Policies and Procedures for Infusion Therapy of the Older Adult
Total Page：16
File Type：pdf, Size：1020Kb
Policies and Procedures for Infusion Therapy of the Older Adult 3rd edition Policies and Procedures for Infusion Therapy of the Older Adult 3rd edition Copyright© 2016 by the Infusion Nurses Society, Inc. All rights reserved. No part of this book may be reproduced without written permission from the Infusion Nurses Society. Contents PREFACE . 6 THE AGING PROCESS . 7 1. GENERAL ORGANIZATIONAL POLICIES Infusion Team . 20 Competence and Competency Validation . 22 Product Evaluation, Integrity, and Defect Reporting . 25 Informed Consent . 27 First Dose Administration in Alternative Care Settings . 31 Latex Sensitivity or Allergy . 34 Adverse and Serious Adverse Events . 36 2. INFECTION PREVENTION AND SAFETY COMPLIANCE Hand Hygiene . 40 Sharps Management . 43 Medical Waste Disposal . 45 Durable Medical Equipment Disinfection . 46 Standard Precautions . 48 Transmission-Based Precautions . 51 3 Policies and Procedures for Infusion Therapy of the Older Adult 3. VASCULAR ACCESS DEVICE PLACEMENT Vascular Access Device (VAD) Planning . 56 Local Anesthesia . 62 Short Peripheral Catheter (SPC) Placement . 66 Ultrasound-Guided Short Peripheral Catheter (SPC) Placement . 73 Short Peripheral Catheter (SPC) Insertion via the External Jugular (EJ) Vein . 78 Ultrasound-Guided Midline Catheter Insertion . 83 Ultrasound-Guided Peripherally Inserted Central Catheter (PICC) Insertion Using Modified Seldinger echniqueT (MST) . 92 Ultrasound-Guided Nontunneled Central Vascular Access Device (CVAD) Insertion Using Modified Seldinger Technique (MST) . 102 Ultrasound-Guided Nontunneled Central Vascular Access Device (CVAD) Insertion Using Seldinger Technique . 113 4. SITE CARE AND MAINTENANCE Administration Set Change . 124 Maintaining Vascular Access Device (VAD) Patency: Flushing and Locking . 127 Vascular Access Devices (VADs): Ongoing Assessment, Site Care, and Dressing Change . 132 Vascular Access Device (VAD) Removal . 138 5. INFUSION-RELATED COMPLICATIONS: IDENTIFICATION & INTERVENTION Air Embolism . 144 Allergic Reaction and Anaphylactic/Anaphylactoid Reactions . 147 Catheter Damage . 151 Central Vascular Access Device (CVAD) Malposition . 155 Central Vascular Access Device (CVAD) Occlusion . 159 Central Vascular Access Device (CVAD)-Associated Venous Thrombosis . 166 Circulatory Overload . 169 Infiltration/Extravasation . 172 Nerve Injuries . 182 Phlebitis . 185 Vascular Access Device (VAD)-Associated Infection . 189 4 Contents 6. OTHER INFUSION-RELATED PROCEDURES Preparing Immediate-Use Parenteral Medications . 194 Implanted Vascular Access Port: Accessing and Deaccessing . 197 Phlebotomy: Blood Sampling from a Vascular Access Device (VAD) . 203 7. OTHER INFUSION ACCESS Intraspinal Access Device: Care and Management . 212 Subcutaneous Access Device: Placement and Infusion Administration . 220 Intraosseous Access Device: Placement, Care, and Management . 225 8. INFUSION THERAPIES IV (Intravenous) Administration: Continuous Infusion, IV Push, Intermittent Infusion . 230 Transfusion Therapy . 241 Parenteral Nutrition . 248 Antineoplastic Therapy . 252 Biologic Therapy . 259 Patient-Controlled Analgesia (PCA) . 263 Moderate Sedation . 268 Therapeutic Phlebotomy . 272 Resources . 277 Illustrations . 279 The Policies and Procedures for Infusion Therapy of the Older Adultis intended to reflect current knowledge and practices of the clinical specialty of infusion therapy. Because clinical practice continually evolves based on ongoing research, users should make an independent assessment of the appropriateness and applicability of a policy or procedure in any specific instance, and should also consider the applicable federal and state laws and regulations, as well as the standard of care in a particular jurisdiction, as these may take precedence. INS is not responsible for injury to persons or property, or other harm, arising from the use of the Policies and Procedures. 5 Policies and Procedures for Infusion Therapy of the Older Adult Preface Many older adults require infusion therapy for medical management of a variety of conditions or diseases. When caring for this special patient population, it’s important to understand physiologic changes that occur as a result of the aging process, and the potential effects those changes may have on infusion-related outcomes. Awareness of clinical implications associated with infusion therapy interventions will enable accommodation for any special infusion care needs of the older adult patient. This third edition of Policies and Procedures for Infusion Therapy of the Older Adult aligns with the Infusion Nurses Society’s (INS’) 2016 Infusion Therapy Standards of Practice (the Standards) and serves as a guide to clinical practice. The format for this edition has been expanded. Not only does it include the policy (which defines a course and purpose of an action) and the procedure (the steps to be taken), it also offers new sections on key points, assessment, patient/caregiver education, and home care/alternative site implications. While there are areas of care, such as infusion-related complications and infusion therapies, that don’t fit the typical policy and procedure format, their inclusion was deemed important because they have a direct impact on the delivery of infusion care. And where applicable, a section introduction, “Considerations for the Older Adult,” has been added throughout to emphasize the needs of the older adult patient. The basis of this revision’s content is Policies and Procedures for Infusion Therapy, 5th edition, which incorporates the updates and robust research contained in the 2016 Standards. A bibliography accompanies each policy and procedure as a resource for readers seeking more information. Since the Standards was the primary reference for development of the policies and procedures, individual standards are not cited in each section’s bibliography in order to minimize repetition. I want to recognize and thank the following nurses for their thoughtful reviews and input: Cynthia Brown, MSN, ARNP, GNP-BC, CRNI®; and Mary Walsh, BS, RN, CRNI®. INS believes that better patient outcomes result when there is consistency in practice. Incorporating practices from Policies and Procedures for Infusion Therapy of the Older Adult provides the framework to do just that. Mary Alexander, MA, RN, CRNI®, CAE, FAAN Chief Executive Officer, Infusion Nurses Society 6 The Aging Process The Aging Process Older adults require infusion therapy for a variety of conditions or diagnostic indications. An assessment includes a system-by-system examination; a review of medical, medication, and infusion therapy history; confirmation of ability to perform activities of daily living (ADLs), functional status, and psychological and safety assessments. Family and/or caregiver, current contact information, community resources, and advanced directives are included. Aging Theories Aging is dependent on nutritional, environmental, educational, socioeconomic, genetic, physiologic, and spiritual factors. Aging theories range from the biologic to the psychosocial. No one ages the same, given all the unique factors. Because the population of older adults is increasing, older people are classified into 3 major groups: 1. Young old: 65 to 74 years 2. Middle old: 75 to 84 years 3. Old old: 85 years and older The following is a summary of considerations that may affect infusion-based approaches to device selection, vascular access site care and management strategies, and anticipated outcomes. Physiological Changes and General Infusion Considerations Integumentary System Many changes occur in the integumentary system that can have a significant impact on the provision of infusion therapy services. As the individual ages, there is a decrease in fluid-to-body mass ratios. In addition to a loss of collagen and elasticity, this makes the skin texture more pliable. With the loss of subcutaneous fat, the veins will have a tendency to roll. The number of sweat cells decrease and diminish in efficiency with less sebum produced, which results in a decreased ability to perspire, further enhancing skin dryness. Skin will appear looser as the number of papillae (the cells that hold the 3 layers of the skin tightly together) decreases. Sensory changes that can accompany aging may cause a decrease in the thirst reflex mechanism, leading to dehydration. Hydration imbalances may make skin turgor evaluation a poor assessment tool. Hydration as a form of “pretreatment” may be necessary before infusion therapy can be initiated. Skin turgor assessment for hydration status should be performed either mid-sternum or between the eyes, instead of on the hand. The number of sensory nerve endings decreases with age as does the older adult’s ability to perceive pain. This increases the risk that damage to the skin will be delayed or will go unnoticed. Should a medication or solution infiltrate into the 7 Policies and Procedures for Infusion Therapy of the Older Adult underlying tissues, it may not be immediately recognized. This can lead to a delay in treating an infiltration, increasing potential damage to the tissues. The epidermis becomes thin and inelastic with age. Collagen fibers decrease in number and function, contributing to the skin’s loss of flexibility and elasticity. The epidermis is rendered more fragile and heals more slowly as the skin-cell turnover rate decreases. A thinner outer skin layer makes the skin a less effective barrier against the introduction of microorganisms. Looser skin and a loss of subcutaneous tissue make the veins less