IVT Procedures

          There are 5 main procedures for the return demonstration to be done during the IVT program. These procedures are based from the ANSAP's booklet.

Procedure I: IVF infusion

     A. SETTING UP:

1. Verify written prescription and make IV label.
2. Observe ten (10) rights when preparing and administering IVF.
3. Explain procedure to reassure patient and/or significant other, secure consent if necessary.
4. Assess patient's vein; choose appropriate site, location, size/condition.
5. Do hand hygiene before and after the procedure.
6. Prepare necessary materials for procedure (IV tray wih IV solution, administration set, IV cannula, forceps soaked in alcohol with cover (this should be exclusively used for I.V.), plaster, tourniquet, gloves splint, and IV hook), sterile 2x2 gauze or transparent dressing. 
7. Check the sterility and integrity of the IV solution, IV set and other devices.
8. Place IV label on IVF bottle duly signed by RN who prepared it (patient's name, room no., solution, time and date).
9. Open IV administration set aseptically following the infection control measures.
10. Open IV administration set aseptically and close the roller clamp and spike the infustate container aseptically.
11. Fill the drip chamber to at least half and prime it with IV fluid aseptically.
12. Expel air bubbles if any and put back the cover to the distal end of the IV set (get ready for IV inserertion).

     B. INSERTING IV CANNULA UTILIZING DUMMY ARM
          Prepare complete IV tray with IV infusions; Dummy Arm and over-theneedle catheter or Butterfly needle. 

1. Verify the written prescription for IV therapy; check prepeared IVF and other things needed.
2. Explain procedure to reassure the patient and significant others and observe the 10 rights.
3. Do hand hygiene before and after the procedure.
4. Choose site for IV.
5. Apply tourniquet 5 to 12 cm. (2-6 in.) above injection site depending on condition of patient.
6. Check for radial pulse below tourniquet.
   Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry (No touch technique).
   Note: CDC Universal precuation: Always wear gloves when doing any venipuncture.
   
7.  Using the appropriate IV cannula, pierce skin with the correct technique.
8. Upon backflow visualization, continue inserting the catheter into the vein.
9. Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the catheter until the hub is 1mm to the puncture site.
10. Slip a sterilize gauze under the hub. Release the tourniquet; remove the stylet while applying digital pressure over the catheter with on finger about 1-2 inches from th etip of the inserted catheter.
11. Connect the infusion tubing of the prepared IVF aseptically to the IV catheter. 
    
     Note: When steel-winged needle (butterfly) is used:
    
              A. Connect the IV tubing to the steel-winged needle connector and prime the needle with IV fluid.
              B.  Using the steel-winged needle, pierce skin with the needle beel up, positioned on a 5-10 degree angle.
              C. With steel-winged needle, parallel on the skin enter the vein directly and advance needle 1/4 inch after successfully performing venipuncture check for backflow. Remove tourniquet.
              D. Do not reinsert stylet once pulled out to prevent breakage of catheter that may cause embolism.
    
    
    
    
    
12.  Open the clamp and regulate the flow rate. Reassure patient.
13. Anchor needle firmly in place with the use of:
                  
                   a. transparent tape/dressing directly on the puncture site.
                   b. tape (using any appropriate anchoring style)
                   c. Band-Aid
    
    Note: Never place unsterile tape directly on IV insertion site. Instead, place a small piece of sterile OS and then secure it with adhesive tape.  
     
14.  Tape a small loop of IV tubing for additional anchoring. Apply splint, if needed.
15. Calibrate the IVF bottle and regulate flow of infustion according to prescribed duration.
16. Label of IV tape near the IV site to indicate the date of insertion, type and gauge of IV catheter and countersign.
17. Label with plaster on the IV tubing to indicate the date when to change the IV tubing.
18. Observe patient and report any untoward effect.
19. Document in the patient's chart and endorse to incoming shift.
20. Discard sharps and waste according to Health Care Waste Management (DOH/DENR). 

     C. CHANGING AN IV SOLUTION

1. Verify doctor's prescription in doctor's order sheet; countercheck IV label IV card, infusate sequence, type, amount, additives (if any), and duration of infusion.
2. Observe 10 rights.
3. Explain procedure to reassure th epatient and significant others and assess IV site for redness, swelling, pain, etc.
4. Change IV tubing and cannula if 48-72 hours has lapsed after IV insertion. 
5.  Prepare necessary materials; place on an I.V. tray.
6. Check terility and integrity of IV solution.
7. Place IV label on the IV bottle.
8.  Wash hands before the procedure.
9. Calibrate new IV bottle according to duration of infusion as per prescription. 
10. Open and connect the I.V. tubing into the solution bottle.
11. Close the roller clamp. 
12. Regulate the flow rate according to the prescribed infusion rate. Expel air bubbles, if evident.
13. Reiterate assurance to patient and significant others.
14. Discard all waste materials according to Health Care Waste Management (DOH/DENR).
15. Document and endorse accordingly.

     D. DISCONTINUING AN IV INFUSION

1. Verify written doctor's order to discontinue IV including IV medications. 
2. Observe 10 rights.
3. Assess and inform the patient of the discontinuation of IV infusion.
4. Prepare the necessary materials; IV tray or injection tray with sterile cotton balls with alcohol, plaster, pick-up forceps in antiseptic solution, kedney basin and band aid.
5. Wash hands before and afer procedure.
6. Close the roller clam of the IV administration set.
7. Moisten adhesive tapes around the IV catheter with cotton ball with alcohol; remove plaster gently.
8. Use pick-up forceps to get cotton ball with alcohol and without applying pressure, remove needle or IV catheter then immediately apply pressure over the venipuncture site.
9. Inspect IV catheter for completeness.
10. Place dressing over the venipuncture site.
11. Discard all waste materials including the IV cannula according to Health Care Waste Management (DOH/DENR).
12. Reassure patient.
13. Document time of discontinuance, status of insertion site and integrity of IV catheter and endorse accordingly.

Procedure II: Blood Transfusion

1. Verify doctor's written prescription and make a treatment card according to hospital policy.
2. Observe 10 rights when preparing and administering any blood or blood components.
3. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others and secure consent. Get patient histories regarding previous transfusion.
4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719 - National Blood Service Act of 1994).
5. Request prescribed blood/blood components from blood bank to include blood typing and X-matching and blood result of transmissible disease.
6. Using a clean lined tray, get compatible blood from hospital blood bank.
7. Wrap blood bag with clean towel and keep it at room temperature. 
8. Have a doctor and a nurse assess patient's condition. Countercheck the compatible blood to be transfused against the X-matching sheet noting ABO grouping and RH, serial no. of each blood uni, and expiry date with the blood bag label and other laboraory blood exams as required before transfusion (Hgb and Hct).
9. Get the baseline vital signs - BP, RR, PR and Temp before transfusion. Refer to MD accordingly.
10. Give pre-med 30 minutes before transfusion as prescribed.
11. Do hand hygiene before  and afer the procedure.
12. Prepare equipment needed for BT (IV injection tray, compatible BT set, IV catheter/needle G 19/19, plaster, tourniquet, blood, blood components to be transfused, Plain NSS 500 cc, IV set, needle gauge 18 (only if needed), IV hook, gloves, sterile 2x2 gauze or transparent dressing, etc.
13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with Plain NSS on another site, anchor catheter properly and regulate IV drops. 
14. Open compatible blood set aseptically and close roller clamp. Spike blood bag carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles (if any), Use needle g. 18 or 19 for side drip (for adults) or g. 22 for pedia (if blood is given through the Y injection port, the gauge of needle is disregarded).
15. Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle from BT administration set and secure with adhesive tape. 
16. Close roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on.
17. Transfuse the blood via th einjection port and regulate at 10-15 gtts/min. initially for 15 minutes and then at the prescribed rate (usually based on the patient's condition).
18. Monitor th epatient within the first 5-10 minutes of transfusion and refer immediately to the MD for any adverse reaction.
19. Observe/Assess patient on an on-going basis for any untoward signs and symptoms such as flushed skin, chlls, elevated temperature, tichiness, urticaria and dyspnea. if any of these symptoms occur, stop the transfusion, open the IV line with Plain NSS and regulate accordingly, and report to the doctor immediately.
20. Swirl the bag gently from time to time to mix thse solid ith the plasma. N.B. one BT set should be used for 1-2 units of blood.
21. When blood is consumed, close the roller clamp of BT, and disconnect from IV lines then regulate the IVF of Plain NSS as prescribed.
22. Continue to observe and monitor patient post transfusion, for delayed reaction could still occur.
23. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed an/or per insitution's policy.
24. Discard blood bag angd BT set and sharps according to Health Care Waste Management (DOH/DENR).
25. Fill-out adverse reaction sheet as per institutional policy.
26. Remind the doctor about the administration of Calcium Gluconate if patient has several units of blood transfusion (3-5 more units of blood). 

Procedure III: Administering IV Drugs

     A. IV MEDICATION INCORPORATION OF DRUG INTO IV BOTTLE/BAG

     Note: Put the Protocol of the Hospital in consideration.

1. Verify the written medication card against the M.D. prscription; observe hospital policy on drug administration.
2. Observe 10 rights when preparing and administering medication.
3. Explain procedure (medication and action) to reassure patient and significant others and check patency and IV site.
4. Verify for skin test of drug for IV incorporation (if skin testing is necessary).
5. Do hand hygiene before and afer the procedure.
6. Prepare the necessary materials needed for this procedure such as: injection tray, syringes needed, right drug to be incorporated either in vial or ampule.
7. Disinfect injection port of the vial and the ampule before breaking then aspirate the right dose aseptically.
8. Remove the cover of the administration set, maintain sterility and incorporate prepared drug into the airway aseptically. Recap airway after.
           Note: if the administration set has no airway, pull out the set and incorporate the prepared drug and re-spike the IV set to the bottle then place the label (all these should be done aseptically).
    
9. Swirl the IV botle to mix the drug with IVF and regulate the flow rate accordingly.
10. Observe for 5-10 minutes for any drug interaction while reassuring the patient; monitor VS.
11. Document the procedure done on th epatient's chart.
12. Discard sharp and other wastes according to Health Care Waste Management (DOH/DENR).

     B. IV MEDICATION PUSH THROUGH THE IV PORT

1. Verify medication card against the written doctor's prescription.
2. Observe the 10 rights when preparing and administering medication.
3. Explain procedure to reassure patient and significant others (the name of medicine and action/ineraction of medication) before administration.
4. Do hand hygiene before and after the procedure (use gloves especially for chemotherapeutic and other vesicant drugs).
5. Check patency and other reaction signs of swelling, redness, phlebitis, etc... if any of these are evident, do not give the drug.
6. Check for skin rest result of drug for IV push, drug-drug, drug IV fluid incompatibility, dosage (computation).
7. Prepare the necessary materials for the procedure such as: right drug, right diluent needed, IV injection tray, syringes with needles, alcohol, etc.
8. Disinfect injectin port of the diluent, vial or ampule as may be appropriate.
9. Aspirate right amount of diluent for the drug (if the drug needs to be diluted).
10. Aspirate the right drug dose; disinfect the Y-injection port of th eIV adminsitration set-catheter IV port.
11. Close the roller clamp of the IV tubing from the bottle and push IV drug aseptically and slowly according to the manufacturuer's recommendation.
12. Using same syringe, aspirate 1-2cc  of IVF to flush the medicine given.
13. Regulate rate of IV fluid infustion as prescribed (if needed).
14. Reassure patient and observe for signs and symptoms of adverse drug reaction.
15. Discard sharps and other waste according to Health Care Waste Management (DOH/DENR).

     C. IV MEDICATION INCORPORATION INTO VOLUMETRIC CHAMBER

1.  Verify the written M.D. prescription and follow hospital policy on drug administration.
2. Observe 10 rights when preparing and administering medication.
3. Explain procedures to patient (medicine and action) and check IV site. Verify for skin test of the drug before IV incrporation.
4. Prepare the necessary materials for the procedure such as right drug and dose, right diluent needed, IV injection tray, syringes and needles.
5. Do hand hygiene before and afer procedure.
6. Check present IV fluid label, level and the incoporated medicine in the Volumetric Chamber or IV bottle if with incorporated medicine, check for drug-drug incompatibility and if the on-going IV fluid in the Volumetric Chamber is to be consumed in 6-8 hours, request a prescription and keep thw hole set sterile for succeeding doses.
7. Aspirate prepared right drug with correct dose.
8. Add desired IVF diluent into volumetric chamber by opening the sliding clamp from the bottle then close the clamp.
9. Disinfect rubber injection port of the volumetric chamber and incorporate the drug. Mix gently.
10. Open the clamp of the airway at the volumetric hamber and incoporate the drug. Mix gently.
11. Regulate flow rate of IVF infusion accordingly.
12. Place IV label on volumetric chamber indicating drug incorporated and flow rate. 
13. Reassure/monitor patient when incorporated medicine is consumed; clamp airway of Volumetric Chamber, add IVF and regulate flow rate of main IVF as prescribed. 
14. Discard waste according to Health Care waste Management (DOH/DENR).
15. Document in the patient's chart the drug administered and patient's condition.
16. Document in the patient's chart the IVF Sheet and Kardex (of changes in IV rate/time due).

     D. IV MEDICATION PUSH THROUGH THE HEPARIN-LOCK DEVICE

     Note: Some Hospitals do not use Heparin anymore

1. Check medication card against the written doctor's prescription.
2. Observe 10 rights when preparing and administering medication.
3. Explain procedure to the patient (name of the medicine and action) before administration.
4. Gather equipment to include/but not limited to IV tray, Normal Saline diluent or Isotonic solution, 2.5 cc syringes (2-3 pcs) as needed.
5. Do hand hygiene before and after the procedure (use gloves especially for chemo drugs).
6. Prepare medication to be administered, e.g. antibiotic, and draw it up into a syringe.
7. Fill a tuberculin syringe with Heparin solution. N.B. Heparin solution is usally prepared with 0.1 cc Heparin plus 0.9 cc Normal Saline or isotonic solution as prescribed by the doctor.
8. Fill the 2.5 cc syringe with isotonic solution or Normal Saline Solution; 1cc each.
9. If using Heparin Lock device with 3-way stop cock with luer-lock, rotate the stop cock so that the line going to the patient is closed (this will prevent backflow of blood).
10. Remove th ecover of ht einjection por aseptically and keep the sterility of the cover.
11. Check the patency, open the IV line and inject NSS or isotonic solution to flush the Heparin Solution as prescribed by th eDoctor.
12. Close the IV line and remove saline syringe and insert medication syringe into th eport. Give IV push 5-10 minutes for IV potent drug. For 2-3 IV medication, give at least 30 minutes to 1 hour interval. After each drug administered via IV push, flush with 2-3 cc saline solution.

      Note: Normal Saline can take the place of Heparin. Studies have shown the efficacy of NSS. Heparin  solution can be used if normal saline or Isontonic solution is not available and as prescribed by the MD.

 Procedure IV: Parenteral Nutrition Administration, Peripheral Access / Central Vascular Access

     A. PARENTERAL NUTRITION INFUSION UTILIZING THE PERIPHERAL ACCESS

1. Verify doctor's prescription.
2. Eplain the procedure to reassure patient and significant other (benefits, risks, duration, changes in volume and flow rate, etc.).
3. Secure consent from patient or/and authorized member of the family.
4. Prepare parenteral solution and all other devices needed for the parenteral administration, taking into consideration the mode of administration such as:
   
   
             
        a. Peripheral access
        b. Central access
   
   
5. Check the integrity and functionality of the parenteral solutin and IV devices.
6. Observe 10 rights in safe drug administration.
7. Assess patient and choose suitable vein, location and get baseline vial signs.
8. Do hand hygiene and maintain asepsis throughout th eprocedure.
9. Prepare Parenteral Nutrition solution (follow procedure I: Setting Up).
10. Insert IV catheter aseptically (large, bore0catheter. Follow procedure I in IV insertion).
11. Connect th etubing to the prepared parenteral solution and regulate flow rat as prescribed.
12. Dress IV sites as per IV standard.
13. Label IV site and solution as per IV standard.
14. Continue to reassure patient and do pertinent health education.
15. Dispose waste materials according to Health Caare Waste Management (DOH/DENR).
16. Document procedure and observations with corresponding nursin gintervention in the patient's chart like I and O , weigh daily, etc.
17. Monitor patient periodically and report unusual findings if there are signs of infection, hyper and hypoglycemia, change of color and consistency of solution, etc.
18. Document observation and intervention as necessary. 
19. Reassure patient.

     B. PARENTERAL NUTRITION INFUSION UTILIZING CENTRAL VASCULAR ACCESS

1. Follow procedure in Procedure IV-A in Peripheral Access from steps 1-9.
2.  Assist surgeon in Open or Closed Central Vascular Access Procedures (Maintain asepsis throughout the procedure).
3. Connect the IV administration set to the central vascular access catheter aseptically and regulate flow rate as prescribed.
4. Assess dressing over central vascular access for swelling, redness, pain and foul smelling discharges.
5. Monitor/reassure patient.
6. Document observations and circmstances as necessary.
7. Discard waste materials according to Health Care Waste Management (DOH/DENR).

     C. DISCONTINUING PARENTERAL SOLUTION INFUSION

1. Verify written prescription (Discontinues upon completion of TPN requirements, (e.g. 24 hours, 12 hrs or in the occurrence of any adverse reaction).
2. Observe 10 rights.
3. Explain procedure to the patient and significant others.
4. Prepare the necessary materials to be used in discontinuing TPN utliizing Peripheral / Central Vascular Access (Prepare sterile dressing set and stitch scissor for Open Central Vascular Access).
5. Follow doctor's prescription, e.g. elcetroly; weight; blood laboratory monitoring.
6. Monitor patient closely and document observation and intervention.
7. Refer to MD for any unusual observations.
8. Discard waste materials according to Health Care Waste Management (DOH/DENR).

Procedure V: One-on-One IV Insertion

1. Do hand hygiene before and after th eprocedures.
2. Follow procedure in IV insertion aseptically and accordingly.
3. Discard Waste Materials according to Health Care Waste Management (DOH/DENR).

Suggested Score

1st attempt                              -  20 pts highest score

2nd attempt                             - 15 points only

2nd attempt with hemtaoma  - less 2-3 points from 15 points

3rd attempt                              - 10 points only

3rd attempt with hematoma  - less 2-3 points from 10 points

Reference: ANSAP. Nursing Standsards on Intravenous Practice (8th ed.).