IV Therapy

HISTORICAL BACKGROUND •

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In 1993 the Nursing Standards on Intravenous Practice was established October 1993 – 1993 – ANSAP Board Members and Advisers had undergone the Training for Trainers at Philippine Heart Center February 4, 1994 – 1994 – the first edition of Intravenous Standards on IV therapy was printed and circulated June 9-11, 1994 – 1994 – first Training for Trainers as conducted in Cagayan de Oro May 17, 1995 – 1995 – another revision was made to incorporate the PRC – BON protocol.

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In 2002 – to ensure safe and quality nursing practice in IV I V therapy, therapy, more revisions were made by the special committee committee of the Association of Nursing Administrators of the Philippines, Inc., (ANSAP) in collaboration with the PRC-BON due to the new concept and evolving technology

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IVT Training Program (ANSAP) is primarily designed to comply with PRC, Board of  Nursing Resolution Resolution No. 08 of 1994, with wi th the provision of the Philippine Nursing Act of  1991, RA 7164 (Article V Section 37) and to th erapy ensure safe practice in IV therapy

PHILOSOPHY OF ANSAP •

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ANSAP envisions itself to be a cohesive, proactive professional association, committed to excellence in nursing It believes that safe and quality nursing care to patients is the primary responsibility of nurses It believes that those who practice IVT nursing are only those registered nurses who are adequately trained and have completed the training requirements in the IVT Training Program for Nurses as prescribed by ANSAP

Definition: •

Intravenous (IV) therapy is the insertion of a needle or catheter/cannula into a vein, based on the physician’s written prescription. The needle or catheter/cannula is attached to a sterile tubing and a fluid container to provide medication and fluids.

Objectives of the IVT Standards 1. Serve as guide for nurses in providing safe and quality nursing care to patients relative to IV therapy. 2. Promote the application of principles underlying the administration of IV therapy. 3. Recognize the ethico-legal implications of IV therapy

SCOPE OF PRACTICE A. Role Definition The IV nurses are registered nurses committed to ensure the safety of all patients receiving IV therapy.

B. Description of Practice 1. Ethico-legal implications ANSAP, Inc. upholds quality nursing practice and is going to continue with the IVT training for the following reasons:

a. Nursing curriculum does not provide indepth training in parenteral IV drug administration i.

An in-depth IV training may be included in the BSN curriculum but without actual IV insertion to patients

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ANSAP believes that parenteral IV drug administration is an invasive procedure

b. The Nurse Administrator has the command responsibility for the whole nursing practice in the Health Care Facility

c. Globally, the IV therapy certification is a mandatory requirement for the nurse practitioner d. IVT Training is voluntary; only those nurses who are adequately trained and have completed the training requirements in the IVT Program for Nurses as prescribed by ANSAP will be issued an IV Certificate of Training and the IVT Card of  ANSAP The IV nurse also upholds the Nurse’s Code of  Ethics and the established Nursing Standards on IV Practice of ANSAP and the Standards of  Nursing Service

2. Basis of Practice a. Legal therapeutic prescription of a licensed physician b. Thorough knowledge of the vascular system, interrelatedness of the body system with proficiency in the skill of the IV therapy c. Recognize of holistic approach to patient care d. Collaboration with members of the health team e. Net working and linkages with the external environment f. Individual professional accountability g. The utilization of the nursing process, through:

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assessment – collection of pertinent data to arrive at a nursing diagnosis

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Planning – formulation of nursing care plan relevant to IV therapy

iii. Implementation of Planned Care – nursing activities for IV management of patient iv. Evaluation – assessment of the effectiveness of  care, based on pre-determined objectives

3. Clinical skills The IV therapy nurses shall be proficient and competent in all clinical aspects of the IV therapy.

4. Procedures The IV therapy nurses shall performed procedures that include but not limited to the following, according to established ANSAP hospital policies: a. Carry out the physician’s prescription for IVT b. Perform peripheral venipuncture (all types of  needles and cannulas) excluding the insertion of  subclavian and cut-down catheter c. Based on physician’s written prescription, prepare, initiate, monitor, and terminate IVT d. Administer blood and blood components as prescribed by the physician

e. Determine solution and medication incompatibilities f. Change IV site, tubings and dressings, according to IVT Standards g. Establish flow rates of solutions, medications, blood and blood components as prescribed by the physician h. Proficient technical ability in the use, care, maintenance and evaluation of IV equipment i. Nursing management of patients receiving IVT and peripheral/central/parenteral nutrition in various set-ups (hospital, home and others)

 j. Adherence to established infection control practices k. Observation and assessment of all adverse reactions related to IVT and initiation of appropriate nursing interventions l. Appropriate documentation relevant to the preparation, administration, and termination of all forms of IVT

5. Indications of IVT a. to maintain hydration and/or correct hydration in patients unable to tolerate sufficient volumes of oral fluids/medications b. Parenteral nutrition c. Administration of drugs, ie chemotherapy, other drugs d. Transfusion of blood or blood components

6. Contraindication of peripheral IVT Administration of irritant fluids or drugs through peripheral access (ie highly concentrated, high osmolarity solutions like Na Chloride, Hypertonic K Chloride, etc..) 7. Quality assurance All IVT nurses shall follow/implement the ANSAP Nursing Standards on IV Practice

8. Technology The IVT nurses shall continue to evaluate, control/recommend procedures and products for clinical application used in IVT in order to keep up with advancing technology.

9. Communication Skills The IVT nurses shall possess verbal and written communication skills in translating ideas and facts to patients, health care members and others. 10.Coordinative and Collaborative Functions The IVT nurses shall participate in: a. Hospital-related committees

b. Continuing education programs related to IVT c. Other activities related to IVT

11.Patient education The IVT nurses have the responsibility of  educating patients and significant others on pertinent aspects of IVT. 12.Management and supervisory skills The IVT nurses shall establish parameters of IVT care/services and shall be accountable for their decisions. They shall be capable of supervising others under their jurisdiction. 13.Research Since research is an inherent component IVT nursing, the IVT nurses initiate/participate in investigations, validation, and development of  this aspect of nursing practice. They participate in dissemination of results for improvement.

14.Continuing education Continuing education and staff  development are vital to professional advancement. In this regard, the IVT nurses actively participate and share knowledge with other disciplines.

OBJECTIVES OF IVT TRAINING PROGRAM 1) Define the roles and responsibilities of the nurse in the administration of intravenous therapy including documentation/evaluation. 2) Define the ethico-legal implication of IV therapy within the scope of nursing practice as stated in the nursing law. 3) Identify the appropriate sites for venipuncture by strengthening the knowledge of the anatomy and physiology of the vascular peripheral and integumentary system.

4) Observe principles of strict asepsis during the actual implementation of the IVT practice. 5) Recognize the clinical pathogens of  microorganisms to gain a better understanding in the control of infectious process as it relates to IVT practice. 6) Describe the steps in the procedure for performing a venipuncture using various techniques and IV catheters. 7) Identify drugs commonly administered through IV therapy and understand the significance of the therapeutic effects.

8) Explain the need for corrective and/or replacement therapy in body fluids and electrolyte disturbances. 9) Recognize the subjective and objective symptoms which the patients may experience during IV fluids, blood and blood components and IV chemotherapy administration with its potential for anaphylaxis and execute the proper nursing intervention. 10)Implement the nursing process in administration of IVF, TPN, and IV medications.

Standards of Nursing Practice for IVT Structure Criteria: Entrance Requirements: 1) BSN graduate, registered professional nurse with current license from PRC. 2) Demonstrate behavioral characteristics such as honesty, reliability, initiative, and  judgment. 3) Demonstrates communication and technical skills.

Completion requirements: 1. RN participating in the 3 days Basic IVT Training Program. Must have successfully participated in the preparation to be able to accomplish the required IV injections.

2. RN practicing the art and science of IVT must have completed the training requirements as prescribed by the ANSAP.

Renewal/Revalidation of an IV Therapy Card: 1. The IV therapy card is renewable every 3 years for IVT nurses, trainers, and preceptors. 2. Renewal shall require attendance to IV related updates equivalent to 24 CEU and approved by the ANSAP.

Loss of IVT nurse card: •

Replacement of lost IV card (supported with an affidavit of loss) may be obtained from the National ANSAP office after submitting its corresponding certificates of Training or a certification of the trainer, stating the place and dates of the training attended and the photocopy of the official list of participants of  the IVT training attended

Cancellation of the IV card: 1. When the PRC License is not renewed 2. When there is any violation of Nursing law 9173

3. When IV card is not renewed for more than 5 years from the date of issuance. 4. When there are violations in the standards of  IVT practice.

Philippine Nursing Act of 2002 Republic Act No. 9173 •

An act providing for a more responsive nursing profession repealing for the purpose R.A. 7164. Otherwise known as the Philippine Nursing Act of 1991 and for other purposes.

Article IV Examination and Registration Section 12 License examination:

All applicants for nursing shall be required to pass a written examination, which shall be given by the board in such places, and dates as may be designated by the Commission; provided, that it shall be in accordance with Republic Act no.8981 otherwise known as PRC Modernization Act of 2000

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Rule IV – Nursing Education

Section 26. Requirements for inactive nurses returning to practice. Nurses who have not actively practiced the profession for 5 consecutive years and are returning to practice of the nursing profession shall undergo 1 month of didactic training and 3 months of practicum.

Standard Policies and Procedures Key points prior to initiation of IVT: 1. Physician’s prescribed treatment •

 Patient’s name  Type and amount of solution  The flow rate  The type, dose and frequency of medications to

be incorporated/pushed  Others affecting the procedures (x-rays, treatments to the extremities, etc…)

2. Patient assessments  Clinical status of patient  Patient diagnosis  Patients age  Dominant arm (non)  Condition of vein/skin  Cannula size  Type of solution  Duration of therapy

3. IV set and equipment preparation  Check for expiration date  Check for clarity; any presence of holes on plastic

cover (packaging); plastic container (bag) for presence of sediments or insects  Check label against the physician’s written

prescription  Label for any medication that are added: date,

time, dose of medication and amount compatibility of drug with the solution  Functionality of infusion pump, patient

controlled analgesia (PCA)

4. Medications Nurses administering IVT should have a knowledge on all medications administered including dosages, drug interactions and possible clinical effects on the vascular system.

10 Golden Rules for Administering Drugs safely 1. Right drug 2. Right drug to right patient 3. Right dose 4. Right drug by the right route 5. Right drug at the right time 6. Document each drug you administer 7. Teach your patient about the drug he is receiving 8. Take a complete patient drug history 9. Find out if the patient has any drug allergies 10. Be aware of potential drug – drug or drug – food interactions

Choice of Cannula for Peripheral Infusion •

Factors to consider for the choice of cannula are:

1. Purpose of the infusion 2. Type of infusion 3. Size and condition of the patient’s vein 4. Duration of treatment 5. Condition of patient nursing alert: choose the shortest catheter with the smallest gauge appropriate for the type and duration of the infusion. The higher the gauge number, the smaller the bore of the catheter

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Selection of Venipuncture Site The patient’s condition and age, the size and vein condition, type and duration of therapy and functional utilization of the hand shall be assessed to ensure ideal and safe IV access. Anchoring of cannula and tubing Good anchoring allows normal blood flow, prevents movement of cannula and irritation of  vein thus protecting the puncture site. Catheter care, use of dressing of site for easy transparency; puncture site should be covered with micropore or tape.

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IV Cannula removal Peripheral IV cannulas and the site are routinely changed aseptically or re-sited every 72-96 hrs and IV tubings every 72 hrs or when necessary. Administration of IV medications, Investigational (research) drugs, IV push, blood and blood components, IV chemotherapy and TPN Prior to the administration of the above, the indication shall be explained to the patients and/or to the significant others.

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Quality control of Iv solutions All IV fluids shall be inspected prior to use and check for visible sediment, turbidity, discoloration, leaks, cracks, damaged caps and expiration date.

Documentation of IVT Proper documentation provides:  An accurate description of care that can serve as legal protection  A mechanism for recording and retrieving information  A record for health insurers and retrieving information documenting the insertion of a venipuncture device or the beginning of therapy. •

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The following information of care that can serve as legal protection:  –

Size, type, and length of cannula/needle

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Name of person who inserted the IV catheter

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Date and time of insertion

Label the IV solution specifying:  –

Type of IV fluid

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Medication additives and flow rate

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Use of any electronic infusion device

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Duration of therapy and nurse’s signature

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In addition to the above documentation, the following information is documented in the patient’s chart:  –

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Location and condition of insertion site Complications, patient’s response and nursing interventions

Patient teaching and evidence of patient understanding (for example ability to explain instructions or perform a return demonstration)

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Signature of nurse

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Other observations

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Infection Control Measures to reduce risk of infection:

 Wash hands before starting an IV or before

handling any of the IV equipment  Use an approve antiseptic (as per hospital’s

protocol) to clean the patient’s skin  Cut/clip the hairs of the venipuncture site if 

necessary. Do not shave.  Do not re-use a catheter or needle

Complications from IV therapy • • • • • • • • • •

Infiltration Thrombophlebitis Circulatory overload Air embolism Catheter embolism Infection of venipuncture site Systemic infection Speed shock Allergic reaction Pulmonary congestion

Procedural Problems Associated with IVT • • • •

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Fluctuating flow rate Runaway IV Sluggish IV Tubing/loose connection/disconnection Blood back up on tubing IV line obstruction/kinking of IV tubing Clogged filter Break in aseptic technique Leaks; due to inappropriate device