Indications of Venipuncture
and IV Infusion Therapy
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When no other route of administration is available. Pt. cannot take in oral substances
To restores & maintains fluid & electrolyte balances
To provides medication & chemotherapeutic agents
To transfuse blood & blood products
To delivers parenteral nutrients & nutritional supplements
When administration of continuous or intermittent medication is required
When administration of bolus medication
Indications for Venipuncture & IV Infusion Therapy
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When administration of intravenous anesthetics is required for the surgical pt.
For the administration of diagnostic reagents: radiopaque dyes used for radiographic images
For monitoring & maintaining hemodynamic functions (homeostasis)
Benefits & Uses for IV Therapy
Benefits: allows for more accurate dosing, it’s a fast method of delivery which works immediately
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Drug administration
– Provides rapid & effective administration of medications
*Antibiotics, thrombolytics, cardiovascular drugs, anticonvulsive drugs,
histamine- receptor antagonist, antineoplastic, analgegics
- Immediate & accurate administration of medication
– Allows for IVP, a direct single dose
– For the use of long-term continuous infusion (short-term during hospital stay)
– PPN (peripheral parenteral nutrition) when limited nutritional therapy rather than
total pareteral nutrition is needed.
• Total parenteral nutrition (TPN) – given through a central line
- Provides essential nutrients to blood organs & cells by IV route
- TPN is usually customized for ea. Pt. in order to meet their energy & nutrient
Requirements
- Contains proteins, carbohydrates, fats, vitamins, traces of elements and water.
- TPN should only be used when the gut is unable to absorb nutrients.
- Can be used indefinitely, however, TPN may cause liver damage.
- (PPN) peripheral parenteral nutrition – is a limited nutritional therapy; it:
o contains fewer non-protein calories, lower amino acid concentration than
TPN
o may be used for approx. 3 wks.
• Blood administration
- restores & maintains adequiate circulatory volumes
- maintains homeostasis
- prevents cardiogenic shock
- increases the blood’s oxygen-carrying capacity
IV Delivery Methods
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By peripheral veins - usually the distal arms & hands
Lower extremities are avoided, may be used in children
– Primary Lines
– Secondary Lines (IVPB)
– Intravenous Push (IVP)
– Heparin Lock Flush (HL), Saline Lock
– Intravenous Pump Use
Cannulas - Cannula selection
Cannula size
• 14, 16, 18 ga.
• 20 ga.
• 22 ga.
• 24 ga.
Clinical Application____________________________
- trauma, suregery, blood transfusion
- continuous or intermittent infusion, also blood adm.
- use in children and elderly, or for general use (GI lab)
- Fragile veins, children
IV Delivery Methods
• Central line veins - a flexible catheter inserted into large central vein
– Inserted by by a physician in the : Jugular vein; Subclavian vein; or Femoral vein
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Procedure performed by a MD – requires a consent
PICC lines & Midline Catheters
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PICC – (Peripherally inserted central catheters) – performed by a trained nurse. The tip of the
catheter reaches the subclavian and terminates at the superior vena cava. Post x-ray required for
determining placement.
Midline catheters - are long catheters (> 3 inches in length). they are peripherally inserted with the
tip located at the level with the axilla, and distal to the shoulder.
Peripheral IV
In for short periods of time
Relatively easy to put in
Is accomplished by nursing staff
Less complications
Some drugs & fluids may be irritable to vein
Do not infuse fluids with a pH < 5 or >9
Cannot give anything > 500mOsm/L
VS.
Central Lines
Can be left in for longer periods of time
Required skilled person for placement (MD)
PICC line (RN with special training)
May infuse chemotherapy
May infuse parenteral nutrition formulae
May exceed 10% dextrose and 5% protein
Delivery Pumps
NO Free Flow
• Safety mechanism that prevents free flow
• If not sure how to operate, ask!!!!
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Always keep alarms on.
Venipunture Sites
Dorsal digital vein
Cephalic vein
Accessory cephalic vein
Median cubital vein
Basilic vein
Dorsal
metacarpals
Cephalic vein
Dorsal venous network
Cephalic vein
Median vein
Median cubital
vein
REMEMBER:
5 Rights of Medication Administration
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Right drug
Right dose
Right client/patient
Right route
Right time
Starting an I.V.
1. Assembles equipment
IV. Bag, IV tubing, IV start kit, tape, op-stie dressing, IV cathlon needle, syringe, gloves
IV pump, medication, Medication administration record (MAR);
2. Positions clients and adjusts lighting
Explain to the patient, make them feel comfortable, present self-confident
3. Washes hands and applies gloves
Allow pt to see you wash hands
4. Prepares equipment
clean bedside table, use aseptic technique - uses body fluid precautions
5. Selects and prepares venipuncture site
 ETOH swabs/pads70%, apply in a circular motion 2-3 inch diameter, moving from the
center towards the outside. Allow area to dry. No fanning, blotting, or blowing!
THEN
 Apply povidone-iodine (betadine swab) = also in a circular motion. Center to outwards.
Allow to dry for 30 seconds
 Caution: If patient is allergic to Iodine then use alcohol swab with friction until final
application is visually clean. Dry for 30 seconds
6. Applies tourniquet - do not tie a knot, tourniquet must be easily removed.
7. Enters skin with needle either next to or directly over vein
Keep the bevel of the needle up. Enter at a 10-30 degree angle
8.
Observes for “pop” and flashback of blood; advance the needle a little bit more (2 cm)
separate the cathlon and needle stylate
9.
Carefully advances needle (cathlon) - the stylate further separates from the cathlon as it is
advanced.
10. Releases tourniquet
Apply pressure over the vein, above the venipucture to prevent blood leaking before removing
stylate. Remove the stylate and attach the IV tubing
11. Opens clamp on I.V. tubing
If giving an IVP medication or heplock flush, be sure to push fluid slowly
12. Observes for swelling at I.V. site
13. Applies appropriate dressing – chevron or H method
14. Tapes the needle and tubing - use opsite dressing
15. Sets flow rate
16. Labels I.V. site
17. Documents
18. States the difference between catheter and heparin lock set-up
Discontinue I.V.
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Practice standard precautions.
Clamp tubing – stop fluid infusion.
Gently peel the tape back
Withdraw catheter. Place gauze over site and gently slide the plastic catheter out of the patient's
arm.
Use direct pressure for a 2-3 minutes to control any bleeding.
Place a band aide over the site
Documentation
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Date
Time
Site description
Attempts
Gauge
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IV fluids or HL
Name of solution
Rate of flow
Patient toleration
Complications
Types of IV Solutions
IV solutions are based on the patient’s medical history and diagnosis, the type of fluid volume deficit
being treated (overload or dehydration). The IV solution is also selected on the type of electrolyte
content and osmolarity (tonicity)
• Isotonic – a solution with the same osmalility as body fluids, such as plasma.
– total electrolyte content approx. 310 mOsm/L
• Hypertonic – is a solution with greater concentration of solutes than body plasma
– total electrolyte content > 375 mOsm/L
• Hypotonic – is a solution with lower concentration of solutes than body plasma
– total electrolyte content < 250 mOsm/L
Colloids - Colloid osmotic pressure (or oncotic pressure) = is the osmotic (pulling) force of albumin
(proteins) in capillary reabsorption. It draws water into the vascular space. These would be hypotonic
solutions like: Albumin (a component of blood); Dextran; Hetastarch
Crystalloids - electrolyte solutions that move freely between the Intravascular and Interstitial spaces.
These are isotonic solutions like: D5W and Normal Saline 0.9%
IV solutions can be used to correct fluid imbalances. They are usually dependent upon the solution’s
osmolarity (concentration) as compared to the serum osmolarity.
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Osmolarity concentrations of solutions are expressed in mOsm/L (milliosmol per liter of
solution)
Normal serum is approximately – 300 mOsm/L, and it is the same osmolarity as other body
fluids
A < low serum osmolarity suggests fluid overload
A > high serum osmolarity suggests hemoconcentration , dehydration
NOTE: Normal serum = 300 mOsm/L; it’s the same osmolarity as other body fluids
Isotonic
• Osmolarity (tonicity) of the solution is the same solute concentration as serum and other body fluids
• Infusing solution doesn’t alter concentration of serum; therefore, osmosis doesn’t occur.
• Isotonic solutions stay where they are infused, inside blood vessel
• Intravascular/ECF volume expanders
• Examples: D5W, 0.9%NS , L.R. , Electrolytes are considered isotonic
Isotonic Solutions: Examples & Considerations
0.9% NS
2.5%Dext/.45NS
D5W
D5/ 0.11% NS
Plasmalyte
Lactated Ringers
Monitor for CHF & HTN
Ringers Solution
D 2.5% / ½ LR
No D5W with> ICP
Don’t give LR in liver disease. Unable to metabolize lactate
No LR if pH>7.5; converts Lactate  HCO3
Hypotonic
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Osmolarity (tonicity) of the solution is < than serum osmolarity. It has a lower solute concentration.
Fluids shift out of intravascular fluid into the interstitial & intracellular fluid; because fluid is pulled
towards the area of higher osmolarity. In this case, the intracellular fluid has higher osmolaritiy.
Hydrates cells, reduces circulatory fluid.
• The purpose for hypotonic sol. is to replace cellular fluids; or treat hypernatremia or other
hyperosmolar conditions,
• Isotonic solutions: half strength NS (½ N.S), 0.33% NaCl; D2.5W
• Too much will deplete intravascular fluids, decrease BP, cause cellular edema and cell
damage. (rupture)
Hypertonic
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Osmolarity (tonicity) of the solution is > than the serum osmolarity. Solute concentration is higher
than the solute concentration of serum as well as the extracellular fluid
Fluids shift out of the intracellular & interstitial fluid into the intravascular fluid
- This effect is temporary since dextrose is metabolized quickly
May be ordered in post-op pts to reduce edema, stabilize BP and regulate urine output
(see handout)
Examples of Hypertonic Solution:
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D5 ½ NS;
D5 NS;
D5 0.2% NS
D50W
D10NS
D10W
D10 ½ NS
D5LR
½ N.S
0.33% NaCl
D2.5W
Mannitol
Considerations
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May cause cells to shrink; and may cause damage to endothelial cells
If used in increased intracranial pressure (ICP), it will draw fluids out of cells and
lower the ICP.
Hypotonic solutions may be necessary for children since their daily turnover of water exceeds that of
adults. Children are subject to rapid fluid shifts. Most common pediatric maintenance solutions:
D5% or D10%
NS 0.22%, NS 0.3%
Anything less (or less than 0.2% of sodium chloride) may cause cerebral edema.
Quick Guide to IV Solutions:
A solution is isotonic if its osmolarity falls within (or near) the normal range of serum of 240 – 340 mOsm/L. A
hypotonic solution has a lower osmolarity: a hypertonic solution has a higher osmolarity. This chart lists common
examples of the tree types of IV solutions and provides key considerations for administering them.
Solution
Isotonic
Hypotonic
Examples
Nursing considerations
•Lactated Ringer’s
• Because isotonic solutions expand the intravascular compartment,
closely monitor the patient for signs of fluid overload, especially if he
•Ringer’s
has hypertension of heart failure.
•Normal saline
• Because the liver converts lactate to bicarbonate, don’t give lactated
•Dextrose 5% in water Ringer’s solution if the patient’s blood pH exceeds 7.5
(D5W)
• Avoid giving D5W to a patient at risk for increased intracranial
•5% Albumin
pressure (ICP) because it acts like a hypotonic solution. (Although
usually considered isotonic, D5W is actually isotonic only in the
•Hetastarch
container. After administration, dextrose is quickly metabolized,
•Normosol
leaving only water – a hypotonic fluid.)
•Half-normal saline
• Administer cautiously. Hypotonic solutions cause a fluid shift from
0.45%N.S.
blood vessels into cells. This shift could cause cardiovascular collapse
from intravascular fluid depletion and increased ICP from fluid shift
into brain cells.
•0.33% sodium
chloride
•Dextrose 2.5% in
water
•. Don’t give hypotonic solutions to patients at risk for increased ICP
from stroke, head trauma or neurosurgery.
•Don’t give hypotonic solutions to patients at risk for third-space fluid
shifts (abnormal fluid shirts into the interstitial compartment or a body
cavity) – for example: patients suffering from burns, trauma or low
serum protein levels from malnutrition or liver disease.
Hypertonic
• Dextrose 5% in half-
• Because hypertonic solutions greatly expand the intravascular
normal saline
compartment, administer them by IV pump and closely monitor the
patient for circulatory overload
• Dextrose 5% normal
saline
• Dextrose 5% lactated
Ringer’s
• Hypertonic solutions pull fluids from the intracellular compartment;
so don’t give them to a patient with a condition that causes cellular
dehydration – for example, diabetic ketoacidosis.
Don’t give hypertonic solutions to a patient with impaired heart or
• 3% sodium chloride •kidney
function – his system can’t handle the extra fluid.
• 25% Albumin
• 7.5% sodium chloride
Lippincott Williams & Wilkins. I.V. Therpay made Incredibly Easy.
Patient Assessment
• Check patient’s status before starting fluid replacement.
• What is their age? Are they having surgery? What is the condition of the veins?
This may determine the size of needle you will use.
•Anticipate changes in fluid balance that can occur during IV therapy - check lab.
values.
Do they have a fluid deficits of fluid excess?
Fluid deficits
Wt. Loss
Increased, thready pulse rate
Diminished B/P, (orthostatic hypotension)
Decreased central venous pressure CVP
Sunken eyes, dry conjunctivas, decreased tearing
Poor skin turgor (not reliable in elderly patients)
Pale, cool skin
Poor capillary refill (> 2 seconds)
Lack of moisture in groin and axillae
Thirst
Decreased salivation
Dry mouth,
Dry, cracked lips
Furrows in tongue
Difficulty forming words (patient needs to moisten
mouth first)
Changes in mental status
Weakness
Diminished urine output
Increased hematocrit
Increased serum electrolyte levels
Increased blood urea nitrogen (BUN) levels
Increased serum osmolarity
Fluid excess
Wt. Gain
Elevated blood pressure
Bounding pulse that isn’t easily obliterated
Jugular vein distention
Increased respiratory rate
Dyspnea
Moist crackles or rhonchi on auscultation
Edema of dependent body parts:
(sacral edema in patients on bed rest)
(edema of feet and ankles in ambulatory pts.)
Generalized edema
Puffy eyelids
Periorbital edema
Slow emptying of hand veins when the arm is
raised
Decreased hematocrit
Decreased serum electrolyte levels
Decreased BUN levels
Reduced serum osmolarity
RISKS and Complications r/t IV therapy
EDEMA = an imbalance between extracellular and intracellular fluid/ compartments;
an imbalance in osmolarity (concentration) or osmotic pressure (pulling).
• Bleeding – hematoma, separation of IV tubing
• Blood vessel damage
• Infiltration (IV sol. leaks into surrounding tissues)
• Catheter dislodgement (extravasation) - extravasation from vesicant drugs
• Occlusion – bent catheter, IV flow interrupted, line clamped, Failure to flush device,
blood back-up
• Phlebitis, - tenderness, redness caused by friction from catheter, hypertonic sol. c high
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pH. Can damages the blood vessel.
• may occur with prolonged indwelling IVs, immunocompromised pts, poor
taping.
• Scrupulous aseptic tech. required when handling IVs at anytime.
thrombosis - painful, reddened, swollen vein. IV flow sluggish or stopped. Causes
injury to endothelia cells of vein wall, platelets adhere & can form a thrombus
thrombophlebitis – severe discomfort, reddened, swollen & hardened vein. Caused
by thrombosis and inflammation. Remove IV, restart, warm soaks, report MD
Infection – redness @ site, inflammation, warm to touch, drainage. Sepsis – fever,
chills, general malaise. Failure to maintain aseptic technique.
Circulatory overdose (rapid infusion) – SX neck vein distention or engorgement, respiratory
distress, inc BP, lung crackles. Raise HOB, slow infusion, O2,
• Adverse or allergic reactions – stop infusion, notify MD. f/u protocol for adverse drug reaction
SX: itching, uticaria (rash), bronchospasm, wheezing, edema, anaphylactic reaction (occurs
within minutes to up to 1 hour of exposure).
Anaphylactic shock = flushing, chills, anxiety, agitation, generalized itching, palpitations,
throbbing in ears, wheezing, coughing, seizures, cardiac arrest.
STOP infusions & switch to N.S., maintain open airway, MD, adm, antihistamine steroid or
anti-inflammatory agents, cortisone, epinephrine,.antipyretic as ordered. Monitor pt carefully.
• Air embolism. - SX respiratory distress, unequal breath sounds, weak pulse, inc. CVP, confusion
or loss of conciousness. Cause: air in vascular system - caused: empty solution container – the next
container will push air down the line. Tubing disconnects from venous access or IV bag.
DC IV, place pt in trendelenberg of left side. Give O2, Notify MD. Always purge IV lines, airdetection devices on pumps; secure all connections.
• Drug & IV incompatibility
• Cellulitis – infection
• Vein irritation or pain at IV site
• Severed or fractured catheter – caused by reinsertion of needle into catheter. The fractured
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foreign catheter fragment may act as an emboli. If portion of catheter entered bloodstream, place a
tourniquet above the IV site to prevent progression. Notify MD & radiology.
Never reinsert needle
Venous spasm - caused by severe vein irritation, rapid adm. of cold fluids or blood. Apply warm
soak, slow rate of fluid.
Damage to a nerve, tendon, or ligament - causes extreme pain (electric shock when the
nerve is contracted), numbness, or muscle contraction. Delayed effects may include paralysis,
numbness & deformity. Caused by improper VP or improperly securing (splinting) the IV arm to an
arm board. Like taping too tight.
If pain or damage occurs, stop procedure & remove IV. Avoid repeatedly penetrating tissue.
Don’t encircle arm with tape; don’t apply excessive pressure when taping;
Physiological Interrelated Systemic Risks
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Fluid overload
– Cardiovascular system – inc. BP, HR, exerts the heart.
– R.Atrium releases hormone – Atrial natruiretic peptide (ANP) in response to elevated
BP – it inhibits/blocks the rennin-angotensin mechanism & aldosteron secretion – in
order to decrease BP by allowing Na+ and water to flow out of the body in urine. produces salty urine.
– Nervous system – Pituitary gland secretes hormones that stimulate the kidneys to release fluid
– ACTH (adenocorticotropic hormone) stimulates adrenal cortex to release corticosteriod
hormones, like glucocorticoid and mineralocorticoids.
– Minerolocorticoids helps regulate electrolyte concentrations in extracellular fluids
(particularly K+, Na+). Aldosterone is a mineralocorticoid.
- Aldosterone reduces the secretion of Na+, through kidney tubules reabsorption, helps to
regulate Bicarbonate and chloride, other electrolytes
– Renal system – Renin-angiotensin mechanism which influences blood volume & BP by releases
rennin that acts on angiotensinogen (plama globuline made in the liver). It converts it to
angiotensin I, which then converts that into angiotensin II. (by ACE – antiotensin converting
enyme). Al this to help stablelize BP and extracellular fluid volumes.
This is associated with capillary endothelium in various body tissues (particularly lungs)
– Pituitary gland secretes ADH (vesopressin), in response to increased osmolarity of blood or
decreased blood volume. Stimulates kidney tubule to reabsorb water.
– Respiratory system – can easily become congested and dev. Pulmonary edema, and also develop
blood gasses imbalance.
Complication of CV lines
• Pneumothorax
- usually discovered during CXR
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Chest pain
Dyspnea (SOB)
Cyanosis - because of the diminished oxygen
Decreased or absent lung sounds on the affected side
Thoracotomy & chest tube
- ACT = Acute respiratory distress, Chest wall motion asymmetrical, Tracheal shifting
Nutritional assessment
Medical HX. Allergies & intolerance to foods. HT, Wt, ideal body wt, body frame, BMI. Skin turgor,
bruising, muscle wasting, ill-fitting denture & denture caries, dry mouth, darkening of mouth lining,
infections or irritations in and around the mouth. Neck swelling, low albumin levels . Dietary intake.
Metabolic complication•Monitor BS levels - Hyperglycemia (infuse insulin)
•Hyperosmolar hyperglycemic non-ketotoc syndrome - stop dextrose, rehydrate
•Hypokalemia - Hypomanesemia - Hypophosphatemia - hypocalcemiz - metabolic acidosis
•Liver dysfunction – decrease carbs & IV lipids. Consider cyclic infusion rather than continuous
•Hyperkalemia – decrease potassium
Factors Affecting Desired Flow Rate
• Change in cannula position- bent cannula can occlude flow; also level of IV bag (ht
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of liquid)
Patency of the cannula. – diameter of aannula and tubing; thrombus formation will
impede flow
Also, the longer the tubing, the slower the flow. Viscosity of solution
Venous spasm.
Crying infants.
Local complications: Phlebitis, or thrombophlebitis.
Be sure to monitor the flow for patency; IV site, recheck calculations
PEDIATRIC IV ADMINISTRATION
Fluid volume is based on child’s age, size and 24 hr. needs
Before starting an IV in children:
 Parpare the parents and child for the stressful procedure
 Gather all necessary equipment – to minimize interruptions
o Infusions pumps calibrated for pediatric use
o Small needle size: 24-22 ga. IV site: foot, scalp vs. hand.
o Use IV tubing with a graded buretrol or solumet drip chamber (60 gtts/min)
o Use of buffered lidocaine: EMLA, or LMX4 (lidocaine & prolocine)
o Child positioning – parental assistance vs. restraints
o Check for latex sensitivity.
 Anticipate changes in fluid balance that can occur during IV therapy – this is very
crucial before any serious complication develops.
 Apply tourniquet over a washcloth to reduce pain or use a tourniquet belt, B/P
cuff.
 Use an age appropriate approach
o Distracting activities, toy therapy, introduce to child that is coping well,
handling equip., no use of restraints,
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Other Pediatric Considerations
Difficulty evaluating drug response – how do you assess ringing in the ear of a child
who doesn’t talk?
Vulnerable to overdose – infants may still have immature livers, or kidneys
Increase risk for fluid overload – know the minimum dilution for safe administration
of IV meds.
Dehydration poses a risk for toxic accumulation
• Subject to rapid fluid shifts
• Intraosseous infusion – use in emergency trauma. A large-bore needle inserted into
the medulla cavity of a long bone (Tibial tuberosity, the distal 3rd of the femur in
newborns)
o Watch for oozing, swelling at site and dependent areas, the tissue of the
leg.
o Complication skin necrosis, fractures, osteomyelitis, cellulitis
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Patient Teaching
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Assess patient’s previous experience
Explain procedure
Explain purpose of medication
Length of time
Ease anxiety, allow them to express feelings
Homecare instructions: care, hep-flush, hygiene & bathing, what to watch for, SX of
infection, phlebitis, when to report to MD
• Demonstrate of skill for administering medication (IM, via G-tube)
• Document teaching