≥ 92% of participants will know IV legalities, infection control, safe injection, and documentation.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know IV legalities, infection control, safe injection, and documentation.
After completing this continuing education course, the participant will be able to meet the following objectives:
It is not uncommon for licensed practical nurses (LPNs) to have the authority to perform intravenous (IV) therapy. Fluid and medication therapy, nutritional administration, and the establishment of an IV access are prevalent tasks and often necessary in many healthcare settings. The responsibility of IV therapy should not be taken lightly, as it is a service to be performed when giving optimal care to our patients. Suboptimal performance with IV therapy, including practicing out of scope and incorrect documentation, can lead to poor patient outcomes and legal challenges.
Every healthcare facility has IV therapy policies that outline IV practices and are dependent upon the type of care being provided. These policies are required to obtain accreditation. The facility policy is often developed based on local, state, and national standards. However, these policies cannot go beyond what the state's nurse practice act (NPA) permits.
The legalities of IV practice in the state of Florida are discussed in this course. However, the content discussed in this course may not be the standard for other states and other facilities. Please check your own state's rules and regulations, including the NPA, regarding IV therapy by LPNs.
“Under the direction of a registered nurse (RN)” means that the RN has delegated IV therapy functions. The RN does not always have to be on the premises for IV therapy to occur.
The following are outlined in Florida’s NPA. An NPA is designed to protect patients and healthcare workers by outlining and regulating education and the scope of practice (Huynh and Haddad, 2022).
An LPN can be more involved in IV therapy if they have completed an approved course with a return demonstration and are approved by a facility. Administration of IV therapy involves infusion or injection through a peripheral venous system.
An LPN can perform certain aspects of IV therapy via central lines after appropriate education and training (FAC, 2015).
The following is outlined under the Florida Administrative Code and Registrar and considered to be the standards for competency and knowledge requirements for IV therapy.
Aspects of IV therapy that are outside the scope of practice of the LPN unless, under the direct supervision of the RN, physician, or dentist include the following:
Now that the Florida scope of practice for LPN IV therapy has been defined and the coinciding requirements have been listed, it is time to discuss infection control.
IV therapy is an invasive procedure. A strict aseptic technique for initiating venipuncture, its care, and site maintenance is necessary to prevent the transmission of bloodborne pathogens.
Exposures can occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood.
It is important to note that the risk of infection is very low if the source's viral load is undetectable, but there is still a risk (OSHA, 2001).
Infection control is crucial when inserting any type of catheter. Not only are LPNs at risk of occupational exposure, but we also put our patients at risk of serious infections and complications if we do not maintain clean or aseptic technique. Maintaining proper technique when initiating and maintaining IV therapy is essential to prevent infections.
A more serious infection that may spread to other parts of the body via the bloodstream will have more severe symptoms, such as hypotension, trouble breathing, and a comatose state (Moriyama et al., 2022).
There are certain steps that should be followed to help prevent these infections from occurring, and they include the following:
Now that we know why we must adhere to infection control precautions and standards, it is time to discuss how to do so.
Controls are incorporated into the healthcare work setting to avoid or reduce exposure to potentially infectious materials. Healthcare-associated transmission is the transmission of microorganisms that is likely to occur in a healthcare setting that can be reduced by using engineered controls, safe injection practices, and safe work practices. Engineered controls are equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are equipment and practices that allow the performance of injections in an optimally safe manner for patients, healthcare providers, and others that reduce exposure to occupational hazards.
An example of engineered controls is sharps boxes that are used so staff do not get stuck by blood-contaminated needles or blades.
Nurses, including LPNs, sustain the largest proportion of sharps injuries of all healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals do get injured. Some of these injuries expose professionals to bloodborne pathogens that can cause infection.
Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary when alternatives for skin penetration are unavailable. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a device design and selection guideline.
Sharps equipment should be disassembled using forceps or other devices. Suturing should always be done with a needle holder, forceps, or other tools. Do not use fingers to hold tissue when suturing or cutting. Never leave sharps on a work field. If used needles or other sharps are left in the work area or are discarded in a sharps container that is not puncture-resistant, a needlestick injury may result. Injury may occur when a healthcare professional attempts to transfer blood or other body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the target (Alfulayw et al., 2021).
Safe injection practice in hospitals is well established. However, outbreaks of infections with hepatitis B and hepatitis C amongst patients have been traced back to ambulatory care facilities and associated with non-compliance with safe injection practices, identifying the need to define and reinforce safe injection practices in outpatient care settings. Reusing needles, multidose vials, and work areas containing sterile and contaminated injection supplies contribute to the problem. There has been a lack of understanding of aseptic technique, a lack of oversight, and a failure to follow up on infection control breaches. The following are safe injection practices that apply to the use of needles, cannulas that replace needles, and, where applicable, IV delivery systems.
Employers must establish exposure control plans that include post-exposure follow-up. LPNs and other employees must comply with incident reporting requirements mandated by the OSHA bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. Hepatitis B immune globulin (HBIG), hepatitis B vaccine, and antiretroviral agents for HIV post-exposure prophylaxis (PEP) should be available for timely administration, either by providing access on-site or by creating linkages with other facilities or providers to make them available off-site.
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended as it may do further harm. Report the exposure to the government agency responsible for managing exposures. Usually, one person in a facility is appointed responsible for this reporting (CDC, 2021). Reporting is necessary as PEP treatment may be recommended as soon as possible.
Post-exposure care for hepatitis B is dependent upon the source's status. LPNs with written documentation of a complete hepatitis B vaccine series but who have not received postvaccination testing should receive a single vaccine booster dose. LPNs who have received only part of the hepatitis B series should receive the appropriate dose of HBIG and complete the vaccine series.
Currently, no recommendations exist for post-exposure prophylaxis for hepatitis C.
Exposure to HIV can be frightening and should be handled according to the facility’s policies.
PEP should occur as soon as possible after exposure to HIV.
As we have discussed, there are many aspects of IV therapy, including the scope of practice and infection control. Another element of IV therapy involves legal responsibilities. Administering IV therapy to patients is one of the nurses' most legally significant tasks. Lawsuits can arise for a variety of reasons and include the following:
Always adhere to the seven "rights" of giving medications to prevent lawsuits. They are:
Failure to adhere to these principles of medication delivery can result in fines, loss of license, and even jail time.
We live in a culture of measurement. Actions, observations, and intent are all subject to review and comparison toward desired standards. Records must be generated, stored, and maintained to meet pressures internal to our profession and those that exist externally. Medical documentation has become a component of health care as significant as rendering hands-on, direct-person interventions. Updating our documentation premise and process knowledge is essential to honing our professional and technical skills.
The challenge today is to provide concise yet comprehensive records that accurately portray the patient's experience while meeting the standards of professional and organizational care, regulatory requirements, fiscal responsibility, and criteria for reimbursement. The care record is a legal document and includes information from nurses and other health professionals who have contributed to patient outcomes.
The health record should read like a novel with a beginning (admission), a middle (active treatment to better the patient), and an end (discharge or transfer). When the documentation records are unclear and do not directly define why care is being given and the result of the care, then there are definite issues affecting payment for care and organizational accreditation. Meeting the record of care elements of performance is a continuing challenge. It is important to know what is required and ensure those requirements are met. Unfortunately, forgetting or neglecting to date and time documentation entries is one of the top reasons health organizations fail standards.
Documentation in the patient chart provides a means by which health professionals can communicate information to each other. Notes on what each of us observes and how we respond with interventions or by forming care plans must be entered into the chart.
Major institutions have created documentation standards to help guide LPNs and other healthcare professionals. The American Nurses Association (ANA) has published the Scope and Standards of Practice and Principles for Nursing Documentation.
|Documentation Do's||Documentation Don'ts|
Specific guidelines apply regardless of the documentation format you use. The following tips will help ensure that your recordkeeping can be defended in the courtroom.
Legibility is essential. Never second-guess someone else's writing. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are crucial for safe patient care because they enhance your professionalism. Ensure a dictionary is kept at the nurses' station and post a list of commonly misspelled words. Avoid abbreviations altogether when possible. If you must use them, use only abbreviations approved by your facility.
Make sure you have the CORRECT CHART for the CORRECT PATIENT before you begin writing. The medical record is a permanent legal "business record," and entries must not be made in pencil or erasable ink; write in permanent ink.
If anything is secured into the medical record with tape (monitor strips, blood product labels, etc.), use double-sided tape or tape only onto blank paper. Even though the tape is clear and can be read through by the naked eye, a copy machine may "black out" the taped area. Faxes must be copied before inclusion in the chart. Unless you have a plain paper copy machine, the ink on the fax may be water-soluble and fade in a few days.
Avoid block charting, such as "11:00 PM to 7:00 AM," as it gives the impression of vagueness. Note the exact times of all critical treatments, physician contact, or notices to supervisors. Any time you leave a message with someone in a physician's office, note the time and the name or title of the person taking the message.
Make sure the "proper" person does the documentation. For example, The Joint Commission (TJC) states that an RN should perform and document the initial assessment and care plan (TJC, 2016). Documentation by the proper person is essential in educational, nutritional, and rehabilitation assessments.
Avoid documentation practices that either allow or allude to the alteration or falsification of a medical record. Eliminate excess white space in your record.
Do not make entries in advance. Wait until things happen before marking them down. Even the most predictable events can get off schedule in patient care.
To correct written entries, put a single line through the error, then add your initials and the correction date. You may note "error" or "mistaken entry." Do not use whiteout or tape designed to obliterate typographical errors. Do not correct another's error. Likewise, if you disagree with an entry, do not record your opinion next to the disputed entry. Discuss your conclusions with a supervisor to ensure that the patient receives the best care and that the chart reflects respect for all healthcare team members (American Health Information Management Association [AHIMA], 2014).
Never chart for someone else. Do not write anything if you did not participate in an activity or observe someone else's care. If you are on duty when a nurse calls to report that she forgot to record a patient interaction, chart it in the following way:
"At 8:35 AM, Nurse Joann Green called and reported that at 5:30 AM this morning, she observed…."
Keep documentation objective. Do not chart opinions or assumptions. Rather than "the patient was unresponsive," your notes should report what you saw through objective assessment. Document what you see, hear, or smell. Avoid phrases like "perhaps,” "maybe," or "I think."
Be careful to avoid labeling the patient. For example, avoid descriptive terms like "demanding,” "drug seeking,” "abusive,” "lazy,” "drunk,” "mean,” "litigious," or "out-of-control." Instead, note observations as a description of the behaviors.
Unusual occurrences and patient injuries need to be documented. Objectively record what you witness without making any conclusions or unsubstantiated assumptions.
Always document a patient's uncooperative behavior. For example:
Document any safeguards or other preventive measures to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
A chart should note that the facility's safekeeping for valuable possessions system was explained and made available to the patient. Encourage the patient or family members to send any possessions home. If they agree, have them sign their names next to a documented statement. Discuss the availability of a safe and ensure that all items put in the safe are recorded on a receipt complete with the patient's name and ID number. Describe each item in detail using objective language, for example, a “yellow ring with a clear stone” instead of charting a “gold diamond ring.” Update the list of valuables frequently for long-term patients. Before a patient is transferred, take an inventory of the list of valuables to verify the location of the items.
Document medication administration as thoroughly as possible. Note the date, time, initials, method of administration, and, if applicable, the site where the medication was given. Document the site of the infusion, the type and amount of fluid, any medications added, and the administration rate of IV infusions.
If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the drug. When omitting a medication, document the rationale. For example, "pain medication held pending stabilization of vital signs." If a medication order is being questioned, tactfully document your conversation with the physician. If someone is giving your patient medication while you are off the unit, ensure that person charts that they administered the drug.
It is easy to fall into the trap of quick charting as tasks and responsibilities build up. However, care should be taken to avoid common charting errors (FAC, 2013). These common errors include:
Charting should be FACTUAL, ACCURATE, COMPLETE, and TIMELY.
There are certain precautions that LPNs must take to prevent mishaps from occurring, ones that could spell legal trouble. To name a few, LPNs must not work outside their scope of practice, must adhere to policies and protocols to prevent infections, and ensure their charting follows the above guidelines.
The state of Florida has outlined the steps and consequences of accidental and intentional errors.
The state of Florida has enlisted the help of a probable cause board to determine a probable cause of an incident.
There are specific reasons that LPNs may receive a citation, such as practicing out of scope.
These are only a few examples pertinent to the LPN scope of practice. LPNs should abide by all rules set forth to ensure optimal patient outcomes.
The board deems the following violations to be minor:
These violations are listed as minor. However, they may have lasting effects on the career of an LPN.
Unprofessional conduct can result in citations, fines, and loss of employment.
The legislature created the board to protect the public from nurses who do not meet minimum requirements for safe practice or pose a danger to the public. The suspensions, restrictions of practice, and conditions of probation used by the board in discharging its duties shall include, but are not limited to, the following:
The board ensures that the LPN remedies any disciplinary action taken against them.
It is often easy to make mistakes when caring for a patient, whether through IV therapy or documentation. Care should be taken to ensure all requirements and standards are met.
Joe is an IV-trained LPN who works at an outpatient infusion center. The RN left sick around noon. The doctor is preparing to leave at his usual time, 5 PM. Joe still has an hour left of chemo for one patient who is doing well. Joe does not say anything because he does not want his boss, the doctor, to be upset with him. He also does not want to remind the doctor that he cannot be by himself as an LPN. What if the doctor thinks about hiring an RN-only staff?
The law states that an LPN can only do chemotherapy under direct supervision. If Joe is the only staff on the premises, he is practicing outside his scope of practice. He might get away with it. On the other hand, if something happens to the patient, he could lose his license. Because Joe did not notify the doctor of the situation, Joe has taken on sole responsibility, which is malpractice. It is also not an ethical thing to do. Joe had an obligation to remind the doctor that the RN left early and the doctor had to be on the premises until the infusion was complete.
IV therapy is a common practice for LPNs. Skills and tasks we perform often can become mundane, and we may consider cutting corners to spare time. Cutting those corners can result in legal trouble, including citations, fines, and losing a license that was worked so hard for. LPNs should ensure that IV therapy is performed correctly and within the correct scope of practice. While IV therapy is being performed, infection control precautions and aseptic technique should be at the forefront of the mind, as IV insertion is an invasive process. IVs can expose a patient to unnecessary bacteria if improper technique is used. Should an incident that puts the patient and LPN at risk occur, proper precautions should be taken. If an LPN is exposed to potential diseases such as hepatitis B or HIV, post-exposure may include PEP, vaccines, and blood draws. Documentation of the incident and regular chart documentation, in general, should follow the guidelines for legally defensible charting and the dos of documentation. Failure to do so may result in further unintended consequences. Following your state’s NPA and guidance for IV therapy is pertinent for LPN and patient success.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.