HHC Health & Home Care Clinical Policy And

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HHC HEALTH & HOME CARE Section: 9-1 Infusion Therapy: Administration of Intravenous Therapy in the Home __RN PURPOSE: To provide a peripheral venous route for the administration of solutions and/or medications that will maintain or replace body stores of fluids, provide nutrition, treat illnesses, or be used in diagnostic tests. CONSIDERATIONS: 1. Prior to instituting therapy the nurse will: a. Review the physician's order for the type of solution, amount/dosage to be infused, rate of infusion, frequency, route and duration. b. Obtain patient’s allergy history. c. Obtain a signed informed consent form. THIS MUST BE DONE BEFORE BEGINNING THERAPY. d. Instruct the patient or caregiver regarding storage and handling of supplies, and patient care required in the absence of the nurse. e. Review the actions, usual dose, indications for use, side effects, goals of therapy, and incompatibilities of the solution or medication to be administered. Note: For the purpose of consistency, all plastic catheters and needles will be referred to as CANNULAS and special techniques noted for using plastic intravenous catheters and stainless steel intravenous needles. 2. In selecting equipment, consider the following: a. Duration and purpose of therapy: (1) Steel needles (butterfly) may be used for short-term (less than 24 hours) or one-time dosing of nonirritating infusates given with the nurse in attendance. (2) Plastic catheters are indicated in long-term continuous or intermittent therapy, and when giving potentially irritating infusates. Description: A plastic/silicone catheter inserted over a hollow stylet (needle). The needle is removed once the catheter is in the vein. b. Cannula length and gauge: (1) The size of the cannula lumen must be less than the lumen of the vein. Choose the smallest gauge that is adequate for the prescribed rate and type of infusate (22-24 is recommended). (2) The length of the cannula may be directly related to infection and/or embolism formation; therefore, the shortest cannula that will accommodate the therapy is required. Length should not be more than 3/4" to 1 1/4" for a distal, peripheral site. 3. In selecting a vein, consider the following: a. Location: (1) Use most distal, superficial vein first. (2) In elderly patients, veins of the hands may be unsuitable due to the lack of supporting tissue. (3) A large vein should be used for long-term therapy, and hypertonic or potentially irritating drugs or solutions; i.e., peripheral parenteral nutrition or hydration fluids with potassium. (4) Avoid using areas of flexion. (5) Veins of the antecubital fossa should be avoided and reserved for obtaining blood samples, placing PICC lines or midline catheters. (6) Veins of the lower extremities, affected arms of ancillary dissection (mastectomy), and veins of arms with A-V shunts may not be used without a specific physician's order. b. Condition of veins: (1) Select a healthy, resilient vein above areas of previous infiltration, bruising or inflammation. (2) Vein should feel round, firm, elastic and engorged - not hardened. 4. Techniques to distend the vein include: a. Apply a tourniquet 4-8 inches proximal to the selected site. b. Request patient to open and close fist several times. This will make the vein more prominent. c. Place extremity in a dependent position and place the patient in a comfortable supine position. d. Massage in the direction of venous flow. e. Palpate to differentiate arteries from veins. f. Apply heat with heating pad or warm, moist towel for approximately 15 minutes to promote vein relaxation and dilation. 5. The bevel of the cannula needle should be angled up 30 degrees when attempting to access the vein, to reduce the risk of piercing the vein's back wall. 6. All tubing must be primed to remove the air prior to attaching to the patient's cannula. 7. A short microbore extension set should be attached to all peripheral cannulas. 8. Without obscuring the insertion site, secure catheter hub with sterile tape or sterile surgical strips; do not apply tape directly to catheter-skin junction site. 9. IV tubing must be changed according to the national standards listed below: a. Primary continuous - every 72 hrs. b. Secondary continuous - every 72 hrs. c. Primary intermittent - every 24 hrs. d. Secondary intermittent - every 24 hrs. e. Blood products tubing - after each unit f. TPN tubing - every 24 hrs. g. Fat emulsion (LIPIDS) – every 24 hours if administred continuously. If a single unit of Lipids is administered change set after each unit.10. Injection/access ports attached to an infusion catheter shall be of luer-lok design or configuration. (the taping of connections rather than the use of leur-lok's is not a practice that is recommended by the INS.) 1. When administering intravenous therapy in the home, health care workers adhere to Standard Precautions. (See Infection Control: Standard Precautions, No. 14.01.) 12. The use of arm boards to immobilize an extremity is allowed to prevent potential infiltration or phlebitis in an uncooperative, disoriented or elderly patient or child. The arm board should be removed and patients’ extremity circulatory status should be assessed at established intervals. 154
HHC HEALTH & HOME CARE Section: 9-1 Infusion Therapy: Administration of Intravenous Therapy in the Home __RN 13. After two unsuccessful attempts at cannula placement, the nurse should consider requesting assistance from her/his supervisor/manager. 14. Excess hair at the intended site should be clipped, not shaved, because of the potential for microabrasions, which increase the risk of infection. 15. Use at least two (2) patient identifiers prior to administering medication. EQUIPMENT: Gloves Tourniquet Alcohol applicator (wipe/swab/disk/ampule) Antimicrobial applicator (wipe/swab/disk/ampule) Cannula IV solution IV tubing 0.22-micron filter 3-5cc syringe with normal saline Small extension set, i.e., 5-inch microbore Leur-lok injection port/connector 2x2 gauze sponges, sterile Transparent permanent adhesive dressing Tape IV pole Arm board (optional) Puncture-proof container Impervious trash bag Disposable apron (optional) Protective eye wear (optional) The latest CDC guidelines, 08/2002, advise against the use of topical antibiotic ointments or creams on insertion sites except when using dialysis catheters because of their potential to promote fungal infections and antimicrobial resistance. PROCEDURE: 1. Adhere to Universal Precautions. 2. Explain procedure and purpose to patient/caregiver. 3. Assemble the equipment on a clean surface, close to the patient. 4. Question patient regarding allergies to adhesive tape and iodine. 5. Place patient in a comfortable position, making sure that site is accessible and stable. 6. Ensure adequate lighting. 7. Wash hands and don gloves. 7. Prepare equipment. a. Check patient's name and expiration date on fluid container. b. Check fluid container for prescribed solution, leakage, particulate matter, and discoloration. c. Add medication, if necessary. Label the container with name of additive, date, time and RN initials. d. Connect IV tubing with filter to fluid container and flush air from tubing. Fill drip chamber halfway. Maintain sterility of free end of tubing. e. Hang solution container a minimum of 3 feet above insertion site. f. Prime small extension set to be added to IV catheter. 8. Assess hand or arm for appropriate venipuncture sites. 9. Apply tourniquet. 10. Clean the skin. a. If the site is excessively hairy, clipping is recommended. b. Clean skin with an alcohol applicator. Apply in a circular motion starting at the intended site and working outward, using friction. Allow to air dry. If using a 2% chlorhexadine solution, use a back and forth scrubbing motion. Allow to air dry. Only one application is necessary. No alcohol rep is required. c. Repeat with antimicrobial applicator. Allow to air dry. DO NOT BLOT. Do not retouch cleansed area due to contamination of site. 11. Anchor the vein by holding the skin taut below the selected site. 12. Insert the cannula at a 30-45 degree angle beside the vein. 13. When skin is pierced, lower the angle of the cannula almost parallel to the skin. Gently apply pressure and enter the vein. 14. When backflow of blood is evident, advance the cannula forward keeping the inner needle (stylet) stationary until the hub is flush against the insertion site. 15. Release the tourniquet. Apply pressure above site to occlude blood flow. Remove stylet and connect extension set. Flush line with 3-5cc of normal saline. Observe site for swelling or discomfort. 16. Connect IV tubing, securing to extension set and leur-lok injection port/connector. 17. Start infusion slowly while observing site. 18. Secure the cannula hub to the patient with tape. Do not cover the insertion site and the hub/tubing connection. 19. Cover with transparent dressing. 20. Secure IV tubing with tape to prevent tension on the insertion site. 21. Use an arm board, if indicated. 22. If using an infusion pump to regulate the drip rate, please refer to the manufacturer's instructions on the package. 23. Regulate the drip rate if infusing by gravity and apply time tape to solution container. The formula to determine drops per minute is: gtts/cc of infusion set x hourly volume = gtts/min. 60 min./hr. If a microdrip set is used, the number of drops/minute equals the amount of solution/hour. This type of set is recommended since calculation is simple to remember and the patient/caregiver can learn to regulate the flow easier. 24. Discard soiled supplies in appropriate containers. 155
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HHC Health & Home Care Clinical Policy And

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