Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [257], C).
2. 2.Show
   Before administering any prescribed drug, check that it is due and has not already been given.
   To protect the patient from harm (NPSA [268], C).
3. 3.Show
   Before administering any prescribed drug, look at the patient's prescription chart and check the following:

   1. the correct patient is being given the drug
   2. drug
   3. dose
   4. date and time of administration
   5. route and method of administration
   6. diluent as appropriate
   7. validity of prescription
   8. signature of prescriber
   9. the prescription is legible.
   To ensure that the correct patient is given the correct drug in the prescribed dose using the appropriate diluent and by the correct route (DH [61], C; NMC [257], C).

   To protect the patient from harm (DH [61], C; RPS [317], C).
   If any of these pieces of information are missing, unclear or illegible, do not proceed with the administration. Consult with the prescriber.
   To prevent any errors occurring. E
4. 4.Show
   Calculate and check the dosage of the drugs required over a 24‐hour period.
   To establish the correct doses of drugs (Pickstone [284], E).
5. 5.Show
   Wash hands with bactericidal soap and water or an alcohol‐based handrub, and assemble the necessary equipment.
   To minimize the risk of infection (Fraise and Bradley [98], E; NHS England and NHSI [233], C).

Procedure

1. 6.Show
   Check the name, strength and volume of the subcutaneous drug(s) against the prescription chart.
   To ensure that the correct type and quantity of fluid are administered (NPSA [268], C; RPS [317], C).
2. 7.Show
   Check the expiry date of the drug(s).
   To prevent an ineffective or toxic compound being administered to the patient (NPSA [268], C).
3. 8.Show
   Check that the packaging is intact and inspect the container and contents in good light for cracks, punctures and air bubbles.
   To check that no contamination of the infusion container has occurred (NPSA [268], C).
4. 9.Show
   Check the identity and amount of drug to be prepared. If an electronic identity check system for patient and/or medicine identification is in place, then use in accordance with hospital policy and procedures.
   To minimize any risk of error, and to ensure safe and effective administration of the drug (NPSA [268], C).
   Consider:

   1. compatibility of drugs
   2. stability of mixture over the prescription time
   3. any special directions for dilution, for example pH or optimum concentration
   4. sensitivity to external factors such as light
   5. any anticipated allergic reaction.
   To enable anticipation of toxicities and the nursing implications of these (NPSA [268], C).
   If any doubts exist about the listed points, consult a pharmacist or appropriate reference works.
    
5. 10.Show
   Prepare the medication as described in Procedure guidelines 15.11, 15.12, 15.13, or 15.14. Using a Luer‐Lok syringe, draw up the drugs required with diluent to measure the total volume (this will depend on the type of syringe pump used). See Box 15.11 for CME Medical T34 recommended volumes and Action figure 10 for a CME Medical T34 syringe pump.
   To ensure accuracy and avoid any infusion errors. To ensure the drug is prepared correctly (NPSA [268], C).
6. 11.Show
   Inspect the fluid for discoloration, haziness, and crystalline or particulate matter. If this is found, discard and re‐evaluate drug compatibility. Note: this can occur even if the mixture is theoretically compatible, thus making vigilance essential.
   To prevent any toxic or foreign matter being infused into the patient (NPSA [268], C).

   To detect any incompatibility or degradation (NPSA [268], C).
7. 12.Show
   Establish the correct rate setting of the pump using the correct calculation.
   To monitor rate and ensure the drug is infused safely (Dickman et al. [70], E; Pickstone [284], E).
8. 13.Show
   Complete the drug additive label and fix it onto the syringe without obscuring the markings.
   To identify which drug has been added, when and by whom, and to be able to visually inspect the amount in the syringe (NPSA [268], C).
9. 14.Show
   Wash hands with bactericidal soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (Fraise and Bradley [98], E; NHS England and NHSI [233], C).
10. 15.Show
    Connect the prepared syringe to a 100 cm microbore driver set with needle‐free Y connector injection site.
    This length of tubing allows the patient greater freedom of movement. E
11. 16.Show
    Prime the infusion by gently depressing the plunger of the syringe until the fluid is visible at the end of the infusion set. Priming the infusion set after calculation will reduce the delivery time by approximately half an hour for the first infusion. Do not alter previously the calculated rate setting despite the volume reduction in the barrel of the syringe.
    To remove extraneous air from the system. E

    To ensure the patient receives the drugs immediately and accurately. E
12. 17.Show
    Place the syringe and infusion set in a clean receptacle. Wash hands and proceed to the patient.
    To minimize the risk of contamination (Loveday et al. [176], C; NHS England and NHSI [233], C).
13. 18.Show
    Check the identity of the patient against the prescription chart, syringe drug additive label and with the patient if possible. If an electronic identity check system for patient and/or medicine identification is in place, then use in accordance with hospital policy and procedures.
    To minimize the risk of error and ensure the correct drug is administered to the correct patient (NPSA [268], C; RPS [317], C).
14. 19.Show
    Apply an apron and assist the patient into a comfortable position.
    To aid patient comfort. E
15. 20.Show
    Expose the chosen site for infusion.
    To gain access to the site. E
16. 21.Show
    Apply gloves and clean the chosen site with a swab saturated with 70% isopropyl alcohol. Wait until the alcohol evaporates.
    To reduce the risk of infection and prevent a stinging sensation on insertion of the needle (Fraise and Bradley [98], E; Loveday et al. [176], C).
17. 22.Show
    Pinch a fold of skin firmly.
    To elevate the subcutaneous tissue. E
18. 23.Show
    Insert the infusion needle into the skin at an angle of 45° and release the grasped skin. (If using a cannula, remove the stylet and connect the extension set.)
    Positioning shallower than 45° may shorten the life of the infusion site. E
19. 24.Show
    Apply a transparent dressing to secure the infusion device.
    To prevent movement and reduce the risk of mechanical phlebitis and infection (Fraise and Bradley [98], E; Loveday et al. [176], C; Weinstein and Hagle [363], E).
20. 25.Show
    Check that the infusion set and syringe are securely connected.
    To ensure that there is no disconnection so that the drug(s) are administered correctly. E
21. 26.Show
    Connect the syringe to the syringe pump.
    To ensure the syringe is correctly connected to the syringe pump. E
22. 27.Show
    Press the ‘Back’ key to adjust the actuator to accommodate the syringe. Lift the barrel arm and ensure the syringe is loaded correctly. If the syringe is not loaded into the barrel, collar and plunger correctly, this will be identified on the LED screen.
    To ensure the syringe is in the correct position. C
23. 28.Show
    The pump will detect the size and brand of syringe. Check and confirm by pressing the ‘YES’ key.
    To enable the pump mechanism to operate correctly (manufacturer's instructions, C).
24. 29.Show
    Set a new programme for each syringe.
    To clear the previous programme and reduce the risk of error (manufacturer's instructions, C).
25. 30.Show
    Set pump measurements for the deliverable volume in the syringe.
    To check the volume is as required. E
26. 31.Show
    Press ‘YES’ to confirm the volume to be infused. Press ‘YES’ to confirm the infusion duration. The pump will display the rate calculated for the volume and duration set by the user. Then press ‘YES’ to confirm.
    To complete set‐up of the device (manufacturer's instructions, C).
27. 32.Show
    Secure the syringe in the clear Perspex lock box (for syringes of 30 mL or larger only).
    To ensure extra security and minimize the risk of errors in infusion rates. E

Post‐procedure

1. 33.Show
   Discard waste, making sure that it is placed in the correct containers, for example sharps into a designated receptacle.
   To ensure safe disposal and avoid injury to staff. To prevent reuse of equipment (HWR [137], C; MHRA [201], C).
2. 34.Show
   Complete the patient's prescription chart and other hospital and/or legally required documents. This should include infusion device serial number and infusion device and site checks.
   To comply with local drug administration policies and ensure the safe administration and monitoring of the infused drug and accurate records. To provide a record in the event of any queries (RPS [317], C). To prevent any duplication of treatment (RPS [317], C).
3. 35.Show
   Monitor the patient for any infusion‐related complications.
   To detect complications promptly (Dickman et al. [70], E; Dougherty [75], E; MHRA [208], C; Pickstone [284], E; Quinn [292], E).
4. 36.Show
   Ask the patient to report any pain or tenderness at the infusion site and if they experience any change in their symptoms or have new symptoms.
   To ascertain whether there are any problems that may require nursing care and to enable referral to medical staff where appropriate. E