Page 1 of 4 DESCRIPTION/OVERVIEW Intravenous (IV) therapy will ...

Title: Intravenous TherapyDESCRIPTION/OVERVIEWIntravenous (IV) therapy will be administered and monitored utilizing established guidelines.REFERENCES Perry, E.M., & Potter, P. (2010). Clinical Nursing Skills & Techniques (7 th ed.). St. Louis,Missouri: Mosby - Elsevier CDC “Guidelines for Prevention of Intravascular Catheter-Related Infections”, August 9,2002/51(RR10); 1-26 Infusion Nurses Society. Infusion Nursing Standards of Practice. Journal of Infusion Nursing(supplement) 2006. Wiegand D, Carlson K: AACN Procedure Manual for Critical Care, Elsevier Inc, 2005AREAS OF RESPONSIBILITYAll Nursing UnitsApplies To: All HSC HospitalsResponsible Department: All Nursing UnitsRevised: 6/2010GuidelinePatient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) AdultGUIDELINE PROCEDURE1. Registered Nurses (RN), Graduated Nurses (GN), and Licensed Practical Nurses II (LPN II)who have demonstrated competence, may start and discontinue peripheral IVs. Nurse Interns andStudent Nurses (SN) under the direct supervision of an RN may also start and discontinueperipheral IV’s.1.1 Other non-nursing medical personnel who have demonstrated competence in IVtherapy, and have IV therapy as part of their scope of practice, maystart/discontinue and administer IV therapy.1.2 Only RNs, supervised GNs, Interns, and SNs and other non-nursing medicalpersonnel may give IV push medications based on unit policy and scope ofpractice. After successful completion of the IV Therapy module, and appropriatedocumentation of competence, LPNs may also give IV push medications2. Initiation of venipuncture should be limited to two (2) attempts per person. Considercontacting Rapid Response Team to use their doppler to start a difficult IV. Carefulconsideration should be given to other venous access modalities if peripheral IV access is notobtained after a limited number of attempts. Patients who potentially require long-term IVtherapy should be assessed for long-term catheter placement.3. Selecting IV site and catheter3.1 In the adult population, a Licensed Independent Provider’s (LIP) order is neededto place an IV in the lower extremities. The IV should be transferred to an upperextremity or central line as soon as possible.3.2 An IV will not be started in a patient’s arm in which a functional arterio-venous(AV) shunt exists, or on the surgical side of a post mastectomy patient, or into thesame arm which has an existing PICC.3.3 Any IV initiated pre-hospital should be restarted within 24 hours of admission._________________________________________________________________________________________________________________Title: Intravenous TherapyOwner: Nursing Practice CouncilEffective Date: 7/7/2010Doc. # 2636Page 1 of 4

3.4 Two large bore IVs of at least 18 gauge diameter in large veins are required forany emergency situation where large volumes of fluid and IV medicationsmight be required. The antecubital site is preferred. When the patient’s conditionis stabilized, the site should be changed if possible to a site not overlying a jointwith a smaller diameter catheter.3.5 If caustic agents are ordered or anticipated, a central line or a site on the proximalforearm is preferred. Do not choose a site over a joint if at all possible and avoidthe medial antecubital vein unless no other site is available. Caustic substancesshould not be infused through an IV located in the lower extremity. Consultpharmacy for a current list of caustic agents.3.6 In a cardiopulmonary emergency, vasoactive medications (including Dobutamine,Dopamine, Norepinephrine, Epinephrine and Esmolol) may be administeredperipherally, but central access should be established as soon as possible.4. Routine Care4.1 Standard precautions will be used when performing all aspects of IV therapy.Aseptic technique will be used for all venipunctures and dressing changes.4.2 Dressing changes should be done whenever the dressing becomes damp,loosened, soiled, or as needed.4.3 All patients on IV therapy should be monitored for intake and output (I&O).4.4 All IV bottles/bags should be changed at least every 24 hours. All cassettes andtubing should be changed every 72 hours, with the following exceptions:4.4.1 Intralipid, Total Parenteral Nutrition (TPN), Peripheral ParenteralNutrition (PPN), dextrose solution 10%, and tubing of thesesolutions must be changed every 24 hours. TPN and PPN filterswill be replaced with tubing change.4.4.2 Pressure line tubing (arterial, central venous pressure, pulmonaryartery catheter)and flush solution should be changed every 96hours.4.4.3 All bottles/bags and tubings must be labeled with date and timehung.4.5 Peripheral IVs4.5.1 Change sites every 96 hours or as needed. If no alternative site isavailable, it is possible to get one twenty-four hour extension of theIV site if the current site is patent, intact, and exhibiting no signs orsymptoms of infection, phlebitis, or infiltration. An LIP order mustbe obtained for the IV site extension, and the reason for extensiondocumented in the nursing notes.4.5.2 Peripheral IV sites will be assessed at least every four hours foradult patients, and every two hours in pediatrics. The LIP will benotified if signs/symptoms of infection, infiltration, or phlebitis arepresent.4.6 Saline Locks4.6.1 A saline lock is an angiocath in a cannulated vein that is capped offfor intermittent venous access.4.6.2 Site assessments must be documented q 1 hour while medication isinfusing.4.6.3 When the saline lock is not in use, flush q 6-8 hours with normalsaline flush. Refer to unit specific requirements for documentation._________________________________________________________________________________________________________________Title: Intravenous TherapyOwner: Nursing Practice CouncilEffective Date: 7/7/2010Doc. # 2636Page 2 of 4

5. IV Infiltration5.1 Assessment5.1.1 Signs/symptoms may include: extremity discolored, edematous,leaking/weeping, induration, pain/discomfort/numbness at the siteor of the extremity, blisters, sloughing of the skin, loss of pulse,and/or change in skin temperature,5.1.2 Additionally, assess for IV site position/venous return/a change ordecrease of IV flow rate. Occlude the vessel distal to the cathetertip. Usually, the IV will stop flowing if the vein is intact.5.2 Treatment5.2.1 Discontinue the infiltrated IV and solution immediately. Performneurovascular check. Notify LIP.5.2.2 Continue assessment of the extremity (neurovascular checks andskin changes) hourly following caustic infiltration and every fourhours for all other infiltrates. Once the findings have stabilized,assess every four hours until resolved or patient is discharged.5.2.3 Elevation of the extremity and the application of warm or coldhave no effect on the resolution of the infiltration but may be usedfor patient comfort after an LIP order is obtained.5.3 Documentation should include site, signs and symptoms, medication/solution infusingat the time of infiltration, neurovascular status, notification of LIP, LIP orders, nursinginterventions to include treatments, and patient response to treatment.6. IV Occlusion6.1 Remove and change the injection cap if the cap or port becomes occluded,or leakage occurs from the injection site.6.2 Occluded needles and catheters should never be flushed or irrigated. This mayresult in pulmonary embolism. Discontinue them immediately.7. Key Documentation7.1 Document IV procedure in the medical record. Include who started the IV, thenumber of attempts made, and the patient’s response to the procedure.7.2 Document the date, time, site, size and length of angiocath.7.3 Document IV site assessment at least every four hours or as needed.7.4 The following patients should have the IV site monitored and documented hourly:7.4.1 Caustic (non-chemotherapy) substance infusion7.4.2 Fragile/friable veins7.5 In the presence of two or more IV sites, document which solutions, additives, andmedications are infusing through each site.7.6 Document date, time, and site condition with each dressing change.7.7 When an IV is discontinued, document the date, time, site condition and that thetip of the catheter is visibly intact.AGE OR DEVELOPMENTAL VARIATIONS1. Pediatric/neonatal peripheral IV site changes: Change site when vein irritation orinfiltration is apparent. Ideally, peripheral IV sites should not be left in place for morethan seventy-two hours. IV site extensions for pediatric/neonatal patients may be requiredwithout a physician’s order on a case-by-case basis._________________________________________________________________________________________________________________Title: Intravenous TherapyOwner: Nursing Practice CouncilEffective Date: 7/7/2010Doc. # 2636Page 3 of 4

2. Infusion pumps are used on all pediatric IVs. Volume control devices should be used forpediatric/neonatal IV infusions. No more than two (2) hours + 10ml of any IV solutionwill be placed in the volume control device at any one time.3. Pediatric/neonatal IV bottles/bags must be changed every 72 hours with IV tubing unlessfluids are admixture, TPN, Interlipids, or dextrose 10%.4. A physician’s order is not needed if the lower extremity is used for IV therapy in thepediatric/neonatal patient.5. There is no recommendation for the use of chlorhexadine/alcohol solution on infantsless than 2 months old.UNIT OR AREA SPECIFICS1. Neonatal patient in NBICU may have Dopamine, Dobutamine and PGE infuse through aperipheral IV if a central line is unavailable.2. In the case where electrolytes are added to IV fluid in a volume control device in aneonatal patient, a second volume control device will be placed distally so there will beno more than two (2) hours + 10ml of solution in the second volume control device.3. Dopamine, Dobutamine, Morphine and Fentanyl drips can hang for 48 hours in pediatrics.(Reference area specific pediatric guidelines for infusion and fluid line changes).SUMMARY OF CHANGESReplaces “Intravenous Therapy”, (5/2007)#1. Licensed Practical Nurse II (LPNII) added.#2. “Consider contacting Rapid Response Team to use their doppler to start a difficult IV”added.#3.2 “or into the same are which has an existing PICC” added.#7.4.1 “non-chemotherapy” added.RESOURCES/TRAININGResource/DeptClinical EducationInternet/LinkDOCUMENT APPROVAL & TRACKINGItem Contact Date ApprovalOwnerNursing Practice CouncilConsultant(s)Margaret Hurst, BSN, RN, OCN, Irene Zamora, MSN, RN, CNSCommittee(s)Clinical Operations PP&G Committee, Nurse Practice PP&G SubcommitteeYNursing Officer Sheena Ferguson, Chief Nursing Officer YOfficial Approver Sheena Ferguson, RN, MSN, CCRNr, CNS, CNO YOfficial Signature Date: 7/7/2010Effective Date 7/7/2010Origination Date 10/1997Issue Date Clinical Operations Policy Coordinator 7/8/2010ATTACHMENTSNone_________________________________________________________________________________________________________________Title: Intravenous TherapyOwner: Nursing Practice CouncilEffective Date: 7/7/2010Doc. # 2636Page 4 of 4