Transcript Monitoring and Documentation

Monitoring and
Documentation
Principles of IV Therapy
BSN336
Phillips 15 step venipuncture
method
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Before initiating cannulation follow steps 1-5
Step 1: Checking the Physician’s Order
Step 2: Hand Hygiene
Step 3: Equipment Preparation
Step 4: Patient Assessment and
Psychological preparation
Step 5: Site Selection and Vein Dilatation
Phillips steps (cont)
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Vein Dilitation(cont)
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Type of solution
Condition of vein
Duration of Therapy
Cannula size
Patient age
Patient preference
Patient acitvity
Presence of disease or previous surgery
Presence of shunt or graft
Patient receiving anticoagulation therapy
Patient with allergies
Vein Dilatation(cont)
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Ways to increase blood flow in the upper
extremities
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Factors affecting the capacity for dilatation
Blood pressure
 Presence of valves
 Sclerotic veins
 Multiple previous I.V. sites
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Ways to dilate vein
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Gravity
Fist clenching
Tapping
Warm compresses
Blood pressure cuff
Tourniquet
Multiple tourniquets
Transillumination
Ultrasonography
Cannulation
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The site must tolerate the rate flow
The site must be capable of delivering the
medications ordered
The site must tolerate the gauge of cannula
needed
The patient must be comfortable with the site
chosen
The site nust not impede the patient’s activities
of daily living
Tips for selecting veins
A suitable vein should feel relatively
smooth, pliable with valves well spaced
 Veins will be difficult to stabilize in a
patient who has recently lost weight
 Debilitated patients and those taking
corticosteroids have fragile veins that
bruise easily
 Sclerotic veins are common among
narcotics addicts
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Tips for selecting veins(cont)
Sclerotic veins are common among the
elderly population
 Dialysis patients usually know which
veins are good for venipuncture
 Start with distal veins and work
proximally
 Veins that feel bumpy, like running your
finger over a cat’s tail, are usually
thrombose or extremely valvular
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Phillips tips(cont)
Step 6: Needle Selection
 Step 7: Gloving
 Step 8: Site Preparation
 Step 9: Vein Entry
 Step 10: Catheter Stabilization and
Dressing Management
 Step 11: Labeling
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Phillips tips(cont)
Step 12: Equipment Disposal
 Step 13: Patient Education
 Step 14: Rate Calculations
 Step 15: Monitoring and Documentation
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Documentation
Date and time of insertion
 Manufacturer’s brand name and style of
device (lot number
 The gauge and length of the device
 Specific name and location of the
accessed vein
 The infused solution and rate of flow
 Infusing by gravity or pump
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Documentation
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The number attempts for a successful I.V.
starts
Condition of extremity prior to access
The patient’s specific comments related to the
procedure
Patient response, excessive anxiety, patient
movement, or an untoward response
Signature
Documentation of observation
Tenderness
 Temperatures at and around the site
 Discoloration
 Swelling
 Draining
 Actions taken by the nurse
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Discontinuation of I.V. Cannula
Discontinue if the integrity of the cannula is
compromised or the physician orders
the discontinuation.
1. Put on gloves
2. Obtain a dry 2-inch by 2-inch gauze
pad. Avoid alcohol
3. Loosen the tape and apply the gauze
pad loosely over the site
Discontinuation of I.V. Cannula
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Remove the cannula and transparent
dressing as one unit, without pressure over
the site
After the catheter is removed, apply direct
pressure with the sterile gauze pad over the
site
An adhesive bandage may be applied to the
venipuncutre site after bleeding is controlled.
Document site apperance, how tolerated,
appearance of catheter
Phlebotomy Technique
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Preparation of the healthcare worker
Assessing the patient’s physical
disposition
Identifying the patient
Approaching the patient
Selecting a puncture site
Selecting and preparing equipment and
supplies
Phlebotomy technique (cont)
7. Preparing the puncture site
8. Choosing a venipuncture method
9. Collecting the samples in the
appropriate tubes and in the correct
order
10. Labeling the samples
11. Assessing the patient after withdrawal
of the blood specimen
Phlebotomy technique (cont)
10. Labeling the samples
11. Assessing the patient after withdrawal of the
blood specimen
12. Considering any special circumstances that
occurred during the phlebotomy procedures
13. Assessing criteria for sample recollection or
rejection
14. Prioritizing patients and sample tubes.
Test Requisitions
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Patients full name
Patient’s identification or medical
record number
Patients date of birth
Types of test to be performend
Date of test
Room number and bed (if applicable)
Physician’s name and/or code
Test Requisitions
Test Status (timed, stat, fasting, etc.)
 Billing information (optional)
 Special precautions (potential bleeder,
faints easily, HIV, HepB or C
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Lab tubes