Flushing or Administering Medications Through a Central Line

Pursuant to Title 20—DEPARTMENT OF COMMERCE AND INSURANCE Division 2200—State Board of Nursing Chapter 6—Intravenous Infusion Treatment Administration: Qualified practical nurses shall only perform venous access and intravenous (IV) infusion treatment modalities according to the specific provisions of section 335.016, RSMo, 20 CSR 2200-5.010, and this chapter. A qualified practical nurse shall only perform such activities under the direction and supervision of a registered professional nurse, or a person licensed by a state regulatory board to prescribe medications and intravenous infusion treatments.

*THIS PROCEDURE IS TYPICALLY PERFORMED BY A REGISTERED NURSE

The use of this procedure guideline assumes that the registered nurse has the nursing education and skills to perform this task. This procedure guideline does not replace nursing clinical judgment. The registered nurse should contact the student’s health care team for guidance on how to perform this procedure.

Considerations: 

• This is a complex procedure that requires the registered nurse to have the necessary education, training and experience to perform this procedure.

• This procedure requires additional resources including a second person to assist with the procedure, 30 minutes of uninterrupted time, and the ability to perform this procedure using Aseptic non touch technique (ANTT®).  

• If the registered nurse does not have the capability to perform this procedure, then the registered nurse should discuss with the student’s parents/guardians and health care provider to arrange a different plan. 

• Be sure to take steps to ensure student’s privacy when performing procedure. 
• Determine the need for assistance of another person to hold or comfort the student while performing the procedure to ensure that Aseptic non touch technique (ANTT®) is used. 
• A single use syringe should never be used more than once (even on the same lumen).  
• A 10 ml syringe filled with normal saline should not be divided into several doses and used for multiple lumens.  

• Student should have an emergency kit readily available at all times (including field trips). 
• Use single-dose vials or prefilled, labeled syringes for all vascular access device flushing and locking.
• During the initial flush, slowly aspirate the vascular access device for free-flowing blood return that is the color and consistency of whole blood, an important component of assessing catheter function prior to administration of medications and solutions. 
• Do not forcibly flush any vascular access device with any syringe size. If resistance is met and/or no blood return noted, take further steps (e.g., checking for closed clamps or kinked sets, removing dressing) to locate an external cause of the obstruction. 
• Be sure to determine what type of needleless connector set the student uses and follow the appropriate clamping sequence to reduce blood reflux based on type of needleless connector used:  
• Negative displacement – flush, clamp, disconnect  
• Positive displacement – flush, disconnect, clamp  
• Neutral and antireflux – no specific sequence required 
• NOTE: The procedure below outlines the steps for a negative displacement central line, you will need to edit the procedure for positive or neutral displacement central lines.  
  
  
  Supplies:
• Student’s Individualized Health Care Plan (IHCP) and health care provider’s order

• Parent/Guardian authorization form
• Gloves
• 70% isopropyl alcohol pads or other antimicrobial swab as directed by student’s health care provider’s orders
• 10 ml syringes filled with normal saline
• Heparin flush, if ordered
• Spare chlorhexidine dressing kit

• Chlorhexidine catheter dressing kit:
  • Sterile gloves 
  • Mask 
  • No sting barrier 
  • 2% chlorhexidine gluconate in 70% isopropyl alcohol, Povidone iodine swab sticks, or student specific cleaning supplies 
  • Alcohol wipes 
  • Sterile gauze 
  • Transparent occlusive dressing  
  • Adhesive tape 
  • Hand sanitizer 
  • Adhesive remover 
  • Biopatch 
  • Extra clamp 

• Emergency Kit:
  • Chlorhexidine kit
  • Catheter cap
  • Stat lock
  • Clean gloves
  • Flushing supplies:
    • Alcohol wipes
    • 10 ml syringes
    • Heparin flush

Procedure:

1. Review health care provider’s order
2. Ensure proper documentation of parent/guardian authorization to administer medication
3. Clean your workstation with soap and water or disinfectant wipe
4. Gather supplies and place on clean surface
5. Review the six rights of medication administration to be sure it is:
   
   a. The right student
   b. The right medication
   c. The right dose
   d. Being given at the right time
   e. Being given by the right route
   f. Being given for the right reason
6. Ensure that the medication has not expired
7. If medication is expired do not administer it, contact parent/guardian and health care provider
8. Review the student’s allergy status
9. Explain the procedure to the student at their level of understanding
10. Position student
11. Wash hands
12. Put on gloves
13. Place clean drape on workstation
14. On clean workstation place the two saline syringes, medication syringe, and heparin syringe along with four 70% isopropyl alcohol pads or other antimicrobial swab as directed by student’s health care provider’s orders
15. Prepare the saline and heparin syringes for administration
16. Remove the cap from the saline syringe being careful to not touch the inside of the cap or the tip of the syringe
17. Lay the cap down on your clean workstation with the inside of the cap facing up
18. Remove air from syringe by pulling back on plunger, then pushing forward until all air is removed
19. Tap the syringe to move air bubbles, if needed
20. Pick up the cap, being careful not to touch the inside of the cap or the tip of the syringe and replace the cap on the tip of the syringe
21. Repeat step 14 for the other saline syringe and the heparin syringe
22. Inspect the medication syringe for air bubbles, leaks, cracks, particulate matter, and clarity of medication
23. Medication syringe should not need to have air removed if prepared by a pharmacy
24. If air bubbles are present, gently tap syringe and dispel air bubbles
25. Assist student in removing clothing to uncover the dressing
26. Examine tubing and cap to ensure that all components of the system are compatible and secured, to minimize leaks and breaks in the system
27. Scrub the access cap for a time of no less than 15 seconds (or the amount of time indicated on student’s Individualized Health Care Plan (IHCP)), using 70% isopropyl alcohol (or cleaning agent as prescribed) and vigorous scrubbing
28. Allow access cap to air dry for at least 15 seconds, do not blow or fan
29. Hold on to the needleless syringe connector and attach the prefilled 10 ml normal saline syringe into the center of the cap while maintaining the sterility of the syringe tip
30. A smaller syringe may push too much pressure into the catheter and cause it to burst
31. Unclamp the line
32. Slowly inject normal saline into vascular access device, noting any resistance or sluggishness of flow, and slowly aspirate until brisk blood return is obtained
33. Inability to flush or absence of blood return from a central vascular access device requires further investigation about the causes, see below for Problems Flushing the Line
34. Push the normal saline into the catheter using the push-pause method (10 short boluses of 1 ml interrupted by brief pauses)
35. Clamp the line
36. Hold on to the needleless syringe connector and disconnect the syringe from injection port after flushing
37. If medication is to be administered, review the six rights of medication administration again to ensure that it is for:
    
    a. The right student
    b. The right medication
    c. The right dose
    d. Being given at the right time
    e. Being given by the right route
    f. Being given for the right reason
38. Scrub the access cap for a time of no less than 15 seconds (or the amount of time indicated on student’s Individualized Health Care Plan (IHCP), using 70% isopropyl alcohol (or cleaning agent as prescribed) and vigorous scrubbing
39. Allow access cap to air dry for at least 15 seconds, do not blow or fan
40. Hold on to the needleless syringe connector and attach the medication syringe
41. Unclamp the line
42. Slowly push the medication from the syringe per health care provider’s orders or over the recommended amount of time per drug manufacturer
43. Clamp line
44. Hold on to the needleless syringe connector and remove medication syringe
45. Scrub the access cap for a time of no less than 15 seconds (or the amount of time indicated on student’s Individualized Health Care Plan (IHCP), using 70% isopropyl alcohol (or cleaning agent as prescribed) and vigorous scrubbing
46. Allow access cap to air dry for at least 15 seconds, do not blow or fan
47. Hold on to the needleless syringe connector and attach the prefilled 10ml normal saline syringe
48. Unclamp the line
49. Flush with 10ml normal saline using the push-pause method
50. Inject the normal saline flush at the same rate as the medication administration rate to ensure that the entire dose has reached the bloodstream
51. Clamp line
52. Hold on to the needleless syringe connector and disconnect the syringe after flushing
53. Scrub the access cap for a time of no less than 15 seconds (or the amount of time indicated on student’s Individualized Health Care Plan (IHCP), using 70% isopropyl alcohol (or cleaning agent as prescribed) and vigorous scrubbing
54. Allow access cap to air dry for at least 15 seconds, do not blow or fan
55. Hold on to the needleless syringe connector and attach the prefilled Heparin syringe
56. Unclamp the line
57. Administer the Heparin flush to cap the lumen using the push-pull method
58. Clamp the line on to the needleless syringe connector and remove the syringe from injection port after flushing
59. Discard used supplies in appropriate receptacles
60. Remove gloves
61. Wash hands
62. Assist student in dressing
63. Document assessment, intervention and outcome in student’s health care record
64. Follow up with student’s parents/guardian and health care provider as needed

Problems Flushing Line:

If there is trouble flushing the line (inability to flush or sluggish line), the following steps should be taken:

• Assess for possible causes of catheter occlusions
• Ensure that the catheter is not clamped
• Have the student change positions by lifting the arm on the side of the insertion site, turning from side to side, coughing, or other maneuvers to change body/catheter position
• If still unable to flush after completing the above steps remove the syringe and reclamp the line
• Contact parents/guardians and health care provider
  
  
  Emergency care:
  If the catheter comes out:
  • Wash hands
  • Put on gloves
  • Hold firm pressure over the site for at least 5 minutes
  • Cover it with gauze and tape
  • Call parents/guardian and student’s health care provider immediately

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References:

Froedtert and The Medical College of Wisconsin. (2019). Home infusion IV administration using IV push (S-A-S-H method). Retrieved June 9, 2023, from https://www.froedtert.com/sites/default/files/upload/docs/patients-visitors/pharmacy/home-infusion/iv-push-administration-sash.pdf  

Infusion Nurses Society, Inc. (2021). Aseptic non touch technique (ANTT®). In Policies and procedures for infusion therapy: Home infusion. (2nd Ed.). (pp. 42-44).  

Infusion Nurses Society, Inc. (2021). Infusion medication and solution administration. In Policies and procedures for infusion therapy: Home infusion. (2nd Ed.). (pp.245-261).  

Infusion Nurses Society, Inc. (2021). Maintaining vascular access device patency: Flushing and locking. In Policies and procedures for infusion therapy: Home infusion. (2nd Ed.). (pp.124-130).  

Intravenous infusion treatment administration. Missouri Code of State Regulations. Rules of department of commerce and insurance. Division 2200–State board of nursing chapter 6. (2019). Retrieved June 20, 2023, from https://www.sos.mo.gov/cmsimages/adrules/csr/current/20csr/20c2200-6.pdf  

Lynn, P. (2019). Changing the dressing and flushing central venous access device. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 355-357).  

Nickel, B. (2021). Infusion therapy standards of practice 2021 – Mitigating central line complications. [Webinar]. BD. Retrieved June 9, 2023, from https://event.webcasts.com/starthere.jsp?ei=1476887&tp_key=575983a54f  

Pediatric Home Services. (2015). Flush an IV catheter using the sash method. . Retrieved June 8, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/flush-an-iv-catheter-using-the-sash-method/?play=1  

Ullman, A.J. and Chopra, V. (2022, November 22). Routine care and maintenance of intravenous devices. In A. Cochran & I. Davidson (Eds.), UpToDate. Retrieved June 9, 2023, from https://www.uptodate.com/contents/routine-care-and-maintenance-of-intravenous-devices?search=central%20venous%20line%20care&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3631889060  

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Acknowledgment of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN

School Nurse Supervision Specialist | Therapylog

Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

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Page last reviewed: September 1, 2021
Page last updated: September 1, 2021; February 14, 2024/no-video
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The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.

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