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Managing complications in ivt


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This lecture will help Intravenous Therapy Nurse Preceptors to get started.

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Managing complications in ivt

  2. 2. History of IV Therapy in the Philippines
  3. 3. September 1993– The PRC. Board of Nursing called for a conference. There was a conscientious discussion on Nursing Practice, Article V. Section 27 especially on I.V. Injection.
  4. 4. The Board of Nursing which was then chaired by Dr. Aurora Yapchiongco challenged the ANSAP. October 1993 – A final draft of standards on I.V. Therapy was submitted to PRC Board of Nursing by the Committee on Standard before the PNA Convention in Bacolod City.
  5. 5. October 1993 – Training for Trainers for ANSAP Board Members and Advisers. February 4, 1994 – PRC-BON Resolution No. 08 June 9-11, 1994 – Training for Trainers at Cagayan de Oro City.
  6. 6.  May 17, 1995 – Protocol Governing Special Training on the Administration of IV Injections for RNs adopted ANSAP's IV Nursing Standards of Practice.  June 13, 1995 – Department Circular No. 100.S.1995 was disseminated by DOH.
  7. 7. 2002 – Special Committee by ANSAP in collaboration with PRC- BON was founded. RA 9173 – Philippine Nursing Law of 2002. August 25, 2006 – Nursing Standards on Intravenous Practice 7th edition was released.
  8. 8. THE COMMITTEE ON NURSING STANDARDS ON INTRAVENOUS THERAPY Ma. Linda G. Buhat, RN, Ed.D. Jovita R. Pilar, RN, MBA, DPA Sr. Estrella L. Crisologo, SSpS Perla B. Sanchez, RN, Ph.D., FPCHA Leonila A. Faire, RN, MAN
  9. 9. PHILOSOPHY OF ANSAP Envisions itself to be a cohesive, pro- active, professional Association, committed to excellence in nursing. Believes that safe and quality nursing care to patients is the primary responsibility of nurses.
  10. 10. Believes that those who practice IV therapy nursing are only those registered nurses who are adequately trained and have completed the IV Therapy Training Program for Nurses as prescribed by ANSAP.
  11. 11. DEFINITION OF IV THERAPY Intravenous (IV) Therapy – insertion of a needle into a vein, based on the physician's written prescription. The needle is attached to a sterile tubing and a fluid container to provide medication and fluids.
  12. 12. OBJECTIVES OF THE IV THERAPY TRAINING PROGRAM  Gain knowledge on the history of IV Therapy in the Philippines.  Define the role and responsibilities, and the ethico-legal implications of IV therapy within the scope of nursing practice as stated in the Philippine Nursing Law.
  13. 13.  Identify the nursing accountability in drug administration and blood components transfusion.  Advocate patients and family rights.  Identify the different risk factors and complications associated with IV therapy and recognize the specific interventions/nursing management.
  14. 14.  Identify the importance of patient and family education and implement the nursing process in the practice of IV therapy as reflected in the nurses’ documentation.
  16. 16. SCOPE OF PRACTICE ROLE DEFINITION The IV nurses are registered nurses committed to ensure the safety of all patients receiving IV Therapy.
  17. 17. DESCRIPTION OF PRACTICE ETHICO-LEGAL IMPLICATIONS: ANSAP, Inc. upholds quality nursing practice and is going to continue with the IV Therapy Training for the following reasons:
  18. 18. a. Nursing curriculum does not provide in-depth training in parenteral IV drug administration.
  19. 19. a.1. An in-depth IV Training maybe included in the BSN curriculum but without actual IV insertion to patients. a.2. ANSAP believes that parenteral IV drug administration is an invasive procedure.
  20. 20. b. The Nurse Administrator has the command responsibility for the whole nursing practice in the Health Care Facility.
  21. 21. c. Globally, the IV Therapy certification is a mandatory requirement for the nurse practitioner
  22. 22. d. IV Therapy Training is voluntary; only those nurses who are adequately trained and have completed the training requirements in the IV Therapy Program for Nurses as prescribed by ANSAP will be issued an IV Certificate of Training and the IV Therapy card of ANSAP
  23. 23. TRENDS IN IV THERAPY  81% - 85% patients in the hospital receive some form of IV therapy  More nursing time is spent to IV therapy  Multi-disciplinary health care setting
  24. 24. WHY DO WE NEED TO BE UPDATED REGARDING IV THERAPY?  More medications are being administered intravenously now than before.  Nurses are assuming greater responsibilities related to IV medication administration.
  25. 25.  Many technical improvements have been made in equipment, and innovative and time-saving measures have been developed to increase the efficacy of the therapy.
  26. 26. MODES OF ADMINISTRATION  Continuous I.V. infusion  Intermittent Infusion  Direct I.V. infusion or I.V. push directly into the vein through an existing I.V. line use of specialized device such as PCA
  27. 27. INDICATIONS  Restore and maintain body fluids  For drug administration like chemotherapy  For the administration of parenteral nutrition  To provide an access in the administration of dye in some diagnostic procedures  To monitor the hymodynamic status of critically ill clients
  28. 28.  I.V. Therapy is practiced in all health care settings  I.V administration includes a variety of skills e.g. starting the infusion, assessing the patient during the therapy, knowing the advantages/ disadvantages of different delivery system, drug interaction/adverse effects and many more.  Contemporary nursing practice could not exist without I.V. therapy.  I.V. therapy, should be treated as a specialty risk area!
  29. 29. DEVICE AND EQUIPMENT The selection of device or equipment is basically dependent on: Indication of I.V therapy Clinical status of the client Duration of treatment Type of solution / drugs to be administered Condition of the veins Patient’s activity level
  30. 30. As a general rule the shortest and smallest gauge that can satisfy the indication of therapy should be used Technology should enhance quality care not withstanding the cost Single use devices should never be reused
  31. 31. VASCULAR ACCESS DEVICES 1. Peripheral Venous Access Devices a. Over-the-needle catheter b. Winged steel needle set 2. Central Venous Catheters a. Non tunneled catheters b. Tunneled catheters c. Peripherally inserted central catheters d. Implanted vascular access ports
  32. 32. PERIPHERAL VAD 1. Over-the-needle catheter – long- term therapy for the active or agitated patient 2. Winged steel needle set – short- term therapy for cooperative adult patient. Used for patients with fragile and sclerotic veins.
  33. 33. OVER-THE-NEEDLE CATHETER  Advantages  More comfortable for the patient.  Radiopaque thread for easy location.  Safety needles prevents accidental needle sticks.  Activity restricting device is rarely required.  Disadvantages  Difficult to insert.  Extra care is requires to ensure that needle and catheter are inserted into the vein.
  34. 34. WINGED STEEL NEEDLE SET  Advantages  Easiest device to insert.  Ideal for non- irritating IV push drugs.  Available with a catheter that can be left in place.  Disadvantages  Can easily cause infiltration.
  35. 35. NEEDLE SELECTION Recommended Gauges: 1. Gauge 16-18 – Trauma 2. Gauge 18-20 – Infusion of hypertonic solutions; Blood administration 3. Gauge 22-24 – Pediatric patients 4. Gauge 22 – Patients with fragile veins
  36. 36. INFUSION PUMPS Features:  Functions based on the programmed delivery.  The patient lines can be kept to a minimum.  The right drug and the right dose will be infused.
  37. 37. - Proactive Planning for all surgical patients • Intravenous (IV) Patient Controlled Analgesia with systemic opioids. • Patient Controlled Epidural Analgesia with opioids or opioid/local anesthesia mixtures (or intrathecal opioids) •Peripheral Nerve Blocks including (but not limited to) intercostals nerve blocks, celiac plexus nerve block,etc. with local anesthetic and steroid PATIENT- CONTROLLED ANALGESIA
  38. 38. NEEDLELESS SYSTEM Feature:  Can be used for all forms of IV therapy.  Completely closed system.  Reduces the risk of air embolisms and backflow.
  40. 40. PATIENTS WITH SPECIAL CONSIDERATIONS: 1. Pediatric Patients 2. Elderly Patients 3. Obese Patients 4. Patients undergoing Chemotherapy 5. Patients in Shock
  41. 41. PEDIATRIC PATIENTS  Best sites includes the hands, feet, antecubital fossa, and scalp because it has an abundant supply of veins.  Use topical or transdermal anesthetic at least 30 minutes to 1 hour before insertion.  Use mummy restraints.  Engage mother to keep patient calm.
  42. 42. ELDERLY PATIENTS  Venous distension may take a few moments longer due to slower venous return.  Skin elasticity is lost making it more difficult to stabilize the veins.  Veins are more fragile.  Skin preparation materials must be at room temperature.  Phlebitis may develop without pain due to decreased sensitivity of nerve endings.
  43. 43. OBESE PATIENTS  Has excessive adipose tissues.  Create a visual image of the venous anatomy.  Select a longer catheter.
  44. 44. PATIENTS UNDERGOING CHEMOTHERAPY  Veins may be hard and sclerosed due to frequent drug therapy.  Select unused veins.  Maintain strict asepsis.  Know each drug’s potential for damaging tissue. Chemotherapeutic drugs are classified as vesicants, irritants or nonvesicants.
  45. 45. PATIENTS IN SHOCK  Create a visual image of the venous anatomy.  Use larger veins and secure adequately.  Do cut-down method as the last resort.
  47. 47. RISKS 1. Needlestick injury 2. Infectious organism exposure
  48. 48. NEEDLESTICK INJURY An AIDS patient became agitated and tried to remove the intravenous catheters. Hospital staff struggled to restrain the patient. During the struggle, an IV infusion line was pulled, exposing the connector needle. A nurse recovered the connector needle at the end of the IV line and attempted to reinsert it. The patient kicked her arm, pushing the needle into the hand of the second nurse. Three months later, the nurse who sustained the needlestick injury tested positive for HIV1.
  49. 49. PREVENTION:  Avoid the use of needles where safe and effective alternatives are available.  Avoid recapping needles.  Report all needlestick and other sharps related injuries to ensure that you receive appropriate follow-up care.  Create/maintain a safe, comprehensive disposal system.
  50. 50. INFECTIOUS ORGANISM EXPOSURE Prevention:  Do proper hand hygiene.  Do not reuse tourniquets.  Wear gloves.  Cleanse insertion sites with the recommended solutions.
  51. 51. IV THERAPIST, HOW SAFE ARE YOU?  In a CDC study, 89 percent of HCW exposure to HIV were caused by percutaneous injuries.  As many as 40 percent of HCW who sustain needlesticks become infected with HBV  In 2004, more than 1,000 HCW became infected with HBV
  52. 52. OCCUPATIONAL RISKS ASSOCIATED WITH IV THERAPY  Physical hazards; Accidents , abrasions, contusions and chemical exposure  Exposure to Infectious Agents
  53. 53.  The following list is a summary of some of the rules to be observed in the workplace: HEPATITIS B vaccine STANDARD PRECAUTIONS SHARPS AND WASTE DISPOSAL PROTECTIVE DEVICE/EQUIPMENT GLOVES LAUNDRY COMMUNICATING HAZARDS
  54. 54. ECONOMIC CONCERN I.V. therapy is more costly than oral, subcutaneous, or intramuscular methods of delivering medications.
  56. 56. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 1. Phlebitis *Clotting at the catheter tip (thrombophlebitis) *Device left in the vein too long *Friction from catheter movement in the vein *Poor blood flow around the device *Solution with high or low pH or high osmolarity *Redness at the tip of the catheter and along the vein *Tenderness at the tip of device and above *Vein hard on palpation *Remove the device *Apply a warm pack *Notify the physician *Document the patient’s condition and your interventions *Restart the infusion using a larger vein for initiating infusate, or restart with a smaller-gauge device to ensure adequate blood flow *Tape the device securely to prevent movement
  57. 57. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 2. Infiltration *Device dislodged from vein or perforated vein *Blanching at site *Continuing fluid infusion even when vein is occluded, although rate may decrease *Cool skin around site *Discomfort, burning, or pain at site *Feeling of tightness at site *Slower flow rate *Swelling at and above IV site (may extend along entire limb) *Remove the venipuncture device *Periodically assess circulation by checking for pulse and capillary refill *Restart the infusion in another limb *Notify the physician *Check the IV site frequently (especially when using an IV pump) *Don’t obscure the area above the site with tape *Teach the patient to observe the IV site and report discomfort, pain or swelling
  58. 58. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 3.Catheter dislodge- ment *Loosened tape or tubing snagged in bedclothes, resulting in partial retraction of the catheter *Dislodged by a confused patient attempting to remove it *Catheter backed out of the vein *Infusate infiltrating into tissue *Remove the catheter *Tape device securely on insertion *Use armboard
  59. 59. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 4. Severed catheter *Catheter inadvertently cut by scissors *Reinsertion of the needle into the catheter *Leakage from the catheter shaft *If the broken portion of the catheter is visible, attempt to retrieve it. If unsuccessful, notify the physician *If the broken portion of the catheter enters the bloodstream, place a tourniquet above the IV site to prevent its progression *Notify the physician and radiology department *Avoid using scissors around the IV site *Never reinsert the needle into the catheter *Remove the unsuccessfully inserted catheter and needle together
  60. 60. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 5. Hematoma *Leakage of blood into tissue *Vein punctured through ventral wall at time of venipuncture *Bruising around venipuncture site *Tenderness at venipuncture site *Remove the venipuncture device *Apply pressure and cold compresses to the affected area *Recheck for bleeding *Document the patient’s condition and your interventions *Choose a vein that can accommodate the size of the intended venous access device *Release the tourniquet as soon as successful insertion is achieved
  61. 61. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 6. Venous spasm *Administration of cold fluids or blood *Severe vein irritation from irritating drugs or fluids *Very rapid flow rate (with fluids at room temperature) *Blanched skin over the vein *Pain along the vein *Sluggish flow rate when the clamp is completely open *Apply warm soaks over the vein and surrounding area *Slow the flow rate *Use a blood warmer for blood or packed red blood cells when appropriate
  62. 62. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 7.Nerve, tendon, or ligament damage *Improper venipuncture technique, resulting in injury to surrounding nerves, tendons, or ligaments *Tight taping or improper splinting with arm board *Delayed effects, including paralysis, numbness, and deformity *Extreme pain (similar to electric shock when nerve is punctured) *Numbness and muscle contraction *Stop procedure *Notify the physician *Don’t repeatedly penetrate tissues with the venipuncture device *Don’t apply excessive pressure when taping or encircling the limb with tape *Pad the arm board and, if possible, pad the tape securing the arm board
  63. 63. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 8.Circulatory overload *Flow rate too rapid *Miscalculation of fluid requirements *Roller clamp loosened to allow run-on infusion *Crackles *Discomfort *Increased blood pressure *Large positive fluid balance (intake is greater than output) *Neck vein engorgement *Respiratory distress *Raise head of the bed *Administer oxygen as needed *Notify the physician *Administer medications (probably furosemide) as ordered *Use a pump, controller, or rate minder for elderly or compromise d patients *Recheck calculations of fluid requirements *Monitor the infusion frequently
  64. 64. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 9. Systemic infection *Failure to maintain aseptic technique during insertion or site care *Immunocompro mised patient *Poor taping that permits the access device to move, which can introduce organisms into the bloodstream *Prolonged indwelling time of device *Severe phlebitis, which can set up ideal conditions for organism *Contaminated IV site usually with no visible signs of infection *Fever, chills, and malaise for no apparent reason *Notify the physician *Administer prescribed medications *Culture the site and the device *Monitor vital signs *Use scrupulous aseptic technique when handling solutions and tubings, inserting the venipuncture device, and discontinuing the infusion *Secure all connections *Change IV solutions, tubing, and the access device at recommended times.
  65. 65. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 10.Air embolism *Empty solution container *Secondary solution container empties; next container (primary) pushes air down line *Disconnected tubing *Decreased blood pressure *Increased central venous pressure *Loss of consciousness *Respiratory distress *Unequal breath sounds *Weak pulse *Discontinue the infusion *Place the patient in Trendelenburg’s position to allow air to enter the right atrium and disperse through the pulmonary artery *Administer oxygen *Notify the physician *Document the patient’s condition and your interventions *Purge the tubing of air completely before infusion *Use the air- detection device on the pump or the air- eliminating filter proximal to the IV site *Secure connections
  66. 66. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 11.Allergic reaction *Allergens such as medications *Bronchospas m *Itching *Tearing eyes and runny nose *Urticarial rash *Wheezing RED FLAG: An anaphylactic reaction can occur within minutes after exposure, including flushing, chills, anxiety, agitation, *If reaction occurs, stop the infusion immediately *Maintain a patent airway *Notify the physician *Administer an antihistaminic steroid, an anti- inflammatory, and antipyretics drugs, as ordered *Give 0.2 to 0.5 ml of 1:1,000 aqueous epinephrine subcutaneously *Obtain the patient’s allergy history. Be aware of cross- allergies *Assist with test dosing *Monitor the patient carefully during the first 15 minutes of administratio n of a new drug
  67. 67. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures generalized itching, palpitations, paresthesia, throbbing in ears, wheezing, coughing, seizures, and cardiac arrest *Repeat the epinephrine dose at 3- minute intervals and as needed, as ordered *Administer cortisone if ordered
  68. 68. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 12. Occlusion *Blood backup in the line when the patient walks *Hypercoagulabl e patient *Intermittent device not flushed *Line clamped too long *IV flow interrupted *Use mild flush pressure during injection *Don’t force the flush *If unsuccessful, reinsert the IV device *Maintain IV flow rate *Flush promptly after intermittent piggyback administratio n. *Have the patient walk with his arm folded to his chest to reduce the risk of blood backup
  69. 69. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 13. Thrombophl ebitis *Thrombosis and inflammation *IV Reddened, swollen, and hardened vein *Severe discomfort *Remove the device; restart the infusion in the opposite limb if possible *Apply warm soaks *Watch for IV therapy-related infection (thrombi provide an excellent environment for bacterial growth *Notify the physician *Check the site frequently *Remove the device at the first sign of redness and tenderness
  70. 70. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 14. Thrombosis *Injury to the endothelial cells of the vein wall, allowing platelets to adhere and thrombus to form *Painful, reddened, and swollen vein *Sluggish or stopped IV flow *Remove the device; restart the infusion in the opposite limb if possible *Apply warm soaks *Watch for IV therapy-related infection (thrombi provide an excellent environment for bacterial growth *Notify the physician *Use proper venipuncture techniques to reduce injury to the vein
  71. 71. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures 15. Vein irritation at the IV site *Solution with a high or low pH or high osmolarity, such as 40 mEq/L of potassium chloride, phenytoin, and some antibiotics (such as vancomycin and nafcillin) *Pain during the infusion *Possible blanching if vasospasm occurs Rapidly developing signs of phlebitis *Red skin over the vein during infusion *Slow the flow rate *Try using an electronic flow device to achieve a steady regulated flow *Dilute solutions before administratio n. For example, give antibiotics in a 250-ml solution rather than 100 ml *If the drug has a low pH, ask a pharmacist if it can be buffered with sodium bicarbonate (refer to facility policy)
  72. 72. Mechanical Risks Possible Causes Signs/ Symptoms Nursing Interventions Prevention Measures *If long-term therapy of an irritating drug is planned, ask the physician to use a central IV line
  74. 74. Fluctuating flow rate Runaway IV Sluggish IV Tubing / loose connection/ disconnection Blood back up in tubing
  75. 75. IV line obstruction/kinking of IV tubing Clogged filter Break in aseptic technique Leaks; due to inappropriate device
  77. 77.  I.V. therapy is the preferred mode of treatment because of its rapid onset.  Nurses are assuming more nursing responsibilities in I.V. therapy.  More nursing time is allotted to I.V. therapy  I.V. Therapy is a risk specialty area.
  78. 78. WHAT TO DO WHEN INFUSION SLOWS DOWN OR STOPS1. Assess the I.V. system to locate the problem. Start at the insertion side. Check for infiltration, extravasation, or phlebitis. 2. Check for patency. Obstruction of flow is caused or affected by the following factors:
  79. 79.  2.1 Patients limb is flexed; patient lying on the side. Reposition limb to release venous pressure.  2.2 Tip of needle or cannula is against the vein wall. Lift or pull- back the needle or cannula a little.  2.3 Adhesive taping maybe too tight, release every apply tapes.
  80. 80.  2.4. Small cannulas or tubing may kink or fold, gently adjust.  2.5. Local edema or poor tissue perfusion from disease can block venous flow. Transfer I.V. line to an unaffected site.  2.6. Presence of precipitates in solution either from incompatibility of fluids and medications or from infusion. Replace the entire venipuncture device and solution. It may expose the patient to embolism.
  81. 81.  3. Check the clamps. Some sets have two:  the roller clamp and the side clamp. Check if both are open or if these are properly adjusted.  4. Check the patency of the air vent; reposition it if needed.
  82. 82.  5. Check fluid level: if empty replace as prescribed. If solution is too cold, it may cause venous spasm and decrease the flow; keep room temperature regulated. Check the spike of the set; push it more inside the fluid bag or adjust it.
  83. 83.  6. Check filters: ordinary sets usually do not have in-line filters. If it has, follow the manufacturer’s guide instructions. Blood transfusion filters retain blood product debris. If flow rate decreases or stops after more than one unit has been transfused you may have to change the set.
  84. 84. • 7. Check tubings: if patient is lying on it or if it is kinked or it may be crimped with too tight roller clamps, release and round-up the tubing to its original shape • 8. Is gauge of the needle too small? Is fluid container too low above the venipuncture site? Adjust it around 36-48 inches above the site.
  85. 85. Patient and Family Education and Documentation
  86. 86. PATIENT AND FAMILY EDUCATION Before insertion:  Describe the procedure.  Tell the patient about how long the catheter will stay in place.  Provide information that the procedure may hurt a little.  Tell that the IV fluid may feel cold at first.
  87. 87. During therapy: Instruct to report any discomfort. Explain any restrictions as ordered. Teach the patient how to care for his IV line. Inform them that the presence of blood in the tubings is normal.
  88. 88. At removal: Explain that removing a peripheral IV line is a simple procedure. Teach patient on how to apply pressure until the bleeding stops.
  89. 89. DOCUMENTATION Purposes: For communication For history and legal purposes For audit For research purposes For quality management
  90. 90. RECORD THE FOLLOWING:  Date, time and venipuncture site.  Equipments used.  Rates of solution.  Patient’s tolerance to the procedure.  Health teachings given.  Update your records as often as needed.  Must be clear, concise and consistent.
  91. 91. INFUSION SHEET Date Started Time Started # of Infusion Site of IV Insertion / Type of Cannula / Dose / Rate / Drug Incorporation Present (IV Fluids/Blood Products/Chemo/TPN) Date Terminated Time Terminated Full Signature of RN 31 Aug. 2008 8:10 AM #1 L metacarpal vein, Introcan Safety G. 22, D5NM 1L X 6 hours at 42 gtts/min 31 Aug. 2008 2PM Maristiel A. Sas, RN 31 Aug. 2008 2PM #2 L metacarpal vein, Introcan Safety G. 22, PNSS 1L X KVO at 11 gtts/min
  92. 92. MULTI-DISCIPLINARY PROGRESS NOTES 08/31/08 6-2PM 8AM 8:10AM 8:15AM For IV insertion D – for IV insertion of D5NM 1L as ordered. A – assessed patient. - explained the procedure and addressed patient’s concerns. - materials prepared aseptically. R – IV line inserted; patient tolerated the procedure well - instructed patient on how to prevent catheter dislodgement. - used materials discarded accordingly. Maristiel A. Sas, RN
  94. 94. SCENARIO One: Arm is swollen, cool to touch, but with blood return.
  95. 95. SCENARIO Two: Vein is hard, skin is red, swollen, and warm to touch, but good infusion, and good blood return
  96. 96. SCENARIO Three: Infusion is sluggish, I.V. site looks phlebitic
  97. 97. SCENARIO Four: Infusion ran too fast.
  98. 98. SCENARIO Five: Blood pressure drops quickly and pulse rate increases after tubing change.
  99. 99. SCENARIO Six: Unsuccessful insertion, catheter tip is gone.
  100. 100. SCENARIO Seven: New I.V. with red streak over the vein, pain at site.
  101. 101. SCENARIO Eight: I.V. site suddenly turns red, patient complains of itching and develops rashes.
  102. 102.  Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP). 2000. Nursing Standards on Intravenous Practice 7th EDITION.  Cahil, Matthew. I.V. Therapy made Incredibly Easy. Springhouse Corporation, Pennsylvania.  Dionne, Lynn. Manual of I.V. Therapeutics. Philips, F.A., Davis Co. Philadelphia. REFERENCES
  103. 103.  Intravenous Nursing Society, Supplement to Journal of Intravenous Nursing, Jan./February 1998 vol.21, Fresh Pond Square, 10 Faucett street, Cambridge, MAO 218.  Lippincott Williams and Wilkins. 2005. JUST THE FACTS I.V. Therapy.  Nursing Journal May and July 2000.
  104. 104. Let’s call it a DAY!