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Policies and Procedures

I. New or established IV Patients

 

  1. New patient: RN will collect new Patient Intake, Consent and IV Consent Form.

  2. It is recommended to receive lab work for continuous IV therapy.

  3. Upon first visit with patient, RN will review intake paperwork and perform brief assessment with emphasis on questioning for any known heart, liver or kidney disease.

  4. Established Patients: RN will discuss perform pertinent physical exam

Blood pressure

   Pulse

   Temperature

   Respirations and Pulse Ox

      I. Aid patient in deciding on what benefits they are looking for and advise them on the IV or shot that most closely fits those parameters.

      II. Discuss what to expect during IV and when to notify RN of concerns.

      III. Make sure patient is nourished and well hydrated before and during the infusion.

   5. Prepare IV per sterile technique

 

 

II. Starting a peripheral IV

  1. The licensed provider orders intravenous therapy.

  2. This order includes

Base solution with volume

Additives with volume

Flow rate

Frequency

   3. Identify patient and patients order

Label infusions with patient identifying information such as name/initials and solution name. DO NOT write on the bag with marker. Please write on tape that is stuck to the bag.

   4. Vital signs will be taken before and after each infusion by the RN or medical assistant.

Report abnormal findings to the RN as soon as possible.

   5. IV will be started by RN.

   6. Restrictions on site of insertion

Do not attempt feet or legs without physician’s order.

Do not attempt a limb in which the axillary lymph nodes have been removed.

Any patient with a known history of blood clots is not a candidate for IV therapy

   7. Attempting IV insertion

No more than two unsuccessful attempts may be performed without doctor’s authorization.

   8. Documentation must be complete including but not limited to pre, post vitals, site, gauge, number of attempts, adverse SE, drip rate, start and stop time.

   9. Site will be cleaned with approved aseptic technique using chlorhexidine scrub x1 minute until site is clear.

   10. Apply tourniquet proximal to the selected puncture site on top of a thin layer such as shirtsleeve. Do not apply to tightly and remove immediately after use.

   11. Make sure patient is hydrated and nourished before starting IV. Continue to hydrate during IV.

   12.Check on patient status before each IV.

III. IV Therapy Complications

  1. Infiltration

  2. Phlebitis

  3. Speed shock

  4. Vasovagal

  5. Anaphylaxis

  6. Cytokine storm

  7. Flushing: due to magnesium: slow infusion

  8. Lightheadedness: several factors from hydration, nourished, IV too fast.

  9. Odd taste/smell: B-vitamins or DMSO in the bag. This is normal.

  10. Soreness at the IV: infiltration or adjustments are needed in pH/osmolality of the bag

 

IV. Supplies

a.  Tubing

Administration sets must have a minimum of 15-micron filter along with y-port access.

b. Catheters must be OSHA safety needles

c. Tegaderm

d. Anchoring tape

e. Appropriate sharps, gauze

 

V. Compounding

a. Any time more than 3 additives (2 in a bag) are added to a bag or syringe ISO 5 must be used.

b. Check dates for expiration

c. Check for correct dosage and correct medication/additive

d. General mixing order

1. Use single access devices when possible

2. Utilize gloves, gown, or mask

3. Should occur within 1 hour of patient arrival and no later.

4. Minerals should be added first and vitamins/amino acids last.

Zinc and MTE always first and agitate bag

Vitamins and amino acids next

Methyl-B12 should always be added last and only right before IV insertion.

DMSO should always be added only right before IV insertion

 

VI. Complications

Ecchymosis and Hematoma: Localized mass of blood outside the vessel wall

 

Causes:

1.Nicking vein during venipuncture

2. Discontinuing IV cannula/needle without pressure over site and without adequate amount of time- at least 30 seconds

3. Applying a tourniquet too tightly, over previously attempted venipuncture site

4. Poor vessel integrity

Signs and Symptoms:

  1. Discoloration at site

  2. Site swelling and discomfort

Prevention:

  1. Use indirect method for starting IV

  2. Apply tourniquet just before venipuncture

Treatment:

  1. Apply pressure after catheter/needle removed

  2. Elevate extremity above the patient’s head to maximize venous return

  3. Reassuring patient ecchymosis is short term

 

Infiltration: Infiltration of IV fluid or medication into the surrounding tissue outside the vein wall

Causes:

  1. Puncture of vein upon insertion of needle

  2. Dislodgement of cannula

  3. Phlebitis

Signs and Symptoms:

  1. Coolness of the skin around the site

  2. Taut skin

  3. Edema

  4. Pain

  5. Backflow absent

  6. Infusion rate slowing, but continues to infuse

Prevention:

  1. Make sure catheter or needle is in vein before infusing IV

  2. Stabilize IV well with tape

  3. Check IV frequently

Intervention:

  1. Stop IV immediately and remove catheter or needle, dress puncture site/APPLY PRESSURE TO SITE FOR 1MINUTE

  2. Apply ice if infiltration was detected within 30 minutes, otherwise apple warm compress

  3. Elevate site about heart level

 

Extravasation: Infiltration of a medication into the surrounding tissue outside the vein

Signs and Symptoms:

  1. Edema

  2. Formation of blisters and subsequent sloughing of tissue leading to necrosis

  3. Pain or burning at the site

  4. Infusion stopped or slowing

  5. Skin blanching or coolness

Prevention:

  1. Choose best site for IV

  2. Secure the cannula or needle well

  3. Avoid too rapid infusion

  4. Dilute medications correctly

  5. Check IV site frequently

  6. Make sure you are in the vein before infusing

 

Thrombosis: Trauma to the endothelial cells of the venous wall causes platelets to the vein wall leading to a formation of a clot.

Causes:

  1. Blood backing up into the IV system

  2. Low IV flow rate limiting fluid movement

  3. Location of IV

  4. Obstruction of flow rate

  5. Attempt at restarting fluid flow rate, after IV tubing dry for extended period of time

  6. Trauma to wall of vein

Signs and symptoms

  1. Pain at the site

  2. Site warm to touch

  3. Sluggish or no infusion rate

Prevention

  1. Manage flow rate

  2. Check IV often

  3. Choose micro drip tubing of 60 gtts/ml if a low flow rate is desired

  4. Avoid joint flexion areas for IV placement

  5. Use filters

  6. Avoid cannulation of lower extremities

Treatment:

1. Discontinue IV and restart in an alternate location

(Different arm is preferable

2. Apply cold compress

3. Refer for medications such as urokinase

 

Phlebitis: inflammation of the intima of the vein due to mechanical, chemical injury or bacterial infection

 

Causes:

  1. Trauma to the vein with cannula or needle

  2. Irritation due to type of fluid infused

  3. Introductions of pathogens related to contaminated needle or site prior to insertion

Signs and symptoms:

  1. Redness at the site

  2. Local swelling

  3. Palpable chord along vein

  4. Site warm to touch

  5. Sluggish infusion rate

  6. Increased temperature

Prevention:

  1. Don’t use a larger catheter or needle than necessary

  2. Stabilize IV well

  3. Dilute IV solution appropriately

  4. Do not infuse IV too rapidly

  5. Use filters such as 0.22 micron

  6. Use appropriate pH for IV solutions

  7. Use aseptic/ sterile technique and hand washing

  8. Rotate IV site every 72 hours

Treatment:

1. Stop IV

2. Apply hot/cold compress

3. Give oral anti-inflammatory treatment

 

Allergic Reaction: Hypersensitivity to IV solution or materials used for infusing the solutions

 

Causes:

  1. Materials used in IV tubing and bag

  2. Materials used in gloves

  3. Reactions to solutions and additives to solutions such as preservatives

Signs and symptoms:

  1. Itching

  2. Rash

  3. Tachypnea, SOB

  4. Tachycardia

Prevention:

  1. Test dose before actual IV given via intradermal injection

  2. Use glass vs. plastic containers

  3. Have compounding pharmacist mix IV nutrients

  4. Use preservative free compounds

Treatment:

1. Stop IV immediately

2. Use appropriate medications to treat allergic reactions.

 

Infection at Insertion Site

Causes:

  1. Site not cleaned well enough

  2. Needle or cannula contaminated

Signs and symptoms:

  1. Pain and tenderness at site

  2. Redness at site

  3. Swelling at site

Prevention:

1. Aseptic technique

2. Use of anti-microbial ointment at site

 

Treatment:

  1. Discontinue IV

  2. Clean site and apply anti microbial ointment

 

Venous Spasm: Vein spasm during insertion of IV and during or after infusion of fluid

Causes:

  1. Patient mental anxiety

  2. Difficulty inserting cannula or needle

  3. Irritation of fluid infused

Signs and symptoms:

  1. Difficulty locating vein after insertion of cannula or needle

  2. Pain at site

Prevention/Treatment:

  1. Warm IV site prior to starting IV

  2. Release and reapply tourniquet

  3. Dilute any medication used

  4. Slow IV rate

  5. Use warm pack during treatment

 

Circulatory Overload: Infusion of excessive amounts of sodium solution

Causes:

  1. Too rapid infusion of sodium solution

  2. Too rapid infusion into a patient with cardiac or renal disease

Signs and Symptoms:

  1. Tachypnea, SOB

  2. Edema

  3. Puffy eyelids

  4. HTN

  5. Weight gain

  6. Wide variance of intake and output of fluid

  7. Distended neck veins

  8. Rise in venous pressure

Prevention:

  1. Monitor infusion rate

  2. Do not catch IV up if it is behind

  3. Monitor fluid volume in and out

  4. Know patient’s health history

Treatment:

  1. Decrease IV flow rate

  2. Monitor Vital signs

  3. Give O2

  4. Raise head of chair or bed

  5. Administer diuretic if necessary

  6. Keep patient warm to promote peripheral circulation

 

Septicemia: General systemic infection

Causes:

  1. Poor technique

  2. Pathogens entering at the IV site

  3. Contaminated IV solutions or medications

Signs and Symptoms:

  1. Chills followed by abrupt increase in patient temperature

  2. Nausea, vomiting, diarrhea

  3. General malaise

  4. Abdominal pain

  5. Tachycardia

Prevention:

  1. Aseptic technique

  2. Check dating on all solutions

  3. Check all solutions and equipment

Treatment:

  1. Restart IV at alternate site

  2. Initiate anti-microbial treatment

  3. Monitor patient closely

 

Shock: Occurs when a foreign substance, usually medication, is rapidly introduced into the circulation

 

Causes:

  1. To rapid IV push or drip

  2. Medication not diluted properly

Signs and Symptoms:

  1. Dizziness

  2. Headache

  3. Tightness in chest

  4. Hypotension

  5. Irregular pulse

  6. Progression of shock

Prevention:

  1. Reduce the size of drops of medications by using a micro drip set

  2. Know the appropriate dose/administration of medications

  3. Know well what medications you are administering

Treatment:

  1. Give antidote or resuscitation medications if needed

  2. Have emergency equipment available

  3. Call 911

 

VII. Allergic and Anaphylactic Reactions:

  1. Initiate this procedure if any patient begins to have itching, swelling in tongue, throat or skin, wheals, persistent sneezing etc.

  2. Immediately close roller clamp but DO NOT discontinue IV.

  3. If patient is experiencing itching, swelling in tongue, throat or skin, wheals, persistent sneezing, oral 25-50mg of diphenhydramine may be used to suppress allergic reaction every 2-4 hours as needed. Max 300mg orally/day and 400 IV/IM.

  4. If patient is experiencing significant shortness of breath and is in distress, administer Epinephrine as directed below and follow up with IM, IV or oral diphenhydramine.

  5. If anaphylaxis is present and epinephrine is needed, call 9-1-1

 

IM administration of Diphenhydramine

  1. Put on gloves of appropriate size.

  2. Draw 0.5-1.0ml diphenhydramine into 1ml syringe.

  3. Change needle to 25g needle.

  4. Clean area of skin with two IPA pads in a circular motion moving outwards.

  5. Insert needle at a right angle to the skin, to a depth of one inch (depending on depth to reach muscle.)

  6. Depress syringe until contents have been completely infused into muscle.

  7. Remove needle and apply pressure with gauze.

 

IV administration of Diphenhydramine

  1. Put on gloves of appropriate size.

  2. Draw 0.5-1.0ml diphenhydramine into 10ml syringe.

  3. Draw up 0.9% to fill 10cc syringe.

  4. Clean Y-site of IV line with IPA pad.

  5. Insert needle into Y-site.

  6. Depress syringe until contents have been completely infused.

  7. Remove needle and reassess patient every 15 minutes.

 

Epinephrine Administration: Epipen

  1. To use EpiPen auto-injector:

  2. Form a fist around the auto-injector with the black tip pointing down. Pull off the safety cap.

  3. Place the black tip against the fleshy portion of your outer thigh.

  4. With a quick motion, push the auto-injector firmly against your thigh.

  5. Remove the auto-injector from your thigh.

 

Epinephrine Administration Procedure:

  1. Draw up 1:1000 Epinephrine 1cc syringe insert an 18g 1” needle on tip of syringe. Do not administer this dose on child less than 100 lbs.

  2. With a 25g needle placed on the syringe, insert the needle at a 45-degree angle to administer the dose subcutaneously (use area easily accessible). Alternatively, administer the dose intramuscularly in the deltoid muscle.

  3. Administer 0.2-0.5ml and remove syringe.

  4. Draw up 1 vial of 50mg/ml Diphenhydramine and inject using sterile technique into the deltoid muscle.

  5. If symptoms of anaphylaxis return, administer another 0.2-0.5 of the syringe.

  6. Doses of Epinephrine should be 5-15 minutes and record them.

  7. Check the patient’s vital every 10-15 minutes and record them.

  8. Record dose and time of Epinephrine and Diphenhydramine administered.

  9. Have a copy of these available to EMT upon arrival.

  10. Fill out incident report including dose and times of any emergency medications given and frequency of vitals recording.

 

VIII. Needle Stick Procedure

At ReVitaLife Wellness, LLC, we maintain safe needle techniques to help prevent needle stick injuries. In the event that a needle stick occurs please use the following procedure:

  1. Within 15 minutes of the needle stick:

Contact medical director

Obtain the following information from the patient that the needle came from:  vaccination status including tetanus and hepatitis B

History of possible exposure to blood borne pathogens

IV drug use

Unprotected sexual activity

Body piercing or tattoos

Receipt of blood and/or blood products

History of dialysis

Travel outside of the United States in the last year

Other

 

Complete Incident Report

Patient testing

 

The patient will be tested for HIV 1 and 2 antibodies and Hepatitis C

The testing will be completed at Labcorp or PCS.

If on site testing is available then an on site test will be performed.

RevitaLife Wellness, LLC will pay for this testing.

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