Pediatric IV Therapy – page 5 P28.02
PROCEDURE / P28.02TITLE: Pediatric IV Therapy
Issuing Department: / General Nursing – Pediatrics
Clinical Director Signature:
Departments Involved:
Effective Date: / 09/79
Review Dates: / 01/05
Revision Dates: / 01/02, 02/08, 5/11, 08/14, 4/15
This procedure rescinds any previous publication covering the same material
I. PURPOSE
To establish a procedure for the administration of IV therapy to the pediatric patient (inpatient and outpatient).
II. OBJECTIVE
To provide a safe, adequate route for administration of IV fluids and medications.
III. PROCEDURE
A. Pediatric IV’s may be initiated and maintained by an RN with a licensed independent practitioner’s (LIP) order. IV fluids and medications are to be administered with a LIP order and given by an RN.
B. IV site, gauge of catheter, and condition of site will be documented every shift.
C. An infusing IV is to be assessed every hour. The condition of the site is also assessed every hour and documented accordingly.
D. An IV site that is used intermittently will be observed hourly and documented accordingly.
E. IV site will be assessed every hour for site appearance and signs of complications: note presence or absence of redness, swelling, drainage, tenderness, or streaking. Initiate steps to intervene if complications are present and document findings in the patient’s medical record. Remove any barriers occluding the insertion site appearance with each assessment.
F. When PRN adapter is not in use it is to be flushed with 2-3mL NS (with no benzyl alcohol), every twelve hours. The PRN adapter is to be clamped during the final flush, and remains clamped every time it is not in use. (If the LIIP wishes Heparin flush it must be so ordered).
G. For IV site selection consider veins in the hand, forearm, antecubital area, and upper arm below the axilla, as well as veins of the scalp, foot, and fingers in infants and toddlers. Avoid the ventral surface of the wrist due to pain on insertion and possible damage to the radial nerve.
H. Scalp veins may be cannulated in infants less than 9 months of age. The feet may be cannulated in an infant of non-walking age. Hands and antecubital may be used at any age. The RN may attempt 2 times to insert the IV, and then another nurse must attempt to place the IV. After 4 attempts, the physician should be notified for further instruction.
I. Common IV sites for infants and children:
J. Peripheral IV catheters in children may remain in place as long as there are no signs of complications; routine rotation is not necessary.
IV. EQUIPMENT
A. 22G – 24 G Nexiva IV catheter for infants and small children; 24G – 20G Nexiva IV catheter for older children.
B. Gather IV supplies:
1. Prevantics swab
2. 2x2 gauze pad
3. Small tourniquet
4. Tegaderm
5. Tape
6. Arm board
7. Netting or gauze
8. Physician ordered IV solution
9. B-Braun syringe pump or Baxter Colleague Pump
10. Tubing
11. Coban WILL NOT BE USED to secure an IV site
12. Extension set if not the Nexiva IV catheter, flushed with normal saline
V. PROCEDURE
A. A second person to assist with pediatric IV starts is helpful.
B. Assemble equipment preferably in area away from child’s bed or room, which is considered their “safe” area.
C. Perform hand hygiene.
D. Don gloves.
E. Prepare site and insert IV.
F. Secure site with Tegaderm and tape.
G. Start IV infusion
1. B-Braun Syringe Pump
a. Use the Infusion Pump with micro-bore tubing for infusions with volumes < 60 mL
b. Prime the tubing with normal saline
c. Program medication and/or IV solution as ordered by the LIP into the syringe pump
d. Infusion medication or IV solution as ordered by the LIP
e. Flush with normal saline when medication infusion is complete
2. Baxter Regular Infusion Pump
a. Use for volumes > 60 mL
H. Discard used supplies, placing needles in the appropriate sharps container.
I. Perform hand hygiene.
J. When administering intermittent medications through PRN adaptor, flush with 2-3mL NS without benzyl alcohol, administer med then flush again with 2-3mL NS without benzyl alcohol. May be followed with Heparinized solution as ordered by the LIP.
VI. Guidelines for IV Tubing and IV Bag Changes
A. IV Tubing Changes
Blood Products / Propofol / IV admixtures by nursing / Commercially available IV fluids
Medication drips (except if manufactures stability gives less than 24 hours use pharmacy gives expiration) / Pharmacy prepared IV fluids with or without additives (i.e. D10 NS with KCL)
VII. PRECAUTIONS
A. Volume programmed in Baxter pump should never exceed 1-2 hours, as a reminder to the RN to check site hourly.
B. There should NEVER be a bag of IV fluid hanging that is greater than the amount the child/infant has ordered for 24 hours. Remove excess fluid from the bag before hanging.
C. Since pediatric patients cannot observe and report changes in their IV site, they must be OBSERVED AT LEAST HOURLY. Parents should be instructed on reportable signs and symptoms.
D. Fluids/medications must be attached to patient within 1 hour of spiking the bag/hanging syringe.
E. Filters must be used only with specified medication.
F. All fluids must be labeled with an expiration date and time.
G. Spiked bags of clear IV fluid: label with a 48 hour expiration and time.
H. IV medication drip prepared by nursing label with a 24 hour expiration date and time.
I. IV fluids taken out of over wrap but not spiked: 50 mL bag (14 days). > 100 mL (30 days).
VIII. GROWTH AND DEVELOPMENT CONSIDERATIONS
A. Newborn: Respond to calm, soothing voices, allow to such on pacifier or other known soothing object. They are still easily startled by loud noise or sudden movement. Swaddling securely keeps infant secure and warm.
B. Infants – one month to one year: Respond best to parent or caregiver for soothing and calming. Other staff should help restrain infant leaving parent free to give emotional support. Singing, toys, music, or other favorites of infant may help distract. Swaddling or holding of infant must be done securely, but so as not to compromise cardio-pulmonary status.
C. Toddler – one to three years: Beginning independence and self-preservation, as well as stranger anxiety are characteristic of their age. Detailed explanations are not yet understood. As with infants, toddlers need to be well secured by other staff, while parents support only. Once the IV is inserted, careful securing of the site with armboards, splints, and protective cups is essential.
D. Preschool – three to five years: Perceive pain as punishment, fear loss of control and bodily injury. Are able to comprehend partially when instructions or explanations given. Care should be given to explaining IV is not a punishment, and liberal dressings help to hide and minimize the feeling of disfigurement.
E. School age – five to 12 years: Able to understand explanations and think logically. Fear separation from peers and bodily disfigurement. The sight of a needle increases anxiety, so keeping angiocath out of view may be helpful. Rarely need restraint during insertion and enjoy talking about themselves and their favorite activities.
F. Adolescents – 12 to 18 years: Moving toward adulthood, fear loss of control; prefer privacy for difficult or unpleasant procedures. Need assurance that IV will not leave any permanent or disfiguring scars.
IX. DOCUMENTATION
A. Record date, and time of insertion, number and location of attempts, identification of insertion site by anatomic descriptors or landmarks. Condition of site, dressing, dressing changes, site care, patient report of discomfort or pain and any change in site appearance.
B. Document condition of site prior to and after any infusions or medications as well as patency.
C. Upon removal of the IV, document the following: condition of the site, condition of the catheter, dressing applied, patient response, patient education, and date/time of removal.
X. REFERENCES
A. Alexander, M., Corrigan, A., Gorski, L., Hankens, J., and Penicca, R. (2010) Infusion Nurses Society Infusion Nursing: An evidence-based approach, 3rd edition, St. Lois, MD: Saunders and El Sevier.
B. Infusion Nurses Society (2011). Policies and Procedures for Infusion Nursing, 4th Edition.
C. Infusion Nurses Society (2011). Infusion Nursing Standards of Practice.
D. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011).