Policy Manual sample

MDT Home Health Care Agency, Inc. ** (To maintain a closed system and reduce risk of infection.) 5. Observe for warning signs of infiltration at venipuncture site. ** (Swelling and/or pain indicate that catheter is not in vein and needs to be changed.) If IV is to be used for intermittent therapy, flush device with 2cc of normal saline, then with 1 cc of 100u/cc heparin solution, if ordered by physician. Always use positive pressure when flushing an IV. 6. Cover insertion site with transparent dressing, leaving extension tube connection exposed. 7. Anchor extension tube in a “U'' shape with tape. 8. Stabilize extremity on padded arm board, if necessary. 9. Check and regulate flow rate according to physician's order. 10. Label IV dressing with the following: a. Date and time b. Type, length and gauge of needle c. Initials of IV nurse 11. Discard used equipment using Universal Precautions. Documentation Record the procedure in the resident's/patient’s medical record. Include the following, 1. Date and time of insertion 2. Type, length and gauge of catheter 3. Location of insertion site 4. Number of IV attempts 5. Type of dressing applied 6. Residents/Patients response 7. Nurse's signature Peripheral IV: Site Monitoring 1. Purpose: to assure proper infusion of IV solutions, reduce risk Of complications, and allow for early detection of IV related complications. 2. Guidelines a. IV sites will be monitored at least once every 8 hours by an IV qualified nurse. b. Peripheral IV devices will be removed and restarted in another site routinely ever 72 hours. (A physician's order is required to leave an IV in longer than 72 hours.) c. Peripheral IV devices will be removed and restarted in another site at the first sign of complications. d. Occluded IVs should be removed: NOT IRRIGATED. 3. Procedure/Key Points a. Observe IV site for: i. EDEMA (Swelling is an early sign of Infiltration.) ii. Redness (Redness noted in the area of the tip of the catheter and along the vessel is an indicator of phlebitis.) iii. Moisture or exudates at the insertion site. (Check for loose connections. If purulent drainage is present, notify physician immediately. Obtain cultures of catheter and exit site. b. Palpate the IV site for the following: i. Tenderness (Pain indicates early signs of phlebitis.) ii. Temperature change (Coolness can indicate infiltration; heat can indicate infection, inflammation of phlebitis.) iii. Palpable vein cord (Hard vein cord indicates phlebitis.) c. Observe IV tubing for following: Home Health Agency Nursing Manual J-32