Adult Health Nursing II

Adult Health Nursing II
College of Nursing ABSN Program Adult Health Nursing II Block 7.0 Topic: Infusion Therapy Module: 1.1

Complete the Dosage Calculation Workbook, DOC 1.20
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 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. Dosage Calculation Assignment: Complete the Dosage Calculation Workbook, DOC 1.20 Complete the Dosage Calculation Assessment with a grade of 90% or greater. Block Module 1.1

Infusion Therapy Adult Health II Block 7.0 IV Therapy
Block Module 1.1

Webliography On the Alfa Site: Look under the Med Surg II tab:
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 On the Alfa Site: Look under the Med Surg II tab: Management of IV Equipment Advanced IV Preparation Block Module 1.1

Learning Outcomes 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.

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. Block Module 1.1

Some Key Terms Air embolism Central venous catheter
Extravasation of vesicant fluid Fluid Overload / Circulatory Overload Infiltration Peripherally Inserted Central Catheter (PICC) Phlebitis Thrombophlebitis Block Module 1.1

Infusion Therapy 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  extremes of both osmolarity (normal range ) & pH can cause damage to vein  fluids & meds with pH <5 & >9 & with osmolarity >500 should not be infused through a peripheral vein Block Module 1.1

Goals of Infusion Therapy
Maintain or correct fluid and electrolyte balance Maintain or correct acid-base balance Administer parenteral (IV) nutrition Administer blood or blood products Administer medications Block Module 1.1

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 Block Module 1.1

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. Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

Never Use Fluids past date of expiration Outer Wrapping Removed
Fluid Discolored Bag Leaking Block Module 1.1

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. Block Module 1.1

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 Block Module 1.1

Peripheral IV Catheters
Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

Site Selection Type of Solution Condition of Vein
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 Block Module 1.1

Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

Vein Entry Gloves are worn during entire procedure
Pull skin below puncture site Insert needle bevel up at 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 Block Module 1.1

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 Block Module 1.1

IV with Transparent Dressing
Block Module 1.1

Block Module 1.1

Patient Education Inform on any limits on movement
Explain alarms for controller/pump Instruct the patient to report any redness, swelling, pain Block Module 1.1

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) Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

PICCs 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 Initial gauze dressing should be replaced with transparent dressing within 24 hr Ideal for long-term IV therapy Dwell time can be months or years RNs can draw blood specimens from PICC port Low incidence of infection, other complications Block Module 1.1

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) Block Module 1.1

Tunneled IV Catheters Trade names: Hickman, Broviac, Groshong
Indicated for frequent, long-term therapy Used when PICC not best choice (e.g., paraplegics) or when implanted port not desired d/t frequent needle sticks for access No dressing required Dwell time: years Flushed with NS or heparin after each use Block Module 1.1

Implanted Ports Used when long-term (>year) access is required. Used for chemotherapy. Surgically placed under the skin. No portion is visible. Usually placed on upper chest. Available in single or dual port. Catheter enters either subclavian or internal jugular vein. Port access using Huber needle to puncture the skin & port Remove Huber needle carefully -- needle stick frequently occurs to RN Flush after each use & at least monthly w/NS &/or heparin per facility protocol Block Module 1.1

Implanted Ports Block Module 1.1

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 Block Module 1.1

Administration Sets Each type of set has a drip chamber
And a drip system: macrodrip or microdrip *60 gtt/mL *15 gtt/mL Block Module 1.1

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 hours with the primary set See Iggy, Charts 15-2 & 15-3, p. 220 for Best Practice for intermittent IV therapy Block Module 1.1

Large volume IV infusion bag
Piggyback bag Drip chamber IV catheter ports IV pump IV catheter Block Module 1.1

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 Module 1.1

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” Block Module 1.1

Pump Specific Administration Sets
Made specifically for use with electronic infusion devices Block Module 1.1

Review: Administration Sets
Primary Secondary Intermittent Pump-specific What is their purpose? How often are they changed? Block Module 1.1

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 Block Module 1.1

Block Module 1.1

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 Block Module 1.1

Elastomeric Balloons Used for intermittent meds, usually in home health or other community-based setting. Delivers med in preset amount of time. No power source required. Block Module 1.1

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. Block Module 1.1

Prepare Equipment: Sterile Technique
Block Module 1.1

Prepare Equipment: Prime Tubing & Remove Air Bubbles
Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 hours Change IV fluid containers every 24 hours or follow facility protocol Label dressing, solutions, and tubing clearly Block Module 1.1

Local Complications of IV Therapy
Block Module 1.1

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 Block Module 1.1

Infiltration & Extravasation: Leakage of Vesicant Fluid
Tissue destruction d/t extravasation of vesicant fluid Infiltration Block Module 1.1

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 Block Module 1.1

Infiltration Scale Grade Grade Clinical Criteria 1 2 3 4 No symptoms
No symptoms 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 3 Gross edema > 6 inches in any direction Mild-moderate pain Possible numbness 4 Skin tight, leaking Skin discolored, bruised, swollen Deep pitting tissue edema Circulatory impairment Moderate—severe pain Infiltration of any amount of blood product, irritant, or vesicant Infiltration Scale Grade 1 2 3 4 Block Module 1.1

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 Block Module 1.1

Phlebitis Scale Grade Clinical Criteria No symptoms 1
No symptoms 1 Erythema at access site, with or without pain 2 Pain at access site with erythema and/or edema 3 Streak formation Palpable venous cord 4 Palpable venous cord >1 inch in length Purulent drainage Block Module 1.1

Systemic Complications
Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

Infection 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 Block Module 1.1

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 Block Module 1.1

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 Block Module 1.1

Adult Health Nursing II

Similar presentations

Presentation on theme: "Adult Health Nursing II"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Adult Health Nursing II

Similar presentations

Presentation on theme: "Adult Health Nursing II"— Presentation transcript:

Similar presentations

About project

Feedback