College of Nursing ABSN Program Adult Health Nursing

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!” YOU MUST ENSURE 100% ACCURACY. § Assignment: § Complete the Dosage Calculation Workbook, DOC 1. 20 § Complete the Dosage Calculation Assessment with a grade of 90% or greater. Block 7. 0 Module 1. 1 2

IV Therapy Infusion Therapy Adult Health II Block 7. 0 Module 1. 1 3

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 Block 7. 0 Module 1. 1 4

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. 5

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 7. 0 Module 1. 1 6

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 7. 0 Module 1. 1 7

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. p. H of IV solutions range from 3. 5 -6. 2 extremes of both osmolarity (normal range 270 -300) & p. H can cause damage to vein fluids & meds with p. H <5 & >9 & with osmolarity >500 should not be infused through a peripheral vein Block 7. 0 Module 1. 1 8

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 7. 0 Module 1. 1 9

Prescribing Infusion Therapy § Physician’s order required § Order for IV fluids must include: § Specific type of fluid § Rate of administration (e. g. , 125 m. L/hr or 1000 m. L/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 7. 0 Module 1. 1 10

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 7. 0 Module 1. 1 11

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 7. 0 Module 1. 1 12

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 7. 0 Module 1. 1 13

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 7. 0 Module 1. 1 14

Never Use Fluids past date of expiration Outer Wrapping Removed Fluid Discolored Bag Leaking Block 7. 0 Module 1. 1 15

Vascular Access Devices (VADs) § VADs are plastic catheters placed in the blood vessel used to deliver fluid & medications § Characteristics of therapy (medication type, p. H & 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; implanted ports; & dialysis caths. Block 7. 0 Module 1. 1 16

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 7. 0 Module 1. 1 17

Peripheral IV Catheters Block 7. 0 Module 1. 1 18

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 7. 0 Module 1. 1 19

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 7. 0 Module 1. 1 20

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 7. 0 Module 1. 1 21

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 7. 0 Module 1. 1 22

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 Block 7. 0 Module 1. 1 23

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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 Block 7. 0 Module 1. 1 25

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 7. 0 Module 1. 1 26

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 Chlora. Prep 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 Block 7. 0 Module 1. 1 27

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 7. 0 Module 1. 1 28

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 Block 7. 0 Module 1. 1 29

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 7. 0 Module 1. 1 30

IV with Transparent Dressing Block 7. 0 Module 1. 1 31

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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 Block 7. 0 Module 1. 1 33

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 7. 0 Module 1. 1 34

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 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 7. 0 Module 1. 1 35

Central IV Catheters § Appropriate for all fluids regardless of p. H, 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 7. 0 Module 1. 1 36

PICCs 1. 2. 3. 4. 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 Block 7. 0 Module 1. 1 37

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 m. L 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 10 m. L NS before & after med § Use transparent dressing & change per protocol usually every 7 days & prn (wet, loose, soiled) Block 7. 0 Module 1. 1 38

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 Block 7. 0 Module 1. 1 39

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 Block 7. 0 Module 1. 1 40

Implanted Ports Block 7. 0 Module 1. 1 41

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 7. 0 Module 1. 1 42

Administration Sets • Each type of set has a drip chamber • And a drip system: macrodrip or microdrip *15 gtt/m. L *60 gtt/m. L Block 7. 0 Module 1. 1 43

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 Block 7. 0 Module 1. 1 44

Large volume IV infusion bag Piggyback bag Drip chamber IV catheter ports IV pump IV catheter Block 7. 0 Module 1. 1 45

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 46

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 7. 0 Module 1. 1 47

Pump Specific Administration Sets § Made specifically for use with electronic infusion devices Block 7. 0 Module 1. 1 48

Review: Administration Sets § § Primary Secondary Intermittent Pump-specific § What is their purpose? § How often are they changed? Block 7. 0 Module 1. 1 49

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 m. L/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 7. 0 Module 1. 1 50

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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 7. 0 Module 1. 1 52

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. Block 7. 0 Module 1. 1 53

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 7. 0 Module 1. 1 54

Prepare Equipment: Sterile Technique Block 7. 0 Module 1. 1 55

Prepare Equipment: Prime Tubing & Remove Air Bubbles Block 7. 0 Module 1. 1 56

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 7. 0 Module 1. 1 57

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 7. 0 Module 1. 1 58

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 7. 0 Module 1. 1 59

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 7. 0 Module 1. 1 60

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 Block 7. 0 Module 1. 1 61

Local Complications of IV Therapy Block 7. 0 Module 1. 1 62

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 7. 0 Module 1. 1 63

Infiltration & Extravasation: Leakage of Vesicant Fluid Infiltration Tissue destruction d/t extravasation of vesicant fluid Block 7. 0 Module 1. 1 64

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 7. 0 Module 1. 1 65

Infiltration Scale 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, Block 7. 0 Module or 1. 1 vesicant 66 4

Phlebitis and Post-infusion Phlebitis § Redness (usually the 1 st 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 7. 0 Module 1. 1 67

Phlebitis Scale 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 Block 7. 0 Module 1. 1 68

Systemic Complications Block 7. 0 Module 1. 1 69

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/O 2 as ordered Block 7. 0 Module 1. 1 70

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 7. 0 Module 1. 1 § Examine catheter. Block closely when discontinuing 71

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 m. L of air Block 7. 0 Module 1. 1 72

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 7. 0 Module 1. 1 73

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 7. 0 Module 1. 1 74

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 7. 0 Module 1. 1 75