PROTOCOL FOR THE ADMINISTRATION OF

INTRAVENOUS FLUIDS AND MEDICATION BY

REGISTERED NURSES

Version: 2
Ratified by: Provider Services Clinical Governance and
Patient Experience Group
Date ratified: 29.07.08
Name of originator/author: Jackie Roberts, Community Matron
Name of responsible committee/individual: Provider Services Clinical Governance and
Patient Experience Group
Date issued: July 2008
Review date: July 2010
Target audience: All clinical staff

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CONTENTS PAGE

1. Introduction 3

2. Scope 3

3. Aims 3

4. Objectives 3

5. Responsibilities 3

6. Training 4

7. Procedure 4

8. Recording 5

9. Risk Management Considerations 5

10. Observing the Patient 8

11. Peripheral Cannula Related Infusion Complications 8

12. Management and Reporting Adverse Reactions 8

13. Completion of the Intravenous Infusion 8

14. Monitoring 8

15. Associated Policies 9

16. References and Bibliography 9

Appendix 1 – Referral for Intravenous Infusion 10

Appendix 2 – Pre Infusion Baseline Observation 11
Appendix 3 – Intravenous Infusion Care Plan 12
Appendix 4 – Intravenous Infusion Care Plan (2) 13
Appendix 5 – Observations, Reactions and Comments 14
Appendix 6 – Communication Sheet 15
Appendix 7 – Blood – I.V. Fluid and Additive Prescription Chart 16
Appendix 8 – Fluid Balance Chart 17
Appendix 9 - Discharge Letter 18
Appendix 10 – Phlebitis Scale &Infiltration Scale (INS 2000) 19/20

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 1. INTRODUCTION

This protocol has been developed to ensure that intravenous fluids and/or
medication is administered by competent registered nurses who, following training
can demonstrate that they can undertake the procedure safely with minimal
associated risks to the patient.

The protocol offers the registered nurse a framework to work within to manage and
minimise the potential risks associated with the administration of intravenous
fluids/medication. This protocol should be used in conjunction with the resuscitation
council (UK) algorithm for the management of anaphylaxis as detailed in ERYPCT
medical emergency and resuscitation policy (2008).

2. SCOPE

This policy applies to all PCT employees, irrespective of age, race, colour, religion, disability,
nationality, ethnic origin, gender, sexual orientation or marital status, domestic
circumstances, social and employment status, HIV status, gender reassignment, political
affiliation or trade union membership. All employees will be treated in a fair and equitable
manner recognising any special needs of individuals where adjustments need to be made.
No member of staff will suffer any form of discrimination, inequality, victimisation, harassment
or bullying as a result of implementing this policy.

3. AIMS

To ensure the safety of all patients who receive this treatment

To facilitate a safe working practice environment for the registered nurse.

4. OBJECTIVES

To reduce the risk associated with the administration of peripheral intravenous

infusions and medications.

To raise Registered nurses awareness of the possible hazards involved in

undertaking the procedure and the actions required to reduce and manage them
should they arise.

5. RESPONSIBILITIES

The correctly completed prescription for intravenous fluids/medication is the

prescriber’s responsibility.

All registered nurses can undertake the exchange of clear and pre-mixed infusible
solutions that can be administered via peripheral gravity feed administration sets.

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 The registered nurse performing the infusion must ensure that all measures are
taken to reduce the risk of complications throughout the administration of peripheral
intravenous infusion and medications, and are required to utilise the documentation
as detailed in the appendices in all cases were an intravenous infusion is
undertaken.

The registered nurse administering the peripheral intravenous infusion and

medication should have knowledge of indications for therapy, side effects, potential
adverse reactions and appropriate interventions.

6. TRAINING

Managers will ensure that all nursing personnel are fully aware of the protocol.
Managers are responsible for ensuring that all staff who are expected to be involved
in the intravenous infusion/medication process receives appropriate training. The
immediate line manager must keep a record of all staff who have received training.

Intravenous medication should only be administered by a doctor or a registered

nurse who has undertaken specific training and is deemed competent in the task of
administration of peripheral intravenous medications.

New members of staff who can demonstrate they have undertaken valid appropriate
training in the administration of peripheral intravenous medications/fluids through
documented evidence may be deemed competent following practical assessment.

7. PROCEDURE

7.1 Pre-administration checks

Prior to the administration of peripheral intravenous medication and fluids the

registered nurse is responsible for:
ƒ Ensuring the procedure is explained to the patient and informed consent is
gained and documented.
ƒ Determining whether the patient has any known allergies and that this is
documented.
ƒ Ensuring the patient is provided where available with written information on the
procedure planned.
ƒ Ensuring that the patient has been identified as per ERYPCT “Policy for
Patient Identification (2008) – updated version.
ƒ Ensuring that the patient has been assessed as appropriate to receive the
medication intravenously and that all biochemical evaluations and baseline
observations are recorded and performed as per manufacturer’s guidance.
ƒ Ensuring the patient is provided where available with written information on the
procedure planned.

7.2 Prescribing

The intravenous prescription chart (appendix 7) must specify:

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 ƒ Patient’s name, date of birth, unit number, NHS number and any known
allergies.
ƒ Type of intravenous medication/fluid to be administered.
ƒ Method/duration of administration of the intravenous medication/fluid.
ƒ Dose of intravenous medication.
ƒ Type and volume of any diluent.
ƒ Any special instructions.

8. Recording

All documentation relating to the intravenous infusion/medication process must be

completed correctly and should be recorded and filed in the patient’s notes on
completion.

The Registered Nurse giving the intravenous medication/fluid must ensure that all
labelling includes the following:-

ƒ Name of the drug

ƒ Strength
ƒ Total amount volume
ƒ Any additives/and or mix (need to ensure the patient has given informed
consent if mixed drugs are to be used)
ƒ Route of administration
ƒ Lot no’s and expiry dates

The Registered Nurse is required to document the following in relation to patient

cannula/access devise

ƒ Size of cannula
ƒ Where sited
ƒ Date and time sited
ƒ Type of dressing used to secure.

9. Risk Management Considerations

9.1 Labelling of Intravenous Infusions, Medications and Flushes

The NPSA 2008 recommends that :-

“All syringes, including flushes and infusions, must be labelled immediately after
preparation by the person who prepared them.
The only exception to this is in situations where preparation and bolus (push)
administration is one uninterrupted process and the unlabelled product does not
leave the hands of the person who prepared it. Only one unlabelled medicine must
be handled at one time.”

“For high risk injectable products, such as concentrated heparin, consider the use of
double checking systems such as independent review”

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 If following the preparation of intravenous infusions and or medications these are not
administered immediately they must be stored as per manufacturers guidance
ensuring the product is labelled showing the following:-

Patient’s name, date of birth, unit number,

Medication and diluent,
Date and time of preparation,
Date and time of expiry

If the above have not been adhered to the solution should not be used and should
be discarded immediately.

9.2 Infusion Devices

The Medical Devices Agency defines the term “infusion device” as a means of
delivering fluids or drugs in solution to the patient by the intravenous, subcutaneous,
epidural, parenteral or enteral route.

The Medical Devices Agency identifies three factors that may have a significant
impact on the use of the infusion device safely, these include training, maintenance
and decontamination.

ƒ Electronic infusion devices should be used to administer intravenous

medication and or fluids where appropriate, however manufacturers guidance
should be sourced via product literature prior to their use.
ƒ All staff involved in the use of infusion devices should ensure they are
competent in its use and receive updated training as appropriate in light of new
equipment and or medical device agency alerts.
ƒ All infusion devices are required to be maintained as per ERYPCT policy and
also in line with manufacturer’s guidance. Records for this should be
maintained utilising a log book for each device detailing serial numbers and
service history.
ƒ All infusion devices should be decontaminated after each use using mild soap
and water. The use of alcoholic rub is not recommended.

9.3 Administration Sets

ƒ Only recommended or designated administration sets should be used in

electronic infusion pumps.
ƒ Administration sets should be changed every 72 hours whilst infusing fluids and
or solutions, or immediately on discovering contamination of the administration
set.

9.4 Site Preparation

ƒ If it is deemed appropriate to remove hair prior to cannulation and application of

dressing that this should be done using scissors. The area should not be
shaved, this is to prevent agitation of the area and to reduce the risk of cross
contamination and or infection.
ƒ The use of a local anaesthetic should only be used under prescription.

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9.5 Dressing Selection

ƒ A transparent semi permeable dressing should be used to secure the cannula

site. This should also be changed every time the cannula is changed.

9.6 Cannula Selection

ƒ Individual cannulas should be selected using the smallest gauge and shortest
length in relation to the client’s vein and intravenous medication to be given.
ƒ Canulas should be changed every 72 hours or sooner if indicated by using the
phlebitis scale and infiltration scale as indicated in appendix 10.

9.7 Maintaining Patency and access

The use of peripheral intravenous access devises is widespread and used to provide
access for venepuncture and administration of fluids/medications. Maintenance of
their patency is important to reduce the discomfort and also expense of replacement.

The NPSA 2008 recommends that:-

“The use of heparanised solutions to flush access catheters should be kept to an
absolute minimum. All wards and departments are advised to only stock sodium
heparin products of 1,000 units/ml or less”
Unnecessary exposure to heparin flushes of any strength should be avoided with the
following being identified as some of the risks

9.8 Allergic Reactions

The potential for bleeding complications.

Risk of medication error and or incompatibility with medication to be infused.
Risk of heparin induced thrombocytopenia.

ƒ The patency of the canula will be checked prior to the administration of

medicines and or solutions.
ƒ The canula/access device will be flushed at established intervals to promote
and maintain patency and to prevent the mixing of incompatible medications
and or solutions.
ƒ The access device should be flushed with 0.9% normal saline as per erypct
patient group directive using a pulsating, push and pause method.
ƒ Flushing with 0.9% normal saline should be performed before, between and
after administration of medications and or solutions.

10. OBSERVING THE PATIENT

All patients receiving intravenous medication/solutions should have their blood

pressure, pulse and temperature recorded pre and post infusion and during the
infusion depending on the time taken to infuse and also as per manufactures
instructions.

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 All patients receiving intravenous infusions should have their fluid balance
documented and monitored.

11. PERIPHERAL CANNULA RELATED INFUSION COMPLICATIONS

Phlebitis and infiltration are recognised complications of intravenous Infusion

therapy.

Phlebitis and infiltration scales are indicated in appendix 10 and Peripheral canula
should be monitored and graded utilising these pre and post intravenous infusion or
when complications occur. All peripheral canulas should be graded daily when not in
use.

12. MANAGEMENT AND REPORTING ADVERSE REACTIONS

If a reaction is suspected medical staff should be informed immediately and the

patient’s vital signs recorded.

In the case of a suspected reaction or a significant change from the patient’s pre
infusion vital signs:

ƒ Stop the infusion – reassure the patient

ƒ Obtain a prompt medical assessment
ƒ Change the administration set and maintain venous access with normal saline
0.9%
ƒ Record the vital signs and volume of urine passed
ƒ Complete an adverse incident form

13. COMPLETION OF THE INTRAVENOUS INFUSION

On immediate completion of the intravenous infusion all patients should have their
vital signs monitored and recorded. If the patient’s vital signs are not within the
patients normal parameters or an adverse reaction is suspected the patient must
receive prompt clinical assessment and appropriate treatment.

On discharge all patients must be given a discharge letter which details the
procedure and informs the patient of actions to take in case of any potential side
effects and or follow up required. Patients will be advised of any self care advice and
who to contact with regards to queries and or complications.

14. MONITORING

Patient complaints
Adverse incident reporting
Staff training records
Clinical Audit of the administration of intravenous medications/solutions – biannually.

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 15. ASSOCIATED POLICIES

Reference guide to consent or examination [DOH 2001, ERYPCT 2008]

Policy for the correct identification of patients [ERYPCT 2008]
Policy and procedure for the management and administration of medicines
[ERYPCT 2008]
Policy for the reporting and management of adverse incidents [ERYPCT 2007]
Policy for medical emergency and resuscitation (ERYPCT2008)
ERYPCT Medical Equipment and Medical Devices training policy (ERYPCT2005)
Syringe Driver Policy (ERYPCT 2008)

16. REFERENCES AND BIBLIOGRAPHY

NMC guidelines for record keeping 2005.

RCN standards for infusion therapy 2005.
Medical devices agency 2003, device bulletin infusions systems.
National patient safety agency rapid response report (apr) 2008, risks with
intravenous heparin flush solutions
Nice clinical guidance 2, prevention of healthcare-associated infection in primary and
community care 2003.
Royal Marsden manual of clinical nursing procedures sixth edition
Ingram P, Lavery I (2005) peripheral intravenous therapy: key risks and implications
for practice, nursing standard. 19, 46, 55-64.
Jackson A (1998) infection control: a battle in vein; infusion phlebitis. Nursing Times
94, 4, 68-71.
Ins (2000) standards for infusion therapy, Cambridge MA: INS and Becton
Dickinson. (III).

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 APPENDIX 1

REFERRAL FOR INTRAVENOUS INFUSION

Name: Date of Birth:

Address:
Unit Number: /
NHS No
Tel No:
Sex: Ethnic Origin: Religion:

Next of Kin: Tel No:

Home Carer(s): Tel No:

Social Services Assessor: Tel No:

Reason for Infusion Request:

Any relevant Blood Results

Present Medical History: Previous Relevant Medical History:

Any Factors Which May Increase Risk Of

Allergies: Reaction:

Medications: Consultant/General Practitioner involved in care:

Address and Tel No.

Previous Infusion Episodes (dates):

Suitability to Infuse as a Day Case

Date of Infusion: Discharge Information:

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 APPENDIX 2
PRE INFUSION BASELINE OBSERVATION

Name Date of Birth Unit No

Has informed consent been obtained What information has the patient received?
from the patient?

Yes No

Blood Pressure: Pulse: Temperature: Oxygen Saturation:

Sufficient intake of air

Sufficient intake of water/nutrition

Elimination

Moving and Handling

Promotion of Normality (include communication)

Prevention of Hazards

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 APPENDIX 3

INTRAVENOUS INFUSION CARE PLAN

Name Date of Birth Unit No

PROBLEM: CONDITION REQUIRING AN INTRAVENOUS INFUSION

GOAL: TO REDUCE ASSOCIATED RISKS OF RECEIVING AN INTRAVENOUS INFUSION
SUPPORTING DOCUMENTS: Reference Guide to Consent or Examination (DOH 2001, ERYPCT
2005)
Policy for the correct identification of patients (ERYPCT 2008)
Policy and procedure for the management and administration of medicines (ERYPCT 2008)
Policy for the reporting and management of adverse incidents (ERYPCT 2007)
Royal College of Nursing, Standards for Infusion Therapy 2005

PLAN OF CARE:
• Gain written informed consent for the intravenous infusion. Explain procedure and reason for
the intravenous infusion to patient/carer and possible side effects. Give the patient written
information in relation to the intravenous infusion as able.
• Identify patient as per Policy for Correct Identification of Patients.
• Check intravenous product as per intravenous infusion policy.
• Record Temperature, Blood Pressure, Pulse and oxygen saturation levels, to establish a
baseline set of observations, repeating post infusion and hourly whilst infusion in progress or
as per IV data instructions.
• Check canula site each time baseline observations are done and post infusion and record
using phlebitis and infiltration scale.
• Encourage patient to report any symptoms/abnormalities.
• Maintain accurate fluid balance for at least 24 hours from the start of the infusion. In the case
of day hospital patients, monitor fluid balance for duration of infusion.
• Change administration set every 72 hours.
• Peripheral canula to be changed every 72 hours.
• Use transparent semi-permeable dressing to secure canula, do not cover access port.
• Dispose of administration set and used infusion bags as per waste management
policy/infection control manual.
• In the event of an adverse reaction stop infusion immediately, and follow instructions as per
intravenous infusion Policy and inform medical staff.
• Evaluate plan of care after infusion in patient care plan.

PATIENT SPECIFIC CARE

NURSE SIGNATURE: PRINT NAME:

DATE:
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 APPENDIX 4

INTRAVENOUS INFUSION CARE PLAN (2)

Name Date of Birth Unit No

Date/Time Evaluation Signature

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 APPENDIX 5

OBSERVATIONS, REACTIONS AND COMMENTS

Name Date of Birth Unit No

Hospital: Date:

Baseline vital signs must be recorded prior to the Intravenous Infusion and at intervals as
recommended by product literature

Date
Time

40ºC

39

38

37

36

35
200
34

180

160

140

120

100

80

60

40

20

0
02
Sats

Phlebitis/infiltration
Score
Patient
Satisfaction

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 APPENDIX 6
COMMUNICATION SHEET

Name Date of Birth Unit No

Date Time Communication Signature

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 APPENDIX 7
BLOOD – I.V. FLUID AND ADDITIVE PRESCRIPTION CHART

Instructions: Prescriber to sign even if no ‘additive’ is ordered. After each 24 hours draw horizontal line in red ink. File in case notes.

Name Date of Birth Unit No Allergies

Additive Signature Date and Time

Date Type of Rate of Batch/Bottle Number Time Time Volume
I.V. Fluid Infusion Name and Prescriber’s Dispensed Started Witness Stopped Infused Dripset I.V. Site
mls/hrs dose Signature Dept. or changed changed
person
Electro-
lyte

Drug

Electro-
lyte

Drug

Electro-
lyte

Drug

Electro-
lyte

Drug

Electro-
lyte

Drug

Electro-
lyte

Drug

Electro-
lyte

Drug

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 APPENDIX 8
FLUID BALANCE CHART
Name Date of Birth Unit No

Sheet Number: Date:

VOLUME OF INTAKE VOLUME OF OUTPUT
as WATER as ELECTROLYTES in solution
One hour period up Urine Drainage Diarrhoea Naso
to:- Mouth or Batch No. Type of Volume Additives and gastric or
stomach tube Fluid Sputum vomit

01:00

02:00

03:00

04:00

05:00

06:00

07:00

08:00

09:00

10:00

11:00

12:00 midday

13:00

14:00

15:00

16:00

17:00

18:00

19:00

20:00

21:00

22:00

23:00

24:00 midnight

TOTAL for PERIOD

a.m. to a.m.
p.m. p.m.

TOTAL for 24 hrs.

BALANCE FOR 24 hrs. Body Weight:

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 APPENDIX 9
DISCHARGE LETTER

Date:

Dear Doctor

Name: Date of Birth:

Address:

Your patient was admitted to the Day Hospital on:……………………………………

For: ……………………………………………………………………………………………....

…………………………………………………………………………………………………….

…………………………………………………………………………………………………….

…………………………………………………………………………………………………….

…………………………………………………………………………………………………….

…………………………………………………………………………………………………….

Discharge observations:..………………………………………………………………………

.……………………………………………………………………………………………………

....……………………………………………………………………………………………........

Advice given:..…………………………………………………………………………………...

…………………………………………………………………………………………………….

…………………………………………………………………………………………………….

Yours sincerely

Name
Job Title

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 APPENDIX 10

Phlebitis Scale
(Jackson 1998)

0
IV site appears healthy.
No signs of phlebitis

OBSERVE CANNULA

1
One of the following is evident. Possibly first signs of
• Slight pain near IV sight
Or phlebitis
• Slight redness near IV sight

OBSERVE CANNULA

2
Two of the following are evident. Early stage of phlebitis
• Pain at IV sight
• Erythema
• Induration RESITE CANNULA

3
All of the signs are evident. Medium stage of phlebitis
• Pain along path of
Cannula
• Erythema RESITE CANNULA
• Induration
Consider Treatment

4
All of the signs are evident and Advanced stage of phlebitis
extensive.
• Pain along path of Or the start of thrombophlebitis
Cannula
• Erythema
• Induration RESITE CANNULA
• Palpable venous cord Consider Treatment

5
All of the signs are evident and Advanced stage of
extensive.
• Pain along path of thrombophlebitis
Cannula
• Erythema
• Induration INITIATE TREATMENT
• Palpable venous cord Resite Cannula
• Pyrexia

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 APPENDIX 10 CONT.D

INFILTRATION SCALE (INS 2000)

Grade Clinical Criteria

0 • No symptoms
1 • Skin balanced
• Oedema <1 inch (2.5 cm) in any direction
• Cool to touch
• With of without pain
2 • Skin balanced
• Oedema 1-6 inches (2.5 cm -15cm) in any
direction
• Cool to touch
• With or without pain
3 • Skin balanced, translucent
• Gross oedema > 6 inches (15cm) in any direction
• Cool to touch
• Mild to moderate pain
• Possible numbness
4 • Skin balanced, translucent
• Skin tight, leaking
• Skin discoloured , bruised, swollen
• Gross oedema >6 inches (15cm) in any direction
• Deep pitting tissue oedema
• Circulatory impairment
• Moderate to severe pain
• Infiltration of any amount of blood product, irritant,
or vesicant.

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