Article Outline
Because this issue of NAINR is devoted to Vascular Issues, varying practices and policies around the country has quickly become evident. Clinical practice needs to be consistent with standards and science-based policies and procedures. The most beneficial step in reviewing current practices and policies is to initiate interdisciplinary discussions regarding current practice and policies. Discussion alone can increase the health care providers’ awareness and use of policies as well as identify opportunities for improvement. This issue of NAINR provides a sampling of current practices recently published by the National Association of Neonatal Nurses (NANN). NANN Guidelines for Neonatal Nursing Policies, Procedures, Competencies, and Clinical Pathways1 is a useful tool for benchmarking or creating policies and procedures. This new manual, now in its fourth edition, can serve as a template for policies, clinical guidelines, and standard procedures in any level II or III nursery. It can be used to “jumpstart” discussions related to current practices and procedures. The “why” of our practice needs to be continuously questioned.
One such NANN Policy is titled Intravenous Therapy (Table 1).
Table 1. Intravenous Therapy
| General Guidelines |
| • All intravenous and intra-arterial fluids must be ordered by a physician or Advanced Practice Nurse (APN). Fluids may be administered through a peripheral vein, umbilical vein, midline catheter (MLC), umbilical artery, peripherally inserted central catheter (PICC), or central venous line. Record the date and time the line was inserted on the nursing flowsheet. |
| • Administer all fluids via IV or syringe pump. It is recommended that all connections be luer locks. If this is not available all non-luer locks on umbilical, arterial, or central lines should be taped lengthwise with adhesive tape. |
| • Check the administration site for leakage, infiltration, and inflammation every hour; discontinue the IV if any problems are present and restart it at another site. Check the fluid hourly; record the type of fluid administered, as well as site checks, on the IV section of the nursing flowsheet. |
| • When changing glucose concentrations or additives in the IV solution, flush the tubing completely with new solution before reconnecting it to the infant. Limit glucose concentration to no more than 12.5% when infusing through a peripheral vein. Higher concentrations may be infused through a central line. |
| Peripheral IV |
| • Gather the pump, tubing (flushed with the ordered IV solution), an IV catheter, sterile IV saline, a T-connector, 2% chlorhexidine gluconate, sterile saline wipes, 2-in. × 2-in. gauze, tape, Tegaderm™ (St. Paul, MN), and a padded arm board. |
| • Identify the patient using two patient identifiers. |
| • Prepare the patient's skin with 2% chlorhexidine gluconate and allow it to air dry 30 s before inserting the IV. |
| • Position the infant as needed. Check for good peripheral circulation in the extremity. |
| • Flush a small amount of sterile IV saline (1 ml) when the IV is inserted to ensure that it is functioning well and that there is no blanching of the skin. Check for flash back. |
| • Label the IV syringe with the patient's name, solution used, additives and amounts, and the date and time of preparation. |
 There should be no more than three IV-insertion attempts per RN. |
| Saline Lock |
| Use a saline lock to provide venous access for IV fluids or medications and to facilitate giving medications without continuous IV fluids or repeated venipunctures. |
| Flush the catheter every 3-4 hr with 0.2-0.5 ml sterile IV saline solution to maintain patency. It may be flushed more often, if needed. Note the site condition on the nursing flowsheet. Flush the catheter with 0.2-0.5 ml sterile IVsaline solution following medication administration. |
| Document the insertion site, flush quantity, needle size, and site appearance on the IV section of the nursing flowsheet. |
| IV Tubing Change |
| • Change all IV solutions every 24 hr. Change lipid tubing every 24 hr, and change all other tubing every 72 hr. Label all tubing with date, time, and initials. |
| • Change all components of administration sets and infusion fluids when the IV fluid is visibly contaminated, a closed system is opened accidentally (e.g., tubing is found disconnected), or possible sepsis related to the IV site or fluids has occurred. The IV system should remain a closed system between solution changes. |
| • If a dressing becomes wet or nonocclusive, change it immediately. |
| • Patients with intravenous infusions should be evaluated every hour for evidence of cannula-related complications. Evaluation should include gentle palpation of the insertion site through intact dressing. If a patient has an unexplained fever or there is pain or tenderness at the insertion site, the dressing should be removed and the IV site inspected. |
| • Record the insertion date on the last page of the nursing flowsheet. |
| • Label the IV tubing with the date and time the bag was hung and the date and time it should be changed. |
| • Label syringes with the type of solution and the date and time they were hung. |
| • Document hyperalimentation (HAL) solution, IV solutions, and tubing changes. |
| • Document when other IV solutions are changed in the IV section of the nursing notes. |
| • Tubing for central lines, PICCs, and umbilical arterial catheters or umbilical venous catheters may be assembled under clean conditions. You do not need to wear a mask and gloves, but connection sites should remain sterile. |
| IV Pumps |
| Check the infusion rate every hour and record the amount infused, as indicated by the counter on the panel. Subtract the previous amount from the present reading to determine the amount infused during the previous hour. |
| Every 12 hr, the amount of fluid infused should be totaled. Consult a physician or APN before increasing or decreasing the infusion to correct any significant difference (>20%). Review IV orders and pump settings at shift changes with the medication and chart audits. |
| At 11 am and 11 pm, an RN should reset the volume infusion counter to zero and total the intake volumes. |
| Hyperalimentation and Lipid Solutions |
| HAL solution consists of an appropriate amino acid solution, glucose, vitamins and minerals, and often a lipid emulsion. It is used to provide or supplement nutrition for infants who cannot be fed adequately or at all. The solution must be ordered daily by a physician or APN. HAL is administered through a peripheral vein, PICC, or central venous catheter. |
| Each bottle must be ordered daily, and the requisition must be sent to pharmacy so that the solution will arrive on the unit before the current solution has been hanging for 24 hr. The HAL solution and tubing must be changed daily every 24 hr. Refrigerate the solution if it will not be used within 2 hr. |
| No medications may be added to the HAL solution after it leaves the pharmacy. Medications may be ordered and added by the pharmacy under sterile technique. The compatibility of medications with the solution determines what can be added. Check with a physician or APN and the pharmacy to ensure compatibility. |
| Hyperalimentation Administration |
| • Always hang an equal dextrose solution if HAL is stopped for any reason (e.g., solution runs out, the line breaks) to prevent severe hypoglycemia or apnea. Usual dextrose concentration maximums are 12.5% peripherally and up to 15% centrally. If you are administering HAL for more than 1-2 hr, check with a physician or APN for the need for electrolytes. |
| • Obtain the infant's labwork, as ordered. |
| • Document HAL and intravenous lipid IV fluids. |
| Lipid Administration |
| Lipid solutions come 20% and should be given as continuous infusions (not bolus), piggybacked with HAL solution or IV fluids. Infuse lipids over 24 hr. Periodic triglyceride monitoring is suggested for all infants receiving lipids. |
| HAL Solution Checklist |
| • Infant's name |
| • Weight on the order versus the weight printed on the IV bag |
| • Dextrose concentration |
| • Amount of lipids and protein in per kg amounts |
| • Flow rate of solution per hour |
| • Amount of additives in per kg amounts |
| • Lipid concentration |
This policy outlines current evidence regarding Intravenous therapy in the neonate which can create measurable criteria to hold all staff accountable. Evidence reviewed during policy development addressed topics such as the use of alcohol versus 2 % Chlorhexadine gluconate and tubing changes.2, 3, 4, 5
A practice that is typically a high-risk/low-volume procedure is addressed in the Intraosseous Infusion policy. Intraosseous (IO) access allows administration of drugs, fluids, and blood products directly into bone marrow. IO is recommended for neonates in shock who require emergent vascular access when other methods of vascular access have failed.6
A more specialized policy is the Peripherally Inserted Central Catheters (PICC) and Midline Catheters (MLC) policy. This policy, can guide the neonatal nurses’ practice from routine care of a PICC/MLC line to the removal of a PICC or MLC. A specialized competency is also available that outlines clear expectations regarding specialized performance criteria.1
The complexity of health care organizations and diverse nursing populations requires that guidelines be structured with clearly identified expectations to follow. Organized policies can enhance an environment of safety and reduce system errors.7 Although controversy exists regarding many current neonatal practices, support from both nursing and medical leadership within an organization is probably the best way to facilitate a change in practice.
References
- . NANN guidelines for neonatal nursing policies, procedures, competencies, and clinical pathways. www.NANN.org/publications2006;
- . Guidelines for the prevention of intravascular device-related infections. Retrieved May 2004, from http://www.cdc.gov/ncidod/hip/ivguide.html2002;
- . Infusion nursing standards of practice. Journal of Infusion Nursing. 2006;29:S1–S92
- . A retrospective chart review of risk factors for extravasation among neonates receiving peripheral intravascular fluids. Journal of Wound Ostomy Conteinence Nursing. 2006;33:133–139
- . Neonatal intravenous extravasation injuries: evaluation of a wound care protocol. Neonatal Network. 2006;25:13–19
- . Intraosseous infusion: a new option for neonates. Neonatal Intensive Care. 2003;16:44–46
- . The perinatal patient safety nurse: a new role to promote safe care for mothers and babies. AWHONN, the Association of Women’s Health, Obstetrics, and Neonatal Nurses. JOGNN. 2006;35:417–423
PII: S1527-3369(06)00109-7
doi:10.1053/j.nainr.2006.09.011
© 2006 Published by Elsevier Inc.
