INTESTINAL TUBE Insertion 1. Wash hands. Gather equipment and supplies. 2. Verify correct patient using 2 identifiers-information on wrist band, verbal check, birth date or medical record number on chart. 3. Explain procedure to patient. Patient should be in sitting position (high fowlers is preferred), if possible, to reduce the risk of aspiration and to allow for better access to nose. 4. It is recommended that the nurse and patient establish a wait a minute signal that can be used by the patient during insertion to tell the nurse to stop for a moment. 5. Don clean gloves. Sterile gloves are not needed as this is a clean procedure. 6. To determine the approximate length of tube that must be inserted to reach the stomach, hold tube up to patient s face and measure the combined distance from the tip of the nose to the earlobe, and to the xyphoid process of the sternum. Mark this length directly on tube and document on the patient s chart. If tube is to be placed in the duodenum or jejunum, add an additional 6 to 10 inches of length to be mark on the tube. 7. The nurse should examine the patient s nostrils for any obstruction or deformity that may cause difficulty in passing the tube. Also, the nurse should ask about surgery or injury to the nose that might obstruct passage. For instance, if a patient had any recent EGD with banding, a nasogastric tube would be contra-indicated. Information regarding bleeding tendencies or use of anticoagulants is also necessary to detect patients who might bleed during insertion. If this is the case, always confirm with the MD whether this procedure should be done and chart accordingly. 8. A large syringe (60 ml) is always used with small bore tubes because smaller syringes exert too much pressure on the tube and may cause the tube to rupture. Make sure your syringe has a compatible head to fit into the feeding tube end. 9. Some brands have the stylet already threaded inside. The stylet facilitates advancement of the tube by making it rigid. Ensure the stylet is connected to hub. 10. If lubricant is bonded to the tube, it should be activated by flushing the tubing with 5 mls of water. Rinsing the tube inside and out with water also allows for the gliding of the tube through the esophagus. 11. Applying a lubricating gel to the first ten centimeters of the tube may ease the discomfort of insertion into the patient s nares. An anesthetic spray may also be used to ensure patient comfort. 12. Instruct the patient to tip the head back slightly. Gently insert the tube into the largest nostril and back along the floor of the nostril in a slightly downward motion toward the ear. Encyclopedia of Nursing Page 1
13. As soon as the tube reaches the back of the throat, the nurse should instruct the patient to tilt her head forward. This closes the epiglottis and opens the esophagus. Continue to pass the tube a few centimeters at a time while twisting clockwise until the pre-measured length is inserted. Tape the tube temporarily to prevent movement while verifying placement. 14. Aspiration of gastric contents indicates correct placement. Most clinicians also verify correct tube placement by x-ray. 15. At this stage some resistance may be felt. To help the tube past this point, give the patient a cup of water with a straw or ice chips with a spoon. Tell the patient that you are going to advance the tube as he\she drinks the water or swallows the ice chips. 16. With patients who are less alert, the nurse may gently stroke the patient s throat to initiate a swallow. Another technique to advancing the tube is to slowly and gently twist the tube. 17. If the patient gags or chokes, the nurse should stop and check the patient s mouth and throat. The tube may have become coiled in the back of the throat. Be aware that each person s gag reflex differs in sensitivity. If the tube is not coiled in the throat, encourage frequent swallowing to quickly pass the tube past the gag reflex area. 18. If the tube enters the trachea instead of the esophagus, the patient may cough or show signs of respiratory distress. 19. If these signs occur, the nurse should pull the tube out slightly until the tip lies in the back of the throat. 20. Reinsertion may then be attempted when the patient is comfortable and ready. 21. The nurse should be aware that misplacement of the tube into the trachea can occur without observable signs and symptoms. 22. Aspiration of gastric contents indicates correct placement. Most clinicians also verify correct tube placement by x-ray. 23. Some recommend removing the stylet prior to x-ray. Others recommend removing the stylet after x-ray, in case further manipulation of the tube is necessary. 24. Once removed, the stylet should NEVER, under any circumstances, be reinserted. To do so may cause it to perforate the tube and/or the patient s GI tract, causing serious injury. After placement is confirmed, discard stylet after its removal from the tube. 25. Commercial tube holders, a soft band-aid, or a small adhesive dressing may be used to anchor the tube near the bridge of nose. 26. Document correct placement, length of tube inserted, and patient response to procedure. Encyclopedia of Nursing Page 2
27. A duodenal or jejunal tube that will travel on to the small intestine should be taped with enough slack so it can continue to pass into the small intestine by peristalsis. 28. To facilitate passage, some physicians order metoclopramide to be infused 15 minutes prior to insertion. This drug increases gastric motility and lowers esophageal sphincter tone. Other recommendations include giving 10 mg metoclopramide, waiting 10 minutes, then advancing 10 cm more if a tube meets resistance to advancement. 29. After insertion of an intestinal tube, the patient should be positioned on the right side for at least 2 hours. This would aid in the tube passing through the pylorus via gravity. 30. Having the patient sit in an upright position in a chair or ambulate will also facilitate passage of the tube into the duodenum. 31. An x-ray is always taken, usually 4 to 12 hours after the tube is placed in the stomach, to confirm movement of the tube into the duodenum or jejunum. Tube Feedings 1. Verify correct patient using 2 identifiers-information on wrist band, verbal check, birth date or medical record number on chart. 2. Verify order for feeding, i.e., kind of formula or amount usually ordered as mls per hour. Explain procedure to patient. Verify tube placement before starting feeding. 3. With continuous feeding, the formula is delivered in small constant volumes, usually between 50-125 mls per hour over 16 to 24 hours. Continuous feedings are administered by an enteral feeding pump which delivers the fluid at a constant rate. 4. Continuous feeding is also ordered for patients who have a tube inserted into the duodenum or jejunum as the small bowel is more sensitive to volume and osmolality than the stomach. 5. With intermittent feeding, the adult patient is usually given 240, 360, or 480 mls of solution four to six times a day as prescribed by the dietician. 6. Beginning feedings by intestinal tube should be a progressive process over a 1 to 3 day period in order to allow the patient s GI tract time to adjust to the formula. 7. Fill formula reservoir and prime tubing. Affix date and time of the feeding preparation to the bag. 8. Check for residuals. 9. Securely attach primed feeding tubing to gastric tube. 10. Set rate of infusion. Start tube feeding. Encyclopedia of Nursing Page 3
11. Assure that head of bed is at least 30 degrees to prevent esophageal reflux and aspiration of tube feeding into lungs. 12. Assess patient periodically for tolerance to tube feeding. If signs of intolerance (diarrhea, abdominal pain, high residuals etc.) are noted, the rate of the tube feeding should be decreased. 13. When feeding is finished, disconnect tubing and flush with 60 mls water or whatever quantity of water is ordered 14. Document procedure and how patient tolerated feeding. Checking for Residuals 1. Verify correct patient using two identifiers- information on wrist band, verbal check, birth date or medical record number on chart 2. If the patient is on intermittent feedings, the nurse should check for residuals before each feeding. Gently aspirate stomach contents, measure the amount, and record. With continuous feeding, this is done every 4 to 6 hours. Amount of residual should be checked and documented just before next feeding. 3. If the amount of gastric residual is 50 % or more than the volume of the formula infused hourly, the feeding is stopped and the amount is rechecked in two hours. If the amount of residual is 50% or more than the amount given in the last feeding, the feeding should not be given and the physician should be notified. 4. Follow agency protocol regarding returning residual to stomach after measurement. 5. Gastric residuals cannot be measured in patients with intestinal tubes since the small intestine does not have the same capacity as the stomach. 6. The patient should be monitored, including daily weights and vital signs every 8 hours. 7. When measuring Intake and Output, it is important to separate the amount of formula from any additional fluid that is given via the tube. 8. Document procedure and patient response. Encyclopedia of Nursing Page 4
Preventing Complications 1. Aspiration of stomach contents is the most dangerous complication of tube feedings, and is a fairly common occurrence in those patients who are at high risk including those who are unconscious, weak, confused, intubated, or have an impaired gag reflex. Aspiration is also more probable if there are large gastric residuals hours after feeding. 2. A measure to prevent aspiration with patients on either intermittent or continuous feedings is to raise the head of the bed 30 to 45 degrees. The head of the bed should remain raised for ½ to one hour following feeding. 3. Another preventive measure is to check for tube placement before administering an intermittent feeding. This is done by aspirating the tube with a 60 ml syringe and checking for the ph of gastric contents. Check for residuals, also. 4. Diarrhea is another frequent complication of tube feeding. Precautionary measures include giving formula at a rate and strength tolerated by the patient, giving formula that is fresh and uncontaminated, and giving lactose-free formula to a patient who is lactose-intolerant. 5. Another possible complication is infection. The safest policy is to use only recently prepared formula which has been mixed by nutritional services, newly opened, canned, or pre-packaged formula. 6. New formula should not be added to that which has been hanging for a period of time. Acceptable length of time for powdered products is 4 hours. Hang time for canned formula is usually 8 hours. Refer to agency policy. 7. After each intermittent feeling, the empty bag and tubing should be rinsed with water and allowed to air dry. 8. The delivery system should be changed every 24-48 hours. Always label the bag or bottle and dispose of unused contents, if policy dictates a time limit. 9. Left-over formula should be refrigerated and labeled with the time and date. If not used within 24 hours, it should be discarded. 10. Document procedure and patient response. Declogging of Tube 1. Verify correct patient using two identifiers- information on wrist band, verbal check, birth date or medical record number on chart. Verify tube placement. Encyclopedia of Nursing Page 5
2. Tubes can often become clogged. Thorough irrigation with water at regular intervals is very important. Timing of the irrigation will vary according to agency policy, the type of tube inserted and the viscosity of the feeding solution 3. General guidelines are that irrigation is usually performed with 20 to 50 mls (for adults) of ordered fluid in a 60 ml syringe. 4. Patients on continuous feedings have tube irrigated every 4 to 6 hours and every time the feeding is stopped such as when the feeding bag is changed. 5. Patients on intermittent feedings should have tubes irrigated after each feeding is completed. It is important to flush the tube after checking for residuals. 6. With frequent flushing, many milliliters of solutions can be given during a 24 hour period. Therefore, any flush solution must be recorded as intake. 7. Document procedure and patient response. Medication Administration 1. The nurse should follow the six rights of medication administration- right patient, right medication, right dosage, right time, right route, and right documentation. 2. Verify the correct patient by 2 identifiers- information on wrist band, verbal check, birth date or medical record number on chart. 3. If at all possible, avoid crushing and dissolving solid drugs for tube instillation. Also, sustained release or enteric-coated tablets or capsules, should not be crushed because such drugs contain substances that contribute to clogging. It is important to use liquid forms of medications, if at all possible. If your patient is on medications that can be given in a liquid form, make sure to inform MD and/or Pharmacist to change the prescription to reflect this. 4. It is also important to avoid giving muciloid bulk-forming agents through gastrointestinal tubes. When mixed with water, such agents quickly congeal and occlude the tube. 5. If two incompatible drugs are to be given at the same time, it is necessary to irrigate the tube with 30 mls of water between drugs. This avoids incompatibility reactions within the tube. The amount of flush solution may be changed if the patient is receiving many medications and he/she is on a fluid-restricted diet. 6. Mixing the medication with the formula should be avoided. Some drugs can alter the emulsion of the feeding. As a result, the formula looks like curdled milk and can clog the tube. Encyclopedia of Nursing Page 6
7. It is also recommended the feeding tube be flushed with 30 ml of water after medications administration. The amount of flush solution should be recorded as intake on the Intake and Output sheet. 8. Document medication administration and patient response to procedure and medication. Tube Removal 1. Wash hands and don gloves. 2. Verify correct patient using two identifiers- information on wrist band, verbal check, birth date or medical record number on chart. 3. Explain procedure. 4. First, irrigate the tube with 30 mls of water, then with enough air to clear the tubing of liquid. Have an emesis basin ready, in case patient vomits. Remove tape. 5. Crimp the tube by folding it over on itself and gently, but quickly, pulling the tube out. 6. Dispose of tube and tubing. Clean patient s face and nares with washcloth for comfort. Remove gloves. Wash hands. Document procedure and patient tolerance. Encyclopedia of Nursing Page 7
CHEST TUBES 1. Chest tubes are drains that remove fluid or air from the space between the visceral pleura of the lungs and the parietal pleura of the chest wall. Insertion 1. Check the agency s policies and procedures regarding chest tube insertion and patient care. 2. Verify correct patient using two identifiers- information on wrist band, verbal check, birth date or medical record number on chart. 3. Explain the procedure to the patient. 4. Make sure an informed consent has been completed. 5. Gather equipment. This would include several different sizes of chest tubes: 6 to 26 French for infants and children and 20-40 French for adults 6. A thoracotomy tray will also be needed. Have 2 pair of correct size of sterile gloves and vaseline gauze available. A new sterile chest tube drainage collection device will be needed. 7. To prepare the device for use, fill the water seal to 2 cm with sterile water. This creates a water seal that prevents air from re-entering the tubing. 8. Suction, if ordered, is connected to the wall unit. Make sure you have suction tubing available for connection from drainage container to wall suction. However, suction should be regulated by the mechanism on the collection device. Suction on the chamber should be adjusted with high enough pressure to drain the chest but not damage tissue. This is usually a gentle bubbling. 9. Wash hands. 10. Follow Time Out procedure to assure the correct side of the chest has been identified and marked and to verify correct patient and incision site prior to incision. 11. Medicate patient, if physician s order or agency protocol. 12. Assist patient to Fowler s or semi-fowler s position. 13. Assist the physician as necessary. The patient will be draped with sterile towels, and local anesthetic injected. Encyclopedia of Nursing Page 8
14. A small incision will be made and the pleural space opened by finger dissection or the use of a hemostat. The chest tube is inserted and sutured into place. Provide assurance to the patient and monitor for changes in condition. 15. The chest tube is connected to the drainage tube of the suction control chamber. The chamber must be kept lower than patient s chest at all times. This allows gravity drainage and prevents back flow. Never clamp the chest tube! 16. A sterile dry dressing or moist occlusive dressing is applied around the chest tube. It should be as airtight as possible. 17. The connection between chest tube and chest drainage tube is reinforced with tape to prevent dislodgement. Care should be taken not to occlude the connection 18. The connections should be assessed for patency and air leaks. It should be an airtight connection. 19. Any excess tubing should be coiled, taped, or pinned to the bed. 20. A chest x-ray will be ordered to confirm placement. 21. Document procedure and patient response. Post-procedure Care 1. The patient should be monitored for possible complications. A complete assessment immediately following the procedure should act as a baseline for evaluating improvement or worsening of patient s condition later. 2. Monitor vital signs. Check respiratory status-rate, rhythm, expansion, percussion, skin color, nasal flaring, chest retraction and oxygen saturation. Check for increase in anxiety or shortness of breath. 3. Check dressing to make sure it is occlusive. Typically the dressing is not changed but rather reinforced and taped, if drainage is present. 4. Palpate skin around chest tube insertion site. If air is present in the subcutaneous tissue (termed subcutaneous emphysema ) this may indicate tension pneumothorax. 5. Check all connections. These should be visible and securely taped. 6. Check drainage. If heavy or bloody, and it does not diminish after the 1 st hour, notify physician. The slide clamp should never be clamped closed when moving a patient. The only time the clamp may be closed is if the doctor orders it in order to test the possibility of removing it. Encyclopedia of Nursing Page 9
7. Drainage in excess of 100 mls should be considered excessive. 8. Check drainage unit. Keep it lower than the patient s chest and away from bed frame. Position the unit so that it will not tip over. To ensure this, tape can be used to affix it to the floor. 9. Check and chart the amount, character and rate of drainage in the collection chamber. Refill air seal chamber to 2 cm water. Bubbling in water seal should be gentle. 10. If bubbling stops suddenly, check for kinked tubing. If bubbling is vigorous, check for an air leak. 11. Check for tidaling-when water level raises with inspiration, and lowers with expiration. 12. Document procedure, amount of drainage, and patient condition. General Care Guidelines 1. Activity should not be impaired except for being connected to chest tube drainage unit. Keep tubing free of kinks. 2. Fowler s position is optimal with frequent turning toward chest drainage unit to promote drainage. 3. Incentive spirometry, deep breathing, and pain control are used to promote comfort, adequate respiration, and to prevent pneumonia. Troubleshooting 1. If fluid movement in the tube stops, do not milk or strip the tubing. Milking can increase hydrostatic lung pressure to - 400 cm of water- far above the normal range of 6 to 12 cm water. Repositioning patient may increase fluid flow. 2. If tubing becomes disconnected, do not clamp. Place the end of tube in a bottle of sterile water. This restores a water seal until a new drainage unit is ready and connection re-established. Clamping the tubing may inadvertently cause a tension pneumothorax. 3. If an air leak is suspected and cannot be found, clamp tubing briefly at intervals along length of tubing. 4. If chest tube comes out, use petroleum gauze to cover incision. The gauze should be at the bedside for emergencies. Encyclopedia of Nursing Page 10
Tube Removal 1. Indications for chest tube removal would include: normal breath sounds bilaterally, drainage less than 50 mls in 24 hours, tidaling, or cessation of fluctuation in the water seal chamber. 2. Verify correct patient using two identifiers- information on wrist band, verbal check, birth date or medical record number on chart. 3. Explain procedure - There may be a short, brief pulling or burning sensation, but no pain once tube is out. Administer pain medication, if ordered. 4. Gather supplies. Wash hands. Don clean gloves. 5. Position patient as requested by physician. Dressing is loosened and knot on anchoring suture cut. 6. Patient should be instructed to inhale deeply or bear down and hold breath. 7. The tube is quickly and gently pulled and suture tied. 8. The incision site is covered with air-tight dressing 9. The nurse should follow up with post procedure protocol according to agency policy. This could include a chest x-ray and monitoring vital signs and respiratory status for recurrent or new pleural problems. 10. Document procedure and patient response. Disposal of Chest Tube Drainage Unit 1. Wash hands. Use universal precautions- gloves and goggles, if risk of spray exists. 2. Disposable unit should be capped and red bagged. Encyclopedia of Nursing Page 11
Intavenous Fluid Administration 1.. Equipment and supplies needed include: - IV stand - Tubing and extension tubing - Bottle or bag of IV solution - Adhesive tape - Tourniquet or blood pressure cuff - Sterile gauze or transparent occlusive dressing - Alcohol and betadine pledgets 2. Sometimes a local anesthetic can be used. 3. Over the needle catheters - There are many types of over the needle catheters. They consist of a radiopaque plastic catheter and needle. They are available in different gauges (16-24g), and they come in lengths from 1 ¼ to 2 inches long. - An IV catheter should have a safety device to protect the nurse during and following catheter insertion and needle removal. Site Selection 1. Choose a site with prominent veins near the skin surface. 2. If venous dilatation is poor, it can be increased prior to insertion by warming the areas with a compress, having the patient hang the arm over the edge of the bed, or gently tapping the skin to make the vein more prominent. 3. Common sites include the peripheral veins of the hands and arms. Veins of the wrist and elbow should be avoided because the patient may flex the joint and dislodge the IV. Also, sites over joints are uncomfortable for the patient who has to limit mobility when long-term therapy is necessary. 4. For short-term venous access, the dorsum of the hand is a good choice. Look for a vein which branches distally. If the vein is entered at the junction of the branches, rolling of the vein is minimized. Rolling of the vein being entered is a problem often encountered in patients with tough vein walls. Encyclopedia of Nursing Page 12
5. Other major insertion sites include the large vein on the radial side of the distal forearm above the wrist, and when easily visualized, a vein on the volar aspect of the forearm. 6. Peripheral veins in the legs and feet are generally not used because blood stasis resulting from gravity can cause phlebitis to develop more quickly than in other IV sites. Veins in the feet, however, can be used in infants before they begin to pull up to a standing position. Site Preparation 1. Verify correct patient using two identifiers- information on wrist band, verbal check, birth date or medical record number on chart. 2. Explain procedure. Thoroughly wash hands and don gloves. 3. Hang the IV solution on the IV stand and flush the tubing. Make sure there is not air any where in the line. Prime and set the IV pump. 4. Tear or cut sections of adhesive tape and place them within reach. 5. Apply the tourniquet or blood pressure cuff proximal to the site. 6. If a tourniquet is used, apply it a few inches above the chosen site. It should be tight enough to impede venous flow but not so tight that it occludes arteries. An arterial pulse should still be palpable distal to the tourniquet. 7. If a blood pressure cuff is used, it should be inflated until the pressure is midway between the patient s diastolic and systolic pressures. In an emergency, 100 mm Hg is reasonable for the patient with a palpable pulse. 8. Cleanse the site thoroughly with povidone-iodine or alcohol gauze pads. Allow the site to dry. 9. Local anesthetics should be used intradermally whenever possible as they can facilitate painless venipuncture, especially with larger size catheters. 10. Use a small needle and syringe with approximately 0.5 ml of local anesthetic. The medication should be slowly injected until a weal forms, carefully avoiding distortion of the skin over the vein. (The weal will conceal the vein somewhat, even if the local is carefully injected). Encyclopedia of Nursing Page 13
Catheter Insertion 1. To stabilize the vein, traction should be applied to the skin distal to the entry site with the nondominant hand. 2. The dominant hand should hold the catheter, with the needle bevel up, at a 15 to 20 degree angle to the vein. 3. The needle should be inserted with steady pressure until a slight pop is felt and blood appears in the needle hub. If no blood is seen, wait a second or two, then check again. 4. If blood returns immediately and then stops, a valve in a large vein may be obstructing flow. The needle or catheter can be withdrawn slightly or advanced to a different position until the blood flows freely. 5. With the non-dominant hand, the catheter and needle should be advanced ¼ inch further into the vein. 6. The needle is then pulled back with the dominant hand. 7. Advance the catheter carefully to the hub. 8. Withdraw needle. Initiate the safety feature. 9. Pressure should be applied over the catheter tip to prevent bleeding. 10. Remove the tourniquet or deflate the blood pressure cuff. 11. Attach the IV tubing to the hub and start the infusion. 12. If a hematoma or swelling occurs at the entry site, the catheter is incorrectly placed and the vein punctured. The catheter should be removed and pressure applied with a gauze pad. Select a new site, and insert a new catheter. Securing Catheter 1. If the infusion flows smoothly, use gauze or a cotton ball to remove any blood or spilled solution on the skin. A sterile gauze or transparent film occlusive dressing is usually placed over the site. 2. The catheter should be secured with tape, making a loop of the tubing, taping again so that if the tubing is pulled, the tension is on the tubing and not on the catheter itself. 3. It is also important to label the site with the time and date of insertion and the initials of the caregiver who started the IV. Encyclopedia of Nursing Page 14
4. Depending on the IV site chosen, an arm board may or may not be necessary. An arm board is most often used when the venipuncture site is at a joint such as the wrist or elbow. 5. A long splint should be used if the site is near the antecubital fossa. 6. A short splint should be adequate if the venipuncture site is in the lower arm, the wrist, or hand. 7. Follow institutional policy as to length of time between IV site and tubing changes. IV Regulation 1. The physician orders the length of time the IV infusion should run. The nurse is responsible to calculate the correct flow rate and program the pump correctly, and check the infusion to make sure the IV fluids are delivered in the time ordered. 2. The use of an IV pump is standard procedure. However, the nurse must understand and be able to use a simple formula to determine the drip rate of an IV solution to be able to program the pump correctly. 3. To calculate drip rate use the following formula: total milliliters to be delivered x drip factor = drip rate total minutes For example, if 1,000 ml needed to be delivered in 8 hours using a drip factor of 15, the drip rate would be calculated as: 1,000 mls x 15 = 31.24 or 32 drops per minute 480 minutes 4. Check the IV site, flow rate, and pump function every one or two hours, per hospital protocol. 5. If the infusion is too fast or too slow, the nurse needs to check the position of the arm, the patency and position of the tubing and catheter, and the height of the infusion bag or bottle. 6. If the rate is behind schedule, the nurse should follow hospital policy concerning how fast the drip rate can be increased without causing a fluid overload. Encyclopedia of Nursing Page 15
Preventing Complications 1. Patients must be monitored closely for complications arising from the IV insertion or the infusion. Sites must be checked regularly (according to facility protocol) with findings documented after each assessment. 2. Complications include infiltration, extravasation, or phlebitis. 3. The clinical signs of infiltration are swelling, coolness, and pallor at the IV site. The patient may also complain of discomfort or pain. 4. Check the site by palpating the surrounding tissue for edema or for changes in skin temperature. 5. The signs of extravasation include burning, stinging, and pain as well as induration, erythema, and venous discoloration or swelling at the site. 6. The patient s complaints of pain may also indicate the presence of phlebitis or inflammation of the vein. This can occur as a result of mechanical or chemical injury to the vein. Symptoms of phlebitis are redness, warmth, or swelling at the IV site. 7. When infiltration, extravasation, or phlebitis occur, a new venipuncture site is chosen and the injured vein is not used for future infusions. There are also protocols to follow for treatment of the IV site after certain drugs infiltrate. Variance reports may need to be completed when these complications occur. 8. Priming the tubing, whether by manual or IV pump, is done by compressing the drip chamber, turning. 9. If a few bubbles do enter the tubing, the roller clamp can be released to allow the fluid to run until no air is seen. 10. While the primary tubing is being primed, it is also important to check the Y port sites. They should be turned upside-down and tapped gently to remove air as the solution flows past. 11. During the infusion, the drip chamber should be kept one-half full. The fluid acts as a water seal which also prevents air from entering the tubing. 12. Make sure the roller clamp is moved down to the proximal or patient end of the tubing. Then even if a large amount of air enters the tubing, the IV can be stopped and air removed more safely. 13. Air can also enter the tubing when the IV runs dry. The air usually will not reach the patient due to venous pressure, but when the new bag or bottle of solution is added, the fluid can force the air down the tubing and into the patient. Encyclopedia of Nursing Page 16
14. To remove air, use a hemostat to clamp the tubing below the Y port, and then access the line with a syringe. Now, when the roller clamp is opened, air and solution are pulled into the syringe, and the tubing filled with solution, and the IV continued without the possibility of air entering the tubing. 15. To prevent air entering the primary tubing from a secondary line, the infusion should be stopped when there is still medication in the drip chamber. Certain brands of IV pumps have a feature that primes the tubing as well as back priming. Refer to the instruction manual on the pump to best utilize your facility s pumps. 16. Teach the patient to avoid sudden movements of the arm, which would stretch or place tension on the tubing. 17. The tubing should not be dangled below the level of the IV site. This will cause blood to backup into the IV tubing. 18. The alert and oriented patient should be instructed to call the nurse if any of the following occurs: - If there is air in the tubing. - If the solution stops dripping, - If the site become swollen or painful, - If the IV insertion site is leaking - Or, if blood appears in the tubing. Discontinuing the IV 1. The infusion is discontinued when: - There is a problem and the IV fluid cannot be infused. - The patient s hydration status is satisfactory and no further IV solutions are needed. This is usually when patient is able to take adequate oral fluids. - IV access is no longer needed for administration of medications. - Inform patient it should not be a painful procedure. 2. After confirming the physician s order to remover the IV and identifying the patient using 2 identifiers, the nurse should don gloves to prevent contact with blood. 3. Clamp the infusion tubing so it does not leak onto the patient or bed linen. Encyclopedia of Nursing Page 17
4. The tape should be loosened while holding the needle or catheter firmly and with gentle pressure applied to the skin. This will prevent injury to the vein. 5. A gauze square should be placed over the venipuncture site, and the catheter should be withdrawn by pulling it out along the line of the vein. 6. Pressure should be applied to the site for 2 or 3 minutes. Steady pressure helps stop bleeding and prevents hematoma formation. If the patient is on anti-coagulant therapy, pressure may be needed for a longer period of time. Keep in mind that the larger the gauge of needle that was inserted and the larger the vein, the longer it will take to stop the bleeding. 7. A sterile dressing may be firmly applied to continue pressure and provide sterility until the venipuncture seals. 8. It is important to check the catheter to make sure it is intact. If the tip has broken off, it should be reported immediately. 9. All disposable IV equipment should be safely discarded in the proper containers. Sharps, of course, should be placed in impervious containers designated for that purpose. 10. The procedure and the nurse s assessment of the patient s response should be documented. The insertion site should be closely inspected and documented as normal, or reddened, or hematoma present/absent, etc. The amount of fluid infused should be recorded on the Intake and Output sheet. Infusion Pump 1. The use of an infusion pump is required for all patients receiving IV therapy. The most important factor in the use an infusion pump is patient safety the precise administration of the prescribed fluids and/or medication in a specific amount of time. 2. The infusion pump is particularly valuable for patients who are critically ill or when they may need infusion of potentially harmful fluids or medications which require precise measurement. 3. Most of the latest models of infusion pumps are volumetric they deliver fluids at a constant volume (mls per hour). 4. With some pumps, more than one infusion can be programmed to run through the same tubing. The piggyback can run at one rate, and when it is finished, the pump will restart the primary IV at its predetermined rate. Encyclopedia of Nursing Page 18