Republic Act No.

9173 October 21, 2002 AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION, REPEALING FOR THE PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN AS "THE PHILIPPINE NURSING ACT OF 1991" AND FOR OTHER PURPOSES. ARTICLE VI Nursing Practice Section 28. Scope of Nursing. - A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. A members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to: (a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established; (b) establish linkages with community resources and coordination with the health team; (c) Provide health education to individuals, families and communities; (d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the utilization of knowledge and decision-making skills of a registered nurse; and (e) Undertake nursing and health human resource development training and research, which shall include, but not limited to, the development of advance nursing practice; Provided, That this section shall not apply to nursing students who perform nursing functions under the direct supervision of a qualified faculty: Provided, further, That in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence by continual learning through continuing professional education to be provided by the accredited professional organization or any recognized professional nursing organization: Provided, finally, That the program and activity for the continuing professional education shall be submitted to and approved by the Board.

Veins of the Hand1. Digital Dorsal veins2. Dorsal Metacarpal veins3. Dorsal venous network4. Cephalic vein5. Basilic veinVeins of the Forearm1. Cephalic vein2. Median Cubital vein3. Accessory Cephalicvein4. Basilic vein5. Cephalic vein6. Median antebrachialvein

INTRAVENOUS THERAPY IV Statistics 85% of all hospitalized patients have some type of IV therapy 118 million IV catheters inserted yearly COMPLICATIONS PHLEBITIS Inflammation of the vein wallprecursor to sepsis What causes phlebitis? IV left in too long Cannula too large Vein in poor condition Acidic solution or high osmolality Infusion rate too fast Preventions Choose vein appropriately Location Size Soft, spongy, resilient No pain or tenderness or redness with injection INFILTRATION Leaking of nonvesicant fluid into tissues surrounding the vein Check IV site every two hours Complications Nerve compression requiring fasciotomy EXTRAVASATION

Inadvertent administration of vesicant drug into surrounding tissues Calcium Magnesium Phenergan Potassium chloride Antibiotics Chemotherapy drugs Vasopressors (Dopamine, epinephrine) Dextrose > 10% Lorazepam Dilantin

INFECTION Cellulitis: An acute, spreading, bacterial infection below the surface of the skin characterized by redness (erythema), warmth, swelling, and pain. Usually localized. Sepsis: clinical symptoms of systemic illness, such as fever, chills, malaise, hypotension, and mental status changes. Sepsis can be life threatening. INFECTION > 200,000 infections per year More than 60,000 patients die annually from bloodstream infections caused by intravenous therapy Cost for one patient is $56,000 Annual US total = $2.3 billion Causes Poor insertion site Squad starts Unsterile start IV left in too longchange q 96 hours! Hub contamination Cellulitis

Prevention Hand washing Sterile technique Catheter size Insertion site Site inspection every two hours Encourage patient to report any discomfort Patients Worst Nightmare!!!! Muscle Man IV! STARTING AN IV 1. Talk with patient 2. Gather equipment 3. Set up fluid and tubing on pump 4. Check patient order and ID band & allergies 5. Wash your hands!! 6. Select a vein 7. Select a catheter size 8. Apply tourniquet 5-6 inches above insertion site 9. Never leave tourniquet on longer than one minute 10. Then Remove tourniquet and prepare equipment STARTING AN IV (CONT.) 11. Open equipment and connect flush to J-loop 12. Loosen caps of IV and J-loop but leave in place for sterility. (They should just slide off when you pick up the device). 13. Cleanse skin with chlorhexidine gluconate solution in back & forth motion X 30 seconds 14. Allow to dry for 30 seconds Put on Gloves!!! 16. Immobilize vein

17. Position needle 10-15 degree angle over site 18. Insert cannula bevel up 19. Watch for blood backflow 20. Advance cannula 21. Only try twice before calling another RN to help STARTING AN IV (CONT.) 28. Document!

Other sites to avoid include: veins below a previous I.V. infiltration veins below a phlebitic area sclerosed or thrombosed veins areas of skin inflammation, disease, bruising, or breakdown an arm affected by a radical mastectomy, edema, blood clot, or infection an arm with an arteriovenous shunt or fistula.

COMPLICATIONS Infiltration occurs when IV fluids enters the subcutaneous space & around the venipuncture site

Cause: Dislodgement of the IV cannula from the vein results in infusion of fluid into the surrounding tissues

Preventions: Ensure that IV and distal tubing are secured sufficiently with tape to prevent movement Splint arm or hand as necessary Check IV site frequently for complications Proper venipuncture technique

Interventions: Stop infusion immediately and remove IV needle or catheter Restart IV in the other arm If infiltration is moderate to severe, apply warm, moist compresses and elevate limb Document interventions and assessment Thrombophlebitis/Phlebitis inflammation of vein often accompanied by clot formation

Causes: Injury to vein during venipuncture, large-bore needle/catheter use Irritation to vein due to rapid infusions or irritating solutions Slow infusion rate due to clot formation at the end of the needle/ catheter

Preventions: Anchor needle or catheter securely at insertion site Change insertion site at least every 72 hours or according to hospital policy Use large vein for irritating fluid because of higher blood flow, which rapidly dilutes irritant Sufficient dilute irritating agents before infusion

Interventions: Apply cold compress immediately to relieve pain and inflammation Discontinue IVF and remove catheter/needle immediately Follow the moist, warm compresses to stimulate circulation and promote absorption.

Document interventions and assessment Bacteremia/Septicemia contamination of IV site and solution which results to fever, chills and general malaise.

Causes: Incorrect insertion of catheter Contaminated equipment or infused solution The critically ill or immunosupressed patient is at greatest risk of bacteremia

Prevention: Practice good handwashing Use strict asepsis when inserting IV or changing IV dressing Observe IV site routinely Provide routine care along with proper dressing Maintain integrity of infusion system

Intervention: Discontinue IV line and restart it in another vein as ordered Notify physician Circulatory Overload a condition which results when a client receives IV fluid faster than the body can distribute and excrete.

Causes Delivery of excessive amount of IV fluids

Preventions: Always monitor intake and output when patient has an IV line Know patient cardiovascular history Splint arm or hand if IV flow rate fluctuates too widely with movement

Interventions: Decrease IV to KVO rate- 10gtts/min Raise patients head to facilitate breathing

Keep patient warm to promote peripheral circulation Air Embolism an abnormal circulatory condition in which air gas travels through the bloodstream and becomes lodged in a blood vessel.

Causes: Air enters the catheter during tubing changes Air in tubing delivered by IV push or infused by infusion pump

Prevention: Clear all air from tubing before infusion Change solution containers before they run dry Ensure that all connections are secured

Intervention: Immediately, turn patient on his/her left side and lower head of the bed Notify the physician immediately Administer oxygen PRN Stay with the patient Document interventions and assessment Hemorrhage/Bleeding

Causes: Loose connection of tubing or connection port Inadvertent or accidental removal or peripheral or central catheter Anticoagulant therapy

Preventions: Tape all catheters securely- use transparent dressing when possible for peripheral or central catheters. Tape the remaining catheter lumens in a loop so tension is not directly on the catheter. Keep pressure on site at least 10 minutes after removal of catheter for anticoagulated patients.

Interventions: Pressure dressing may be applied over the site to control the bleeding Notify the physician.

Venous Thrombosis

Causes: Infusion of irritating solutions Infection along catheter may preclude this syndrome Fibrin sheath formation with eventual clot formation around catheter. This clot will eventually occlude vein.

Preventions: Ensure proper dilution of irritating substances Ensure superior vena cava catheter tip placement for irritating solutions

Interventions: Stop fluid immediately and notify health care provider Reassure patient and institute appropriate therapy: Anticoagulants Heat Elevation of affected extremity Antibiotics