ADMINISTERING INTRAVENOUS transfusion, Neonate or Pediatric blood

MEDICATIONS transfusion
Intravenous Medications (IV)  26 (purple) Pediatrics, Neonate
-are solutions administered directly into the Administering IV medications
venous circulation via a syringe or intravenous  All medications are administered using the
catheter (tube). ten rights, with the addition of the right rate
Indications for IV medications  Movement of the patient can affect the flow
 When the oral route is unavailable or rate
unsuitable (e.g., when a person is unable to  Potassium is always diluted and never given
swallow as a bolus
 When drugs are destroyed by stomach acid  Sterile technique is used when medications
 When drugs are not absorbed orally are added to IV fluids
 When high blood concentrations of a drug  Most facilities require certification to
are needed quickly administer chemotherapy drugs
 To obtain a rapid response in emergency Administration sets
situations  Primary intravenous set
Initiating IV therapy -consists of bag of solution, regular tubing
 Selection of the IV site set, needles connector and IV stand
Consider:  Secondary or piggyback intravenous set
o Accessibility of the vein, its general -medications to be given intravenously often
condition added to an existing IV line by using the
o Type of fluid to be given piggyback method
o Duration of IV therapy  Parallel intravenous set
 Veins preferred for infusions and -a y-type administration set used to infuse
intermittent doses of medications are those certain blood products
distal to the antecubital area  Large-volume infusion
 Cephalic, basilica, and antebrachial veins of  Controlled-volume set
the lower arm and the veins on the back of -infusion pump administers small volumes
the hand are the sites of choice for most of fluid or medication
adult patients  Intermittent intravenous device (saline or
Choosing IV catheter size PRN lock)
 <1 year: 22, 24 gauge (g) -established by applying Luer-lock cap or an
 1-8 years: 18, 20, 22 gauges extension set to the IV cannula
Administering medication via infusion
 >8 years: 16, 18, 20 gauges
1. Check the medical orders
 14g (orange) Trauma, Rapid blood
2. Read the label of the drug
transfusion, Surgery
3. Make sure the drug label indicates that it is
 16g (gray) Rapid fluid replacement, Trauma, for IV use
Rapid blood transfusion 4. Check for any documented drug allergies
 18g (green) Rapid fluid replacement, 5. Review drug actions and side effects
Trauma, Rapid blood transfusion 6. Consult the compatibility chart or drug
 20g (pink) Most infusions, Rapid fluid reference
replacement, Trauma, Routine blood 7. Determines how much the client
transfusion understands the purpose and technique for
 22g (blue) Most infusions, Neonate, administering the medications
Pediatric, Older adults, Routine blood 8. Perform assessments that will provide a
transfusion basis for evaluating the drug’s effectiveness
 24g (yellow) Most infusions, Neonate, 9. Inspect the current infusion site for swelling,
Pediatric, Older adults, Routine blood redness, and tenderness
10. Prepare the medication, taking care to read 5. Check for any documented drug allergies
the medication label at least 3 times 6. Assess the client’s fluid status and perform
11. Have a second nurse double check your drug other assessments that will provide a basis
calculations for evaluation the drug’s effectiveness
12. Wash hands or perform alcohol based hand 7. Inspect the current infusion site for swelling,
rub redness, tenderness
13. Check the client’s identification band 8. Determine how much the client understands
14. Clamp or stop the current infusion of fluid about the purpose and technique for
15. Swab the appropriate port on the container administering the medication
of IV fluid 9. Plan to administer the medication 30-60
16. Instill the medication through the port into minutes of the scheduled time from drug
the full container of infusing fluid administration established by the agency
17. Lower the bag and gently rotate it back and 10. Obtain a volume control set
forth 11. Determine the drop factors on the volume –
18. Suspend the solution and release the clamp control set and calculate the rate of infusion
19. Regulate the rate of flow by using the roller 12. Have a second nurse double check your
clamp or programming the rate on the calculations for the rate of infusions
electronic infusion device 13. Wash hands or perform alcohol based hand
20. Attach a label to the container of fluid rub
identifying the drug, its dose, time it was 14. Close all the clamps on the volume – control
added and your initials set and insert the spike into the IV solutions
21. Record the medication administration 15. Seal the air vent located to the side of the
22. Check the client and the progress of the spike on the volume control set if the
infusion at least hourly solution is in a plastic bag, is the container is
23. Document: glass leave the air vent open
Client and site assessment data 16. Release the clamp above the fluid chamber
The date, time, drug, dose and initials 17. Fill the calibrated chamber with
Solution to which drug has been added approximately 30ml of IV solution and
Client’s response retighten the clamp
Administering medication trough an IV port 18. Squeeze and release the drip chamber until it
1. Prepare the medication in a syringe is half full
2. Locate the port nearest the IV insertion site NOTE: for volume control sets with a
3. Swab the port with alcohol sponge membrane filter, the clamp below the drip
4. Pierce the port with needle or needless chamber must be open when the drip chamber is
adapter filled or the set will be damaged
5. Kink the tubing above the access port 19. Open the lower clamp until the tubing is
6. Observe for blood in the tubing near the IV filled with fluid; then re-clamp
catheter or insertion device 20. Open the clamp above the calibrated
7. Gently instill a few lengths of a milliliter container; fill the chamber with the desired
8. Release the tubing volume of fluid and re-clamp
9. Continue the pattern of kinking the tubing, 21. Swab the injection port on the calibrated
instilling a small amount of drug, and container
releasing the tubing until the medication has 22. Instill the prepared medication
been administered over the specified period 23. Rotate the fluid chamber back and forth
Administering medication using volume 24. Connect the tubing to the client’s IV
control set or soluset catheter
1. Check the medical orders 25. Release the lower clamp and regulate the
2. Review the drug action and side effects drip rate
3. Consult a compatibility chart or drug 26. Add a label to the fluid chamber identifying
reference the name of drugs, dose, time it was added
4. Read the label on the medication and your initials
27. Return before the time the medications is 8. Assess during infusion for untoward
due to finish instilling reactions
28. Release the upper clamp when the fluid
chamber is empty and refill it with next Blood transfusion
hours’ worth of fluid -is the introduction of blood or blood
29. Readjust the rate if necessary components into the venous circulation
30. Remove the drug label from the chamber Whole blood
31. DOCUMENT: -contains all blood components
a. Client and site assessment data  PRBCs
b. The date, time, drug, dose and  WBCs
initials  Platelets
c. Solution to which drug has been  Clotting factors
added  Immunoglobulin
d. Client’s response o Used only when a patient loses a
Intravenous device (Saline or PRN lock) large amount of blood.
-a saline lock (hep-lock), is an iv catheter that is o Must be transfused within 24hrs of
threaded into a peripheral vein, flushed with collection
saline and then capped off for later o Rarely needed, more efficient and
-the device have a port at one end of the lock effective to give only the
and a needless injection cap at the other end of components needed to manage the
the extension tubing between two ends specific condition.
-the device can be converted to iv infusion to an Components of whole blood
intermittent injection port  Packed RBC –contains hemoglobin, an iron
-suitable for client who require long-term access containing protein responsible for
for administering medications may have transporting oxygen in the blood
specialized catheter or port to allow central  RBCs are separated from plasma and
venous access (receiving chemotherapy) platelets and given for anemia and blood
Procedure: administering IV medication via loss due to trauma or surgical blood loss
saline lock  Platelets –are cellular components that
Equipment assist in the clotting process in blood vessel
 Intermittent infusion device injuries. They are given for
 Needless system device thrombocytopenia (low platelets in the
 Normal saline solution blood) and platelet function abnormalities
 2 prefilled saline syringes
 Granulocytes –a type of WBC separated
 Infusion pump
from whole blood given to patient with low
1. Wash hands
granulocyte count or as a supportive therapy
2. Gather equipment. Fill two syringes with
for patient on chemotherapy
enough normal saline at 3ml to flush saline
 Fresh frozen plasma (FFP) –is taken from
lock
whole blood and frozen within 24hrs of
3. Confirm the client’s name. explain the
collection. Plasma is the liquid portion of
procedure
blood, containing 92% water and 8% plasma
4. Clean injection port with alcohol swab allow
proteins, including albumin, fibrinogen,
to dry. Insert syringe into port
globulin and other clotting proteins
5. Open clamp and gently aspirate to check the
o Is given for clotting deficiencies,
patency of tubing
6. Flush tubing and observe for swelling, liver disease and hemophilia
redness or discomfort into site  Cryoprecipitate –often referred to as
7. Cleanse port again with alcohol swab allow “Cryo”. Is the precipitated material obtained
to dry. Connect IV tubing to saline lock, from FFP when thawed. It contains
slightly open clamp and regulate drops per coagulation factor VII and XIII, fibrinogen,
minute vonWillebrand factor and fibronectin
 o It is given to prevent or control  Blood administration tubing can be used for
bleeding in patients with up to 2 units of blood. However, under usual
hemophilia, von Willebrand disease, circumstances, the blood transfusion will
to correct low fibrinogen levels and take around 3-4hrs, so tubing will need to be
for other clotting disoders changes with each unit of blood
 Each unit of blood or blood products must
ABO system be transfused within 4hrs of issue from
-is based on the presence or absence of the A blood bank
and B antigens  Do not give any drugs through IV line in
 Type A has the A antigen which blood is transfusing. Normal saline is
 Type B has the B antigen the only solution that can be added to blood
 Type AB has both or blood products
 Type O has neither  Vital signs –temperature, bp, pulse and
-the compatibility of blood types between donor respiration must be assessed and
and recipient is dependent on the presence or documented according to the hospital policy
absence of A and B antigens and antibodies Example:
The Rh system -before initiating the transfusion
-is based on the present or absence of the major -15 minutes after transfusion is initiated
D antigen on the surface of the RBCs -every 30 minutes x2, then hourly
 A person who has the D antigens is Rh At completion of blood transfused
positive  The physician may order for the patient to
 A person who does not have the D antigen is be pre-medicated prior to the transfusion
Rh negative with antipyretic or antihistamine to help
 Rh + = presence of D antigen prevent immunologic transfusion reaction
 Rh - = D antigen absent such as fever or histamine release
Compatible blood types  The nurse stays with the patient during the
If patient has: They can receive: first 15 minutes, assessing for signs and
Type O Only type O symptoms or “transfusion reactions” which
Type A Type A or O could include anything from a mild rash or
Type B Type B or O itching to a life threatening acute hemolytic
Type AB Any type – A,B,AB or reaction
O (known as universal Assess the following:
recipient) -skin rash/hives, itching flushing
-increased body temperature
If patient has: They can donate to:
-body chills or shivering
Type A Types A and AB
-SOB or difficulty of breathing
Type B Type B and AB
-significant changes in vital signs
Type AB Only type AB -pain, anxiety, nausea
Type O All types – A,B,AB -changes in mental status
and O (known as -chest pain, tightening sensation
universal donor)
 Continue to monitor the patient for any of
these symptoms throughout the transfusion
Blood transfusion
 If transfusion reactions are observed, act
Blood typing and cross matching –will
immediately by:
determine the patient’s ABO group and Rh type
o Stopping the blood transfusion
Blood transfusion includes any of the following:
o Maintain the IV line with normal
 Whole blood
 Packed RBCs saline @ 30ml/hour
 Plasma o Provide emergency care if needed
 Platelets o Notify the physician and obtain
orders
 o Notify the blood bank of transfusion 18. Hang the container on the IV pole about 1
reaction meter (36in) above the planned venipuncture
o Return remaining blood and tubing site
to the blood bank in a sealed 19. Open the upper clamp of the normal saline
container tubing & squeeze drip chamber until it
o An incident report needs to be covers the filter & 1/3 of the drip chamber
completed for the blood transfusion above the filter
reaction 20. Tap filter chamber to expel any residual air
Initiating, maintaining & terminating a blood in the filter
transfusion 21. Remove the cover at the tip of the blood
1. Verify that signed consent form was transfusion set
obtained if required 22. Open the main flow rate clamp & prime the
2. Assess the vital signs tubing with saline
3. Determine any known allergies or previous 23. Prepare the blood bag:
adverse reactions to blood a. Invert the bag gently several times
4. Note specific signs related to the client’s to mix the cells with plasma
pathology & reason for transfusion b. Export the port on the blood bag by
5. Explain the procedure & its purpose to the pulling the back table
client c. Suspend the blood bag
6. Ask the client’s full name & check the ID 24. Close the upper clamp below of the IV
band solution container. Open the upper clamp of
7. If the client has an IV solution infusing, the blood bag.
check whether the needle & solution are 25. Readjust flow rate with main clamp
appropriate to administer blood. The needle 26. Observe the client closely for first 15
should be gauge 18 or 19, & the solution is minutes:
not compatible , remove it & dispose it a. Run the blood slowly for the first 25
according to agency policy minutes at 20 drops per minute
8. If the client does not have IV solution b. Note adverse reactions such as
infusing, check agency policies. In some vomiting, chills, nausea, skin rash or
agencies an infusion must be running before tachycardia
the blood is obtained from the blood bank. 27. Document relevant data including the time
9. Obtain a correct blood component for the started, vital signs, type of blood, blood unit
client by checking the physician’s order with number, sequence number (no.1 of 3 ordered
requisition units), site of venipuncture, and size of the
10. Recheck with another nurse or personnel the needle & drip rate
blood obtained with the necessary 28. Monitor the client every 15 minutes after
information initiating the transfusion. Check the vital
11. Make sure that the blood is left at room signs of the client. If there are no signs of
temperature for no more than 30 minutes reaction, establish the required flow rate
before starting the infusion 29. Assess the client every 30 minutes or more
12. Carry the equipment to bedside often, depending on the health status
13. Verify the client’s identity by asking the including vital signs until 1 hr post
client’s full name & checking the ID band transfusion
14. Set up the infusion equipment 30. If no infusion is to follow, wear gloves,
15. Put on gloves clamp the blood running and remove the
16. Close all the clamps on the Y-set: main flow needle
rate clamp & both Y-line clamp 31. If the primary IV is to be continued, flush
17. Insert one y-set piercing pin with twisting the maintenance line with saline solution.
motion (spike) into a container of 0.9% Disconnect the blood tubing system from
saline solution the primary system. Adjust the drip to the
desired rate
32. Discard the administration set according to
agency policy. Needles should be placed in a
labeled puncture-resistance container
designed fro such disposal. Blood bags &
administration sets should be bagged &
labeled before being sent for administration
& processing
33. Remove gloves
34. Again monitor vital signs
35. Document relevant data such as:
a. Completion of transfusion
b. Amount of blood transfused
c. Blood unit number & vital signs