-IV Review orders for completeness, amount and type of fluid, infusion rate, and length of therapy.

therapy. Follow 6 rights Check for consent, history of allergies: iodine, adhesive, latex Hand hygiene; organize materials Aseptic technique for sterile packages Check IV solution- 6 rights; check for additives, check color, clarity, expiration date, leaks Wear gloves Open tubing, close clamp ASAP Spike saline bag- ASEPTIC Prime tubing- compress and release drip filter to fill about way. Remove cap at end of tubing and open roller to prime. Remove air bubbles by tapping firmly. Replace cap at end of tubing Apply gloves? Change gloves? Apply tourniquet high to make veins more prominent Apply tourniquet 4-6in. from proposed site check for presence of radial pulse Select vein- clip arm hair if needed Use aseptic swab to clean site: 1.) horizontal 2.) vertical 3.) circular motion- in moving out Allow to dry and dont touch Anchor vein about 1 -2in. distal to site and perform venous puncture with bevel up 1030 Watch for blood return flash to indicate good stick Keep skin taut and advance catheter while retracting needle until locked Place needle in sharps container Release tourniquet Keep catheter stable with non-dominant hand Quickly connect end of saline lock or IV tubing- dont touch point of entry. Secure connection If saline lock, flush. Begin infusion by slowly opening clamp on IV tubing Secure catheter with non-dominant hand to prepare dressing Observe sight for swelling Dressing: carefully remove backing and apply one edge of dressing. Gently smooth remaining dressing over IV site. Leave connection between tubing and catheter hub uncovered Remove outer covering and smooth dressing over site Curl a loop of tubing along the arm and secure with tape

Label dressing- include date and time of IV insertion, gauge and length, initials Chart

-Blood Infusion Assessment Verify Dr.s order- 6 rights Check pt. history: Any allergies? Previous reaction? Type and cross-match within 72 hours? S/S of reaction: chills, fever, hypotension, chest pain Verify IV is patent, non-infiltrated, or swollen Check consent Know indications for blood product (i.e. PRBCs for Hct) Obtain record pre-transfusion vital signs immediately before Diagnosis Decreased cardiac output; Deficient fluid volume Planning Expected outcome: pt. has improved activity tolerance, cardiac output at baseline, labs reflect improvement Implementation Retrieve blood from blood bank. Start infusion within 30 min Check blood for leaks, bubbles, clots, purple color Double check blood with another RN Verify: transfusion # and pt. ID match. Pt. name correct on all documents? Check ID # and DOB. Check unit # on blood bag with form. Verify blood types and Rh type match. Check expiration date on blood. Double check everything! If any discrepancy, return blood to bank until resolved. Review purpose of administration and tell pt. to report any change of feelings Empty catheter or have pt. void Perform hand hygiene and put on gloves Open Y-tube set, clamps closed. Spike saline and prime tubing Gently agitate blood unit bag and spike Close saline clamp above filter and open clamp to blood to prime Tap filter chamber to ensure residual air is removed Attach primed tubing to IV and open to run at 2mL/min (20gtts/min) Monitor vital signs Q5, 15, 30 min x 1 hour after transfusion After blood is infused, clear line with saline, discard blood bag per policy. Dispose of supplies Evaluation Monitor IV site with every vital signs check Observe for S/S of reaction: fever, chills, flushing, itching, dyspnea, rash Observe pt. and lab values for response to treatment

-Dressing Care for a Central Venous Access Device (CVAD) Before performing dressing care, confirm the type of central venous access device that is in place. Also determine whether the dressing needs to be changed. Generally, a gauze dressing needs changing and insertion site care every 48 hours or as needed. A transparent dressing needs changing and care every 7 days or as needed. Position the patient comfortably with his or her head slightly elevated, and explain the procedure, instructing the patient not to move during your care. Don clean gloves and a mask. (If needed, put a mask on the patient too.) Then remove the old dressing. To do this, lift and remove the dressing in the direction the catheter was inserted. Discard the soiled dressing in a biohazard plastic bag. If a catheter stabilization device was used, remove it with alcohol. Observe the insertion site and surrounding area for signs of skin breakdown and infection: such as redness, swelling, tenderness, exudate, and bleeding. Check the catheter and hub for intactness, and note the catheters centimeter mark to detect migration. After removing and discarding your disposable gloves, open the CVAD dressing kit using sterile technique. Then don a pair of sterile gloves. With alcohol or antiseptic swabs, clean the catheter and insertion site in the following patterns: o Horizontal o Vertical o Circular, from the insertion site out Let the antiseptic dry completely. Apply skin protectant to the entire area, and let it dry. When the skin is no longer tacky, apply a new catheter stabilization device following the manufacturers instructions. Apply a sterile transparent dressing or gauze dressing. For a transparent dressing, remove the adhesive backing. Apply one side of the dressing over the skin, and then gently smooth the rest of it over the insertion site, leaving the end of the catheter hub uncovered for access. Label the dressing as required. Labeling typically includes the date and time of the dressing change and your initials. Discard the used supplies, and perform hand hygiene. As part of your follow-up care, routinely monitor the patients vital signs, staying alert for signs of infection. Chart date and time changed, any abnormalities

-Blood Draw Assess pt.s diagnosis, state of disease, and therapy. Plan treatment schedule, type of VAD used, need for blood sample, site for skin integrity and infection, that it is functioning properly before therapy, need for irrigation in dressing change, and MD order for meds, fluids, blood products, or blood sampling Assess hydration status, skin turgor, texture, and I&O. Ask if allergies: iodine, latex, meds? Know manufacturers directions concerning the particular VAD being used. Explain procedure to pt. and family. Tell them of need to stay still Ask pt. name, DOB and compare to MAR Position pt. in a comfortable position with head slightly elevated Arrange supplies: (3) 12mL syringes, NS vial, Iodine and alcohol swab Wipe vial with alcohol then draw up 10mL NS with blunt syringe from vial for flush Remove air bubbles from syringe Remove blunt needle- put in sharps if needless access device used Pick up port (proximal) with non-dominant hand and swab with Betadine. Allow time to dry completely Attach empty syringe to port- UNCLAMP1st draw- 7cc- (waste)- sharps- re-clamp 2nd draw- (for lab)- UNCLAMP- ask lab how much they need drawn- re-clamp 3rd draw- attach saline lock- check for bubbles. -UNCLAMP- flush 8mL in a pulsating action to create turbulence When you get down to 1-2mL, CLAMP while pushing to have NS left in the tubing Dispose of supplies, remove gloves, wash hands Chart- lab was here; draw from port, flushed well without incident? Amount of flush

-Trach Assess s/s of upper/lower airway obstruction: wheezes, crackles, gurgling on inspiration or expiration, restlessness, ineffective coughing, diminished breath sounds Contraindications: neck trauma/surgery, bleeding disorders, laryngospasm, gastric surgery with high anastomosis Explain procedure: will help clear airway and relieve breathing problems; temporary coughing, sneezing, gagging, or SOB; encourage coughing out secretions, position in semi-fowlers or sitting upright w/head hyperextended; place pulse-ox on pt.s finger and leave in place. Lay towel across chest Wash hands- apply mask and goggles or face shield Connect tubing to suction machine, turn it on, and set vacuum regulator to 90-100 Have pt. deep breathe or increase 02 to 100% (to decr. suction-induced decline in 02) Prepare suction catheter using sterile technique Open sterile basin w/out touching inside- fill w/100mL NS Apply sterile glove on both hands and drape pt. w/white drape Pick up catheter w/dominant hand and connect to tubing w/non-dominant handDominant hand must remain sterile! Check that tubing is working by suctioning NS in basin- lubricates catheter Quickly insert catheter using dominant thumb and forefinger into inner cannula while pt. is inhaling and until you either meet resistance or pt. coughs. Pull back 1cm. Apply intermittent suction by venting catheter w/non-dominant hand; slowly withdraw catheter while rotating back and forth between thumb and forefinger Encourage coughing and monitor for resp. distress. If resp. distress, w/draw cath and supply 02 as needed Reconnect mechanical ventilation and replace 02 delivery device Encourage deep breaths or bag-valve to reoxygenate Rinse cath and connecting tubing with NS until clear Assess resp. status and repeat 1-2 times as needed. Allow 1 min between passes Verbalize: after trachea is clear perform oral suctioning Disconnect cath from tubing; roll cath around finger and pull glove off inside out w/cath in glove and discard. Turn off suction device Remove towel and reposition pt. Return O2 to original level; discard saline, remove face shield, and wash hands Assist pt. to comfortable position and provide oral hygiene Evaluation: Compare pt.s resp. assessment and pulse-ox values before and after suctioning. Ask pt. is breathing is easier, if congestion is decreased. Observe character of airway secretions

Record: amt., color, consistency, & odor of secrections; route of suctioning and pt. response -Dressing changeWhile replenishing O2 store, prepare equipment on bedside- open lids to NS and peroxide. Put on sterile gloves. Open trach pkg. Fill large and 1 small trough w/NS. Fill smaller trough w/peroxide. Dominant hand will remain STERILE. Place plastic drape on pt. Hyperoxygenate pt. if <92% While touching outer aspect only, unlock and remove inner cannula w/non-dominant hand. Drop into peroxide. Use small brush to remove secretions inside and outside inner cannula. Hold inner cannula over basin & rinse w/NS Replace inner cannula and secure lock by connecting 2 dots W/saline-saturated q-tips and 4x4, clean exposed outer cannula and ostomy from the inside out (top) and inside out (bottom). Use 4x4 to dab skin/site lightly Have someone hold trach tube in place- take prepared ties and thread thru eyelet. Tie securely w/1 fingerbreadths room underneath. Apply dressing under clean ties and faceplate Position pt. in comfortable position and assess resp. status Replace any O2 source Remove gloves and face shield-discard Replace caps on NS and peroxide Wash hands Record: resp. assessments before and after procedure, type & size of trach tube, freq., extent and, pt.s tolerance to procedure

-Central Line Assess: pt.s diagnosis, state of disease, skin integrity Before performing dressing care, confirm the type of central venous access device that is in place. Also determine whether the dressing needs to be changed. Assess hydration status. Check for allergies. Verify name and DOB Explain procedure to pt. and need to remain still Position pt. in comfortable position w/head slightly elevated Wash hands and apply gloves Clean proximal port w/iodine and allow to dry completely 1st draw- w/10cc syringe and blunt needle into port. Unclamp port and w/draw 7mL blood. Close clamp, remove syringe 2nd draw- for lab- 10cc syringe and blunt needle, w/draw as ordered by lab. Close clamp, remove syringe Using a 3rd 10cc syringe & blunt needle w/NS (no air bubbles!), unclamp port, flush line. Push 2mL at a time to create turbulence. Clamp and push at same time for positive pressure. Close clamp, remove syringe Dispose of soiled supplies, remove gloves, wash hands -Dressing change Wash hands- apply mask and gloves remove old dressing. Assess site Open sterile dressings, swabs, and tape. Apply sterile gloves. Prepare tape strips Using iodine swabs, cleanse site in circular motion, starting at site and moving outward. Let solution dry completely and secure tubing Apply sterile 4x4 over site. Tape edges to pt.s skin. Label w/date, time, initials Dispose of soiled supplies and used equipment. Remove gloves, wash hands Restart continuous infusions Record: meds, blood products, and parental nutrition given or samples obtained o Condition of site (redness, swelling, drainage) o Patency of line, ability to draw blood, difficulties w/line o Pt. education o Dressing change and any complications