POLICIES & PROCEDURES
Title:
INTRAVENOUS AND/OR PERIPHERAL
SALINE LOCK INSERTION AND
MAINTENANCE
ID Number:
Authorization
[X] Tri-Hospital Nursing Practice Committee
1.0
1118
Source: Nursing
Date Revised: November 2007
Date of Previous Revision: Sept. 2005
Date Effective: May 1999
Scope: Royal University Hospital
Saskatoon City Hospital
St. Paul’s Hospital
POLICY
Who may start IV
Physician Order Required
Special Considerations
IV site preparation
Change IV Site
- RN/RPN/GN competent in IV starts (NICU-Level 2 orientated RN
only)
- Nursing Students under direct RN/GN/RPN supervision
- LPN/GPN who have successfully completed the IV/Blood Admin.
Course
- Yes, except in an emergency situation or for restarts
- Maximum of 2 attempts per nurse, then consult more experienced
personnel
- Monitor site visually or by palpation through the intact dressing q shift
and when patient complains of pain or tenderness at IV site or has an
unexplained fever
- Continuously running solutions containing medications (e.g. heparin,
insulin) must run on the primary port (A) of the IV pump
- IV bags with medication added by nurse must be labeled with
medication name and dose
- Pediatric areas - IV pump should be used with all infusing IVs; all IV
bags must be labeled, even if no medication is ordered
- Chlorhexidine 2% or Chlorhexidine2% and Alcohol 70%
- Allow antiseptic to air dry on insertion site before cathlon insertion
- Infants under 2 months Alcohol 70%
- Adults - every 96 hours or as soon as possible when aseptic technique
during insertion cannot be ensured
- Pediatrics - change IV site only when dysfunctional
Page 1 of 5
Policy & Procedure: Intravenous and/or Peripheral Saline lock Insertion and Maintenance # 1118
Change Solution & Tubing
- All tubing will be labeled with the time and date it was changed
- IV solution & tubing - every 96 hours (stability of medication in
solution may require more frequent change)
- Medication filters - change every 72 hours
- Lipid and all PN solution, filter & tubing - change every 24 hours
- Blood & blood products - should hang no longer than 4 hours
- Blood and blood product tubing - as per Blood Product Administration
policy
- Intermittent use tubing - change every 96 hours
- Infection Control recommendation: Change tubing whenever site is
changed
-
Sterile Dressing over IV
insertion site
Flush Saline Lock
Pump Pressures/Alarm
LPN/GPN Role – IV
Therapy
Documentation
- Transparent semi permeable dressing (IV3000) OR
- Sterile gauze dressing with sterile tape to secure hub (e.g. Steri-strips)
- All dressings changed as needed to maintain dry and intact dressing or
when IV site changed
Pediatric IV taping guidelines:
- Use tegaderm (teddy bear) IV dressing to secure cathlon
- Tape fingers/toes and wrist/ankle to IV board (if using). Leave one end
of tape doubled over for easy removal
- Use double sided tape then cover with single sided tape to secure
arm/leg to the arm board
- Use ½ med cup (tape over edges) over the IV site
- Use tubular gauze (no kerlix) or a thin cotton sock over arm/foot board
if required
- No scissors to be used when removing tape or arm/footboards
- Check tapes/arm boards every shift and change q48-72h (except tape at
IV site)
- Adults: 3mls 0.9% sodium chloride every 24 hours and prn following
use
- Pediatrics: 1 ml 0.9% sodium chloride or 25units Heparin diluted to
1ml with 0.9% sodium chloride q12h & prn as ordered (PICU: q8h &
prn)
- Neonates: 0.8 mls (or double catheter & extension amount) 0.9%
sodium chloride every 4-6 hours
- Pediatric areas: Defaulted to 2 PSI. Chart patient and IV pump
pressures as per unit policy
- Neonates: Set IV pump pressure alarm at 1.4 PSI
- Adults: Pump pressures default setting - 10 PSI
- Refer to Table on pages 3 and 4 of this policy
- Record solution type and volumes on a fluid balance sheet
- Document insertion and ongoing care of IV on appropriate record
every shift and prn
Page 2 of 5
LPN Role – Intravenous and/or Peripheral Saline Lock Insertion and Maintenance
Education Courses the LPN has completed
Competency
Observe the infusion site for
signs of infiltration and
inflammation and record
observations
Set up IV bag and tubing
including priming infusion line
Observe, regulate and record
the rate of flow of IV solutions
Change an IV solution bag
and/or refill the buretrol when
there are no medications added
to the solution
Observe and regulate primary
infusions, after medication by
secondary infusion or buretrol
has been absorbed.
Trouble shoot IV pump alarms
Change a peripheral
intravenous site dressing
Has not completed the
Medication or /IV Courses
Has completed the
Medication Administration
Course
( not the IV/Blood
Administration Course)
Has completed the
Medication Administration and
IV/Blood Administration
Courses
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√
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The RN responsible for the
medication should be informed
if flow rate adjustments are
required while the medication
is infusing
Press “silence” on pump and
report
The RN responsible for the
medication should be informed
if flow rate adjustments are
required while the medication
is infusing
Press “silence” on pump and
report
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√
Page 3 of 5
√
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Policy & Procedure: Intravenous and/or Peripheral Saline lock Insertion and Maintenance # 1118
Discontinue IV infusion and
catheter from a peripheral
venous site
Monitor and discontinue
heparin and saline locks
Initiate peripheral infusion line
upon physician’s order
Flush saline lock
Prepare and administer
medications for infusion as per
medication order
IV Push Medications*
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no
no
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no
no
no
no
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no
no
no
* NOTE: IV medications must be given at intermittent rate as described in the IV Reference manual
Page 4 of 5
2.0
PURPOSE
2.1
3.0
4.0
To minimize the risks of infection and other complications associated with the insertion
and maintenance of intravenous catheters.
PROCEDURES - refer to Nursing Interventions and Clinical Skills – 3rd Ed.
3.1
Insertion of a Peripheral Intravenous Catheter: pages: 676 – 689
3.2
Initiation of a Peripheral Saline Lock: page: 682
3.3
Set up Bag and Tubing, Change IV Bag, Adjust IV Drip Rate, Discontinue IV Catheter:
pages:689-708
REFERENCES
1. American Heart Association (2002) PALS Provider Manual
2. Association for Professional in Infection Control and Epidemiology (2005) APIC Text in
Infection Control & Epidemiology, Wash, USA: Chapter 24 –Intravascular Device
Infections
3. Centers for Disease Control and Prevention (2002). Guidelines for the Prevention of
Intravascular Catheter – Related Infections.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
4. College of Physicians and Surgeons of Saskatchewan -Laboratory Quality Assurance
Program (2004) Transfusion Guidelines for Hospitals in Saskatchewan.
5. Competency Profile for Licensed Practical Nurses of Saskatchewan, Version 2 (July 11,
2005): Saskatchewan Association of Licensed Practical Nurses and Alberta Health and
Wellness Health Workforce Planning Branch, Edmonton.
6. Department of Laboratory Medicine (May 2002).SHR Laboratory Service Manual,
Saskatoon Health Region, Saskatoon, Saskatchewan
7. Elkin, M, Perry, A &Potter, P. (2004) Nursing Interventions & Clinical Skills –3rd Edition.
Philadelphia, PA: Mosby: Chapter 29-Intravenous Therapy.
Page 5 of 5