/ CHHS17/001

Canberra Hospital and Health Services

ClinicalProcedure

Intravenous Fluid Administration in the Rapid Assessment Unit (Adult patients only) for Advanced Practice Nurses

Contents

Contents

Purpose

Scope

Alerts

Section 1: Sodium Chloride 0.9% and Hartmann’s Solution

Maximum daily dose/Duration

Patient Criteria

Exclusions

Adverse Reactions

Monitoring/Observations

Referral Criteria

Legal Issues

Implementation

Related Policies, Procedures, Guidelines and Legislation

Definition of Terms

References

Search Terms

Attachments

Attachment 1 – APN initiating a fluid order:

Purpose

The purpose of this procedure is to enable Advanced Practice Nurses (APN) of the Rapid Assessment Unit (RAU) Canberra Region Cancer Centre (CRCC), to chart intravenous fluids for administration to adult oncology, haematology, radiation oncology and palliative care patients, with disease and/or treatment related side effects who are attending the RAU.

This procedure aligns with the relevant National Safety and Quality in Health Service Standards (NSQHSS).

Scope

This document pertains to adult oncology, haematology, radiation oncology and palliative care patients admitted and treated within the Rapid Assessment Unit, CRCC, Canberra Hospital and Health Services (CHHS).

This document applies to Advanced Practice Nurses (RN3.1) of the RAU only.

Alerts

Excessive fluid administration causes hypernatraemia, resulting in dehydration of internal organs, hypokolaemia and acidosis.

1000mL over two hour’s as a standard rate; slower or faster administration rate as per clinical presentation of patient within RAU determined by the Advanced Practice Nurse.20mL/kg as initial fluid bolus is recommended as per the Australian Resuscitation Council (ARC) Guideline 11.5 for fluid resuscitation (2015).

Monitoring and observations are mandatory and must be documented appropriately as per CHHS Policy Clinical Procedure Vital Signs and Early Warning Scores, including urine output and fluid balance.

Section 1: Sodium Chloride 0.9% and Hartmann’s Solution

Maximum daily dose/Duration

Maximum order 1 x 1000mL bag of Sodium Chloride 0.9% in the event of:

  • Fluid shift (sepsis)
  • Dehydration

Maximum order 1 x 1000mL bag of Hartmann’s Solution in the event of:

  • Volume loss secondary to
  • Nausea
  • Vomiting
  • Diarrhoea
  • Surgical loss

Patient Criteria

Adult patients who have received treatment (chemotherapy, immunotherapy, radiotherapy, or surgery within the last three (3) months, or palliative care services) experiencing disease and/or treatment related side effects requiring intravenous hydration presenting with(yet are not limited to):

  • nausea
  • vomiting
  • diarrhoea
  • dehydration (poor oral intake)
  • electrolyte imbalance
  • sepsis
  • febrile neutropenia
  • hypovolaemia

Exclusions

Patients with a history/presentation of:

  • congestive cardiac failure
  • pulmonary oedema
  • severe chronic renal impairment
  • severe heart failure

Clinical assessment of hydration and volume status will be performed on all patients, and administration of intravenous fluid will be based on a risk versus benefit basis. Thorough assessment and documentation of the patient’s medical history must be identified prior to administration of intravenous fluid. For charting of intravenous fluid by the APN see Attachment 1.

Adverse Reactions

  • nausea
  • vomiting
  • cramps

Monitoring/Observations

  • Regular observationsincluding pulse, blood pressure, respiratory rate, temperature and Sa02 as per the Modified Early Warning Score (MEWS) – these will be recorded on arrival, and then as indicated by patient clinical condition, and in line withCHHS Policy Clinical Procedure Vital Signs and Early Warning Scores.
  • Clinical review at 15 minutes, 30 minutes and 60 minutes of infusion, then as indicated according to clinical condition of patient.

Referral Criteria

Senior medical or RAU Nurse Practitioner to review patient if there are any signs of:

  • adverse reaction
  • significant derangement of vital signs
  • deteriorating condition
  • inadequate response to infusion

Please note:

  • The APN is required to seek guidance and supervision with clinical decision making via the Nurse Practitioner of RAU or the relevant Registrar/Consultant in relation to all patients that attend the Rapid Assessment Unit receiving intravenous fluids.
  • Intravenous hydration orders may only be exercised and authorised by the Advanced Practice Nurse (RN3.1) of the Rapid Assessment Unit, CRCC, in consultation with the RAU NP or appropriate Registrar/Consultant.
  • Intravenous hydration standing orders preclude the need for an individual order to be written and signed by the treating doctor. This is in line with the philosophy of RAU, which is to provide timely access and urgent care for the cancer and palliative care populations in the CRCC.

Legal Issues

  • 0.9% Sodium Chloride and Hartmann’s Solutions are unscheduled medications, and therefore not subject to legislative restrictions.
  • The Advanced Practice Nurse within RAU and registered in the ACT has an approved extended scope as a health practitioner and may initiate sodium chloride 0.9% or Hartmann’s solutions intravenously as per this Clinical Procedure.
  • Documentation and recording must be observed as for any prescription of fluid.

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Implementation

This procedure will be implemented via:

  • Director of Nursing and Clinical Director of Medical Oncology/RAU meeting
  • CACHS Clinical Governance Committee
  • RAU Project Meeting
  • Rapid Assessment Unit staff meeting

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Related Policies, Procedures, Guidelines and Legislation

Policies

CHHS Nursing and Midwifery Continuing Competence Policy and Standard Operating Procedure, Document Number DGD12-050

Procedures

CHHS Febrile Neutropenia Management Procedure, Canberra Hospital and Health Services, Document Number CHHS15/065

CHHS Clinical Procedure Chemotherapy Care of Adult Patient (eviQ). Document Number CHHS15/056

CHHS Clinical Procedure Vital Signs and Early Warning Scores. Document Number CHHS14/048

Guidelines

Australian Resuscitation Council (ARC) Guidelines (2016):

Guidelines 11.5 Medications - Fluids.

eviQ Cancer Treatments Online (2016) NSW Health. Assess Patients for Dehydration:

National Institute for Health and Care Excellence (NICE) (2013). Intravenous Fluid Therapy in Adults.

Nursing and Midwifery Board of Australia. Fact Sheet: Advanced Practice Nursing. Australian Health Practitioners Regulation Authority; 2015.

Surviving Sepsis: Society of Critical Care Medicine (2012):

United Kingdom Oncology Nurses Society (UKONS) 24 Hour Triage System – Rapid Assessment and Access

National Safety and Quality in Health Service Standards (NSQHSS)

  • Standard 4 – Medication Safety
  • Standard 5 – Patient ID and Procedure Matching
  • Standard 6 – Clinical Handover
  • Standard 9 – Clinical Deterioration

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Definition of Terms

Advanced practice nursing (APN) is the term used to define a level of nursing practice that uses comprehensive skills, experience and knowledge in nursing care.

The Nursing and Midwifery Board of Australia (National Board) define APN as the application of advanced levels of knowledge, skill and experience by the nurse to the nurse-patient/client relationship.

The basis of advanced practice is the high degree of knowledge, skill and experience applied in the nurse-patient/client relationship in order to achieve optimal outcomes through critical analysis, problem solving and accurate decision-making(Nursing and Midwifery Board of Australia 2015).

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References

  1. United Kingdom Oncology Nurses Group. 24 Hour Triage Rapid Assessment and Access Took Kit; 2011.
  2. Surviving Sepsis Campaign. International Guidelines for Management of Severe Sepsis and Septic Shock; 2012. p. 595.
  3. Australian Resuscitation Council (ARC) Guideline 11.5 – Medications in Adult Cardiac Arrest; 2016. p. 10.
  4. National Institute for Health and Care Excellence (NICE) Guideline [CG174] Intravenous Fluid Therapy in Adults in Hospital; 2013.
  5. National Safety and Quality Health Service Standards (NSQHSS)
  6. Nursing and Midwifery Board of Australia. Fact Sheet: Advanced Practice Nursing. Australian Health Practitioners Regulation Authority; 2015.
  7. eviQ Cancer Treatments Online. Assessing Patients for Dehydration. NSW Health; 2016.

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Search Terms

Intravenous hydration, Sodium chloride, Hartmann’s, Rapid Assessment Unit, Advanced Practice Nurse, intravenous fluid

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Attachments

Attachment 1 – APN initiating a fluid order:

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended / Section Amended / Approved By
December 2016 / Document amended / CHHS Policy Committee

Attachment 1 – APN initiating a fluid order:

On the appropriate section of the CHHS fluid order chart, the APN must record:

  • full name, signature & position when initiating the order under ‘M.O. Signature’
  • the type of fluid, type of access (central/peripheral) and rate (minimum over two hours)
  • the expiration/duration of this specific order

Example:

Doc Number / Version / Issued / Review Date / Area Responsible / Page
CHHS17/001 / 1 / 05/12/2017 / 01/05/2018 / CACHS / 1 of 8
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register