Transcript AAA Infusion Therapy

College of Nursing
ABSN Program
Adult Health Nursing II
Block 7.0
Topic: Infusion Therapy
Module: 1.1
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!”
 Assignment:
 Complete the Dosage Calculation Workbook,
DOC 1.20
 Complete the Dosage Calculation Assessment
with a grade of 90% or greater.
YOU MUST ENSURE 100% ACCURACY.
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IV Therapy
Adult Health II
Block 7.0
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 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
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1. 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.
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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.
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Air embolism
Central venous catheter
Extravasation of vesicant fluid
Fluid Overload / Circulatory Overload
Infiltration
Peripherally Inserted Central Catheter (PICC)
Phlebitis
Thrombophlebitis
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Delivery of parenteral medications and fluids
through a wide variety of catheters and
locations
Virtually 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
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Maintain or correct fluid and electrolyte
balance
Maintain or correct acid-base balance
Administer parenteral (IV) nutrition
Administer blood or blood products
Administer medications
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 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
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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.
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 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
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 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
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 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
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Fluids past date of expiration
Outer Wrapping Removed
Fluid Discolored
Bag Leaking
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 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.
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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
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Peripheral IV Catheters
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Short Peripheral IV Caths
1. Plastic cannula built around
a sharp stylet
2. Length ¾-1 ¼ inches
3. Dwell time 72 to 96-hours,
then they are removed, and
changed to another site
4. If patient requires therapy
longer than 6-days, a PICC or
central line should be
considered
5. Highest risk of exposure to
blood borne pathogens if
accidental needle stick occurs
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 Assess for patient allergies: latex
 Explain procedure to decrease anxiety
 Instruct patient on the
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Purpose
Procedure
What physician has ordered and why
Mobility limitations
Signs and symptoms of complications
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 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
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 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
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 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
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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
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 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 povidoneiodine
– Cleanse site in circular motion
out or follow manufacturer's
recommendation
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 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
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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
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 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
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IV with Transparent Dressing
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 Inform on any limits on movement
 Explain alarms for controller/pump
 Instruct the patient to report any redness,
swelling, pain
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 Document:
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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)
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 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
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 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
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PICCs
1.
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3.
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5.
Inserted by RN with special training
18-29 inches long w/1-3 lumens
Inserted in basilic or cephalic vein
Tip rests in superior vena cava
CXR required to check placement
before use
6. Initial gauze dressing should be
replaced with transparent dressing
within 24 hr
7. Ideal for long-term IV therapy
8. Dwell time can be months or years
9. RNs can draw blood specimens from
PICC port
10. Low incidence of infection, other
complications
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 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)
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Tunneled IV Catheters
1. Trade names: Hickman,
Broviac, Groshong
2. Indicated for frequent, longterm therapy
3. 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 required
5. Dwell time: years
6. Flushed with NS or heparin
after each use
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Implanted Ports
1. 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 & port
7. Remove Huber needle carefully -needle stick frequently occurs to RN
8. Flush after each use & at least monthly
w/NS &/or heparin per facility protocol
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Implanted Ports
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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
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•Each type of set has a drip
chamber
•And a drip system:
macrodrip or microdrip
*15 gtt/mL
*60 gtt/mL
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 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
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Large volume IV
infusion bag
Piggyback bag
Drip chamber
IV catheter ports
IV pump
IV catheter
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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 Block 7.0 Module 1.1
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 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”
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 Made specifically for use with electronic infusion
devices
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Primary
Secondary
Intermittent
Pump-specific
 What is their purpose?
 How often are they changed?
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 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
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 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
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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.
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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
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 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
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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
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 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
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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
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 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
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Local
Complications of IV
Therapy
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 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
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Infiltration
Tissue destruction d/t
extravasation of
vesicant fluid
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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
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Grade
Clinical Criteria
0
No symptoms
1
Grade
1
Skin blanched
Edema < 1 inch in any direction
Cool to touch
With or without pain
2
Skin blanched, translucent
Edema 1-6 inch in any direction
Cool to touch
With or without pain
0
2
3
3
4
Skin blanched, translucent
Gross edema > 6 inches in any direction
Cool to touch
Mild-moderate pain
Possible numbness
Skin blanched, translucent
Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema > 6 inches in any direction
Deep pitting tissue edema
Circulatory impairment
Moderate—severe pain
Infiltration of any amount of blood product,
irritant,
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4
 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
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Grade
Clinical Criteria
0
No symptoms
1
Erythema at access site, with or without pain
2
Pain at access site with erythema and/or edema
3
Pain at access site with erythema and/or edema
Streak formation
Palpable venous cord
4
Pain at access site with erythema and/or edema
Streak formation
Palpable venous cord >1 inch in length
Purulent drainage
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 Infusion of fluids at a rate greater than
patient’s system can accommodate
 Signs:
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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
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 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
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 Examine catheterBlock
closely
when discontinuing 71
 Get all air out of infusion set & add-on
devices
 Air can enter patient’s bloodstream through:
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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
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Local
Systemic
 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
 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
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 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
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 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
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