CLINICAL GUIDELINES DISTRICT NURSING and INTERMEDIATE CARE Schedule of guidelines attached: DNICT03 Community Procedure for the Administration of Intravenous Drugs via Bolus The guidelines scheduled above were approved by the Professional Advisory Group on 16 th September 2004 Review date: September 2005
CONTENTS: DNICT03 COMMUNITY PROCEDURE FOR ADMINISTRATION OF INTRAVENOUS DRUGS VIA BOLUS...2 Rationale...2 Principles...2 Equipment...3 Procedure...3 Preparation...3 Step One...3 Step Two...4 Step Three...4 References...4 Appendix 1 Visual Infusion Phlebitis Score...5 Appendix 2...6 INFILTRATION SCALE...6 Appendix 3...7 PERIPHERAL INTRAVENOUS CANNULATION SITE OBSERVATION CHECK LIST...7 1
DNICT03 COMMUNITY PROCEDURE FOR ADMINISTRATION OF INTRAVENOUS DRUGS VIA BOLUS Compiled by: CNS (DN Educator) This procedure must be carried out in collaboration with protocol for I.V therapy in the community. Rationale Administration of intravenous drugs via bolus can be defined as the introduction of a fixed volume of drug(s) into the cannula. The aim of this procedure is to ensure that the prescribed drug will be given to the correct patient, at the correct time, in the correct dose, without intrinsic or extrinsic contamination occurring. Principles 1. The principles of asepsis, including hand washing, minimal touch technique and the cleansing of access points prior to use are essential. 2. The infusion site should be inspected at least daily and prior to drug administration, for complications (1,2), including use of the Visual Phlebitis Score (appendix 1), Infiltration Scale (appendix 2) and details recorded on the Site Observation Check List (appendix 3). 3. Drugs prescribed for administration must be included in the agreed local formulary. 4. History of allergies should be ascertained prior to administration of drugs. Caution is essential where there are allergies to food/medicines and medical advice must always be sought in these situations. 5. The nurse administrating medications/solutions should have knowledge of the indications for therapy, side-effects and potential adverse reaction, and appropriate interventions (3) 6. Drugs should be prepared and administered immediately. Any excess should be discarded. 7. The administration of medication should be performed over the specified time in order to prevent the development of speed shock and fluid overload (4). Refer to local formulary. 8. If multiple drugs are being administered, the cannula must be flushed between each drug administration with up to 5mls of Sodium Chloride 0.9% (5) 9. If on assessment the use of an add-on device is indicated, these should always be of a luer-lok design, be changed with each cannula (6) and should be primed with 0.9% Sodium Chloride according to manufacturers recommendations. 10. Any adverse reactions should be reported via the yellow card system and by the completion of a clinical incident form. In the event of anaphylaxis being suspected, follow PCT Patient Group Direction: Administration of Adrenaline 2
Equipment Disposable latex/vinyl/nitrile gloves Plastic apron Sharps bin 70% alcohol swab ie. steret Clinical procedure sheet x 2 10ml/20ml luer lock syringes, amount dependant on number of drugs administered Blue needles as required 10mls Normal Saline 0.9% ampoules, amount dependant on number of drugs administered Complete anaphylaxis pack, sphygmanometer, stethoscope and face mask Prescribed medication and diluent Medical directive Yellow bag for disposal Documentation Procedure If no cannula is in place or a change of cannula is indicated on assessment: it will be necessary to initially follow the procedure for insertion of peripheral cannula Preparation 1. Ensure patient meets eligibility criteria for intravenous therapy. 2. Read nursing notes and ascertain previous history of allergies. 3. Explain procedure to patient and obtain patient consent. 4. Wash hands and put on apron 5. Check medical directive Step One 1. Inspect the injection site for any complications and consult patient re: any sensitisation to site. Utilise Visual Phlebitis Score and Infiltration Scale and document findings using Site Observation Check List. If complications present abort the procedure and revert to procedure for cannulation/phlebitis/infiltration as appropriate. 2. Open clinical procedure sheet and prepare equipment onto field, using non-touch technique. Place sharps bin to side of field. 3. Wash hands and put on gloves 4. Draw up N/Saline flush, minimum of 10mls (5mls per individual flush unless otherwise specified). 5. Check name of drug, expiry date and rate at which bolus can be administered 6. Draw up prescribed medication according to manufacturers instructions 7. Place clinical procedure sheet under patients arm 3
8. In order to establish patency of the vein, cleanse port with streret and flush cannula gently with 5mls N/Saline. Detach syringe. 9. If patency of the vein is not established, abort procedure and resite cannula. 10. Administer drugs into port ensuring the correct order and correct rate of administration. Detach syringe. Between each drug administration, flush gently with 5mls N/Saline. Step Two 1. Following administration of final drug, flush port gently with 5mls N/Saline. 2. Be aware of potential and immediate side effects of the drug during administration and carry out necessary action if required. Refer to anaphylaxis procedure if needed. 3. Consult the patient during the injection to check for any discomfort. 4. Observe the vein and surrounding tissue for any complications, consulting appropriate procedure if indicated. 5. Ensure that the cannula is well secured and comfortable. 6. Ensure all sharps are disposed of into sharps bin and other clinical waste into yellow bag 7. Remove apron and gloves. Wash hands. Step Three 1. Ensure patient is comfortable. 2. Complete nursing notes, including the medication administration sheet and site observation check list. References Ayliffe, G.A.J. et al. (1992) Control of Hospital Infection: A practical handbook. London. Chapman and Hall Medical. Hart, S.(1999) Infection control in intravenous therapy, in Dougherty, L and Lamb, J. Intravenous Therapy in Nursing Practice. London. Harcourt, Chapter 11. Nicol, M.(1999) Safe administration and management of peripheral intravenous administration, in Dougherty, L and Lamb, J. (1999) Intravenous Therapy in Nursing Practice. London. Churchill Livingstone. Dougherty, L.(2000) Drug administration, in Dougherty, L and Lamb, J. (1999) Intravenous Therapy in Nursing Practice. London. Churchill Livingstone. Weinstein, S.M.(1993) Plumer s principles & practice of intravenous therapy (5 th Ed). Philadelphia. J.B. Lippincott Company. RCN (2003) Standards for infusion therapy. RCN. London. 4
Appendix 1 Visual Infusion Phlebitis Score 5
Appendix 2 INFILTRATION SCALE Grade Clinical Criteria 0 No Symptoms 1 Skin blanched Oedema <1 inch (2.5cm) in any direction Cool to touch With or without pain 2 Skin blanched Oedema 1-6 inches (2.5cm-15cm) in any direction Cool to touch With or without pain 3 Skin blanched, translucent Gross Oedema > 6 inches (15cm) in any direction Cool to touch Mild to moderate pain Possible numbness 4 Skin blanched, translucent Skin tight, leaking Skin discoloured, bruised, swollen Gross oedema > 6 inches (15cm) in any direction Deep pitting tissue oedema Circulatory impairment Moderate to severe pain Infiltration any amount of blood product, irritant, or vesicant 6
Appendix 3 PERIPHERAL INTRAVENOUS CANNULATION SITE OBSERVATION CHECK LIST Patient name: D.O.B. Date Time Phlebitis scale score Action taken Infiltration scale score Action taken Dressing intact Yes/No Dressing changed Yes/No Signature 7