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Canterbury and the West Coast

Level 1 IV Therapy

1. Identify the process for Nursing and Midwifery Staff to attain Canterbury and West Coast Level 1 IV Certification

2. Show awareness of the key responsibilities of administration of IV therapy3. Identify the eight key complications of IV therapy administration4. Identify the timeframe that IV equipment can be safely utilised5. Describe how risk is minimised in the administration of IV therapy6. Identify the actions to take following an anaphylaxic reaction7. Describe how risk is minimised in the administration of blood and blood

products8. Describe the process of blood product administration9. Identify actions to take when an adverse blood reaction occurs

Your Logo

Objectives

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

Policies

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

Handouts

1 1

Volume 12

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

Assessment

The Volume 12 Fluid and medication manual can be located on the CDHB internet page

3322

http://www.ivnnz.co.nz

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

1. Attend Mandatory IV Lecture2. Complete all theory and practical sections of the

Canterbury and West Coast IV Assessment3. Understand the action and reaction of the

medication that you are administering4. You agree to accept the responsibility for the

administration of the prescribed intravenous therapy.

To gain your Canterbury/West Coast Level 1 IV Certificate

Assessments– Clinical calculations Assessment (100%)– Theory Assessment/s based on Volume 12 (85%)– IV Practical Checklist (100%)

It is expected that all Registered Nurses, Midwives and new EN Scope attain their level 1 IV Competency (unless exempted by workplace eg. Mental Health)

No recertification is required, instead regular clinical audits occur. Recertification is only required if away from the

organisation for over 12 Months

To gain your Canterbury/West Coast Level 1 IV Competency Level 2 IV allows a staff member to care for

and access the following IV devices – PICC , Hickman and Central Venous lines. Also an additional portacath Competency can be attained if required for your area

Venepuncture, allows a staff member to obtain blood from a peripheral blood vessel.

The Peripheral IV Cannulation competency allows the staff member to place a peripheral cannula in a blood vessel

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

IV Peripheral Cannulation

Venepuncture

Level 2 IV Competency

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

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TransportabilityIV Competencies are recognised by the following

Nurse Maude

Southern Cross Hospital

St Georges Hospital

Oxford Clinic

Pegasus Group and the Rural Canterbury PHO

All CDHB and WCDHB Hospitals

Key Policies

Double Independent Checking

Double Independent Checking is the key step in the medication safety process• Both staff interpret the prescription independently

• Both staff perform calculations independently

• Both Staff perform the patient identification checks at the patients bedside

• Both staff are present through all stages of preparation, drawing up and administration of the medication.

CDHB (2012) Fluid and Medication Checking Procedure

Role of the Double Independent Checker

• The Double Independent Checker is just as legally accountable as the person administering the drug

• They must be present for ALL stages:

� Preparation and drawing up

� Administration

� Bedside checks

� Documentation

Includes TWO staff to the bedside

Medications that require Double Independent Checking

� Any Controlled Drug/Infusion� Any Blood or Blood Products� Warfarin and Oral Cytotoxic’sAND Any fluid/medication administered by the below routes

� Intra muscular

� Intra dermal� Subcutaneous

� Intravenous� Intrapleural� Intrathecal

� Epidural routePlease Note: Exceptions only where local policy stipulates - e.g. rural, specialist mental health. For Child Health and Neonatal Policy please refer to Volume Q

Need to Gain the following competencies1. Independent Medication Administration

Competency. This will enable an enrolled Nurse to independently administer oral medications, and undertake independent double checking responsibilities. This is attained by completing the clinical calculations and theory components of the level 1 IV therapy competency.

Transitioned Enrolled Nurses

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2. Level 1 IV Competency (EN Scope)Once a transitioned Enrolled Nurse has completed their Level 1 IV Competency they can;

– Enrolled Nurses can double independent check with another Enrolled Nurse who has also completed their independent medication administration competency when their designated registered health professional is not available

– May Administer IV Saline Flushes as per local policy– May Administer IV fluids (without additives or Potassium)– May Administer IV or SC Premixed bags i.e. N/Saline 0.9% or

Dextrose 4% in N/saline 0.18% premixed bags which are running 8-12 hourly (Adults only)

Transitioned Enrolled Nurses

� Must check all Medications and Fluids with their designated Registered Nurse

� May clamp tubing or turn off a pump if an infusion has completed

� Monitor whether an IV infusion is running to time� Perform hourly patient checks when an IV infusion

is in progress� Maintain the patient fluid balance record

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

• Can be initiated by Registered Nurses and Midwives• For ‘Urgent’ clinical situations when the prescriber is

unavailable to come to the clinical area

• Recorded in Red on the prescription chart

• Repeated by prescriber to second checker (RN/RM/EN but not student nurse)

• One verbal order for a class A or B drug is acceptable if a pre-existing order for that drug is present

• Exceptions e.g epidural boluses, blood, paediatrics, significant renal disease or abortion inducing medications

Verbal Telephone Orders

� The verbal order is given by the Medical Officer� The verbal order is repeated to the medical officer by the nurse

receiving the order and also provides a running total of the amount of drug the patient has already received

� The Medication is then drawn up by the nurse who received the order

� The Verbal order is repeated by the nurse as the medication is handed to the Medical Officer, and the ampoule is second checked by the Medical Officer.

� The order is documented, and then signed by the Medical Officer at the conclusion of the Emergency Situation.

Verbal Orders in an Emergency Situation

1. Hypersensivity2. Infiltration3. Extravasation4. Phlebitis5. Infection6. Fluid Overload7. Air Embolism8. Anaphylaxis

1. Hypersensivity2. Infiltration3. Extravasation4. Phlebitis5. Infection6. Fluid Overload7. Air Embolism8. Anaphylaxis

Complications of IV Therapy

Nursing Made Incredibly Easy! (2008) I.V. Essentials: Complications of peripheral I.V. therapy, 6(1). pp 14-17Intravenous Infusions and Related Tasks [retrieved 23/11/11 from

http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-08_Intravenous_Infusions.html

Complications of IV Therapy

• Hypersensitivity/Allergy

• Infiltration - Infiltration occurs when I.V. fluid leaks into surrounding tissue

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Complications of IV Therapy

• Extravasation - the leaking of vesicant drugs into surrounding tissue causes tissue necrosis

• Phlebitis - Inflammation of a vein

Complications of IV Therapy

• Infection.

• Fluid Overload

• Air Embolism

• Any medication may potentially trigger anaphylaxis. The most common to do so include antibiotics, aspirin, ibuprofen, and other analgesics

Anaphylaxis

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

Anaphylaxis and Other Drug Reactions

Mild Dizziness, tingling, flushing/warmth, puritis

Moderate Flushing, urticaria, nasal congestion, sneezing,

lacrimation, angio-oedema, erythema

Severe Hoarseness, nausea, vomiting, laryngeal

oedema, dyspnoea, abdominal pain/cramps,

substernal pressure

Life

Threatening

Bronchospasm, stridor, syncope, hypotension,

dysrythmias, coma, confusion

Anaphylaxis Vs Vasovagal

More likely to be tachycardic More likely to be bradycardic

More likely to be hypotensive More likely to be normotensive

Less likely to be pale or sweaty More likely to be pale and to sweat

More likely to have puritis Never have puritis

May have airway obstruction Never have airway obstruction

May have uticaria Never have urticatia

Loss of consciousness usually not

immediate

Loss of consciousness more likely to be

immediate

Less likely to feel better when lying down Often feel better when lying down

Always follows administration of drug Sometimes follow painful intervention

Less likely to have tonic-clonic jerks if

unconscious

More likely to have a few topic-clonic jerks

after loss of consciousness

•• AA--BB--CC– High-flow oxygen.

– Lie patient flat and elevate legs.

• ADRENALINE– 0.5 ml of 1:1000 IM (0.5 mg). Repeat every five minutes if needed.

• Antihistamines: promethazine 25-50 mg IM (preferred) or via slow IV push; or cetirizine or loratadine both 20 mg PO.

• Hydrocortisone 200 mg IV (onset of action 4-6 hours).

• Intravenous fluids - normal saline to maintain blood pressure.

• Nebulised salbutamol 5 mg (bronchospasm).

• Nebulised adrenaline 2 ml of 1:1000 (2 mg) diluted to 4 ml in normal saline (stridor).

• IV adrenaline is indicated if the situation is life threatening with circulatory collapse, and/or the patient is unresponsive to the above initial treatment. Cardiovascular monitoring must be available. Begin with 0.5-1 ml of 1:10,000 (0.05 mg to 0.1 mg) and increase dose incrementally as required. Very rarely up to 1 mg (10 ml of 1:10,000) may be required every five minutes.

Anaphylaxis: Immediate Management

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

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Infection Prevention and Control

• Hand hygiene – ‘The 5 Moments for Hand Hygiene’

• Standard Precautions– Use of non-sterile gloves for Health Care Worker protection

when potential for blood and body fluid exposure – Other Personal Protective Equipment e.g. mask, apron when

necessary– Sharps safety practices

• Aseptic non-touch technique (ANTT)– Asepsis for all invasive procedures

Key Infection Prevention measures

Replacement timeframes

IV Lines – 72 HoursBut 24 hourly for Blood/TPN/ and certain Medications

IV Cannula –72 HoursChecked at the start of the shift and at least every eight hours when not in use

Intermittent Infusion – Single Use Only then discard

Blood Filters – 8 Hours or 2-4 units of blood

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

Green IV Line Stickers

Aseptic Non-Touch Technique

�Always use aseptic non touch technique (ANTT)

�Identify key parts of the equipment you are using

�Do not contaminate these key parts

�Always use luer lock syringes

�Always use blunt non coring needle to access plastic polyamps, drug bottles and when transferring drugs to IV bags, and filter needles when drawing up from glass ampoules

Phlebitis Score

Visual Phlebitis Score

0 No Symptoms Observe Cannula

1 Erythraemia at insertion site,

with or without pain

Observe Cannula

2 All the above plus oedema Resite Cannula

3 All the above, plus streak

formation/Palpable Cord

Resite Cannula – Consider

Treatment

4 All the above, plus palpable

venous cord > 1 inch (2.54cm)

and discharge

Resite Cannula – Consider

Treatment

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Sharps Safety Equipment – Single Use Only

Blood Transfusions How Precious?

WHOLE BLOOD

Red Cells $253Cryoprecipitate

$365

FFP $195

Platelets $755

Albumin 4% & 20% $96

Immunoglobulin $156

Prothrombinex $266 Intragam P $1058

G&S $45

• To correct loss:

- bleeding, destruction, reduced production

- plasma - burns

• To increase Haemaglobin

• To correct clotting deficits – induced by disease processes or medications

• Neonatal exchange transfusion

• To boost the immune system

Why do we give transfusions? Key risks of receiving a blood transfusion

• HIV – Less than 1 in a million.

• Hepatitis C – Less than 1 in a million

• Hepatitis B – one in 100,000.

• Bacterial Infections – less than 1 in a

100,000.

• Patient given blood that does not match.

STAFF ERROR

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Blood products are prescribed on the Fluid Prescription form:

– Number of units

– Rate of transfusion

– Any pre med

– Any diuretic required

– Blood warmer

– Irradiated product

Medical staff must complete the Blood Bank request form

and not the usual Laboratory form

How are blood products prescribed

• Discuss with the patient and explain the procedure

• Obtain Baseline TPR,SpO2, and BP

• Record on normal observation chart.

• Check IV device – is it patent?

• Check consent & prescription

• Then…Send blood request form to blood bank, or go

and collect. A Registered Nurse or Midwife needs to

sign as the requester

Before getting the blood product

To collect the blood, you can use the NZ Blood Service Blood Bank which is on the lower ground floor of the Parkside block. As the blood is dispensed by laboratory scientists it can be obtained/delivered by

– Orderlies/Hospital Aides

– Nursing and Midwifery Staff– Sending the request via the Lamson Tube

System (delivered this way as well)

Blood Collection Points – Christchurch Hospital

As there is no Blood Service onsite, blood is

delivered from the NZBS at Christchurch

Hospital via taxi, ambulance or shuttle. Once it

arrives it is put into the blood fridge in your

location, where it can be collected.

Blood Collection Points – Other Hospitals

Blood Fridge TPMH

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Two Nurses/Midwives must check blood details & patient details at the patients side.

–The Requester must be CDHB IV certified, EN’s must have their level 1 IV Certification to second check blood products.

Check the appearance of unit of blood for

– The presence of clots, clumps or abnormal cloudiness

You must check – The patients hospital armband for clarification of

patient identification against the Prescription chart and the blood

request form which is returned with unit of blood.

At the Bedside

• Always uses a 20 micron filter• Change the filter after every 2 bags of blood or 8 hourly –

whichever comes first• Only one unit of blood is administered at a time.• Commence the transfusion within 30 minutes of issuing, if you

suspect delay, return the blood to Blood Bank/Blood fridge immediately

• Complete the transfusion within 4 hours• Discard tubing and bag, place sticker on the back of the blood

request form and then document the date and time completed

NEVER PUT BLOOD IN A WARD FRIDGE

When transfusing

Blood must NOT

be mixed with

any other DRUG

or SOLUTION

other than

Normal Saline.

You can’t mix Blood !

If it is Fresh, it

needs a Filter

If it comes in a

bottle – no need

to use filter

Filter ? Observations during the transfusion

Baseline

15 minsfrom baseline

30 minsfrom baseline

Hourly until the infusion is completed

Final set of obsat the conclusion of the transfusion

Remain with patient for the first full 15 minutes

Start again for each new unit

A. Check the blood bag labels and patient ID to ensure the details match

B. Slow transfusionC. Consider giving an

antipyretic for pyrexia and antihistamine for urticaria

D. Continue transfusion at a slower rate with increased monitoring

If symptoms increase treat as a moderate reaction.

Action !

First febrile reaction:Body core temperature has increased more than one degree from their baseline. •Stable haemodynamicly•No respiratory distress•No other symptoms

Occasional urticarial spots with no other symptoms

Mild Reaction ?

A. Stop the transfusion immediately and review

B. Check the blood bag details against patient ID to ensure it is the correct blood product.

C. Disconnect blood & IV set (keep don’t discard) This will be sent to the blood bank for testing

D. Flush cannula to keep patent.E. Call for medical assistance

Follow NZBS transfusion protocol management guidelines for

Adverse Transfusion Reactions

Action !Moderate or Severe Reaction ?

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USED TO FILL FLUID VOLUME AND/OR CARRY OXYGEN

1. Oxygen therapeutics – mimic O2 carrying capacity

- hemopure, Oxygent, PolyHeme

2. Volume Expanders

- Ringers, NS, D5W, Haemacel, Gelofusin

• Allows for all blood types, no need to cross match

• Decreased risk of infection

• Store at room temperature

• Store for longer

Blood Substitutes Questions

THANK YOU!Canterbury District Health Board (2009) Management Guidelines for Common medical Conditions (13th

Edition), Christchurch, New Zealand: CDHB

Harrison's principles of internal medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005. Hypovolemia

Harrison's manual of medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005. Hypo/Hypernatremia

Martin, S. (2003) Intravenous Therapy, Business Nriefing: Long term health care Strategies 2003, retrieved 23/11/11 from http://www.touchbriefings.com/pdf/14/ACF7977.PDF

Nursing Made Incredibly Easy! (2008) I.V. Essentials: Complications of peripheral I.V. therapy, 6(1). pp 14-17

Brookside Associates (2008) Intravenous Infusions and Related Tasks: Lesson 1: Initiate an Intravenous Infusion and Manage a Patient With an Intravenous Infusion, retrieved 23/11/11 from http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-08_Intravenous_Infusions.html

Barts and the London Queen Mary’s School of Medicine & Dentistry (2005) Prescribing Skills - Modules for self directed learning, retrieved 10/12/12 from http://www.smd.qmul.ac.uk/prescribeskills/

References

New Zealand Blood Service (2008) Transfusion Medicine Handbook , retrieved 10/12/12 from http://www.nzblood.co.nz/Clinical-information/Transfusion-medicine/Transfusion%20medicine%20handbook

Infusion Nurses Society (2010) Infusion Nursing (Third Edition). USA: Saunders

Popovsky, M.A. (2009) Transfusion – associated circulatory overload: the plot thickens. Transfusion, Vol49. pp2-3

References