college of nursing absn program adult health nursing ii block 7.0

College of NursingABSN ProgramAdult Health Nursing II

Block 7.0

Topic: Infusion Therapy Module: 1.1

Block 7.0 Module 1.1 2

Assignment: Complete the Dosage Calculation Workbook,

DOC 1.20 Complete the Dosage Calculation Assessment

with a grade of 90% or greater.

Dosage Calculation

A thought to remember regarding dosage calculations:

“If you get a 90% on the dosage calculation assessment, it is an “A” or “Pass.”

“If you do dosage calculations at work as a nurse @ a 90% accuracy level, that could lead to the worst day of your life, and the last day of your

patient’s life!”

YOU MUST ENSURE 100% ACCURACY.

Block 7.0 Module 1.1

Infusion Therapy

3

Adult Health II Block 7.0

IV Therapy


Webliography For lots of supplementary materials on IV Therapy (and much, much

more…) go to :

Saddleback College (2010). Assisted learning for all (alfa). [Website]. Retrieved from http://www.saddleback.edu/alfa/

On the Alfa Site: Look under the Med Surg II tab: Management of IV Equipment Advanced IV Preparation

5

Learning Outcomes1. Discuss the purpose and goals for infusion therapy.

2. Verbalize & Demonstrate all appropriate steps when initiating intravenous therapy using a short peripheral IV catheter and discontinuing the IV access.

3. Verbalize & Demonstrate the procedure for changing intravenous solutions and intravenous tubing.

4. Analyze & Prioritize nursing responsibilities for the patient with an IV access, including short peripheral catheter, PICC line, tunneled catheter, & implanted port.

5. Analyze & Demonstrate the procedure for a central line dressing change.


Learning Outcomes

6. Analyze & Demonstrate appropriate documentation for IV Therapy.

7. Analyze & Demonstrate the assessment, prevention, & management of complications related to infusion therapy and venous access.

8. Compare and contrast indications for the use of isotonic, hypotonic, and hypertonic intravenous solutions.


Some Key Terms Air embolism Central venous catheter Extravasation of vesicant fluid Fluid Overload / Circulatory Overload Infiltration Peripherally Inserted Central Catheter (PICC) Phlebitis Thrombophlebitis


Infusion TherapyDelivery of parenteral medications and fluids through a wide variety of catheters and locationsVirtually all clients will have some type of infusion therapy during their hospital stay.Infusion therapy is also delivered in all types of healthcare settings.pH of IV solutions range from 3.5-6.2 extremes of both osmolarity (normal range 270-300) & pH can cause damage to vein fluids & meds with pH <5 & >9 & with osmolarity >500 should not be infused through a peripheral vein


Goals of Infusion TherapyMaintain or correct fluid and electrolyte balance

Maintain or correct acid-base balance

Administer parenteral (IV) nutrition

Administer blood or blood products

Administer medications


Prescribing Infusion Therapy Physician’s order required Order for IV fluids must include:

Specific type of fluid Rate of administration (e.g., 125 mL/hr or 1000 mL/8

hr) Drugs & specific dose to be added to the solution,

such as electrolytes or vitamins A drug prescription must include:

Name of drug (generic preferred) Dose & route Frequency & time of administration

Dilution for infusion meds usually done by pharmacy


Isotonic, hypotonic, and hypertonic solutions In isotonic fluids, cells maintain normal size because of fluid balance. In hypotonic solutions, the body fluids shift out of the blood vessels and into cells and the interstitial space. In hypertonic solutions, the fluid is pulled from the cells and the interstitial tissues into the vascular space.


Types of IV Solutions: Isotonic Have approx. same osmolarity as body fluids

(270 to 300)

Cause an Increase in extracellular fluid volume

Do not enter cells because no osmotic force exists to shift the fluids therefore, patient at risk for fluid overload, esp. older adults

Examples: 0.9% saline Lactated Ringer’s


Types of IV Solutions: Hypotonic

More dilute solutions and have a lower osmolarity (<270) than body fluids

Cause the movement of water in to cells by osmosis

EXAMPLES: 0.45% normal saline


Types of IV Solutions: Hypertonic

More concentrated solutions and have a higher osmolarity (>300) than body fluids

Concentrate extracellular fluid and cause movement of water from cells in to the extracellular fluid by osmosis

Examples:3% saline


Never Use

Fluids past date of expiration

Outer Wrapping Removed

Fluid Discolored

Bag Leaking


Vascular Access Devices (VADs) VADs are plastic catheters placed in the blood vessel

used to deliver fluid & medications

Characteristics of therapy (medication type, pH & osmolarity, length of time for therapy) determine the site & type of vascular access.

Type of fluid & length of need determine type of catheter with the goal of minimizing the # of catheter insertions & adverse reactions.

7 major types: Short peripheral caths; Midline caths; PICCs; non-tunneled central caths; tunneled central caths; implanted ports; & dialysis caths.


Key Points on the Procedure Verify physician order. Hand hygiene. GLOVES! Prepare equipment. Assess patient & explain procedure. Select site. Site preparation Vein entry. Catheter stabilization and dressing

management. Label dressing Equipment disposal Documentation


Peripheral IV Catheters


Short Peripheral IV Caths1. Plastic cannula built around a sharp stylet2. Length ¾-1 ¼ inches3. Dwell time 72 to 96-hours, then they are removed, and changed to another site4. If patient requires therapy longer than 6-days, a PICC or central line should be considered5. Highest risk of exposure to blood borne pathogens if accidental needle stick occurs


Patient Teaching Assessment Assess for patient allergies: latex

Explain procedure to decrease anxiety

Instruct patient on the Purpose Procedure What physician has ordered and why Mobility limitations Signs and symptoms of complications


Peripheral-Short: Placement Avoid veins on palm side of wrist where

median nerve is located Cephalic vein starts at thumb and travels up

arm, prominent and east to see, feel CAUTION: Median nerve can intersect the

area of the cephalic vein Immediately stop & remove catheter if client

reports paresthesia, numbness or sharp shooting pain. Choose another site.

Limit # of attempts to 2 let another RN do it See Iggy Chart 15-1, p. 216, for Best Practice


Site Selection/Placement Superficial veins in dorsal venous network basilic,

cephalic, & median veins & branches Use non-dominant arm when possible Avoid hand veins in older adult clients or active clients

receiving therapy Avoid palm-side veins Avoid veins in fingers & thumbs smaller diameter

allows little blood flow & easily infiltrate Avoid areas of flexion (wrist, AC) if possible Avoid veins on an extremity with lymphedema (e.g.,

post CVA or mastectomy), paralysis or a dialysis graft/fistula

Start with the most distal location and move proximally when selecting site


Site Selection Type of Solution

Fluids that are hypertonic, like antibiotics and potassium chloride, are irritating to vein walls

Select a large vein in the forearm Start at the BEST and LOWEST vein

Condition of Vein A soft straight vein is ideal Avoid: bruised veins, red, swollen veins, site near

a previous discontinued site


Nice to Know: “Vein Viewer”

• Resembles a small X-ray machine on wheels

• Shines an infrared light onto an arm or leg and projects a real-time image of the vascular system lying beneath the skin.

• The device is hands-free and projects a neon-green image which guides the nurse as they use the sense of touch to verify a vein’s location


Gauge Size for Peripheral Catheters Use the shortest length and smallest gauge to

deliver prescribed therapy 14-to-16 gauge: multiple trauma, heart surgery 18-20 gauge: major trauma or surgery, blood

administration 20-22 gauge: fluids & medications 22-24 gauge: used for all types of standard IV

solutions and clear IV meds; best for patients >65 years old

See Iggy, Table 15-1, p.216

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Site Preparation• If excessive hair to area, remove

only with clippers or scissors– Shaving not recommended

• Cleanse site with antimicrobial solution– Follow facility policy– Use of a 2% chlorhexidine and

alcohol solution, like ChloraPrep has been associated with reduced infections

– Povidone iodine—assess for allergies

– Alcohol—use before povidone-iodine

– Cleanse site in circular motion out or follow manufacturer's recommendation



Dilatation of Vein Position extremity lower than heart for

several minutes

Have patient clench fist

Warm compresses if necessary

‘Tourniquet’ (constricting band) Apply 4-8 inches above site Do not leave on >4-6 minutes Do not occlude arterial flow


Vein Entry Gloves are worn during entire procedure Pull skin below puncture site Insert needle bevel up at 30-45 degree angle When flashback occurs, lower angle,

advance 1/8 further Advance catheter into vein, preferably with

one hand technique Remove tourniquet while stylet is still in

catheter Secure catheter in place Flush with normal saline


Catheter Stabilization and Dressing Management

Catheter should be stabilized in manner that does not interfere with visualization of site

Cover with a transparent semi-permeable membrane (TSM) (“Tegaderm”)

Dressing should be changed every 72 hours, depending on facility policy


IV with Transparent Dressing

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Patient Education Inform on any limits on movement

Explain alarms for controller/pump

Instruct the patient to report any redness, swelling, pain


Nursing Responsibilities for Peripheral IV

Document: Date & time of insertion Type & gauge of catheter Name of vein accessed or cannulated Number & location of attempts Type of dressing How patient tolerated the procedure

If used intermittently, flush with NS every 8-12 hr to prevent occlusion

Monitor for signs of phlebitis (redness, warmth, induration) & infiltration (localized swelling, coolness, IV flow does not stop with pressure over the tip)


Geriatric Considerations Aging skin becomes thinner and loses

subcutaneous fat: fragile skin tears & bruises avoid veins on the hands if possible

Use 22 or 24 gauge catheter Looser tourniquet or tourniquet over

gown Minimal tape If veins large and tortuous, NO

tourniquet Skin antisepsis is very important

because of compromised immune status

Hard, cordlike veins should be avoided Because of changes to cardiac/renal

system, infusion volume and flow rate should be monitored closely


Central IV Catheters Appropriate for all fluids regardless of pH,

osmolarity, or medication type rapid hemodilution d/t catheter tip resting in superior vena cava

Requires x-ray for verification of tip placement prior to use

Only PICC line can be inserted by specially trained RN all other central lines must be placed by MD


PICCs1. Inserted by RN with special training2. 18-29 inches long w/1-3 lumens3. Inserted in basilic or cephalic vein4. Tip rests in superior vena cava5. CXR required to check placement

before use6. Initial gauze dressing should be

replaced with transparent dressing within 24 hr

7. Ideal for long-term IV therapy8. Dwell time can be months or years9. RNs can draw blood specimens from

PICC port10. Low incidence of infection, other

complications


RN Responsibilities for PICCs Assess site at least every 8 hr Note redness, swelling, drainage, tenderness &

condition of dressing Change end caps per facility protocol usually

every 3 days Use 10 mL or larger syrince to flush the line Clean insertion port with alcohol for 3 sec. & allow

to dry completely prior to accessing Flush intermittent medication administration per

protocol usually 10mL NS before & after med Use transparent dressing & change per protocol

usually every 7 days & prn (wet, loose, soiled)


Tunneled IV Catheters1. Trade names: Hickman,

Broviac, Groshong2. Indicated for frequent, long-

term therapy3. Used when PICC not best

choice (e.g., paraplegics) or when implanted port not desired d/t frequent needle sticks for access

4. No dressing required5. Dwell time: years6. Flushed with NS or heparin

after each use


Implanted Ports1. Used when long-term (>year) access is

required. Used for chemotherapy. 2. Surgically placed under the skin. No

portion is visible.3. Usually placed on upper chest.4. Available in single or dual port.5. Catheter enters either subclavian or

internal jugular vein.6. Port access using Huber needle to

puncture the skin & port7. Remove Huber needle carefully --

needle stick frequently occurs to RN8. Flush after each use & at least monthly

w/NS &/or heparin per facility protocol


Implanted Ports


Administration Sets: Primary and Secondary

• Primary container may be plastic or glass

• Primary tubing used to infuse primary IV fluid

• Infusion may be by gravity or pump

• Secondary administration set or piggyback set is attached for intermittent infusion of medications


Administration Sets•Each type of set has a drip chamber•And a drip system: macrodrip or microdrip

*15 gtt/mL *60 gtt/mL


Secondary Sets or Piggyback Attached at a Y-connection site located

above the IV pump Used for intermittent medications If multiple medications required, use new

secondary IV tubing for each medication The backpriming method may be used Sets are changed every 72-96 hours with the

primary set See Iggy, Charts 15-2 & 15-3, p. 220 for Best

Practice for intermittent IV therapy


Large volume IV infusion bag

Piggyback bag

Drip chamber

IV catheter ports

IV pump

IV catheter


Add-on Devices• Extension sets: Luer-lok

design to ensure set firmly connected (do NOT use tape)

• Filters: – Remove particulate

matter and air from system

– Should be placed close to the hub of catheter as possible

• Needleless systems are used to reduce injuries from needlesticks

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Intermittent Administration Sets Used to infuse multiple meds when no

primary continuous fluid is needed Replace tubing every 24 hr d/t greater

potential for contamination of both ends of this tubing

The IV catheter is capped with a needless connection device or “hep-lock”



Pump Specific Administration Sets Made specifically for use with electronic infusion

devices


Review: Administration Sets Primary Secondary Intermittent Pump-specific

What is their purpose? How often are they changed?


IV Pumps Force fluid into the vein under pressure

Models vary widely in many ways, however all volumetric pumps generally involve the nurse entering the infusion rate in mL/hr

Unlike a manual IV setup that depends upon gravity, pumps will continue to force fluid into the patient's tissues, even if the cannula has become dislodged from the vein


Syringe Pump Used for very small

amounts of fluid that must by infused over an extended period of time

Controls how quickly the plunger on the syringe is depressed

Medication given at a constant rate for a specified period of time, which is difficult to do accurately by hand


Elastomeric Balloons 1. Used for

intermittent meds, usually in home health or other community-based setting.

2. Delivers med in preset amount of time.

3. No power source required.


PCA (Patient Controlled Analgesia) Pump

Provide an important mechanism for delivering analgesia

Embedded computer is programmed by RN to give a specified amount of opiate intravenously every time the patient pushes a button.

To help prevent excessive drug administration, the onboard computer ignores further patient demands until a lockout period (usually set for 5–10 minutes) has passed.

Can result in respiratory depression; requires routine monitoring of respiratory status is required. Consider continuous pulse ox monitoring.

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Prepare Equipment: Sterile Technique



Prepare Equipment: Prime Tubing & Remove Air Bubbles


Labeling

IV set-up should be labeled in 3 spots IV dressing: date, time, catheter,

initials Tubing: usually date, time, initials Solution: use label; do not mark

on bags with marker


Documentation When Inserting Peripheral IV Access

Date/time Gauge of device & number of attempts Location of vein accessed, site condition Presence of blood return, ability of fluid to

flush or flow Infused solution & any additives Rate of flow: record amount infused (I & O) Infusion by gravity/pump Patient’s response to the procedure Pt Education:

- Notify nurse if burning/swelling at site- Explanation of I & O

Name / Signature of person starting IV


Discontinuation of Therapy When physician orders or integrity compromised Put on gloves Obtain a sterile 2-by-2-inch gauze pad. Avoid use

of alcohol. Loosen tape, apply pad over the site Remove cannula and dressing as one unit,

without pressure over the site After removal, apply direct pressure Assess site Inspect cannula to ensure that it is intact May apply adhesive dressing


Documentation When Discontinuing Peripheral IV Access

Date and time Whether or not the IV catheter was intact Condition of the IV site Type of dressing applied (such as a pressure

dressing) Amount of fluid infused Patient’s response to the procedure Name of the person discontinuing the IV

infusion


Nursing Responsibilities Check orders carefully! IV puncture provides a direct route of entry into

bloodstream hand hygiene, strict aseptic technique, clean site with antimicrobial in inner to outer circular motion

Prime tubing remove all air and secure connections

Be careful not to contaminate when spiking bag Change tubing and site every 72-96 hours Change IV fluid containers every 24 hours or

follow facility protocol Label dressing, solutions, and tubing clearly


Local Complications of IV

Therapy


Infiltration Leakage of fluid into surrounding subcutanteous tissue Also, extravasation or infiltration of a vesicant

medication that causes tissue damage

IV rate slows down pump alarms d/t occlusion

Swelling at the site; leaking around the site

Blanching or coolness of skin

Burning, tenderness

STOP infusion and remove catheter


Infiltration & Extravasation: Leakage of Vesicant Fluid

InfiltrationTissue destruction d/t

extravasation of vesicant fluid


Prevention / Interventions Avoid venipuncture over an area of flexion Anchor cannula securely Use an armboard if patient restless/active Assess IV site at least every 2 hours for pain,

edema, coolness Assess for blood return, but this is not

foolproof Monitor IV for slowness or cessation of flow Do not rub infiltrated area, can cause bruising Elevate extremity and apply warm compresses


InfiltrationScale Grade

0

1

2

3

4

Grade Clinical Criteria0 No symptoms

1 Skin blanchedEdema < 1 inch in any directionCool to touchWith or without pain

2 Skin blanched, translucentEdema 1-6 inch in any directionCool to touchWith or without pain

3 Skin blanched, translucentGross edema > 6 inches in any directionCool to touchMild-moderate painPossible numbness

4 Skin blanched, translucentSkin tight, leakingSkin discolored, bruised, swollenGross edema > 6 inches in any directionDeep pitting tissue edemaCirculatory impairmentModerate—severe painInfiltration of any amount of blood product, irritant, or vesicant


Phlebitis and Post-infusion Phlebitis Redness (usually the 1st sign) & increased

warmth at site Pain & burning at site & length of vein Edema May become hard, cord-like Remove IV cath, use warm compresses Document using INS phlebitis scale


Phlebitis ScaleGrade Clinical Criteria

0 No symptoms

1 Erythema at access site, with or without pain

2 Pain at access site with erythema and/or edema


Streak formation

Palpable venous cord


Streak formation

Palpable venous cord >1 inch in length

Purulent drainage


Systemic Complications


Circulatory / Fluid Overload Infusion of fluids at a rate greater than

patient’s system can accommodate Signs:

May c/o shortness of breath/cough Elevated BP Eye puffiness/edema Engorged neck veins May have “moist” breath sounds

Slow the IV rate! Notify physician Raise client to upright position Monitor VS/O2 as ordered


Catheter Embolism A shaving or piece of catheter breaks free Signs

Decrease in BP Pain along vein Pulse weak, rapid, thready Cyanosis nailbeds and circumorally

Treatment Discontinue catheter, place tourniquet high on arm X-ray will confirm

Prevention Never reinsert a needle back into a catheter when

starting IV Examine catheter closely when discontinuing


Air Embolism Get all air out of infusion set & add-on

devices

Air can enter patient’s bloodstream through: Cut IV tubing Unprimed infusion sets Ports & injection caps Drip chambers with too little fluid Vented infusion containers that are allowed to

empty completely

Death can result with as little as 10 mL of air


InfectionLocal Site red, swollen, warm, may

have purulent drainage Caused by break in aseptic

technique during insertion or handling of equipment. Or lack of proper hand hygiene or skin antisepsis

Treatment: Clean site, save catheter tip in sterile container for culture, notify physician

Prevention: STRICT aseptic technique! Hand hygiene! Maintain dressing

Systemic Fever, chills, headache,

general malaise. If severe, vascular collapse and death

Cause: Same as local Treatment: Save entire

IV set and sample of IV fluid, notify physician, blood culture, IV antibiotics

Prevention: Same as local


Nursing Measures to Prevent Complications

Observe access sites every 2 hr for signs of infection or infiltration

Strict sterile technique when inserting IV catheter Clean site with 2% chlorhexidine preparation, 70%

alcohol, or iodine per protocol. Let air dry before insertion.

Change peripheral IV sites every 3 days Do not use arms with PICC lines for blood

pressure or phlebotomy Do not use hand veins for vesicant medication


Nursing Responsibilities Before accessing any port to administer meds

or for any reason, swab with alcohol Fluid (circulatory) overload can occur with

rapid infusion of fluids, especially with the very young and old, cardiac, renal, liver disease

A client with CHF is typically not given solutions with saline

A diabetic usually does not receive solutions with dextrose

Lactated Ringers solution contains potassium, usually not given to patients with renal disease

college of nursing absn program adult health nursing ii block 7.0

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