History of IVT in the PhilippinesPhilosophy Envisions itself to be a cohesive, pro-active, professional association, committed to excellence in nursing. Believes that safe and quality nursing care to patients is the primary responsibility of nurses.

Believes that those who practice I.V. therapy nursing are only those R.N.s who are adequately trained and have completed the training requirements prescribed by ANSAP. RA 7164 The Philippine Act of 1991 Sec. 27 (a) Art. V states that I.V. injection is within the scope of nursing practice. 1993 Nursing Standards on Intravenous Practice was established. October 1993 Training for Trainers for ANSAP Board Members and Advisers. February 4, 1994 PRC-BON Resolution No. 08 June 9-11, 1994 Training for Trainers at Cagayan de Oro City. May 17, 1995 Protocol Governing Special Training on the Administration of I.V. Injections for RNs adopted ANSAP's I.V. Nursing Standards of Practice. 2002 Special Committee by ANSAP in collaboration with PRC-BON was founded. RA 9173 Philippine Nursing Law of 2002. August 25, 2006 Nursing Standards on Intravenous Practice 7th ed was released.

Why do we need to be updated regarding I.V. therapy? More medications are being administered intravenously now than before.

Nurses are assuming greater responsibilities related to I.V. medication administration.

Many technical improvements have been made in equipment, and innovative as well as time-saving measures have been developed to increase the efficacy of the therapy.STANDARDS ON IV THERAPY1. Initiation Technique

2. Drug Administration

3. Maintenance

4. Termination

5. Documentation

6. Infection Control and ComplicationsDEFINITION OF IV THERAPY Intravenous (IV) Therapy insertion of a needle into a vein, based on the physician's written prescription. The needle is attached to a sterile tubing and a fluid container to provide medication and fluids.Objectives of the IV Therapy Standards Serves as a guide for nurses in providing safe and quality nursing care to patients relative to I.V. therapy. Promotes the application of principles underlying the administration of I.V. therapy. Recognizes the ethico-legal implications of I.V. therapy. THE ETHICO LEGAL ASPECTS OF IV THERAPYBASICDUTIES AND RESPONSIBILITIES OF IV THERAPISTS1. Interpret and carry out the physicians prescriptions for IV therapy.

2. Prepare, initiate and terminate IV therapy based on physicians written prescription.

3. Perform peripheral venipuncture (all types of needles and cannulas) excluding the insertion of subclavian and cut down catheter.

4. Determine solution and medication incompatibilities.

5. Administer computed medications, chemotherapeutic drugs, flow rates of solutions, compatible blood/blood components and parenteral nutrition as prescribed by the physician.

6. Assess all adverse reactions related to IV therapy and initiate appropriate nursing interventions.

7. Establish nursing care plan related to IV Therapy.

8. Adhere to established infection control practices.

9. Maintain proper care of IV equipments.

10. Document relevant data in the preparation, administration and termination of all forms of IV therapy.LEGAL BASISIV THERAPY AND LEGAL IMPLICATIONS

R.A. 7164 The Philippine Nursing Act of 1991 Section 28 states that in administration of IV injections, special training shall be required. IV Nursing Standards of Practice developed by the ANSAP should be used. In giving IV injections, nurses should follow the policies of their agencies. Board of Nursing Resolution No.8 Sec.30 (c) Art.VII or administratively under Sec.21 Art.III states that any registered nurse without training and who administers IV injections to patients shall be held liable, either criminally, administratively or both. R.A. 9173/The Philippine Nursing Act of 2002, Article VI Nursing Practice, SEC.28.Scope of Nursing (a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to administration of written presentation for treatment, therapies, oral, topical and parenteral medications. That in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice.ETHICAL ISSUESCODE OF ETHICS FOR NURSES IN THE PHILIPPINES

ETHICS according to Webster Dictionary, is the study of the standards of conduct and moral judgment.

NURSING ETHICS is concerned with the principles of right conduct as they apply to the nursing profession.NURSES AND PEOPLE

Values, customs and spiritual beliefs held by individuals are to be respected.

Nurses hold in strict confidence personal information acquired in the process of giving nursing care.NURSES AND PRACTICES

Nurses are accountable for their own nursing practice.

Nurses maintain or modify standards of practice within the reality of any given situation.

Nurses are the advocates of the patients.

Nurses are aware that their actions have professional, ethical, moral and legal dimensions.NURSES AND CO-WORKERS

Nurses maintain collaborative working relationships with their co-workers and other members of the health team.

They recognize their capabilities and limitations in accepting responsibilities and those of their co-workers when delegating responsibilities to them.NURSES AND SOCIETY

Nurses are contributing members of society. They assume responsibilities inherent in being members and citizens of the community/society in which they live/work.

Nurses recognize the need for change and initiate, participate, and support activities to meet the health and social needs of the people.NURSES AND THE PROFESSION

Nurses are expected to be members of professional organizations of nurses.

Nurses help to determine and implement desirable standards of nursing practice and nursing education.

Nurses should initiate and involve themselves in structured and non-structured research activities within their existing milieu.

Nurses should assert the implementation of labor standards and lobby for favorable legislations to improve existing socio-economic conditions of nurses.The Nursing Service Administrators of the PhilippinesMISSION

Provision of efficient and effective nursing services.

Promote quality health care for people as a basic human right.

Be responsible for planning, organizing, directing and controlling the programs and activities of the Nursing Service towards optimum quality nursing care.ARTICLE II

THE ANSAP CREED; CORE VALUES & BELIEFS1. The nursing profession is a commitment to God and people;2. The nursing service is responsible and accountable for quality nursing care;3. The nursing service is a major function in any health care delivery system and deserves a corresponding importance in the organizational structure;4. A high level of self-discipline and committed leadership are essential factors in the effective management of health care services;5. The nursing services is most important asset, aside from its clients, are its caring, competent and productive personnel;6. Competence enhances the publics assurance of quality nursing care, therefore, nursing personnel must be selected and appointed to positions consistent with their qualifications; 7. The client is the reason for the existence of the nursing profession; all efforts should be directed to his care and should consider his uniqueness, personal worth, dignity, and socio-cultural values;8. The implementation and maintenance of approved standards of nursing practice and nursing administration are bases for effective and efficient nursing service;9. Nursing service is integral in the quality of education of students; and10. A unified stand is vital in achieving their objectives through membership in professional organizations, such as the Philippine Nurses Association (PNA), the Association of Nursing Service Administrators of the Philippines (ANSAP), and other specialty groups in nursing.ARTICLE IIINORMS OF PROFESSIONAL CONDUCT

SECTION 1. Dedication to God and people.

SECTION 2. Responsibility and accountability for quality nursing service.

SECTION 3. Leadership and Technical Competence.

SECTION 4. Responsibility and Accountability for Nursing Practice.

SECTION 5. Commitment to the Nursing Profession.ARTICLE IV

GENERAL PROVISIONS

Section 1. Creation of Ethics Committee that shall be responsible to adjudicate violations against the NSA Code of Ethics and adopt such rules and sanctions as the association is authorized to do.SECTION 2. Legal Force.

SECTION 3. Moral Force.SECTION 4. Dissemination.SECTION 5. Sanctions.SECTION 6. Amendment.SECTION 7. EffectivityCODE OF GOOD GOVERNANCE FOR THE PROFESSIONS IN THE PHILIPPINES E.O. No. 220 - Directing the adoption of the Code of Good Governance for the Professions in the Philippines on June 23, 2003. General Principle of Professional Conduct

Professionals are required not only to have an ethical commitment, a personal resolve to act ethically, but also have both ethical awareness and ethical competency. Specific Principles of Professional Conduct1. Service to Others2. Integrity and Objectivity

3. Professional Competence

4. Solidarity and Teamwork5. Social and Civic Responsibility

6. Global Competitiveness

7. Equality of All Professions PROFESSIONAL VALUES

CARING

is the locus of all attributes used to describe NURSING. It is not only the main value of NURSING but the Essence. It is not only a nursing act because to care is human and to be human is caring. 5 Cs of Caring

Compassionate

Concern

Caring

Committed

Willingness to perform her responsibilities Confident

Assertive

SmartConscientious

HonestCompetent

Knowledgeable

Effective/ EfficientRELATED LAW OFFENSES

LEGAL ASPECTS AND THE NURSE

The Republic Act 9173 or the Philippine Nursing Act of 2002 is the best guide the nurse can utilize as it defines the scope of nursing practice. Negligence Commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same or similar circumstance would or would not do. The Doctrine of Res Ipsa LoquiturThree conditions are required to establish a defendants negligence without proving specific conduct:1. That the injury was of such nature that it would not normally occur unless there was a negligent act on the part of someone;2. That the injury was caused by an agency within control of defendant;3. That the plaintiff himself did not engage in any manner that would tend to bring about the injury.Example:

A patient came in walking to the out-patient clinic for injection. Upon administering the injection to his buttocks, the patient experienced extreme pain. His leg felt weak and he was subsequently paralyzed. MalpracticeRefers to a negligent act committed in the course of professional performance.Example is the giving of anesthesia by a nurse or prescribing medicines. IncompetenceThe lack of ability, legal qualificationsor fitness to discharge the required duty.Example:

Although a nurse is registered, if shes not yet an IV therapists, she is not allowed to give IV medications or do the IV insertion. Assault and BatteryAssault is the imminent threat of harmful or offensive bodily contact.

Battery is an intentional, un consented touching of another person.

It is, therefore, important that before a patient can be touched, examined, treated or subjected to medical/surgical procedures, he must have given a consent to this effect.Example: If a patient refuses an injection and the nurse gives it anyway, the latter can be charged for battery.LEGAL TERMINOLOGIES THAT ALSO APPLY IN IV THERAPY

CIVIL ACTION

a non-criminal action whereby one seeks to protect, enforce, or declare a right or address a civil wrong close to him or her. When the harm occurs, the guilty party may be required to pay damages to the injured person. CRIMINAL ACTION

an action brought about by a state or federal law enforcement agency or by an official agency on behalf of an individual, to protect ones person or property or to protect society in general. Punishment includes imprisonment, fine or both. DEPOSITION

a discovery procedure which is an oral question and answer proceeding, under oath and recorded, wherein the attorneys seek to find out what testimony and evidence will be confronting them in a lawsuit. It is an informal proceeding with lawyers of all parties present. INTERROGATORY

another discovery procedure which is the written equivalent of a deposition. RULE OF PERSONAL LIABILITY

every person is liable for his own wrongdoing. No one can bypass this rule with personal assurance. STATUTE OF LIMITATIONS

the time limit set by each state legislature in which civil or criminal action can be brought. TORT

a private wrong by act or omission, which can result in a civil action by the harmed person. SUBPOENA

the process or "paper command" by which the person served must appear at a certain time and give testimony to the court. It is an order under the seal of the court for which one can be held for contempt of court for ignoring the subpoena. SUMMONSnotification served upon defendant to appear before the court.NURSING LIABILITIES AND PREVENTIVE MEASURES

Points to Observe in Order to Avoid Criminal Liability1. Be very familiar with the Philippine Nursing Law.

2. Beware of laws that affect nursing practice.

3. At the start of employment, get a copy of your job description, the agencys rules, regulations and policies.

4. Upgrade your skills and competence.

5. Accept only such responsibility that is within the scope of your employment and your job description.

6. Do not delegate your responsibility to others.

7. Develop good interpersonal relationships with your co-workers, whether they be your supervisors, peers or subordinates.

8. Consult your superiors for problems that may be too big for you to handle.

9. Verify Doctors prescriptions that are not clear to you or those that seem to be erroneous.

10. The doctors should be informed about the patients conditions.

11. Keep in mind the value and necessity of keeping complete and accurate recording.

12. Patients are entitled to an informed consent.STANDARDS OF NURSING INFUSION CARE REQUIREMENTS TO BECOME AN IV THERAPIST1. Entrance Requirements

Level of academic preparation: A BSN graduate, RN, with a current license from the PRC.

Behavioral characteristics :Honesty, reliability, initiative, flexibility and judgment.

Demonstrates communication and technical skills.

2. Completion Requirements

3 days Basic IV Therapy Training Program must have successfully participated.

3. Renewal/Revalidation of an IV Therapy Card

The IV Therapy Card is renewable every three (3) years.

Attendance to IV related Updates equivalent to 24 CEU.

4. Loss of The IV Therapy Nurse Card

Presenting an affidavit of loss.

Submitting Certificate of Training.

Photocopy of the official list of participants of the IV therapy training attended.

5. Cancellation of the IV Card

PRC License is not renewed.

Any violation of Nursing Law 9173.

IV Card is not renewed for more than 3 years.

Violations in the Standards of IV Therapy practice. The IV Therapy Program consists of discussions of concepts in IV therapy and demonstration of skills in access-related situations. It has a twenty-four (24)-hour didactic lecture and a practicum with the following evaluation methods:1. Written examinations: pre and post tests

2. Completion of the required number of actual cases for each of the following competencies:

Initiating and maintaining peripheral IV infusion (3 cases).

Administering IV drugs (3 cases)

Administering and maintaining blood and blood components (2 cases).

The participants will be rated as follows: (a) Didactic 50%; and (b) Practicum 50%.

Dehydration: Definition defined as "the excessive loss of water and electrolytes from the body

Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both. Infants and children are more susceptible to dehydration than adults because of their smaller body weights and higher turnover of water and electrolytes.

So are the elderly and those with illnesses

dehydration occurs when losses are not replaced adequately and a deficit of water and electrolytes develop.

These may occur in Vomiting or diarrhea Presence of an acute illness where there is loss of appetite and vomiting: Pneumonia DHF Other Acute Ilnesses Excessive urine output, such as with uncontrolled diabetes or diuretic use

Excessive sweating (sports)

Burns

Since diarrhea and vomiting are the most common causes of dehydration in children, the volume of fluid loss may vary from 5 ml/kg (normal) to 200 ml/kg

Concentration of electrolytes lost also varies

NaCl and K are the most common electrolytes lost through stools

Dehydration:Checking the main sx

In order to diagnose the type of dehydration, you need to know the History and you must do a thorough physical examination We classify type of dehydration depending on the amount of water and electrolytes lost These are reflected by the signs and symptoms the child will present

Dehydration: Classification Dehydration is classified as no dehydration, some dehydration, or severe dehydration based on how much of the body's fluid is lost or not replenished.

When severe, dehydration is a life-threatening emergency

Graded according to the signs and symptoms that reflect the amount of fluid lost.

There are usually no signs or symptoms in the early stages

As dehydration increases, signs and symptoms develop. Initially, thirst, restlessness, irritability, decreased skin turgor, sunken eyes and sunken fontanelles.

As more losses occur, these

effects become more pronounced. Signs of hypovolemic shock (SEQUELAE)

1. diminished sensorium (lethargy)

2. Lack of urine output

3. Cool moist extremities

4. A rapid and feeble pulse

5. Decreased BP

6. Peripheral cyanosis

7. DEATH.Clinical Signs of Dehydration

Poor Skin Turgor

Summary of Management According to Degree of Dehydration Summary of Management According to Degree of Dehydration Summary of Management According to Degree of Dehydration WHO Treatment Plan AThree rules of home treatment: 1. give extra fluids2. continue feeding3. advise when to return to the doctorDo not give:

Very sweet tea, soft drinks, and sweetened fruit drinks. These are often hyperosmolar (high sugar content). Can cause osmotic diarrhea, worsening dehydration and hyponatremia. Also to be avoided are fluids with purgative action and stimulants (e.g., coffee, some medicinal teas or infusions). WHO Treatment Plan B ORS(ml) the mother slowly gives the recommended amount of ORS by spoonfuls or sips Note: If the child is breast-fed, breast-feeding should continue. After 4 hours, reassess and reclassify dehydration, and begin feeding to provide required amounts of potassium and glucose. WHO Treatment Plan B

WHO Treatment Plan C

WHO Treatment Plan CMAINTENANCE REQUIREMENTS1. HOLIDAY-SEGAR METHOD

Estimates caloric expenditure in fixed weight categories

Assumption

100 cal metabolized : 100 mL water

Not suitable for neonates < 14 days

Overestimates fluid needs EXAMPLE

What is the maintenance fluid rate for a an 8 year old child weighing 25 kg using the Holiday-Segar Method?

100 x 10=1000 ml

50 x 10= 500 ml

20 x 5= 100 ml

1600 ml/day

4 x 10=40 ml

2 x 10=20 ml

1 x 5= 5 ml

65 ml/hrEXERCISE

Using the Holiday-Segar Method, what is the full maintenance requirement and rate for a 10 year old patient who weighs 37 kg?BODY SURFACE AREA METHOD

Assumption: caloric expenditure is related to BSA

Not used in children < 10 kg

BSA METHOD

BSA FormulaSurface area (m2) =

ht (cm) x wt (kg)

3600

EXAMPLEUsing the BSA method, what is the maintenance requirement of an 8 year old who weighs 25 kg and is 132 cm tall? BSA Formula

0.92 m2=

132 cm x 25 kg

3600

Water= 1500ml/0.92/day= 1630 ml

Na+

= 40 mEq/0.92/day= 43.5 mEq

K+

= 30 mEq/0.92/day= 32.6 mEq

EXERCISE

Using the BSA Method, what is the maintenance requirement of a 12 year old boy who weighs 37 kg and is 142 cm tall? DEFICIT THERAPY

Calculated Assessment

Clinical Assessment

CALCULATED ASSESSMENTFluid deficit (L) = preillness weight (kg) illness weight (kg)

% Dehydration = (preillness weight illness weight)/preillness weight x 100%

CLINICAL ASSESSMENT

FLUID REPLACEMENT

ICF & ECF COMPARTMENTS

ICF & ECF COMPARTMENTS

In dehydration, there are variable losses from the extracellular and intracellular compartments

Percentage of deficit is based on total duration of illnessBASIC

MATH CONCEPTS

DECIMALS

All figures to the left of the decimal point are whole numbers

All figures to the right of the decimal point are decimal fractions

. 385=. 3 8 5 CHANGING FRACTIONS TO DECIMALS:

Fractions can be changed to decimals by dividing the numerator and the denominator

= 3 4 = 0.75

PERCENTAGE

Percentage ( % ) means hundredths

Percent ( % ) is the same as a fraction with denomination as 100.

3% =

CHANGING PERCENT TO A DECIMAL & CHANGING DECIMAL TO PERCENT

To change percent to a decimal, remove the percent sign and divide the number by 100 or move the decimal point two places to the left.

4% = 4/100= .04 or0.04

To change a decimal to a percent, multiply by 100 or move the decimal point two places to the right and place % sign.

0.04 X 100 = 4% or 0.04 = 4%

RATIO

A Ratio consists of two numbers as separated by a colon ( : )

e.g. 1 : 4

A ratio indicates that there is a relationship between the two numbers.

A ratio is an indicated fraction.

e.g. = 1 : 4

The numbers in ratio must be expressed in the same terms.

e.g.3 inches : 2 feet = 3 : 24

(feet changes to inches)PROPORTION

It is a statement showing that the two ratios have equivalent values

1 : 50= 2 : 100

If one value is not known, it can be solved by using the term X.

1 : X = 2 : 100 or THE METRIC SYSTEM

It is the international decimal system of weights and measures

In the metric system, fractions are expressed as decimals

In the decimal system, the fraction is written as 0.5METRIC SYSTEM

Liter = vol. of fluids

milli = one thousandths

Gram = weights of solids

centi = one hundredths

Meter = measure of lengthdeci = one tenth

mcg = one thousandths RULE OF CONVERSION

When converting from a larger unit of measure to a smaller unit, multiply the larger unit by (1000, 100, 10) or move the decimal to the right.

When converting a smaller unit of measure to a larger unit, divide the smaller unit by (1000, 100, 10) or move the decimal to the left.

e.g. 2.5 grams = ___________ mg.APOTHECARIES SYSTEM

Grain (gr)Dram OunceMinims

PoundsApproximate Equivalent Value:

1 gr

= 60 mg

1 ml

= 15 minims (16 minims)

1 ounce=30 ml

1 ounce= 30 Gm

1 kg

= 2.2 pounds

e.g. 60 gr = _________ mg.

4 oz = _________ ml.HOUSEHOLD MEASURES

1 teaspoon (tsp)= 4 5 ml

1 Tablespoon (Tbsp) = 3 teaspoons (tsp)

1 Tablespoon

= 15 ml

1 milliliter

= 15 drops (gtts)

e.g.5 ml = ______

CONVERSION OF TEMPERATURENormal Temperature = 37C = 98F

Conversion of Centigrade (Celsius) to Fahrenheit:

Conversion of Fahrenheit to Centigrade (Celsius):

Interpretation of Doctors Order for Drugs

The nurse must understand the order perfectly before acting on it

> The Drug

> The Dose

> The Route

> The Frequency

If any of the above are unclear or open for interpretations, it is the Responsibility of the nurse to clarify the order with the physician.Example:

The order reads : Inderal 2 x4

a. What is the Drug?

b. What is the Dose?

c. What is the Route?

d. What is the Frequency?

e. Does this order need clarification?

The order reads : Lasix 10 mg IV 1 ml O.D.

a. What is the Drug?

b. What is the Dose?

c. What is the Route?

d. What is the Frequency?

e. Does this order need clarification?GENERAL FORMULA FOR DRUG CALCULATION1. D

x Q

S2. Calculation by Ratio : Proportion

8 mg : x = 16 mg : 1 tab

(works for any computation of Dosage if you have a given and a need to determine the unknown).Rule :

1. Units for each ratio must be the same.

2. Units for each ratio must be placed in the same order.

Computation of Dosages:

When the dose prescribed is in milligram (mg) and the dose available is in Gram (Gm) or vice versa.

E.g. The order reads : 0.008 Gm of Morphine Sulfate IV q 4 hours prn for pain.

Ampule available is labeled 10 mg/ml.

1. What do you know?

0.008 Gm - 8 mg

10 mg/ml -

2. What do you need to know? Known amount in cc for 0.008 Gm dose

3. Setting up the proportion:

a. the units for each ratio must be placed in the same order

b. the units for each ratio must be the same ( mg to mg )

8mg : X = 10 mg : ml

c. solve for the correct dosage

8 mg : X = 10 mg : ml

10 mg X = 8 mg/ml

X = 8 mg/ml

10 mg

X = .8 ml

When the dose is ordered in one system and the dose on hand is in another system.

E.g. The order reads : codeine sulfate gr P.O. q 8 hrs PRN for pain. Tablets

on hand are labeled 0.015 Gm tablets.

1. What do you know? Known

gr

1 gr = 60 mg

0.015 Gm / tab1 Gm = 1000 mg

= .25

2. What do you need to know?

# of tablets for gr dose

3. Setting up the proportion

a. the units for each ratio must be the same

b. the units for each ratio must be placed in the same order.

.25 gm : X = 0.015 gm : 1 tab

15 mg : x = 15 mg : 1 tab

4. Solve for the correct dosage:

15 mg : x = 15 mg : 1 tab

15 mg x = 15 mg / tab

x = 15 mg / tab

15 mg

x = 1 tab Computation of Correct Insulin Dosage

U - 40 means

U - 80 means

U - 100 means

Insulin syringes are calibrated according to the strength of insulin with which it is to be used.

U 40 insulin needs a U 40 syringe

U 80 insulin needs a U 80 syringe

If this can not be done, the dose can be converted to milliliters

Dose Required

Dose on Hand

Fractional Dosages in Infants and Children

Childrens Doses

Clarks Rule:

weight of child in pounds X A.D. = childs dose

150

Body Surface Area e.g. Wt = 10 kg

BSA X A.D. = childs dose

1.7

BSA = 4(wt in kg) + 7 = BSA in m

wt in kg + 90

= 4(10 kg) + 7 = 47

10+ 90

= .47 m

Childs dose = .47 m X 500

1.7

Youngs Formula:

Age of child in Years X A.D. = Childs dose

Age of child + 12CALCULATION OF FLUID VOLUME (BASED ON BODY WEIGHT) 1. WEIGHT --- 1 10 kg. --- 100ml/kg.

Eg. Wt = 8 kg. --- 800cc

2. WEIGHT --- 11 20 kg.--- 1,000+50ml/excess b.wt.

Eg. Wt = 15 kg. 1,000=250ml = 1,250ml

15 50

-10 X 5 5 250

3. WEIGHT

> 20 kg.

Eg. Wt = 27 kg. 1,500 + 20 ml/excess b.wt.

1,500 + 140 ml = 1640 ml.

27 20

-20 X 7 7 140

Calculation of IV Flow Rates

Calculation of cc/hr is essential in most IV therapy.

Volume

# of hrs

E.g.1 L over 8 hrs = 125 cc/hr

50 cc over 20 minutes = 150 cc/hr

Calculation of gtt/min (Long Method)

STEPS :

1. Need to know cc/hr to calculate

2. Gtt factor = gtt / ml

gtt factors : macrodrip 10, 15, 20 gtts/ml

microdrip 60 gtt/mlEXAMPLE : LONG METHOD

Doctors Order : Run 1L D5W over 8 hours

Microdrip - 1000 ml 8 hours = 125 cc/hr

125 cc x 60 gtt/ml = 125 gtt/ml

60 min 1

10 gtt/ml set 125cc x 10 gtt/ml = 20 21 gtt/min

60 min 1

15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min

60 min 1

20 gtt/ml set 125 cc x 20 gtt/ml = 41 42 gtt/min

60 min 1

SHORT METHOD

cc / hr 6for 10 gtt / min

cc / hr 4for 15 gtt / min

cc / hr 3for 20 gtt / min

cc / hr = gtt / min for microdrip set Pharmacology at IV Therapy R.A. # 9502 - An act providing for cheaper and quality medicines, amending for the purpose Republic Act No. 8293 or the Intellectual Property Code, Republic Act No.6675 or the Generics Acts of 1988, and Republic Act No. 5921 or the Pharmacy Law,and for other purposes

R.A. # 9165 Dangerous Drug Act of 2002 - An Act Instituting the Comprehensive Dangerous Drugs Act of 2002, repealing republic act no. 6425, otherwise known as the Dangerous Drugs Act of 1972, as amended, providing funds therefor and for other purposes

RA 9173 Philippine Nursing Law of 2002 have stated that parenteral injection is in the scope of nursing practice.

Board of Nursing Resolution No.8 Sec.30 (c) Art.VII or administratively under Sec.21 Art.III states that any registered nurse without training and who administers IV injections to patients shall be held liable, either criminally whether causing or not an injury or death to the patient.Pharmacokinetics

- The process by which a drug is absorbed, distributed, metabolized, and eliminated by the body.

PHARMACOKINETICS - what the BODY does to the DRUG (processes)Pharmacokinetic PROCESSES

Absorption Distribution Metabolism ExcretionPharmacodynamics

The study of the action or effects of drugs on living organisms. PHARMACODYNAMICS - what the DRUG does to the BODY (EFFECTS)Pharmacodynamics

Symptomatic Curative Restorative Preventive DiagnosticAn I.V. Medications may be ordered when:

rapid therapeutic effect.

cant be absorbed by the GI tract.

The client may receive nothing by mouth.

controlled administration rate

I.V. Medication may be given by:

Drug injection Intermittent infusion

Continuous infusion

Benefits Rapid Response

Effective Absorption

Accurate Titration

Less Discomfort

Risks Solution and drug incompatibilities.

Poor vascular access in some clients.

Immediate adverse reactions.

IncompatibilityDrug + Diluent = must be compatible-The more complex the solution, the greater the risk of incompatibility

An incompatibility results when two or more substances react or interact so as to change the normal activity of one or more components.Incompatibility may result in the loss of therapeutic effects and may occur when:

Several drugs are added to large volume of fluid to produce an admixture.

Drugs in separate solutions are administered concurrently or in close succession via the same IV line

A single drug is reconstituted or diluted with the wrong solution

One drug reacts with another drugs preservativeHazards of intravenous medications

Mixing of two incompatible drugs in a solution can cause an adverse interaction.

Poor Vascular Access

Clients who require frequent or prolonged I.V. therapy may developed small, scarred, inaccessible veins from repeated venipunctures or infusion of irritating drugs.If peripheral venous access isnt possible, the doctor may use a central vein, commonly by the subclavian route.Adverse Drug Reaction

- A response to a drug that is noxious and unintended and occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for modification of physiological function (WHO).The following are some adverse drug reactions that you might notice:

Skin rash

Easy bruising

Bleeding

Severe nausea and vomiting

Diarrhea

Constipation

Confusion

Breathing difficulties What should you do if you suspect an ADR?

Stop the medication immediately.

Report the incident to the physician.

Monitor the client. 10 GOLDEN RULES FOR ADMINISTERING DRUGS SAFELY

Administer the right drug.

Administer the right drug to the right patient.

Administer the right dose.

Administer the drug by the right route.

Administer the drug at the right time.

Document each drug you administer.

Teach your patient about the drug he is receiving.

Take a complete patient drug history.

Find out if the patient has any drug allergies.

Be aware of patient drug drug or drug-food interactions.Common Medication Errors

Wrong dose (overdose, underdose, missed dose)

Wrong medication to wrong patient

Wrong medication to right patient

Wrong medication due to wrong dispensing

Wrong interpretation of doctors prescriptions for drugs

Wrong infusion rate ( over infusion, under infusion, missed order ) Transcription of medication and treatment orders

Interpretation of Doctors Order for Drugs

The nurse must understand the order perfectly before acting on it

> The Drug

> The Dose

> The Route

> The Frequency

If any of the above are unclear or open for interpretations, it is the Responsibility of the nurse to clarify the order with the physician.Definition of Terms:

Transcription of medical orders- is the act of writing out medical orders.

Kardex- is the summarize written presentation of all the care and treatment of the patient.

Medication/Treatment sheet- is the legal documents in the patients chart were medicines and treatments administered to the patient are written, acknowledged and administered by nurses.

Physicians Order Sheet- is a legal document wherein medical orders are written and use as reference of nurses in the transcription and executing nursing care. All medication and treatment orders must be written legibly and must contain the following:

a. generic name and brand name of medicines

b. Dosage of the medicines

c. Frequency of administration

d. Route of administration

e. Signature over printed name of attending physician or authorized representative

f. Date and time order was writtenThe registered nurse indicates that he/she has checked and completely transcribe the medical order by signing his/her name with the date and time directly right after the doctors order. As a general rule, telephone orders are received and carried out only in emergency cases by nurses. Nurses receive telephone orders only from consultants.RNs will review all orders immediately after the physician writes.Patient / Family Teaching

Inform the client about the medication you are about to administer.

Reason why the medication is to be give.

Adverse effect he may experience

Pain

Redness

SwellingDocumentation

Type and amount of drug given

Date and time given

Confirmation that the I.V. line was patent

Patients response to the medication

Condition of the insertion site

Ongoing monitoring that you providedWhere to Document

Nurses Progress Notes

Medication Sheet

Infusion Sheet

Vital Signs Monitoring Sheet

Input and Output Monitoring SheetNomogram Find your weight in the right column and your height in the left column. Place a straightedge on the nomogram so the weight and height are connected. The point where the straightedge crosses the center column denotes your body's surface area in square meters.Coming to the Surface

Basal Surface AreaChilds Dose =

Childs BSA

X average

173 m2

adult dose

(average adult BSA)GENERAL FORMULA FOR DRUG CALCULATION

1. desired strength x total ml of solution

strength on hand2. Calculation by Ratio : Proportion

8 mg : x = 16 mg : 1 tab

(works for any computation of Dosage if you have a given and a need to determine the unknown).

Rule :

1. Units for each ratio must be the same.

2. Units for each ratio must be placed in the same order.

Calculating Administration Rates

One must know two key components before using the formula:

Drop factor of the IV administration set

Amount of solution to be infused over one hour

Rate Calculations

Macrodrip Set 10 drops = 1 ml

15 drops = 1 ml

20 drops = 1 ml

Microdrip Set 60 drops = 1 ml

Blood Set 10 drops = 1 ml

FORMULADrip Rate (gtts or mgtts/min) =

Total no. of ml x Drip Factor Total no. of min.

FORMULA

ml per hour =

Total no. of ml

Total no of hoursOther factors affecting Flow Rate:1. Gauge of the catheter

2. Viscosity of the infusate

3. Height of the IV stand

4. Condition of the veins

5. Condition of the patient

VENIPUNTUREThe Integumentary and Vascular SystemIntegumentary SystemTwo Main Layers:

1. Epidermis outer layer composed of squamous cells.2. Dermis inner, thicker layer consisting of blood vessels, hair follicles, sweat glands, small muscles, and nerves.Sensory Receptors

Mechanoreceptors skin tactile perceptions

Thermoreceptors process cold, warmth, and pain

Nociceptors process painVascular SystemVariations:

1. Arteries carries blood from the heart to the body.

2. Veins carries blood from the capillaries towards the heart.

3. Capillaries resembles a hair follicle.Layers of the Blood Vessel:

2. Tunica Media middle layer; is formed by a layer of circumferential smooth muscle and variable amounts of connective tissue; collapses or distends as pressure changes.

3. Tunica Intima innermost layer; delimits the vessel wall towards the lumen of the vessel and comprises of endothelial lining and connective tissue.

Peripheral Vascular MAJOR TYPES OF VEINS (ARM)

1.) Digital Veins

2.) Metacarpal Veins best choice

3.) Cephalic Veins

4.) Basilic VeinsMajor Types of Veins:

1. Digital lateral and dorsal portions of fingers

2. Metacarpal dorsum of hand

3. Cephalic along radial bone of forearm

4. Basilic runs up to the ulnar boneKey Points Prior to IV Initiation

1. Physicians order

2. Patient assessment

3. IV set and equipment preparation

4. MedicationsPhysicians Order

1. Initiation is based upon the written order of a licensed physician.

2. The order must indicate:

a. Patients name

b. Type and amount of solution

b. Flow rate

c. Type, dose, and frequency of medications to be incorporated/pushed.

d. Orders affecting the procedurePatient Assessment

1. Clinical status of the patient

2. Patients diagnosis

3. Patients age

4. Dominant arm

5. Condition of the vein/skin

6. Cannula size

7. Type of solution

8. Duration of therapy

Choosing the Right Vein

Prioritize the ideal veins for venipuncture.

Begin with distal veins.

Watch out for bifurcated or branched veins.

Do not perform venipuncture at the palm side of the wrist and cephalic veins of the wrist.

Palpate for arterial pulse in order to avoid puncturing the arteries if the site chosen is cephalic or the inner aspect of the arm.

Other sites to avoid include:

Veins below a previous IV infiltration.

Veins below a phlebitic area.

Sclerosed or thrombosed veins.

Areas of skin inflammation, disease, bruising, or breakdown.

An arm affected by a radical mastectomy, edema, blood clot, or infection.

An arm with an arteriovenous shunt or fistula.IV Set and Equipment Preparation

1. Check for expiration date.

2. Check for clarity.

3. Check label against physicians written prescription.

4. Label any medications added.

5. Functionality of infusion pumps, PCA.Medications

1. Nurses should have a knowledge on all medications administered including:

a. Dosages

b. Drug interactions

c. Possible clinical effectsVenipuncture Techniques

1. Vein dilatation

2. Site preparation

3. Catheter insertion

4. Securing the catheterVein Dilatation

1. Tourniquet place 6-8 inches above the venipuncture site.

2. Gravity position the extremity below the heart.

3. Fist clenching open and close his fist.

4. Warm compress maximum of 10 minutes.

5. Multiple tourniquet technique use of 2-3 tourniquets.Site Preparation

1. Do not shave site. Remove hair with clippers only.

2. Depilatories are not recommended.

3. Cleanse with one of the following solutions:

a. 2% Chlorhexidine gluconate

b. Povidone-iodine

c. 70% Isoprophyl alcohol

4. Work from the center outward in a circular motion.Catheter Insertion

1. Hold skin taut.

2. Adjust angle of insertion.

3. Puncture vein and observe flashback.

4. Release tourniquet.

5. Upon flashback visualization, lower catheter parallel to skin.

6. Advance needle and catheter together 1/8 inch.

7. Thread catheter into vein.

8. Place middle finger over vein distal to catheter tip

9. Stabilize catheter hub with index finger

10. Withdraw needle with a swift, continuous motion parallel to the skin

11. Dispose of needle immediately into sharps container

Securing the Catheter

Basic Methods:

1. Chevron method

2. U method

3. H methodChevron Method

Cut a strip of tape then place under the cannula, parallel to the hub.

Cross the end of the tape over the cannula.U Method

Cut a strip of tape and place it under the hub of the cannula.

Bring each side of the tape up, folding it over the wings of the cannula in a U shape.H Method

Cut three strips of tape and place one strip over each wing of the cannula.

Place the third strip over the wings perpendicular to the first two.

Reminder for all methods:Maintaining Peripheral IV Therapy:

1. Changing the dressing

2. Changing the IV solution

3. Changing the administration set

4. Changing the IV siteMANAGING COMPLICATIONS OF IV THERAPYRisks Associated with IVTRisks1. Needlestick InjuryAn AIDS patient became agitated and tried to remove the intravenous catheters. Hospital staff struggled to restrain the patient. During the struggle, an IV infusion line was pulled, exposing the connector needle. A nurse recovered the connector needle at the end of the IV line and attempted to reinsert it. The patient kicked her arm, pushing the needle into the hand of the second nurse. Three months later, the nurse who sustained the needlestick injury tested positive for HIV1.

Prevention: Avoid the use of needles where safe and effective alternatives are available.

Avoid recapping needles.

Report all needlestick and other sharps related injuries to ensure that you receive appropriate follow-up care.

Create/maintain a safe, comprehensive disposal system.2. Infectious Organism ExposurePrevention: Do proper hand hygiene.

Do not reuse tourniquets.

Wear gloves.

Cleanse insertion sites with the recommended solutions.IV Therapist, How Safe Are You? In a CDC study, 89 percent of HCW exposure to HIV were caused by percutaneous injuries.

As many as 40 percent of HCW who sustain needlesticks become infected with HBV

In 2004, more than 1,000 HCW became infected with HBVOccupational Risks Associated With IV Therapy Physical hazards;

Accidents , abrasions, contusions and chemical exposure

Exposure to Infectious Agents

The following list is a summary of some of the rules to be observed in the workplace:

HEPATITIS B vaccine

STANDARD PRECAUTIONS

SHARPS AND WASTE DISPOSAL

PROTECTIVE DEVICE/EQUIPMENT

GLOVES

LAUNDRY

COMMUNICATING HAZARDSCOMPLICATIONS ASSOCIATED WITH IVTPROCEDURAL PROBLEMS ASSOCIATED WITH IV THERAPY Fluctuating flow rate

Runaway IV

Sluggish IV

Tubing / loose connection/ disconnection

Blood back up in tubing

IV line obstruction/kinking of IV tubing

Clogged filter

Break in aseptic technique

Leaks; due to inappropriate deviceTROUBLESHOOTING PROMPTLY AND EFFECTIVELY I.V. therapy is the preferred mode of treatment because of its rapid onset.

Nurses are assuming more nursing responsibilities in I.V. therapy.

More nursing time is allotted to I.V. therapy

I.V. Therapy is a risk specialty area.WHAT TO DO WHEN INFUSION SLOWS DOWN OR STOPS1. Assess the I.V. system to locate the problem. Start at the insertion side. Check for infiltration, extravasation, or phlebitis.

2. Check for patency. Obstruction of flow is caused or affected by the following factors:

2.1 Patients limb is flexed; patient lying on the side. Reposition limb to release

venous pressure.2.2 Tip of needle or cannula is against the vein wall. Lift or pull-back the needle

or cannula a little.

2.3 Adhesive taping maybe too tight, release every apply tapes.

2.4. Small cannulas or tubing may kink or fold, gently adjust.

2.5. Local edema or poor tissue perfusion from disease can block venous flow.

Transfer I.V. line to an unaffected site.

2.6. Presence of precipitates in solution either from incompatibility of fluids and medications or from infusion. Replace the entire venipuncture device and solution. It may expose the patient to embolism.

3. Check the clamps. Some sets have two:the roller clamp and the side clamp. Check if both are open or if these are properly adjusted.

4. Check the patency of the air vent; reposition it if needed.

5. Check fluid level: if empty replace as prescribed. If solution is too cold, it may cause venous spasm and decrease the flow; keep room temperature regulated. Check the spike of the set; push it more inside the fluid bag or adjust it.

6. Check filters: ordinary sets usually do not have in-line filters. If it has, follow the manufacturers guide instructions. Blood transfusion filters retain blood product debris. If flow rate decreases or stops after more than one unit has been transfused you may have to change the set.

7. Check tubings: if patient is lying on it or if it is kinked or it may be crimped with too tight roller clamps, release and round-up the tubing to its original shape

8. Is gauge of the needle too small? Is fluid container too low above the venipuncture site? Adjust it around 36-48 inches above the site.NOSOCOMIAL INFECTION is: Also known as healthcare acquired infection

Traditionally referred as hospital acquired infections

Infections that develop during hospitalization

One of the leading causes of death and increased morbidity for hospitalized patients

Of which are mostly caused by drug resistant strains of bacteriaINFECTION RELATED TO IV THERAPY DEVICES

Local Infection

Invasion and multiplication of microorganisms in body tissues which may be clinically unapparent or result in local cellular injury due to competitive metabolism toxins, intracellular replication or antigen antibody response

Systemic Infection

A systemic disease caused by pathogenic organisms or their toxins in the bloodstream

Catheter Colonization: The isolation of 15 colony forming units (CFUs) of any microorganism by semiquantitative culture (roll-plate method) or 103 CFUs by quantitative culture (sonication technique), from a catheter tip or subcutaneous segment in the absence of simultaneous clinical symptoms. Local catheter-related infection: Exit site Infection: purulent drainage from the catheter exit site, or erythema, tenderness, and swelling within 2cm of the catheter exit site. Port-pocket infection: erythema and necrosis of the skin over reservoir of totally implantable device, or purulent exudates in the subcutaneous pocket containing the reservoir. Tunnel infection: erythema, tenderness, and indurations of the tissues overlying the catheter and more than 2cm from the exit site. Systemic Catheter infection: isolation of the same microorganisms from catheter culture and from the blood of a patient with accompanying clinical symptoms of a BSI and no other apparent source of infection. Catheter-related bloodstream infection is the isolation of the same microbe from blood cultures that is known to be significantly colonizing the catheter of a patient. Primary BSI is one that arises without apparent local infection elsewhere due to the same microbe. Other Nosocomial Infection

Urinary tract infection

Surgical site infection

Ventilator-associated pneumonia

Intravascular device-related bloodstream infection

Clostridium difficile- associated diarrhea MODE OF TRANSMISSION

It is the method of transfer by which organism moves or is carried from one place to another

E.g. Hands of the health care worker may carry bacteria from one person to another. How does catheter-related infection occur?

Infection of short-term catheters is frequently been due to microbes from the skin moving

along the catheter surface where the catheter enters the skin.Risk Factors

Type of catheter used

The number of lumen of the catheter has. Total parenteral nutrition

Duration of catheterization

Catheter site insertion

Expertise of the person inserting

Management of catheter after insertion

Guidewire exchange

Use of dressing

Use of triple antibiotic ointment

Common pathogens of BSI

Candida albicans Staphylococcus aureus Enterobacter cloaceae Staphylococcus epidermidis Pseudomonas aeruginosa Enterococcus fecalis Breaking the Chain of Infection Levels of Aseptic Control

PRINCIPLES OF PREVENTION OF INFECTION

Consider every person (patient of staff) infectious

Wash hands the most practical procedure for preventing cross contamination (person to person)

Wear gloves before touching anything wet broken skin, mucous membranes, blood or other body fluids (secretions or excretions) or soiled instruments and other items

Use physical barriers (protective goggles, face masks and aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated

Use safe work practices, such as not recapping or bending needles, safely passing sharp instruments and properly disposing of medical waste

Isolate patients only if secretions (airborne) or excretions (urine and feces) cannot be contained

Decontaminate process instruments and other items (decontaminate, clean, high level disinfect or sterilize using Infection Prevention Practices

Prevention

Selection of a subclavian, basilic, or cephalic vein site rather than an internal jugular or femoral site

Avoid use of TPN catheters for other infusion purposes

Use of special team for insertion and maintenance of catheter

Avoid the use of triple antibiotic ointment on central venous catheterREVIEW INFECTION RISK FACTORS AND PRACTICES

Infection is the presence and growth of a microorganisms that produces tissue death

Wash your hands

Routinely clean and disinfect surfaces

Handle and prepare food safely

Get immunized

Us antibiotics appropriately

Keep pets healthy

Avoid contact with wild animalsPRINCIPLES OF SAFE IV CARE / PRACTICES

Use aseptic technique to avoid contamination of sterile injection equipment

Do not administer medications from a syringe to multiple patients, even if the needle of cannula on the syringe is changed

Use fluid infusion and administration sets for one patient only and dispose after use

Use single dose vials for parenteral medications whenever possible.

Use proper personal protective equipment (PPE).

Adhere to safety waste protocol according to institutions policy.VENIPUNCTURE TECHNIQUES USING VARIOUS CATHETERS AND DEVICES

The use of needleless system

Proper use of sharp containers

Monitoring and Assessment

The use of appropriate dressing

Health Care Worker Education and Training

Surveillance for Catheter Related Infection

Handwashing

Barriers Precautions During Catheter Insertion and Care

Catheter Insertion

Catheter Site Care

Selection and Replacement of Intravascular DevicesGeneral Recommendations For Intravascular Device Use

Health Care Worker Education and Training

Surveillance for Catheter Related Infection

Handwashing

Barriers Precautions During Catheter Insertion and Care

Catheter Insertion

Catheter Site Care

Selection and Replacement of Intravascular Devices

Replacement of Administration Sets and Intravenous Fluids

Intravenous Injection Ports

Preparation and Quality Control of Intavenous Admixtures

In line Filters

Intravenous Therapy Personnel

Needleless Intravascular Devices

Prophylactic antimicrobialsParenteral Nutrition SolutionHyperalimentation-iV Hyperalimentation -may contain two or more of the following elements:

Carbohydrates

Proteins

Lipids

Electrolytes

Vitamins and Minerals

Trace Elements

Water Total Parenteral Nutrition-It is given when a patient requires an extended period of intensive nutritional support. Peripheral Parenteral Nutrition (Partial Parenteral Nutrition)

Normally prescribed for patients who can tolerate some oral feedings but cannot ingest adequate amounts of food to meet their nutritional needs. Indications for Total Parenteral Nutrition Long term therapy (2 weeks or more)

Supply large quantities of nutrients and calories (2,000 to 3,000 calories/day or more)Indications for Total Parenteral Nutrition

Debiliating illness lasting longer than 2 weeks.

Inability to sustain adequate weight with oral or enteral feedings.Indications for Total Parenteral Nutrition Deficient or absent oral intake for longer than 7 days , as in cases of multiple trauma, severe burns, or anorexia nervosa.

Loss of at least 10% of pre illness weight. Indications for Total Parenteral Nutrition Serum albumin level below 3.5g/dl.

Chronic vomiting or diarrhea.

GI disorders that prevent or severely reduce absorption. Indications for Total Parenteral Nutrition Poor tolerance of long-term enteral feedings.

Inflammatory GI Disorders.Indications for Peripheral Parenteral NutritionShort term Therapy (3 weeks or less) is used to: Maintain nutritional state in patients who can tolerate relatively high fluid volume.Indications for Peripheral Parenteral Nutrition Who usually resume bowel function and oral feedings in a few days, and who arent candidates for CV catheter.

Provide approximately 1,300 to 1,800 calories/day. Methods of Administration Central Venous Infusion

-long term parenteral nutrition

Peripheral Infusion

-short term parenteral nutrition (1-3 weeks)Administering Parenteral Nutrition Continuously- 24 hour period

Cyclically-receives the entire 24-hour volume over a shorter period, perhaps 8,10,14 or 16 hours.

Verify doctors orders.

Explain the procedure.

Obtain consent.

Select best available vein as the insertion site.

PPN should be at room temperature.

Proper use of infusion pump.

Check the written order against the written label on the bag.

Proper labeling.

Watch out for swelling at the peripheral insertion site.

Maintain the infusion rate and care for the tubing, dressing, infusion rate and I.V. devices.

Monitor patient for signs and symptoms of sepsis:

-glucose in urine

-altered level of consciousness

-chills

-malaise

-hyperglycemia

-leukocytosis

-elevated temperature

Dont allow TPN solutions to hang for more than 24 hours.

Change the tubing and filter every 24 hours, using strict aseptic technique. Make sure that all tubing junctions are secure.

Perform IV site care and dressing changes.

Check the infusion pumps volume meter and time tape to monitor for irregular flow rate. Gravity should never be used to administer TPN.

Record the patients vital signs when you initiate therapy. Be alert for increased body temperature- one of the earliest signs of catheter-related sepsis.

Monitor your patients glucose levels.

Accurately record the patients daily fluid intake and output.

Assess the patients physical status daily. Weigh him at the same time each morning. Suspect fluid imbalance if the patient gains more than 1lb. per day.

Monitor the results of routine laboratory tests .

Provide emotional support.

Provide frequent mouth care for the patient.

Document all assessment findings and nursing interventions Discontinuing therapyWhen to wean and when not to weanTOTAL PARENTERAL NUTRITION

- wean for 24 hours to prevent rebound hypoglycemia.PARTIAL PARENTERAL NUTRITION

- can be discontinued without weaning.Handling PN Hazards

Catheter Related

Metabolic

MechanicalCatheter Related Complications

Clotted catheter

Reposition the catheter.

Dislodge catheter

Place a sterile gauze pad treated with antimicrobial agent on the insertion site and apply pressure.

Cracked or broken tubing

Change the tubing immediately.

Pneumothorax

Assist with chest tube insertion.

Maintain chest tube suction as ordered.

Sepsis

Remove the catheter and culture the tip.

Give appropriate antibiotics as ordered.Metabolic Complications

Hyperglycemia

Start insulin therapy as ordered.

Adjust the TPN flow rate as ordered.

Hypoglycemia

Infuse dextrose as ordered.

Metabolic acidosis

Adjust the formula and assess for contributing factors.Mechanical Complications

Air Embolism

Clamp the catheter.

Place the patient in trendelenburgs position on the left side.

Give oxygen as ordered.

If cardiac arrest occurs, initiate cardiopulmonary resuscitation.

Venous Thrombosis

Notify the doctor.

Administer heparin as ordered.

Venous flow studies may be done.

Too rapid an infusion

Check the infusion rate.

Check the infusion pump.

Extravasation

Stop the I.V. infusion.

Assess the patient for cardiopulmonary abnormalities.

Phlebitis

Apply gentle heat to the insertion site.

Elevate the insertion site, if possible.Patient and Family Education

Assess patient and familys level of understanding.

Inform the patient and family everything about all that they need to know regarding parenteral nutrition in a manner that they comprehend. Secure inform consent about the procedure if the patient needs to have a central line for total parenteral nutrition.

Inform patient regarding the proper regulation of the parenteral nutrition.

Inform the patient to report any unusual feelings such as chest pain, tachycardia, pain at the insertion site and the likes that may indicate air embolism.

Inform the patient regarding the importance of blood sugar monitoring while on parenteral nutrition. Inform the patient the signs and symptoms of hyper and hypoglycemia and report it if ever experienced.Documentation

TPR blotting Sheet/Vital Signs Monitoring Sheet

Infusion Sheet

Diabetic Record Sheet

Nursing Care Plan

Progress Notes

Intake and Output SheetWHAT IS CANCER?

Large group of malignant diseases with some or all of the ff characteristics:

a. Abnormal cell proliferation

b. Lack of controlled growth and division

c. Ability to metastasize

A few diseases that result from faulty or abnormal genetic expression caused by changes that have occurred in the DNA.

The uncontrolled growth of cells due to damage to DNA (mutations) and, ocassionally due to an inherited propensity to develop tumors. Chemotherapy

A systemic intervention used in the treatment of certain disease conditions

In modern-day use, refers primarily to the use of cytotoxic agents to treat CANCER.

CHEMOTHERAPEUTIC AGENTS- Used only when disease prognosis shows that patient would benefit from the treatment The Cell Cycle

Broadly, most chemotherapeutic drugs work by impairing mitosis (cell division), effectively targeting fast-dividing cells.

In cancer, cells rapidly divide and does not enter the resting phase because they are unresponsive to growth-inhibitory signals.

Only a percentage of the cancer cells are killed with each course of chemotherapy. Therefore, repeated dosesor cycles of chemotherapy must be done. GOALS

CURE CONTROL PALLIATION Chemotherapy may be used as

1.) Adjuvant therapy

2.) Neoadjuvant therapy3.) Chemoprevention4.) Myeloablation

Classification of Chemotherapy DrugsCYCLE-SPECIFIC

Antimetabolites

interfere with nucleic acid synthesis

Attack during S phase of cell cycle

Cytatabine, floxuridine, fluorouracil, hydroxyurea, methotrexate, thioguanine

Enzymes

Useful only for leukemias

Asparaginase

Plant Alkaloids

Cycle-specific to M Phase

Prevent mitotic spindle formation

Vinblastine, vincristine CYCLE-NONSPECIFIC Alkylating Agents

Disrupt deoxyribonucleic acid (DNA)

Carboplatin, Cisplatin, Cyclophosphamide, Ifosfamide, Thiotepa

Antibiotics

Bind with DNA to inhibit synthesis of DNA and RNA

Bleomycin, doxorubicin, idarubicin, mitomycin, mitoxantrone CYTOPROTECTIVE AGENTS

Protect normal tissue by binding with metabolites of other cytotoxic drugs

Dexrazoxane

Mesna FOLIC ACID ANALOGS

Antidote for methotrexate toxicity

Leucovorin HORMONE AND HORMONE INHIBITORS

Interfere with binding of normal hormones to receptor proteins

Manipulate hormone levels

After hormone environment

Usually palliative,not curative

Androgens, Antiandrogens, Antiestrogens, Estrogens, Gonadotropin, Progestins Other AntiCancer AgentsNovel Agents

Monoclonal Antibody

Trastuzumab (Herceptin)

Rituximab (Mabthera)

Cetuximab (Erbitux)

Tyrosine Kinase Inhibitor

Imatinib (Glivec)

EGFR Inhibitors

Erlotinib (Tarceva)

Gefitinib (Iressa)

VEGF Inhibitors

Bevacizumab (Avastin)

BIOLOGICAL THERAPY

Consists mostly of the administration of biological response modifiers Also includes the use of immunotherapy Biological response modifiers

Alter the bodys response to therapy

May cause direct cytotoxicity

Immunotherapy

Uses drugs to enhance the bodys ability to destroy cancer cells

Seeks to evoke effective immune response to human tumors by altering the way cells grow, mature, and respond to cancer cells

May include the administration of monoclonal antibodies and immunomodulatory cytokines

Immunotherapy

Monoclonal antibodies

Specifically target tumor cells

More recent form of biotherapy that manipulates the bodys natural resources instead of introducing toxic substances that arent selective and cant differentiate between normal and abnormal processes or cells

Recognizes only a single unique antigen

Rituximab (Rituxan)

Trastuzumab (Herceptin)

Immunotherapy

Immunomodulary cytokines

Intracellular messenger proteins (proteins that deliver messages within cells)

Colony-stimulating factors

Erythropoietin (Epogen), Granulocyte colony-stimulating factor (Neupogen), Granulocyte-macrophage CSF (Leukine)

Interferon

Interleukins

Tumor Necrosis factorRoutes of Administration

Oral Route Subcutaneous and Intramuscular IV administration IV push IV piggy back (large volume) Direct Introduction Intrathecal Intrapleural Intraperitoneal Chemoembolization Ommaya reservoirSafehandling Chemotherapeutic Agents

Chemotherapeutic Drugs are hazardous drugs. a hazardous drug is defined as an agent that presents a danger to healthcare personnel due to its inherent toxicity.

They are carcinogenic

They are genotoxic

They are teratogenic

There is evidence of toxicity at low dosesPREPARING CHEMOTHERAPEUTIC DRUGS

1. GATHERING THE EQUIPMENT Before preparing chemotherapeutic drugs, be sure to gather all the necessary equipment, including:

Patients medication order or record

Prescribed drugs

Appropriate diluent (if necessary)

Medication labels

Long-sleeped gown

Chemotherapy gloves

Face shield or goggles and face mask

20G needles

Hydrophobic filter or dispensing pin

PREPARING CHEMOTHERAPEUTIC DRUGS

Syringes with luer-lock fittings and needles of various sizes

IV tubing with luer-lock fittings

70% alcohol

Sterile gauze pads

Plastic bags with hazardous drug labels

Sharps disposal container

Hazardous waste container

Chemotherapy spill kit ORGANIZING DRUG PREPARATION AREAS

Prepare chemotherapeutic drugs in well-ventilated workspace

Perform all drug admixing or compounding within a Class II Biological Safety Cabinet or a vertical laminar airflow hood with a HEPA filter, which is vented to the outside

If a Class II Biological Safety Cabinet isnt available, it is recommended to use a special respirator

Have close access to a sink, alcohol pads, and gauze pads as well as Chemotherapy hazardous waste containers, sharps containers, and chemotherapy spill kits

Make sure that all hazardous waste containers are made of punctureproof, shatterproof, leakproof plastic

Make sure that yellow biohazard labels are available for labeling all chemotherapy-contaminated IV bags, tubings, filters, and syringes

Make sure that red sharps containers are available for disposal of all contaminated sharps such as needles.

2. WEAR PROTECTIVE CLOTHING Essential protective clothing includes a cuffed gown, gloves, and a face shield or goggles and a face mask Gowns should be disposable, water-resistant, and lint-free with long sleeves, knitted cuffs, and a closed front Gloves should be disposable, powder-free, and made of thick latex or thick nonlatex material Double gloving is an option when the gloves arent of the best quality.SAFETY MEASURESGENERAL MEASURES

At the local level, most health care facilities require nurses and pharmacists involved in the preparation and delivery of chemotherapeutic drugs and care of the patient with cancer.

Take care to protect staff, patients and the environment from unnecessary exposure to chemotherapeutic drugs Make sure your facilitys protocols for spills are available in all areas where chemotherapeutic drugs are handled, including patient-care areas Refrain from eating, drinking, smoking or applying cosmetics in the drug-preparation area.ACCIDENTAL EXPOSURE

If a chemotherapeutic drug comes in contact with your skin, wash the area thoroughly with soap and water to prevent drug absorption into the skin

If the drug comes in contact with your eye, immediately flush the eye with water or isotonic eyewash for at least 5 minutes, while holding the eyelid open

After an accidental exposure, notify your supervisor immediately.WASTE DISPOSAL Place all contaminated needles in the sharps container; dont recap needles Use only syringes and IV sets that have a luer-lock fitting Label all chemotherapeutic drugs with a yellow biohazard label Transport the prepared chemotherapeutic drugs in a sealable plastic bag thats prominently labeled with a yellow chemotherapy biohazard label Dont leave the drug-preparation area while wearing the protective gear you wore during drug preparation.HANDLING A CHEMOTHERAPY SPILL

Put on protective garments, if you arent already wearing them

Isolate the area and contain the spill with absorbent materials from a chemotherapy spill kit

Use the disposable dustpan and scraper to collect broken glass or desiccant absorbing powder. Carefully place the dustpan, scraper

and collected spill in a leakproof, punctureproof, chemotherapy-designated hazardous waste container

Prevent aerosolization of the drug at all times

Clean the spill area with a detergent or bleach solutionADMINISTERING CHEMOTHERAPEUTIC DRUGS

Gathering the equipment

Prescribed drugs

IV access supplies

Sterile PNSS

IV syringes and tubings with luer lock

Leakproof chemical waste container

Chemotherapy gloves

Chemotherapy spill kit

Extravasation kit.Preventing Infiltration

Use a low-pressure infusion pump to administer vesicants through a peripheral vein, to decrease the risk of extravasation

Use a central venous catheter for continuous vesicant infusionsGuidelines in giving vesicants

Use a distal vein that allows successive proximal venipunctures

Avoid using the hand, antecubital space, damaged areas, or areas with compromised circulation

Dont probe or fish for veins

Place a transparent dressing over the site. Start the push delivery or the infusion with normal saline solution

Inspect the site for swelling and erythema

Tell the patient to report burning, stinging, pain, pruritus, or temperature changes near the site

After drug administration, flush the line with 20mL of NSS.Concluding Treatment Dispose of all used needles and contaminated sharps in the orange sharps container

Dispose of PPEs in yellow chemotherapeutic waste container

Dispose of unused medications, considered hazardous waste, according to your facilitys policy

Wash hands thoroughly

Document the ff.

sequence in which the drugs were administered

site accessed, the gauge and length of the catheter, and the number of attempts

name, dose, and route of the administered drugs

Type and volume of the IV solutions and adverse reactions and nursing interventions

According to facility policy, wear protective clothing when handling body fluids from the patient for 48 hours afterMANAGING COMPLICATIONS OF CHEMOTHERAPY1. ALOPECIA Hair loss that occurs as chemotherapeutic drugs destroy the rapidly growing cells of hair follicles

May be minimal or severe

Occurs 2-3 weeks after treatment begins

Almost always temporary

Signs and Symptoms Hair loss that may include eyebrows, lashes and body hair

Nursing Interventions Minimize shock and distress by warning the patient of this possibility

Discuss with the patient why it occurs

Describe to the patient how much hair loss to expect

Emphasize to the patient the need for appropriate head protection against sunburn

Inform the patient that new hair may be a different texture or color

Give the patient sufficient time to decide whether to order a wig

Inform the patient that his scalp will become sore at times due to follicles swelling

Prevention measures For patients with long hair, suggest cutting hair shorter before treatment because washing and brushing cause more hair loss.2. ANEMIA Occurs as chemo drugs destroy healthy cells and cancer cells

RBCs are destroyed and cant be replaced by the bone marrow

Signs and symptoms Dizziness, fatigue, pallor, and shortness of breath after minimal exertion

Low hemoglobin level and hematocrit

May develop slowly over several courses of treatment

Nursing Interventions Monitor hemoglobin level, hematocrit, RBC count; report dropping values

Be prepared to administer a blood transfusion or erythropoietin

Prevention Measures Instruct the patient to take frequent rests, increase his intake of iron-rich foods, and take a multivitamin with iron as prescribed

If the patient has been prescribed a drug such as epoetin, make sure he understands how to take the drug and what adverse effects he should watch for and report.3. DIARRHEA Occurs because the rapidly dividing cells of the intestinal mucosa are killed

Complications include weight loss, F&E imbalance, and malnutrition

Signs and symptoms An increase in the volume of stool compared with the patients normal bowel habits

Nursing Interventions

Assess frequency, color, and consistency of stool

Encourage fluids, give IV fluids and potassium supplements as ordered

Prevention measures Use dietary adjustments and antidiarrheal meds

Provide good perianal skin care.4. EXTRAVASATION The inadvertent leakage of a vesicant solution into the surrounding tissue

Signs and Symptoms

Initial signs and symptoms may resemble those of infiltration blanching, pain, swelling

Symptoms possibly progressing to blisters; to skin, muscle, tissue and fat necrosis; and to tissue sloughing.NOTE: Blood return is an INCONCLUSIVE test and shouldnt be used to determine if IV catheter is correctly seated in the peripheral vein. To assess peripheral IV placement, flush the vein with NSS and observe site for swelling. Extravasation of Doxorubicin

Nursing Interventions Stop the infusion

Check your facilitys policy to determine if the IV catheter is to be removed or left in place to infuse corticosteroids or a specific antidote.

Notify the physician

Instill the appropriate antidote according to facility policy. Usually, youll give the antidote for extravasation either by instilling it through the existing IV catheter or by using a 1 mL syringe to inject small amounts subcutaneously in a circle around the extravasated area

After the antidote has been given, remove the IV catheter

Preventive measures Verify IV line patency and placement by flushing with normal saline soln

Remember, When in doubt, take it out!

Use a transparent, semi-permeable dressing for inspection of site.

5. INFILTRATION The inadvertent leakage of a nonvesicant solution or medication into the surrounding tissue

Infusion-site related

Signs and symptoms Blanching

Change in IV flow rate

Numbness and tingling in swollen area due to nerve compression injury leading to compartment syndrome

Swelling around IV site (the swollen area will be cool to touch)

Nursing Interventions Remove the IV catheter

Insert a new IV catheter in a different location

Prevention Measures

Check for infiltration before, during, and after the infusion by flushing the vein with normal saline solution.6. LEUKOPENIA Reduced leukocytes or WBCs

Occurs as WBCs and cancer cells are destroyed by chemo drugs

Signs and Symptoms Susceptibility to Infections

Neutropenia

Nursing Interventions Watch for the nadir, the point of lowest blood cell count

Be prepared to administer colony-stimulating factors

Institute neutropenic precautions

Teach the patient and caregiver about:

Good hygiene practices

Signs and symptoms of infection

The importance of checking the patients temperature regularly

How to prepare low-microbe diet

How to care for vascular access devices

Instruct the patient to avoid

Crowds

People with colds or respiratory infections

Fresh fruit

Fresh flowers

Plants7. NAUSEA and VOMITING

Can appear in 3 different patterns

Anticipatory

Acute

Delayed

ANTICIPATORY NAUSEA and VOMITINGSigns and Symptoms Nausea and vomiting thats a learned response from prior nausea and vomiting after a dose of chemotherapy

High anxiety levels (acts as a trigger)

Nursing Interventions Posttreatment control of nausea and vomiting may prevent future anticipatory episodes

Prevention measures Pretreat the patient with lorazepam (Ativan) at least 1 hr before arriving for treatment

Patients with overwhelming anxiety may need IV lorazepam before chemo is administered

ACUTE NAUSEA and VOMITINGSigns and symptoms Nausea and vomiting occurring within the first 24 hours of treatment

Nursing Interventions

Treat the patient with acute nausea and vomiting with antiemetic drugs

Dexamethasone

Granisetron

Lorazepam

Metoclopramide

Ondansetron

DELAYED NAUSEA and VOMITINGSigns and Symtoms

Nausea or vomiting starting or continuing beyond 24 hours after chemo has begun

Nursing Interventions The administration of serotonin antagoninsts, corticosteroids, various antihistamines, benzodiapines, and and metoclopramide is usually effective in treating patients

Prevention Measures Administer antiemetic before chemo begins

Some patients with delayed nause and vomiting are treated with an antiemetic for 3 days or longer.8. STOMATITIS Inflammation of the lining of the oral mucosa

Can spread into the esophagus and pharynx

Signs and Symptoms

Painful mouth ulcers that range from mild to severe appearing 3 to 7 days after certain chemotherapeutic drugs are given

Nursing Interventions Instruct the patient to perform meticulous oral hygiene

Administer topical anesthetic mixtures as appropriate

If pain is severe, opioid analgesics may be prescribed until the ulcers heal

Prevention Measures Instruct the patient to suck on ice chips while receiving certain drugs that cause stomatitis; this decreases the blood supply to the mouth, thus decreasing ulcer formation.9. THROMBOCYTOPENIA Reduced blood platelet count

Signs and Symptoms Bleeding gums

Coffee-ground emesis

Hematuria

Hypermenorrhea

Increased bruising

Petechiae

Tarry stools

Nursing interventions

Monitor patients platelet count

Avoid unnecessary IM injections or venipuncture

If an IM injection or venipuncture is necessary, apply pressure for at least 5 minutes; apply a pressure to the site.

Instruct the patient to

Avoid cuts and bruises

Shave with an electric razor

Avoid blowing his nose

Stay away from irritants that would trigger sneezing

Avoid using rectal thermometers

Instruct the patient to report sudden headaches (which could indicate potentially fatal intracranial bleeding).10. VEIN FLARE Occurs during infusion of an irritant into the vein

Signs and Symptoms Bright redness possibly appearing in the vein along with blotches or hives on the affected arm

Burning pain or aching along the vein as well as up through the arm

Nursing Interventions If the reaction is severe, injection of an IV steroid may be required

If the patient complains of pain or burning during the infusion:

Increase the dilution of the infused medication

Decrease the infusion rate

Restart the IV in a different vein.BLOOD A mixture of cells A complex TRANSPORT mechanism Transports hormones Removes waste products Regulates body temperature Protects the body Promotes hemostasis Supplies oxygen BLOOD VOLUME: 8% of total body weight = varies by age & body composition.COMPOSITION OF BLOOD Temperature

38(C (100.4(F)

pH

7.35 - 7.45

Specific Gravity

1.048 1.066

Body weight

7%

5 times the viscosity of water

Volume

Male

5 6 Liters

Female

4 5 Liters

1. Plasma Liquid part of the blood Consists of serum and fibrinogen Contains plasma proteins such as:

Albumin = regulates & maintains

Serum globulins = for transportation

Fibrinogen, prothrombin, plasminogen = to stop the bleeding

Cellular Components Formed elements of blood2. RBC = responsible for oxygen transport3. WBC = play a major role in defense against microorganisms4. Platelets = function in hemostasis Blood: An Emotional Topicthe sweeping story of a substance that has been feared, revered, mythologized, and used in magic and medicine from earliest timesa substance that has become the center of a huge, secretive, and often dangerous worldwide commerce.From the publishers description of the bookTRANSFUSION Refers to the administration of any of several blood products. BLOOD TRANSFUSION Is lifesaving therapy for patients with a variety of medical and surgical conditions in need for blood.

Blood Transfusion may be necessary for any of the following reasons: Hemorrhage (blood loss) caused by trauma or high blood loss surgery

Red cell destruction

Decreased red cell production National Blood Services Act of 1994 Also known as the Republic Act 7719 AN ACT PROMOTING VOLUNTARY BLOOD DONATION PROVIDING FOR AN ADEQUATE SUPPLY OF SAFE BLOOD, REGULATING BLOOD BANKS, AND PROVIDING PENALTIES FOR VIOLATION THEREOF. Who CAN and CANT give Blood Eligible Donors Must: Be at least age 18 Weigh at least 110 lb (50 kg) Free from skin disease Not have donated in the past 56 days Have a hemoglobin level of at least 12.5 g/dl (women) or 13.5 g/dl (men)

Ineligible Donors include those: Who have HIV or AIDS Who have taken illegal drugs I.V. Who have had sex with prostitutes in the past 12 months Who have had sex with anyone above categories

Who have had hepatitis With certain types of cancer (other than minor skin cancer) With hemophilia Who have received clotting factor concentrations.Blood Collection Methods 3 Types of Blood Donor Sources for Routine Blood Collection: Unrelated Donor (Allogeneic)

Directed Donor

Autologous Donor (Self)

NURSES MUST BE: Knowledgeable about blood products

Safe administration How to monitor patients before, during and after therapy

Assure that informed consent has been obtained before starting a transfusion.

Appropriate information to include in patient education includes:

Benefits Risks Alternatives to transfusion Document all patient education regarding transfusion therapy, and the responses of patients and family members after teaching.

Patient Education Provide patient and family information to blood transfusion therapy: The need for blood transfusion

Advantages of blood transfusion

Possible reactions related to the blood transfusion therapy

Voluntary blood donation actTransfusion Precautions Dont add medications to the blood.

Dont transfuse the blood product if you discover a discrepancy in the blood number, blood slip type, or patient identification number.

Dont piggyback blood into the port of an existing infusion set.Stop transfusion if your patient shows:

Shows changes in vital signs

Is dyspneic or restless Develops chills, hematuria, or pain in the flank, chest or back

BEFORE TRANSFUSION When assessing your patient before a transfusion:

Obtain important medical history information Review pertinent laboratory values Review the doctors order, including any special processing requested Perform physical assessment

When you received the delivery from the blood bank, you should receive both the product and the transfusion record that corresponds to it.

Inspect for the following: Labels Integrity of Unit Appearance

Perform the verification process to ensure the correct blood is being given to the correct patient.

Two qualified individuals should verify the patient and unit identification. Assess the patency of the patients vascular access. Check and recheck vital signs 15 minutes after starting the transfusion. DURING TRANSFUSION Administer the blood or component at the recommended rate.

Stay with the patient for the first few minutes of the transfusion

Review signs and symptoms of what the patient should report to you.

Discontinue transfusion immediately once the patient manifest symptoms of transfusion reaction, assess the patient and notify the doctor. Finally, document the transfusion in the patients chart. AFTER TRANSFUSION Continue to monitor patient for any signs and symptoms of reaction for at least one hour after the transfusion.

Obtain any ordered post-transfusion laboratory studies.

SAFETY PRECAUTIONS Make sure that YOU are protected too by:

Wear proper Personal Protective Equipment (PPE) Always perform disinfection technique.

If possible, use a needleless system.

If using sharps, do not recap the needle.

Always observe proper waste disposal according to your institutions policy.

If there are spills, never touch the blood with bare hands.

Make sure that blood bag is secured.

Always double or triple check.

Always perform HAND HYGIENE Acute Transfusion Reactions usually appear within the first 5-15 minutes after the transfusion is started.

Types of Acute Transfusion Reactions: Acute hemolytic Transfusion Reaction

Febrile nonhemolytic Transfusion Reaction

Mild allergic (Urticarial)

Anapylactic

Transfusion Associated Circulatory Overload

Transfusion Related Acute Lung Injury

Septic Transfusion Reaction

Symptoms you might see during an acute transfusion reaction include:

Temperature increase of more than 1C or 2F

Bloody urine

Chills

Hypotension

Severe low back, flank, or chest pain

Low or absent urine output

Nausea and vomiting

Dyspnea, wheezing

Anxiety, "sense of impending doom"

Diaphoresis

Generalized bleeding, especially from punctures and surgical wounds. WHAT TO DO IF TRANSFUSION REACTION OCCURS When they do occur, it is usually because of ABO incompatibility between patient and donor during transfusion of red cells.

Ensure that the intended recipient is getting the intended unit at the time of transfusion.

Should any of these symptoms occur, discontinue the unit immediately, hang normal saline (on a new tubing) to maintain vascular access, and call for assistance. Closely monitor the patients vital signs and symptoms. Notify the physician and obtain further orders to address the patients symptoms. Recheck the patients identifying information against the transfusion record and blood bag. All bags, tubings, filters, and paperwork should be retained and forwarded per hospital policy. DOCUMENTING BLOOD TRANSFUSIONS Date and time the transfusion was started and completed

Name of the health care professional who verified the information of the patient and the blood

Catheter type and gauge

Total amount of the transfusion

Patients vital signs before and after the transfusion

Infusion device used

Flow rate and if blood warming was used

Vital signs obtain prior to, during, and after the transfusion

Name of the component, unit number

Evidence of possible transfusion reaction.

Document interventions done and to whom you notified.

Patients outcome.

Patient and Family Education and Documentation

Why patient and family education?

Many patients are not accustomed to IV therapy.

He may be apprehensive.

He may