Pre‐procedure

ActionRationale

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   Explain and discuss the procedure with the patient. Evaluate the patient's knowledge of cytotoxic therapy. If this knowledge appears to be inadequate, offer an explanation of the use, action, dose and potential side‐effects of the drug or drugs involved.
   To ensure that the patient understands the procedure and gives their valid consent. The patient has a right to information (NMC [177], C; van der Molen [259], E).
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   Check that the patient has given their consent and is fit to receive the treatment.
   To ensure that the patient gives a valid informed consent and is fit for treatment (NMC [178], C).
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   Put on gloves and an apron before commencing the procedure.
   To protect the nurse from local contamination of skin or clothing (Polovich et al. [194], C). Note: with careful handling technique this risk is minimal but splashes can occur when changing syringes or infusion containers.
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   Prepare the necessary equipment for a safe and aseptic administration procedure. This includes spiking initial chemotherapy infusion bags over a deep plastic tray in the clinical room.
   To minimize the risk of local and/or systemic infection (Fraise and Bradley [77], E). Patients are frequently immunosuppressed and at greater risk of hospital‐acquired infection (Weinstein and Hagle [265], E). To contain any splashes. E
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   Check that the prescription and medication have been first checked by another chemotherapy‐competent nurse and then check that all details on the syringe or infusion container are correct when compared with the patient's prescription, before opening the sterile packaging.
   To ensure the patient is given the correct drug that has been dispensed for them. To prevent wastage (NMC [177], C).
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   Be aware of the immediate effects of the drug.
   To observe the patient during administration for any known side‐effects. To be prepared to manage any side‐effects that occur (NMC [177], C).
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   Take the medication and the prescription chart to the patient.
   To prevent error and comply with professional guidelines (NMC [177], C).
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   Check the patient's identity, drug, dose, route and timing of administration.
   To ensure the medication is administered to the correct patient (NMC [178], C).

Procedure

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   Ensure that an appropriate device has been inserted. Inspect the device site, and consult the patient about sensation around the site.
   To detect any problems, for example phlebitis, which would render the device unusable (Dougherty [57], E; Lavery and Ingram [131], E).
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   Check the patency of the vein for blood return and then flush using 0.9% sodium chloride.
   To determine whether the vein will accommodate the extra fluid flow and irritant drugs and remain patent (Weinstein and Hagle [265], E).
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   Ensure the syringe is attached carefully to the needle‐free injection site of the administration set, extension set or injection cap.
   To prevent disconnection and possible contamination (European Policy Recommendations [73], C).
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   Secure a good connection by always using Luer‐Lok syringes.
   To prevent leakage or separation, which may occur due to pressure during administration, resulting in spray and contamination (European Policy Recommendations [73], C).
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   Take care when removing the blind hub, changing syringes, and inserting the administration set spike when changing infusion bags (which must be done with the bag lying flat within a deep plastic tray).
   To avoid leakage or splashes and contamination of the nurse or patient. To prevent mis‐spiking the bag and puncturing it (European Policy Recommendations [73], C).
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   Check the injection site or injection cap at the end of the procedure.
   To ensure that there is no leakage (European Policy Recommendations [73], C).
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   Act promptly by washing the area with soap and water if any contamination of an individual is noted.
   To prevent any local skin reaction (itchiness, redness or inflammation of the skin). To prevent absorption via skin, mucous membranes, and so on (Polovich et al. [194], C).
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   Administer drugs in the correct order: antiemetics, then vesicant cytotoxic drugs, then all others.
   To ensure that those agents likely to cause tissue damage are given when venous integrity is greatest, that is, at the beginning of the administration process (Gabriel [80], E).
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   Ensure the correct administration rate.
   To prevent ‘speed shock’. To prevent extra pressure and irritation within the vein (Weinstein and Hagle [265], E).
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    Observe the vein throughout for signs of infiltration or extravasation, for example swelling or leakage at the site of injection. Note the patient's comments about sensation at the site, for example pain.
    To detect any problems at the earliest opportunity. To prevent any damage to soft tissue, and to enable the remainder of the drug(s) to be given correctly at another site. To enable prompt treatment to be given, thus minimizing local damage and possibly preserving venous access for future treatment (Polovich et al. [194], C). (For further information see Methods for preventing extravasation.)
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    Flush the device with 5–10 mL 0.9% sodium chloride between drugs and after administration.
    To prevent drug interaction. To prevent leakage of drug from the puncture site on removal of the device (Dougherty [59], E).
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    Be aware of the patient's comfort throughout the procedure.
    To minimize trauma to the patient. To involve the patient in treatment and detect any side‐effects and/or problems that may then be avoided at the next treatment. E

Post‐procedure

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   Record details of the administration in the appropriate documents including start and stop times, infusion site and rates checks and any problems during administration.
   To prevent any duplication of treatment and to provide a point of reference in the event of queries and adhere to professional guidelines (NMC [178], C).