Infusion Therapy Learning Exercise: Infusion Documentation

Transcription

1 Infusion Therapy Learning Exercise: Infusion Documentation INFUSION OF DOCUMENT IN DOCUMENT PERIPHERAL PICC LINE BLOOD TRANSFUSION SPINAL EPIDURAL CLPNA Infusion Therapy: Infusion Documentation Exercise page 1

2 Answers for Infusion Documentation INFUSION OF DOCUMENT PERIPHERAL IV Fluids administration amount type of fluid administered, time of administration start end. commencement of infusion completion of bag In Out fluid chart amount, time, type time of administration of fluids IV dressing/ tubing date, time applied, initials IV Medications time, amount in bag, type of fluid administering Labels for minibag time: start end, initials prior to hanging bag MAR sign for ordered medications given administering meds prior client, administration of medication, postadmin. monitoring, complications, interventions to ameliorate (Nursing Process), Client family teaching s/interventions CLPNA Infusion Therapy: Infusion Documentation Exercise page 2

3 INFUSION OF DOCUMENT PICC LINE IV Fluids administration amount type of any fluid administered, time of administration start end. commencement completion of infusion In Out fluid chart amount, time, type time of administration of fluids Site dressing/tubing date, time applied, initials on a label attached IV Medications time, amount type of fluid in bag administering Labels for bag time: start end, initials prior to hanging bag MAR sign for ordered medications given administering meds Insertion site, observations of site equipment, total length of catheter, length of catheter inserted, client monitoring, administration of medication, postadmin. monitoring, complications, interventions to ameliorate (Nursing Process), client family teaching s/interventions CLPNA Infusion Therapy: Infusion Documentation Exercise page 3

4 INFUSION OF DOCUMENT BLOOD TRANSFUSION Consent Form client name, date, physician name, procedure. prior to commencement of. In emergency situation, as close to commencement of Blood amount type of blood/blood product administered, time of administration start end. commencement completion of In Out fluid chart amount, time, type time of administration of fluids Site dressing/tubing date, time applied, initials on a label attached Consent conversation with physician Consent or refusal given check that this has been documented in the health before the is started start stop date time of the s/interventions Transfusion Service form Type, volume service identification number of the blood component or product prior to commencement of Transfusion Record Identification of the person performing the commencement of Identification of the second person who verified the blood component or product for commencement of Client health All additional vital signs time they were captured as they are ed Any signs symptoms of adverse reaction subsequent follow up at the time of observing CLPNA Infusion Therapy: Infusion Documentation Exercise page 4

5 Transfusion Documentation/Tag Notification Client teaching performed Follow up testing done/client outcome All hospitals require the return of the documentation/tag to the laboratory (in some cases this may happen electronically). Client Notification All inpatients must be notified they have received a blood component or blood product. Become familiar with the mechanism of notification of in your hospital. after teaching completed after completed after completed on completion of the CLPNA Infusion Therapy: Infusion Documentation Exercise page 5

6 INFUSION OF DOCUMENT SPINAL / EPIDURAL Consent Form client name, date, physician name, procedure. prior to commencement of injection or infusion. Site dressing/catheter date, time inserted, initials on site dressing, catheter total length length inserted Medications infusion time, amount type of fluid in bag time of administration Labels for bag time: start end, initials, labelled epidural or spinal MAR sign for ordered medications given administering Pain Assessment Tool(s) pain level, onset, quality, duration conducting Sedation Scale Level of consciousness, depth of respirations hourly, then every 2 hours, then every four hours Insertion site, observations of site catheter, total length of catheter, length of catheter inserted administering meds client monitoring prior to administration of medication, postadmin. monitoring, complications, interventions to ameliorate (Nursing Process), client family teaching s/interventions CLPNA Infusion Therapy: Infusion Documentation Exercise page 6