NURSING PROTOCOL - MUHC
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1 k NURSING PROTOCOL - MUHC Medicatin included N Medicatin included THIS IS NOT A MEDICAL ORDER Title: This nursing prtcl is attached t: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr pediatric patients Interprfessinal prtcl: Selectin f skin antiseptic slutin fr skin preparatin fr intravascular access and site care in children MUHC Hand Hygiene Plicy Tetracaine 4 % (Ametp) medicatin administratin plicy EMLA medicatin administratin plicy 1. PURPOSE The purpse f this prtcl is t describe the prcedure fr insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter. 2. PROFESSIONALS AND PATIENT POPULATION Pediatric patients requiring subcutaneus injectins via an Insufln catheter. Nurses emplyed at the MUHC wh care fr children requiring subcutaneus injectins via an Insufln catheter. Licenced Practice Nurses (LPN) wh meet the abve criteria and wrk within the limits f their rle and in discussin and cllabratin with a nurse. Candidates t the Prfessin f Nursing(CPN) wh meet the abve criteria and wrk within the limits f their rle and under the supervisin f a nurse. 3. ELEMENTS OF CLINICAL ACTIVITY Prfessinals are respnsible t knw the limits and extent f their practice as related t the particular prtcl. Indicatins An Insufln is an indwelling subcutaneus catheter that can be used t administer a subcutaneus medicatin. Once the Insufln is inserted, it allws administratin f the subcutaneus medicatin withut piercing the skin thus minimizing pain assciated with the prcedure. Medicatins cmmnly administered using an Insufln include: Heparin and lw mlecular weight heparin (dalteparin, enxaparin) Granulcyte clny stimulating factr (GCSF) Mrphine Desmpressin (DDAVP) Cytarabine (Ara-C) Revisin date: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr 1
2 Interfern Precautins Insulin fr the management f diabetes is nt usually administered using an indwelling subcutaneus catheter. In certain circumstances, this apprach may be used in cnsultatin with the diabetes team. Cntraindicatins An Insufln shuld nt be used t administer a cntinuus subcutaneus infusin. D nt use fr SC IVIG administratin Equipment needed: Fr Insufln insertin: Insufln catheter with dressing (dressing cmes in package) Antiseptic swab as per the Interprfessinal prtcl: Selectin f skin antiseptic slutin fr skin preparatin fr intravascular access and site care in children Clean (nn-sterile) glves Disinfectant wipes Fr Insufln remval: Clean (nn-sterile) glves Sterile 2 X 2 gauze Adhesive bandage Prcedure: Nte: The use f an indwelling subcutaneus catheter such as an Insufln fr intermittent medicatin administratin requires the presence f sufficient subcutaneus tissue. Prcedure fr insertin: 1. Explain prcedure t patient and family. 2. Cnsider the use f strategies t reduce prcedural pain and anxiety such as distractin, cmfrtable psitining and/r the administratin f sucrse. Cnsider btaining a medical prescriptin fr a tpical anesthetic. 3. Wipe cunter surface t be used during the prcedure with a disinfectant wipe and allw t dry. 4. Assemble equipment. 5. Perfrm hand hygiene accrding t the MUHC hand hygiene plicy. 6. Dn clean glves 7. Select an insertin site. Cnsider child s age and develpmental level when selecting a site. The catheter shuld nt be inserted near a scar, bruise, skin lesin r abrasin. Avid skin flds r areas where clthing may rub r cnstrict. Ensure selected site is nt within a 5 cm radius f the umbilicus. If the patient is t self-administer, psitin the hub f the Insufln fr ease f access fr the patient. See Figure 1. Revisin date: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr 2
3 Figure 1: Recmmended Insertin Sites 8. A secnd persn may be required t assist with psitining and immbilizatin fr the insertin prcedure. 9. Disinfect skin at insertin site using a rubbing mtin cvering an area larger than the dressing with recmmended antiseptic swab and allw t dry. 10. Open Insufln package by peeling back paper cver. 11. Hld catheter hub between thumb and index finger and remve prtective cap. Place the prtective cap n the end f the catheter hub (see figure 2 belw) 12. Pinch skin at the site f insertin and insert the Insufln at a 20 t 45 degree angle in ne smth, quick mvement, with the bevel angled upward (refer t Figure 3). 13. Remve needle by hlding the catheter hub firmly and slwly pulling ut the needle. Never reinsert the needle t repsitin the catheter as reinsertin culd shear the catheter. Discard needle in a sharps cntainer. 14. Secure Insufln by applying the adhesive dressing prvided starting frm the catheter end ensuring that the insertin site is cvered and clearly visible. Ensure the catheter hub remains accessible.. Smth ut dressing using gentle pressure t ensure adhesin. Revisin date: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr 3
4 15. Remve glves and perfrm hand hygiene. 16. Dcument lcatin f insertin and tlerance f prcedure in the nursing prgress ntes. Figure 3: Insufln insertin Care and maintenance f the Insufln catheter Site f insertin shuld be inspected daily fr signs f ptential cmplicatins. The insertin site must be assessed prir t medicatin administratin. Dcument site assessments in the nursing prgress ntes. Ptential cmplicatins include: Disldgement Signs f infectin such as redness, inflammatin and/r presence f exudate Blckage r kinking f the catheter Bruising Bleeding Pain Leakage Presence f signs f cmplicatins requires remval f the Insufln catheter and reinsertin f a new Insufln at a different site. In the absence f cmplicatins, the site f insertin shuld be changed every 3 t 7 days. If there are signs f redness, pain, swelling, exudate, r bleeding, the site may need t be changed sner. D nt exceed a greater than 7 day dwell time. If mre frequent changes f insertin site are required (mre frequent than every 3 days), cnsideratin shuld be given t the apprpriateness f using an indwelling catheter rather than separate subcutaneus injectins. Medicatin administratin Revisin date: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr 4
5 The dead space vlume f the Insufln catheter is ml. There is n need t flush the catheter befre r after medicatin administratin. If mre than 10% f the medicatin is lst due t the catheter dead space, cnsult the physician and pharmacist. A small amunt f flush slutin may be required in this rare circumstance. If the Insufln catheter is t be remved after insertin, a minimum f minutes shuld elapse prir t remval t ensure adequate absrptin f the medicatin. The needle used t inject medicatin shuld be the smallest gauge pssible (27 gauge r less). Needle length shuld nt exceed 8 mm (3/8 f an inch). When inserting the needle int the silicne membrane f the Insufln catheter, rtate the syringe gently as the needle is advanced. Rtating the needle helps it t mve away frm the inner wall f the hub. D nt administer multiple medicatins thrugh a single Insufln. A separate Insufln shuld be used fr each type f medicatin injected. If using mre than ne Insufln fr the same patient, the lcatin f the Insufln being used t administer each medicatin shuld be clearly dcumented n the CMAR and the name f the medicatin fr which the Insufln is being used shuld be written n the dressing. Dcument medicatin administratin n CMAR. Prcedure fr remval 1. Explain prcedure t patient and family. 2. Perfrm hand hygiene and dn clean glves. 3. Peel ff adhesive dressing beginning at the end f the catheter then remve catheter. 4. Apply pressure t insertin site using a sterile gauze pad. 5. Assess site and apply adhesive bandage. 6. Discard used supplies in the sharp cntainer 7. Remve glves and perfrm hand hygiene. 8. Dcument reasn fr remval and tlerance f prcedure in nursing prgress ntes. Main Authr: Eren Alexander, Nursing Practice Cnsultant Cnsultants: Debrah Meldrum, NPDE Hematlgy Onclgy and Ambulatry Services Isabelle St-Sauveur, CNS Pediatric Day Hspital Services Elissa Remmer, NPDE NICU Nancy Dumuchel, Diabetes educatr NPDQM cmmittee 4. APPROVAL PROCESS Institutinal and prfessinal apprval Cmmittees Date [yyyy-mm-dd] Pharmacy and Therapeutics Pediatrics (if applicable) Revisin date: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr 5
6 Cmmittees Date [yyyy-mm-dd] Adult Pharmacy and Therapeutics (if applicable) MUHC Adult Site Medicatin Administratin Plicy (MASMAP) (if applicable) MUHC Pediatric Medicatin Administratin Plicy (PMAP) (if applicable) Clinical Practice Review Cmmittee (if applicable) Nursing Executive Cmmittee and Cuncil f Nurses (NEC and CN) (if applicable) Multidisciplinary Cuncil (if applicable) MUHC Central Executive Cmmittee f Cuncil f Physicians Dentists and Pharmacists Cmmittee (ECPDP) (Obligatry if attached t a cllective rder) Final apprval Signature f Chairpersn: 5. REVIEW DATE T be updated in maximum f 5 years r sner if presence f new evidence r need fr practice change. 6. REFERENCES BC Children s Hspital (2013). Indwelling subcutaneus catheter (Insufln ): Insertin, medicatin administratin and remval. Insufln guide. Intrapump Infusin Systems. Retrieved frm February 2 nd, Mntreal Children s Hspital Nursing Plicy and Prcedure Manual Inserting and remving an Insufln subcutaneus catheter. The Ryal Children s Hspital Melburne (2014) Subcutaneus catheter devices Management f Insufln and BD Saf-T-Intima devices. Revisin date: Nursing Prtcl: Insertin, care, medicatin administratin and remval f an Insufln subcutaneus catheter fr 6
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