8: IV/SQ Maintenance

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1 Section 8: IV/SQ Maintenance Section Author(s): abalmforth & wbethurum Field Guide Section 8: IV/SQ Maintenance 1

2 Section 8: IV & SQ Maintenance 2 Section 8: IV/SW Maintenance Field Guide

3 Section Contents IV/SQ Supplies and Syringes...5 IV Supplies...5 Syringes for Injection...5 SQ Infusions/Intermittent Injections...5 Intravenous/Subcutaneous Access Devices Reference Sheet...7 Field Guide Section 8: IV/SQ Maintenance 3

4 4 Section 8: IV/SW Maintenance Field Guide

5 IV/SQ Supplies and Syringes IV Supplies UltraSite needleless valve used for all IV connections. The UltraSite valve should be on the end of every central line port and peripheral IV. Blue replacement caps should be placed over the end of disconnected IV tubing and syringes that have medication in them. This is the needleless alternative to putting a needle on the end of tubing and syringes to keep them sterile. QualMed provides IV/SQ supplies in the home when they are involved in the patient care, for every patient that has IV fluids or continuous IV/SQ medication being administered. QualMed is not involved in patients that have IV/SQ access, such as a central line that is not being used or a site for intermittent SQ injections. The Denver Hospice has supplies stocked in the Supply Room to care for these lines. Heparin and Saline flushes may be obtained from Enclara. o Refer to the blue grid under Central Lines in Field Book for specific heparin concentrations, volumes and frequencies for flushing central lines. Syringes for Injection Only Monoject Safety Syringes, a needle safe syringe, should be used for IM, SQ or intradermal injections Regular needle insulin syringes are available in the storeroom. These should be used ONLY for patients whom we provide syringes for insulin or other SQ injections (i.e., these should only be used by patients who are giving their own injections). Nurses must use the Monoject Safety Syringe when giving an injection. SQ Infusions/Intermittent Injections A 24 gauge 0.75 Peripheral IV Catheter should be used for continuous or intermittent SQ medications. The catheter is placed in the SQ tissue, usually the abdomen, thigh or back of the arm. To place the catheter, insert the needle (and catheter) and then pull out the needle. The flexible plastic catheter is left in the SQ tissue. Anchor the catheter well. IV/SQ Supplies & Syringes Revised: 03/28/2011 Author: wbethurum Field Guide Section 8: IV/SQ Maintenance 5

6 6 Section 8: IV/SW Maintenance Field Guide

7 DOCUMENTATION GUIDELINES FOR ALL TYPES OF ACCESS DEVICES Upon insertion document: 1) Catheter type 2) Size (for ports document length and gauge of non-coring needle) 3) Any pt/family teaching in the nurse visit profile With every dressing change document: 1) The above information 2) Site appearance (erythema, edema, exudate?) 3) Catheter patency (if patency or access problems, document interventions taken) 4) Type of dressing applied Don t forget to document all: 1) Needle/catheter/adapter changes 2) Blood samples taken 3) Complications with flushes/blood draws 4) Interventions implemented 5) Catheter dressings with date and initials. PEARLS: 1)Nurse should not try more than twice to achieve correct catheter placement new nurse should try 2)Clip hair not shave at the insertion site to help prevent infection 3)Use a gauze dressing if pt diaphoretic or if the site is oozing blood change every 2 days 4)Pt/family should be taught to inspect all catheter sites daily for s/s infection or dislodgement and to report immediately to TDH (Yellow) Revised: 08/09/2011 Reviewed by: Sarah Kolman RN, MA, CHPN GENERAL INFORMATION FLUSHING (ALWAYS USE PUSH/PAUSE/ POSITIVE PRESSURE) BLOOD DRAWING DRESSING Intravenous/Subcutaneous Access Devices Reference Sheet SUBCUTANEOUS PERIPHERAL LINE MIDLINE Requires adequate subcutaneous tissue Use clean gloves and prep site w/ chlorhexidine Use 24 gauge IV catheter Ensure no blood aspirated on insertion Cover with a transparent dressing Appropriate for up to ~ 5ml medication infusion/hr May administer up to ~ 60 ml/hr normal saline (may use more than one site for more fluids) DO NOT USE NON-CORING NEEDLE (HUBER NEEDLE) Flushing only required after administering meds so that all meds clear the catheter Can not draw blood from this catheter (catheter is not in a vein) Change dressing w/ catheter change Sterile dressing not indicated Placed by LPN-IV certified or competent RN Use clean gloves and prep site w/ chlorhexidine Use 24 gauge IV catheter Cover with a transparent dressing PIVs should not be routinely replaced instead obtain catheter with longer dwell time Minimum 2ml NS before and after use Heparin lock not recommended Often difficult to obtain blood sample but appropriate to try (turn off infusions, apply a tourniquet ~3 inches proximal to insertion site, waste ~3 ml blood, obtain blood for sample and transfer to blood tubes via Blood Transfer Device appropriate even for coags Change within a week with site change Change if soiled or non-occlusive Sterile dressing not indicated ADAPTER Change with every catheter change with catheter, AFTER DRAWING BLOOD or if removed SITE / NEEDLE / LINE Short term ( up to7 days for meds and 1-2 days Site within a week or PRN if site develops REMOVAL for fluids) and prn if site develops erythema, edema, phlebitis, infection, infiltration or occlusion occurs leaking, ecchymosis, burning or pain If Thorazine infusing SQ, change site q24-48hours.. MAINTENANCE FLUSHING OF UNUSED LUMENS Not a central line For infusions or treatments lasting ~ 1-4 weeks Catheter distal tip in upper arm Placed by certified RN from infusion pharmacy Use 10ml or larger syringe Minimum 3ml NS before and after use, then 3ml heparin 10 u/ml Often difficult to obtain blood sample but appropriate to try (turn off infusions, apply a tourniquet ~3 inches proximal to insertion site, waste ~3 ml blood, obtain blood for sample and transfer to blood tubes via Blood Transfer Device appropriate even for coags Use caution: catheter may not be sutured Sterile procedure using sterile dressing kit q 7 days (gauze dsg q 2 days) Change earlier if soiled or non-occlusive with catheter, AFTER DRAWING BLOOD or if removed No routine site To remove catheter: remove dressing, slowly pull cath using hand over hand motion & apply vaseline gauze with pressure dressing for 24 hrs No special care required. Minimum 2 ml NS flush every 12 hours Minimum 3 ml NS flush every 12 hours followed by 3 ml heparin 10 u/ml *May use heparin 100 u/ml in place of heparin 10 u/ml if needed * Reference: Journal of Intravenous Nursing, Infusion Nursing Standards of Practice, Vol. 34, No. 1S, Jan/Feb 2011

8 Intravenous/Subcutaneous Access Devices Reference Sheet ~ Page 2 GENERAL INFORMATION PICC NON-TUNNELED CENTRAL LINE TUNNELED CENTRAL LINE IMPLANTED PORTS Central line (distal tip is in the superior vena cava) Prior to use, patency shold be confirmed/documented by presence of blood flow and ability to flush with NS) if not, consider obtaining order for Cath Flo May remain for ~ one year Placed by certified RN from our infusion pharmacy Examples: subclavian, IJ or femoral central line Short term : max dwell time unknown Prior to use, patency should be confirmed/documented by presence of blood flow and ability to flush with NS) if not, consider obtaining order for Cath Flo Clamp when changing adapter Not placed by nurses Usually single/double/triple lumen Valved (ie Groshong): Transparent blue catheter without a clamp Non-valved (ie HICKMAN/HOHN/BROVIAC): Opaque white catheter with clamps Long term catheters max dwell time unknown Prior to use, patency should be confirmed/documented by presence of blood flow and ability to flush with NS) if not, consider obtaining order for Cath Flo Long-term max dwell time unknown Entirely under the skin Access with non-coring needle (i.e. Huber needle) for use Prior to use, patency should be confirmed/documented by presence of blood flow and ability to flush with NS) if not, consider obtaining order for Cath Flo Placed in OR Single or double lumen FLUSHING (ALWAYS USE PUSH/PAUSE/ POSITIVE PRESSURE) BLOOD DRAWING DRESSING Use 10 ml or larger syringe Minimum 5ml NS before and after use, then 5ml heparin 10 u/ml Turn off all infusions Flush w/ 5ml NS Waste 5ml blood Withdraw appropriate amount of blood for tests Flush with 10ml NS followed by 5ml heparin 10 u/ml prn Change adapter Use caution: catheter may not be sutured Sterile procedure using sterile dressing kit q 7 days (gauze dressing q 2 days) Change earlier if soiled or non-occlusive Use 10 ml or larger syringe Minimum 5ml NS before and after use, then 5 ml heparin 10 u/ml Turn off all infusions Flush w/ 5ml NS Waste 5ml blood Withdraw appropriate amount of blood for tests Flush with 10ml NS followed by 5ml heparin 10 u/ml prn Change adapter Catheter is usually sutured Sterile procedure using sterile dressing kit q 7 days (gauze dressing q 2 days) Change earlier if soiled or non-occlusive 8 Section 8: IV/SW Maintenance Field Guide Use 10 ml or larger syringe Minimum 5 ml NS before and after use, then (NON-VALVED ONLY) 5ml heparin 10 u/ml Turn off all infusions Flush w/ 5ml NS Waste 5ml blood Withdraw appropriate amount of blood for tests Flush with 10ml NS followed by (NON-VALVED ONLY) 5ml heparin 10 u/ml prn Change adapter Dressing change with sterile procedure using sterile dressing kit q 7 days (gauze dressing q 2 days) until well healed Change earlier if soiled or non-occlusive Once well-healed, dressings are optional Use 10ml syringe minimum Min 5ml NS before/after, then 3-5ml heparin 100u/ml Turn off all infusions Flush w/ 5ml NS Waste 5 ml blood Withdraw appropriate amt of blood for tests Flush with 10ml NS then 3-5 ml heparin 100 u/ml Sterile procedure using sterile dressing kit to access with non-coring needle transparent dressing q 7 days (gauze dressing q 2 days) if soiled or non-occlusive Chart needle gauge and length on the dressing ADAPTER q 7 d and if removed q 7 d and if removed q 7 d and if removed With needle or if removed SITE / NEEDLE / LINE No routine site No routine site Catheter removed by MD Non-coring needle q 7 d (sterile procedure with central REMOVAL To remove catheter: see instructions in Lippincott To remove catheter: see instructions in Lippincott Catheter may be repaired if external portion is broken line dressing tray) See Lippincott for information on how to remove a noncoring needle MAINTENANCE FLUSHING OF UNUSED LUMENS (Yellow) Revised: 08/09/2011 Reviewed by: Sarah Kolman RN, MA, CHPN Minimum 5 ml NS flush q 24 hours followed by 5 ml heparin 10 u/ml Minimum 5 ml NS flush q 24 hours followed by 5 ml heparin 10 u/ml Nonvalved minimum 5 ml NS flush at least q 24 hours followed by 5 ml heparin 10 u/ml Valved minimum 5 ml NS flush weekly (no heparin) *May use heparin 100 u/ml in place of heparin 10 u/ml if needed * Reference: Journal of Intravenous Nursing, Infusion Nursing Standards of Practice, Vol. 34, No. 1S, Jan/Feb 2011 ACCESSED -Min 5ml NS flush then 3-5 ml heparin 100u/ml once a week (use heparin 10u/ml if flushing more than 2 times/week) UNACCESSED -Min 5 ml NS flush then 3-5 ml heparin 100u/ml once a month