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.
Contact hours for LPNs in any state are earned by completing this course. This is part of a series of 24 contact hours of courses to prepare for LPN IV Certification in Florida. Florida certification participants must schedule a 6-hour live presentation and return demonstration to complete IV Certification. The live presentation is not provided by CEUFast.com.
Participants will initiate and maintain IV therapy within the legal and safe practice parameters.
After completing this continuing education course, the participant will be able to meet the following objectives:
This course discusses the legalities of the state of Florida. Please check your own state’s rules and regulations regarding IV therapy by LPNs.
Every health care facility has IV therapy policies. These policies are required to obtain accreditation. There are standards that are commonly used by committees developing the facility policy. But remember, these policies cannot go beyond what the state's nurse practice act permits.
64B9-12.001 Statement of Intent and Purpose.1
(1) The “practice of practical nursing” as defined by Section 464.003(3)(b), F.S., includes the “administration of treatments and medication,” under direction, and holds the licensed practical nurse “responsible and accountable for making decisions . . . based upon the individual’s educational preparation and experience in nursing.” As medical science advances and the demands for health care in Florida grow, the scope of nursing practice, in general, and of the practice of practical nursing, in particular, is expanding. It has become necessary that the licensed practical nurse, when qualified by training and education and when approved by the institution at which the licensed practical nurse is employed, engage in the limited administration of intravenous therapy both to serve the public and to allow the professional nurse to better perform those acts requiring professional nursing specialized knowledge, judgment and skill.
64B9-12.002 Definitions.1
(1) “Administration of Intravenous Therapy” is the therapeutic infusion and/or injection of substances through the venous peripheral system, consisting of activity which includes: observing, initiating, monitoring, discontinuing, maintaining, regulating, adjusting, documenting, planning, intervening and evaluating.
(2) “Under the direction of a registered professional nurse” means that the registered professional nurse has delegated intravenous therapy functions to a qualified licensed practical nurse. The registered professional nurse does not in all instances have to be on the premises in order for the licensed practical nurse to perform the delegated functions.
64B9-12.003 Aspects of Intravenous Therapy Outside the Scope of Practice of the LPN.1
(1) Aspects of intravenous therapy which are outside the scope of practice of the licensed practical nurse unless under the direct supervision of the registered professional nurse or physician and which shall not be performed or initiated by licensed practical nurses without direct supervision include the following:
(a) Initiation of blood and blood products;
(b) Initiation or administration of cancer chemotherapy;
(c) Initiation of plasma expanders;
(d) Initiation or administration of investigational drugs;
(e) Mixing IV solution;
(f) IV pushes, except heparin
(2) Although this rule limits the scope of licensed practical nurse practice, it is appropriate for licensed practical nurses to care for patients receiving such therapy.
64B9-12.004 Authority for the LPN to Administer Limited Forms of Intravenous Therapy.1
(1) With the exception of those aspects of intravenous therapy deemed outside the scope of practice of the licensed practical nurse by Rule 64B9-12.003, F.A.C., above, and subject to the approval of the institution at which the licensed practical nurse is employed, any licensed practical nurse who meets the competency knowledge requirements of Rule 64B9-12.005, F.A.C., below, is authorized to administer intravenous therapy under the direction of a registered professional nurse.
(2) Individuals who have completed a Board approved prelicensure practical nursing education program, professional nursing students who qualify as graduate practical nurses, or licensed practical nurses who have not completed the specified course under Rule 64B9-12.005, F.A.C., may engage in a limited scope of intravenous therapy under the direction of a registered nurse, physician or dentist. This scope includes:
(a) Perform calculation and adjust flow rate;
(b) Observe and report subjective and objective signs of adverse reactions to IV administration;
(c) Inspect insertion site, change dressing, and remove intravenous needle or catheter from peripheral veins.
(d) Hanging bags or bottles of hydrating fluid.
64B9-12.005 Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy.1
(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C.
Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse’s ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse’s personnel file.
Venipuncture is an invasive procedure. Strict aseptic technique for venipuncture, care, and maintenance of the site is necessary.
Bloodborne pathogens are any pathogenic microorganisms found in the blood or other bodily infectious material that can cause disease in humans. Examples of bloodborne pathogens include hepatitis B virus, hepatitis C virus, human immunodeficiency virus (HIV), malaria, syphilis, viral hemorrhagic fever, arboviral infections, Creutzfeldt-Jakob disease, and relapsing fever. The three bloodborne pathogens that are the most commonly involved in occupational exposures in healthcare workers are hepatitis B, hepatitis C, and HIV.2
Exposure to a bloodborne pathogen is defined as:
Exposures 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. Percutaneous injuries and splash exposures appear to be equally involved, and the most common cause of a percutaneous injury appears to be puncture wounds from hollow-bore needles.
Factors that may determine the overall risk for occupational transmission of a bloodborne pathogen include:
Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary with factors such as these3:
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.
Avoiding occupational blood exposures is the primary way to prevent transmission of hepatitis B virus, hepatitis C virus, and HIV in health-care settings. However, hepatitis B immunization and postexposure management are integral components of a complete program to prevent infection following bloodborne pathogen exposure and are important elements of workplace safety.4
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. Engineering 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. Work practice controls change practices and procedures to reduce or eliminate risks.
Nurses sustain the largest proportion of sharps injuries of all healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals are also injured.5 Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most important of these pathogens are hepatitis B, hepatitis C, and HIV. Infections with each of these pathogens are potentially life-threatening and preventable.
Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. Since 1993, the use of safety-engineered sharps devices has increased while the use of conventional sharps devices has decreased. Percutaneous injury rates have decreased dramatically, and many studies have proven that the use of safety-engineered devices has significantly decreased the number of needlestick injuries.6 A number of sources have identified the desirable characteristics of safety devices. These characteristics include the following:
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 where alternatives for skin penetration are not available. 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 guideline for device design and selection.
Needles should NEVER be recapped, bent, broken, or removed from contaminated syringes. Recapping by hand is prohibited under the OSHA bloodborne pathogens standard [29 CFR 1910.1030] unless no alternative exists. Sharps should be disposed into a puncture-proof container.
There is exposure to percutaneous injuries during procedures where there is an opportunity for percutaneous exposure, especially where there is:
Sharp equipment should be disassembled using forceps or other devices. Suturing should always be done with a needle holder, forceps, or other tool. 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.
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.7 The reuse of needles, multidose vials, and work areas containing both sterile and contaminated injection supplies contributed to the problem. There was a lack of understanding of aseptic technique, a lack of oversight, and 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 intravenous delivery systems. Examples of these include safe injection practices include:
It has been estimated that between 20-40% of all hospital-acquired infections are caused by cross-infection from the hands of healthcare workers.8 Studies have clearly shown that the hands of healthcare workers are often contaminated with microbial flora and that the amount of time spent performing patient care increases the amount of contamination. Handwashing is the most important measure to reduce the transmission of microorganisms, and handwashing reduces infection rates, even in high-risk patient populations. Hands should be washed or alcohol-based rubs should be used between patient contacts and after gloves are removed. Hands should be washed after contact with blood, body fluids, secretions, excretions, and contaminated equipment. It may be necessary to wash hands between tasks on the same patient to prevent cross-contamination of different body sites.
Employers are required to establish exposure control plans that include post-exposure follow up for their employees and to comply with incident reporting requirements mandated by the 1992 OSHA bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. HBIG, hepatitis B vaccine, and antiretroviral agents for HIV 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.9
The following are recommendation for immediate action after exposure.
Provide immediate care to the exposure 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.
Report the exposure to the government agency responsible for managing exposures. Reporting is necessary because PEP treatment may be recommended.
Administering lV therapy to patients is one of the most legally significant tasks nurses perform. Lawsuits arise for a variety of reasons:
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. In order to meet pressures internal to our profession as well as those which exist externally, records must be generated, stored, and maintained. Medical documentation has become a component of health care as significant as the rendering of hands-on, direct person interventions. Updating our knowledge of documentation premise and process is essential to hone our professional technical skills.
Medical documentation refers to any written or electronically generated information about a client which describes the services or care provided. Documentation may be in the form of paper records or electronic documents. Electronic documents include computer created medical record files, faxes, e-mails, texts, pictures, video or audio recordings. Through documentation, key observations, decisions, actions, and outcomes can be communicated, as well as preserved in a lasting fashion. The intent of documentation is the creation of a lasting accurate accounting of what occurred and when it occurred.
The challenge today is to provide succinct, yet comprehensive records that accurately portray the client's experience while meeting the standards of professional and organizational care, regulatory requirements, fiscal responsibility, and criteria for reimbursement. This record of care is a legal document and includes information from nurses and various other health professionals who have contributed to client outcome.
The health record should read like a novel with a beginning (admission), middle (active treatment to better the client), and an end (discharge or transfer). When it isn’t clear in the record why care is being given, the result of what the care given is, or even if there is any care given at all, 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 they are and make sure they are met. Staff forgetting or neglecting to date and time documentation entries is one of the top reasons for health organizations failing standards.
Documentation in the client chart provides a means by which health professionals can communicate information to each other. Notes on what each of us observes as well as how we respond with interventions, or by forming plans of care, must be entered into the chart.
Documentation of IV therapy should include:
Quality nursing documentation:
| Documentation Do's | Documentation Don'ts |
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Certain guidelines apply regardless of the documentation format you use. The following tips will help ensure that your record keeping 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, not only for safe patient care but also because they enhance your professionalism. Make sure a dictionary is kept at the nurses’ station and post a list of commonly misspelled words. Avoid abbreviations completely when possible. If you must use them, use only abbreviations approved by your facility.
Make sure you have the CORRECT CHART, for the CORRECT CLIENT before you begin writing.
The medical record is a permanent legal "business record," and as such, entries must not be made in pencil or erasable ink. Write in permanent ink. Stick to blue and black ink. As a rule, courtroom proceedings will use copies of the record. Copying and electronic scanning machines duplicate blue and black ink with the highest clarity. If you use a highlighter in your record, perhaps as a way of noting discontinued medication, make certain that your medical records department can effectively copy highlighted information — some copy machines "gray out" any writing covered by highlighter.
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 itself is clear and can be read through by the naked eye, a copy machine may "black out" the taped area. Faxes must be copied prior to inclusion in the chart. Unless you have a plain paper copy machine fax, the ink on the fax may be water-soluble and fade in a matter of days.
EVERY PAGE of the record must have the date and patient name. This is required for a record to be admitted in a courtroom setting.
Your complete signature is required once per page. Your complete signature is your name followed by your professional designation.
When adding a progress note, follow institutional policy to determine if you are to note the time that the entry is being added, rather than the time that the observation took place.
Avoid block charting, such as “11:00 p.m. to 7:00 a.m.” This type of documentation gives the impression of vagueness. Note 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 certain the “proper” person does the documentation. For example, The Joint Commission requires that the initial assessment and care plan be performed and documented by a registered nurse. Documentation by the proper person is especially important in educational, nutritional, and rehabilitation assessments.
Avoid documentation practices that either allow or allude to alteration or falsification of a medical record. Eliminate excess white space in your record. When making a progress note, write flush to the margin. Likewise, when you have completed your thought, draw a line through any remaining blank space on the line before signing your name. Do not leave blank lines between entries.
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 date of correction. You may note “error” or “mistaken entry.” Do not use white out or tape designed to obliterate typographical errors. Do not correct another’s error. Likewise, if you do not agree 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 possible care, and the chart reflects respect for all health care team members.
When possible, chart as soon as you can after you make an observation or provide care. This helps eliminate the chance of forgetting important data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made on a following day, always cross-reference the entry so that the reader will read the additional note in the proper sequence. The following steps will eliminate misunderstanding):
Never chart for someone else. If you did not participate in an activity or observe someone else’s care, do not write anything. 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 a.m., Nurse Joann Green called and reported that at 5:30 a.m. this morning she observed…”
Understand countersigning. Only countersign notes when required by the institution.
“Student Nurse name/Entry Reviewed by Jane Doe R.N.”
“Student Nurse name/Jane Doe R.N.”
Keep documentation objective. Do not chart opinions or assumptions. Rather than writing "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 client. 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. Use quotation marks when documenting comments from the patient, roommate, or visitors. Record the patient’s vital signs, physical condition, mental condition, subjective complaints, physician’s notification and arrival, and details of treatment. However, do not mention in the client’s record that an incident report or occurrence report was filled out.
Always document a client’s uncooperative behavior. For example;
Document any safeguards or other preventive measures you are taking to protect your client (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
Chart that the facility’s safekeeping for valuable possessions system was explained and made available to the client. Encourage the client or family members to send any possessions home. If they agree, have them sign their names next to a documented statement to that effect. Discuss the availability of a safe and make sure that all items put in the safe are recorded on a receipt complete with the client’s name and ID number. Describe each item in detail using objective language. For example, yellow ring with clear stone instead of charting a gold diamond ring. Update the list of valuables frequently for long-term clients. Before a client is transferred, take an inventory of the valuables list to verify location of items.
Document medication administration as thoroughly as possible. Note the date, time, your initials, the method of administration, and the site where the medication was given if it is an injection. Document the site of the infusion, the type and amount of fluid, any medications added, and the administration rate of IV infusions. At least once a shift, note the condition of the IV site along with the type and size of the catheter.
If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the medication. 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 client medication while you are off the unit, make sure that person charts that he or she administered the medication.
Avoid verbal and telephone orders whenever possible because of the high risk of errors. However, since it is not always possible, the proper method for documentation of verbal or telephone orders includes:
