1/10/14

Pregnancy Risk Categories (FDA Definitions)

Pregnancy Risk Categories (FDA Definitions)

 Category A: Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities.

Category B: (1) Animal studies show no adverse fetal effects, but there are no controlled human studies, or (2) animal studies show adverse fetal effects, but well-controlled human studies do not.

Category C: (1) Animal studies show adverse fetal effects, but there are no controlled human studies, or (2) no animal or wellcontrolled human studies have been conducted.

Category D:Well-controlled or observational human studies show positive evidence of human fetal risk. Maternal benefit may outweigh fetal risk in serious or life-threatening situations.

 Category X: ContraindicatedWell-controlled or observational human and/or animal studies show positive evidence of serious fetal abnormalities. Fetal risks far outweigh maternal benefit.
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Flushing Peripheral and Central Lines

Catheter Type
Solution
Strength
Frequency
Peripheral Vascular Access Devices (VAD)
■ Peripheral IV line
NS
N/A
3 mL daily and
PRN
■ Midline catheter
Heparin
10 units/mL
5 mL daily and
PRN
Peripherally Inserted Central Catheters (PICC)
■ Groshong PICC
NS
N/A
5 mL per lumen
every 7 days and
after each use
■ Per-Q-Cath
(Pediatric VAD)
Heparin
10 units/
mL
2.5 mL (child) or
0.5 mL (infant) q
8h and after
each use
Central Venous Catheters (CVC)
■ Valved-tip (no
clamps)
NS
N/A
5 mL per lumen
weekly and PRN
■ Open-ended
(clamps)
Heparin
10 units/mL
5 mL daily and
PRN
Implanted Port Catheters
■ Groshong
Port-A-Cath
Heparin
100 u/mL
5 mL daily and
PRN



Routine Care of Peripheral and Central Lines

■ Clamps: Open-ended catheters will always have clamps to prevent the backflow of blood and air embolisms. All openended catheters must be flushed with heparin to minimize fibrin collection and clot formation.
■ No Clamps: Valved-tip catheters do not have any clamps and require saline flushes—use positive-pressure flush technique.
■ End-Caps: Change the end cap(s) every 7 days or sooner if any blood, cracks, or leaks are seen.
■ Syringe Size: The smaller the syringe size, the greater the pressure in pounds per square inch (PSI); greater PSI increases the potential for catheter damage. Therefore, a syringe size of 10 mL or greater is recommended for all central-line flushes.
■ Positive Pressure Flush:To reduce the potential for blood backflow into the catheter tip, which promotes clot formation and catheter occlusion, always remove needles or needleless caps slowly while injecting the last 0.5 mL of NS.
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Troubleshooting IV Complications

Decreased or No Infusion Rate
■ Assess IV site for infiltration.
■ If IV insertion site is close to a joint, straighten extremity.
■ Use a padded arm board to help maintain alignment.
■ Inspect entire length of tubing for kinks or holes.
■ Inspect stopcocks and other flow-control devices.
■ Ensure that burette (pediatrics) contains correct amount of fluid.
■ If not using an infusion pump, raise the height of the IV bag.
■ Attempt to flush with 3 mL of NS, but if a significant amount of resistance is encountered, notify the IV therapy team or RN. If IV therapy is unavailable, discontinue IV and restart a new one, preferably on the opposite arm.

Pain at the IV Site
■ Assess IV site for infiltration, phlebitis, and irritation from tape.
■ Ensure adequate stabilization of IV catheter.
■ If IV insertion site is close to a joint, straighten extremity.
■ Use a padded arm board to help maintain alignment.
■ Consult the pharmacy or Davis’s Drug Guide to ascertain if a medication being infused can cause pain or irritation.
■ Notify the IV therapy team or RN if unsuccessful at relieving pain or discomfort.

Blood Backing Up into the IV Tubing
■ Two common causes are allowing the IV bag to run dry (corrected by changing to a new bag) or hanging the IV bag at a level that is lower than either the IV insertion site or the Pt’s heart (corrected by increasing the level of the bag).
■ Note: If bag is allowed to run dry, the tubing may fill with air. After changing to a new bag, the air in the tubing can be removed by inserting a large syringe into the port distal to the air and aspirating, as the tubing is re-primed.
■ Occasionally, an artery is cannulated. If this is suspected, palpate for a pulse under the insertion site and inspect for pulsation of blood in the tubing (D/C IV and hold direct pressure for at least 5 minutes).

Leaking Fluid at the IV Site
■ Assess IV site for infiltration.
■ Inspect the connection between the tubing and IV catheter.
■ If all connections are patent, err on the side of safety and assume that the site is infiltrating, even if the IV is infusing freely. Call for an IV therapy consult.
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Complications of Starting/Maintaining IVs

Infiltration
Phlebitis
Assessment:
Swelling, tenderness, decreased or no infusion rate, blanching of skin, and site is
cool to touch.

Intervention:
D/C IV and restart in a new site. Apply warm
compress to the affected area.
Assessment:
Classic sign is red line along course of vein. Other signs include redness, heat, swelling, and tenderness.

Intervention: D/C IV and restart in a new
site. Apply warm compress to the affected area.


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IV Piggyback (IVPB) Setup

IV Piggyback (IVPB) Setup
■ Confirm order and ensure bag is clearly labeled.
■ The piggyback bag must be higher than the IV bag. To do this, hang the primary bag from an extension hook (see right).
■ Use most proximal access port on primary line.
■ Adjust piggyback stopcock to desired rate.
■ After infusion is complete, the primary IV bag will begin to drip again. Discard IVPB bag.
■ Reconfirm that primary drip rate is correct.
■ Document: medication, infusion rate, date, and time.

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IV Insertion Guide

IV Insertion Guide
Notice how the catheter is slightly shorter than the needle. This is why the needle needs to be advanced 1-2 mm farther after the initial flash back and before advancing the catheter and removing the neddle.
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Starting an IV

■ Prepare the Pt: Explain procedure, answer any questions, and give reassurance.
■ Gather equipment: IV bag with primed tubing, sharps container, catheter, tape, dressing, tourniquet, antiseptic swabs, gloves, IV catheter of appropriate size.
■ Organize supplies:Tear tape, hang IV solution with primed tubing close by, sharps container within easy reach, 2x2 or other dressing.
■ Apply tourniquet: Proximal to intended insertion site, either mid-forearm or above the elbow; don gloves.
■ Locate vein: Palpate with fingertips. To further enhance dilation, gently tap, apply heat/warm soak, have patient make a fist, or dangle arm below heart.
■ Cleanse site: Using moderate friction, cleanse in a circular motion, moving outward from intended site.
■ Put on gloves: While waiting for cleansed area to dry, avoid touching site once it has been prepared.
■ Apply traction: Opposite the direction of the catheter.
■ Position needle: Bevel side up, 15 –30 . Note: Hold the needle with the thumb and pointer finger in a way that allows for visualization of the flash chamber.
■ Insert needle: Perform venipuncture and observe for “flash back” in flash chamber. Lower catheter almost parallel to the skin, and insert the needle 1–2 additional mm. This is done to ensure that the catheter has also entered the vein.
■ Advance the catheter: Thread catheter into vein while maintaining skin traction and pulling back on needle.
■ Release the tourniquet: After releasing tourniquet, apply digital pressure just above the end of the catheter tip while gently stabilizing the hub of the catheter.
■ Remove needle: Remove and discard into approved sharps container.
■ Connect IV tubing: Open clamp, and observe for free flow of IV fluid.
■ Secure catheter: Apply tape and sterile dressing per policy.
■ Clean up: Discard soiled equipment per hospital policy.
■ Document: Per hospital policy and guidelines.
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Mixing Insulin

Mixing Insulin
A. Use only an insulin syringe. Start by withdrawing enough air into an insulin syringe that is equal to the combined amount of the total dose of insulin to be given. Without actually fripping the needle into the NPH solution itself, pressurize the NPH vial with the amount of the air equal to the amount of NPH to me mixed with the regular insulin and then remove the syringe.

B. Inject the remaining air into the regular vial, and then withdraw the ordered amount of regular insulin into the syringe.

C. After withdrawing the ordered amount of regular insulin, remove the syringe, and expel any air bubbles

D. Reinsert the syringe into the already pressurized NPH vial and withdraw the ordered amount of NPH
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Types of Insulin

Types of Insulin

Agent
Onset
Peak
Duration
Rapid-acting
insulins
insulin lispro (Humalog)
5 min
60–90 min
4–6 hours
insulin aspart (NovoLog)
10–20 min
1–3 hours
3–5 hours
Short-acting
insulins
concentrated insulin: Iletin II regular (concentrated) Insulin U-500.
Caution: Do not administer IV because of the potential for overdosage.
30–60 min
2–3 hour
5–7 hours
regular insulin: (Humulin R, Insulin-Toronto, Novolin R, Iletin II Regular,
Velosulin BR)
Caution: Regular insulin is the only insulin that can be administered IV.
SC route:
30–60 min

IV route:
10–30 min
SC route:
2–4 hours

IV route:
15–30 min
SC route:
5–7 hours

IV route:
30–60 min
Intermediateacting
insulins
isophane (NPH): (Humulin N, NPH
Iletin II, Novolin Ge NPH, Novolin N)
1–2 hours
8–12 hours
18–24 hours
lente: (Humulin L, Novolin Ge Lente, Novolin L)

No longer manufactured as of July, 2005
1–2 hours
8–12 hours
18–24 hours
Long-acting
insulins
insulin glargine (Lantus)
Caution: Lantus insulin cannot be mixed
with other insulins; may cause
unpredictable results.
Onset: 1 hour. Provides a constant
concentration over a 24-hour period
with no pronounced peak.
Onset: 1 hour. Provides a constant
concentration over a 24-hour period
with no pronounced peak.
Onset: 1 hour. Provides a constant
concentration over a 24-hour period
with no pronounced peak.
insulin detemir (Levemir
2–4 hours
None
24 hours
ultralente: (Humulin U, Novolin U)
No longer manufactured
4–8 hours
16–18 hours
36 hours
Pre-mixed
insulins
(Note: other
mixes are
available)
NPH/regular: (Humulin 50/50, Humulin
70/30, Novolin 70/30)
30–60 min
2–8 hours
24 hours
aspart protamine/aspart (NovoLog Mix
70/30)
10–20 mi
2 1/2 hours
24 hours
lispro protamine/lispro (Humalog Mix
75/25)
5 min
2 hours
22 hours
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SC Injection Technique

SC Injection Technique

■ Always observe Pt rights and standard precautions.
■ Select and cleanse appropriate sight with an alcohol swab.
■ Don gloves and hold syringe in dominant hand.
■ With nondominant hand, either pinch or spread skin.
■ Note: If less than 1 inch can be pinched between fingers, pinch skin and insert needle at a 45 angle. If more than 1 inch can be pinched, spread the skin and insert needle at a 90 angle.
■ Insert needle to the hub with one steady motion.
■ Do not aspirate when administering heparin or insulin. Otherwise, aspirate to ensure that needle is not in a blood vessel.
■ Inject medication and withdraw needle.
■ Massage site and cover with a Band-Aid (do not massage site when administering heparin).
■ Discard equipment per facility guidelines.
■ Document medication, dose, site of injection, and Pt’s response to the medication.
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Angle of Injection

Angle of Injection
3 types Angle of Injection
1 Intramuscular
2 Subcutaneous
3 Intradermal

  Anterior aspect of the forearm
ID Sites
SC Injection Sites
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Injections Intradermal (ID), Subcutaneous (SC), and Intramuscular (IM)




ID
SC
IM
Site
Inner
forearm,
chest,
and back
Upper posterior arm,
upper back, low
back, anterior lateral
thigh, and abdomen
Gluteus, thigh,
and deltoid
muscles
Gauge
27–30 g
25–28 g
23 g
Length
1/4–3/8”
3/8–5/8”
1–1 1/2”
Angle
10–15
90 or 45 for very thin
patients
90
Volume
0.1–0.2 mL
0.5–1 mL
Up to 3 mL; small
muscles
(deltoid) no
more than 1 mL
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Z-Track Method for Giving IM Injections


Z-Track Method for Giving IM Injections
1. Identify injection site.
2. Pull skin to one side.
3. Insert needle deep IM.
4. Inject medication.
5. Withdraw neddle.
6. Release wkin.
7. Medication is prevented from oozing back out.
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