Intravenous Therapy

GUIDELINESI.Resident Candidacy for IV Therapy1. The resident medically needs an IV and the diagnosis is onthe chart.i. If the IV therapy is ordered for four (4) or more weeks,it is recommended that the patient have a venousaccess device placed.ii. The resident has adequate vascular access to completethe course of ordered IV Therapy.2. The IV solutions are medically safe for IV administration.3. A physician initiates the orders and is available forcomplications and emergencies.II.Excluded IV Medications and Therapies1. Investigational drugs.2. Chemotherapy Agents3. Total Parenteral Nutrition (TPN)4. IVs in lower extremities, unless specifically ordered by aphysician.5. Removal of clots from an IV catheter by irrigation. Refer todeclotting procedure.III. Processing the IV order1. The IV order should be received from a physician by eitherverbally or written form. The order shall then be faxed orphoned in to the pharmacy, transcribed onto the IVMedication Sheet, Telephone Order Slip (if appropriate) andPhysician Order Sheet. When completed, the order will besigned and dated.2. A licensed nurse must call or fax in all IV orders or refills forsolutions and medications.-1-

GUIDELINES3. Stat IV orders must be called into the pharmacy by a nurse assoon as the order is received.4. A complete IV order should include the following:Primary IV Orderi.ii.iii.iv.v.vi.vii.viii.ix.Resident’s NameDiagnosis for IV TherapyRoute (central or peripheral)IV solution, volumeAny additivesRate, length of therapyHeparin flush strength, volume and frequencyDoctor’s NameDate, Time and nurse’s signature if a telephone orderHeparin t’s NameDiagnosis for IV TherapyRoute (central or peripheral)Medication (strength/dose)Frequency of administrationLength of therapyRate of infusionNormal saline flush before and after medicationHeparin flush strength, volume and frequencyDoctor’s NameDate, Time and nurse’s signature if a telephone order5. Licensed practitioner orders without specific time frame as toduration of therapy will have a facility stop order policy.i. IV solutions daysii. Antibiotic therapy daysIV.IV Solutions/Medications: Storage1. Solutions should remain in their original packaging until readyfor use-2-

GUIDELINES2. Solutions should be stored in a cool, dry area unlessrefrigeration is indicated.i. Remove one (1) liter bags from the refrigerator 1 hourprior to infusion.ii. Remove bags containing more than one (1) liter 2 hoursprior to infusion.iii. Remove 50-250 cc bags from the refrigerator ½ hourbefore infusion.iv. DO NOT USE MICROWAVE to warm IV bags: unevenheating may occur.v. Do not expose IV solutions to direct sunlight.3. Adequate refrigerator space to store solutions andmedications must be provided.4. The refrigerator temperature should be set between 36 and46 F to maintain stability.5. Upon delivery, arrange older solutions so they will be infusedbefore the more recently prepared solutions.V.IV Solutions/Medications: Handling1. All IV solutions will be changed every 24 hours once spiked.2. The nurse hanging the IV solutions/medications will label thebag with the date, time and initials.3. All IV solutions with medications added by the pharmacist willbe labeled according to pharmacy procedures.4. If an IV rate has been changed from the rate stated on thepharmacy label, the facility nurse should label the IVcontainer with the current rate and notify the pharmacy.5. IV solutions/medications will be administered within the StateGuidelines for that drug category.-3-

GUIDELINES6. All IV solutions/medications will be documented on the IVMedications Sheet or approved facility form.7. All IV containers will be inspected for integrity, including:i.ii.iii.iv.v.Cracks---if bottle formCloudiness or discolorationDamage to containerParticlesExpiration date8. All solutions/medications will be labeled and billed as residentspecific items.9. All supplies and pumps will be provided and billed as residentspecific items.VI.IV Solutions and Supplies: Destroying and Returning1. All IV narcotic drugs will be destroyed by a pharmacist andRN (or according to state and federal regulations) anddocumented.2. Return Drug Rules and Regulations vary by state and shouldbe made available by the IV pharmacy provider.3. The following items may not be returned:i.ii.iii.iv.Narcotic IV medicationsMedications pre-mixed in a syringe, bag or bottleTPN solutionsContaminated or damaged preparations, unless relatedto a resident reaction.v. Opened or expired medications, solutions or suppliesvi. IV bags or bottles without a prescription label attached.4. Only unopened plain IV solutions, factory added KCl andsupplies may be returned to the pharmacy with theprescription label intact for credit to the resident’s account.Refer to #2 above.-4-

GUIDELINES5. IV solutions prepared with an Add-Vantage bag and vial orsnap vial and bag may be returned to the pharmacy with theprescription label intact if done so before the 4 weekexpiration for credit to the resident’s account if/when the IVsolution is used for another patient.6. It is the facility’s responsibility to return all resident specificIV equipment within the billing month. The resident’s accountwill then be credited.VII. IV Tubing1. All IV tubing should be labeled when hung with date, time andnurse’s initials.2. Tubing should be changed as follows:i. Continuous peripheral IV tubing is to be changed every24 hours unless otherwise specified by facility.ii. Continuous central line tubing is changed every 24hours.iii. Intermittent IV Therapy via heparin or saline lock tubingis changed every 24 hours and the needle or needlelessconnector is changed before every dose administration.iv. IV piggyback or secondary tubing is changed every 24hours.v. All IV tubing and needles should be changedimmediately upon suspected contamination, or if notlabeled with a date and time hung.3. All tubing changes will be documented consistently.4. All tubing connections will be secured with a luer lockingsystem or line connections securing device.-5-

GUIDELINESVIII. Peripheral IV Catheters and Needles1. All peripheral venous catheters and needles will be changedevery 72 hours and PRN signs or symptoms of complications.A physician’s order is required to leave an IV in for longerthan 72 hours, except where the manufacturer of the devicehas provided FDA clearance for longer dwell times2. Manufacturer written recommendations will serve as theguideline for specific venous access device dwell times.3. Residents with limited access and long-term therapy shouldbe considered for a central venous access, deep peripheralaccess or midline access devices.4. Only radiopaque IV catheters should be used.5. Products should be inspected for integrity and sterility. Alldamaged products should be reported to the pharmacy andnot used on a resident.6. Discard all IV needles and stylets, uncut/unclipped, uncappedin a rigid one-way sharps container, which has a clearobservation panel.7. A new sterile IV catheter or needle is required for every IVinsertion attempted.8. All peripheral IVs will have an injection cap extension setattached to the catheter hub to maintain a closed system.The injection cap extension set will be changed with routineIV site changes.9. Transparent film dressings will be changed with every IV siterotation, if it becomes soiled or non-occlusive (non-adherent)to the skin.10. Transparent film dressings will be changed every 72 hours.-6-

GUIDELINES11. If a gauze dressing is used, and the site cannot be visualized,the dressings will be changed every 24 hours to permitassessment of the site for complications.12. All IV dressings should be labeled with date, time gauge,length of IV canula and nurse’s initials.I.Central Venous Devices1. All central lines will be luer lock capped or have a luer lockinfection cap extension set applied to maintain a closedsystem.2. Extension sets and/or injection caps will be changed twiceweekly with the dressing change and PRN leakage orsuspected contamination.3. A smooth Dravon clamp will be at the bedside of everyresident with a central venous catheter except Groshongcatheters and PICC lines.4. A transparent film dressing is the preferred type of centralline dressing for ease of site assessment. This transparentfilm dressing is changed weekly and PRN soiling,contamination and non-occlusiveness (non-adherent).5. A gauze dressing may be used for the first 24 hours after theinsertion of a central venous device. The gauze dressingshould be changed every 24 hours and PRN saturation ordislodgement.6. If a 2x2 gauze is used under the transparent dressing, thenthe dressing should be changed every 24 hours to permitassessment of the site.7. All dressings should be labeled with date, time and nurse’sinitials.8. Heparin flushes must be ordered by the physician and shouldinclude strength, amount and frequency of flushing.-7-

GUIDELINES9. Heparin flushes are intended to maintain patency by filling theIV device, to prevent blood coagulation.10. Recommended flushing guidelines:i.ii.iii.1-3 cc of 10 units/cc of Heparin Flush solution perlumen or multi-lumen catheters.Heparin Flush solution at a volume 1.5 times theinternal volume of the catheter/device.Implantable vascular access devices (Mediport, Port-acath, etc.) are accessed and flushed every month with5cc of Heparin Flush solution 10 units/cc. Accessedports are flushed and maintained using the standardflush protocol.11. A 5cc Normal Saline flush should be used to flush central lineIVs before and after medication administration.12. Finish with Heparin flush.13. A positive pressure flushing technique should be used.14. Acetone alcohol must not be used on or near the centralvenous catheter.J.Documentation and Monitoring1. The IV Medication Sheet is part of the medical record.2. All IV medications, solutions and flushes will be documentedon the IV Medication Sheet or facility specific form.3. Intake and Output records are maintained for all residentsreceiving hydration and electrolyte replacement. IV Intakerecords are appropriate when intermittent IV Piggyback insmall volumes is the single IV therapy.4. All IV procedures will be documented consistently on the IVMedication Sheet or in the progress notes. Areas to bedocumented should include:-8-

GUIDELINESi.ii.iii.IV insertion documentation: Catheter type, gauge andlength, insertion site, number of insertion attempts,type of dressing, type of flush used and amount,resident’s response, date, time and nurse’s signature.Routine shift monitoring documentation: IV siteappearance and location, signs and symptoms ofcomplications and interventions, resident’s response totherapy, date, time, and signature.Removal of IV device removed, location of deviceremoved, resident’s response, date, time andsignature.5. Documentation should be done at least every shift6. All documentation will include date, time and IV nurse’ssignature or initials.7. All residents receiving IV Therapy need a nursing care planreflecting the goals and outcomes of therapy.8. Routine charting in the progress notes should be doneaccording to facility, State and Federal regulations.K.IV Medication Administration Times1. Medication administration times may differ from the standardmedication pass time schedule.2. If an IV medication dose is off schedule by more than one (1)hour, the following actions should be taken:i.ii.iii.iv.v.Record the actual IV medication administration time inboth the IV Medication Sheet and Resident ProgressNotes; include the reason for variance inadministration time.Re-time IV medication dosing scheduleContinue with therapy, using new time scheduleNotify MDNotify Pharmacy-9-

GUIDELINESL.Emergency IV Supplies1. An emergency locked IV kit will be provided for the facility byM Chest Pharmacy.2. A backup infusion control device may be provided for thefacility.3. Emergency supplies are to be stored according to facilitypolicy.4. Use of the Emergency Kit is to be documented on theEmergency Kit Usage form and faxed to the pharmacy so thatthe correct patient’s account is charged. Items used from thekit and not charged to a resident will be charged to thefacility.5. The pharmacy will exchange opened emergency kits on aroutine basis. The nurse opening the IV Emergency kit isresponsible for notifying the pharmacy and completion of thePatient Charge Slip.- 10 -

PROTOCOLSA.IV Antibiotic1. Purpose: Antibiotic therapy is the administration ofmedication, specifically designed to destroy organismscausing infections. The intravenous route is used tomaintain a therapeutic blood level and produce an effect toeradicate or reduce infective agents.2. Guidelinesi.ii.iii.iv.Only FDA approved drugs will be administeredDrugs will be reconstituted per manufacture’srecommendations and guidelines.Antibiotics will be available and administered withinState guidelines.IV first dose recommendations:1. Resident has no known history of allergic reactionsto the ordered medication or related medications.2. Will be determined on a case-by-case basisa. The nurse receiving the antibiotic ordershould request PRN orders forallergic/anaphylactic reaction anddocument these orders3. Nursing Responsibilitiesi.ii.iii.iv.v.vi.vii.viii.Know the resident’s allergy profile.Notify the pharmacy of all resident allergies.Know facility’s policy and procedures for allergicreactions to drugs.Know signs and symptoms of a drug allergy response.Observe the resident closely during the first through thethird dose of a new antibiotic for signs and symptoms ofan adverse allergic reaction.Administer the medication on time and infuse asordered.Monitor the resident for a minimum of every 30 minutesduring antibiotic infusion.If the resident exhibits any signs of an allergic reactionor anaphylaxis: (loss of consciousness, shock, hives,sudden onset of pain)-1-

PROTOCOLS1.2.3.4.5.6.B.Stop IV agentEstablish/maintain airwayCall 911 and attending physicianMaintain a patent IVHave normal saline or lactated ringers availableRefer to Anaphylaxis/Allergic Reaction ProtocolIV Push1. Purpose: IV push medication administration is the directinjection of undiluted medication into a vein. IV pushes areused to: Administer a bolus dose of a drugintravenouslyAdminister a drug that cannot be diluted; i.e.LasixGive an emergency dose to provide animmediate drug effectAchieve immediate peak drug levels in thebloodstream2. Guidelinesi. All IV push medications must be administered by an IVqualified nurse, based upon facility specific jobdescriptions or individual State Board of NurseExaminer’s rules and regulations.ii. IV push medications may be injected directly into thevein, through an existing IV line, or through a heparinlock.iii. If using a pre-existing IV line:1. Use the closest injection port to the catheter2. Close the roller clamp on the tubing to preventback flow of medication3. Flush with normal saline 0.9% 1cc4. Give the IV push medication, using correct rate5. Flush with normal saline 0.9% 1cc using the samerate as the IVP medication6. Open the roller clamp and resume the infusion-2-

PROTOCOLSiv. Residents will be monitored closely throughout theentire administration time and IV push will bestopped immediately if any adverse reaction occurs.v. Complications of any medication administered IVmay include “speed shock” or anaphylaxis. Specificcomplications will relate to the individual drugadministered.vi. The qualified nurse, administering IV pushmedications is responsible for knowing:1.2.3.4.5.The indication for the drugUsual IV actions, adverse actions and side effectsRate of administrationDilution factors, if any, required by manufacturerMonitoring and assessment parameters for themedication.v. Categories of IV push drugs may include: diuretics,corticosteroids, dextrose, anti-emetics, narcotics andantihistamines.vi. IV push medication considerations should includeexpertise of staff and the type of monitoring required(i.e. cardiac monitor) in evaluating theappropriateness of administration in the long-termcare setting.-3-

PROTOCOLSIV Push DrugsInitial MonitoringParametersDrugRateLasixSlow over 1-2 min; Nofaster than 4mg/min insevere renalimpairmentBP initially, at 30 min.,60 min.Fluid/electrolyte status.Hearing (may causedeafness)(check for tinnitus)Steroids (Solu Cortef,Solu Medrol, Decadron)Slow over 1-2 min.BP initially, at 30 min.,60 min.50% Dextrose3 ml/min.Fluid status, local pain,blood sugar levelAnti-emeticsSlowly permanufacturer’sdirections.BP initially, Alleviation ofnausea.NarcoticsSlowly permanufacturer’sdirections.BP initially, LOC, resp.,alleviation of painAntihistaminesSlowly permanufacturer’sdirectionsAlleviation of symptoms,BP and resp.C.Anaphylaxis Allergic Reaction1. Purpose: To treat a life-threatening reaction to an antigen.2. Guidelinesi. Stop infusion of the drugii. Assess signs and symptoms including respiratorystatus rapidlyiii. Call 911 and physician immediatelyiv. Keep IV patent-4-

PROTOCOLSv. Be ready to start IV infusion of normal saline orlactated ringers and to administer epinephrine.vi. Monitor resident’s vital signs. If resident becomeshypotensive, elevate his legs and keep him supine.vii. If cardiopulmonary arrest occurs, initiate resuscitation(or in accordance with Advance Directives).3. Nursing Responsibilities and Interventionsi.ii.iii.iv.v.vi.Always check resident’s allergy history beforetreatmentBe cautious with residents who have many allergiesKnow the location and contents of the IV emergencysupply kit.Know your local emergency unit telephone numberand send second rescuer to call.Check vital signs frequently (every 10-15 minutes)until resident is transported. If resident remains atfacility assess vital signs every 15-30 minutes for thefirst four hours after onset of the reaction.Observe and record changes in respiratory orcardiovascular status for severe reactions, look foranother reaction 12-24 hours later.**Note: The resident is still at risk forbronchospasms, upper respiratory obstructions,tachycardia and hypotension for 24 hours afterreaction.4. Signs and Symptoms

J. Central Venous Catheters: Occlusion 10 1. Definition 2. Signs and Symptoms 3. Possible Causes 4. Nursing Actions 5. Prevention Measures K. Central Venous Catheters: Deep Vein Thrombosis 11 1. Definition 2. Signs and Symptoms 3. Possible Causes 4. Nursing Actions 5. Prevention Measures L. Central Venous Catheters: Local Infection 13 1 .