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Intravenous Therapy: Discontinuing the IV and Changing To A Heparin Lock

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What is a heparin lock?

A heparin lock, also known as a saline lock, is a plastic device with a covered rubber entry screwed into the hub of an existing IV catheter.

It allows access to the vein without having to run IV fluids into the body.

When is an IV line changed into a heparin lock?

These are the two occasions when heparin lock is placed:

  1. when IV line has been discontinued but the access to the vein is needed for continuous infusion of fluid or medication changes
  2. when client requires IV medications but does not necessarily need continuous fluid infusions

What are the advantages of having a heparin lock?

Changing to a heparin lock allows:

  • an improved client mobility
  • quick medication administration during emergency cases
  • access to vein without necessarily having an IV line

What is the main disadvantage of a heparin lock?

The main disadvantage of a heparin lock is blood clotting.

This can be prevented through a Saline Flush wherein a normal saline is regularly flushed into the heparin lock.

Materials Needed:

  • Gloves
  • Syringe with saline flush solution
  • Sterile needles
  • Alcohol swab

Discontinuing the IV And Changing To A Heparin Lock

Steps

Rationale

1. Check health care provider’s order to discontinue IV and to insert a saline lock. Ensures accurate placement of saline lock.
2. Wash hands and put on clean gloves. Reduces number of microorganisms.
3. Check client’s identification bracelet. Ensures correct procedure is performed for the client.
4. Explain procedure and reason for discontinuing IV to client. Decreases anxiety.
5. Prepare supplies at bedside. Ensures smooth procedure.
6. If inserting a new heparin lock: Prime the extension tubing with saline and place the saline lock on it. Follow the procedures for starting an IV, including assessing and preparing the site, inserting the IV catheter. Do not attach the IV catheter to the IV tubing. Instead, attach it the to the extension tubing. Dress the site per protocol. Priming the extension tubing prevents air from being forced into the vein.
7. If discontinuing an IV and converting to a heparin lock: Stop IV infusion.

  • For IV tubing,roll clamp to close IV tubing.
  • For infusion pump,turn switch to off.
Stops the flow of fluid in the IV tubing.
8. Place heparin lock:

  • Open sterile package with needleless adapter heparin lock.
  • For existing IV, loosen IV tubing and remove.
  • Screw heparin lock into hub of tubing
  • To check for patency remove cap from one-way valve following vigorous scrubbing with alcohol at the connection site. Connect needleless Leur-locking syringe to the valve. Inject solution into IV site per protocol, using gentle pulsating motions to create turbulence. Remove syringe and replace sterile cap at end of tubing.
Secures the heparin lock.
9. Check for patency of IV:

  • Clean heparin lock with antiseptic solution (usually alcohol wipe).
  • Insert saline syringe with 25-gauge needle into center of diaphragm. (Needleless system will not require needle.)
  • Pull back gently on syringe and watch for blood return.
  • Inject saline slowly into lock.
  • Assess client’s pain at site.
Ensures the IV is patent so that the heparin lock will function. Flushing with saline clears the lock.

  • Flushing should be done slowly.
  • Assess for pain to ensure site is patent.
10. Keep lock patent with heparin or normal saline. Every 8 hours:

  • Clean the rubber diaphragm with an antiseptic swab (not applicable if needleless system).
  • Insert the syringe or needleless adapter with heparin or saline into the diaphragm.
  • Inject heparin or saline slowly into lock.
Ensures patency of saline lock.
Only use heparin if prescribed as “flush with heparin” or if institutional policy requires it. Needleless system reduces risk of needle sticks.
11. Remove the syringe or needleless adapter from the diaphragm and swab it with an antiseptic swab. Discard needle or adapter in sharps container. Reduces transmission of microorganisms. Reduces risk of needle sticks.
12. Assess the site for any signs of leakage, irritation, or infiltration. Detects problems with the site that need additional assessment and intervention.
13. Remove gloves and dispose with all used materials. Wash hands. Reduces transmission of microorganisms.

Note. Adapted from Fundamental and Advanced Nursing Skills. Third Edition, p. 1056-1059, by G. B. Altman, 2010,
Delmar: Cengage Learning.

What to document?

Document:

  • date and time the IV line was discontinued and heparin lock was placed
  • abnormal findings at the IV insertion site
  • type of solutions infused in lock – whether it’s heparin or saline

Key Considerations:

  • Discontinuing the IV line and changing to a heparin lock is a responsibility of a nurse that cannot be delegated to an unlicensed or untrained personnel.
  • Many institutions, adapting recent studies, flush heparin locks with normal saline solution rather than heparin before and after a medication is administered to maintain patency of a heparin lock.
  • If swelling is noted at IV site, stop pushing the heparin lock. Pull back the plunger and check for blood return. If there is no blood, remove and start a new heparin lock in another site and flush with saline.

Intravenous Therapy: IV Bag and Tubing Preparation

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What is the purpose of the IV solution during intravenous therapy?

The IV solution corrects and prevents the client’s fluid and electrolyte imbalances.

Different IV solutions are prescribed to different clients who required intravenous therapy such as:

  • those with acute illness
  • those required to have nothing per orem
  • those with severe burns

What are the most common IV tubings?

These are IV tubings a nurse must be familiar with:

  • Primary Tubing – have no ports or multiple ports
  • Secondary Tubing – used when another solution is added to the primary tubing
  • Filtered Tubing – used in blood transfusion to filter the blood

Aside from the type, what must the nurse need to know about IV tubing?

The nurse must be familiar with the size of the tubing to be able to accurately count the IV flow rate.

Macrodrop IV tubing can vary from 10, 15, or 20 gtts per milliliter.

Microdrop IV tubing has a rate of 60 gtts per milliliter.

Materials needed:

  • Gloves
  • IV solution in a bag
  • IV tubing as order
  • Sterile 2 x 2 gauze

IV Bag and Tubing Preparation 

1. Check health care provider’s order for the IV solution. Ensures accurate administration of the solution.
2. Wash hands. Reduces transmission of microorganisms.
3. Check client’s identification bracelet. Ensures medication is given to the correct client.
4. Prepare new bag by removing protective cover. Check the expiration date on the bag and assess for cloudiness or leakage. Allows for quick, smooth preparation. Ensures that the solution is sterile.
5. Open new infusion set. Unroll tubing and close roller clamp. Prevents fluid from leaking after IV bag is spiked.
6. Spike bag with tip of new tubing and compress drip chamber to fill halfway. Promotes rapid flow of solution through new tubing without air bubbles.
7. Open roller clamp, remove protective cap from the end of the tubing, and slowly flush solution completely through tubing. Removes air from tubing. Prevents entry of air into the venous system, a cause of air embolus. If fluid enters tubing too rapidly air bubbles occur.
8. Close roller clamp and replace cap protector. Prevents fluid from leaking and maintains sterility of tubing.
9. Apply clean gloves. Reduces the transmission of microorganisms
10. Remove old tubing and replace with new tubing:

  • Place sterile 2 × 2 gauze under IV catheter or heparin lock.
  • Stabilize hub of catheter or needle and gently pull out
  • old tubing.
  • Quickly insert new tubing into hub of catheter or
  • needle.
  • Open roller clamp to establish flow of IV solution.
  • Reestablish drip rate.
  • Apply new dressing to IV site.
  • Absorbs fluids that may drip during the procedure, preventing contamination of surrounding areas.
  • Prevents accidental dislodging of catheter or needle.
  • Prevents backflow of blood or the entrance of air into the vein.
  • Prevents catheter occlusion and maintains IV flow at prescribed rate.
  • Maintains IV flow at prescribed rate.
  • Provides protection from infection and accidental dislodgement.
11. Discard old tubing and IV bag. Prevents accidental transmission of microorganisms.
12. Remove gloves and dispose with all used materials. Reduces transmission of microorganisms.
13. Apply a label with date and time of change to tubing. Calculate intravenous drip rates and begin infusion at prescribed rate. Allows for planning of next change.
14. Wash hands. Reduces transmission of microorganisms.

Note. Adapted from Fundamental and Advanced Nursing Skills. Third Edition, p. 1030-1032, by G. B. Altman, 2010,
Delmar: Cengage Learning.

What to document?

Document the following:

  • Date, time and name IV solution was started
  • Date and time IV tubing was changed

Key Considerations:

  • Before administering medications through IV, ensure its compatibility with the IV solution to prevent untoward reactions.
  • Always check the temperature of the IV solution so that it’s not too warm or too cold before administering it to the client.
  • Teach client to alert the nurse before the solution in the IV bag runs out so that the appropriate replacement will be given in due time.
  • If the IV tubing gets contaminated by needle piercing during the IV piggyback injection, stop the medication administration. Remove the needle and replace cap of the needle to maintain its sterility.  Stop IV flow, obtain a new tubing and change existing tubing using proper aseptic technique. Discard contaminated tubing and place a new IV tubing and solution and finally administer the IV piggyback medication.

Intravenous Therapy: Assessment and Maintenance of an IV Insertion Site

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Why should the IV insertion site be regularly assessed and maintained?

Assessment and maintenance of an IV insertion site is done to ensure that the client does not suffer any untoward complications connected to IV therapy.

What indicates a normal IV insertion site?

  • Healthy Vein. A healthy vein is round, firm, elastic and engorged without hardened, bumpy or flattened areas.
  • Absence of signs and symptoms of complications. The IV insertion site must be free from redness, swelling, bleeding, warmth at the IV site, pallor, pain or discharge.

Assessment and Maintenance of an IV Insertion Site

Steps Rationale
1. Review the doctor’s order for IV therapy. Ensure accuracy of the administration of IV therapy.
2. Review for hypersensitivity to medications. Prevents risk of allergic reactions.
3. Review client’s IV site record and Intake and Output records. To check for previously noted IV site problems or fluid and electrolyte imbalances.
4. Wash hands and obtain vital signs. Decreases transmission of microorganisms and checks changes in client’s cardiovascular system.
5. Check IV fluid for the following:

  • right fluid
  • right additives
  • right rate
  • right volume at the beginning of shift
Ascertains client is receiving the appropriate IV therapy.
6. Check IV tubing connections. To avoid fluid leaks.
7. Check the gauze IV dressing and vein site for the following:

  • Dampness
  • Redness
  • Warmth
  • Swelling
  • Pain
  • Drainage
These are early signs and symptoms of IV insertion site complications: infection, infiltration or phlebitis.
8. Document according to institution policy:

  • Name of IV solution with additives
  • Rate of infusion
  • IV site condition
  • Time assessed
Provide record of significant IV site findings and proof of regular IV site observation.
9. Wash hands and do aftercare. Decreases transmission of microorganisms.

What must the nurse do with the abnormal IV site assessment findings?

IV Site Complication Nursing Intervention

Hypersensitivity

Note for:

  • fever
  • joint swelling
  • rash
  • hives
  • wheezing
  • Discontinue the infusion.
  • Notify doctor immediately.

Infiltration

Note for:

  • swelling
  • discomfort
  • burning sensation
  • cool skin
  • pallor of site
  • Stop infusion and discontinue IV.
  • Elevate affected extremity.
  • Restart new IV site above previous site or opposite extremity.
  • Document findings and intervention done.
  • Notify doctor for follow-up care.

Phlebitis

Note for:

  • redness
  • tenderness at tip of the IV catheter
  • edema over vein
  • warmth of IV site or general elevated temperature
  • Stop infusion.
  • Apply warm packs for client’s comfort.
  • If necessary, restart new IV site on the opposite arm with larger vein and smaller device.
  • Document findings and intervention done.
  • Notify doctor for follow-up care.

Extravasation

Note for:

  • burning or stinging discomfort
  • cool skin
  • redness
  • swelling 
  • Follow agency’s protocol for extravasation.
  • Stop IV flow or remove IV line.
  • Estimate amount of extravasated solution.
  • Instill appropriate antidote per agency protocol. The commonly used antidote is phentolamine [Regitine].
  • Elevate extremity.
  • Document findings and intervention done.
  • Notify doctor.

Key Considerations:

  • Elderly patients have fragile veins that are prone to infiltration. Extra careful assessment must be done.
  • Always teach client the signs and symptoms of IV insertion site complications so that they know what to report.