rest of the ati notes

Replacing IV solution

1. Verify and select correct IV solution bag and compare to the medication administration record (MAR) or physician orders.2. Introduce yourself, identify patient, and explain procedure.4. Remove outer plastic packaging and squeeze bag to test for leaks and expiration date. Assess for precipitates or cloudiness. Hang new IV solution on IV pole.5. Pause the EID or close the roller clamp on a gravity infusion set.6. Remove protective plastic cover from the new IV solution tubing port.7. Remove the old IV solution bag from the IV pole. Turn IV bag upside down, grasping the tubing port. With a twisting motion, carefully remove IV tubing spike from old IV solution bag.8. Using a gentle twisting motion, firmly insert the spike into the new IV bag.9. Fill the drip chamber by compressing it between your thumb and forefinger. Ensure the drip chamber is one-third to one-half full. Check IV tubing for air bubbles.10. Open clamp and regulate IV infusion rate via gravity, or press start on the EID as per physician orders.11. Label new IV solution bag as per agency policy. Time tape gravity IV solutions as per agency policy

Converting a saline lock to an IV infusion

1. Verify physician orders to convert IV infusion to a saline lock.2. Perform hand hygiene; collect supplies.3. Identify yourself; identify the patient using two identifiers and comparing the MAR to the patient's wristband; explain the procedure to the patient.5. Stop IV infusion with clamp or turn off EID. Apply clean gloves.6. Scrub the connection area between the hub and IV tubing for 15 seconds and let dry for 30 seconds.7. Disconnect primary tubing from the extension tubing; ensure the positive pressure cap remains on the extension tubing. Place a sterile cap on end of IV tubing if tubing will be reconnected for later infusion.8. Scrub the hub for 15 seconds and let dry for 30 seconds.9. Attach 10 ml syringe prefilled with 0.9% normal saline and flush saline lock to clear the positive pressure cap. Do not bottom out syringe.10. Remove syringe and discard.11. Clamp extension tubing.12. Wipe top of positive pressure cap with alcohol swab to remove fluid residue.13. Document procedure as per agency policy.

Replacing IV tubing

4. Prime new administration set using a new IV solution bag and new IV tubing.5. Hang new administration set (primed primary line and IV solution) on IV pole.6. Clamp old IV administration set. Remove IV tubing if on an EID.7. Clean the connection between the distal end of old IV tubing and the positive pressure cap. Scrub the area for 15 seconds and let it dry for 30 seconds.8. Remove the protective cap on the distal end of the new IV administration set.9. Carefully disconnect the old tubing from the positive pressure cap and insert the new IV tubing into the positive pressure cap attached to the extension tubing.10. Open the roller clamp on the new tubing to regulate flow rate, or insert new tubing into the EID and restart IV rate.11. Check IV site for patency, and signs and symptoms of phlebitis.

Administering large volume IV medication solutions

5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning).7. Complete necessary assessments as required. Assess IV site for patency.8. Prime the secondary IV line by "back filling" using the empty IV mini bag attached to the secondary IV line.9. Ensure piggyback mini bag is hung above the primary IV solution bag.10. Ensure clamp on secondary tubing is open.Checklist 64: Administering an Intermittent Intravenous Infusion Using Existing Secondary Line Disclaimer: Always review and follow your hospital policy regarding this specific skill. Safety Considerations: Review the advantages and disadvantages of IV medications. Always label the IV mini bag at the medication cart with the patient name, date, time, medication dose (e.g., Gravol 50 mg), concentration, and your initials. Once the medication is prepared, keep in a secure area. NEVER administer an IV medication through an IV line that is infusing blood, blood products, heparin IV, insulin IV, cytotoxic medications, or parenteral nutrition solutions. Central venous catheters (central lines, PICC lines) require special pre- and post-flushing procedures and specialized training. You will need a watch with a second hand to time the rate of administration. The use of IV infusion pumps requires specialized training to avoid programming errors. Refer to the resources at the end of this chapter for links to reviewing IV infusion devices. Steps Additional Information 1. Prepare one medication for one patient at the correct time as per agency policy. Always check the physician's order, PDTM, and MAR. Mathematical calculations may be required to determine the correct dose to prepare. Always apply the SEVEN rights of medication administration. Review the agency policy and the PDTM. If a medication is a stat, first-time, loading, or one-time dose, be extra diligent in reviewing the PDTM. Memory slips are a common source of error with medication administration. Complete all assessments and laboratory values that may influence the medication administration. If piggyback (secondary) medication is made up by the health care provider, ensure the medication label on the mini bag includes the patient name, date, time, medication added, dose and concentration, expiry time, and your initials. Some health agencies require a second independent check with high-alert medications. Always follow agency policy. 2. Bring medication and MAR to bedside. Create privacy if possible.Additional equipment required includes secondary tubing, a metal or plastic extension hanger, an alcohol swab, and a timer with a second hand. Creating privacy provides comfort to patient. 3. Compare the MAR printout with the patient's wristband, and use two patient identifiers (name and birth date), according to agency policy, to confirm patient ID.This ensures you have the correct patient and complies with agency standard for patient identification. Compare MAR with patient's wristband 4. Ask about allergies.This ensures allergy status is correct on the MAR and the patient's allergy band.5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning).Keeping patient informed of what is being administered helps decrease anxiety.6. Perform hand hygiene.Hand hygiene prevents the transmission of microorganisms. Hand hygiene with ABHR 7. Complete necessary assessments as required. Assess IV site for patency.IV medications may require assessment of vital signs and lab values prior to administration. IV site must be patent prior to use. 8. Prime the secondary IV line by "back filling" using the empty IV mini bag attached to the secondary IV line.Check expiration date on secondary IV tubing. Open the clamp on the secondary IV line and lower the mini bag below the primary IV line. This will cause IV solution from the primary IV bag to enter the old mini bag and clear out the secondary IV line. Allow approximately 25 ml of IV solution to enter the used mini bag. Lower secondary IV bag below primary and open clamp to flush out secondary IV line Once the secondary IV line is cleared, close the clamp on the secondary IV line, and ensure the drip chamber is 1/2 full. Remove the old mini bag from the secondary IV tubing and place on the bedside table. Carefully remove sterile blue cover on new medication bag, and insert the spike of the secondary IV tubing into the new IV bag, being careful to avoid accidental contamination. Insert spike into secondary IV bag Open clamp on the secondary IV tubing. Open clamp on secondary IV line 9. Ensure piggyback mini bag is hung above the primary IV solution bag.Position of the IV solutions influences the flow of the IV fluid into the patient. The setup is the same if the medication is given by gravity or through an IV infusion pump. Always follow manufacturer's directions for infusion pumps. Set up for secondary IV infusion 10. Ensure clamp on secondary tubing is open.This prevents the patient from missing a dose of medication. Open clamp on secondary IV tubing 11a. If using gravity infusion, use the roller clamp on the primary set to regulate the rate. The rate will be calculated for gtts/mins. 11b. If using an IV infusion pump, set the rate according to the PDTM. Most infusion pumps automatically restart the primary infusion at the previously established rate.12. Leave IV mini bag and tubing in place for future drug administration. Check agency policy to verify if this practice is acceptable.

Administering "piggyback" IV medications

Open the clamp on the secondary IV line and lower the mini bag below the primary IV line. This will cause IV solution from the primary IV bag to enter the old mini bag and clear out the secondary IV line. Allow approximately 25 ml of IV solution to enter the used mini bag.8. Prime the secondary IV line by "back filling" using the empty IV mini bag attached to the secondary IV line.9. Ensure piggyback mini bag is hung above the primary IV solution bag.10. Ensure clamp on secondary tubing is open.Checklist 64: Administering an Intermittent Intravenous Infusion Using Existing Secondary Line Disclaimer: Always review and follow your hospital policy regarding this specific skill. Safety Considerations: Review the advantages and disadvantages of IV medications. Always label the IV mini bag at the medication cart with the patient name, date, time, medication dose (e.g., Gravol 50 mg), concentration, and your initials. Once the medication is prepared, keep in a secure area. NEVER administer an IV medication through an IV line that is infusing blood, blood products, heparin IV, insulin IV, cytotoxic medications, or parenteral nutrition solutions. Central venous catheters (central lines, PICC lines) require special pre- and post-flushing procedures and specialized training. You will need a watch with a second hand to time the rate of administration. The use of IV infusion pumps requires specialized training to avoid programming errors. Refer to the resources at the end of this chapter for links to reviewing IV infusion devices. Steps Additional Information 1. Prepare one medication for one patient at the correct time as per agency policy. Always check the physician's order, PDTM, and MAR. Mathematical calculations may be required to determine the correct dose to prepare. Always apply the SEVEN rights of medication administration. Review the agency policy and the PDTM. If a medication is a stat, first-time, loading, or one-time dose, be extra diligent in reviewing the PDTM. Memory slips are a common source of error with medication administration. Complete all assessments and laboratory values that may influence the medication administration. If piggyback (secondary) medication is made up by the health care provider, ensure the medication label on the mini bag includes the patient name, date, time, medication added, dose and concentration, expiry time, and your initials. Some health agencies require a second independent check with high-alert medications. Always follow agency policy. 2. Bring medication and MAR to bedside. Create privacy if possible.Additional equipment required includes secondary tubing, a metal or plastic extension hanger, an alcohol swab, and a timer with a second hand. Creating privacy provides comfort to patient. 3. Compare the MAR printout with the patient's wristband, and use two patient identifiers (name and birth date), according to agency policy, to confirm patient ID.This ensures you have the correct patient and complies with agency standard for patient identification. Compare MAR with patient's wristband 4. Ask about allergies.This ensures allergy status is correct on the MAR and the patient's allergy band.5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning).Keeping patient informed of what is being administered helps decrease anxiety.6. Perform hand hygiene.Hand hygiene prevents the transmission of microorganisms. Hand hygiene with ABHR 7. Complete necessary assessments as required. Assess IV site for patency.IV medications may require assessment of vital signs and lab values prior to administration. IV site must be patent prior to use. 8. Prime the secondary IV line by "back filling" using the empty IV mini bag attached to the secondary IV line.Check expiration date on secondary IV tubing. Open the clamp on the secondary IV line and lower the mini bag below the primary IV line. This will cause IV solution from the primary IV bag to enter the old mini bag and clear out the secondary IV line. Allow approximately 25 ml of IV solution to enter the used mini bag. Lower secondary IV bag below primary and open clamp to flush out secondary IV line Once the secondary IV line is cleared, close the clamp on the secondary IV line, and ensure the drip chamber is 1/2 full. Remove the old mini bag from the secondary IV tubing and place on the bedside table. Carefully remove sterile blue cover on new medication bag, and insert the spike of the secondary IV tubing into the new IV bag, being careful to avoid accidental contamination. Insert spike into secondary IV bag Open clamp on the secondary IV tubing. Open clamp on secondary IV line 9. Ensure piggyback mini bag is hung above the primary IV solution bag.Position of the IV solutions influences the flow of the IV fluid into the patient. The setup is the same if the medication is given by gravity or through an IV infusion pump. Always follow manufacturer's directions for infusion pumps. Set up for secondary IV infusion 10. Ensure clamp on secondary tubing is open.This prevents the patient from missing a dose of medication. Open clamp on secondary IV tubing 11a. If using gravity infusion, use the roller clamp on the primary set to regulate the rate. The rate will be calculated for gtts/mins. 11b. If using an IV infusion pump, set the rate according to the PDTM. Most infusion pumps automatically restart the primary infusion at the previously established rate.12. Leave IV mini bag and tubing in place for future drug administration. Check agency policy to verify if this practice is acceptable.

PREPARING IV INJECTABLE MEDICATIONS

Open the medication box and pull out the medication vial. "Pop off" the plastic cap on the top of the vial. Remove an alcohol wipe from the package and scrub the top of the medication vial, with friction and intent, for 20 s. Use the clock to make sure that you have scrubbed for the appropriate amount of time. From the syringe drawer, obtain the smallest syringe that will accommodate the volume of solution to be aspirated from the medication vial. Open the syringe package using aseptic technique by peeling the paper packaging at the syringe tip end until you are able to grasp the syringe outer barrel. You may then drop the packaging onto the counter. Move the syringe between your dominant ring finger and middle finger, taking special care not to contaminate the syringe tip or the area of the plunger that extends into the barrel by touching them to any surface or fingers. Retrieve the needle package with your non-dominant hand. Open the needle package using aseptic technique by peeling the paper packaging at the needle hub end until you are able to grasp the outer cap. Take special care not to contaminate the needle hub by touching it to any surface or fingers. Drop the needle packaging onto the counter. Using aseptic technique, connect the needle to the syringe tip. If any of the connection points are contaminated, you must obtain new supplies and start over. Take the cap off of the needle and place it onto the counter, taking care not to contaminate the point of the needle. Secure the medication vial with your non-dominant hand and insert the needle into the soft, rubber portion of the vial. While holding the vial and the syringe together, invert them and bring them to eye-level. Take special care not to contaminate the syringe tip and the needle. Withdraw the appropriate amount of fluid from the vial by drawing back slowly on the syringe plunger until the "right" medication volume is obtained, making sure that the needle tip is below the solution level at all times. The volume to be withdrawn is calculated based upon medication dosage and the medication concentration in the vial. Assess the syringe for air bubbles and the appropriate volume. If air bubbles are present, gently tap the syringe with your finger or a pen to release the air bubbles and then eject the air. Adjust needle tip to below the level of the fluid and withdraw more fluid until the desired volume is reached. Withdraw the needle from the vial, taking care not to contaminate the needle tip. Set the vial down on the counter while holding the needle and syringe upright in the air. Engage the needle safety device using your dominant thumb. Set the syringe with the needle and the medication down on the counter. Using tape or a pre-printed medication label (if available), write the medication name and dosage amount on the label and place it on the syringe. Some institutions may require more information, depending upon their medication labeling policies. Dispose of any wrappers or packages in the garbage. If the medication vial contains any unused medications, dispose of the medication fluid according to institutional policies. Dispose of the empty medication vial in the sharps container, according to institutional policies.

Preparing IV tubing

Perform hand hygiene. ... Check order to verify solution, rate, and frequency. ... Gather supplies. ... Remove IV solution from outer packaging and gently squeeze. ... Remove primary IV tubing from outer packaging. ... Move the roller clamp about 3 cm below the drip chamber and close the clamp. 7. Remove the protective cover on the IV solution port and keep sterile. Remove the protective cover on the IV tubing spike.8. Without contaminating the solution port, carefully insert the IV tubing spike into the port, gently pushing and twisting.9. Hang bag on IV pole.10. Fill the drip chamber one-third to one-half full by gently squeezing the chamber. Remove protective cover on the end of the tubing and keep sterile.11. With distal end of tubing over a basin or sink, slowly open roller clamp to prime the IV tubing. Invert backcheck valve and ports as the fluid passes through the tubing. Tap gently to remove air and to fill with fluid.12. Once IV tubing is primed, check the entire length of tubing to ensure no air bubbles are present.13. Close roller clamp. Cover end with sterile dead-ender or sterile protective cover. Hang tubing on IV pole to prevent from touching the ground.14. Label tubing and IV bag with date, time, and initials.

§ Questionable reconstitution

Problem: Reconstituting a medication results in cloudiness, discoloration, or precipitation of the diluent. Possible cause: The wrong diluent was selected for reconstitution. It is also possible that the visible change is appropriate for that medication. Intervention: Never inject a questionable IV medication. If the medication has been reconstituted improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper diluent for a medication. Review the package insert or consult a pharmacist to verify the expected appearance of the reconstituted medication.

§ Drug/fluid incompatibility

Problem: The IV fluid or solution appears cloudy or has visible precipitate after medication has been added. Possible cause: Incompatibility of the drug to the solution or the drug-to-drug mix Intervention: Never administer questionable IV medications or compounded solutions. If the medication has been mixed improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper solution for piggyback and large-volume medication infusions. Always check and cross-reference medication compatibilities. If your agency's policy permits multiple uses of one secondary line, make sure the current and previous solutions and medications are compatible. Otherwise, set up separate secondary lines and flush between medications.

Interrupted IV infusion

Problem: The line or pump occlusion alarm sounds. Possible causes: The IV line is not patent, the IV is in a location that occludes when the patient changes position, the tubing is kinked, the IV loop or line is clamped, the roller clamp is in the off position, or the pump was loaded improperly. Intervention: Begin at the patient, correcting each problem: Check for IV patency, tubing patency, and position; open all occluding clamps; and check the infusion pump settings and setup. If the location of the IV causes flow occlusion when the patient moves, consider restarting the IV line at another site.

Extravasation

Problem: The tissue around the IV site is pale or discolored and cool to the touch. Possible cause: Inadvertent administration of an irritant solution or medication into the surrounding tissue. Vasoconstrictors, calcium, and chemotherapy drugs are examples of drugs known to cause tissue necrosis with extravasation. The area of tissue damage varies with the concentration of the medication, the quantity of extravasated fluid, and the duration of the extravasation process. Assessment: The pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation and could ultimately become necrosed. Blistering and tissue sloughing may not appear for a few days. Intervention: Extravasation is an emergent situation, as it can cause serious tissue necrosis. Stop the IV infusion and discontinue the IV line. Consult your agency's policy or a pharmacist for specific care of the extravasated tissue or use a medication manual to determine the appropriate care (for example, injection of phentolamine within the extravasation border). Follow your agency's policy for proper documentation. Establish new IV access in the opposite extremity if IV therapy must continue. Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. If central access is available, infuse solutions and medications known to cause tissue necrosis via central venous access. Educate the patient about activities and signs and symptoms of infiltration.

Infiltration

Problem: The tissue surrounding the IV insertion site is swollen, pale, and cool to the touch. Possible cause: Unintentional administration of solution or medication into the surrounding tissue Assessment: Leaking from the IV site with slowing or occlusion of fluid flow. The patient reports blanching, burning, tenderness, discomfort, and coolness in the area surrounding the IV insertion site. May also experience fluid leaking from the puncture site. Intervention: Stop the IV infusion and discontinue the IV line. Elevate the extremity. Warm or cold compresses may be used according to the solution infiltrated and the facility policy. Encourage active range of motion, and follow your agency's policy for site care and documentation of infiltrated IVs. Establish new IV access proximal to the original site or in the opposite extremity if IV therapy must continue. Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. Educate the patient about activities and signs and symptoms of infiltration.

§ Medication error potential

Problem: The wrong dose was prepared. Intervention: Discard the prepared dose and prepare a new dose correctly. Check your agency's policy for waste procedures and documentation and for crediting the patient's pharmacy account. Prevention: Adhering to the six rights of medication administration is essential for preventing medication errors.

§ Precipitation during administration

Problem: While administering an IV bolus (push) medication, cloudiness or precipitation forms in the tubing. Possible cause: The line was not flushed properly with normal saline prior to injecting an incompatible medication. Intervention: Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. Follow your agency's protocol for wasting and crediting medication and prepare another dose to administer. Observe the site for signs of venous irritation. Prevention: Follow proper technique for flushing the IV line with normal saline before and after injecting IV medications.

§ Midline catheters are usually used for therapies lasting 1 to 4 weeks. They range from 3 to 8 inches long and may be single or double lumen. They are inserted via the veins in the upper arm, preferably the basilica vein due to its large diameter and straight path. The catheter tip rests no further into the venous network than the ancillary vein. Only nurses with additional education are qualified to insert midline catheters. Those patients that can benefit from midline catheters include:

Those with limited peripheral veins Altered peripheral skin integrity Longer term IV antibiotics Heparin infusions for DVT Repeated steroid infusions

§ Questionable solutions

problem: The IV fluid in the bag or a pre-mixed medication solution appears cloudy or discolored or has visible precipitate. Possible cause: The solution may be expired or contaminated or might have been stored improperly (exposed to temperature extremes). Intervention: Never administer questionable IV fluids. Discard or return questionable or expired solutions according to your agency's policy. Prevention: Review the package insert or consult a pharmacist to verify the expected appearance of the medication. Always store IV fluids and pre-mixed medication solutions according to the manufacturer's or the pharmacy's guidelines. Remove from stock and dispose of any IV bags that have expired or are not in their original, sealed packaging.

§ Pharmacogenetic research offers new insights about drug interactions and the importance of individualized drug therapy. Because nurses monitor the effects of administered medications, it is important to have a basic understanding of gene-based drug metabolism.

§ Cytochrome P450 (CYP450) enzymes are essential for the metabolism of many medications. More than 50 drug-metabolizing isoenzymes have been found in humans; so far, 10 have been associated with functional polymorphism, a genetic variation in one or more specific isoenzymes. Unlike genetic defects, polymorphisms occur in more than 1% of humans, and CYP450 polymorphism is thought to be present in as many as 20% of specific populations. CYP polymorphism can make a patient more susceptible to the adverse effects of a medication or reduce a medication's therapeutic action. Some drugs, hormones, and chemicals found in foods can inhibit or induce the function of CYP450 enzymes, resulting in significant drug interactions.

§ Inflammation and clot formation

§ Problem: The IV site is swollen, red, and warm. § Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions § Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.) § Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue. § Prevention: Make sure the medication's concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency's policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.