Do you know what is the important of water? Adult body weight needs about 55%-65% of water. However, it is differ from adult body where about 95% of water needed in their body while an elderly or obese person, they need around 40% of water in their body. If person lost a lot of water from their body, whether acute or chronic, that can effect a lot of range of problems from mild lightheadedness to convulsions, coma, and in some cases, death.
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That is why intravenous fluid therapy becomes some of important part in hospital care. Some need fluid to maintain water balance and the others require it as replacement or restorative therapy.
Intravenous therapy, or IV therapy consists of administering essential fluids directly into the vein. Intravenous therapy is one of the most frequently used health care therapies. According to Taber’s Cyclopedic Medical Dictionary edition 20, the definition of intravenous is the injection into a vein of solution,drugs, or blood components.
IV therapy can be needed when the body needs to absorb substances quickly, as well as when the patient is sensitive or unable to take the medications or liquids in other ways such as orally or intramuscularly.
Therefore, there are many potential uses for IV treatments. For dehydrated or severely malnourished patients, IV fluids can quickly deliver electrolytes, nutrients, and water to the body. For example, a client with third-degree burns over 40% of the body is critically ill and has severe fluids and electrolytes imbalances. Fluid therapy must be continuously regulated in a burn client because of continuously changes in fluid and electrolytes imbalances.
The fluid therapy effectiveness in keeping pace with continuing losses and in correcting existing deficits should be reviewed at frequent intervals, bearing in mind that the rate of loss decreases with time. Commonly, the rate of infusion in periodic adjustment should be made in response to information gained by monitoring the patient’s condition and at least one half of the total fluid requirement will have been given in the first 12.this can be referred to John A.D.Settle, Resuscitation and fluid balance, 2006.
Besides that, IV treatments can be used for emergency delivery of drugs, or proper dosage of medication over intervals. Blood and plasma can also be transfused through an IV, in the case of blood loss.
The complication of IV therapy is hematoma, formations resulting from the infiltration of blood into the tissues at the venipuncture site. This is causes by nicking the vein during an unsuccessful venipuncture attempt, discontinuing the I.V. cannula or needle without pressure, applying a tourniquet too tightly above a previously attempted venipuncture site.
Another complication is air embolism that caused by air entering the central vein, which is quickly trapped in the blood as it flows forward. So, as the nurse we must make sure all the connection are tight and remove the air from the tubing or get the new tubing.
Other than that, fluid overloads also one of the complications of IV therapy. This is can cause by an excessive amounts of isotonic or hypertonic crystalloid solutions too rapidly. Death from fluid overload have been reported cited by John L.Demoruella, Willard L.Harrison and Roger E. Flora,1975.
Therefore, to prevent it we must carefully monitor flow rate. The most frequent problem encountered is the maintaining a constant flow rate for the fluid when administer IV therapy. To determine flow rates, the nurse needs to know the amount of fluid to be given in a specified time interval and the drop factor of the administration set to be used. To calculate an hourly IV rate the following formula is use.
Amount required X 500 mls (1pint) x 20 (drop factor) = Drop per minute
24hours x 60minits
Manual regulation of IV fluids is performed by adjusting the roller adaptor on the IV tubing until it reaches the appropriate drip rate per minute. To manually regulate the IV rate, the nurse looks at her watch and times the number of drops that fall into the drip chamber over one full minute. If the rate is too slow, the adapter should be rolled to a looser position to speed the dripping of the IV. If the rate is too fast, the roller adapter should be tightened to decrease the dripping of the IV. Nurses should adjust the roller until the IV rate is set at the correct amount of drops per minute to deliver the IV fluids as ordered. The IV rate must be checked every hour or more often according to the policy of the medical setting to be certain that the rate remains accurate.
The major nursing responsibility to ensure that the solution is flow and maintain as scheduled. This can be done continuous observation and assessment of the patient and the IV site.
After infused, we must assume responsibility for ensuring complete and accurate
documentation. To measure intake and output of IV drip, the nurses should know how much IV fluid has infuse over the shift and know how much IV fluid is left to count for the next shift. This is important to prevent any incident happen during the patients receives IV therapy. To make sure the kidney is functioning properly, nurses need to monitor fluid balance by checking intake and output at least every shift. The patient’s weight need to taken daily and assess vital signs regularly, monitoring the weight gain, monitor blood pressure, or a rising in heart or respiratory rate. (KIM DAVID, RN, MSN, 2007)
AIM
The aim of clinical audit for IV therapy is to make sure the staff nurse follow the right procedure when prepared of IV therapy.
OBJECTIVE
To ensure the nurse ability to calculate the flow rate when administration the intravenous therapy by using the formula.
To ensure the nurse document accurately and completely the IV drip infused in appropriate patient’s record.
METHODOLOGY
LOCATION
For my audit, I was observing staff nurse at the ward that I have posting.
SAMPLE SELECTION
I was chosen 20 staff nurse for my audit randomly. The selection of staff nurses are from level of junior and senior. For my sample selection, the staff nurse will be audit by me based on standard of procedure (SOP).
AUDIT TOOL
I was used SOP that already convert to checklist for my guideline when audit the staff nurse. So, when the staff nurse doing the step of administration IV therapy, I just mark at the checklist form. For objective one, the step is number 17 while the objective 2, the step is number 21.
LIMITATION
For the first problem, that I got during audit is the small amount of staff nurse doing the administration the IV therapy because most of the procedure about the IV therapy was due by JM.
The duration to audit the staff nurse. Although I took 1 month but it is not enough because the ward is busy and we must consider it when the staff nurse not follow the correct step when administration IV therapy.
TIME FRAME
I was started about 1 month for audit the staff nurse.
ETHICAL CONSIDERATION
This audit was got permission from the Sister to audit her staff nurses at ward.
DATA COLLECTION
For this audit, I collect data with observed 20 staff nurses guided with checklist and mark all step of procedure administration IV therapy.
DATA ANALYSIS
All the data that collected from this audit was converted to percentages by manual calculation. The data of number staff nurse that ability to calculate the drop factor for flow rate when administration the intravenous therapy and the nurse document accurately and completely the IV drip infusion in appropriate patient’s record I was distribute in bar chart.
Calculation:
Total number of staff nurses follows the steps ( conformance) x 100 = %
Total sample of staff nurses (10)
Total number of staff nurses follows the steps (non conformance) x 100 = %
Total sample of staff nurses (10)
STANDARD OF PROCEDURE
Great client and introduce self.
Explain procedure to the client.
Perform hand washing.
Prepare the equipments.
Place client in appropriate position.
Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking and the bag is not expired.
Select either a mini or macro drip administration set and the tubing. Do not let the ends of the tubing become contaminated.
Close the flow regulator.
Remove the protective covering from the port of the fluid bag and the protective covering from the spike of the administration set.
Insert the spike of the administration set into the port of the fluid bag with a quick twist.
Hold the fluid bag higher than the drip chamber of the administration set.
Squeeze the drip chamber once or the twice to start the flow. Fill the drip chamber to the marker line(approximately half full)
Open the flow regulator and allow the fluid to flush all the air from the tubing.
Take care not to let the tip of the administration set become contaminated.
Turn off the flow and place the sterile cap back on the end of the administration set.
Remove the protective cap from the end of the administration set and connect it to the plastic catheter.
Adjust the flow rate as desired.
Tape the catheter by ‘U’ method. Using three strips of adhesive tape, each about 7.5 cm along.
Check for patency of line.
Perform hand washing.
Documentation:
21.1. Schedule documented.
21.2. IV infused:
-Dated
-Time indicated fluid name indicated.
-Amount infused indicated
21.3. I/O chart include with :
-name
-MRN
21.4. Document adverse reactions identified.
21.5. Document appropriate measures taken if adverse reaction.
CHECKLIST
NO
PROCEDURE
SOURCE OF INFORMATION
YES
NO
1.
Great client and introduce self.
Observe staff nurse.
2.
Explain procedure to the client
Observe staff nurse.
3.
Perform hand washing.
Observe staff nurse.
4.
Prepare the equipments.
Observe staff nurse.
5.
Place client in appropriate position
Observe staff nurse.
6.
Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking and the bag is not expired.
Check on IV bottle.
7.
Select either a mini or macro drip administration set and the tubing. Do not let the ends of the tubing become contaminated.
Observe staff nurse.
8.
Close the flow regulator.
Observe staff nurse.
9.
Remove the protective covering from the port of the fluid bag and the protective covering from the spike of the administration set.
Observe staff nurse.
10.
Insert the spike of the administration set into the port of the fluid bag with a quick twist.
Observe staff nurse.
11.
Hold the fluid bag higher than the drip chamber of the administration set
Observe staff nurse.
12.
Squeeze the drip chamber once or the twice to start the flow. Fill the drip chamber to the marker line(approximately half full)
Observe staff nurse.
13.
Open the flow regulator and allow the fluid to flush all the air from the tubing.
Observe staff nurse.
14.
Take care not to let the tip of the administration set become contaminated
Observe staff nurse.
15.
Turn off the flow and place the sterile cap back on the end of the administration set.
Observe staff nurse.
16.
Remove the protective cap from the end of the administration set and connect it to the plastic catheter
Observe staff nurse.
*17.
Adjust the flow rate as desired.
Observe staff nurse/Check flow rate.
18.
Tape the catheter by ‘U’ method. Using three strips of adhesive tape, each about 7.5 cm along
Observe staff nurse.
19.
Check for patency of line
Inspect line and site pattern.
20.
Perform hand washing
Observe staff nurse.
*21.
Documentation:
–
21.1. Schedule documented.
Observe staff nurse
IV infused:
–
21.2.1 Dated
Observe staff nurse
21.2.2 Time indicated fluid name indicated.
Observe staff nurse
21.2.3 Amount infused indicated
Observe staff nurse
21.3. I/O chart include with :
-name
-MRN
Observe staff nurse
21.4. Document adverse reactions identified.
Check written evidence.
21.5. Document appropriate measures taken if adverse reaction.
Check written evidence.
RESULT
NO
PROCEDURE
SOURCE OF INFORMATION
YES
NO
1.
Great client and introduce self.
Observe staff nurse.
20/20
–
2.
Explain procedure to the client
Observe staff nurse.
20/20
–
3.
Perform hand washing.
Observe staff nurse.
20/20
–
4.
Prepare the equipments.
Observe staff nurse.
20/20
–
5.
Place client in appropriate position
Observe staff nurse.
20/20
–
6.
Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking and the bag is not expired.
Check on IV bottle.
20/20
–
7.
Select either a mini or macro drip administration set and the tubing. Do not let the ends of the tubing become contaminated.
Observe staff nurse.
20/20
–
8.
Close the flow regulator.
Observe staff nurse.
20/20
–
9.
Remove the protective covering from the port of the fluid bag and the protective covering from the spike of the administration set.
Observe staff nurse.
20/20
–
10.
Insert the spike of the administration set into the port of the fluid bag with a quick twist.
Observe staff nurse.
20/20
–
11.
Hold the fluid bag higher than the drip chamber of the administration set
Observe staff nurse.
20/20
–
12.
Squeeze the drip chamber once or the twice to start the flow. Fill the drip chamber to the marker line(approximately half full)
Observe staff nurse.
20/20
–
13.
Open the flow regulator and allow the fluid to flush all the air from the tubing.
Observe staff nurse.
20/20
–
14.
Take care not to let the tip of the administration set become contaminated
Observe staff nurse.
20/20
–
15.
Turn off the flow and place the sterile cap back on the end of the administration set.
Observe staff nurse.
20/20
–
16.
Remove the protective cap from the end of the administration set and connect it to the plastic catheter
Observe staff nurse.
20/20
–
*17.
Adjust the flow rate as desired.
Observe staff nurse/Check flow rate.
10/20
10/20
18.
Tape the catheter by ‘U’ method. Using three strips of adhesive tape, each about 7.5 cm along
Observe staff nurse.
18/20
2/20
19.
Check for patency of line
Inspect line and site pattern.
20/20
–
20.
Perform hand washing
Observe staff nurse.
15/20
5/20
*21.
Documentation:
–
–
–
21.1. Schedule documented.
Observe staff nurse
20/20
–
IV infused:
–
–
–
21.2.1 Dated
Observe staff nurse
20/20
–
21.2.2 Time indicated fluid name indicated.
Observe staff nurse
20/20
–
21.2.3 Amount infused indicated
Observe staff nurse
8/20
12/20
21.3. I/O chart include with :
-name
-MRN
Observe staff nurse
20/20
–
Document adverse reactions identified.
Check written evidence.
14/20
6/20
Document appropriate measures taken if adverse reaction.
Check written evidence.
10/20
10/20
OBJECTIVE NO.1
Table 1 below has showed the number percentages of staff nurse conformance or non-conformance in calculate the flow rate when administration the intravenous therapy using the formula.
NO
PROCEDURE
SOURCE OF
INFORMATION
COMFORMANCE
%
NON
COMFORMANCE
%
17
Adjust the flow rate as desired.
Observe staff nurse/Check flow rate.
10/20
50%
10/20
50%
Figure 1 above showed the percentages of staff nurse conformance or non-conformance in calculate the flow rate when administration IV therapy by using formula.
ANALYSIS DATA
Based on result, the sample of staff nurse is 20 people. The bar chart show that the percentages of staff nurse in calculate the flow rate when administration IV therapy by using formula. For the step 17, the number of staff nurse that conformance is 10 people (50%) and the number of staff nurse non- conformance is 10 people (50%).
OBJECTIVE NO.2
Table 2 below has showed the number percentages of staff nurse conformance or non-conformance in documentation accurately and completely the IV drip in appropriate patient’s record.
NO
PROCEDURE
SOURCE OF
INFORMATION
COMFORMANCE
%
NON
COMFORMANCE
%
21.
Documentation:
Observe staff nurse.
21.1 Schedule documented.
Observe staff nurse.
20/20
100%
–
–
21.2 IV infused:
21.2.1 Dated
Observe staff nurse.
20/20
100%
–
–
21.2.2Time and fluid name indicated.
Observe staff nurse.
20/20
100%
–
–
21.2.3Amount infused indicated
Observe staff nurse.
8/20
40%
12/20
60%
I/O chart include with:
-name
-MRN
Observe staff nurse.
20/20
100%
–
–
21.4 Document adverse reactions identified
Check written evidence.
14/20
70%
6/20
30%
21.5 Document appropriate measures taken if adverse reaction.
Check written evidence.
10/20
50%
10/20
50%
Figure 2 above showed that percentages of staff nurse conformance or non-conformance in documentation accurately and completely the IV drip in appropriate patient’s record.
ANALYSIS DATA
Based on the result above, the sample of staff nurse in my observation are 20 people. The bar chart for the step 21.1 where show the technique in schedule documented, step 21.2.1 that show the date of IV infused, step 21.2.2 that show the time and fluid type indicated of IV infused, and step 21.3 in intake and output that include name and MRN of patient. All the four of the step that mention above shows that the number of staff nurses that follow the right step in doing the documentation accurately and completely the IV drip in appropriate patient’s record are 20 people (100%).
Mostly the staff nurse can perform very well. For the step 21.2.3, there is the staff nurses that cannot follow the right step in doing documentation of taking the amount of IV infused. From the observation, the number of staff nurse that can conformance the term in step 21.2.3 is about 8 people (40%) and non conformance is 12 people (60%).
For the step 21.4, show the number of staff nurses in doing the documentation of adverse reaction is about 14 people (70%) that follow the correct step and the other 6 people (30%) disobey the designated step.
In step 21.5 that describe the number of staff nurses in doing the documentation of document appropriate measures taken if adverse reaction is equal between correct step and incorrect step. About 10 people (50%) that follow the correct step and another 10 people (50%) do not follow the correct step.
DISCUSSION
OBJECTIVE 1: To ensure the nurse ability to calculate the flow rate when administration the intravenous therapy using the formula.
The result was showed 50% of staff nurse can calculate the flow rate when administration IV therapy using formula and 50% cannot calculate the flow rate using formula.
I was observed the staff nurse when they administration the IV therapy. Mostly, the staff nurse can calculate the flow rate correctly by using formula. Before giving the IV therapy, the staff nurses write the formula in the piece of paper to calculate the flow rate. After that, I was seen that staff nurse use their watch to calculate the drops per minutes. Therefore, they can keep adjusting the clamp and calculate the drop until it reaches the correct rate.
For the rest is 50% of staff nurse that cannot calculate the flow rate by using formula having the reason. Firstly, the set of IV therapy is not standardization. This is because the manufactures calibrate their devices differently. So, before administration the IV therapy, make sure check the ‘drip factor’. For the macrodrip standard deliver is 10, 15 or 20 per millimeter and microdrip usually delivers is 60 drop per millimeter. This can be prove from journal that written by John L.Demoruella, Willard L.Harrison and Roger E. Flora,1975. That journal said that the problem of flow rate calculation is the lack of standardization of commercially available intravenous fluid administration sets. As usual, set deliver 20 drops per millimeter is used. However, there are also sets deliver ten drops per millimeter and 15 or 60 drops per millimeter.
From my observation, the staff nurse just hang the bottle drip and readjust the flow rate without calculate it. Other than that, they just use short cut way to calculate it. Therefore, they cannot practice what they was learn about calculation of IV drip by using formula.
They do not adjust the clamp to achieve flow rate and count the drop for one minute full. When I check the flow rate, there are so slow and so fast. They only hang up the bottle and adjust the flow rate without calculate the drops.
Besides that, the busy ward and few staff nurse influenced in this problem. They cannot practice the correct way because of the workload at the ward. When a few staff nurse at ward, they cannot focus on the one patient. Therefore, when they handle a lot of patient in one time, missed nursing care will happen. From Kalisch, Beatrice J. PhD, RN; Williams, Reg Arthur PhD, R, 2009 staff nurse gave about 7 themes reasons why they missing the care for patients. The 7 themes reasons are poor teamwork, too few staff, time required for the nursing intervention, ineffective delegation, poor use of existing staff resources, habit, and denial.
OBJECTIVE 2 : To ensure the nurse document accurately and completely the IV drip infused in appropriate patient’s record.
Documentation is the final aspect of the nurse’s role and is critical for providing information and gathering of statistics. Monitoring documentation allows monitoring of patient outcomes and the quality of nursing care being provided, and it measures the nurses’ awareness of policies.
For the staff nurse that can perform well in documentation accurately and completely the IV drip in appropriate patient’s record especially for the schedule document, IV infused, document adverse reaction and document appropriate adverse reaction if taken because they are responsible to care about the patient.
Some of the staff nurse do not follow the correct technique in documenting the IV therapy in patients records because they do not have knowledge on how to record the document in the correct way. This reason can be support by the study that have been done by Hemani, who is nurse in Karachi Hospital, that said lack of technical and professional knowledge causes the nurses not doing their job in the proper way.
For the calculating of flow rate, the nurses used the correct formula that has given. It also includes taking the reading of the amount that left in bottle drip. From my observation, when staff nurse documentation the intake and output, they will make sure the regime of IV drip is followed as schedule. Therefore, when closed the intake and output per shift, the carry forward for IV drip is correct. For them, the correct amount of intake and output patient also important for know the balance fluid in the body.
The reason why the staff nurse not documentation accurately especially in amount of infused is lack of skill in mathematic. Mathematical also important in nursing to calculate the amount of fluid that infused. This is because when we have skill and knowledge in mathematics, we can calculate it correctly. Prerequisite for mathematical proficiency for the better performance in many nursing function can be divided to medication calculation, intravenous regulation, and intake and output calculation. This facts can be support from journal that written by O’Shea, E. (1999), Factors contributing to medication errors: a literature review. Journal of Clinical Nursing, 8: 496-504. As the nurse, we are responsible for the administration, must do the calculation and verify that it is correct before hanging.
They just document it by recording the amount of infused. They not calculate the amount of infused. When I observed the staff nurse in documentation of IV drip, mostly just use the nursing notes or ‘kardex’ and follow the regime without observe it is followed as schedule or not. Then, they write into intake output of patient in patient’s record.
Before hanging any IV fluid, make sure that we are knowing perfectly what we hanging, why it has been ordered, and what complications may occur. If there is some volume overload, we need discontinue the fluid immediately, and informed the doctor immediately.
After doing the observation among the selected staff nurses, a few of them doing the documenting adverse reaction identified and documenting appropriate measures taken if adverse reaction in incorrect technique. This is because some of them are lacking the support and resources necessary to seek the best practice recognition for excellence in nursing care. This facts was told by Cecilia Grindel and Marlene Roman in their publication, The medical-surgical nurse: being a Magnet for excellence on April, 2005. In addition, the paper that written by Rozina Roshan Essani and Tazeen Saeed Ali, title Knowledge and Practice Gaps Among Pediatrics Nurses at a Tertiary Care Hospital in Karachi, Pakistan said that the nurses lack of information. This is because thay may have some stress in nurses and can be effect the quality of care. In another reason is because of depression, psychological distress, burden of not knowing things and feeling of being pressurized.
RECOMMENDATION
My objective is to ensure the nurse ability to calculate the flow rate when administration the intravenous therapy and to ensure the nurse document accurately and completely the IV drip infusion in appropriate patient’s record. Therefore, to attain my objective there are many method to follow.
Firstly, as the nurse we should improve our knowledge by attending the conference nursing education (CNE) to gain their knowledge. From this, the nurses can give their opinion and discuss together to solve any issues in nursing. The staff nurse also can continue their studies such as in degree to gain new knowledge and skill. I also suggest to the sister to require their staff nurse for a post basic. Therefore, the staff nurse will be more expert about that.
Besides that, the Sister can organize the workshop or seminar about the administration IV therapy and more focus on calculation of drop factor and documentation after infused IV therapy.
Another suggestion, the Sister should make a timing strip when administration the IV therapy. Not all IV bags start with reading of 0 as the first marking, but may start with a reading of 1. This means that when the IV fluid is on the reading 1, 100 ml of fluid has been infused. This timing strip also include the date and time the IV bag that was hung. For easily reading the time, write the large print for the timing. This is including day and night. Make sure the nurses include the time of the strip at the bottom when IV bag is expected to be empty.
I also recommend to the sister to use IV pumps for all patients that need IV therapy for control the IV flow rate. The nurse sets the pump to deliver a set volume at a set rate. Since they pump against pressure gradients, a constant infusion rate and volume can be maintain even with fluctuations in the patient’s venous pressure.
To handle the problem about the few staff nurse at the ward, I was recommending to the sister to take a new staff nurse to overcome the workload. In medical ward, the busy environments also influence the work of staff nurse. So, I recommend to the sister to limit the patient in ward. We should admit the chronic case and discharge or transfer out the patient that should not in ward. For example, at Hospital Selayang the HINI case is in ward 5B not in medical ward.
ACTION PLAN
To improve the skill and knowledge of staff nurse at ward, the Sister also done the test about the calculation of the drop factor among her staff. From that, the sister can know the level of knowledge their staff.
Other than that, the sister has done the audit about the IV therapy. Before she audits her staff, she taught them how to calculate the drop factor and give the simple formula to remember it. From that, her staff can know more details about it.
For the accurate and completely documentation, my friends and I was help the staff nurse check the label drip and make sure it follow the schedule. As the nurse, we should make sure the label drip is correct with the regime. So, when documentation the amount
