 Handwashing using the Ayliffe Technique 


74

Infection control measures need to be taken when invasive procedures are performed. 

Detailed guidance on this comes from many Department of Health documents, NPSA 

recommendations and the evidence based EPIC 2 findings. These specifically include: 

• Hands MUST be decontaminated immediately before each and every episode of 

direct patient contact or care, and after any activity or contact that could potentially 

result in hands becoming contaminated. 

• Hands that are visibly soiled or potentially contaminated with dirt or organic material 

must be washed with liquid soap and water. 

• When decontaminating hands using an alcohol hand rub, the hands should be free 

from dirt (as above). The hand rub should come into contact with all parts of the 

hand. The hands should be rubbed together vigorously paying particular attention to 

the tips of fingers, thumbs and the area between the fingers until the solution has 

evaporated and dried. Please note that in some Trusts, individual bottles of alcohol 

gel are carried by individual staff, in accordance with NPSA recommendations. 

Hands should be washed with liquid soap and water after several consecutive 

applications of alcohol hand rub. 

• GLOVES MUST BE WORN for all invasive procedures. They should be disposed of 

as clinical waste and hands decontaminated after removal. 

• Disposable plastic aprons should be worn when there is a risk the clothing may be 

exposed to blood, body fluids secretions or excretions . 

• An aseptic, non touch technique (ANTT) should be used for catheter site care and 

accessing the system. Following hand antisepsis, clean gloves and an ANTT or 

sterile gloves should be used when changing the insertion site dressing, line 

manipulation or during IV drug administration 

• Administration sets to be changed in accordance with the CINS guidelines 

All of these precautions are necessary to avoid any extrinsic or intrinsic sources of 

infection in IV therapy. 


75

Figure 8.2 Extrinsic and intrinsic sources of infection in IV therapy 

Copyright of the Infection Control Nurses Association 

Guidelines for preventing intravascular catheter-related infection – 2001 


76

Table 8.1 How organisms invade in IV therapy. 

Catheter Insertion Creates an open pathway for skin organisms to enter the patients’ 

bloodstream. 

This is the most common infection route. 

Accessing the Medication, Flushing, Tubing / cap changes all introduce micro 

Catheter 

Infection 

organisms into the lumen. Hub manipulation is the most common 

source of infection in long-term catheters. 

Organisms affecting other sites or systems can move to the 

foreign object (VAD) and cause a Catheter Related Bloodstream 

Infection (CRBSI). 

Contaminated Considered rare. Outbreaks of HIV, Hep B & C have been 

fluid or medication attributed to contaminated multi-dose vials. Polymicrobal 

outbreaks have also been traced to large bags of saline solution 

being used for multiple catheter flushes. 

(Hadaway 2006) 

Getting the Terminology Right 

Aseptic technique 

• Asepsis means freedom from infection or infectious (pathogenic) microorganisms. 

• For a venous access device related infection to occur, it must be contaminated by a 

sufficient number of virulent, pathogenic organisms. 

• Aseptic technique is a technique that prevents such a level of pathogenic organisms 

from entering the patient’s blood stream. 

• It is achievable in the clinical setting. 

Aseptic Non-Touch Technique (ANTT) 

Aseptic Non-Touch Technique maintains asepsis and is non-touch in nature. This is an 

important factor to appreciate as other terms such as “sterile technique”, are often used 

inaccurately and subsequently can confuse practitioners and patients. 


77

Sterile Technique 

• Sterile means “free from all microorganisms” 

• It is not possible to achieve a true sterile technique for most IV procedures in a 

typical environment – even when wearing sterile gloves. 

Should gloves be worn when preparing and administering IV medications 

The answer is YES. Wear sterile gloves if you cannot avoid touch the key parts 

of the equipment OR wear non-sterile if you can. 

Key parts 

These are parts of the equipment that come in contact with blood and liquid 

infusion and should not be touched even with sterile gloves. 

It cannot be emphasised enough that the risks from infection can nhave 

catastrophic consequences for patients in your care. You therefore have a duty to 

be aware of the risks and the evidence based measures necessary to reduce 

them. 

Reflection 8 

Focusing on the equipment and your knowledge of ANTT and key parts, identify 

the “key parts” in the preparation and administration of IV medications. Give the 

reason why you think it is a key part. 

Key part 

Reason 

________________________ 

_________________________ 

________________________ 

_________________________ 

________________________ 

_________________________ 

________________________ 

_________________________ 


78

________________________ 

_________________________ 

________________________ 

_________________________ 

________________________ 

_________________________ 

________________________ 

_________________________ 

________________________ 

_________________________ 

Activity 8 

Ask a colleague to observe you perform hand washing using the Ayliffe 

technique. Obtain their feedback. Alternatively, use the posters available on 

your ward (or figure 8.2) to guide you in your hand washing practice. 


79

9. HOME INTRAVENOUS THERAPY 

Reasons for Home Care 

Patients with infections (for example, bone infections) are often hospitalised for 

weeks or months in order to receive intravenous antibiotics. Other patients have to 

travel quite a distance to get their intravenous access device flushed or checked. 

The aim of home care is to enable patients to receive the treatment they require 

within their own home environment once a thorough risk assessment has been 

completed. 

Figure 9.1 Conditions currently treated by IV Therapy 

o Endocarditis 

o Cellulitis 

o Osteomyelitis 

o MRSA 

o Spinal abscess 

o Lung abscess 

o Soft tissue infections 

o Haematological oncology 

o Palliative care 

o Home Parenteral Nutrition 

o Renal patients 

The Advantages of home IV Therapy 

The advantages of home therapy can be grouped under three main headings; 

1. The Patient; 

• Psychological benefits of being able to return to their home environment, family 

and lifestyle and exercise some autonomy and control over their care. 

• Health benefits, as they are no longer at risk of hospital acquired infection. 

• Patients can resume their usual diet and activities 


80

• Financial benefits as patients who have prolonged hospital admissions can find 

that their benefits and pension withheld. 

• Families no longer have the extra financial burden that hospital visiting incurs 

• Home IV therapy has shown to aid recovery, prevent anxiety, depression and 

malnutrition, which often occur when patients are hospitalised for long periods. 

2. Health Care Professionals 

• Able to learn and develop their skills leading to increased job satisfaction as 

they are able to play a greater role in the patient’s ‘total care’ 

3. Organisational benefits 

• Prevent admission into secondary care. 

• Reduces the number of ‘bed days’ a patient would otherwise require, thereby 

making effective use of resources. 

• Assists in meeting Government targets. 

Criteria for home IV therapy 

• Patients who require Intravenous Home Therapy must be referred to the 

appropriate clinical nurse specialist for assessment and to District Nurse Liaison 

to arrange discharge. 

• The discharging nurse will complete a patient assessment which will include past 

medical history noting any allergies and this should be clearly documented in the 

patient’s notes. 

• Patients who are to be discharged into the community on intravenous therapy will 

have clear documentation in their case notes by consultant and a discharge plan. 

• The patient must have an appropriate intravenous access device, which is safe 

for community use and the situation must be individually risk assessed. 

• An identified carer or district nurse must be identified and clearly documented in 

the patients’ case notes. 

• The patient, carer and/or district nurse will have completed training with the nurse 

specialist and will have been assessed for safety and competence prior to 

discharge. 


81

• For patients/carers who are administering the antibiotic therapy it is essential to 

educate them about the signs of an allergic/anaphylactic reaction and the 

appropriate action to take. 

Consent 

The patient must sign consent to treatment in the community. The consultant caring 

for the patient must document clearly in the note that he/she wishes the patient to 

receive intravenous therapy in his or her own home. 

Contra-indications 

• Any patient with a history of drug abuse will not be permitted to have an 

intravenous access device in the community setting and will require care as an 

in-patient. 

• The patient must be established on their therapy. 

• If the nurse does not feel the patient, carer and/or district nurse is safe or 

competent they have the right to refuse or delay the patients’ discharge. 

• Any patients who cannot give consent in writing or verbally will require special 

consent. 

• The patient must be registered with a GP. 

Essential training 

The patient/carer/district nurse must have received the appropriate training from the 

clinical nurse specialist and must be deemed confident and competent in line care. 

The competency assessment form must be signed. 

Guidelines for Intravenous Home Therapy 

• Ensure that the patient has an appropriate line for discharge 

• Antibiotics must be rationalized by medical microbiology. 

• Discharge can take several days from referral and therefore requires advanced 

planning and good coordination. 

• Identify clinical carer, e.g. partner or district nurse. 

• Identify training needs of carer or district nurse. 


82

• Ensure district nurse/carer/patient is confident and competent in line care and 

management. 

• Organise ancillaries and antibiotic collection/delivery. 

• Ensure there is a prescription chart for community use, including flushes, saline 

and antibiotics. 

• Ensure patient/carer/district nurse has contact numbers for use when required. 

• Arrange out patient appointment to assess how patient is coping. Is the patient 

concordance 

• Is Blood monitoring required What needs to be measured How often 

• Ensure patient has a follow up appointment at the discharging hospital. 

The current scope in clinical practice across hospital and home IV care is enormous 

and developing all of the time. It is important therefore to keep abreast of changes in 

practice and it is hoped that the CINS guidelines and supplementary care plans will 

provide you with a valuable resource for your practice. In the appendices attached to 

this workbook is an example care plan which has been annotated and the 

competency guidance for key procedures. Please look carefully at these and discuss 

any queries you have about them on your study day or during your skills lab practice 

so that you and your assessor in practice can be confident of the standard of care 

which is required. 


83

10. References and Further reading 

• British Medical Association & the Royal Pharmaceutical Society of Great 

Britain (2007) British National Formulary 53 London: BMJ Publishing Group 

Ltd 

• Collaborative Intravenous Nursing Service (CINS) (2007) Clinical Guidelines: 

Intravenous Access Care and Maintenance in Hospital and at Home 

Cheshire and Merseyside NHS North West CINS 

• Department of Health (2001) Guidelines for preventing infections associated 

with the insertion and maintenance of Central Venous Catheters. Journal of 

Hospital Infection 47(supplement) S47-S67 

• Department of Health (2003) Winning Ways: Working together to reduce 

Healthcare Associated Infection in England London: The Stationary Office 

• Department of Health (2005) Saving Lives: a delivery programme to reduce 

healthcare associated infection including MRSA: skills for implementation 

London: The Stationary Office 

• Dougherty L (2002) Delivery of intravenous therapy. Nursing Standard. 16, 

16. 45 – 52. 

• Dougherty, L & Lister, S. (eds) (2004) Royal Marsden Hospital Manual of 

Clinical Nursing Procedures (6 th ed.) Oxford:Blackwell 

• Finlay, T. (2004) Essential Clinical Skills for Nurses – Intravenous Therapy 

Oxford:Blackwell Science 

• Goodwin,M & Carlson,I (1993) The Peripherally Inserted Catheter: a 

retrospective look at 3 years of insertions. Journal of Intravenous Nursing 

16(2) 92-103 


84

• Hadaway, L (1998) Catheter Connection Journal of Vascular Access Devices 

3(3) 40 

• Hadaway L (2006) Keeping Central Line infection at bay. Nursing 36(4) 58 – 

63. 

• Hand, H. (2001) The Use of Intravenous Therapy Nursing Standard 15 (43) 

47-52 

• Higgins, C. (2000) The Risks Associated with Blood and Blood Product 

Transfusion British Journal of Nursing 9(22) 2281-2290 

• Hyde L (2002) Legal and professional aspects of intravenous therapy. 

Nursing Standard. 16, 26. 39 – 42. 

• Infusion Nurses Society [INS] (2000) Standards for Infusion Therapy 

Massachussetts: Nurses Society 

• James, L., Bledshoe, L. & Hadaway, L.C. (1993) A retrospective look at tip 

location and complications of peripherally inserted central catheters. Journal 

of Intravenous Nursing 16(2), 104-109. 

• Jones, A (2004) Dressings for the management of catheter sites – a review 

JAVA 9(1) 1-8 

• Maki, D.G., Ringer, M., Alvarado, C.J. (1991) Prospective randomised trial of 

povidine-iodine alcohol and chlorhexidine for the prevention of infection 

associated with central venous and arterial catheters. Lancet 338: 339-343. 

• Mermel, L.A. et al., (2001) Guidelines for Management of intravascular 

catheter related infections.J. Intravenous Nursing 24(3) 180-205 


85

• Pratt, R.J., Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones, 

S.R.L.J., McDougall, C., Wilcox, M.H. (2007) EPIC 2: National Evidencebased 

Guidelines for Prevention of Healthcare Associated Infections in 

Hospitals in England Journal of hospital Infection 65 (supplement 1) S1-S64 

• Rickard, N.A.S. (2003) Reducing Risk Associated with Central Venous 

Catheters British Journal of Nursing 12 (5) 274-282 

• Royal College of Nursing [RCN] (2005) Standards for infusion Therapy. RCN: 

London. 

• Scales K (1996) Legal and Professional aspects of intravenous therapy. 

Nursing Standard. 11, 3. 41 – 46. 

• Sheppard, M. & Wright, M. (2002) Principles and Practice of High 

Dependency Nursing London: Balliere Tindall 

• Todd, J. (1998) Peripherally Inserted central Catheters Professional Nurse 

13(5) 297-302 

• Vincent, J.L. (2003) Nosocomial Infections in Adult Intensive Care Units The 

Lancet 361 (9374) 2068-77 

Useful electronic resources 

• Department of Health (England) 

www.dh.gov.uk 

• Evidence-based Practice in Infection Control 

www.epic.tvu.ac.uk 

• Health and Safety Executive 

www.hse.gov.uk 


86

• Infection Control Nurses Association 

www.icna.co.uk 

• National Patient Safety Agency 

www.npsa.nhs.uk 

• National Institute for Health and Clinical Excellence (NICE) 

www.nice.org.uk 

• Nursing and Midwifery Council 

www.nmc-uk.org 

• Royal College of Nursing 

www.rcn.org.uk 

• Skills for Health 

www.skillsforhealth.org.uk 


87

11. Appendices 


Appendix 1 PATIENT CARE PLAN FOR CARE OF PERIPHERAL VENOUS CANNULA. 

The care plan is designed to be used in conjunction with CINS 

Guidelines for vascular devices. 

Manufacturers’ specific recommendations should be noted and 

adhered to by individual practitioners. 

Patient addressograph label / patient name 

Identify site/s by numbering. 

SITE 

NUMBER 

DATE 

TIME 

COLOUR/ 

GAUGE 

REASON FOR 

SITING 

CONSENT 

Y/N 

SIGNED REMOVED 

DATE 

SIGNED 


Type of device Risks Actions Variations / Comments SIGN 

PERIPHERAL 

VENOUS 

CANNULA 

Infection due to loss of 

skin integrity 

Site clean and protected with sterile dressing as per 

CINS guidelines. 

Minimum of daily inspection of site for signs of 

inflammation or infection. 

Practitioner’s comments 

here, e.g. patient sensitive 

to IV 3000, recommended 

dressing is …. 

Jo Bloggs 

Observe patient for signs of line infection 

(vip score) 

When VIP score 2 or above remove promptly. 

Ensure administration lines in place for no longer 

than 72 hrs. 

Replace any infusates with additives and their 

administration lines at 24hrs if constituted in ward 

environment. 

Label infusion lines with date for renewal. 

Use needle free systems instead of 3 way 

taps/bungs. Change needle free systems as 

indicated by manufacturers instructions 

Air embolus 

Recommend all attachments are needle free devices 

and are securely fastened. This guideline does not 

promote the use of 3 way taps. 

Ensure air dispelled from medication / flushes / 

infusates prior to administration. 


Type of device Risks Actions Variations / Comments SIGN 

Occlusion of lumen. 

Maintain patency via 0.9% Saline flushes as per 

CINS guidelines, post drug / infusion administration. 

Bleeding from site / line 

itself. 

Line displacement 

Line in situ when no 

longer required. 

Ensure compatibility of drugs / infusates to avoid 

precipitation. 

If difficult to flush then remove/re-assess. 

Observe for signs of bleeding from site. 

Upon removal of cannula ensure adequate pressure 

is applied to site for cessation of bleeding. 

If bleeding problematical check clotting times. 

Check each time line accessed for signs of 

displacement (extravasation and/or infiltration). 

Remove immediately if displaced. 

Anchor lines to avoid accidental displacement 

Using fixation devices as in CINS guidelines. 

Ensure prompt removal when line no longer required. 

E.g .Patient anti 

coagulated – will need 

agreement on accepted 

clotting ranges at time of 

removal. 

CINS workbook 

draft 8.7 (adult) complete 91

Clinical Competency Frameworks 

For Cheshire and Merseyside NHS North West 

Intravenous Access Care and Maintenance 

In Hospital and at Home 

Developed by 

Collaborative Intravenous Nursing Services 

(CINS) 

CINS June 2007 


1. Introduction 

The practice of IV administration and blood sampling through peripheral and 

central venous access devices is an essential procedure for healthcare 

practitioners to be able to undertake competently. Correct care and maintenance 

of these devices is also vital inorder to protect the patient from infection and 

prolong the life of the device. Healthcare Professionals who use vascular access 

devices should be formally trained to ensure that identified knowledge, skills and 

behavioural competencies are learned. The validation of these competencies, 

through formal assessment, ensures that practitioners are competent and safe to 

practice. This framework is designed to ensure that all staff working for or on 

behalf of the Trust provide an optimum level of service delivery to this specific 

patient population. The advice and guidance contained within this framework is 

based upon the latest research based evidence and has been agreed by the 

Collaborative Intravenous Nursing Service (Merseyside and Cheshire) 

2 Objectives of the Guidance 

2.1 To identify competencies required to perform the procedures. 

2.2 To provide guidance on best practice. 

2.3 To provide guidance on the supervision and process of assessment. 

2.4 To provide guidance on the maintenance of competencies. 

3 Scope of the Guidance 

3.1 The term procedure(s) refers to the following; 

• Flushing of Central Venous and peripheral vascular access devise 

• Disconnecting ambulatory chemotherapy infuser / infuser from central 

venous access devices 

• Intravenous administration of drugs 


• Intravenous access via totally implanted venous access devices (TIVAD) 

eg Port-a-Cath 

• Care and maintenance of a central venous access device or peripheral 

cannula 

• Blood sampling from a central venous device 

3.2 The scope applies to Healthcare Professionals who will undertake theses 

procedures. It is envisaged that these procurers will be undertaken by 

Healthcare professionals who are Band 5 or above. However in certain 

cases it may be necessary for staff of a lower band to perform the above 

procedures as part of specific job role (eg flushing a cannula). Where this is 

the case then it is recommended that a written protocol is included within the 

job description. 

3.3 The proposed procedure should not be performed unless valid consent has 

been gained. 

3.4 The procedure may be performed in the clinical area or in the patient’s 

home. 

4 Skill Pathway 

4.1 Identification of the learning need – This may done by the candidate or the 

manager but if done by the candidate then manager’s approval must be 

sought. It is hoped though that the learning need will be identified through 

mutual agreement at an individual professional development plan / Appraisal 

meeting. 

4.2 Candidate to attend a recognised training study day (see section 5). 

4.3 Candidate to complete and pass theoretical element of the learning package. 


4.4 Candidate to undertake a period of supervised practice. (see section 6). 

4.5 Assessment of competence by an approved member of the training team 

within 3 months of attending the study day (see section 7). 

4.6 Candidate to complete competency training checklist and sign statement of 

intent along with manager and return to the training department / clinical skills 

lab 

4.7 Independent practice can begin when certificate is received by the candidate 

4.8 The practitioner must continue to demonstrate competency in the following 

areas in order to undertake the skill; 

4.8.1 Underpinning knowledge, skills and behavioural competencies required 

for safe practice. 

4.8.2 Demonstrate the ability to communicate the proposed procedure to the 

patient and obtain valid consent. 

4.8.3 Undertake the procedure in accordance with legal and ethical issues 

4.8.4 Demonstrate compliance with standard precautions in the prevention 

and control of infection. 

4.8.5 Carry out the procedure in a safe and competent manner. 

4.8.6 Utilise appropriate equipment in the correct manner. 

4.8.7 Identify clinical risks and take appropriate actions to avoid potential 

complications. 

4.8.8 Demonstrate accuracy and consistency in recording and reporting 

including adverse incidents. 

4.8.9 Demonstrate up-to-date knowledge based on local and national 

standards and guidelines. 

4.8.10 Demonstrate professional behaviour in accordance with the Code of 

Professional Body. 

4.9 If a Health Care Professional who is new to the Trust but has undertaken the 

skill within their last workplace (external to their new Trust) and wishes to 

continue with the skill then it may not be necessary for them to undertake the 


study day or required number of supervised practices’. 

4.10 The individual should have documented evidence that they completed training 

and undertook the skill at their last place of work 

4.11 There should not be a gap of more than 6 months since they last practiced 

4.12 They should undertake an update with an approved member of the learning & 

development team. 

4.13 If they have not had CINS recognised training they must also complete the 

workbook and pass the test papers. 

4.14 They should undertake at least 1 supervised assessment with an approved 

member of the training team before having a formal assessment of their 

competency 

5 Acquisition of Knowledge and Skills 

The underpinning knowledge and behavioural competencies for the skill need to be 

taught before the candidate can progress to supervised practice. These will gained 

by the following methods listed bellow 

5.1 Successful completion of the pre-course workbook. 

5.2 Attendance to the study day, both theory and the practical workshop. 

5.3 Successful completion of the workbook and written test. Pass score 

required on each component. 

5.4 Demonstration of acceptable level of skill on a mannequin/simulator in the 

classroom setting. 


6 Supervision of Practice 

6.1 Supervised practice will commence on the study day which will be 

undertaken by the facilitator in the classroom setting. 

6.2 Succeeding supervision of practice will be in the clinical area/patient's home. 

If the clinical workplace does not provide sufficient opportunities to practice 

the skill, the candidate may arrange to work with a relevant practitioner. 

6.3 The candidate must undertake at least 3 supervised practice (except for care 

and maintenance of peripheral cannula which requires a minimum of 1 

supervised practice) with a Patient, before final assessment 

6.4 The practice supervisor/assessor will have: 

• Record of Trust approved personal competence in the area that 

supervised practice is being undertaken. 

• Practiced that skill for at least 1yr on a regular basis 

• Possess a relevant teaching and assessing qualification e.g. Mentorship 

in Clinical Practice module, ENB 998. 

• Be familiar with the CINS guidelines for IV care and maintenance (2007) 

7 Assessment of Competence 

7.1 Competence will be recorded using the supervised assessment, final 

assessment and competency completion checklist forms 

7.2 The course study module will include a pre-course workbook with reflective 

practice. 


7.3 The course study module will include a written paper with 3 parts Pass 

mark: Part 1: 100%, Part 2: 80%, Part 3: 80%. A maximum of three 

attempts made following which referral to be made to line manager. 

7.4 A minimum of 3 successful supervised assessments (1 supervised 

assessment for care and maintenance of peripheral cannula) will be 

required before the candidate can undertake a final assessment of 

competency. All assessments have to be completed with a patient. 

7.5 Final assessment of competence must be undertaken by a member of the 

training team, relevant Specialist Nurse Practitioner, or person approved by 

them using the Final Assessment of Practice form. 

7.6 Competence should be attained within 3 months from the date of the study 

day. 

7.6 Once competency is attained, the Competency Checklist and statement of 

intent should be completed by the candidate and the manager who should 

then send a copy to the training department 

7.7 Only when the candidate has received the certificate can they practice 

unsupervised 

8 Continuing Education 

8.1 Individuals will be responsible for maintaining their own practice and 

competence. This may be done by linking in to other wards or teams. 

8.2 Attend update sessions which will be communicated to all staff by the 

person responsible for the delivery of training. 


9 Roles and Responsibilities 

9.1 The guidelines will be maintained by the CINS group 

9.2 The guidelines need to be acted upon by the following: 

• Training Facilitators / Leads 

• Qualified Assessors and Mentors 

• Health Care Professionals who will undertake the procedures 

• Clinical Leads 

• Ward Managers/Team Leaders. 

• Pharmacy department 

10. Monitoring and Audit 

10.1 The Clinical Skills Centre/Training and Development Department should 

collate a report of personnel who have achieved the competency. 

10.2 Annual declaration of competence during annual professional 

development plan / appraisal meetings with managers 

11. Documentation 

11.1 Related policies & procedures. This document should be read in conjunction 

with: 

• CINS guidelines 

• Risk Management Stategy 

• Waste Management Policy 

• Infection Control Manual 

• Anaphylaxix guidelines 

• Pharmacy Policy 

• Consent Policy 

• Local Trust Policies 


12. Relevant Legislation/Statutory Requirements 

The following guidance was used in the production of this document: 

1. Royal College of Nursing (2005) Standards for Infusion Therapy 

2. Nursing and Midwifery Council (2004) Guidelines for the Administration of 

Medicines 

3. Nursing and Midwifery Council (2004) Code of Professional Conduct 

Knowledge Skills Framework: 

For each IV Access Core Clinical 

Core Dimensions 

KSF Level 

1: Communication 1 2 3 4 

2: Personal & People Development 1 2 3 4 

3: Safety & Security 1 2 3 4 

4: Service Development 1 2 3 4 

5: Quality 1 2 3 4 

6: Equality & Diversity 1 2 3 4 

HWB5: Undertake care activities to meet the health and 

wellbeing needs of individuals with a greater degree of 

dependency 

HWB7: Contribute to planning, delivering and monitoring 

interventions and/or treatments 

1 2 3 4 

1 2 3 4 


Index to IV access core clinical competencies & 

documentation 

Page 

Clinical Competency Framework for Flushing Peripheral and Central 

Venous Catheters 102 

Clinical Competency Framework for the Administration of 

Intravenous Drugs through vascular access devices 104 

Clinical competency framework for the care and maintenance of 

Central Venous Access Devices (CVADs) 107 

Clinical Competency Framework for the Care and Maintenance of a 

Peripheral Cannula 109 

Clinical Competency Framework for Blood Sampling from a Central 

Venous Access Device 

111 

Clinical Competency Framework for the Intravenous Access of 

Totally Implanted Venous Access Devices (TIVAD) eg Porta-a-Cath 113 

Clinical Competency Framework for Disconnecting Ambulatory 115 

Chemotherapy form Central Venous Access Devices 

Competency Checklist and Statement of Intent 117 

Assessment for collection of blood and blood products 118 

Assessment of administration of blood and blood products 122 


Supervised Practice Assessment Record 

Flushing Central Venous Access Devices (CVAD) 

& 

Peripheral Cannula 

Instruction: Please tick (√) if performed, cross (X) if not performed, or write N/A if deemed not applicable 

Surname Forename Ward / Area / Department Assessment 

Dates 

Supervisors Name: 

1) 

2) 3) 

Skills Lab 

Correct equipment 

collected 

Transporting 

Preparing the 

patient 

Hand washing 

Performs procedure 

Patient comfort & 

safety 

Infection Control 

Documentation 

Sterile pack 

Chlorhexidine 2% in alcohol solution 

Syringes, needles, 0.9% normal saline, heparinised saline 

(10units/ml) where applicable 

Checks packaging and expiry dates 

Safely transfers equipment to patient 

Identifies patient and explains procedure 

Obtains valid consent from patient 

Encourages questions 

Establishes comfort and privacy of patient 

Decontaminates hands using the Ayliffe technique 

Opens equipment, maintains sterile field 

Places sterile field as close to device as possible 

Prepares flushing solution in an aseptic a manner 

Cleanses needle free system with chloxhexidine 2% in alcohol 

swab 

Flushes lumen (using push / pause technique for CVAD) with 

0.9% normal saline (heparinised saline (10units/ml) where 

clinically indicated) 

Clamps lumen 

Disposes of equipment and sharps as per trust policy 

Ensures line is secure and comfortable 

Explains care of CVAD / peripheral cannula to patient 

Disposes of equipment & sharps as per trust policy 

Maintains aseptic technique throughout 

Decontaminates hands as per trust policy 

Documents procedure in patients records 

Completes VIP Score 

Documents any other information in case 

Initial of Supervisor: 

Initial of Practitioner: 

The number of supervised practices may vary between individuals. Further copies can be obtained from 

your training department if required 


Final Assessment of Practice 

Flushing Central Venous Access Devices 

& 

Peripheral Cannula 

The final assessment must be undertaken by a member of the Learning & Development 

team, Specialist Nurse Practitioner or person approved by them 

Name: 

Job Title: 

Department: 

Organisation: 

Assessor’s Name: 

Date: 

Activity Pass Refer Comments 

Correct equipment collected 

Transporting 

Preparing the patient 

Hand Hygiene 

Correct positioning of patient and 

preparation of environment 

Performs procedure correctly and 

safely (as per policy) 

Patient comfort and safety 


Completes documentation in line 

with local policy 

Outcome: 

If Outcome of final assessment is refer 

Continue supervised practice 

Review progress – Re-take final assessment again 

when ready (final assessment must be done before 

independent practice can occur) 

Organise a 1 month review Date of review: 

Practitioner: sign 

Assessor: sign 

Date: 



Administration of IV drugs through a Vascular Access Device (VAD) 


Surname Forename Ward / Area / Department 

Assessment Dates 

Supervisors Name: 1) 

2) 

Correct 

equipment 

collected 

Transporting 

Preparing the 

patient 


Performs 

procedure 

3) 

Sterile pack and gloves 

Appropriate sterile equipment 

needles/straw/syringes/giving sets 


Antibiotic, additive, infusion, diluents as prescribed 

Heparin 100units / ml, Heparinised saline 10 units/ ml 

as indicated (refer to specific VAD guideline) 


Checks Right Medication, Right Dose, Right Time, 

Right Route 

Checks drug for any possible incompatibility issues 

Is aware of potential complications of the drug to be 

administered 

Correctly performs calculations for dose and rate 





Checks for allergies 


Decontaminates hands using the Ayliffe technique as 

per trust policy 



Prepares intravenous antibiotics/additives/infusor with 

non touch technique as per trust policy 

Cleanses needle free system with Chlorhexidine 2% in 

alcohol solution 

Flushes VAD with 0.9% Sodium Chloride prior to drug 

administration as per VAD guidelines 

Administers intravenous antibiotic/additive/infusor as 

per hospital policy. 

Monitors for any adverse reaction 

Flushes VAD with 0.9% Sodium Chloride following drug 

administration as per policy 

Administers heparinised saline 10units/ml or heparin 

100 units/ ml as indicated see specific VAD guidelines 

Disposes of equipment as per trust policy 

Skills Lab 

Continued over the page 


Continued from over the page 

Administration of IV drugs through a Vascular Access Device (VAD) 




2) 

3) 

Skills Lab 


safety 


Documentation 


Explains care of VAD to patient 













Administration of, IV drugs 



Name: 

Job Title: 

Department: 

Organisation: 


Date: 



Transporting 











Outcome: 









Date: 



Care and Maintenance of Central Venous Access Devices 





2) 3) 

Skills Lab 


collected 

Transporting 





safety 


Documentation 



Sterile Gloves x 1 


Appropriate Dressings 







as per trust policy 

Observes site using VIP scoring and takes 

appropriate action 


Removes existing dressing in an aseptic manner 

Places sterile dressing towel as close to CVAD as 

possible 

Cleanses skin covering surrounding CVAD with 


Applies appropriate dressing 



Explains care of CVAD to patient 






Documents any other information in case records 







Care and Maintenance of Central Venous Access Devices 


team, Specialist Nurse Practitioner, or person approved by them 

Name: 

Job Title: 

Department: 

Organisation: 


Date: 



Transporting 











Outcome: 




when ready (final assessment must be passed before 





Date: 



Care and Maintenance of Peripheral Cannula 





2) 3) 

Skills Lab 

Only required if 

further practice 

needed 


collected 

Transporting 





safety 


Documentation 





Appropriate Dressings 











Removes existing dressing in an aseptic manner 

Places sterile dressing towel as close to peripheral 

cannula as possible 

Cleanses skin covering surrounding peripheral 

cannula with Chlorhexidine 2% in alcohol solution 

Applies appropriate dressing 



Explains care of peripheral cannula to patient 









The number of supervised practices may vary between individuals. Should you require more practice 

please use the two end columns 



Care and Maintenance of Peripheral Cannula 



Name: 

Job Title: 

Department: 

Organisation: 


Date: 



Transporting 











Outcome: 









Date: 



Blood sampling from a Central Venous Access Devices 





2) 3) 

Skills Lab 


collected 

Transporting 





safety 


Documentation 



Sterile Gloves 


Syringes, 0.9% Sodium Chloride 

Heparin / Heparinised saline 10 units/ ml as 

indicated (refer to specific CVAD guideline) 

Appropriate blood bottles and blood forms 











Places sterile dressing towel as close to CVAD as 

possible 

Prepares syringes with Sodium Chloride 0.9% 

Cleanses needle free system with Chlorhexidine 

2% in alcohol solution or skin surrounding CVAD 

Withdraws blood as per guidelines 

Flushes CVAD with Sodium Chloride and uses 

heparin / heparinised saline where clinically 

indicated 

Transfer blood into bottles and fills out blood 

bottles and forms as per trust policy 
















Blood sampling from a Central Venous Access Devices 


team, Specialist Practitioner or person approved by them 

Name: 

Job Title: 

Department: 

Organisation: 


Date: 



Transporting 











Outcome: 









Date: 



Intravenous access to Totally Implanted Venous Access device (TIVAD) 

e.g. Port-a-Cath 





2) 3) 

Skills Lab 


collected 

Transporting 

Preparing the 

patient 


Performs 

procedure 


safety 


Documentation 



Syringes, needles, 0.9% normal saline, heparinised 

saline (100units/ml) 








Decontaminates hands using the Ayliffe technique as 

per trust policy 


Places sterile dressing towel as close to TIVAD as 

possible 

Prepares flushing solution in an aseptic a manner and 

primes non-coring needle including extension tubing 

with 0.9% sodium chloride clamps tubing 

Locates TIVAD by palpation & changes sterile gloves 

Cleanses skin covering TIVAD with Chlorhexidine 2% in 

alcohol solution 

Inserts non-coring needle attaches syringe and flush 

with push / pause technique with 0.9% sodium Chloride 

Assesses skin covering TIVAD for swelling and repeats 

flushing process with heparinised saline (100units/ml) 

Removes needle and applies pressure over TIVAD until 

bleeding stops 



Explains care of TIVAD to patient 









If first attempt fails, one further attempt is permitted, if the principles of asepsis are maintained. 



Intravenous access to Totally Implanted Venous Access device (TIVAD) 

e.g. Port-a-Cath 



Name: 

Job Title: 

Department: 

Organisation: 


Date: 



Transporting 











Outcome: 









Date: 



Disconnecting Ambulatory Chemotherapy Infusor/ Infuser from 

Central Venous Access Devices 


Surname Forename Ward 



2) 

Correct 

equipment 

collected 

Transporting 

Preparing the 

patient 


Performs 

procedure 

Patient comfort 

& safety 

Infection 

Control 

Documentation 

3) 



Syringes, needles, 0.9% normal saline, heparinised saline 

(10units/ml) where applicable 

Luer Lock stopper 

Plastic bag marked cytotoxic waste 









Places sterile dressing towel as close to CVAD as possible 

Prepares flushing solution in an aseptic a manner 

Closes catheter clamp and handles line connected to IV tubing 

with swab impregnated with Chlorehexidine 2% alcohol 

solution 

Disconnects infusor line from CVAD, applies luer lock stopper 

to the end of infusor line and seals infusor in the plastic bag 

marked cytotoxic waste 

Cleanses needle free system with chloxhexidine 2% in alcohol 

swab 

Flushes lumen of CVAD using push / pause technique with 

0.9% normal saline (heparinised saline (10units/ml) where 

clinically indicated) 

Clamps lumen of CVAD 

Disposes of equipment and sharps as per trust policy 



Disposes off equipment and sharps as per trust policy 








Skills Lab 





Disconnecting Ambulatory Chemotherapy Infusor/ Infuser from 

Central Venous Access Devices 



Name: 

Job Title: 

Department: 

Organisation: 


Date: 



Transporting 











Outcome: 









Date: 


Competency Checklist and Statement of Intent 

Name: 

Job Title: 

Organisation: 


Manager’s Name: 

Department: 

Assessment criteria Date signature Print 

Identified need for clinical skill with 

manager 

Read relevant sections of CINS & 

Infection control policy 

Attended a Trust recognised study 

session / update 

Completed theory papers 1,2, & 3 and 

passed. 

Undertaken an appropriate period of 

supervised assessment 

Final assessment by a member of 

Learning & Development team / 

Specialist nurse practitioner within 3 

months of undertaking study session 

Flushing CVAD & peripheral 

Cannula 

Administering IV drugs through a 

VAD 

Care & maintenance of a CVAD 

Care & maintenance of a 

peripheral cannula 

Blood Sampling from a CVAD 

IV access to TIVAD 

Disconnecting ambulatory 

chemotherapy Infusor / Infuser 

from CVAD 

Competency Achieved In 

Learner’s Statement 

I confirm that I have met the required standard and that I am confident to perform the 

procedures listed above unsupervised both safely and competently and fully understand and 

accept my responsibilities towards the patient, myself and the Trust/PCT when undertaking 

these procedures. I agree to maintain my clinical competence in this skill and keep myself 

updated (yearly updates recommended). 

Signed: Print: Date: 

Base: 

Designation /Job Title: 

PLEASE MAKE 3 COPIES OF THIS FORM 

Copy 1 – To be sent to the Learning & Development team, upon receipt you will be issued with a 

certificate. 

Copy 2 – To be held by your manager as a record of competency 

Copy 3 – To be retained by you for your professional portfolio and KSF 


Assessment for the collection of blood and blood products 

You MUST attend a blood transfusion awareness session before completing this 

assessment. This competence is linked to the Knowledge and Skills Framework 

dimensions in communication, health and safety and health and well being, and is 

developed in conjunction with the National Patient Safety Agency (NPSA). 

Observational Assessment 

Competence & Elements of skill 

Did the member of staff demonstrate effective use of health and 

1 2 

safety measures by: 

a) Washing their hands 

b) Using personal protective equipment 

c) Adhering to local infection control procedures 

Patient preparation 

Did the member of staff before collecting the blood product check: 

a) The patient is aware / and understands the necessity for the 

transfusion 

b) The patient has given their verbal consent 

c) The patient is wearing a hospital identification nameband 

d) The patient has venous access 

e) The product is prescribed 

f) The vital signs are within acceptable limits for the patient’s 

condition 

g) The availability of equipment 

h) Staffing levels on the ward / area 

i) The patient’s condition requires a transfusion 

Patient identification check for the conscious patient 

Did the member of staff: 

a) Attain the collection documentation i.e. prescription sheet, for the 

collection of blood products 

b) Ask the patient to verbalise their: 


• Full forename and surname 

• Date of birth 

c) Match the information provided with the patient’s nameband and 

documentation to be used for collection 

Patient identification check for the unconscious patient or patient 

unable to verbally respond 

Did the member of staff check: 

a) Attain the collection documentation i.e. prescription sheet, for the 

collection of blood products 

b) Match the information against the patients nameband checking: 

• Patient’s full forename and surname 


• Hospital identification number 

Matching the patient information on the blood product to the: 

a) Collection documentation i.e. prescription sheet 

b) Compatibility sheet 

c) Blood transfusion register 

Did the member of staff correctly check: 

a) Patient’s full forename and surname 

b) Date of birth 

c) Hospital identification number 

Matching the product information on the blood product to the: 

a) Compatibility sheet 

b) Blood transfusion register 

Did the member of staff correctly check: 

a) The correct product for collection I.e. Blood or FFP 

b) The 14 digit alphanumeric number 

c) Product expiry date 

d) Blood group 

e) Integrity of the unit 

Documentation 

Did the member of staff correctly document the removal of the blood 

product from the issue fridge by documenting in the blood transfusion 


egister: 

a) Printing their name 

b) Signing their name 

c) Recording the correct date 

d) Recording the correct time using the 24-hour clock 

e) Indicating if an insulation box was used for transportation 

f) Completing the ‘time taken’ section on the compatibility sheet 

Transportation and handover of blood products 


a) Transport the blood product immediately to the clinical area 

b) Not leave the blood product unattended at any point 

c) Hand the blood product over to an appropriate member of staff 

immediately 

d) Inform the member of staff of the time the blood product was 

removed from the issue fridge 

Insulation transport box for blood ONLY (if collecting, more than 1 unit) 


a) Use the appropriate cool packs 

b) Complete the documentation on the side of the insulation box 

c) Not leave the blood product unattended at any point 

d) Hand the blood product over to an appropriate member of staff 

immediately 

e) Inform the member of staff of the time the blood product was 

removed from the issue fridge 

f) Ensure the blood was used / returned within 3 hours of 

collection 

Competent Y / N 

Signature of learner & Date 

Signature of assessor & Date 

All of the above must be achieved to pass this assessment 


Knowledge Assessment 

Did the candidate know and understand the importance of: 

Using open-ended questions for patient identification 

The importance of checking the patient identification on the blood 

collection documentation 

The potential risks in the blood product collection process 

Why patient information should not be SOLELY checked against the 

compatibility form 

Not carrying FFP, Platelets, Cryoprecipitate, Human Albumin and 

Anti-D in an insulation transport box 

This competence is to be renewed every 3 years 


Assessment of administration of blood and blood products 

You MUST attend a blood transfusion awareness session before completing this 

assessment. 

This competence is linked to the Knowledge and Skills Framework dimensions in 

communication, health and safety and health and well being, and is developed in 

conjunction with the National Patient Safety Agency (NPSA). 


Did the member of staff carry out the four types of pre-transfusion checks 

1 2 

correctly 

a) Personal 

b) Equipment 

c) Patient 

d) Blood component 

a) Personal: clean hands, wear personal protective equipment and adhere to 

infection control guidelines at all times 

b) Equipment: check that all equipment is clean and available (i.e. 

prescription chart, observation chart, giving set) 

c) Patient: carry out a baseline assessment of the patient; check venous 

access has been obtained prior to blood being collected from the fridge; 

read through the prescription; and check that the patient understands why 

they are going to receive a transfusion and verbal consent is obtained 

d) Blood component: check the quality of the blood product, expiry dates 

and any special transfusion requirements 



1 2 

Patient identification for the conscious patient (x2 appropriate 

staff): 

Did the member of staff ask the patient to state their: 

a) Full forename and surname 

b) Date of birth 

Did the member of staff check for correlation: 

c) The details on the patient’s nameband 



• Hospital number 

d) The details on the prescription sheet 

e) The details on the unit of blood product 

Did the member of staff check the blood unit details against the: 

a) Blood product unit 

b) Compatibility form 

Patient identification for unconscious patients or patients unable to verbally 

respond (x2 appropriate staff): 

Did the member of staff check: 

a) The details on the patient’s nameband 



• Hospital number 

a) The details on the prescription sheet 

b) The details on the unit of blood product 

Did the member of staff check the blood unit details against the: 

a) Blood product unit 

b) Compatibility form 



1 2 

Did the member of staff record the patient’s vital signs 

a) Blood pressure 

b) Pulse 

c) Respiratory rate 

d) Temperature 

Administering the transfusion 

Did the member of staff ensure the transfusion was commenced within: 

a) 30 minutes of collection for blood 

b) Immediately on arrival to ward for Platelets, FFP and Cryoprecipitate 

c) As soon as required for Human Albumin and Anti-D 

And can ensure the transfusion will be complete within: 

a) As prescribed or 4 hours from removal of fridge for Blood, FFP and 

Cryoprecipitate 

b) As prescribed or 30 minutes for Platelets 

c) As prescribed for Human Albumin and Anti-D 

Monitoring the transfusion 

Did the member of staff Record the patient’s vital signs as per Trust policy: 

a) At the start of the transfusion 

b) 15 minutes after the start of the transfusion 

c) Throughout the transfusion for blood 

d) At the end of the transfusion 

e) Dispose of equipment safely 

Documentation 

Did the member of staff record the following information on the prescription sheet: 

a) Blood product unit number 

b) Signed given / checked by 

c) Time and date the transfusion started 

d) Time and date the transfusion ended 

Did the member of staff document in the patients nursing / medical notes the 

transfusion episode 


Did the member of staff (if last unit in the transfusion episode): 

a) Complete and return the Traceability documentation to the blood 

transfusion laboratory as per National Law 

b) If not last unit understands the importance of carrying the above 

Condition / Behaviour of patient condition monitored throughout. 

Any adverse reaction reported and appropriate action taken. 

Patient left comfortable following administration. 

Events followed a logical sequence. 

Competent Y / N 

Signature of learner & Date 

Signature of assessor & Date 

IT IS UP TO THE PRACTITIONER TO UTILISE THESE SKILLS AS 

MUCH AS POSSIBLE 

All of the above must be achieved to pass the assessment 

Knowledge assessment 

Does the member of staff know and understand the importance of: 

Using open-ended questions for patient identification 

The timescales for administering blood and blood products safely 

after it has been collected from the issue fridge 

Correct procedure if unconscious patient or unable to give verbal 

identification 

The risks associated with checking the blood compatibility form 

against the blood product instead of the information on the 

patient’s nameband 

Monitoring the patient’s vital signs throughout the blood 

transfusion 

This competence is to be renewed every 3 years 


BLOOD TRANSFUSION COLLECTION: 

Assessment Print Name Sign Name Date Time Competent 

1 Y/N 

Comments 

2 Y/N 

Comments 

BLOOD TRANSFUSION ADMINISTRATION: 

Assessment Print Name Sign Name Date Time Competent 

1 Y/N 

Comments 

2 Y/N 

Comments

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