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Administering Blood and Blood Products

Administering Blood and Blood Products

Equipment
■ Clean nonsterile gloves.
■ Blood product.
■ 250 mL normal saline IV solution.
■ Blood administration set with a 200-micrometer filter and Luer-Lok
connection (if there is no filter on the tubing, you must attach one).
■ Be Smart! Although nurses commonly use a 20-gauge catheter, for
routine transfusion, a 22- or 24-gauge can be used. You would need
an 18- or 20-gauge catheter to transfuse large amounts of blood
rapidly.
■ Be Smart! When choosing an IV catheter for transfusion, the
primary consideration should be the size of the patient’s veins
and not an arbitrary catheter size.
■ IV pole.
■ Watch with a second hand or digital readout.
■ Thermometer.
■ BP cuff with sphygmomanometer.
■ Stethoscope.

Assessment
■ Confirm the patient’s need for blood products by assessing VS, urine output, and laboratory studies.
■ Be Safe! Check the history for previous transfusions and reactions. Verify the patient’s blood type.
■ Assess that the existing IV catheter is patent and the proper size for blood product administration.
■ Assess the IV insertion site for signs of infiltration, phlebitis, infection, or inflammation.
■ Assess for allergy to tape.

Post-Procedure Reassessment
■ Be Safe! Monitor for signs of fluid overload and for signs and symptoms of transfusion reaction.
■ Check laboratory studies, such as complete blood count, to help evaluate the effectiveness of therapy and identify transfusion reaction.

Key Points
■ Verify that informed consent has been obtained.
■ Verify the prescriber’s order, noting the indication, and rate of infusion.
■ Administer any prescribed pretransfusion medications.
■ Obtain a blood administration set and 250 mL of IV normal saline solution.
■ Obtain the blood product from the blood bank according to your institution’s policy.
■ With another qualified staff member, and using two identifiers, verify the patient and blood product identification (e.g., birth date, hospital ID number, blood type).
■ Be Safe! Contact the blood bank immediately if there are discrepancies, and do not administer the blood product.
■ Document on the blood bank form the date and time the transfusion is begun.
■ Check that all clamps are closed on the blood administration set; label the tubing.
■ Hang the normal saline and prime the tubing.
■ Gently invert the blood product container several times.
■ Spike the blood product and hang the blood on the IV pole.
■ Obtain a set of VS.
■ Scrub the port with an alcohol or CHG-alcohol antiseptic swab for at least 15 seconds
■ Attach the administration set tubing to the IV catheter.
■ Slowly open the roller clamp closest to the blood product.
■ Be Safe! Infuse the first 50 mL slowly and remain with the patient for the first 5 minutes.
■ Measure VS at 5 minutes, 15 minutes, and 30 minutes; then hourly.
■ Observe for and ask the patient to report symptoms of transfusion reaction.
■ When the blood has transfused, flush the line with the saline solution.
■ Disconnect the tubing from the IV catheter, and dispose of the blood product container and tubing per agency policy.
■ If a second unit of blood is to be transfused, the same administration set may be used.
■ Administer any post-transfusion medications prescribed.

Documentation
■ Chart the date, time, and reason the transfusion was started.
■ Document transfusion VS according to institution policy (many institutions have a special form for this).
■ Record the amount of blood transfused on the I&O record.
■ Chart any complications and the interventions taken.
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Discontinuing a Peripheral IV

Discontinuing a Peripheral IV

Equipment
■ Clean nonsterile gloves, sterile 2 in. 2 in. gauze dressings.
■ 1-in. tape or transparent semipermeable dressing.
■ Linen-saver pad.

Assessment
■ Verify the order and assess the patient’s readiness to have the IV fluid discontinued (e.g., tolerating oral fluids, has adequate urine output, laboratory values are within normal limits). Post-Procedure Reassessment
■ Assess the integrity of the removed catheter; compare the length to the original insertion length to ensure the entire catheter is removed.
■ Be Smart! If a catheter defect is noted, report to the manufacturer and regulatory agencies and complete an incident report according to agency policy.
■ Monitor the patient’s response to oral fluids after IV therapy is discontinued. Note changes in the patient’s condition that might indicate the need to re-establish IV therapy.

Key Points
■ Be Smart! Place a linen-saver pad under the extremity with the IV catheter to prevent soiling patient’s clothing or bed linen.
■ Don clean nonsterile gloves, and close the roller clamp on the administration set.
■ Carefully remove the IV dressing, catheter stabilizer, and tape securing the tubing.
■ Scrub the catheter-skin junction with an antiseptic pad.
■ Place a sterile 2 in. 2 in. gauze pad above the IV insertion site and gently remove the catheter. Do not press on the gauze pad while removing the catheter.
■ Be Safe! Apply firm pressure with the gauze pad over the insertion site. Hold pressure for 1 to 3 minutes; hold longer if bleeding persists.
■ Apply a folded sterile 2 in. 2 in. gauze pad. Secure it with tape.

Documentation
■ You will usually record this procedure on a flowsheet or in the electronic patient record.
■ Chart the date and time IV therapy was discontinued.
■ Note the condition of the site, including the presence of any complications.
■ If complications are present, document your interventions and notify the primary care provider.

Do not press on the pad while removing the catheter
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Converting a Primary Line to a Heparin or Saline Lock

Converting a Primary Line to a Heparin or Saline Lock

Equipment
■ Clean nonsterile gloves.
■ Peripheral intermittent lock adapter.
■ 2 syringes containing saline or dilute heparin solution.
■ Linen-saver pad.
■ Transparent semipermeable dressing.
■ Alcohol or other antiseptic swab.

Assessment
■ Assess the patient’s readiness to have the IV fluid discontinued and the site changed to an intermittent lock (e.g., tolerating oral fluids, adequate urine output, and laboratory values within normal limits).
■ Assess for allergy to tape.
■ Assess the IV site for signs of phlebitis, infiltration, extravasation, or infection.

Post-Procedure Reassessment
■ Evaluate catheter patency before each use and routinely every 8 to 24 hours (according to agency policy).
■ Monitor the insertion site for signs of complications, and the patient’s tolerance to the intermittent IV therapy.

Key Points
■ Be Safe! If complications are present or the IV has been in place longer than 72 to 96 hours, remove the IV catheter instead of converting it to an intermittent lock.
■ Don clean nonsterile gloves.
■ Remove the IV lock from the package, and flush the adapter.
■ Remove the IV dressing and the tape that is securing the tubing.
■ Close the roller clamp on the administration set.
■ With your nondominant hand, apply pressure over the vein just above the insertion site; stabilize the catheter hub with your thumb and forefinger.
■ Disengage the old tubing from the IV catheter.
■ Be Smart! If the tubing does not separate from the catheter, use a hemostat to gently twist the lock and separate tubing from catheter.
■ Quickly insert the lock adapter into the IV catheter and turn the lock adapter until snug.
■ Scrub the adapter injection port for at least 15 seconds.
■ Flush the lock adapter again.
■ Apply a sterile transparent semipermeable dressing.
■ Be Safe! Do not cover the lock-hub connection.
■ Label the dressing with the date and your initials.
■ Discard used supplies.
■ Be Safe! Maintain sterility of equipment throughout.

Documentation
■ Chart the date and time the IV line was converted to an intermittent lock device; the size and location of the catheter; and the type and amount of flush solution used.
■ Document the condition of the IV site and any signs of complications.
■ Record on the I&O record the amount of IV fluid infused.
■ Often, IV care is documented on a flowsheet or an electronic patient record.

Flush the adapter
Insert the adapter quickly into the catheter hub
Flush the line again after it is inserted
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Changing IV Dressings (Central Line Dressings)

Changing IV Dressings (Central Line Dressings)

Equipment
■ Clean nonsterile gloves.
■ Central line dressing kit (including sterile gloves, mask, sterile transparent semipermeable dressing, sterile tape, an antimicrobial agent, and a sterile catheter stabilization device).
■ Mask for patient.
■ A sponge containing the antimicrobial agent CHG may be used as a part of the dressing, as well.
■ Note: You can use povidone-iodine followed by alcohol as the antimicrobial if CHG is contraindicated and if the patient is not allergic to iodine.

Assessment
■ Observe the site for excessive bleeding, infection, or other complications.
■ Observe for signs of compromised catheter integrity: wet dressing, kinked, cracked, or leaking catheter.
■ Be Safe! Notify the primary provider if any of these signs are present.

Post-Procedure Reassessment
■ Evaluate the IV insertion site and surrounding tissue for signs of infiltration, inflammation, infection, and phlebitis.
■ Monitor the dressing for dampness, blood, soiling, or loosening.
■ Continue to visually inspect and palpate the catheter-skin junction site for tenderness daily through the transparent dressing.

Key Points
■ Be Safe! Care of CVCs requires meticulous aseptic technique.
■ Obtain sterile central line dressing kit and mask for the patient. If there is no kit, you will need at least a mask, sterile gloves, antiseptic solution, dressing, and tape.
■ Place the patient in a comfortable position. Some guidelines advise semi-Fowler’s.
■ Ask the patient to don a mask or turn his head to the opposite side if unable to tolerate a mask.
■ Don mask and clean nonsterile gloves.
■ Carefully remove the old dressing and stabilization device.
■ Inspect the site for signs of complications.
■ Remove and discard gloves and soiled dressing; wash your hands.
■ Don sterile gloves contained in the kit.
■ Scrub the site for 30 seconds, using swabs contained in the kit.
■ Scrub the sutures (if any) and the catheter, from insertion site to the hub or bifurcation.
■ Allow the site to dry.
■ Apply the dressing that comes in the kit.
■ Apply the new catheter stabilization device, if one is used.
■ Remove the drape, if one was used.
■ Loop the catheter gently and secure it with tape to the skin. Avoid securing it to the dressing.
■ Label the dressing with the date changed, time, and your initials.

Documentation
■ Chart the date and time the dressing was changed, and condition of the IV catheter insertion site.
■ Document any complications of IV therapy and the interventions taken. Document the dressing change on the IV record.
■ Often, IV care is documented on a flowsheet.
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Changing the IV Solution and Tubing

Changing the IV Solution and Tubing

Equipment
■ Nonsterile gloves.
■ Administration set.
■ IV solution.
■ IV pole.
■ Antiseptic swabs that contain solutions such as alcohol or CHG.
■ Be Safe! CHG is not recommended for infants younger than age 2 months.
■ 1-in. nonallergenic tape.
■ Time tape.
■ Watch with a second hand or digital readout.

Assessment
■ Check the IV catheter insertion date (the CDC recommends changing a peripheral IV every 72 to 96 hours).
■ Assess the IV catheter for patency.
■ Assess the IV site for signs of phlebitis, infiltration, infection, or inflammation.
■ Be Safe! If any of these complications exist, discontinue the current IV and start a new one.

 Post-Procedure Reassessment
■ Be Safe! Evaluate proper IV rate regularly (usually hourly). Continue to monitor the insertion site for signs of infiltration, inflammation, infection, and phlebitis.
■ Evaluate the effectiveness of IV therapy by assessing hydration status or expected effect of the IV medication/solution.

Key Points
■ Be Safe! Care of IVs requires careful sterile technique.
■ Prepare and hang the new IV solution and tubing.
■ Close the roller clamp on the administration set.
■ Wearing clean nonsterile gloves, place a sterile swab under the catheter hub.
■ Remove the protective cover from the distal end of the new administration set.
■ Stabilize the IV catheter while applying pressure over the vein just above the insertion site.
■ Disengage the old tubing from the IV catheter and insert the new tubing.
■ Be Smart! If the tubing does not separate, use a hemostat to twist the lock. Grip and twist lightly.
■ Adjust the drip rate or set and turn on the volume control pump.
■ Cleanse the IV site, resecure the IV catheter and tubing connection; loop and tape the tubing.
■ Label tubing and solution with date, initials, rate, and time tape.

Documentation
■ Fluid and tubing changes are usually documented on a flowsheet.
■ If writing a nursing note, document:
■ The date and time the IV fluid and tubing were changed.
■ Type of IV fluid and rate of infusion.
■ The location and condition of the IV catheter insertion site.
■ Any complications of IV therapy and the interventions taken.

Stabilize the catheter and apply pressure over the vein while disconnectingthe administration set
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Initiating a Peripheral IV Infusion

Initiating a Peripheral IV Infusion

Equipment
■ IV solution.
■ Administration set or IV lock and injection caps.
■ IV catheter.
■ If using extension tubing, a saline-filled syringe to prime it.
■ Procedure gloves.
■ Scissors.
■ Antiseptic swabs containing CHG or 70% alcohol wipes.
■ Tourniquet (nonlatex, if available).
■ Sterile catheter stabilization device or 1/2-in. tape; 2 in. 2 in. sterile gauze and/or transparent semipermeable occlusive dressing.
■ 1-in. hypoallergenic tape, preferably clear.
■ Labels, time tape.
■ Linen-saver pad.
■ Arm board, if necessary.
■ Be Smart! For a glass solution container, use vented tubing; for a plastic container, you may use either vented or nonvented tubing.

Assessment
■ Check VS, laboratory values, urine output, skin turgor, breath sounds, and the condition of mucous membranes to confirm the need for IV therapy.
■ Assess the veins on the arms and hands for a potential insertion site.
■ Assess for allergy to tape and check the medical record for complicating factors such as anticoagulant therapy, bleeding disorders, or low platelet count. Post-Procedure Reassessment
■ Monitor the IV site and flow rate (many agency standards require hourly), as well as signs of infiltration, inflammation, and phlebitis.
■ Monitor tolerance of IV therapy: auscultate lungs and monitor VS, I&O, laboratory values, and neck vein distention.
■ Be Safe! Report signs of fluid overload, such as:
■ Crackles.
■ Edema.
■ Shortness of breath.
■ Diminished urine output.
■ Increased BP.
■ Increased heart rate with bounding pulse.
■ Distended neck veins.

Key Points
■ Prepare the IV solution and administration set, including extension tubing and volume control device if used.
■ Apply the tourniquet.
■ Be Safe! Keep the catheter sterile throughout the procedure.
■ Be Smart! Locate a vein. As a rule, select the most distal vein in an upper extremity.
■ Don clean nonsterile gloves and cleanse the site. Allow the antiseptic to dry on the skin. Do not touch the site after cleansing.
■ Use your nondominant hand to apply gentle traction on skin at the insertion site to stabilize the vein.
■ Inform the patient that you are about to insert the catheter.
■ Hold the catheter, bevel up, at a 30° to 45° angle and pierce the skin.
■ Lower the catheter so it is parallel to the skin, and advance it.
■ Watch for a flashback of blood; continue inserting the catheter. Advance the catheter halfway, then remove (or retract) the needle as you insert the catheter the rest of the way—to the hub.
■ While holding the catheter in place with one hand, release the tourniquet with your other hand.
■ Connect the IV administration set or extension tubing to the IV catheter.
■ Adjust the flow rate according to the prescriber’s order.
■ Secure the connection, stabilize the catheter, and apply dressing to the IV insertion site.
■ Secure the tubing by looping and taping it to the skin.
■ Label the dressing, tubing, and IV solution. Apply a time tape.
■ Place an arm board as needed.

Documentation
■ Record the date and time of insertion, gauge and type of catheter, number of attempts, and location of the insertion site.
■ State whether you used a tourniquet, blood returned in the catheter, the IV was flushed, and the type and amount of flush solution used.
■ Describe the dressing and tape type used, the method of stabilizing the IV line, and the type and rate of the IV fluid infusing.
■ Describe patient’s tolerance of the procedure, any adverse reactions, teaching done, and any interventions that were required.
■ Often, IV care is documented on a flowsheet.
■ Document on the I&O sheet the amounts of fluids infused.

Pierce the skin at a 30o to 45o angle
Secure the IV catheter at the hub with transparent dressing
Smooth the transparent dressing to the skin
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Administering Medication through a Central Venous Access Device

Administering Medication through a Central Venous Access Device

Equipment
■ Syringe appropriate for medication volume; needleless device or safety syringe with a filter needle for drawing up the medication.
■ 2 syringes for the flush solution.
■ Saline or heparin flush solution, as prescribed.
■ Alcohol prep pad or CHG-alcohol combination product and gauze pad.
■ Procedure gloves.

Assessment
■ Carefully palpate the area around the insertion site through the dressing.
■ If the patient has tenderness, assess further for other signs of complications.
■ Visually assess the surrounding catheter insertion site for redness, swelling, warmth, or drainage.

Post-Procedure Reassessment
■ Monitor for signs of:
■ Catheter complications (e.g., shortness of breath, chest pain, engorged veins at the surface of the skin, and palpitations).
■ Catheter dislodgment (e.g., neck swelling or pain, bleeding at the site or within the line, palpitations, or gurgling noise or the sound of running water on the side of the catheter insertion).
■ Look for difficulty moving the neck or jaw, headache, or ear pain.
■ Assess for signs of:
■ Catheter-related infection (e.g., fever, increased WBC count, redness, warmth at the site).
■ Leaking or blood backup at the injection ports, tubing connections, and the site.
■ Observe for bleeding at the CVAD site.
■ Assess for allergic response or adverse effects to medication.
■ Conduct a comprehensive pain assessment.

Key Points
■ Be Safe! First verify the medication can be administered safely through a central site.
■ Be Safe! Be sure you’ve are using the correct port.
■ Scrub all surfaces of the catheter port, including the extension “leg,” with an alcohol or CHG-alcohol combination product every time you access the line.
■ Flush the line before and after administering medication. Use saline, heparinized flush solution, or solution from the infusing IV line.
■ Clamp the line between the IV infusion set and the medication port. Open the clamp after medication is administered.
■ After administration, monitor and report suspected CVAD dislodgment, line-related infection, or other complications.

Documentation
■ Record signs of:
■ Allergic response to or adverse effects of medication.
■ Catheter complications, catheter dislodgment, or catheter-related infection.
■ Record the date and time tubing and port cap are changed.
■ Document all medications infused through the CVAD—usually on a flowsheet and/or a MAR.

Multilumen central venous access device
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Administering Medication by Intermittent Infusion (Piggyback Set)

Administering Medication by Intermittent Infusion (Piggyback Set)

Equipment
■ Correct-size syringe for measuring medication.
■ Needleless access cannula or safety needle.
■ Small bag of diluted medication with piggyback tubing.
■ Primary IV solution and tubing (unless one is already infusing).
■ Antimicrobial swabs.
■ Labels for the IV tubing and medication administration system.

Assessment
■ Check the site for redness, swelling, tenderness, and other signs of infiltration or phlebitis. Post-Procedure Reassessment
■ Assess for complaints of pain or discomfort at the site.
■ Be Smart! Intermittent infusions are generally administered over 15 to 60 minutes, so you need to assess the patient as soon as the infusion begins and every 15 to 20 minutes until it is absorbed.
■ Assess for factors that will provide a basis for evaluating the drug’s effectiveness, such as checking BP after administering an antihypertensive agent.

Key Points
■ Be Safe! Ensure the compatibility of the IV solution and medication, in both the primary and secondary (piggyback) systems.
■ Be Smart! Be sure you have the correct tubing. Piggyback tubing is short; tandem tubing is long.
■ Be Smart! Calculate the amount of medication to add to the solution. Use the correct amount and type of diluent solution.
■ Be Safe! Use the correct rate of administration.
■ Be sure the slide clamp is closed. Squeeze the drip chamber, filling it one-third to one-half full.
■ Open the clamp and prime the tubing, holding the end of the tubing lower than the bag of fluid.
■ Be Safe! Affix the correct label to the piggyback bag, identifying the infusate, patient name, start date and hour, discard date and hour, and your initials.
■ Hang the piggyback container on the IV pole. Lower the primary IV container to hang below the level of the piggyback IV.
■ Open the clamp of the piggyback line and regulate to the prescribed infusion rate for the medication.
■ At the end of the infusion, clamp the piggyback tubing, and reset the primary bag to its correct infusion rate.

Documentation
■ Record the appearance of the IV site and patient complaints of pain or discomfort during IV administration.
■ You will usually document on an IV flow record and/or MAR rather than in the nursing notes.
■ Chart a nursing note only if there is a problem (e.g., if the patient experiences pain when you administer the medication).

Piggyback administration set
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Administering Medication by Intermittent Infusion Using a Volume-Control Administration Set

Administering Medication by Intermittent Infusion Using a Volume-Control Administration Set

Equipment
■ Correct-size syringe for measuring medication.
■ Needleless access cannula or safety needle.
■ Small bag of diluted medication with piggyback tubing.
■ Primary IV solution and tubing (unless one is already infusing).
■ Antimicrobial swabs.
■ Labels for the IV tubing and medication administration system.

Assessment
■ Check the site for redness, swelling, tenderness, and other signs of infiltration or phlebitis. Post-Procedure Reassessment
■ Assess for complaints of pain or discomfort at the site.
■ Be Smart! Intermittent infusions are generally administered over 15 to 60 minutes, so you need to assess the patient as soon as the infusion begins and every 15 to 20 minutes until it is absorbed.
■ Assess for factors that will provide a basis for evaluating the drug’s effectiveness, such as checking BP after administering an antihypertensive agent.

Key Points
■ Be Safe! Ensure the compatibility of the IV solution and medication.
■ Be Smart! Be sure you have the correct tubing.
■ Be Smart! Calculate the amount of medication to add to the solution.
■ Use the correct amount and type of diluent solution.
■ Be Safe! Use the correct rate of administration.
■ Close both the upper and lower clamps on the tubing.
■ Open the clamp of the air vent on the volume-control chamber.
■ Maintaining sterile procedure, attach administration spike of the volume-control set to the primary IV bag.
■ Fill the volume-control chamber with the desired amount of IV solution; then close the clamp.
■ Prime the rest of the tubing.
■ Scrub all surfaces of the injection port closest to the patient using an antiseptic swab.
■ Connect the volume-control tubing to the extension tubing.
■ Scrub the injection port on the volume-control chamber; attach the medication syringe using a blunt, needleless device; and inject the medication into the solution in the chamber.
■ Gently rotate the chamber to mix the medication in the IV solution.
■ Open the lower clamp, and start the infusion at the correct flow rate.
■ Be Safe! Affix the correct label to the secondary bag, identifying the infusate, patient name, start date and hour, discard date and hour, and your initials.

Documentation
■ Record the appearance of the IV site and patient complaints of pain or discomfort during IV administration.
■ You will usually document on an IV flow record and/or MAR rather than in the nursing notes.
■ Chart a nursing note only if there is a problem (e.g., if the patient experiences pain when you administer the medication).

Adding medication to the volume-control chamber
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Administering IV Push Through an IV Lock with IV Extension Tubing

Administering IV Push Through an IV Lock with IV Extension Tubing

Equipment
■ Correct-size syringe for measuring medication.
■ Needleless access cannula or safety needle.
■ Antimicrobial swabs.
■ IV extension set.
■ Labels for the IV tubing and medication administration system.

Assessment
■ Check the site for redness, swelling, tenderness, and other signs of infiltration or phlebitis.
■ Perform assessments for evaluating the drug’s effectiveness, such as checking BP after administering an antihypertensive agent. Post-Procedure Reassessment
■ Assess for patient complaints of pain or discomfort at the site.

Key Points
■ Be Safe! Ensure the compatibility of the IV solution and medications.
■ Be Smart! Calculate the amount of medication to administer.
■ Be Safe! Use the correct rate of administration.
■ Determine the volume of extension tubing attached to the access port.
■ Assess the IV site and the patency of the line.
■ Determine the correct primary line port for infusion of medication.
■ Vigorously scrub all surfaces of the injection port closest to the patient with an antiseptic wipe.
■ Administer a small amount of the flush solution and monitor for ease of administration, swelling at the IV site, or patient complaint of discomfort at the site.
■ Again scrub the port.
■ Use a slow, steady injection technique to administer the medication.
■ Be Safe! If you feel resistance when flushing the line, look for a closed clamp on the catheter or tubing or clogged inline filter. Do not proceed until you are sure the catheter is correctly positioned and unobstructed.
■ Remove the medication syringe.
■ Vigorously scrub all surfaces of the injection connector for at least 15 seconds; then attach the flush syringe.
■ Use a slow, steady injection technique when flushing the line.

Documentation
■ Document related patient assessment findings, such as the appearance of the IV site and patient complaints of pain or discomfort during IV administration.
■ You will usually document on an IV flow record and/or MAR rather than in the nursing notes.
■ Chart a nursing note only if there is a problem (e.g., if the patient experiences pain when you administer the medication).

Using slow, steady injection technique through an extension set
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Adding IV Push Medications Through an Infusing Primary IV Line

Adding IV Push Medications Through an Infusing Primary IV Line

Equipment
■ Syringe appropriate for medication volume and the type of line (e.g., peripheral IV, PICC, etc.)
■ Alcohol prep pad, or CHG-alcohol combination product and gauze pad.
■ Procedure gloves.
■ If you are administering through an intermittent device:
■ Two 5- to 10-mL syringes, or one 10-mL syringe with 2 to 10 mL of normal saline for flushing the line, depending on site and facility policy.
■ One 5- to 10-mL syringe containing 2 to 5 mL of heparin flush (or saline) solution.

Assessment
■ Be Safe! Assess the patency of the IV line before infusing. Post-Procedure Reassessment
■ Assess for complaints of pain or discomfort at the site.
■ Check the site for redness, swelling, tenderness, and other signs of infiltration or phlebitis.

Key Points
■ Be Smart! Determine the type and amount of dilution needed for the medication.
■ Determine the amount of time needed to administer medication.
■ Be Safe! Check the compatibility of the medication with the existing IV solution, if it is infusing.
■ Ensure the patency of the line before administration.
■ Prepare the medication from a vial or ampule or obtain the prescribed unit dose and verify medication with the order. Dilute as needed. Temporarily pause the infusion pump to administer the medication.
■ Thoroughly scrub all surfaces of the injection port closest to the patient with the alcohol prep pad or CHG-alcohol combination product. Use povidone-iodine solution (Betadine) only if the patient is sensitive to the other products.
■ Gently aspirate by slowly pulling back on the plunger to check for a blood return.
■ Flush the line before and after administering the medication.
■ If blood is returned (line is patent), pinch or clamp the IV tubing between the IV bag and the port, and slowly administer the rest of the medication.
■ If the IV is patent (e.g., positive blood return), administer a small increment of the medication while observing for reactions to the medication.
■ Be Safe! Maintain sterility.

Documentation
■ Document related patient assessment findings, such as the appearance of the IV site and patient complaints of pain or discomfort during IV administration.
■ You will usually document on an IV flow record and/or MAR rather than in the nursing notes.
■ Chart a nursing note only if there is a problem (e.g., if the patient experiences pain when you administer the medication).

Giving IV push medication through a primary line
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Adding Medication to an IV Infusion

Adding Medication to an IV Infusion

Equipment
■ Prescribed IV solution.
■ Syringe for medication.
■ Needleless access device or safety needle (if a VAD is not available).
■ Alcohol or CHG-alcohol prep pad.
■ Label with medication, dose, date, time, and your initials.

Assessment
■ Assess the patency and appearance of the IV site.
■ Be Safe! Check the medication insert or drug formulary for appropriate time or rate for infusion and for preparation. Post-Procedure Reassessment
■ Check the IV line at least once every hour to ensure that the ordered or calculated rate is maintained.
■ Assess the patient for complaints of pain at the infusion site.

Key Points
■ Check the compatibility of the IV solution and medication.
■ Refer to agency policy regarding maximum number of medications that can be added to one IV solution.
■ Remove any protective covers, and inspect the bag or bottle for leaks, tears, or cracks. Inspect the fluid for clarity, color, and presence of particulate matter.
■ Scrub all surfaces of the IV additive port with an alcohol or CHG-alcohol combination product.
■ Check the expiration date.
■ Assess the patency of the IV site.
■ Maintain the sterility of IV fluids and medication admixture.
■ Mix the IV solution and medication by gently turning the bag from end to end.
■ Be Smart! Affix the medication label to the bag; include the medication name, dose, route, and your name. Be sure the label does not cover the solution label or volume marks.

Documentation
■ If you added medication to an existing IV setup, document related patient assessment findings, such as appearance of IV site and complaints of pain or discomfort during administration.
■ Findings are usually documented on an IV flow record rather than in the nursing notes.
■ Added medications are sometimes charted on the MAR.
■ Chart a nursing note only if there is something outside of the expected findings (e.g., if the IV has infiltrated).

Inserting the needleless access device into the injection port
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Using a Prefilled Cartridge and Single-Dose Vial for IV Administration

Using a Prefilled Cartridge and Single-Dose Vial for IV Administration

Equipment
■ Medication-prefilled cartridge.
■ Alcohol prep pad or CHG-alcohol product.
■ Syringe of the appropriate size for medication volume and viscosity.
■ Filter needle.
■ Safety needle.

Assessment
■ Check that prefilled syringe is intact, and that the medication is clear, with no discoloration, cloudiness, or particles. Post-Procedure Reassessment
■ Assess for a change in color, cloudiness, particles in the medication mixed.

Key Points
■ Be Smart! Before beginning, determine whether that volume is appropriate for the administration site.
■ Maintain the sterility of the needle and medication.
■ Assemble the prefilled cartridge and holder according to manufacturer’s directions.
■ Remove the needle cap from the prefilled cartridge, and set it on a sterile alcohol pad.
■ Hold the cartridge vertically to expel the air and measure the correct dose of medication. Withdraw an amount of air equal to the volume of medication you need from the vial.
■ Hold the cartridge with needle straight and insert the needle into the inverted vial, tip of the needle in the air above the medication (not in the fluid); inject the air into the vial. Be careful not to eject any medication from the cartridge into the vial.
■ While maintaining pressure on the plunger, withdraw the ordered amount of vial medication, being careful not to withdraw any excess.
■ Withdraw the needle or vial access device from the vial at a 90° angle and recap the needle.
■ Be Safe! Always recap a sterile needle using a safety capping device or the one-handed scoop method.

Documentation
■ Document per MAR, according to agency policy.

Injecting air into the vial makes the medication easier to withdraw
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Intramuscular Injection Z-Track Method

Intramuscular Injection Z-Track Method

Equipment
■ Syringe and needle appropriate for volume and site.
■ Alcohol prep pad or CHG-alcohol product.
■ Gauze pad or adhesive bandage.
■ Medication.
■ Procedure gloves.
■ Biohazard (sharps) container.
■ Small piece of gauze or cotton ball.
■ Small adhesive bandage.

Assessment
■ Identify the site of the previous injection.
■ Assess the site for adequate muscle mass, bruises, edema, tenderness, redness, or other abnormalities.
■ Assess for factors that affect absorption of the medication (e.g., decreased IM blood flow, as found in shock).

Post-Procedure Reassessment
■ Observe for bruising or oozing at the site of injection.
■ Observe for local reactions at site (e.g., pain, swelling, redness).

Key Points
■ Maintain sterile technique and standard precautions.
■ Use a 1- to 5-mL syringe and a 21- to 25-gauge, 1- to 3-in. needle (longer needle if the patient is obese).
■ The usual volume per injection is no more than 3 mL.
■ Select an appropriate injection site; identify the site using anatomical landmarks.
■ Be Smart! The ventrogluteal site is preferred. The deltoid site is acceptable for smaller doses and adult vaccines.
■ Be Smart! When giving more than one injection, rotate sites.
■ Position the patient so that the injection site is well exposed and the patient is able to relax the appropriate muscles. Ensure good lighting.
■ Cleanse the site with an antiseptic swab; allow the site to dry.
■ With the side of your nondominant hand, displace the skin away from the injection site, about 2.5 to 3.5 cm (1 to 1.5 in.).
■ Hold the syringe like a dart and briskly insert the needle at a 90° angle to the skin surface. Insert fully.
■ Stabilize the syringe with the thumb and forefinger of your nondominant hand. Keep displacing the skin with your other three fingers.
■ Be Safe! Aspirate before injecting.
■ Press the plunger at a 90° angle and slowly to inject the medication.
■ Wait for 10 seconds; then remove the needle smoothly along the line of insertion. Release the skin.
■ Engage the safety needle device, and dispose of supplies in a biohazard container.
■ Gently blot the site with a gauze pad, and apply an adhesive bandage as needed.

Documentation
■ Record scheduled medications on the MAR.
■ Record PRN medications, including the reason given and response.
■ Record medication, time, dose, and route given.
■ Document therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Document assessment data before, during, and after injection (e.g., pain, bruising, or bleeding at the site).

Displacing the skin and subcutaneous tissue over the muscle
Giving an IM injection while stabilizing the syringe
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Locating Intramuscular Injection Sites

Locating Intramuscular Injection Sites

Assessment
■ Be Safe! Always palpate the landmarks and the muscle mass to ensure correct placement of the needle.

Key Points
Ventrogluteal Site
■ Ask the patient to assume a side-lying position with the legs straight, if possible. Alternatively, use a supine position.
■ On adults, the site is a triangle formed between your fingers when you place your palm on the head of the trochanter, index finger on the anterior superior iliac spine, and middle finger pointing toward the iliac crest.

Deltoid Site
■ Be Safe! Completely expose the patient’s upper arm.
■ Remove the garment; do not roll up the sleeve. Incomplete exposure of site and landmarks creates a risk of injecting into other than muscle tissue.
■ Locate the lower edge of the acromion process (knobby part of shoulder), and go two to three fingerbreadths down (3 to 5 cm).
■ Draw an imaginary line from the anterior axillary crease to the posterior axillary cease. The deltoid site is the resulting inverted triangle.
■ An alternative approach is to place four fingerbreadths across the deltoid muscle, with your top finger on the acromion process. The injection goes three fingerbreadths below the process in the midline of the upper arm.

Vastus Lateralis Site
■ Be Smart! Position the patient lying supine or sitting. The patient may perceive the injection as less painful if supine because he cannot see the needle enter his leg. For some people this provokes anxiety and intensifies pain.
■ Locate the greater trochanter and the lateral femoral condyle.
■ Midlateral thigh: On adults, one handbreadth below the head of the trochanter and one handbreadth above the knee. The site is the middle third of this area, slightly lateral to the midline of the anterior thigh.
■ Be Safe! The vastus lateralis site is safe for patients of all ages and is the recommended site for children younger than 7 months.

Locating the ventrogluteal site
Locating the deltoid site
Locating the vastus lateralis site
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