INTRAVENOUS MODULE LEVEL ONE NMDHB IV COMMITTEE

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1 INTRAVENOUS MODULE LEVEL ONE NMDHB IV COMMITTEE 2012

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3 Contents Level One Intravenous module 1. NMDB IV therapy policy 2. Standard 1 Assessment of clinical competence in IV therapy 3. Module 1 Mathematics for nurses 4. Standard 2 IV therapy and basic fluid & electrolyte balance 5. Module 2 IV therapy and basic fluid & electrolyte balance 6. Standard 3 IV medications 7. Module 3 IV medications 8. Standard 4 Blood & Blood Products 9. Module 4 Blood & Blood Products 10. Standard 5 IV therapy using Pumps 11. Module 5 IV therapy using Pumps 12. Standard 6 IV Opioid administration 13. Module 6 IV Opioid administration 14. Standard 7 Subcutaneous Fluid Administration 15. Module 7 Subcutaneous Fluid Administration These modules have been updated from evidence-based practice and the combined expertise and knowledge of nurses from NMDHB. They have been designed for nursing staff entering NMDHB and as a refresher for staff within NMDHB to maintain competency with NMDHB policy and standards. The modules provide the theoretical base for intravenous therapy. The practical component must be completed before competency is established and validated. These modules are available on the Nursing and Midwifery section of the Intranet. Reference copies are kept in all nursing areas where IV therapy is practised. Further copies are available from the Library at Nelson & Wairau Hospitals. The process for competency assessment is defined in Standard 1 To maintain currency with best practice these modules will be reviewed 3 yearly Issue no. 6 Name Robyn Author District IV & RT Committee: Henderson Nurse Approval date 31 Jan 2012 Position DONM File name IV module Level 1 course index Review date Sept 2015 Signature Page Page 1 of 130

4 POLICY Purpose Scope Related Knowledge Needle-free Systems Prescribing of IV Fluids Checking of IV Fluids Minimum checking /administration requirements Double checking NMDHB Intravenous Therapy This policy is to facilitate the safe delivery of IV Therapy. This policy applies to all Medical Officers, Registered Nurses /Midwives /Enrolled Nurses (RN/ RM/EN) who are employed by or contracted to NMDHB, working in any clinical setting where IV therapy is a part of patient care. Health Professionals administering IV Therapy must be familiar with Infection Control, Medication Policy, and IV Modules. Notes on Injectable Drugs to be available in all areas for reference. Registered Nurses and Registered Midwives must complete IV training and be on the IV register. All intravenous lines are to be a closed system using a needle-free access device All IV fluids must be prescribed by a Medical Officer / Registered Midwife according to NMDHB Prescribing Policy. The prescription must include the following:- - date and signature of Medical Officer/Registered Midwife - exact details of fluid to be administered including any additives - clear instructions about the rate of administration must be given - charting of IV solutions should be for no longer than 24 hours. NB: The patient and prescription for solutions and additives must be reassessed every 24 hours All IV fluids must be checked immediately prior to administration in accordance with Intravenous Therapy Standards Solution / Meds (via peripheral line) EN with RN or RM (Both Currently IV certified ) Single (current IV certification) RN / RM/ MO Double (one RN/RM current IV certification) Under direct supervision RN/RM & 3 rd year studentboth IV certified Clear IV Fluids - including flushes Premixed - Solutions with KCl Blood Products - - (2 RNs/RMs required to sign) Medications (including opioids) and additives other IV Solutions /medications via PICC / CVL - - (2 RNs/RMs required to sign) In addition to the above minimum-checking requirements, double-checking is also required when the RN/RM feels it is necessary for any reason to have the process checked or supervised. The administering RN/RM will independently check the prescription, medication and calculate the medication dose to be administered before asking for a double check. The RN/RM providing the double check will be left to independently check the prescription, medication and calculate the medication dose to be administered. Issue no. 6 Name Robyn Author District IV & RT Committee: Henderson Nurse Approval date 31 Jan 2012 Position DONM File name IV module Level 1 course index Review date Sept 2015 Signature Page Page 1 of 130

5 Enrolled Nurses Student Nurses/Midwives Flushing of IV Lines Blood and Blood Products Verbal Orders Prescribing of Additives/ Medications Allergies Administration of additives/ Medications Antibiotics 1 st dose of antibiotics Both parties must have completed their own independent checks and calculations before any discussion occurs between the administering RN/RM and the RN/RM providing the double check. Enrolled Nurses who are IV Certificated can care for patients with infusions of clear fluids or with pre-mixed KCl and Normal Saline/ Dextrose solutions only. Student Nurses/Midwives may undertake the administration and checking of IV fluids and medication under the direct supervision of the RN/RM but cannot take formal responsibility (i.e. cannot sign) for these tasks. 2 RNs/MW are required to sign All student nurses must adhere to the NMDHB Medication Administration Policy. An RN or RM may flush a malfunctioning IV line with normal saline as per IV standard 3 without requiring verbal or written consent of a Medical Officer. Two RNs /RMs or a MO and RN/RM, to independently check blood and blood products as per double checking requirements above and IV standard 4 prior to administration at the bedside. Enrolled Nurses may not check blood or blood products. Verbal orders should be used in extenuating circumstances only, as per Medication Administration Policy and are to be confirmed in writing within 24 hours by the Medical Officer who gave the order. (2 RNs/RMs are required to listen to and sign the verbal order) Additives must be correctly and clearly prescribed by an authorised Medical Officer. The prescription must include the following : Exact details of the additive to be administered The dose of additive to be administered The method of administration, eg IV push or infusion Clear instructions about frequency of administration of additive If multiple IV lines, order indicates which line to use Date and signature of Medical Officer RNs / RMs/MOs check patient and patient documentation for DRUGS-ALLERGY ALERTS prior to the administration of any medications. Approved additives may be administered intravenously by RNs /RMs under the following conditions : All IV additives are to be checked independently by two RNs/RMs, or one RN/RM and one Doctor, both in the treatment room and at the patient's side, immediately prior to administration ENs may not check IV drugs and additives (except premixed KCl) Additives must be administered through an existing IV access Antibiotics are administered according to manufacturer's instructions, unless otherwise prescribed by Medical Officer. RNs / RMs may give the first and second dose of an IV antibiotic after ensuring: Epinephine 1:1000 (adrenaline) is on hand Medical Officer is aware and available for emergency response in the case of anaphylaxis First and second dose of antibiotics should be administered within the hospital environment Issue no. 6 Name Robyn Author District IV & RT Committee: Henderson Nurse Approval date 31 Jan 2012 Position DONM File name IV module Level 1 course index Review date Sept 2015 Signature Page Page 1 of 130

6 HIGH RISK MEDICATIONS CENTRAL VENOUS LINE Administration into CV Lines Rural Hospitals District Nurses Venepuncture / IV Cannulation References Some medications predispose the patient to greater risks and should be given: Ensuring that patient safety is optimised when administering medications which require specific monitoring and skills. E.g inotropes (dopamine), amiodarone Following completion of the required training of the area in which the medications are administered Using the protocols specific to that area If an unfamiliar drug or route is prescribed refer to Notes on Injectable drugs for guidance. If still uncertain check prescription with Pharmacy and the prescriber before administration RNs must complete a certification process and follow the IV Standards pertaining to these lines where their use is part of patient care. RMs involved in the care of patients with CV lines must work under the supervision of a RN who has completed the certification process. MOs & RNs who have completed the certification process may administer into CV lines. RNs yet to complete the certification process may administer under the direct supervision of a MO or a RN who has completed the certification process. Must follow the variations to this policy as set out in their own specific policies. In settings where there is only one RN on duty and where the fluids/medication/blood is required to be checked by two RNs The fluids/medication/blood and calculations are to be checked by two RNs at the change of shift or when 2 RNs/RMs are available If practicable the medication administration should be timed to coincide with the change of shift If administration must occur out of the change of shift, the checked fluids/medication/blood must be clearly labelled and securely stored, dependant on storage requirements for each as per manufacturer s instructions At the time the administration is to occur, the pre checked fluids/medication/blood is taken to the patient and the fluids/medication/blood and the patient identity are checked by the RN and one other person. (This may be a health care worker or a family member / patient.) The relevant training modules are to be completed by RNs /RMs/ House Surgeons Nelson Marlborough DHB IV Standards and Resource folder/modules Nelson Marlborough DHB Medication Administration policy Notes on Injectable Drugs IVNNZ Framework 2012 Issue no. 6 Name Robyn Author District IV & RT Committee: Henderson Nurse Approval date 31 Jan 2012 Position DONM File name IV module Level 1 course index Review date Sept 2015 Signature Page Page 1 of 130

7 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2011 STANDARD 1 Standard IV Register Assessing Clinical Competence Measuring Competence for new staff or returning staff (after being away >12 months) Maintaining Competence Three Yearly Inability to meet criteria IV Therapy Assessment of Clinical Competence Each Registered Nurse / Midwife and Enrolled Nurse demonstrates their clinical competence in Intravenous Therapy. Level One outlines the minimum requirements and applies to RN/RM/EN working in any clinical setting where IV therapy is a part of patient care. Level Two modules outline specific knowledge and skill required for complex IV therapy. An IV and Related Therapy Register listing the names of staff who have demonstrated competency will be available on the intranet. Level One. The Nurse / Midwife completes level one modules provided at orientation within 30 days of being employed in any clinical area. Level Two. Module completion & assessment will be clinical area specific, and where required completed on the recommendation of the CNM/ACNM The nurse / midwife sits open book IV test on ilearn in a nominated quiet area away from the ward setting Achieves 100% pass in the medication and IV solution flow rate calculation Achieves a minimum pass of 85% in the general theory Spends time with the ward/area I.V. Assessor during orientation to gain up to date information regarding IV therapy in NMDHB Practical Assessment is completed and signed off by an I.V. Assessor, CNM/CMM, Nurse Educator or experienced R/N R/M as delegated by CNM/CMM The nurse / midwife:-completes an ilearn test. Achieves 100% pass in the medication and IV solution flow rate calculation Achieves a minimum pass of 85% in the general theory Maintains up to date knowledge of IV Therapy by accessing available resources i.e. articles, Internet, reading I.V. Newsletter etc The nurse/midwife has clinical skills update with the I.V. Assessor/ Nurse Educator and/or completes a practical sheet A Nurse/Midwife who does not meet the above criteria may re-sit the ilearn test. If subsequently the criteria are still not met they must seek assistance from any of the following and be reassessed within 2 weeks:- I.V. Assessor or Nurse Educator Clinical Nurse Manager, Clinical Midwife Manager or Unit Manager Where a nurse/midwife is unable to pass the test after 2 attempts the Director of Nursing will be informed. The RN/RM/EN when involved with managing IV therapy must remain under the direct supervision of an IV certified RN/RM until competencies are met. Issue no. 6 Name Robyn Author District IV & RT Committee: Henderson Nurse Approval date 31 Jan 2012 Position DONM File name IV module Level 1 course index Review date Sept 2015 Signature Page Page 1 of 130

8 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2011 Removal from IV Register Caring for patients with IV Therapy Any Registered Nurse / Midwife or Enrolled Nurse who does not achieve the required competency level or does not update themselves within three months of their anniversary date will have their name removed from the current IV Register and be required to meet with the DON or Associate DON Registered Nurse s / Midwives seeking certification and who have completed the theory component of the course, can care for patients receiving IV Therapy as long as they are under supervision of IV registered RN/RM Enrolled Nurse s who are IV certified may care for patients receiving clear fluids / premixed KCL only and must be under the direct supervision of an IV certified RN Reference s IVNNZ Framework 2012 NMDHB IV Policy NMDHB Medication administration policy Issue no. 6 Name Robyn Author District IV & RT Committee: Henderson Nurse Approval date 31 Jan 2012 Position DONM File name IV module Level 1 course index Review date Sept 2015 Signature Page Page 1 of 130

9 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 IV Module 1 Mathematics for Nurses Objectives On completion of this module the nurse will be able to: Drug Calculations 1. Calculate desired drug dosages from available strength medications with different units of measurement. 2. Perform accurate drug calculations. 3. Determine the margin of safety Conversions 1. Differentiate between units of volume and units of weight. 2. Use correct abbreviations and symbols for the units of measurement 3. Describe the units, their quantities and their relationship to each other. 4. Perform accurate drug calculations Intravenous Fluid Volume Rate Calculations - mls per Hour 1. Calculate the rate of flow per hour. Intravenous Fluid Volume Rate Calculations - Drops per Minute 2. Calculate the rate of flow per minute Understand strengths of medications 3. Understanding percentages. 4. Understanding ratios. Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 7 of 130

10 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Mathematics for Nurses To practice IV therapy safely, nurses need to be able to competently perform four types of mathematical calculations. This module is divided into four parts - each part describes how to perform one type of calculation, with real-nursing examples, and gives the mathematical theory underpinning the calculation. Rounding: When using decimals numbers can be 'rounded' to the nearest whole number Eg becomes becomes 41 In the assessment, you can do the calculations using your own formula, or this formula. You may use a calculator. Drug Calculations There are several methods to calculate drug doses. In this module we shall look at one, this being What you want X volume (in ampoule or vial) What you have got 1 (i.e. number of grams or milligrams or micrograms or units in ampoule or vial) For example, dexamethasone comes in 8mg in 2ml. The doctor orders 6mg. Nursing problem: how many mls do I draw up? Using the above calculation by hand 6 8 X 2 1 = X 2 1 = 6 4 = 1 ½ 6 8 x Using a calculator Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 8 of 130

11 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Conversions Grams (g), milligrams (mg), and micrograms (microg).are units of weight Litres (L) millilitres (mls) are units of volume Medication is not always ordered in the same unit of weight that it is prepared in, so nurses need to be able to convert grams (g), milligrams (mg), and micrograms (microg). Theory: One gram = 1000 milligrams = micrograms One milligram = 1000 micrograms Hint: when converting from a large or heavier unit of measure to a smaller or lighter one, the number will increase, "Heavy to light - move (decimal point) three to the right" "Light to heavy - move (decimal point) three to the left" Heavy To Light 1 Gram (g) = 1000 milligrams( mgs) 1 Milligram (mg) = 1000 micrograms ( microgs) For example, IV digoxin comes in 500 micrograms in2mls. The doctor orders 0.25mg Nursing problem: how much do I draw up? To convert the required mg to micrograms By hand Step One: convert both the drug prescription and the drug preparation to the same unit of measure : "Heavy to light - move (decimal point) three to the right" mg = = 250 micrograms Step Two: Calculated as above What you want ( 250) X ( 2ml ) volume (in ampoule or vial) = 1ml What you have got ( 500) 1 Using a calculator.25 X X 2 1 Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 9 of 130

12 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 There are certain drugs where for safety reasons the dosage is calculated on a milligram per kilogram basis, then compared to the maximum 24-hour dosage allowed. The majority of infant and child drug doses fit into this category. Details of drug dosages and maximum allowances are found in "The Handbook of Injectable Drugs" (see reference list). As the nurse preparing and administrating the drug, you may wish to check first that the ordered dose is safe to administer. For Example: A 12-month-old child weighs 10kg. You have been asked to give IV 20mg Gentamycin Q8h. The literature states not to exceed 2mg/kg/every 8 hours Step One: What is the maximum Q8h dose this patient can be given? 2mg X 10kg = 20mg Q8h Conclusion this is a safe dose Step Two: How much Gentamycin should I draw up? Gentamycin comes in 80mg in 2ml. What you want X volume (in ampoule or vial) What you have got 1 20 x 2 = 0.5 ml 80 1 using a calculator X Now you have the volume of medication required, check to see the dilution rate in your resource manual Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 10 of 130

13 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Intravenous Fluid Volume Rate Calculations - mls per Hour There are two separate occasions when nurses need to work out "how many mls per hour?" when delivering fluids manually or via a volumetric IV pump, and when administering diluted medications on a mg/time prescription. How to calculate mls per hour Total volume Total time in hours = ml/hr Example One: the prescription is for one unit of blood over 2-3 hours. This particular unit has 336mls in it, according to the label on it. 336 = 168 ml/hr 2 Example Two: 360mg Gentamycin is added to 100mls, and given over 20 minutes 100 = 303ml/hr.33 (being 1/3of an hour) How to calculate diluted medications on a dose per time administration basis Step One: Calculate how many grams, milligrams, micrograms or units there are in each ml of the diluted medications e.g. 500mg Aminophylline is added to 500mls Normal Saline. Number of mg = 500 =1mg/ml Number of mls 500 The prescription is for 25mg/hr. Step Two: Calculate how many mls this is What you want X volume = 25 (mg) X 1 (ml) = 25mls What you have got 1 1 (mg) 1 Use this calculation when setting the rate using a volumetric IV pump. Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 11 of 130

14 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Intravenous Fluid Volume Rate Calculations - Drops per Minute If you are not using a volumetric IV pump, your gravity- delivered infusion will need the drop rate to be set manually. Having established the required ml/hr using the above calculations, the nurse then calculates how many drops per minute the IV should be set at to deliver this volume over the required time frame. The drop factor is the number of drops in 1ml. Depending on the size of the chamber, the IV set will deliver either 10, 20 or 60 drops per minute. You must check the outside of the drip set packaging to determine the drop factor. Usually, the standard giving set delivers 20 drops per minute, the burette set delivers 60. How to calculate drops per minute Step One: Use the formula below to calculate how many mls per hour are required. Step Two: mls per hour X drop rate factor Total time in minutes Example One: (From above examples) 168 (mls of blood per hour) X 20 = 56 drops per minute 60 (minutes in one hour) Example Two: (From above examples) 100 (mls with gentamycin - to go in over 20 minutes) X 20 = 100 dpm 20(number of minutes infusion is to run over) IV Fluids. IV N/Saline 1000 mls is to run over 8 hours. To set rate Step one: 8 x 60 = 480 minutes Step two: 1000mls x 20 (drop factor) = drops per minute (42 d.p.m.) 480 (minutes) using a calculator X Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 12 of 130

15 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Understand strengths of medications Nurses need to have an understanding of the mathematical concepts behind the strengths of fluids and medications that are administered intravenously, so their practice can be as safe as possible. These concepts are a. Understanding percentages b. Understanding ratios Understanding percentages A percentage is the top part of a fraction whose bottom part is 100. So 50% means 'half of' and 25% means 'a quarter of'. 100% means the complete quantity. Percentages are useful because they make it very easy to compare things. Some medications, and most IV fluids, have their strengths described in percentages like normal saline 0.9%, normal saline 0.45%. So which is the strongest? The easiest way to work it out is to ignore the % sign and compare the two numbers. Which is the bigger number, 0.90, or 0.45? Examples of nursing situations when understanding this concept is required: a. Eye Stream eye drops contain 0.4% sodium chloride, 0.075% potassium chloride, 0.03% magnesium chloride, 0.036% calcium chloride, 0.39% sodium acetate, 0.17% sodium citrate dihydrate, 0.01% benzalkonium. Can you list the medications from strongest to weakest? b. Marcain 0.25% and Marcain 0.5 % which is the weakest? Understanding ratios Some medications have their strength expressed in ratios like adrenaline"1: 1000", or adrenaline "1: 10,000" So which is the strongest? The easiest way to work it out is to consider which number would give you the best "odds" should you buy a lotto ticket. If the odds are higher (1 in 1000 chances to win compared to 1 in 10, 000) then that is the stronger medication. Examples of nursing situations when understanding this concept is required: Which is strongest - Marcain 1: 400,000; or Marcain w/adrenaline 1: 200,000? References The Notes on Injectable Drugs (on-line metric converter) (on line percentages tutorial Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 13 of 130

16 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Post modular test: Mathematics for nurses Section 1 Calculations 1. The Doctor has ordered penicillin 600,000 units I.V. Penicillin is available as 1,000,000 units (1 mega) in 2 mls. How many mls would you give? 2. Heparin for injection is available in vials labelled 5000 units/ml. The Doctor has asked you to give a bolus of 3500 units. How many mls would you draw up? 3. Digoxin is available in a paediatric elixir of 50 microg/lml. The Doctor wishes you to give 75 microg q6h. How many mls will you be giving? The infant weighs 8kg. You are not to exceed 45 microg/kg every 24hours. Does the dosage charted meet the safety criteria? 4. Your patient has seizured. The Doctor has ordered Valium 2mg. by slow IV injection. Valium is available in 10mg/2mls. How many mls would be drawn up? Section 2. Conversions 5. Convert mg digoxin to micrograms? 6. Convert 250 micrograms digoxin to mg? 7. Convert 0.4 mg naloxone to micrograms? 8. Convert 2.5 g Amoxil to mg? Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 14 of 130

17 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Section 3 rate calculations- mls per hour 9. The Doctor wishes to give 1000 mls. 5% Dextrose over 8 hours. What would be the rate of flow per hour? 10. The Doctor requests 500 mls Dext/Saline to be given through a metriset over 12 hours. What would be the rate of flow per hour? 11. The Doctor requests 250 mls to be given over 30 mins What would be the rate of flow per hour? Section 4 rate calculations- drops per minute 12. The Doctor wishes to give 1000 mls. 5% Dextrose over 8 hours. How many drops/min would you calculate, using an ordinary IV set? 13. The Doctor requests 500 mls Dext/Saline to be given through a metriset over 12 hours. How many drops/min would you set? 14. The Doctor requests 250 mls to be given over 30 mins using a standard giving set How many drops per minute will you set? Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 15 of 130

18 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/2010 Post Modular Test Answer Sheet Drug Calculations. 1. The Doctor has ordered penicillin 600,000 units I.V. Penicillin is available as 1,000,000 units [ mega] in 2 mls. How many mls would you give? = 1.2 mls 2. Heparin for injection is available in vials labelled 5000 units/ml. The Doctor has asked you to give a bolus to 3500 units every 4 hours. How many mls would you draw up each time? X 1 = 0.7mls 3. Digoxin is available in a paediatric elixir of 50 microg/lml. The Doctor wishes you to give 75 microg q6h. How many mls will you be giving? 75 x 1 = 1.5 ml 50 1 The infant weighs 8kg. You are not to exceed 45 microg/kg every 24hours. Does the dosage charted meet the safety criteria? 45 x 8 = 360 microg/24hours. 75 x 4 = 300 microg /24 hrs yes this is a safe dose. 4. Your patient has seizured. The Doctor has ordered Valium 2mg. by slow IV injection. Valium is available in 10mg/2mls. How many mls would be drawn up? 2 x 2 = 2 = 0.4 ml Convert mg digoxin to micrograms? = 62.5 micrograms 6. Convert 250 micrograms digoxin to mg? = 0.25mg 7. Convert 0.4 mg naloxone to micrograms = 400 micrograms 8. Convert 2.5 g amoxicillin to mg = 2500mg 9. The Doctor wishes to give 1000 mls. 5% Dextrose over 8 hours. What would be the rate of flow per hour? = 125 mls/hr Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 16 of 130

19 NELSON MARLBOROUGH DISTRICT HEALTH BOARD; NMDHB IV Standards STD/01/ The Doctor requests 500 mls Dext/Saline to be given through a metriset over 12 hours. What would be the rate of flow per hour? = mls/hr 11. The Doctor requests 250 mls to be given over 30 mins What would be the rate of flow per hour? = 500mls/hr 12. The Doctor wishes to give 1000 mls. 5% Dextrose over 8 hours. How many drops/min would you calculate, using an ordinary IV set? Step one = 125 mls/hr Step two 125(mls hr) x 20(drop factor 60 = (42) drops per minute 13. The Doctor requests 500 mls Dext/Saline to be given through a metriset over 12 hours. How many drops/min would you set? Step one = mls/hr Step two (mls/hr) x 60( drop factor 60 = (42) drops per minute 14. The Doctor requests 250 mls to be given over 30 mins using a standard giving set How many drops per minute will you set? Step one 250 mls in 30min = 500 mls in 60 mins Step two 500 ml/hr x = (167) drops per minute Issue Number 6 Name Robyn Henderson Author District IV & RT Committee: Nurse Educator/ IV Co-ordinator Date Approved 10/01/2012 Position DONM File name Std 1 Assessment Date Review 10/01/2015 Signature Page 17 of 130

20 STANDARD 2 IV Therapy. Administration of IV Therapy Standard IV Policy Clear and pre-mixed IV fluids are administered in a standardised manner by:- - IV certified Registered Nurse / Midwife / MO - IV certified Registered Nurse/ Midwife/ MO with an uncertified Registered Nurse/ Midwife - IV certified Registered Nurse / Midwife/ MO with an Enrolled Nurse who has completed IV Modules / 3 rd year Student Nurse on practical placement who has completed IV Modules All Nurses/ Midwives / MOs are familiar with the NMDHB IV Policy Procedure Aseptic Techniques Strict aseptic techniques are adhered to throughout the procedure Explanation to patient The patient receives an explanation and gives consent prior to the commencement of the procedure Equipment Correct equipment is selected and prepared Needle free systems to be used Prescription The Intravenous Fluids are checked against the prescription for :- Type Volume Rate Sequential order Checking of IV Fluids - IV Fluids are checked prior to administration for :- - Integrity of seals and bag - Colour and clarity of fluids - Foreign bodies and particulate matter - Expiry date Identifying the patient The RN/RMas indicated above checks the patients wristband details for:- - Name - Hospital number - Verbally confirms name ( where possible) - And confirms these details with the information on the patient s Treatment Chart - Checking Patient - The patient, equipment and fluids are checked HOURLY IV Dressing - The I.V. site is cleansed with Chlorhexidine 2% and alcohol 70%, taped to secure cannula and covered by a sterile transparent occlusive dressing - Site is labelled on insertion and appropriate documentation including peripheral cannulation record form is entered in clinical record Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/ IV Co-ordinator Date Approved 10/01/12 Position DONM File name Std 2 Administration of IV Therapy Date Review 10/01/15 Signature Page 18 of 130

21 Changing IV Fluids / Giving sets Time Extension to cannula Dwell time: Closing off the tubing Setting the infusion rate Condition of site Fluid Record All changes are carried out by :- A Registered Nurse / Midwife or Enrolled Nurse (who are on the current IV List) Each new giving set is labelled with :- Date & Time Tubing is changed:- IV Tubing TPN & Blood Tubing Pressure Monitoring IV Fluids (max time left hanging) 96 hours 24 hours 72 hours 24 hours All IV cannula must have an extension set in situ. (unless the cannula is for obtaining a blood sample) There is no longer a specific dwell time for a peripheral cannula. They should be changed when clinically indicated The tubing is closed off when :- - The bag/bottle is being changed - The line is disconnected - The gate of an infusion pump is to be opened Check the patency of the line and set the infusion rate. IV site is inspected at least once a shift for: - Pain, swelling, heat, necrosis at insertion point - Blanching or moist/soggy skin Remove cannula when any of the above occur and follow infection control protocol. For PICC/CVL see CVAD guidelines. Commencement times, type and volume of fluids are charted in the fluid record Reference: Alexander, M. (ed.). (2006) Infusion nursing standards of practice - supplement to Journal of Infusion Nursing, January/February, 29 (1S). Norwood:Lippincott Williams & Wilkins IVNNZ Framework 2012 NMDHB IV Policy O Grady, N.P., Alexander, M., Burns, L.A., Dellinger, P. & Garland, J. et al., (2011). Guidelines for the prevention of intravascular catheter-related infections. Centres for Disease Control. Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/ IV Co-ordinator Date Approved 10/01/12 Position DONM File name Std 2 Administration of IV Therapy Date Review 10/01/15 Signature Page 19 of 130

22 IV Module 2 Part A: Intravenous Therapy Part B: Basic Fluid, Electrolyte and Acid Base Balance / Imbalance Part A: Intravenous Therapy Objectives: On completion of this module, the nurse will be able to:- 1. Be familiar with current IV policy and standards and understand implications of IV Therapy. Understand nursing responsibilities. 2. Be able to set up IV Therapy into an existing cannula. 3 List factors, which may affect the flow rates of IV infusions. 4. Identify and discuss means of preventing Catheter related infections (CRI) 5. Identify and discuss local complications that most commonly occur with IV infusions. 6. Identify and discuss systemic complications that may occur with IV infusion. Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 20 of 135

23 Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Intravenous Therapy Implications of Intravenous therapy Refer to NMDHB IV Policy: Intravenous Therapy is concerned with checking and administration of drugs and fluids according to policy and standards. It should be performed by nursing staff who have current IV certification. Peripheral catheters are short catheters inserted into the veins of the hand, lower arm or leg. They are used when IV therapy is not expected to exceed five days. Consideration should be given to the most appropriate vascular access device if therapy is expected to exceed five days. Insertion of an intravenous device predisposes the patient to numerous hazards, including local and systemic complications. Systemic complications occur less frequently, but are usually more serious than local complications. Before commencing IV therapy, inspect the IV site. Ensure all documentation including the short peripheral cannula care record is completed and placed in the clinical records & that each IV site has been labelled. This is the responsibility of the cannulator & should include: Insertion date/ insertion site Reinsertion date Name of cannulator If this label is not in place, please complete and put beside the IV site (not obscuring cannula exit site) and in the cannulation record. Administration of intravenous fluids can occur through a number of methods: A continuous infusion through a manually operated administration set 1. Basic administration set (20 drops/ml) 2. Administration set with back-check valve (20 drops/ml) 3. Metriset/Burette (60 drops/ml) 4. Volumetric Infusion / or Syringe Pumps Continuous IV Fluid therapy Equipment in use in NMDHB Hospitals will have the following features: Luer locked Needle free / needle less systems. Single patient use only. Include slide clamp and roller clamp (if not - forceps on hand). Basic infusion set will deliver 20 drops per ml. Metrisets (burettes) deliver 60 drops per ml. Injectable side ports will be available on basic infusion sets. Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 21 of 135

24 Syringe sets will not have an injectable side port. Extension sets will have a slide clamp. Not be used if package is opened or damaged (discard bag). Checking IV Fluids Clear fluids and pre-mixed fluids may be checked by an IV certified Registered Nurse / Midwife / Medical Officer or IV certified Registered Nurse/ Midwife / MO with an uncertified Registered Nurse/ Midwife IV certified Registered Nurse / Midwife / MO with an Enrolled Nurse who has completed IV Modules / 3 rd year Student Nurse on practical placement who has completed IV Modules The intravenous fluids are checked against the prescription for: Type Volume Rate (eg: Normal Saline) (eg: 1000mls) (eg 8 hours) Sequential order and IV line number The IV fluids are checked prior to administration for: Expiry date Integrity of seals and bag Clarity - After removing plastic cover, check for minute leaks by squeezing bag firmly. - If leaks are found, do not use, as sterility may be impaired. Complete incident form, and return bag to stores with explanatory note. NB: There may be moisture on the inside of the cover. This does not mean the bag is leaking but is due to the sterilisation process. - Inadvertently opened bags are to Labelled with date and time. The contents are to be used within 1 month, otherwise discard. If administration/additive port has been punctured, discard. - Colour and clarity of fluids: - Foreign bodies and particulate matter. Fluid should be transparent and clear ( if not, do not use, complete incident form, and return to Stores with an explanatory note) Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 22 of 135

25 Priming IV Giving Sets Aseptic techniques are adhered to throughout the procedure 1. Firmly close roller clamp. Date and time line. 2. Insert spike into port on IV bag and hang bag on IV pole. When inserting the spike into the IV bag, ensure tip penetrates the plastic diaphragm. 3. NB: Take care to avoid contaminating the spike.- ensure aseptic technique is maintained. 4. Fill the drip chamber to at least half full (the IV solution acts as a water seal and prevents air from entering the tubing) by squeezing the chamber. 5. Prime the IV tubing by opening the roller clamp and letting the solution run through until it fills the tubing. As the sets we use have a Y-injection site, it also needs to be primed. To prime a Y-injection site and remove air bubbles, turn it upside down, and tap it hard. 6. Never let IV tubing touch the floor; contamination may occur through microscopic pores in the tubing. 7. NB: Leave the sterilising protector at the end of the IV line when priming to avoid potential contamination of the line. Connecting IV Line IV tubing is connected using an aseptic technique that protects both the patient and nurse. When connecting IV tubing, attach it directly to the needle free / needle less port on the short extension set. 1. Explain procedure to patient ensuring he/she knows what the IV fluids are for. 2. Check patient identification on IV chart with patients wristband prior to commencement of IV infusion and each new bag thereafter. 3. Inspect insertion site for signs of infiltration or phlebitis/infection. 4. Wash and dry hands. 5. Swab luer plug with antiseptic or alcohol swab and allow to dry. 6. Remove protective cap (avoid contaminating end). 7. Attach to needle free / needle less system on the short extension set. 8. Secure line to patient. 9. Commence fluid balance chart. 10. Enter date and time of commencement of fluids on IV orders chart. Commencing Infusion 1. Check patency of line. 2. Release roller clamp and regulate infusion to required calculated rate. 3. Check IV site to observe for signs of infiltration or phlebitis. 4. Splint limb if required to: a. Immobilise joint Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 23 of 135

26 b. Protect IV cannula c. Minimise trauma at insertion site d. It is preferable to keep IV site visible. 5. Recheck rate of infusion to ensure correct flow rate. 6. Chart commencement times, type and volume of fluid in the fluid balance chart. 7. Label the IV tubing with date. Change every 72 hours. Factors which affect flow rate: - Gravity Raising or lowering the IV bag will change the rate of flow - Position of Cannula Always splint limb where the cannula is positioned over joint especially the ante cubital fossa (inner elbow) - Venous Spasm An infusion of cold solution, e.g. blood can impede the flow rate - Inflammation of Vein Phlebitis will reduce the lumen of the vein thus decreasing the flow. - Clot formation at cannula tip. Maintenance 1. The patient, equipment and fluids are checked hourly. 2. The insertion site is exposed, inspected & palpated at least once a shift and condition reported on the short peripheral cannula care record each shift. 3. If there is any cause for concern or early indications of phlebitis at the IV site, this must be recorded on the short peripheral cannula care record and in the progress notes of the clinical record 4. Remove the cannula at stage two of the phlebitis scale e.g. pain, erythema, swelling 5. Remove cannula as soon as it is no longer clinically indicated. Termination of IV infusion Sterile technique and standard precautions apply -wear gloves. On removal of catheter firm pressure needs to be applied to prevent haematoma formation. Removal of Cannula: - Explanation to patient - Turn infusion off - Wash hands - Leave luer on the cannula - Carefully remove all tape, then lift off occlusive dressing - With a sterile swab over the insertion site, withdraw the cannula with a steady motion - Immediately apply pressure to the puncture site with the sterile swab - When bleeding has ceased tape a swab in place Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 24 of 135

27 - Dispose of cannula - Bring fluid balance up to date - Dismantle IV equipment - Record removal of cannula stating condition and location of site in the clinical notes. Complications Complications associated with IV lines include infiltration, localised phlebitis, septic thrombo- Phlebitis, endocarditis, and bloodstream infections. Catheter related infections especially catheter related blood borne infections are associated with increased morbidity, mortality and prolonged hospitalisation. Vigilant nursing can help reduce complications associated with IV lines Severity CRITERIA FOR PHLEBITIS Criteria 0 No pain, erythema, swelling, induration or palpable venous cord at or around insertion site. 1 If one of the following is present: Slight pain at or above the site Slight redness near the site 2 If two of the following are present: Pain at or above the site Erythema Swelling 3 If all or some of the following are present: Pain along the path of the catheter Erythema Induration Venous cord Dwell Time: There is no longer a fixed time frame for dwell time for a peripheral cannula. Cannula should be removed when clinically indicated and the details documented on the cannulation record (Latest CDC guidelines (2011) recommend this dwell time, the Infection Prevention Control service have adopted this recommendation) If any of the following conditions are present Signs or Symptoms of phlebitis Infection Luer unable to be flushed Signs of inflammation Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 25 of 135

28 STEP ACTION 1 Remove cannula immediately. 2 Do not wait until there are obvious signs of inflammation or infection. 3 Assess need for re-siting of cannula Documentation of insertion, the IV site and line changes are an important aid to help reduce catheter site infection. The short peripheral cannula care record is designed to record these details. LOCAL COMPLICATIONS Assessment Intervention Prevention Complications Infiltration of IV Solution Sluggish flow rate Site swollen & cool Site may be painful There is no flow back of blood in the tubing when the bag is lowered as a test Alarming pump may indicate occlusion Phlebitis Site usually painful Sluggish flow rate Oedema in the limb Vein is hard, cord -like, red & warm Stop infusion Remove cannula Comfort measures* Assess on phlebitis scale Slow infusion rate Resite prn Comfort measures* Stabilise cannula well Splint limb when cannula is near a joint Observation of site Aseptic technique Change cannula when clinically indicated Use of J Loop / extension set Slow IV injections rates Give IV injections diluted according to instructions Necrotic ulcer associated with I.V. drugs Septic Thrombophlebitis IV tip sepsis Haematoma Bruising/bleeding at site Check IV medications compatible with infusion fluid. Infection Localised - As above Redness Heat Pain Febrile Unexplained in WBC Systemic - onset may be rapid Stop infusion Inform Medical Officer Monitor vital signs Aseptic technique Correct skin prep at insertion Keep cannula well stabilised with occlusive dressing intact Dwell time no longer than 96 hrs Systemic infection Cellulitis Bacteremia Septicaemia Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 26 of 135

29 Patient appears hot & flushed Pyrexia, chills/rigor Muscle & joint pains Tachycardia Tachypnoea Nausea, anorexia Vomiting Headache Fatigue, apathy, general malaise Keep vein open Inform Medical Officer Blood cultures if pyrexia or rigors May require Antibiotics Antipyretics Topical applications Other treatments Cleanliness of site Swab before accessing Maintain closed system. Avoid routine disconnection of lines for dressing mobilisation etc Bact endocarditis Systemic Complications Circulatory Overload Occurs when the patient receives an excessive amount of fluid. It happens more frequently in elderly patients, infants, or those with cardiac or renal conditions. Assessment: Signs and Symptoms Prevention Interventions Headache Flushed skin Rapid pulse Venous distention - engorged neck veins - raised JVP/CVP Coughing Shortness of breath Increased respirations Variable blood pressure Syncope/shock Pulmonary oedema Identify patient at risk Monitor solution flow per standard Consider using a pump Place patient in semi sitting position during infusion Slow TKVO rate (To Keep Vein Open) Raise patient to sitting position to relieve shortness of breath Notify medical personnel Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 27 of 135

30 Pulmonary oedema Occurs when fluid has leaked through the capillary walls into the airways giving rise to severe Dyspnea Assessment: Signs and Symptoms Prevention Interventions Raised BP Raised J.V.P Shortness of breath Cough- Blood stains Frothy sputum Cyanosis - Late sign - Maintain drip rate with consistent accurate calibration - Do not speed up fluids if they are running behind time - Slow infusion - Sit patient upright - Give oxygen - Notify Medical Personnel - Monitor fluid balance carefully References: BJN 2002 Feb. Vol.11.No. 4 IVNNZ July 2002 :Framework & Competencies for Intravenous and Related Therapies Joanna Briggs Institute 2002: Promoting Best Practice in the Management of Peripheral Intravascular Devices. NMDHB 2009 I.V.modules Nursing 2001 July. Vol. 31 No. 3. Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 28 of 135

31 IV Module 2A Administration of Intravenous Therapy Post Modular Test 1. Clear and premixed intravenous fluids, can be checked out by: a) One IV certified registered nurse or midwife. b) One IV certified registered nurse or midwife, and one IV certified enrolled nurse. b) One IV certified registered nurse or midwife, with an uncertified registered nurse/ midwife c) d) All of the above 2. To prevent thrombophlebitis from occurring, the IV cannula should be resited: a) Every 24 hours. b) If signs and symptoms of phlebitis are present. c) Only when IV site reddened. d) None of the above. 3. After insertion of a peripheral cannula the insertion section of the peripheral cannula care record is completed including: a) Extension set b) Name and designation c) Date and time of insertion d) All of the above 4. If the outer cover of an intravenous fluid bag has been torn and the period of damage is unknown, the IV bag should be: a) Used immediately. b) Placed in fridge for 48 hours. c) Discarded. d) Re-wrapped in another container Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 29 of 135

32 5. All intravenous bags are changed every and intravenous tubing every, (with the exception of TPN) a) 24 hrs 24 hrs b) 24 hrs 96 hrs c) 48 hrs 24 hrs d) 72 hrs 72hrs 6. The rate of flow on a manually operated system may be affected by: a) Height of solution b) Position of IV cannula c) Venous spasm d) All of the above 7. Raising the intravenous bag to a higher level than normal would: a) Encourage clot formation b) Speed up the infusion rate c) Shift the cannula position d) Cause venous spasm 8 If signs and symptoms of phlebitis are present the IV cannula is: a) Left in place but infusion slowed. b) Removed and discarded. c) Continue to use and observe d) Removed and IV cannula placed in special culture medium before being sent to laboratory. 9. The most common sign of infiltration from concentrated solutions or drugs is: a) Marked oedema b) Tortuosity of vein c) Severe pain Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 30 of 135

33 d) Tissue necrosis 10. The drop factor of the standard giving sets used within NMDHB is a) 10 drops per ml b) 20 drops per ml c) 60 drops per ml d) 15 drops per ml 11. Microbiological contamination at time of insertion is the most common cause of IV site infection a) true b) false 12. Infusing fluid too rapidly, thereby overloading the circulation is a real hazard, particularly to: a) The elderly patient b) The cardiac patient c) The impaired renal patient d) All of the above 13. Signs and symptoms of pulmonary oedema are: a) Raised JVP, slow laboured respirations, raised B.P. b) Low B.P, frothy white sputum with cough, rapid respirations. c) Raised B.P, shortness of breath, cough with frothy blood stained sputum. d) Cyanosis, slow laboured respirations, frothy white sputum. 14. Should pulmonary oedema be suspected, the nurse should: a) Stop the infusion and place the patient flat. b) Slow the infusion and sit the patient upright. c) Stop the infusion and position the patient on his left side. Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 31 of 135

34 d) None of the above. 15. To help avoid IV catheter site infections the nurse should: a) Keep cannula well stabilised with occlusive dressing intact b) Swab and allow to dry before accessing c) Avoid routine disconnection of lines for dressing and mobilisation. d) All of the above 16. One nursing responsibility in achieving safe IV fluid therapy is checking the rate of flow, and the amount of solution. a) Every shift. b) Every 4 hours. c) Every hour or more often if required. d) None of the above. 17. Explanation of IV procedures, patient responsibilities and reasons for IV therapy are medical responsibilities rather than nursing. a) True b) False 18. IV flow rates should be suddenly speeded up if IV fluids are behind and need catching up. a) True b) False 19. All IV cannula should have an extension line or J loop in situ a) True b) False 20. The IV site should be inspected a) Once a shift b) 8 hourly c) 12 hourly d) 4 hourly Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 32 of 135

35 IV MULTICHOICE ANSWER FORM Intravenous therapy IV MODULE 2A 1. a b c [d] e 2. a [b] c d e 3. b c [d] e 4. a b [c] d e 5. a [b] c d e 6. a b c [d] e 7. a [b] c d e 8. a b [c] d e 9. [a] b c d e 10. a [b] c d e 11. [a] b c d e 12. a b c [d] e 13. a b [c] d e 14. a [b] c d e 15. a b c [d] e 16. a b [c] d e 17. a [b] c d e 18. a [b] c d e 19. [a] b c d e 20. [a] b c d e Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 33 of 135

36 Part B: Basic Fluid, Electrolyte and Objectives Acid Base Balance / Imbalance After completing this module, the nurse should be able to:- 1. Define homeostasis. 3. List three methods by which fluids are normally lost from the body. 4. Name three organs, which assist in regulating fluid balance. 5. Name two functions of body fluids. 6. Name the main fluid compartments of the body. 7. Name and describe two forces, which move water from one fluid compartment to another. 9. Name and describe two methods by which electrolytes move through semi- permeable membranes. 10. Name an organ, which maintains electrolyte balance. 11. Define an Acid and it's possible effect on the vein. 12. Define a Base and it's possible effect on the vein 14. Define Hypo and Hyperkalaemia. 15. Define Hypo/Hypervolemia 16. Define Hypo/Hypernatraemia. 17. List two conditions, which may cause a fluid deficit. 18. Name two positively charged electrolytes within the body. 19. Name two negatively charged electrolytes within the body. 20. Name the type of fluid most often used to re-hydrate the interstitial space. 21. Name fluids that should be considered for volume expansion. 22. Name the fluid of choice for dehydration across all components. To progress to the next module, the nurse must complete/pass the post modular test. Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 34 of 135

37 BASIC FLUID, ELECTROLYTE AND ACID BASE BALANCE / IMBALANCE Body fluids are in a state of balance when the water and electrolyte components are present in proper proportions, when losses are replaced and excesses eliminated. The composition of body fluids in each compartment remains relatively stable, although there is a constant process of replacement and exchange. This type of stability is known as homeostasis. Homeostasis is a state, which exists when there is constant replacement and exchange of fluids and electrolytes, nutrients and wastes between fluid compartments. Fluid is lost from the body by respiration, perspiration, urination and defecation. When the intake and output of fluid are equal, the body is in fluid balance. Fluid volume is regulated by the kidney, which is controlled by the posterior pituitary gland and the adrenal gland. Anti-diuretic hormone [ADH] is secreted by the posterior pituitary gland and inhibits the excretion of water by the kidney. Increased ADH secretion leads to water re-absorption. Aldosterone is secreted by the adrenal cortex and causes the kidney to retain sodium and secrete potassium. The body's fluid is located within two major compartments. lntracellular fluid (ICF) is located inside the cell. Extracellular fluid (ECF) is located outside the cell. The extracellular fluid includes intravascular and interstitial fluid. lntravascular fluid (IVF) is within the blood vessels. Interstitial fluid (ISF) is located between the cells and the blood vessels. The two main negative electrolytes in the body are chloride (Cl - ) and bicarbonate (HCO 3 - ). The three main positive electrolytes in the body are potassium (K + ), sodium (Na + ), and Calcium (Ca ++ ). An electrolyte is a combination of a positive and negative particle solution, which when dissolved in water will conduct an electrical current. Examples of electrolytes are sodium chloride (NaCL) and potassium chloride (KCL). Diffusion is the movement of particles from a region of greater concentration to a region of lesser concentration. An example of diffusion is the gaseous exchange in the lungs. Osmosis is the movement of water from a region of lesser concentration (of dissolved particles) to a region of greater concentration (of dissolved particles). Oncotic: The pull of the fluids that is exerted by large molecules A hypotonic solution is one with a lesser concentration of dissolved particles. A hypertonic solution is one with a greater concentration of particles. During osmosis, water moves from the more dilute or hypotonic solution, to the more concentrated or hypertonic solution. This represents an effort to equalise the concentrations of both solutions. The body is continuously striving toward a state of equilibrium, or homeostasis. Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 35 of 135

38 Intravascular Space Intersitital Space Intracellular Space BLOOD CELL WATER FLOW In OSMOSIS - fluid moves from an area of lesser concentration to an area of greater concentration to maintain homeostasis. Fluid would flow from the vascular space into the cell in order to dilute the concentration of particles and thereby cause the cell to swell. Intravascular Space Interstitial Space Intracellular Space Fluid Shift Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 36 of 135

39 In ONCOTIC Pressure - fluid moves towards the large molecules. Fluid gets pulled from the interstitial spaces and intracellular spaces and can cause profound dehydration as in diabetic ketoacidosis. However, if your patient has 3 RD spaced, if you give protein intravascularly, you increase the oncotic pressure gradient and pull fluid from interstitial spaces into the vascular spaces thereby increasing circulating volume. Hypertonic solutions "pull" water out of the cells. Mannitol and 50% glucose are examples of hypertonic agents. In the presence of normal renal function, these agents should produce an increase in fluid excretion or a diuretic effect. Solutions having the same concentration in relation to each other are isotonic. An isotonic solution administered to the body will not alter the osmotic concentration. In this situation, movement of water would not occur. Examples of isotonic solutions are normal saline and dextrose 5% in water. Fluid can also move across a membrane because of differences in hydrostatic pressure. The force of the pumping action of the heart at the arterial end of the capillary creates a hydrostatic pressure on the capillary wall and fluid moves from the blood vessel into the interstitial space through the semi-permeable membrane which forms the capillary wall. Therefore fluid can be moved across a membrane by one of two forces, which are osmotic pressure and the hydrostatic pressure or by a combination of pressures. Fluid Imbalances Hypervolaemia is a condition in which there is an excess of fluid volume in the extra cellular compartment. The clinical signs and symptoms of hypervolaemia are:- a) Pulmonary oedema b) Pitting oedema c) Hypertension d) J.V.P. e) Elevated BP Hypervolaemia can occur in: a) Patients who have received too much saline b) Intravenous fluid which has infused too rapidly c) In diseases such as kidney failure d) Side effects of certain drugs such as cortisone Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 37 of 135

40 Hypovolaemia is a condition in which there is a deficit of fluid in the extracellular fluid compartment. Hypovolaemia is caused by a loss of sodium and water. This occurs with conditions that produce excessive fluid loss. The clinical signs and symptoms of hypovolaemia are:- a) Postural hypotension b) Oliguria (decreased urine output) c) J.V.P. d) Dry mucous membranes e) Decreased skin turgor Electrolyte Imbalances The normal potassium level in the body is mmol/l. Hypokalaemia is a condition of low serum potassium. Excessive loss of potassium may be due to:- Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved a) Diuretics, e.g. Lasix b) Excessive infusions of IV solutions c) Conditions that cause diarrhoea/vomiting Manifestations of Hypokalaemia are a) Weakness, b) Muscle cramps c) Cardiac irregularities A seriously low potassium level may cause cardiac arrest. Hyperkalaemia is a condition of high serum potassium. A potassium level of greater than 4.5 mmol/l constitutes Hyperkalaemia. The major causes of excessive potassium levels in the body are: a) Failure to discontinue potassium supplements following cessation of diuretic b) Too rapid infusion of IVs containing potassium c) Conditions affecting the fluid balance of the body, e.g. burns, acidosis. d) Renal Failure A seriously elevated serum potassium level may lead to cardiac arrest. Sodium Imbalances The normal serum sodium is mmol/l. Hyponatraemia is a condition of low serum sodium. Major manifestations of hyponatraemia include:- a). Muscle weakness b.) Fatigue c. ) Confusion d. ) Convulsions e. ) Coma Hypernatraemia is a condition of high serum sodium. Hypernatraemia generally occurs from a loss of body fluid, which is otherwise known as hypovolaemia. 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 38 of 135

41 Acid Base: ph measures the hydrogen ion concentration of serum. Bicarbonate (HCO 3 ) which is a base and carbonic acid (H 2 C0 3 ) normally exist in body fluid. The normal ph of arterial blood is 7.35 to A ph of <7.35 indicates acidosis and a ph of >7.45 indicates alkalosis. Acidosis is a state of increased acid or decreased base. There are two main sources of normal acid in the body: a) Cellular metabolism b) Respiration Alkalosis is a state of increased base or decreased acid. The kidneys regulate the level of base, therefore if for some reason they retain base an alkalosis develops. So, alkalosis can be caused by the lungs excreting increased C0 2 (i.e. more acid lost, therefore more base retained). This may occur with a patient hyperventilating. The Importance of ph in IV Therapy: Most drugs are either weak acids or weak bases. Because of this fact, most IV drugs are not in homeostasis with the body's fluids. The potential for corrosion of the intima of the vessel is significant and should be taken into account before administration through a site. Best practice currently states that the smallest cannula size suitable to infusion need should be utilised in order to dilute the caustic chemicals as much as possible within the circulating blood around the cannula. It is also appropriate for some medications only to be given via central lines e.g. intralipids. If vasoactive medications are necessary, all attempts to infuse centrally should be made to minimise the potential of harm from infiltration. Parenteral Infusions: Drug and IV administration is essentially instantaneous but is also hazardous due to the speed of response, irreversibility, and requirements for skill and sterility. It is important for nursing staff to have a basic understanding of IV fluids and their use in compartment manipulation. A litre of 5% Dextrose given intravenously is distributed equally into all body fluid compartments. A litre of Normal Saline remains in the extracellular compartment and would be the fluid given in several clinical situations including diabetic ketoacidosis. Saline keeps water in the extracellular compartment correcting extracellular depletion. A litre of colloid with the oncotic pressure it exerts stays in the vascular compartment and pulls fluid from the extracellular space and is the treatment for hypovolaemia. Types of colloids that might be administered are blood, albumin, or pentaspan. You have completed this Module and are now ready to sit the post-module test. Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 39 of 135

42 IV Module 2B Basic Fluid, Electrolyte and Acid Base Balance / Imbalance Post Modular Test 1. Total body water is classified by similarities in composition in two main compartments: fluid and fluid. a. plasma interstitial b. intracellular extracellular c. intravascular extracellular d. plasma extracellular 2. Fluid contained within the cells of the body is called a. intravascular b. intracapsular c. extracellular d. intracellular 3. Extracellular fluid, not within cells includes primarily and fluid. a. intracapsular and intravascular b. interstitual and intravascular c. intracellular and intravascular d. intravascular and intracapsular 4. Diffusion is the movement of particles from an area of to concentration. a. low high b. high high c. high low d. low low 5. Osmosis is the movement of water from an area of concentration to concentration. a. low high b. high high c. high low d. low low Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 40 of 135

43 6. Which are the main positive electrolytes in the body? a. K Na Cl b. Cl HC0 3 HP0 4 c. Na Cl HC0 3 d. K Ca Na 7. The main negative electrolytes in the body are? a. K Na b. Cl HC0 3 c. Na Cl d. K Ca 8. A solution which has a lesser concentration of dissolved particles is known as : a. Hypotonic b. Hypertonic c. Normal d. None of the above 9. Which of the following is a hypertonic solution: a. Mannitol b. 5% Dextrose c. 50% Dextrose d. Both "a" and "c" 10. An excess of fluid in the intravascular compartment is known as: a. Hypovolaemia b. Hypervolaemia c. Interstitial oedema d. Isotonic concentration 11. A deficit of fluid in the intravascular compartment is known as: a. Hypovolaemia b. Hypervolaemia c. Interstitial oedema d. Hypotonic concentration 12. The normal potassium level in the body is: a. 4-5 mol/l b u/l c mmol/l d mmol/l 13. A low potassium level is known as: a. Hyponatraemia b. Hypocalcaemia c. Hypokalaemia d. None of the above Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 41 of 135

44 14. The most serious problem which could occur in hyperkalaemia is: a. Pulmonary oedema b. Cardiac arrest c. Rrenal failure d. Muscle weakness 15. The ph in the blood reflects: a. Potassium ion concentration b. Sodium ion concentration c. Hydrogen ion concentration d. All ion concentration 16. The normal ph of arterial blood is: a b c. 7-8 d A ph of 7.2 indicates: a. Alkalosis b. Acidosis c. Normal concentration 18. A ph of 7.6 indicates: a. Alkalosis b. Acidosis c. Normal concentration 19. Your patient has diabetic ketoacidosis and a BSL of An appropriate IV solution for intrastitial re-hydration would be? a. 50 % Dextrose b. Dextrose 4% c. Normal Saline d. Pentaspan 20. If you administer a litre of Dextrose to your patient, in which compartment will the fluid diffuse? a. Extracellular b. Intersitital c. Intravascular d. All of the above 21. Your choice of fluid for treatment of hypovolaemic shock is? a. Dextrose b. Saline c. Colloid d. None of the above Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 42 of 135

45 IV MULTICHOICE ANSWER FORM IV MODULE 2B Basic Fluid, Electrolyte and Acid Base Balance / Imbalance 1. a [b] c d e 2. a b c [d] e 3. a [b] c d e 4. a b [c] d e 5. [a] b c d e 6. a b c [d] e 7. a [b] c d e 8. [a] b c d e 9. a b c [d] e 10. a [b] c d e 11. [a] b c d e 12. a b c [d] e 13. a b [c] d e 14. a [b] c d e 15. a b [c] d e 16. [a] b c d e 17. a [b] c d e 18. [a] b c d e 19. a b [c] d e 20. a b c [d] e 21. a b [c] d e Issue Number 7 Draft Name Robyn Henderson District IV & R/T Date Approved 20/01/12 Position DON File name Std 2 Administration of IV Therapy Date Review 20/01/ Signature Page 43 of 135

46 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards RM/04/2002 STANDARD 3 Standard IV Policy Allergies Compatibility Stability Patient s prescription Calculations Drawing up the medication Explanation to patient Identifying the patient Baseline recordings Medication delivery IV Cannula IV Therapy. Administration of IV Medication Intravenous medications are administered safely in a standardised manner. The NMDHB IV policy is followed Known allergies are identified and documented clearly on the patient s medication chart and in the clinical record. Ensure all additives / medications are compatible with the existing infusing solutions, use the Notes on Injectable Drugs or online alternative as necessary Medications should be checked for stability when added to IV fluids. Only one patient s prescription can be drawn up and prepared at one time The RN s / RMs check all patient details, medication and prescription details in compliance with the NMDHB Medication Policy Medication calculations are carried out independently by two R.N./RM Aseptic technique is adhered to throughout the procedure Use of non-splash back technique Mix all medications well according to manufacturer's instructions Clearly label each syringe with date / time / medication. Needle free systems should be used Used needles are not recapped, bent or broken Used equipment is disposed of in an appropriate container The patient receives an explanation and gives consent prior to the commencement of procedure Two RN s /RMs one of whom is on the current IV Register correctly identify the patient by checking the patient s wristband details for:- Name and verbally confirm with patient where possible Hospital number And confirm the information on the patient s Treatment Chart Baseline recordings are known and recorded prior to administration, where relevant All medications are given according to manufactures instructions, medical orders, patient tolerance Medications are given by the RN/RM who has prepared and drawn up the medication Close clamp during the injection of the medication into tubing The medication is injected and or infused over a prescribed length of time The flow rate is adjusted accordingly An extension set is attached to the IV cannula The IV cannula and site of insertion are inspected and the line checked for patency prior to administration The injection port is swabbed with a chlohexidine 2% & Alcohol 70% swab Issue Number 6 Name Robyn Henderson Author District IV & R/T Committee: Date Approved 01/2/12 Position DON File name Std 3 Admin medslevel one Date Review 01/02/15 Signature Page 44 of 2

47 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards RM/04/2002 and left to dry. Labelling of metriset / bag / bottle / syringe RED Label : MEDICATION ADDED. Used for all medications other than those listed below. GREEN Label : CONTROLLED DRUGS. Used for Controlled Drugs only ORANGE Label : EPIDURALS PURPLE Label : CYTOTOXIC All to include the following details :- Name and strength of medication added Time and date Signatures of two nurses Medication Chart The medication dose and time are recorded and initialled by the RN s / RM s checking & administering the medication * split box on drug chart Side effects Flushing IV additive ports Stopping infusions of IV Medications (eg. Heparin and Insulin) When injecting IV Opioid as an infusion Community Based I.V. Medication Any adverse effects of medications are recorded, reported and the appropriate action taken When injecting medications directly into IV additive ports the cannula should be flushed :- 1. Inject a minimum of 5mls of Normal Saline prior to administering the medication 2. Inject a minimum of 5mls of Normal Saline after administering the medication The above criteria should be met Some infusions e.g. Heparin or Insulin should not be interrupted except on medical advice. Refer to IV Opioid Bolus and Infusion Policy Refer to NMDHB Home I.V. Therapy Guidelines References McClintock, A. D., Kendall, P. D., Woods, D. J., McRae, G. D., Chalmers, G. C., Orange, A. F., Livesey, J. (Eds.) (2004) Notes on Injectable Drugs. Wellington: N.Z. Healthcare Pharmacists Association (Inc). NMDHB IV Policy NMDHB Opioid Bolus and Infusion Policy NMDHB Medication Administration Policy Issue Number 6 Name Robyn Henderson Author District IV & R/T Committee: Date Approved 01/2/12 Position DON File name Std 3 Admin medslevel one Date Review 01/02/15 Signature Page 45 of 2

48 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/2010 IV MODULE 3 Intravenous Medication Objectives On completion of this module, the nurse will be able to: 1. State the safety aspects of IV medication administration in accordance with the Policy: 2. List 4 different ways in which a nurse may administer intravenous medications. 3. State the advantages of the intravenous route for medication administration. 4. Discuss 5 of the 7 major hazards that accompany the administration of intravenous medications. 5. Differentiate between therapeutic, physical and chemical incompatibilites. 6. Identify and discuss the numerous nursing responsibilities that accompany the administration of intravenous medications. 7. Discuss the 6 steps for safe and efficient administration of unfamiliar medicines Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 46 of 126

49 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/2010 Medicine Management Today, intravenous therapy is used extensively for medication administration. To promote safe administration of intravenous medications, the Registered Nurse is required to practice in accordance with Hospital Policy. The standard checking procedure for administration of IV medications is carried out is by two RN's or an RN and IV Certified 3 rd Year Nursing Student. When the medication is unfamiliar to the RN the second checker should be another RN. A written prescription is required for the administration of IV medications, except in the case of an emergency, when verbal orders may be given. The RN should use all available resources in determining the appropriateness of therapy. The nurse is accountable for safe and efficient administration of medicines, therefore if there is any doubt do not administer the medicine. IV medications may be given by nurses in the following ways, and will be discussed in greater depth later on in this module. Bolus form (i) Into the injection site of the IV tubing. (ii) Into the IV cannula via a short extension set. Via an IV bag containing a measured amount of fluid, e.g. Normal Saline mls. Via intermittent infusion - secondary infusion method. In a manually controlled IV infusion, the medication is added to the infusion solution in the bag. or Via a mechanical infusion pump, e.g. volumetric or syringe pump (preferred method). The intravenous route for medication administration offers pronounced advantages: Some medications can only be absorbed by the IV route. Certain medications cause considerable pain and trauma when given IM, therefore should be given IV. The vascular system affords a method for providing:- instant medication action faster peak times shorter time between administration and action few absorption problems Better control over the rate of administration of medications. IV route may be the only route suitable for a patient who cannot tolerate fluids and medications by the gastrointestinal route. Slow IV administration of a medication permits termination of the infusion if sensitivity occurs. Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 47 of 126

50 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/2010 Nursing Responsibilities 1. Follow procedure correctly, checking medications with the appropriate person. In accordance with NMDHB Policy. 2. Ensure written prescription is legible and clear. In accordance with NMDHB Policy. 3. Check patient history, and ask patient for any known medication sensitivities that may result in anaphylaxis. Be mindful of "first dose" risks. 4. Before giving the medication, ascertain the ability of yourself and your colleague. 5. Ensure that the medication can be given by intravenous route. Sensitivity and severe collapse may occur immediately after the medication is given. Have adrenaline, antihistamines and corticosteroids available. Refer to resource material and follow process for unfamiliar medicines. Not all medications are registered for intravenous route in New Zealand; some medications are labelled "not for IV use" or "for intramuscular use only". 6. Check the expiry date. The last day of the said month is acceptable. 7. Study the literature that is supplied with the medication particularly noting: 8. a. Dilution quantity: b. Rate to be given: c. Incompatibilities/antidotes Label all IV solutions or containers to which medications have been added. 9. Identify the patient by asking them to state their full name and date of birth. Check this against the patient's ID bracelet and the medications chart. 10. Explain: a. The procedure b. The IV medication c. The benefits 11. Check the insertion site both visually and by palpation, for signs of phlebitis, infiltration or infection. Before each medication administration, and each duty 12. Wipe the injection port and begin medication administration. Observe for general or local reactions. Usually diluted with sterile water or normal saline for injection Paediatrics: refer to departmental policies for diluent quantity. Check the medication literature for the appropriate rate. Check for the medication literature incompatibilities and antidotes for the medication. Ensure they are available. A medication label should give patient's name, medication; amount, date & time prepared and nurses signatures. This prevents the medication being given to the wrong patient. Follow the principles of informed consent. Dilute medication sufficiently and administer slowly IV cannula to be removed at first signs of redness, pain, swelling or inflammation. Should an adverse reaction occur, stop administration, notify medical staff, and be prepared to resuscitate. Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 48 of 126

51 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/2010 Hazards can be minimised by: 1. Adhering to NMDHB Medication Policy. 2. Refer to all approved resources prior to the administration of the medication to determine the usual dose, diluent, stability, route and administration rate. 3. Prepare and administer medication using an aseptic technique. 4. Needle-free systems should be used wherever possible. Needle-free components and syringes can be disposed of into white plastic waste bags. 5. Be aware of and alert to indications of a medication reaction: Observe for signs and symptoms Discontinue further administration and save used equipment Institute emergency measures as required Notify medical officer Document event in clinical notes Medication Stability The stability of a medication solution for IV administration depends on: 1. Formulation and nature of the medication. 2. ph 3. Degree of dilution 4. Period of time solution stands 5. Order of mixing (end product may be affected) 6. Light 7. Room temperature 1. Formulation & Nature of Medication The nurse generally has little to do with the formulation of an IV medication mixture. However, he/she should be aware that sterile dilutents for the reconstitution of medications are available with or without a bacteriostatic agent. The bacteriostatic agents usually consist of phenol preservatives and should be avoided with certain medications, eg Nitrofurantoin, empthericin B, and erythromycin. These medications should be reconstituted with sterile water for injection. It should also be noted that some medications are extremely unstable when in contact with ordinary plastic material, which absorbs a large percentage of the medication, eg GTN. A special PVC administration set exists for the administration of this medication. 2. ph Plays an important role in the stability of a medication. Changes in ph, occurring when solutions are mixed, can cause serious medication incompatibilities and markedly affect the stability of the medications involved. Solutions of a high ph appear to be incompatible with solutions of a low ph, and can result in the formation of free acids or bases. Eg Amoxycillin deteriorates in acid solutions [low ph]. When added to Normal Saline 0.9%, the stability of the medication is approximately 8 hours. However, when added to 5% Dextrose in water [a more acid solution] its stability is reduced to 4 hours. 3. Degree of Dilution Solubility often varies with the volume of solution in which a medication is introduced. Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 49 of 126

52 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/ Period of Time Solution Stands Decomposition of substances in solution and loss of activity is proportional to the length of time they stand. A nurse should be aware of the length of time an IV with medication additives has been infusing, as well as a prepared IV medication mixture that has been stored in the fridge. 5. Light Light may provide energy for chemical reactions to occur. Therefore, certain medications e.g. Nifedopine, once diluted must be protected from light. This can be achieved by wrapping IV sets and bottles with aluminium foil or specially made blackout material. 6. Room Temperature Heat also provides energy for reactions. After reconstitution or initial dilution, refrigeration prolongs the stability of many medications. 7. Incompatibility Incompatibility between medication formulations can occur, mainly due to changes in ph, when two solutions are mixed. Incompatibilities may be divided into three categories:- i) Therapeutic ii) Physical iii) Chemical Therapeutic Incompatibility can occur when two or more medications are added to a fluid and one medication negates the action of the other. Physical Incompatibility is an interaction between two or more medications that can be observed. A visible change in the mixture may be seen as a:- a. Gas formation b. Colour change c. Precipitation Chemical Incompatibility is an interaction between two or more medications, which you are not able to observe. Since this can go undetected, it has a greater capacity for causing biological effects. Intermittent Infusions: Bolus This technique allows medications to be given on an intermittent basis, through an existing infusion/cannula. To reduce the risk of Chemical Phlebitis follow the dilution rate recommended by the manufacturer. Secondary Infusions - set up in series with the primary infusion on infusion pumps. Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 50 of 126

53 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/2010 Normal Saline Flushing A cannula that is used for intermittent infusions or bolus antibiotics must be flushed with 10 mls normal saline, at least once a duty, to ensure patency. High Risk Medications Some medications predispose the patient to greater risks and should be given by RN's following the protocols specific to that area. Ensure that patient safety is optimised when administering medications from the following groups. Anaesthetics Antiarrhythmics Antihypertensives Arterial Medication Delivery Chemotherapy Electrolyte Infusions Epidural Heparin Infusions Hypnosedatives Insulin Infusions Neonatal/Paediatric Dosing Opioids Oxytocin TPN Vasopressors UNFAMILIAR MEDICINES When an unfamiliar medicine has been prescribed or it is identified that patient safety may be compromised due to specific monitoring and / or skill required for safe administration follow these steps 1. Do not administer the medicine 2. Obtain information about the medicine from NMDHB approved resources i.e. Notes on Injectable Medications, Medicine packer insert, NMDBH medication guidelines, New Ethicals Compendium, Pharmacist as appropriate 3. This includes: Indications Actions Uses Side-effects and adverse reactions Correct dose, rate and route Specific knowledge about the medication: appropriateness of the medication for the patient s age and condition monitoring requirements 4. If concerns are raised consult with the nurse in charge and the prescriber about: a. Knowledge and skill required to administer the medicine b. Monitoring requirements c. Workload and skill mix requirements Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 51 of 126

54 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/ If more information is required or the patient needs to be relocated then consult with the nurse in charge, senior medical officer, Pharmacist as appropriate. 6. Ensure full documentation in Patient s clinical record. For example, medication guideline, special monitoring requirements consultation process You have now completed the Level One intravenous medication therapy module and are ready to sit the Post Module Test References Intravenous Nurses Society. (2000). Policies and Procedures for Infusion Nursing. Korth-Bradley, JM. (1991). A pharmacokinetic primmer for intravenous nurses. J Intravenous Nursing;14(1): Lord, J., Mashford, M., Robertson, M. & Hipwell, C. (Eds). (1996). Guide to Parenteral Administration of Medications 2nd Edition. Sydney. New Ethicals Compendium 7 Th Edition, Auckland, Adis International. McClintock, A., Woods, D., Kendall, P., McRae, G., Chalmers, G., Orange, A. & Little, S. (Eds). (2010). Notes on Injectable Medications. NZ Health Care Association. Wellington, NZ. O Donnell, J. (1992). Understanding adverse medication reactions. Nursing 92;8: Phillips, LD. (1993). Manual of IV Therapeutics. Philadephia, PA: FA Davis,: 407. Weinstein, S.M. (1997). Plumer s Principles & Practice of Intravenous Therapy (6 th edition). Philidelphia: Lippincott. Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 52 of 126

55 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/ IV medications may be checked by IV MODULE 3 Intravenous medication Post Modular Test a) One IV certified registered nurse or midwife b) One IV certified registered nurse or midwife with another registered nurse or midwife c) One IV certified registered nurse or midwife with an IV certified 3 rd year student d) A & B e) B & C 2. An intravenous bolus may be given by a registered nurse through: a) An injection site of the IV tubing. b) An injection site inserted into an IV cannula. c) A syringe inserted directly into the vein d) A and B only 3. The intravenous drug route offers certain advantages over other routes. These are: a) Instant drug action. b) Faster peak times c) Few absorption problems d) All of the above 4. Better control over the rate of administrations of IV drugs can be provided by administering a dilute infusion over a prolonged period of time. a) True b) False 5. Nursing errors in IV drug administration may be minimised if both nurses: a) Check the name of the drug against the prescription b) Independently work out calculations c) Carefully identify the patient d) Check patient history and allergies e) All of the above 6. Intramuscular injection preparations can frequently be used for intravenous use if no other stock is available in the drug cupboard. a) True b) False Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 53 of 126

56 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/ Vascular irritations can be prevented if a nurse: a) Dilutes a drug sufficiently and gives slowly. b) Administers rapidly so that drug can be diluted into patient's bloodstream. c) Removes IV cannula every 24 hours. d) B and C only 8. The solution generally used to dilute intravenous drug preparations is: a) Dextrose/Saline b) Bacteriostatic solution c) Sterile water or normal saline d) 5% Dextrose 9. Prior to injecting IV medication the site should be checked both visually and palpated for signs of infection a) Once a shift b) Every 4 hours c) Each time medication is administered d) a & c e) b & c 10. An important factor in the stability of any IV drug is: a) ph of the IV drugs used b) Amount of dilutant used c) Type of administration set used d) All of the above 11. Decomposition of substances in solution and loss of activity is proportional to the length of time they stand. a) True b) False 12. The best way to protect an IV solution containing drug additives that are sensitive to light is by: a) Darkening the room by closing all the curtains b) Turning off all lights in a patient's room c) Changing the IV solution every hour before it has a chance to deteriorate d) Wrapping IV bag and administration set in aluminium foil or blackout material 13. An interaction between two or more drugs that can be seen by the nurse, is a definition of a: a) Therapeutic incompatability b) Chemical incompatability c) Physical incompatibility d) All of the above 14. The visible changes that a nurse may observe from the above incompatibility are: a) Gas formation b) Colour changes c) Precipitation or hazing d) All of the above Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 54 of 126

57 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/ Information concerning known drug allergies can be found documented on the: a) Nursing history form b) Medication chart c) Medical history notes d) All of the above 16 All IV solutions with drug additives or syringes containing IV drug preparation should indicate: a) Drug type and amount b) Nurse's signature c) Date and time d) All of the above 17. Which of the statements below is incorrect? a) Check and give the IV drug preparation with a second Registered Nurse, without ascertaining your colleague's abilities. b) Check the patient's name and number on the drug order sheet against the name and number on the patient's identification band. c) Be able to read clearly the doctor's written instructions. d) Draw up the correct drug dosage as charted by the doctor 18. To keep an IV cannula patent, if an infusion is not attached the nurse should: a) Flush the IV cannula with IV normal saline 8 hourly. b) Flush the IV cannula with normal saline twice each duty. c) Flush the IV cannula with normal saline daily. d) None of the above. 19. When administering any form of intravenous therapy or IV drug, it is important for the nurse to explain to the patient: a) Why the drug is being given b) The effect the drug may have on the patient c) The name of the drug and duration of treatment if known d) All of the above. 20. The expiry date of a drug normally refers to the day of the month: a) First b) Last c) 20 th d) 10 th Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 55 of 126

58 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/ When using an intermittent infusion, the level of the primary infusion is: a) Not important b) The same height as the secondary infusion c) Higher than the secondary infusion d) Lower than the secondary infusion 22. The flow of fluid from the secondary bag is controlled by: a) Kinking the primary infusion b) The clamp on the secondary infusion c) The clamp on the primary infusion d) Height only 23. Some unfamiliar medications require specific monitoring and safety requirements, it is the nurses responsibility to: a) Check available resource material b) Consult re appropriate location for administration if requires specific monitoring c) Discuss with pharmacist d) Complete full documentation in clinical record e) All of the above 24. Needle free / needleless system components can be discarded into a) Yellow sharps container b) Yellow rubbish bag c) White rubbish bag d) Any of the above Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 56 of 126

59 NELSON MARLBOROUGH DISTRICT HEALTH BOARD: NMDHB IV standards STD/03/2010 IV MULTICHOICE ANSWER FORM Intravenous Drug Therapy MODULE:3 1. a b c d [e] 2. a b c [d] e 3. a b c [d] e 4. [a] b c d e 5. a b c d [e] 6. a [b] c d e 7. [a] b c d e 8. a b [c] d e 9. a b c [d] e 10. a b c [d] e 11. [a] b c d e 12. a b c [d] e 13. a b [c] d e 14. a b c [d] e 15. a b c [d] e 16. a b c [d] e 17. [a] b c d e 18. [a] b c d e 19. a b c [d] e 20. a [b] c d e 21. a b c [d] e 22. a b [c] d e 23. a b c d [e] 24. a [c] d e Issue Number 6 Name Robyn Henderson Author District IV & R/T Educator/IV Coordinator Date Approved 12/01/12 Position DONM File name Std 3 Admin medslevel Date Review 12/01/15 Signature Page 57 of 126

60 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Blood/04/2010 STANDARD 4 Standard IV Therapy : Blood / Blood Products Transfusion Blood and Blood products are stored and issued in an approved manner and are administered in a standardised manner by two Registered Nurse s / Midwife s one of whom is on the current IV Register The second checker may be an IV certified student nurse under DIRECT supervision of the RN Religious beliefs Patient Rights Request for Cross-Match There is an awareness of religious beliefs of the patient which might make a transfusion unacceptable, and this is demonstrated in the documentation In accordance with NMDHB Consent policy and the Code of Health and Disability Consumers Rights written informed consent must be obtained by the medical officer prior to the administration of blood or blood products. Blood samples taken for cross-match must be hand labelled at the patients bedside with a minimum of surname, first name, DOB and/or hospital number, date, time and signature. All questions on the request for blood form must be completed including questions on history of transfusion and pregnancy. Issuing of Cross-Matched Blood Working Hours Non-Working Hours Issued by Laboratory staff to collector. R.N /RM/ EN /student nurse/orderly Collection from cross match fridge only by MO/RN/RM who has completed the required laboratory training programme. Documentation check Only one unit of blood per patient is removed at any one time (unless specifically requested by Medical staff, in instances of emergency or surgery) Only units bearing a cross-match label are removed NB : Blood Products can only be removed by staff approved by the Laboratory Staff NB : Emergency Blood Group O/Rh negative blood is available for life threatening emergency use at the express request of the medical Staff Remove the blood from the Blood Bank cross match fridge and check the following against the details on the Blood Transfusion sheet :- Full name Hospital Number (if available) Date of Birth Check blood unit number on the front of the bag with that on the compatibility label plus expiry date Remove detachable butt from the bag, fill in date / time and sign Leave butt in the folder NB : It is your responsibility to question any discrepancy on the Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 58 of 4

61 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Blood/04/2010 compatibility label and details on the patients transfusion sheet NB: Blood for transfusion is supplied as re-suspended red cells, whole blood is not available. Storage Transfusion time Blood for transfusion is not to be stored in the ward fridge, but should not be kept at room temperature for any longer than 30 minutes before being administered to the patient The transfusion should not take any longer than 4 hours as there is a risk of bacterial proliferation. It is recommended that blood transfusions are not carried out after 2200hrs unless particularly indicated. Giving sets/filters Use standard blood filter (200 microns) for all RBC and fresh frozen plasma given via a pump set as they remove gross fibrin clots The filter is changed after every two units of blood and the filter and giving setl are discarded at the end of the transfusion. Use of IV Pumps Priming set Patient s identification Prescription Cross-match label If a gravity set is used with the 200micron in-line filter an additional blood filter is not required. Use of filters for other blood products is detailed in module 4 Approved pumps: Alaris GP.. Consider using for all at risk patients. Giving sets may be primed with Normal Saline prior to transfusion, if required The patient s identification is checked at the bedside by either :- Medical Officer & RN/RM Two RN s /R M s The wristband details must match those on the Blood Transfusion Form and the cross match labels The patients identification should also be verbally confirmed with the patient whenever possible Prescription details are checked for:- Type of blood product Quantity of blood to be administered Length of transfusion time Attach in the order administered to the back of the Blood Transfusion form after the unit is commenced, completed or abandoned Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 59 of 4

62 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Blood/04/2010 Baseline Observations Monitoring Base line observations are recorded of :- Blood pressure Pulse Temperature Respiration s The following monitoring is carried out during the transfusion:- 1 st 15 minutes (stay with patient) Begin Transfusion slowly Monitor for signs of incompatibility (in emergency situations the transfusion may be administered rapidly under the direction of a Medical Officer) Record all vital signs Every ½ hour Record pulse and respiration s Every 2 hours Record temperature and BP (until the transfusion is completed) Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 60 of 4

63 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Blood/04/2010 A reaction may be recognised as any, or a combination of any of the following new signs or symptoms Signs of a transfusion reaction Temperature > 38.5C Chills Headache Nausea and vomiting Non-productive cough Hypotension Chest pain, feeling of restriction Dyspnoea Anxiety and or restlessness Skin rash Lower back pain and or joint pain Flushing Haematuria Oliguri / anuria Shock Severe gastro-intestinal disturbance Severe respiratory and cardiovascular collapse If reaction occurs STOP transfusion immediately and take the following steps :- IV Medication take and record vital signs inform Medical Officer keep line open with Normal Saline check compatibility details collect specimens as directed document details of the reaction on the Blood Transfusion Reaction form and send, with the remainder of the unit of blood to the Laboratory (along with any specimens) complete online reportable event form and record events in patient s notes It is preferable not to give IV medication during an infusion but, if it is necessary to do so the following procedure should be followed:- Stop transfusion Flush with a minimum of 10mls Normal Saline Give medication Flush with a minimum of 10mls Normal Saline Recommence transfusion Fluid Balance Chart Unused blood and empty blood bags Transfusion details are entered on the Fluid balance chart, including flushing and medication volumes Empty blood bags from uncomplicated transfusions may be disposed of as Controlled waste (NMDHB waste disposal policy). All unused cross-matched blood is to be returned to the Blood Bank in the red bag it is issued in. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 61 of 4

64 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Blood/04/2010 Blood bags where a post transfusion reaction is suspected must be returned to the Laboratory as per the infection control policy returning used blood blood product bags. If for any other reason there is sufficient residual blood remaining in the blood bag that it may leak when compacted must be disposed of as Infectious waste (NMDHB waste disposal policy) References NMDHB Waste Disposal policy NMDHB Returning used blood blood product bags policy Alexander, M. (ed.). (2006) Infusion nursing standards of practice supplement to Journal of Infusion Nursing, January/February, 29 (1S). Norwood:Lippincott Williams & Wilkins. Corkery, C. (2005) Why hand-label blood specimens. The Dissector 33(1). New Zealand Standards Infection Control Standards NZ :2008 Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 62 of 4

65 Blood / Blood Products Transfusion Therapy IV MODULE 4 Objectives: On completion of this module, the nurse will be able to: 1. Administer blood in accordance with the safety practices and policies of Nelson Marlborough District Health Board. 2. List factors which contribute to safe transfusion therapy. 3. Understand the basic science of immunology. 4. Identify factors that govern red cell destruction. 5. Differentiate between the 2 major blood group systems and discuss the pertinent factors relating to each. 6. Identify the 3 main objectives of transfusion therapy. 7. List the blood/blood products and plasma substitutes used regularly in this hospital. 8. Discuss the maintenance advantages and disadvantages about the variety of blood and blood products available. 9. Differentiate between the 2 types of plasma substitutes used in this hospital. 10. Describe the procedure for issue and transfer of blood used in this hospital. 11. List all factors that must be checked before blood is issued and administered. 12. State the correct procedure for handling blood. 13. Differentiate between the varying transfusion reactions and their appropriate treatment. 14. List in order of priority the nursing action to be taken if incompatibility is suspected. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 63 of 4

66 Transfusion Therapy Introduction With the increasing use of blood and its components, transfusion therapy has become an integral part of the daily treatment of patients. Administration of blood products should be performed by competent, wellqualified personnel acting in accordance with the IV policy. Serious problems and complications that can lead to death are associated with the administration of blood and its components. The registered nurse shares with the laboratory and medical personnel a responsibility for safe transfusion therapy and must recognise and understand the symptoms of untoward reactions. Written informed consent must be obtained prior to the administration of blood or blood products. Proper handling of blood is vital. Contamination must be avoided; haemolysis must be prevented. The registered nurse should be familiar with a large variety of available blood products - their advantages, disadvantages and proper procedures for their safe administration. Recognition of the factors that govern red cell destruction (haemolysis) and understanding why sensitivities occur contributes to safe transfusion therapy. Basic lmmunology Immunology is the science that deals with antigens of the blood and their antibodies. Antigens come from 2 sources: a) Inherited body cells eg. Blood groups; b) Foreign substances to the body eg. Toxins, bacteria, viruses. Antigens are both inherent within body cells [eg Antigen A in Blood Group A] and in foreign substances to the body eg toxins, bacteria, viruses. Blood group Antigens are: Found on the surface of the red cell, Are inherited Are glycoproteins or glycolipids Can invoke an immune response Antibodies are also referred to as agglutinins. They are the body's defence mechanism to fight the antigen. Proteins in the plasma React only with their specific antigen found on red cells. Occur naturally (inherited) and can may result from immunisation Cause agglutination in the presence of red cells with the corresponding antigen The severity of an antibody antigen reaction can: 1. Be absorbed onto the red blood cells. This is known as coating and is a mild reaction. 2. Cause the red cells to stick together. This is known as agglutination and is a moderate - severe reaction. 3. Cause the red cells to burst, thereby releasing their haemoglobin. This is known as haemolysis and is a very severe reaction. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 64 of 4

67 ABO System. Blood can be grouped into 4 Blood groups: A, B, AB and O 1. Group A contains antigen A on the red cell and Antibody B in the plasma thus may receive red cells from groups A and O 2. Group B contains antigen B on the red cell and Antibody A in the plasma thus may receive red cells from groups B and O 3. Group AB contains antigen A and B on the red cell and does not have any corresponding Antibody in the plasma thus may receive red cells from groups A, B, AB and O. (Universal receiver) 4. Group O contains no antigens on the red cell but has both Antibody A and B in the plasma. It must receive red cells from group O only. In emergency situations group O may be administered to any other blood group until the ABO grouping is known. When blood for a transfusion is crossmatched, the donor's red blood cells are checked for compatibility with the recipient's plasma. The recipient's plasma should not contain antibodies that will react with the antigen in the donor's red cells. If this does happen, the donors red cells will agglutinate and subsequently haemolyze (disintegrate). Clumps of agglutinated cells could block vital small blood vessels (e.g. in the brain) and the haemoglobin (Hb) released by their disintegration, once in the blood could lead to kidney failure. This is known as a haemolytic transfusion reaction. The table below shows which blood groups can be given to recipients and which blood groups cannot, (i.e., which will cause agglutination). RECIPIENT Group Antigens Cell Antibodies Plasma O 45% None Anti-A Anti-B CANNOT RECEIVE [ie will cause agglutination] Group A Group B Group AB A 40% A Anti-B Group B Group AB B 10% B Anti-A Group A Group AB Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 65 of 4 CAN RECEIVE Group O only Group A Group O Group B Group O AB 5% AB None Group A Group B Group AB Group 0 All people receiving blood must have a blood grouping done (which takes approximately 1 minute) as opposed to cross matching, no matter how urgent the situation. Emergency blood (Group 0-ve) maybe administered on medical orders, in extreme emergencies while blood grouping is done.

68 The Rhesus Factor There are approximately 50 known Rh antigens; antigen D is the factor of concern in transfusion therapy. Rh +ve: antigen D found on the red cells. About 85% of the population Rh ve : no antigen D found on the red cells About 15% of the population Rh ve blood can be administered to Rh +ve types Rh compatibility is extremely important in women of childbearing age. If Rh+ve cells are transfused into a Rh-ve individual, antibodies to the Rh+ve cells may be formed in the blood of the Rh recipient. These antibodies are formed relatively slowly, and do not affect the Rh+ve cells of the first transfusion. If a second transfusion of Rh+ve cells is given to the same Rh-ve individual, then the antibodies produced previously will cause agglutination and haemolysis of the donor cells. Blood collection All blood used in New Zealand is collected by the NZ blood service. All blood donations are screened for AIDS/HIV virus antibodies, Hepatitis B&C and syphilis Objectives of Transfusion Therapy There are three main objectives of transfusion therapy. Maintenance of blood volume. Maintenance of oxygen-carrying capacity of the blood by supplying red blood cells. Maintenance of coagulation properties by supplying the clotting factors. A transfusion of 4-5ml per Kg will increase the circulating haemoglobin by about 10g/l. Transfusion therapy is also vital when blood exchange is imperative, as in the treatment of newborn infants with haemolytic anaemia. In order to achieve the above objectives, the nurse should have a good knowledge about the various products available. These are:- Re-suspended red cells - packed cells + red cell preservative solution. Used to increase tissue oxygenation when critically reduced either by loss of blood or anaemia of other origin Whole blood - special circumstances only. (See below Plasma and plasma components - 1) fresh frozen plasma - used to replace coagulation factors and other plasma proteins when the concentration or activity of these proteins is critically reduced 2) Cryoprecipitate used to replace fibrogen a component of the coagulation system Also Plasma substitutes (non blood products)- eg Voluven 6 %, Gelofusion Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 66 of 4

69 Re-suspended Red Cells Re-suspended red cells are prepared by the removal of all plasma from whole blood. A red cell preservative solution containing sodium citrate and dextrose that will allow blood to be stored for a period of up to 35 days is then added, which increases the volume to mls. As blood gets older, the number of red cells die, proportionately. This means that a unit of blood stored for 35 days would have lost a third of its oxygen carrying red cells. (Therefore, some old blood and fresh blood are used, especially in the case of non-urgent transfusions requiring 3 to 4 units of blood.) Coagulation factors are also affected by the age of the blood. After a week, 50% of clotting activities have been lost. Therefore, if the major objective is to replace clotting factors, fresh frozen plasma/cryoprecipitate should be used in consideration with platelets if required. The advantages of re-suspended red cells are:- 1. A reduced volume allows the infusion of oxygen rich red cells without overloading the circulation. 2 Removal of plasma, which contains leukocytes, greatly reduces the chance of a febrile reaction from occurring. 3 All Re-suspended Red Cells in New Zealand are now leukocyte depleted. This has the advantages of: Reduce incidence of urticarial and anaphylactic reactions Minimal incidence of febrile non haemolytic transfusion reactions Prevents transmission of cytomegalovirus (CMV) or other human white cell antigens NB Sepa -a-cell (leukocyte depletion) filters are not longer required as all Red Cells in New Zealand are now leukocyte depleted. Whole Blood Whole blood is not stocked in Nelson & Wairau hospitals, but can be obtained from Christchurch. In special emergency situations, e.g. massive bleeding, use a combination of re-suspended red cells and, fresh frozen plasma and platelets. Fresh Frozen Plasma For storage plasma is frozen and is referred to as fresh frozen plasma. This is stocked at Nelson and Wairau hospitals. It is stored frozen, and is thawed rapidly at 37 immediately before use by approved personnel. This takes approximately 30 mins. Then it must be used within 24 hours of thawing. It contains coagulation factors including Factor VIII. It is particularly useful in massive transfusion situations to replace lowered levels of coagulation factors Check units and administer as per Blood Administration Standards Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 67 of 4

70 Cryoprecipitate This is stocked at Nelson and Wairau hospitals. It is stored frozen, and is thawed rapidly at 37 immediately before use by approved personnel. This takes approximately 20 mins, the transfusion should then be commenced immediately. Main use is to replace fibrogen following major blood loss. Administration of Blood and Blood Products Blood Administration and special nursing responsibilities that accompany it. The patient s safety depends upon adherence to specific rules regarding safe administration. The nurse is responsible for the following: 1. Patient - blood identification. The avoidance of mistaken identity is imperative. 2. Inspection of blood prior to administration to avoid infusing the patient with hemolyzed, clotted or contaminated blood. 3. Proper technique in handling and administration. 4. Close observation of the patient. Early detection of symptoms of a reaction is important. Severe reactions will occur almost immediately. Issue and Transfer A request form for crossmatched blood (or any blood product) is completed out by the doctor and sent to the laboratory. Information on the form must include the patient's name (surname and first names),dob, hospital number, clinical details, amount of blood, and time needed. Blood is prescribed on the IV fluid chart. If uncertain whether blood will be needed, e.g. theatre cases, then a Group and screen is all that is required. This means that a blood specimen will be retained in the laboratory for generally 3-7 days in the event that a crossmatch is required. All cross match and group and hold samples must be hand labelled with the minimum labelling requirements of: surname, first name, date of birth and or hospital number, date, time and signature. The only acceptable labelling for transfusion samples will be hand written. A collection form for blood products must also be filled out with a patient's name, identification number and blood group. This form must be brought to the laboratory every time crossmatched blood or blood products are collected and the details filled in accordingly. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 68 of 4

71 Details of blood product's collected must be written in the Blood Products Book. During normal laboratory hours, the laboratory staff will issue the blood products to the collector (nursing staff / orderly/ technician). Outside of laboratory hours, only Registered Nurses and Medical Officers (approved by respective laboratories) may take cross - matched blood from the blood bank. Other blood products e.g. Prothrombinex, Intragam can only be collected by the after hours Duty Managers who have completed laboratory QA training Blood - Patient Identification Factors Factors that must be checked in the laboratory (during laboratory hours) between two authorised personnel, before blood is issued are:- Patient's name, DOB, hospital number and blood type (if known), is found on the collection form, and checked against the same identification factors on the blood bag. Blood identification number on blood compatibility tag checked against the blood identification number on the blood unit itself. Expiration date. Factors that must be checked between two registered nurses at a patients bedside prior to administration against the IV fluid order:- 1. The patient's name, DOB, and identification number on the collection form and blood bag checked against the name and number on the patient's identification bracelet. 2. Blood type, blood group, expiry date and blood unit number. Blood cannot be administered to a patient who is without an identification bracelet. (Except in an emergency). Handling Blood To prevent excessive warming, only one unit of blood should be taken at a time except in certain emergencies. Transfusion MUST commence within 30 minutes of the time it leaves the bank. If it cannot be administered immediately, it MUST be returned to the blood bank within this time. Blood MUST never be placed in ward refrigerators. If warm blood is ordered, only special blood warming devices (e.g. Hamilton Blood Warmer) that maintain a controlled temperature of between C should be used to warm the blood in the tubing during administration. Recommended when large volumes of blood are given over a short period of time Hot water must NEVER be used to heat blood. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 69 of 4

72 Rapid Transfusions Responsibilities for ordinary blood infusions are covered systematically throughout the module. However, it should be pointed out that whenever five or more units of blood are required rapidly or when 10 units are given within 24 hours, the use of fresh frozen plasma should be considered, to replace coagulation factors. Normal saline injection (20-50ml) should be used to flush the tubing (over 5-10 min) before initiating or terminating a transfusion, and before any other intravenous fluid is commenced. If normal saline is the first IV solution to be recommenced, then flushing the tubing with normal saline is unnecessary. If the line is contaminated, replace with new line. If there is more than one unit of blood administered, saline need only be infused at the completion of all blood. It is also unnecessary to use saline if the cannula is to be removed. Blood or blood products MUST never be hooked up with 5% Dextrose in water, or run simultaneously with 5% Dextrose in water through a dual injection site. Medication during Blood Transfusion Medication MUST never be added directly to blood or administered simultaneously through the same set. If medications need to be given during blood administration, form a saline lock by: a. Stopping the blood, b. Flushing with 10ml of Normal Saline c. Administer medication via bolus d. Flush tubing with 10ml Normal Saline. e. Recommence blood. Blood Filters - Ordinary Transfusions A pyrogen free micron blood filter must be used for the administration of all whole blood. Resuspended red cells, and fresh frozen plasma/cryoprecipitate. The filter should be compressed and then inserted into the blood bag. Squeezing the filter after insertion can introduce air into the bag. If the filter is not completely covered with blood, slight compression of the bag will fill it. Therefore fill the filter to 3/4 full, above the mesh. Utilising the entire filter results in a much improved flow rate. A single filter may be used to infuse 2 units of blood. Once the blood filter contains debris, it should be discarded. Cannulation A moderate to large vein should be selected for administration of blood or blood products. Blood needs to be administered through an gauge cannula in adults. It is advisable to used a volumetric pump with a smaller size cannula Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 70 of 4

73 Rate of Transfusion The rate of infusion is governed by the patient's clinical condition and the type of blood product being infused. Blood MUST always be infused within four hours because of the danger of bacterial proliferation and red cell haemolysis if kept at room temperature. Calculation of rate is done using the same method as that used for IV's. Carefully monitor the site if blood administration requires a pressure bag or pump. Plasma Components Plasma is the liquid portion of the blood and is a protein-salt solution in which Red and White Blood cells and Platelets are suspended. Plasma, which is 90% water, constitutes about 55% of blood volume. Plasma contains: Albumin - the chief protein constituent Fibrinogen - responsible in part, for the clotting of blood Globulin's - including antibodies and other clotting proteins Plasma serves a variety of functions, from maintaining a satisfactory blood pressure and volume to supplying critical proteins for blood clotting and immunity. It also serves as the medium of exchange for vital minerals such as sodium and potassium. Commonly used plasma products include 1. Fresh frozen plasma 2. Platelets 3. Human serum albumin 4. Cryoprecipitate (Fibrinogen & other coagulation factors) The following table summarises the blood products used in NMDHB hospitals Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 71 of 4

74 Summary Chart of Blood Products Product Indication for use volume Storage In Laboratory Platelets Order as required. Allow 6-8 hours to arrive (2 units held in Nelson) Platelet replacement where quantitative or qualitative deficiency is causing or may cause significant haemostatic response ml Store at 20 C to 24 C. with agitation in a 'rocker' Filter required Yes via infusion set with micron inline filter Administration* Precautions / contraindicati ons Intravenous infusion - complete each unit within 30 minutes Acute transfusion reaction may occur if incompatible or contaminated platelets are transfused Cryoprecipitate contains blood clotting substitutes for seriously ill patients Fibrinogen deficiency Von Willebrand disease ml per unit Store frozen Thaw rapidly at 37 C Yes 200microns in-line filter Intravenous infusion - completed promptly and within 4 hours of thawing Excessive volumes may lead to circulatory overload Haemophilia A FFP Replacement of coagulation factors and other plasma proteins ml Store frozen Thaw at 37 C Yes micron inline filter Infuse over 30 minutes to 4 hours Allergic reaction may occur. Excessive volumes may lead to circulatory overload AHF - Factor V111 For the treatment of factor V111 deficiency due to Haemophilia A Vials of 250 IU or 500 IU Refrigerate 2 C - 8 C Protect from light. Do not freeze New Filter needle for each bottle when Reconstituti ng Reconstitute with 10ml H20, gently agitate to avoid frothing- may take 10 mins. Slow IV injection - 3ml/min rare Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 72 of 4

75 Albumex - 4. (Isotonic) 4% Albumin solution is used for the treatment of shock, in emergencies and in kidney failure 500ml Store below 30 C. Do not freeze No IV infusion via standard giving set Requires a filtered air vent Side effects usually mild and transient Albumex (Hypertonic) 20% Albumin solution is used for patients with ARDS, kidney disease, liver disease and burns 100ml Store below 30 C. Do not freeze No IV infusion via standard giving set Requires a filtered air vent. Usual rate 2ml/min Excess human albumin may lead to circulatory overload Side effects usually mild and transient Prothrombinex contains concentrated clotting factors and can be used for the treatment of Haemophilia B (Christmas disease) And warfarin overdose Vials of 500 IU Freeze-dried powder. Refrigerate 2 C - 8 C Do not freeze New Filter needle for each bottle when reconstituting Reconstitute with H20 provided, gently agitate to avoid frothingmay take 10 mins. Slow IV injection - 3ml/min rare Intragram - p. is used to boost the immune system, such as following a bone marrow transplant and for immune deficiency disorders 50ml, 200ml, Refrigerate 2 C - 8 C Protect from light. Do not freeze No Via normal giving set and volumetric pump IV infusion Undiluted or diluted with up to 4 parts of normal saline. Commence at 1ml/ min. After 15min inc. rate to 3-4 ml/min. over a further 15 min. Monitor vital signs Reactions tend to occur during the first hour of infusion. Side effects include headache, tingling feet, chest discomfort, cramps in hands & classic allergic reactions Rarely - anaphylaxis. Synthetic Plasma Substitutes These are two types of synthetic plasma substitutes currently being used: 1. Voluven 6% 2. Gelofusine Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 73 of 4

76 Gelofusine is a plasma volume expander used for the treatment of hypovolaemic shock. It can be stored for approximately eight years at room temperature Because of its synthetic nature, there is in no danger of transmitting Hepatitis/HIV. Rate of infusion is directly related to level of blood pressure. Experience has shown that when used for large loss of blood and pronounced shock, rapid infusions are tolerated without reaction. Voluven 6% also a plasma volume expander used for the treatment of hypovolaemic shock Its affects are longer lasting - up to 8 hours. It can be used as a prophylactic treatment for: 1. Shock in surgery and 2. Post-op or post-traumatic thromboembolism. When introduced into the blood stream, Haemohes increases the osmotic pressure, draws interstitial fluid into the vessels and increases the blood volume. Similar to Gelofusine it has two advantages over blood and blood products. 1. No storage problem 2. No danger of transmitting Hepatitis/HIV because of its synthetic nature. The physician orders the rate of flow. Rapid infusions may cause circulatory overload due to its osmotic activity. Numerous risks are involved with rapid transfusions, e.g. 1. Circulatory overload with pulmonary oedema 2. Citrate toxicity 3. Cardiac arrest 4. Air embolism After the transfusion is initiated, the nurse should observe the patient as dictated in standard 3. Fatal incompatible transfusion reactions produce symptoms early in the course of the infusion. Transfusion Reactions With every unit of transfused blood, there is still an inherent risk of a transfusion reaction. The nurse should be aware of this fact and be alert to symptoms of untoward reactions. Whenever a transfusion reaction is suspected, the transfusion should be stopped and a Medical Officer contacted for assessment and further instructions before the transfusion is continued or terminated. Depending on the Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 74 of 4

77 type of reaction, it may be possible to give medication and continue the transfusion. The blood bag should be sent, intact, back to the laboratory for analysis, with a report of the reaction. Refer to NZ Blood Service poster "Guidelines for Management of Adverse Transfusion Reactions' jtransfusion reactions may be divided into three main classes: endogenous, exogenous and delayed. A Endogenous Reactions Are those caused by antigen-antibody reaction in the recipient and brought about by the body's response to foreign protein. We will discuss: 1. Haemolytic reactions 2. Febrile reactions 3. Allergic reactions. 1. Haemolytic Reactions Occurs when there is an antigen-antibody reaction in the recipient due to an incompatibility between red cell antigens and antibodies, the antibody combines with red cells possessing the corresponding antigen. The most serious major incompatibility occurs between the recipient's antibodies and the donor's red cells. There are two types of red cell destruction: 1. Intravascular haemolysis in which sensitised red cells are destroyed with haemolysis directly in the blood stream (usually seen in ABO incompatible red blood cells) and 2. Extravascular haemolysis in which the cells are coated with the antibody and subsequently removed by the reticuloendothelial system (as in Rh incompatibility). Intravascular Haemolysis Signs and Symptoms Treatment Virtually all fatal shock by blood transfusion reactions are due to incompatibilities with the ABO blood group system and occur within the first five minutes. The most common cause in an improperly identified recipient blood sample sent to the Laboratory for typing and crossmatching, an improperly identified blood unit or improperly identified blood recipient Chills Fever Flushing of face Burning sensation along vein in which blood is being infused Lumbar and flank pain Chest Pain Frequent oozing of blood at injection site and surgical areas Shock - severe Haemoglobinaemia Haemoglobinuria This is life threatening 1. Stop infusion. 2. Alert emergency response team. 3. Administer IV Normal Saline as ordered and observe for circulatory overload caused by rapid infusion of dilute IV fluids. 4. Colloids maybe ordered 5. Vasosupressors are usually reserved for life threatening situations 6. Peritoneal or haemodialysis may be initiated if renal failure occurs Extravascular haemolysis is manifested by symptoms similar to, but usually less severe than, those for acute intravascular haemolysis. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 75 of 4

78 2. Febrile Reactions Febrile reactions are usually the result of leukocyte antibodies in the recipient directed against the donor's white cells. Rare today as all red cells are leukocyte depleted Patients who have been sensitised to platelet and plasma proteins by numerous transfusions may also have febrile reactions. Febrile symptoms tend to occur late in the transfusion or may occur even after the blood has been infused. The reaction is characterised by flushing of the face, palpitations, cough, tightness in chest, increased pulse rate, chills and fever not lasting more than 8 hours. The treatment is symptomatic. 3. Allergic Reactions Allergic reactions are manifested by urticaria or hives and occasionally are accompanied by chills and fever. Severe reactions may occur with asthmatic symptoms, fever and anaphylactic shock. The infusion should be stopped immediately, on the appearance of any of these symptoms. Treatment consists of administration of antihistamines. Adrenaline or steroids are used in the most severe cases. Following administration of antihistamines, adrenaline or steroids, the transfusion can usually be continued although replacing the unit is often indicated. Delayed Haemolylic Reaction The immune antibody, (produced by the body's response to a foreign antigen in a previous transfusion), is weak and undetectable at cross-match. It is stimulated and increases in strength 2-7 days post transfusions and reacts with the corresponding antigen on the donor's red cells in subsequent transfusions. When the donor's red cells (possessing the corresponding antigen) are infused, they provoke an immune response that rapidly increases antibodies, followed by increased destruction of the transfused cells. The incompatible red cells survive until there is ample antibody to initiate a rejection response. This reaction may be clinically severe with mild anaemia, haemolysis, and an increase in bilirubin occurring 2-11 days after transfusion. A direct Coomb's test may detect the antibody. Other manifestations may include fever, splenomegaly and rarely haemoglobinaemia or haemoglobinuria. B Exogenous Reactions Exogenous reactions are those caused by external factors in the administration of blood, antigen - antibody reactions are absent. We shall discuss circulatory overload, air embolism, hypothermia and citrate toxicity. 1. Circulatory Overload Circulatory overload may occur when blood is infused too rapidly or given to a recipient who has heart failure or an increased plasma volume. Venous pressure will increase if the blood is infused too rapidly. This is especially true in the elderly. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 76 of 4

79 Monitoring the venous pressure guards against over transfusion. The use of packed cells to infuse patients with normal blood volume may prevent overloading. The patient may complain of pounding headache, chest constriction, SOB or dyspnea. The nurse should stop the transfusion, flush with N/Saline to keep line patent, elevate the head and notify the doctor. 2. Air Embolism Air embolism may occur when large amounts of air enter the blood stream, causing tenacious bubbles in the blood to become lodged in the pulmonary capillaries. It may result from faulty technique in changing equipment, careless use of dual injection site and the use of pressure for rapid blood infusion. Air embolism can also occur when using air-vented blood products such as albumin. Symptoms are: cyanosis, dysponea, shock and sometimes cardiac arrest. The infusion should be clamped immediately, the patient turned on the left side, head down. This position traps the air in the right atrium, preventing it from entering the pulmonary artery; the pulmonary valve is kept clear until the air can escape gradually. The doctor is notified. 3. Hypothermia Hypothermia may occur from rapid, massive replacement of cold blood, such an infusion can result in chills, peripheral vasoconstriction and cardiac arrest. Warming blood to 35 C with automatic blood warmers during rapid, massive transfusion prevents hypothermia. Blood administered through a central line must be warmed with a blood warmer. When any patient receives more than 2 units of blood, strong consideration should be given to the use of a blood warmer 4. Citrate Toxicity Citrate toxicity may result from the rapid infusion of large quantities of citrate blood to patients with severely impaired liver function. The liver is unable to metabolise all the citrate ions, which combine with calcium in the blood stream, causing a calcium deficit. Symptoms of excess citrate: tingling of fingers, muscular cramps, convulsions, hypotension and cardiac arrest. Most of the symptoms are absent in the anaesthetised patient, making detection of toxicity difficult. Treatment consists of slow administration; by a doctor, of ionised calcium, e.g. calcium chloride. C. Delayed Reactions Delayed reactions may occur up to 160 days after the infusion, and are the result of transmitted disease or iso-immunisation. Infection risks Routine Blood Precautions are required when performing a blood transfusion. As some patients with HBV, HBC or HIV will be unsuspected or unconfirmed, normal practices must be sufficient to minimise risk even in unknown cases. For this reason, "Standard Precautions" should apply to all potential blood and body fluid contact. It is recommended that clinical staff are vaccinated against Hepatitis B immunisation as per Nelson Marlborough Health District Health Board policy. You have now completed this module, and are ready to sit the post-modular test Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 77 of 4

80 References Anthony, H. & Havoras, J. (1993). Managing Transfusion reactions. Registered Nurse. 56(12): Baranowski, L. (1991). Filtering out the confusion about leukocyte-poor components. Journal of Intravenous Nursing. 14(5): Cook, LS. (1997). Blood transfusion reactions involving an immune response. Journal of Intravenous Nursing. 20(1): Corrigan, A., Pelletier, G. & Alexander, M. (Eds). (1999). Core Curriculum for Intravenous Nursing 2nd Edition. Philadelphia. Lippencott Williams & Wilkins. Dougherty, L. & Lamb, J. (1999). Intravenous Therapy in Nursing Practice. London. Churchill Livingstone. Intravenous Nurses Society. (2000). Policies and Procedures for Infusion Nursing. Josephson, D.L. (1998). Intravenous Infusion Therapy for Nurses-Principles and Practice. New York. Delmar Publishers. New Zealand Blood Service. (2000). NZBS Clinical Compendium. Auckland, New Zealand. New Zealand Standards Infection Control Standards NZ. 8142: Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 78 of 4

81 IV Module 4 Transfusion Therapy Post Modular Test 1. In the blood group system known as ABO, an individual may have cell antigens which are:- a) Found on the surface of the red cell b) Are inherited c) Can invoke an immune response d) Any of the above 2. Antibodies are: a) the bodies defence mechanism to fight antigens b) react only with their specific antigen c) cause agglutination in the presence of red cells with the corresponding antigen d) all of the above 3. If Rh positive cells are transfused into a Rh negative individual, antibodies will be slowly formed in the plasma of the Rh negative recipient. a) True b) False 4. In an Rh negative individual, agglutination and haemolysis of the donor Rh positive cells will occur on the a) lst transfusion b) 2nd transfusion c) Will not occur d) All of the above 5. The objectives of transfusion therapy are to:- i) Maintain blood volume ii) iii) Maintain oxygen carrying capacity of the blood by supplying red cells. Maintain coagulation properties by supplying the clotting factors. a) i) and ii) only b) ii) and iii) only c) i), ii), and iii) d) i) only Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 79 of 4

82 6. The solution remaining after the plasma has been removed and a red cell preservative added, is known as:- a) Amino acid concentrate b) Whole blood c) Packed cells d) Resuspended red cells 7. All units of resuspended red cells will have been tested for the aids retrovirus prior to issuing the unit. a) True b) False 8. The advantages for using resuspended red cells are: - a) Minimal risk of acquiring AIDS b) Reduced volume to prevent circulatory overload c) Reduced risk of having a febrile reaction d) All of the above 9. As blood gets older, the number of red cells die proportionately. a) True b) False 10. Cryoprecipitate is the concentration containing factor V1ll and is used in the treatment of haemophilia a) True b) False 11. The type(s) of plasma used commonly: a) Fresh liquid plasma b) Fresh frozen plasma c) Freeze dried plasma d) All of the above 12. Solution can be prevented from leaking out of any bottle that requires an air vent needle, if the on the administration set is decompressed before inserting into the battle. a) Roller clamp b) Blood bag c) IV tubing d) Drip chamber Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 80 of 4

83 13. Gelofusine is used primarily as a a) Plasma volume expander b) Agent to increase the oxygen carrying capacity c) Replacement agent for missing coagulation factors d) Substitute for red cell replacement 14. Voluven 6% is successful as a plasma volume expander, because:- a) It increases osmotic pressure in the interstitial space b) It may be infused rapidly with no concern of circulatory overload c) It increases osmotic pressure in the blood stream d) It increases the size of the red blood cell. 15. If the section on the cross-match form, marked group and hold, is filled out by the doctor, this indicates that:- a) A specimen of blood is grouped and can be held for 3-10 days in the advent that a crossmatch is needed b) A specimen of blood is grouped, crossmatched and held for 3 days c) A specimen of blood is grouped, crossmatched and held for 48 hours d) None of the above 16. Information on the request form for cross-match of blood should include:- i) Patient's name and identification number ii) Clinical details iii) Number of units required of resuspended red calls iv) Date and time a) i) and ii) only b) i), ii) and iii)' c) i),iii) and iv) d) All of the above 17. When collecting blood or blood products from the laboratory, the collecting form is:- a) Sent through the mail each time b) Brought to the laboratory each time c) Kept in the laboratory d) Not important Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 81 of 4

84 18. The factors which must be identified prior to administration of blood or blood products are:- i) Patient's name, DOB and identification number ii) Type of blood product iii) Blood group iv) Expiry date v) Blood unit number a) All of the above b) i), ii), and v) c) iii), iv) and v) d) i), ii), iii) and v) 19. Blood should begin to be administered within _ minutes after being issued from the laboratory:- a) 30 minutes b) 60 minutes c) 90 minutes d) 120 minutes 20. If the administration of resuspended red cells is going to be delayed for longer that the above period of time, then it is permissible for the nurse to place the unit in the ward refrigerator. a) True b) False mls of should be used to flush an IV administration set at the completion of all blood transfusions:- a) Dextrose saline b) Sterile water c) Normal saline d) 5% Dextrose 22. Blood should never be hooked up with 5% Dextrose in water or run simultaneously with 5% Dextrose through a dual injection site. a) True b) False 23. Many of the fatal incompatible transfusions occur within the first:- a) 5 minutes b) 30 minutes c) 12 hours d) 24 hours Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 82 of 4

85 24. Blood should always be infused within hours to prevent bacteria contamination and red cell haemolysis:- a) 24 b) 12 c) 6 d) lntravascular haemolysis symptoms are usually more severe than those of extravascular haemolysis. a) True b) False 26. Major haemolytic reactions occur when the in the recipient's blood reacts with the in the donor blood:- a) Red cells white cells b) White cells red cells c) Antibodies antigens d) Antigens antibodies 27. Febrile reactions occur in a transfusion but do not last more than hours.- a) Early 24 b) Late 24 c) Early 8 d) Late Which of the following are exogenous reactions? i) Circulatory overload ii) Air embolism iii) Hypothermia iv) Citrate toxicity a) None of the above b) i), ii) and iii) c) ii), iii) and iv) d) All of the above 29. If a patient is suspected of having an air embolism whilst on an infusion, you should:- a) Clamp the infusion b) Place patient on left side, head down c) Notify doctor d) All of the above 30. If a patient with liver impairment is given large amounts of cold blood, he may display symptoms of:- a) Hypothermia b) Citrate toxicity c) Both a) and b) e) A. I. D. S. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 83 of 4

86 IV MULTICHOICE ANSWER FORM TRANSFUSION THERAPY MODULE: 4 1. a b c [d] e 26. a b [c] d e 2. a b c [d] e 27. a b c [d] e 3. [a] b c d e 28. a b c [d] e 4. a [b] c d e 29 a b c [d] e 5. a b [c] d e 30. a b [c] d e 6. a b c [d] e 7. [a] b c d 8. a b c [d] e 9. [a] b c d e 10. [a] b c d e 11. a [b] c d e 12. a b c [d] e 13. [a] b c d e 14. a b [c] d e 15. [a] b c d e 16. a b c [d] e 17. a [b] c d e 18 [a] b c d e 19. [a] b c d e 20. a [b] c d e 21. a b [c] d e 22. [a] b c d e 23. [a] b c d e 24. a b c [d] e 25. [a] b c d e Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 4 Blood Date Review 12/01/2015 Signature Page 84 of 4

87 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards STD/05/2010 STANDARD 5 Standard Guardrails Scope Aseptic Techniques Equipment Explanation to patient Checking flow rates - with medications Check pump load/unload correctly Pump fault IV Therapy : Use of Intravenous Pumps Equipment is assembled and Infusion Pumps operated by certified nursing personnel in a standardised manner. Guardrail is the software programme on the Care Fusion GP pumps. It should be utilised at all times, except in exceptional circumstances, e.g. in OT or ED, where it should be activated after resuscitation is established. Guardrail: Facilitates the standardisation of NMDHB medication protocols and best practice Defines safety limits for each medication within a specific clinical area Provides an audit of medication utilisation and compliance Electronic infusion devices shall be used with all central line infusions, and when warranted by the patient's age and condition, setting, and prescribed therapy. The nurse shall be responsible and accountable for their use of electronic infusion devices. E.N.'s may operate IV pumps for clear pre-mixed fluids only, in accordance with their scope of practice (for relatively stable patient with predictable outcomes). The R.N. retains accountability for direct supervision. Strict aseptic techniques are adhered to. Each area using pumps will have the manufacturer's handbook available for each type and model of pump provided. Only pumps with a current Electrical Safety Certificate will be used. Correct equipment is selected. The equipment is assembled and operated by a RN/RM/EN on the current IV Register. Explanation regarding the pump function is given to the patient when appropriate. Flow rate settings are checked INDEPENDENTLY by two RN s /RM s or one RN/ RM and E/N. All adjustments to rate are visually confirmed by two RN's/ RM s All pumps must be checked at commencement and at every rate change that they have been loaded correctly by an RN/ RM If a mechanical fault occurs or the Electrical Safety Certificate (warrant of fitness) expires, complete the appropriate form (giving details of problem), and send to Bio Medical Electronics Department. If the pump falls or is dropped it must be sent to Medical Electronics for verification of correct operation before it is used again. Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Level one Jan Date Review 22/12/12 Signature Page 85 of 130

88 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards STD/05/2010 After use References Pumps must be cleaned prior to storing, and stored appropriately (electric pumps plugged into mains power.) Alexander, M. (ed.). (2006) Infusion nursing standards of practice - supplement to Journal of Infusion Nursing, January/February, 29 (1S). Norwood:Lippincott Williams & Wilkins Health and Safety In Employment Act 1992 Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Level one Jan Date Review 22/12/12 Signature Page 86 of 130

89 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 IV MODULE 5 INTRAVENOUS THERAPY USING PUMPS In recent times, the gravity fed drip has increasingly become replaced with powered electronic infusion pumps. There are two types of powered electronic infusion devices, the syringe pump and the peristaltic pump. OBJECTIVES After completion of the module the nurse should be able to 1. Understand the function of syringe drivers and infusion pumps. 2. State the indications for use. 3. Chooses appropriate pump and equipment. 4. State requirements for anti-reflux valves. 5. States 5 nursing responsibilities for pumps used in clinical area. 6. Describes appropriate methods of cleaning and care of pumps. 7. Can identify electrical safety requirements. Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator IV Coordinator Date Approved 31/01/12 Position DONM File name Level One IV Date Review 31/01/15 Signature Page 87 of 130

90 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 The Syringe Pump The syringe pump is the oldest and most established powered infusion device. Here, the plunger of a syringe fitted into the pump is gradually depressed over a pre-determined period of time, or at a pre-determined rate. Most syringe pumps either measure the force required to push the plunger at the set rate, or use a special giving set to control the rate of delivery. The Volumetric Pump Most volumetric pumps are peristaltic - the infusion set is squeezed in a rhythmical and cyclical fashion, pushing the fluid along the tubing from the fluid container to the patient. This is done using a line of "fingers" to press against the tubing in a wave-like process. Uses Infusion pumps are indicated for: Safe administration of drugs with low therapeutic index (e.g. opioids, inotropes, insulin) Timely delivery of fluids or medication Prevention of too rapid or too slow an infusion Specific volumes to be delivered accurately Patients requiring strict fluid restriction High-volume infusions Administration of TPN High-dose electrolyte infusions Infusions into a central line Continuous anti-neoplastic infusions Neonatal and paediatric patients (based on age, therapy, diagnosis and condition) Infusion pumps can be used for: Blood and blood products Port-a-caths Central lines Peripheral lines of all gauge sizes Ambulatory patients Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator IV Coordinator Date Approved 31/01/12 Position DONM File name Level One IV Date Review 31/01/15 Signature Page 88 of 130

91 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Nursing Responsibilities and the Use of Electronic Infusion Pumps These devices must be operated as per manufacturer's instructions. The manufacturer's handbook for operation of all pumps in any clinical area will be available. Any new equipment will not be used in clinical practice until the operator has received appropriate training. Condensed operation instructions are displayed on the exterior of current pumps. Infusion pumps must be set up using the correct giving set for the pump to be used, and the set must be primed and inserted as per manufacturer s instructions. For syringe drivers, tubing must be clamped when changing syringes. Filters as appropriate for the type of infusion being delivered (e.g. blood, paclitaxel) can be used with pumps. Check for any special requirements for the solution eg. non PVC tubing Electronic infusion devices are an adjunct to nursing care and do not relieve the nurse from usual patient and site monitoring, visual assessments to confirm correct volume delivery. Administration Check compatibility of drug to be used with other solutions. Set volume to be infused at less than total pack volume Eg. 450mls for 500ml bag 90 mls for 100ml bag Dial infusion rate as prescribed in mls/hour. Check rate with a registered nurse Commence infusion. Note any required observations for particular drug. Check pump is functioning Check pump, equipment and patient hourly for correct rate of delivery Chart volume infused hourly Reset cumulative total on pump to zero when a new bag is commenced. Important points: Check the solution, drug and rate of delivery at the beginning of each shift. The alarm is to be activated / armed at all times Whenever the alarm sounds check the pump immediately to identify the problem If "air in line " either: Clamp the line close to patient, insert syringe with needle into additive port and aspirate air into syringe Or Disconnect line from patient, purge and recommence infusion. When patient is in shower or bath, change to battery power supply. Do not use mains power in wet areas. Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator IV Coordinator Date Approved 31/01/12 Position DONM File name Level One IV Date Review 31/01/15 Signature Page 89 of 130

92 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Maintenance and Storage Each area is responsible for maintenance and storage of their allocated pumps. Pumps are to be plugged into electrical outlet to charge the internal battery when in not in use. Before using the pump, the nurse should visually check that the pump is clean and in good repair, and has a current Electrical Safety Certificate. Faults Any pump that is found to have a fault (or falls) must be sent to Medical Electronics for checking or repair by the duly qualified personnel. Nurses are not to attempt to repair infusion devices. Keep the administration set inserted to allow for a full investigation of the relevant factors. When the pump has been in use place the pump in a plastic bag to send. Fill out the Fault Reporting Form for Infusion Devices in conjunction with the CNM Cleaning The exterior surface of the pump, the door and the mechanism is to be cleaned after each use and if there has been a spillage. Unplug the power cord from the wall outlet before cleaning. Use a cloth dampened with warm water, or a mild non-abrasive detergent mixed with water. DO NOT immerse the pump or allow fluids to enter the instrument housing. Cleaning is the responsibility of the operator using the pump. Standard Precautions should be used Types of pumps within NMDHB Currently different sites hold different IV pumps. Future purchasing will aim for regional consistency of pumps. INFUSION PUMPS GP Care fusion pump with Guard rail Guard Rail The Guardrail safety software helps reduce IV medication errors, improve the overall quality of patient care, track and measure system performance and help increase compliance with national safety standards. Each medication is customized to the NMDHB protocols and infusion delivery parameters can have hard and/or soft Guardrail limits. A Guardrails soft limit is one that can be overridden when clinically appropriate. A Guardrail hard limit cannot be overridden. Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator IV Coordinator Date Approved 31/01/12 Position DONM File name Level One IV Date Review 31/01/15 Signature Page 90 of 130

93 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 SYRINGE DRIVERS GP syringe driver is the preferred syringe driver for IV medication infusions in specialised areas Asena syringe driver NikiT34 for subcutaneous infusions only The assessment for this section is orientation to pumps by the IV Assessor in the clinical area and completion of the I.V. Level One practical skills sheet. References McCarthy & Keay : Professional Nurse Resource File - Infusion Pumps INS Standards Corrigan A, Pelletier, G, Alexander, M: Core Curriculum for Intravenous Nursing Baltimore, Maryland. Joanna Briggs Practice Manual 2001 Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator IV Coordinator Date Approved 31/01/12 Position DONM File name Level One IV Date Review 31/01/15 Signature Page 91 of 130

94 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 STANDARD 6 IV Therapy: OPIOID Bolus & Infusion (Acute Care / Adult Patients) Standard Prescription Intravenous Opioid Boluses and Infusions are administered in a standardised manner according to NMDHB policy N.B. Standards relating to IV Therapy/Administration of IV Medications and Controlled Drug (CD) Policies apply The IV opioid bolus injection is prescribed on the medication chart by a Medical Practitioner The IV opioid infusion is prescribed on the IV chart/medication chart by a Medical Practitioner The written prescription complies with: - the Medication Prescription Policy - IV Standards The prescription includes: - infusion rate limits (including 0mls/hr) - bolus dose size and frequency (prescribed on the patient s treatment chart) Drug Concentration Checking The standard drug concentration used is: Morphine Pethidine Fentanyl 1mg/ml 10mg/ml 10 micrograms/ml All IV opioid boluses are checked by two RN/RMs, (one of whom is on the current IV Level One register). This includes making a written entry in the Register of Controlled Drugs. All IV opioid infusions are checked by two RN/RMs (one of whom is on the current Advanced Analgesia register), including entry in the CD Register, and checking the infusion rate during: IV Pump Labelling initiation of the infusion any rate adjustment change of duty The infusion is to be delivered by an infusion device / PCA pump(rem Bodyguard 575 Pain Manager Pump). A Controlled Drug added label appropriately filled out (including the patients name) is attached to the medication reservoir allowing the graduated numbers to remain visible. Prefilled syringes requires the patients name, date and time opened to be added Issue Number 6 Name Robyn Henderson Author IV & RT Committee: Nurse Educator IV Coordinator Date Approved 31/01/12 Position DONM File name Level One IV Date Review 31/01/15 Signature Page 92 of 130

95 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards RM/04/2003 Administration Observations When an IV opioid infusion is administered the following must be observed: Opioid infusions must not be piggy backed into existing lines The IV line from the opioid reservoir must contain an anti-syphon / anti-reflux device A concurrent gravity fed line connecting to the same cannula must contain an anti-siphon/anti-reflux device A separate IV line and cannula or dedicated lumen of the central line may be used. All recordings are documented on the observation chart Baseline recordings are taken at the commencement of the infusion The following observations are carried out as below: - Sedation Scale, - Respirations, Hourly for first 4 hours, then IF STABLE, 4 hourly - 02 Saturation, thereafter - Pain Score (Pain score not needed if patient asleep) - BP and Pulse BP/P monitoring determined by clinical requirement - PCA Attempts & Given - Sedation Score - Pain Score to be charted on PCA Chart - Nausea & Vomiting Score Supplementary Oxygen Assess need for O2. If in doubt 02 should not be weaned below 2 litres via nasal cannula while receiving IV opioid infusions Withold opioid/stop infusion and notify Duty House Surgeon, or Acute Pain Management Service (APMS) (Nelson) if: Unstable Observations Systolic BP <100mmhg Sedation scale > 2 Respiration <10 min O2 sats <95% If problems are encountered observations should be increased (consider more oxygen) and the prescribing Medical Practitioner or the duty doctor on call or APMS (Nelson should be contacted). Intravenous Naloxone should be readily accessible for use if opiate reversal is required. See Module 6 IV Opioid Administration for advice on Naloxone doses. Equipment for resuscitation should be available for emergency use if required NB: The consultant may advise different observation times/parameters. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 93 of 5

96 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards RM/04/2003 Bolus Procedure Procedure for giving a bolus +/- in conjunction with IV opioid infusions NB: Ensure other treatable causes of pain are excluded, eg urinary retention, Compartment Syndrome. 1) Assess pain level 2) Check BP, pulse 3) Check respiration and sedation level 4) Administer bolus dose (follow manufacturer s instructions for the infusion device being used) or flush with 5ml normal saline if bolus given manually. 5) Wait three minutes, check response 6) Repeat steps 3 to 6 until analgesia satisfactory 7) Restart the infusion (if running) 8) The patient is monitored closely for side effects during the first 15 minutes then take: BP, pulse, respirations, 02 saturation, sedation level and pain score NB: The frequency of these observations may need to be decreased / Increased for certain patients. Incident Pain When to start the Infusion Infusion Rate Adjustment To cover Incident Pain bolus dose(s) need to be given minutes prior to the incident. The infusion is not started until the patient has been made comfortable by bolus doses, and the residual sedation and analgesia of the anaesthetic has largely gone. Changes to infusion rates have a very slow effect on opioid blood levels. The infusion rate may be increased (at RN s discretion) by ml/hr (within prescribed limits) to maintain a higher blood level of opioid drug established by bolus doses. The infusion may be decreased (at RN s discretion) by ml/hr within prescribed limits) to decrease the blood level of opioid drug. The infusion rate is turned off if default parameters are exceeded. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 94 of 5

97 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Side Effects (All treatments require a prescription) Nausea/Vomiting These are treated with regular prescribed antiemetics: Metoclopramide 10mg IV six hourly If ineffective in 10 mins, then add: Ondansetron 4mg IV eight hourly If ineffective in 10 mins, then add Cyclizine 25 50mg IV eight hourly Pruritus: Try topical treatments (cold flannel etc.) If troublesome: Promethazine (Phenergan),also has antiemetic & sedation effect) mg IV slowly PRN eight hourly, or 10-20mgs PO PRN eight hourly Side effects not acceptably controlled by these measures require review by an anaesthetist or the APMS (Nelson) Supplementary Opioid analgesia is supplemented with regular appropriate doses of Paracetamol analgesia and a NSAID (eg Diclofenac), provided there is no contra-indication to these drugs No other opioid (or other CNS depressant) is administered other than the IV Opioid infusion or boluses as charted (most commonly used opiates in NMDHB include Morphine, Fentanyl, Pethidine, Oxycodone and Codeine) Disposal of Any remaining opioid must be correctly disposed of after the bolus is administered. unused opioid The amount wasted must be documented in the CD register. Wasted PCA infusions are to be entered the completion of therapy. If the initial entry was in another department record the wastage in the CD register under a CD wastage page APMS (Nelson) Nelson: The APMS will review patients receiving IV opioid infusions at least once daily on week days, with the on call anaesthetist available at weekends / public holidays. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 95 of 5

98 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Bibliography - American Pain Society (APS) (1997): Perioperative Analgesia: Approaching the 21 st Century, Study Guide. Glenview IL APS - Alexander, M. (ed) (2006) Infusion nursing standards of practice supplement to Journal of Infusion Nursing, Jan/Feb, 29 (1S) Norwood: Lippincott Williams & Wilkins. - Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine Acute Pain Management: Scientific Evidence 2 nd ed (2005) - Intravenous Nurses Society (2000) Policies and Procedures for Infusion Nursing. - Jospehson, DL (1998) Intravenous Infusion Therapy for Nurses Principles and Practice. New York. Delmar Publishers. - Lord, J., Mashford, M., Robertson, M & Hipwell, C. (Eds) (1996) Guide to Parenteral Administration of Drugs, 2 nd Ed. Sydney. McLennan & Petty. - McCaffery, M., & Pasero, C. (1999) Pain: Clinical Manual, 2 nd Ed. Mosby Inc St Louis. - McClintock, A., Woods, D., Kendall, P., McRae, G., Chalmers, G., Orange, A & Little, S. (Eds). (2004) Notes on Injectable Drugs. NZ HealthCare Assoc. Wellington, NZ; 5 th Ed - Mather LE & Smith MT. (1997) Opioid Analgesics clinical pharmacology and adverse effects. In: Stein C (Ed) Opioids in Pain Control Basic and Clinical Aspects. Cambridge University Press, Cambridge. - Portenoy, RK (1996b): Opioid analgesics. In Portenoy, RK, Kannor, RM (Eds) Pain Management: Theory and Practise Philadelphia FA Davis Preferred Medicines List (Oct 2008) 12 th Ed. Canterbury Health. Purse Willis & Aiken Ltd, Christchurch. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 96 of 5

99 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/ Ready, LB, Ashburn M, Caplan RA, et al (1995) Practice guidelines for acute pain management in the perioperative setting: a report of the American Society of Anaesthesiologists task force on pain management. Anaesthesiology 82, p Schug, S. & Large, R (1993) Economic considerations in pain management PharmacoEconomics 3 (4): Shipton, EA (1999) Pain Acute and Chronic 2 nd Ed. Arnold, Hodder Headline Group, London. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 97 of 5

100 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 IV Module 6 Objectives Intravenous Opioid Administration On completion of this module the Nurse will be able to: 1. List the factors that influence pain perception and response. 2. List possible harmful side effects of under-treated severe acute pain. 3. Name the most effective way to measure pain. 4. Name the predictors of opioid dose. 5. Name and discuss properties of opioids. 6. Identify and discuss the properties of Naloxone. 7. Identify the preferred dilution ratio of Morphine, Fentanyl and Pethidine. 8. Identify the average bolus dose for Morphine, Fentanyl and Pethidine. 9. State the average dose interval and rate of injection for intravenous opioid. 10. Be aware of drug incompatibilities for opioids. 11. List the steps required to check out an opioid drug from the CD cupboard. 12. List the eight factors that should be identified on a syringe containing an opioid drug. 13. List the nursing responsibilities following the administration of opioid analgesics. 14. Identify the legal aspects for administering opioids. 15. Comply with the Misuse of Drugs Regulations, 1977, and the NMDHB policy in relation to opioids. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 98 of 5

101 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Introduction (To be read in conjunction with IV Opioid Protocols/Standards) Analgesics are drugs that relieve pain when given in correct doses with the minimum side effects. The International Association for the Study of Pain defines pain as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain can be divided into two components: i) Physical sensation ii) Reaction to pain Pain perception and response are influenced by such variables as age, sex, personality, previous experience, ethnic background, environment and emotions: separation, loss of self-control, lack of privacy, reduced sleep, IVs / drains etc. It is now recognised that under-treatment of severe acute pain can have a number of harmful physiological and psychological effects, and should be seen as a red flag. Possible harmful effects of under treated severe acute pain Respiratory: Cardiovascular Chronic Pain Gastrointestinal Decreased lung volumes, atelectasis, decreased cough, sputum retention, infection, hypoxemia Tachycardia, hypertension, increased peripheral vascular resistance, increased myocardial oxygen consumption, myocardial ischaemia, altered blood flow, deep vein thrombosis Evidence supports the fact that lack of adequate early pain management in the presence of acute pain may set the scene for progression to a chronic pain state Decreases gastric and bowel motility Genitourinary Urinary retention Musculoskeletal Neuroendocrine Psychological Muscle spasm, immobility, (increasing risk of deep vein thrombosis) Increases in the level of catecholamines, cortisol, glucagon, growth hormone, vasopressin, aldosterone and insulin Anxiety, fear, sleeplessness Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 99 of 5

102 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Pain Threshold and Tolerance Pain that increases rapidly in intensity (such as acute myocardial infarction or extensive partial thickness burns) does not usually permit the individual to achieve any control over pain. Pain that is less severe with a slow rise in intensity may permit the individual to exert some control over it. Assessment and Measurement of Pain Patient self-reporting methods are considered the most reliable way to assess pain. Observer observation (including vital signs, patient behaviour) is very unreliable. Discrepancies between a patient s behaviour and the self-report of pain may result from differences in coping skills (eg cultural). The visual analogue scale (VAS) and verbal numerical rating scale (VNRS) are the two methods commonly used within the NMDHB. These are well validated, are easy to explain, measure, and record, and by performing regular assessments (with pain as the 5 th vital sign, ie recorded along with TPR & B/P), numbers are provided for setting pain-management goals. Visual analogue scale: No Pain Mild Discomfort Mod Discomfort Painful Severe Pain Worst Possible Pain Verbal Numerical Rating Scale: 10 worst imaginable pain 5 moderate pain 0 no pain Patients are asked to imagine that 0 equals no pain and 10 equals the worst pain imaginable then rate their pain. These scales can be used in children whenever appropriate; however there are a number of validated tools available for measuring pain in neonates, infants and children. Selected tools must be both age and developmentally appropriate. The VAS and the VNRS can also be used at times for patients who have difficulty communicating their pain. Cognitively impaired adults should be given at least 30 seconds to reply, and the scale repeated at least 3 times if necessary. There are a number of other validated tools also available for use with these patients, as with those whose language or cultural background differs significantly from that of the health care team. For further help if required contact the Pain Management Service (PMS) (Nelson). NB An additional Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 100 of 5

103 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 paediatric self learning package for nursing staff, orientating staff and students is available on the Paediatric Ward, Nelson Opioid Analgesics Opioids are analgesics which act in several ways: a) by elevating pain threshold b) by altering the mood or attitude of the patient from one of concern to one of detachment, promoting a sense of well being or mild euphoria c) by producing sedative and soporific effects All drugs that have Morphine like actions, naturally occurring or synthetic, are called opioids and are referred to as Controlled Drugs. The term narcotic is now confined to a more legal sense referring to drugs capable of producing dependence. The opioids commonly used in pain management produce their effect by binding to the receptor sites in the brain and the spinal cord. There are a number of different types of opioid receptors that all act in slightly different ways and, therefore, produce different side effects. The body also has naturally occurring or endogenous opioids (endorphins, enkephalins and dynorphins). These are found in the brain, spinal cord, gastrointestinal tract and plasma and are released in response to stimuli, such as pain or stress. All opioids have similar actions; they differ among themselves mainly with respect to dose and duration of effect. Analgesia (the relief of pain) is their main action, but they have several side effects, some useful and some that are harmful. Because of their useful side effects, opioids are commonly prescribed pre- or intra-operatively (sedation and euphoria) and for post-operative pain relief (analgesia and sedation). Pethidine should be used with caution especially in patients with renal or hepatic impairment since accumulation of the drug and/or its active metabolite can occur. Predictors of Opioid Dose The best clinical predictor of opioid is patient s age. The reasons for this include age-related alterations in: distribution of the drugs to different tissues. rate of drug metabolism and excretion. opioid receptor numbers or binding affinities. Contrary to traditional belief there is little clinical significant correlation between patient weight and opioid requirement. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 101 of 5

104 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Side Effects Useful side effects of opioid are euphoria (a subjective sense of well being, inner peace), sedation and narcosis (sleep). Their harmful side effects are excessive sedation, respiratory depression, nausea and/or vomiting, hallucinations, dreaming, constipation, urinary retention and pruritus (itch). Possible Side Effects of Opioids Respiratory Central Nervous System Cardiovascular Pruritus Genitourinary Gastrointestinal Allergy Upper airway obstruction (obstructive apnoea), respiratory depression and/or changes in rhythm, decrease in tidal volume Sedation, euphoria, nausea and vomiting, miosis, muscle rigidity Vasodilation, bradycardia, myocardial depression More common with morphine Urinary retention Nausea, vomiting, constipation, spasm of the sphincter of Oddi A true allergy is uncommon Respiratory Depression Respiratory depression is a relatively uncommon (although much feared) complication of opioid administration. Traditionally, respiratory rate has been used as an indicator of clinical respiratory depression, but a decrease in respiratory rate is now recognised to be a late and unreliable sign. A normal respiratory rate can co-exist with marked respiratory depression. The best early clinical indicator of respiratory depression is increasing sedation. This is presumed to be a combined effect of the opioid and an increase in PCO 2 level. With normal respiration, an increase in tone of the muscles of the upper airways precedes contraction of the diaphragm and inspiration. In the presence of opioids and sleep this co-ordination can be abolished and closure of the upper airway may result. This may manifest as snoring (partial upper airway obstruction) or complete upper airway obstruction. Opioids also directly depress the respiratory centre causing decrease in respiratory rate and tidal volume. Opioid Antagonist: Naloxone reverses the actions of all opioids including excessive sedation and the respiratory depressant action of opioids. Given IV, Naloxone will begin to reverse sedation within 1-3 minutes. The patient should then be able to open his/her eyes and talk. The amount of Naloxone required to reverse opioid induced sedation and respiratory depression will vary among patients. Naloxone given in sufficient doses will also reverse the opioid analgesic effects, and patients may experience acute pain or restlessness/agitation. Rapid reversal can potentially cause adverse Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 102 of 5

105 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 cardiac and pulmonary effects, or acute withdrawal syndrome. Administration of Naloxone according to the titration-to effect technique allows reversal of adverse effects while minimising analgesia reversal. Naloxone is available in ampoules containing 400 micrograms in one ml. It can be administered IV, IM or subcut, depending on the urgency required. Usual adult dose is up to 400 microgms IV (the preferred route in an emergency) given in microgm increments or less, every 1-3 minutes over 15 seconds each increment, until desired degree of reversal is reached. Usual paediatric dose is 5-10 microgs/kg increments every 1-3 minutes, until desired degree of reversal is reached. NB: Once reversed, the patient should continue to be observed closely as the duration of Naloxone is shorter than that of most opioids, and Naloxone may need to be repeated. Opioid Administration Opioid analgesics can be given by intravenous, intramuscular or subcutaneous injection, or by the oral route. There are three methods of administering IV opioid analgesia: -bolus dosing (covered in Level One IV Opioid Module) -continuous infusion (covered in Level Two Advanced Analgesia Management) -patient-controlled analgesia (PCA) (covered in Level Two Advanced Analgesia Management) When relying on nurse administration, there is the potential for a period to elapse between the patient s awareness of pain and the actual nurse-administration of the opioid analgesic. To avoid this delay and optimise analgesia (preferably before the patient feels intense pain) the opioid is given as IV loading bolus doses, then can be given as a constant infusion or by PCA. These modalities are adjusted as required to maintain analgesia while limiting side effects. Nursing Responsibilities: Safety in administering opioid drugs depends upon several factors: a) good background knowledge of individual drugs; and b) good understanding of nursing implications and responsibilities. Nurses/midwives must be familiar with all relevant standards, policies and guidelines. Any drug given by the IV route has a systemic effect. It is, therefore, imperative to check compatibility before mixing IV drugs. This can be done by consulting Notes on Injectable Drugs (present in all clinical areas), drug charts, textbooks or the pharmacist. Opioids are incompatible with many medications in common use (particularly alkaline drugs) and solutions, including with each other, Thiopentone and Sodium Bicarbonate, and mixing should be avoided. Opioids are compatible with 0.9% Saline (normal saline), 5% Dextrose, and Dextrose 4% in 0.18% Saline. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 103 of 5

106 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Recording Opioid Medication All IV opioids are administered according to NMDHB IV, Medication Administration and Controlled Drug Policies. Two Registered Nurses or the RN and a Medical Officer must check all IV opioids (including pre-mixed bags/syringes). This includes making a written entry in the Register of Controlled Drugs: patient s name, date, time actual dosage/amount wasted, remaining drug count, name of doctor ordering the opioid and two signatures A co-ordinator or designated person does a weekly check; this meets the Misuse of Drugs Regulations If a discrepancy is noted between the written records and the actual supplies then the CNL must be notified and an incident (reportable event) form completed. The pharmacist is then required to notify the MOH if a discrepancy cannot be accounted for. Other legalities for administering an IV opioid are the same as for any IV drug and may be reviewed in the Hospital Policy. IV Opioid Bolus Administration If sustained pain relief is to be obtained without side effects, small IV doses need to be given frequently (bolus doses). The smaller the dose and the more often it can be given the less variability there will be in blood levels of the drug and the easier it will be to titrate the drug to suit each patient and differing pain stimuli. (This is one of the rationales behind PCA and why PCA has been so effective). Bolus doses are the best way to obtain rapid analgesia and should be used to: obtain initial pain relief (eg immediately after an operation) ie to load the patient so that the blood levels rapidly reach the minimum effective analgesic concentration. Usually done in the Recovery Ward provide analgesia for patients who are hypovolemic or hypotensive, when uptake of drug from muscle is poor cover episodes of incident pain eg dressing changes, physiotherapy, showering or inadequate analgesia Titration of Bolus IV Opioids It may take 15 minutes or more for a less lipid-soluble drug (eg Morphine) to exert its maximum effect on the central nervous system after IV administration. However, this interval is too long if analgesia is to be obtained rapidly. A reasonable balance between absolute safety (ensuring one dose has had its peak effect) and efficacy is to use a dose interval of 3-5 minutes. This has proved safe and effective, as long as staff monitor the patient carefully and are aware that this interval may not represent the true time to peak effect. (See appropriate Opiate Flow Chart). Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 104 of 5

107 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Dilution Because of the potency of opioids and the immediate high blood level, these IV drugs must be diluted. The diluent of choice is normal saline. The desired end solution will vary with the opioid used. However, in general, opioids are diluted up to 10mls. For example: Morphine 10mg is available in a 1ml amp and should be added to 9mls of normal saline. This will give an end dilution of 1m/ml. Fentanyl 100microgms is available in a 2ml amp and should be added to 8mls of normal saline. This will give an end dilution of 10microgm/ml. Pethidine 100mg is available in a 2ml amp and should be added to 8mls of normal saline. This will give an end dilution of 10mg/ml. The average IV doses given to an adult patient in a single instalment over 1-2 minutes are: Morphine mg Fentanyl microgms Pethidine15 25mg Larger than average doses of IV opioids may be specially ordered by the physician, surgeon or house surgeon, or documented in the Standing Orders, eg ICU/CCU. However, the rule of dilution will still apply regardless of the dosage ordered. Label Syringe When an IV opioid bolus has been drawn up and diluted, the syringe must be properly labelled. Identification factors on the syringe should include: the patient s full name and NHI number, the drug including amount, concentration and diluent, the date and time drawn up, as well as signatures of both checking RNs. NOTE: At the end of each shift, the syringe containing the IV opioid must be discarded, regardless of whether the drug was used or not, and the wastage recorded in the Opioid Register. If another dosage is needed then a new syringe must be drawn up and labelled by two RNs for their particular shift. Prior to the Preparation of Opioid Medications Evaluate the patient s need for opioid medication and check the time of the last dose. Record pain score on patient s observation chart (eg.5/10), if possible document time of onset, duration, and quality and location of pain (preferably in patient s own words). Remember that the fullest analgesic effect is achieved if the opioid is administered before the patient experiences intense pain. The patient is the authority and self-report is the most reliable indicator. Assessment includes pain ratings whenever possible. If verbal communication is limited, an elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial expression, may indicate a need for analgesia but Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 105 of 5

108 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 for more reliable assessment, consider alternative tools as appropriate. The presence of a stimulus that causes pain (eg an incision) is sufficient to justify the assumption that the patient has pain. Baseline monitoring as per the acute pain guidelines/standards. As well as respiratory rate, respiratory depth and rhythm should be observed. Administration Administer an IV opioid bolus over 1-2 minutes, through the luer plug of an IV cannula or injection port of an IV fluid administration set (ensure compatibility of IV fluid). Monitor as per guidelines/standards and IV opioid flow chart. Opioid-induced respiratory depression may occur even with small doses, and incidence increases progressively with higher doses in the opioid-naïve patient (generally reaching maximum within 90 minutes following subcutaneous, 30 minutes after IM and 7-15 minutes after IV administration). Following administration the patient should be reassessed as frequently as necessary to determine that the desired level of analgesia has been achieved. See Standard 6 IV Therapy: OPIOID BOLUS & INFUSION (Acute Care/Adult Patients) attached and available on intranet. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 106 of 5

109 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Routine Observations IV Opioid Bolus Flow Chart (ADULT) Pain Score >3 / 10 Yes No Opioid prescribed on Drug Chart (as per Opioid protocol) No Call Medical Personnel Yes Prepare prescription as charted: N/Saline and Morphine 1mg/ml Or N/Saline and Pethidine 10mg/ml Or Consider N/Saline and Fentanyl 10mcg/ml Pain Score >3/10 Yes Sedation Score < 2 BP systolic >100mmHg and Pulse > 50/min and and No Consult with Medical personnel prior to opioid administration Yes Wait 3mins Patient under 75yrs Yes No Give Morphine 1.5mg IV Or Pethidine 15mg IV Fentanyl 15mcg IV Or Give Morphine 2.5mg IV Pethidine 25mg IV Fentanyl 25mcg IV Or Or Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 107 of 5

110 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 BIBLIOGRAPHY: Abbott Pain Management Provider System Operating Manual (1995) Abbott Laboratories, Nth Chicago IL 60064, USA Acute Pain Management: scientific evidence (2005). National Health and Medical Research Council (NHMRC). Canberra, Australia, 2 nd Ed. American Pain Society (APS) (1997): Perioperative analgesia: approaching the 21 st century, Study Guide. Glenview IL APS. Alexander, M. (ed) (2006) Infusion Nursing Standards of Practice-supplement to Journal of Infusion Nursing; Jan/Feb, 29 (1S) Norwood: Lippincott Williams & Wilkins. Intravenous Nurses Society (2000) Policies and Procedures for Infusion Nursing. Josephson, DL (1998) Intravenous Infusion Therapy for Nurses Principles and Practice. New York. Delmar Publishers. MacIntyre, PE., Ready, LB., (1996) Acute Pain Management WB Saunders Co Ltd. McCaffery, M., & Pasero, C. (1999) Pain: Clinical Manual, 2 nd Ed. Mosby Inc St Louis. McClintock, A., Woods, D., Kendall, P., McRae, G., Chalmers, G., Orange, A., & Little, S. (Eds). (2004) Notes on Injectable Drugs. NZ HealthCare Assoc. Wellington, NZ, 5 th Ed McQuay, H. & Moore, A. (1997): The concept of postoperative care. Current Opinion in Anaesthesiology 10, Mather, LE & Smith MT. (1997) Opioid Analgesics- clinical pharmacology and adverse effects. In Stein C (Ed) Opioids in Pain Control-Basic and Clinical Aspects. Cambridge University Press, Cambridge. Portenoy, RK (1996b): Opioid analgesics. In Portenoy, RK, Kannor, RM (Eds) Pain Management: Theory and Practise Philadelphia FA Davis Preferred Medicines List (Oct 2001) 6 th Ed. Canterbury Health. Purse Willis & Aiken Ltd, Christchurch. Schug, S. & Large, R (1993) Economic considerations in pain management PharmacoEconomics 3 (4): Shipton, EA (1999). Pain Acute and Chronic 2 nd Ed. Arnold, Hodder Headline Group, London. Sinatra, RS., Hord, AH., Ginsberg,B & Preble, LM (1992) Acute pain mechanisms and management (Ed) Mosby Yearbook, St Louis. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 108 of 5

111 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 IV MODULE 6 Intravenous Opioid Administration Post Modular Test 1. Factors that influence pain perception and response are variables including a) Age, sex, ethnic background b) Personality, previous experiences, environment and emotions c) Separation, loss of self control, lack of privacy, reduced sleep d) All of the above 2. Pain that is less severe with a slow rise in intensity permits the patient more control over it a) True b) False 3. Possible harmful side effects of under treated pain may include a) Elevating the pain threshold; b) Decreased myocardial oxygen consumption; c) Producing a sedative effect; d) Decreased lung volumes 4 Most effective ways to measure pain include a) Patient self reporting methods b) Nurse observation c) Vital sign measurement d) Patient behaviour 5 The best clinical predictor of opioid dose is a) Weight b) Age c) Sex d) Race 6. Morphine, Fentanyl and Pethidine are incompatible with: a) Each other b) Thiopentone c) Sodium bicarbonate d) All of the above Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 109 of 5

112 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/ Opioids are compatible with: a) Sodium Chloride 0.9% b) 5% Dextrose c) Dextrose 4% in Sodium Chloride 0.18% d) All of these 8. Safety in administering opioid drugs depends on a) Good background knowledge of individual drugs b) Good understanding of pain management c) Good knowledge of associated legal implications d) All of the above 9. The most harmful side effect of all opioids is: a) Nausea and vomiting b) Respiratory depression c) Syncope d) Pruritus 10. The opioid antagonist of choice is: a) Nimodipine b) Anexate c) Naloxone d) Diazepam 11. When giving opioids as a bolus injection, the general practice is to dilute most opioids up to 10mls with normal saline. a) True b) False 12. The average bolus dose of IV Morphine given to an adult patient is: a) 2.5mg b) 4mg c) 5mg d) 10mg 13. An opioid bolus is usually administered to a patient over: a) 5-10 mins b) 2-5 mins c) 1-2 mins d) Less than one min 14. Bolus doses are the best way to achieve rapid analgesia and should be used to: a) Obtain initial pain relief b) Cover episodes of incident pain eg dressing changes, physiotherapy Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 110 of 5

113 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 c) Provide analgesia for patients who are hypovolaemic or hypotensive d) All of the above 15. Patient monitoring with bolus opioids includes: a) Assessment of pain score, sedation scale and respiratory rate prior to administration b) Monitor vital signs after administration c) Evaluate effectiveness of analgesia d) All of the above 16. Sedation can be an early indicator of: a) Pain b) Hypoxia c) Morphine induced CNS stimulation d) All of the above 17. For safety reasons, all syringes containing opioids must be clearly labelled. The identification factors on the syringes should include: a) Drug and amount, diluent and dilution ratio b) Patient's full name and NHI c) Date and time d) Signatures of both checking RNs e) All of the above 18. At the end of each shift a syringe containing an opioid should be discarded, regardless of whether the drug was used or not: a) True b) False 19. Weekly checks of opioid drugs must be done in accordance with the Misuse of Drugs Regulations, 1977: a) True b) False 20. If a discrepancy is noted between the written opioid records and the actual supply in hand, the Nurse must: a) Notify the Clinical Nurse Leader b) Fill out an incident form c) Phone the Police d) A) and B) only Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 111 of 5

114 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 MULTI CHOICE ANSWER FORM Module 6: Intravenous Opioid Administration 1. a b c [d] e 2. [a] b c d e 3. a b c [d] e 4. [a] b c d e 5. a [b] c d e 6. a b c [d] e 7. a b c [d] e 8. a b c [d] e 9. a [b] c d e 10. a b [c] d e 11. [a] b c d e 12. [a] b c d e 13. a b [c] d e 14. a b c [d] e 15. a b c [d] e 16. a [b] c d e 17. a b c d [e] 18. [a] b c d e 19. [a] b c d e 20. a b c [d] e Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 112 of 5

115 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 STANDARD 7 Standard Policy Procedure Condition of site Subcutaneous Therapy Subcutaneous fluids and medications are administered in a standardised manner by:- A Registered Nurse A Registered Nurse & Enrolled Nurse / Student Nurse or A Medical Officer and Enrolled Nurse / Student Nurse 2 Registered nurses for Medications requiring calculations via syringe driver All Nurses are familiar with the NMDHB Medication Administration Policy Aseptic Techniques Strict aseptic techniques are adhered to throughout the procedure Explanation to patient The patient receives an explanation and gives consent prior to the commencement of the procedure Equipment Correct equipment is selected and prepared Needle free / needleless systems to be used Prescription The fluids are checked against the prescription for :- - Type - Volume - Rate - Sequential order Checking of Subcutaneous Fluids IV Fluids are checked prior to subcutaneous administration for :- - Integrity of seals and bag - Colour and clarity of fluids - Foreign bodies and particulate matter - Expiry date Identifying the patient The RN/EN as indicated above checks the patients wristband details for:- - Name - Hospital number - Verbally confirms name ( where possible) And confirms these details with the information on the patient s Treatment Chart SC site is exposed and inspected daily for: Redness, pain, pooling of fluid, heat, necrosis at insertion point Rotate subcutaneous site when any of the above occur and follow infection control protocol. Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 113 of 5

116 NELSON MARLBOROUGH DISTRICT HEALTH BOARD:NMDHB IV standards Std /06/2011 Dressing Changing IV Fluids / Giving sets Changing the site Fluid Record The site is cleansed with 2% Chlorohexidine and alcohol 70%, taped to secure cannula and covered by a sterile transparent occlusive dressing Site is labelled on insertion and appropriate documentation is entered in clinical record. All changes are carried out by :- A Registered Nurse / Enrolled Nurse (who are on the current IV List) Each new giving set is labelled with :- Date & Time Tubing is changed every 96 hours No more frequently than every 7 days or:- If infusion stops/ leaks/ infusion rate too slow/ redness/ irritation. Commencement times, type and volume of fluids are charted in the fluid record Daily weigh is beneficial Reference: Alexander, M. (ed.). (2006) Infusion nursing standards of practice supplement to Journal of Infusion Nursing, January/February, 29 (1S). Norwood:Lippincott Williams & Wilkins Dougherty, L. & Lister, S. (2011) The Royal Marsden Hospital manual of clinical nursing procedures (8 h ed.). Oxford: Blackwell Science. Infusion Nurses Society. (2011). Policies and Procedures for Infusion Nursing.USA:Author Issue Number 7 Name Robyn Henderson Author District IV & R/T Date Approved 12/01/2012 Position DONM File name Std 6 - Opioid Date Review 12/01/2015 Signature Page 114 of 5

117 I.V. MODULE 7 SUBCUTANEOUS FLUID & MEDICATION ADMINISTRATION SUBCUTANEOUS FLUIDS Objectives: On completion of this module, the nurse will be able to: 1. State the advantages of subcutaneous administration of fluids. 2. Discuss the relative contraindications to subcutaneous therapy. 3. Identify additives which may be administered via this route. 4. Identify the sites which may be used for administration. 5. Correctly establish subcutaneous access 6. Discuss care of the site. SUBCUTANEOUS MEDICATIONS Objectives: 1. Understand how to set up, use and terminate the NIKI T34 Syringe Driver. Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Std 7 Subcutaneous Therapy Date Review 22/09/12 Signature Page 115 of 130

118 SUBCUTANEOUS FLUIDS Infusion of fluids into the subcutaneous layer is known as Hypodermoclysis. The subcutaneous administration of fluids has a number of advantages when compared to the intravenous route. These include ease of administration, low incidence of infection, little pain or discomfort, and no need for prolonged immobilisation. This is not an appropriate route for patients in shock. There are many clinical situations where administration of fluid subcutaneously is simpler, safer and less expensive than intravenous administration. These include the administration of fluids in the first few days after a stroke when a patient has swallowing difficulties; when oral intake is poor and fluid intake can be supplemented with subcutaneous fluid administration overnight; when a patient is mildly dehydrated. Studies confirm that normal saline administered subcutaneously is promptly absorbed into the intravascular compartment. It is possible for the infusion to be administered overnight, i.e. from 2000 hours to 0800 hours which allows for other therapies and ambulation during the day. RELATIVE CONTRAINDICATIONS: Cardiac failure Severe electrolyte imbalances Renal failure (other than due to dehydration) PRESCRIPTION: To be charted on IV Fluid Chart. The fluids which may be used are: - Normal saline (0.9%) - Dextrose 4% / Saline 0.18% The amount of fluids / 24 hours is usually calculated by the doctors and is usually in the range of 1.5 to 2.5 litres per day, i.e hourly. Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Std 7 Subcutaneous Therapy Date Review 22/09/12 Signature Page 116 of 130

119 ADDITIVES: 1. Antibiotics are not to be given subcutaneously. 2. No more than 10 mmol KCL may be given per litre. Adverse effects from electrolyte containing solutions are minor provided small volumes are used MEDICATIONS: Commonly given via the subcutaneous route via the NIKI T34 syringe driver in palliative care patients 1. Opioids 2. Anti-emetics and sedatives, eg Maxalon, Haloperidol Detailed guidelines on management and delivery of subcutaneous medications are contained in the self directed learning package - Continuous subcutaneous infusion of medication via syringe driver adults (available on the intranet) SITE: The loose subcutaneous tissues are: Anterior chest wall (preferred site) Anterior aspect of upper arms (avoid in bed bound patients) Anterior aspect of thighs Anterior abdominal wall Upper back for agitated/confused patients to prevent them pulling the line out Not over joints or clavicle. Vascular structures must be avoided. Avoid areas of sepsis. In confused patients it is best to administer the fluids between the shoulder blades. INSERTION: Disposable gloves IV Cannula 22 gauge Saf-T-Intima with microbore extension set Standard giving set for fluids. Alcohol with chlorhexadine swabs Transparent Occlusive Dressing Intravenous fluids ml or 1000 ml bag Use of a small gauge IV cannula is less irritant to the patient than using a metal butterfly needle. Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Std 7 Subcutaneous Therapy Date Review 22/09/12 Signature Page 117 of 130

120 PROCEDURE: Prime the line as per IV infusion. Use a sterile technique. (If using a NIKI T34 Syringe driver the extension set must be primed manually) Choose site as described above Cleanse skin with swab using a circular motion, from the inside out. Pinch up skin and insert needle the full length, towards the heart at an angle of 45 o Secure with transparent adhesive dressing & label with date. Ensure the Documentation Label does not occlude the insertion site. Attach device to giving set Label tubing with date and indicate Subcutaneous Line Record on fluid balance chart and in clinical notes. Set rate, monitor the patient's condition and report to the doctor any problems including circulatory overload, difficulties with breathing and complications as listed. CARE OF SITE: There may be some local oedema at infusion site. This will eventually be absorbed. Periodic massage of site will improve absorption and minimise discomfort The site should be changed no more frequently than every 3-5 days or if the infusion stops The site of the infusion may have to be changed if there is: - Leakage - The infusion rate is too slow. - Infection Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Std 7 Subcutaneous Therapy Date Review 22/09/12 Signature Page 118 of 130

121 SUBCUTANEOUS MEDICATION THERAPY: Subcutaneous Medication Therapy is a method of symptom control by allowing the medications to be absorbed into the body via the subcutaneous tissues, when they cannot be given easily by other methods. Indications for Use: Poorly controlled pain. - Usually after failure to control pain with tablets, elixir & rectally. Nausea or vomiting. - When persistent nausea or vomiting prevents medication from being taken and absorbed, e.g. increased intracranial pressure, intestinal obstruction, constipation. Difficulty swallowing. - When the patient has experienced difficulties swallowing tablets or elixir, e.g. weakness, lack of swallowing reflex, dysphagia, mouth & throat lesions. Non-absorption of oral medication. Absorption from the gut in the last hours is often unreliable. In the terminal phase of an illness when the patient has become unconscious but still requires continual medication. When the rectal route is inappropriate due to constipation, or when medications are not suitable for the rectal route. NIKI T34 Ambulatory Syringe Drivers Subcutaneous medications are usually administered via syringe pumps. Portable subcutaneous infusions syringe drivers are advantageous for both ambulatory and immobile patients: They are discrete and portable Can be managed at home Provide a constant level of drugs Maintains patient independence Patients can be weaned off syringe driver when acute symptoms have subsided. NMDHB uses the NIKI T34 Ambulatory Syringe Driver Medications given via the syringe pumps require complex calculations. These medications must be charted on the Syringe Driver supplementary chart and checked by two Registered nurses or a registered nurse and pharmacist. Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Std 7 Subcutaneous Therapy Date Review 22/09/12 Signature Page 119 of 130

122 The NIKI T34 Syringe Driver is a portable, battery powered infusion device, which provides subcutaneous infusion of drug/s over a determined period of time. The NIKI T34 Ambulatory Syringe Driver and Lock Box The standard syringes used for the NIKI T34 Syringe Driver are BD Plastipak Luer Lock syringes. i.e. BD Plastipak 30ml syringe, BD Plastipak 20mL syringe and BD Plastipak 10ml syringe If replacing a syringe ALWAYS use the same size that was originally loaded to ensure that the dilution within the tubing is consistent. If the medication prescription has changed then the tubing should also be changed. Standardising syringe volumes helps maintain clinical safety within and across different care settings. 10ml syringe fill to a maximum volume of 10ml 20ml syringe fill to a maximum volume of 18.0ml 30ml syringe fill to a maximum volume of 22ml Issue Number 6 Name Robyn Henderson Author District IV & RT Educator/IV Coordinator Date Approved 22/12/10 Position DONM File name Std 7 Subcutaneous Therapy Date Review 22/09/12 Signature Page 120 of 130