53991583 Overview IV Therapy

8/13/2019 53991583 Overview IV Therapy

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Test 1- WALDEN

IV THERAPY:

1. PURPOSE- To access the venous circulation in order to dra !lood "or la!orator# screens

and dia$nostic tests or to ad%inister "luids& electrol#tes& %edications& !lood& !lood

'roducts &and nutritional su''le%ents.

Indicated "or situations hen oral or other 'arenteral routes are not

a''ro'riate.

(ontinuous IV ad%inistration

Inter%ittent IV is used 'ri%aril# "or IV %edication ad%inistration

)olus increase in %edication i%%ediatel#

IV %edications !#'ass the en*#%atic 'rocess o" the liver

+ursin$ Res'onsi!ilities

,noin$ IV sets and their "unctions

(alculatin$ IV dri' rates

iin$ and dilutin$ %edications in IV "luids

,noin$ the %edications& 'ur'oses& and side e""ects

+ursin$ Res'onsi!ilities continued

Assess%ent o" the client& site& in"iltration& rates& adverse reactions& thera'eutic actions

IV route is the "astest onset o" %edication ad%inistration& hoever& once in/ected& the %edication

can not !e retrieved

IV route could 'rovide a direct route "or conta%ination ith 'atho$ens

(losel# %onitor the client "or adverse reactions

IV (onsiderations

Is "luid loss severe or li"e-threatenin$0

hat is %issin$0

hat is current health status0 (o- %or!idities: cardiac& renal& liver& 'ul%onar#& I 2 O


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3ail# ei$ht 4 "luids calculated on chan$es in current ei$ht

5To 6ilo$ra%s o" ei$ht $ain is e7uivalent to 8 liters o" "luid $ain

9 'ounds 8.9 liters "luid

Restorin$ "luids !# IV

h#: "luid; !lood loss& 'recautionar#


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-


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Use o" nettin$ to secure

Avoid restraints 'recaution

ental status assess%ent

EI3

>au$e and luid Rate

8B $au$e @#ello 19-89%l;%in

88 $au$e @!lue 8C-FC %l;%in

8G $au$e @'in6 9G-C9 %l;%in @%aintenance rate

1 $au$e @$reen 9-1G9 %l;%in

@hen lar$e !olus ra'id in"usion needed

>eriatrics

88 4 8B $au$e

Tourni7uet %a# not !e necessar#

Position hand de'endent

+o sla''in$ see !o 19- F 'a$e BBD Techni7ues.

Re%e%!er $eriatric care.

(entral venous catheters

central linesJ

ultilu%en or sin$le lu%en non-tunneled


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aintenance @"lushin$ K shi"t- R+

(entral lines cont.

Uses

$lood sampling

C%& monitoring

Continuous' intermittent drug infusions

iagnostic testing

Simultaneous infusion of seeral medications

%iscous or high-olume fluids ' blood

"& (total parenteral nutrition)

PI(( IV access @alternate access

Peri'herall# inserted central catheters @ar%


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Su!clavian& /u$ular& or "e%oral catheter

Te%'orar# vascular access

To 'orts - !lue and red

Used "or acute he%odial#sis

3 to insert

Sutured to s6in

S'ecial trainin$ to access

Accounta!ilit# and In"usion Thera'#

The R+ is accounta!le "or 6noin$

*hat is ordered

*hy it is intended

+mpact on the patient

Any possible side effects

,o to administer the infusion

,o to maintain the infusion

,o to discontinue properly

,o to document appropriately

R+ Res'onsi!ilities

The R+ re%ains accounta!le and res'onsi!le "or all dele$ated tas6s and %ust have a clear

6noled$e o" the nursin$ sco'e o" 'ractice relative to assess%ent& 'lannin$& i%'le%entation& and

evaluation o" in"usion thera'#& as ell as le$al res'onsi!ilities associated ith dele$ation o"

nursin$ care activities.J @I+S& 8GGG

R+?s Res'onsi!ilities

3ele$ate certain nursin$ tas6s to licensed and unlicensed 'ersonnel

Still res'onsi!le "or tas6s dele$ated

ust evaluate others co%'etenc#& instruct the%& and veri"# 'ro'er trainin$


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Res'onsi!ilities %a# var# a%on$ states and e%'lo#ers

(o%'ati!ilit#

+urse is res'onsi!le to veri"# co%'ati!ilit# o" "luids ith %edication ad%inistered via IV

Or i" a edication is in the IV "luid and a dru$ is $iven inter%ittentl#

+urse %ust %a6e certain "luids and dru$s are co%'ati!le.

IV Thera'#

R+ vs.


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B. (hec6 to see i" the anti!iotic is co%'ati!le ith the soluitions in"usin$.

(O+SI3ER A>E+(Y IV THERAPY PO


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IV Thera'# that is ordered "re7uentl# "or short 'eriods o" ti%e.

EN:

.ocephin 1gm +%&$ / 12 hours doses

emerol 23mg +%& / 4- hours &. pain

IV 'ush @IVP or IV 'i$$#!ac6 @IVP)& secondar#

Re7uires tu!in$ and site chan$e 7 B-D8 hours

re7uent site %onitorin$

luid in"used recorded on chart 7 shi"t

IVP @IV 'ush %edications

(hec6 order

Pre'are %edications and chec6 co%'ati!ilit# ith "luids

Assess site

Select 'ort 'roi%al to 'atient

(lean 'ort ith alcohol sa!

lush ith 1G%l o" +S !e"ore %edication

Insert;attach %edication s#rin$e

Occlude IV tu!in$ a!ove 'ort @'inch

Pull !ac6 $entl# to as'irate !lood return @%a# not $et

In/ect %edication in desi$nated ti%e "ra%e @loo6 u' in dru$ !oo6

Release tu!in$ i" "luids runnin$ - i" saline loc6& "lush ith 1G%l o" +S and loc6

S%all volu%e needs to han$ hi$her

IV PUSH

3ra u' correct dose into a 1G%< s#rin$e.

Veri"# dose ith second nurse

Then add additional saline to s#rin$e to e7ual 1G %


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Pause.


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:ay be anyhere from


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89Q

H#'o'roteine%ia

Volu%e E'ansion

Others are 3etran& s#nthetic colloid %ade o" $lucose-

o!ili*es interstitial ede%a

Hetastarch @Hes'an ade "ro% corn.

o!ili*es interstitial ede%a

Volu%e e'anders

Plas%a 'las%anate @Plas%a 'rotein "raction

(ontains hu%an 'las%a 'roteins in +or%al Saline @+S.

Increases seru% colloid os%otic 'ressure

T#'es o" intravenous solutions

Isotonic

ormal Saline (S) ! .ingers actate(.)

etrose in ater (3*)

H#'otonic

043= ormal Saline

0


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Push "luid into cells : h# %i$ht e see %ental status chan$e0

h# is 39 isotonic in the !a$

A+3 HYPOTO+I( in the vein

>lucose enters the vascular co%'art%ent

Is then ra'idl# %eta!oli*ed !# the


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aintain ater !alance

Pro%ote sodiu% diuresis

3etrose in Saline

39+S

391;8 +S

31G +S

Pro%otes diuresis

(orrect %oderate "luid loss

Prevent al6alosis

Provides calories and sodiu% chloride

Electrol#tes


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h# is an EI3 used "or concentrated !olus ad%inistered.

hat is a concentrated !olus.

TP+

+utritional ade7uate h#'ertonic solution consistin$ o" $lucose and other nutrients andelectrol#tes $iven throu$h an indellin$ 'eri'heral or central line

Used as intervention in severe cases o" %alnutrition.

TP+ 000000

h# should e %onitor >lucose ever# C hours0

h# should e not allo the solution container o" TP+ run out0

h# should e closel# %onitor T P R and );P0 )(0 In"usion site0 h# is ase'sis so vital0

TO START A+ IV==

3e%onstration in la!

E7ui'%ent and Su''lies

IV catheter @8B>A& 88>A& 8G>A& 1>A& 1C>A

IV start 6it @dra'e& cleanin$ and antise'tic 're's& dressin$s& ta'e& la!el& tourni7uet& trans'arent

dressin$

>


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luids vs. PR+ loc6 @saline or he'arin

Tu!in$ and etension

edication; )lood ad%inistration

Pu%'s& dial-a-"lo& volu%e control device @$ravit#

(hildren

Aller$# to iodine& late& or ta'e

Ar% !oard

Trans'arent dressin$; ta'e

Practice correctl#

Assess%ent "or initiatin$ IV thera'#

Asse%!le correct su''lies

Revie 3?s order

9 ri$hts

Assess "or clinical "actors; conditions

Assess 'revious e'erience; e'ectations

(onsider "uture treat%ents

Aller$ies; la! data @!etadine ta'e

Plannin$ "or initiatin$ IV thera'# @$oals

2 E )alance and VS ill return to nor%al

IV line ill !e 'atent

Site ill !e !eni$n

(lient ill understand 'ur'ose

IV site selection

A$e and status o" 'atient

Pur'ose o" the in"usion


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3uration o" thera'#

(ondition o" 'atient?s veins


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Use distal vein to 'roi%al

ar% co%'ress

(hec6 arterial 'ulse to ensure ade7uate !lood "lo to "ill veins

hen 're' i'e accordin$ to 'olic#:

(&'& say distal to proimal)

(hloro-'re'

3o not !lot4 this re%oves anti%icro!ial 'ro'erties

SO ho do e 6no ho "ast to re$ulate the "lo rate00

(ount dro's 19 seconds B $tts ; %inute

Re$ulate "lo rate

Ad/ust rate as 'rescri!ed !# health care 'rovider

"oo slo @ ein clots 'occlude line or client goes into circulatory 'C% collapse

"oo fast @ luid olume ecess (%B)

(alculate rates on 'a'er.

(O+T.

. Per"or% veni'uncture at 8G-FG de$ree an$le.


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3ocu%ent 'rocedure

Patient Teachin$

hen to call the nurse

.edness pain blood dressing loose

lo stops blood in tubing

+% pump alarm

A%!ulate ith IV 'ole& %ove%ent

As6 "or assistance hen needed.

3ocu%entation

o" atte%'ts @I" several %a# chart %ulti'le atte%'tsJ

T#'e o" "luid and "lo rate

Insertion site @A o" catheter

hen in"usion !e$un

Re%e%!er i" it is not docu%ented- IT 3I3 +OT HAPPE+

3O(UE+TATIO+ ENAPA IV catheter

8 atte%'ts

< rist

39 M +S at 1GG;hr

)lood dran

19GG 88>A IV to < rist 8 atte%'ts& !lood dran and sent to la!& 39 M +S 1GG %l;hr 'er

'u%'. Site clear& no redness or ede%a. -------------------------------------------------+ +urse R+

5TIP5

An#ti%e #ou do an#thin$ ith a 'atient?s IV @han$ "luids& $ive %edications& ala#s chec6 the IV

site. I" the IV is not "unctional& then #ou are doin$ nothin$ "or the 'atient. OR #ou %a# !e


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(irculator# overload

Phle!itis @thro%!o'hle!itis

3e"inition: In"la%%ation o" a vein& o"ten acco%'anied !# "or%ation o" a clot

S 2 SN: Indicated !# 'ain& increased s6in te%'& er#the%a alon$ 'ath o" vein @cord alon$ vein

(lots %a# occur

TN: Sto' in"usion and discontinue IV

Bleate etremity arm moist compresses

.estart ne +% if +% therapy is needed

.otate sites / 48-E2,

(auses: 3ru$ irritation& trau%a to vein& in"ection& stasis& i%%o!ili*ation& IV catheter in 'lace too

lon$

In"iltration

3e"inition: 'rocess in hich a "luid 'asses throu$h the tissues

S 2 SN: Indicated !# sellin$ and 'ossi!le 'ittin$ ede%a& 'allor& coolness& 'ain at insertion site&

'ossi!le decrease or a!sent "lo rate

TN: Sto' in"usion and discontinue IV.

.estart +% in ne location if +% therapy indicated

*arm compresses and eleation of etremity

(auses: IV catheter not in vein& in surroundin$ tissue

Etravasatinon

RE>ITI+E around IV SITE

3O not elevate ar%s

3O not a''l# cold or ar% co%'ress

+oti"# health care 'rovider and "ollo instructions.

hat is di""erence in I+I


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3e"inition: collection o" !lood in tissue or s6in due to trau%a& a6a: !ruise

S 2 SN: discoloration& 'ain& locali*ed ede%a to site

Usuall# sel" li%itin$

TN: Initiall# %oderate 'ressure %a# reduce a%ount o" !ruisin$

(auses: trau%a or inco%'lete he%ostasis a"ter sur$er#

)leedin$

(an occur around veni'uncture site and under s6in

(o%%on in clients on he'arin& ASA

A''l# 'ressure dressin$ to site and docu%ent

E


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3e"inition: entr# o" air into venous circulation

(auses: Secondar# to trau%a& IV tu!in$ not 'ri%ed


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ritten order: !lood co%'onent& volu%e& rate o" in"usion

hen a client is to receive !lood& the nurse is lar$el# res'onsi!le "or its sa"e ad%inistration.

A)O and Rh TYPE

A)O- t#'e o" anti$en co%'onents that R)(?s have.

T#'e A A anti$en

T#'e ) ) anti$en

T#'e A) !oth

T#'e O none

Rh- anti$enic su!stance 'resent in R)(?s

I" have Rh

I" do not have Rh-

Autolo$ous trans"usion

(ollect !lood "ro% client 'rior to e'ected sur$ical 'rocedure& rein"use client ith !lood in

sur$er

Salva$e !lood in sur$er# and ad%inister.

Autolo$ous- donate on !lood.

)lood (o%'onents

hole )lood

PR)(

Platelets @Pranuloc#te (oncentrations

Plas%a

(lottin$ actors


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Other volu%e e'anders

hole )lood

Used in esan$uinations@)leedin$ 'atient

(ontains all !lood 'roducts

Usuall# contains BGG %l -

USE3 hen !oth volu%e and cells are needed

hole )lood

R)(& 'las%a& 'las%a 'roteins ith CF %l o" anticoa$ulant.

9GG %l;unit

A)O identical and Rh "actor %ust %atch

Rarel# indicated

Outco%es: 'revention; resolution o" h#'ovole%ic shoc6 and ane%ia

Ris6: volu%e overload

PR)(?s

Red !lood cells ith anticoa$ulant-'reservative @no clottin$ "actors

Unit si*e- 89G to BGG%l;unit

A)O co%'ati!le& Rh "actor %atch

>iven "re7uentl# !lood loss- sur$er#& trau%a

GQ 'las%a has !een re%oved.

Outco%es: resolution o" ane%ia

PR)(s

>iven "or acute and chronic ane%ia &

)lood loss

3esired over hole !lood in cardiovascular 2 renal co%'ro%ised& and elderl# clients !ecause

PR)(s contain less "luid volu%e.


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Platelets @P


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(r#o'reci'itate

Antihe%o'hilliac "actor VIII and "actor NIII

9-1G%l;unit

(ontains no R)( and a s%all volu%e o" 'las%a

A)O co%'ati!ilit# not needed

Outco%es: correction o" "actor VIII& v& NIII and "i!rino$en de"icienc#& cessation o" !leedin$

(r#o'reci'itate

(o%'onents clottin$ "actors

USES: he%o'hilia& "i!rino$en de"icienc#&

3I(.

Plas%a 3erivatives

Al!u%in- al!u%in& $lo!ulin and other 'roteins

Anti!odies destro#ed durin$ 'rocessin$- co%'ati!ilit# not a "actor

Ra'id in"usion %a# cause h#'otension& !ut 89Q al!u%in can cause a si$ni"icantl# increased

!lood 'ressure !ecause o" its a!ilit# to dra "luid into the intravascular s'ace

(annot trans%it he'atitis or HIV in"ection due to the 'asteuri*ation 'rocess used to 're'are

Outco%es: %aintain; ac7uire ade7uate !lood 'ressure and volu%e su''ort

(lottin$ actors


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Outco%e: 'ro%ote circulator# volu%e and tissue 'er"usion !# ra'idl# e'andin$ 'las%a volu%e

+ot a su!stitute "or !lood or its co%'onents

Volu%e e'anders

Re%ain in vascular s'ace and increase os%otic 'ressure

Plas%a e'ander include detran& hetastarch and 'las%a al!u%in

Al!u%in

A

Al!u%in is availa!le in 9 Q and 89 Q

9 Q al!u%in e'ands vascular s'ace %< "or %+E3

O!tain venous access

Validate Vital si$ns

Re7uest !lood release

(on"ir% !lood acce'ta!ilit#

In"use !lood

onitor durin$ the trans"usion

atch "or trans"usion reaction

Vials %ust !e la!eled and a la!el on 't ar% to %atch.

I+ORE3 (O+SE+T

An in"or%ed consent UST !e o!tained and docu%ented 'rior to !lood ad%inistration

E'lanation to the client or "a%il# %e%!er o" %edical indications "or ho%olo$ous @ho%olo$ous

vs. autolo$ous trans"usion and its !ene"its& ris6s& and alternatives

Assess client histor# "or an# 'revious trans"usions and client?s res'onse


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VE+OUS A((ESS

+eed lar$e !ore IV @8G $au$e or lar$er

a# use a 88 >A "or adults ith s%all veins or children- not !est o'tion

(an use a VA3 @central line& !ut a lar$e volu%e o" re"ri$erated !lood in"used ra'idl# into theventricle can cause cardiac d#srh#th%ias

ar%in$ the !lood can reduce the ris6 o" this co%'lication

(aution

Ra'id in"usion ith cold !lood can cause d#srrh#th%ia

I +E(ESSARY TO use s%all $ua$e %a# need to as6 la! to s'lit unit into to !a$s. S%aller

needle can !e used "or 'latelets& al!u%in and clottin$ "actors.

)lood Release

)e"ore $oin$ to !lood !an6& several thin$s %ust !e done: 'ri%e !lood tu!in$ ith +S onl# and

start +S at ,VO& ta6e VS& 're%edicate i" ordered& !andin$J the 'atient

)lood %ust !e 'ic6ed u' "ro% the !lood !an6 !# an R+

The na%e and identi"ication nu%!er o" the reci'ient %ust !e 'rovided and a 'er%anent record

o" this in"o %aintained in !lood !an6

)lood !an6 is re"rid$erator

There is a !oo6 ith lot nu%!ers and 'atient identi"ication data.

Record

FG %inute indo

)lood %ust !e started ithin thirt# %inutes o" o!tainin$ unit "ro% la!

USE )


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Second chec6 is done at !edside !# 8 R+sW co%'are na%e& nu%!er& A)O& Rh co%'at.& !lood

!and

(hec6 date

Ins'ect !a$ "or lea6s& clots& ecessive air

The orst reactions to !lood are usuall# due to %isidenti"ication o" !lood or client

TU)I+>

ust use !lood tu!in$ ith "ilter.

E%'t# to "ull

REA(TIO+S

GQ o" he%ol#tic trans"usion reactions are "ro% i%'ro'er 'atient to 'roduct identi"ication


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+o other %edications to !e $iven in sa%e tu!in$- EVER @


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hat i" the rate o" in"usion slos ithout si$ns o" in"iltration00

Su$$est "lush line ith sterile nor%al saline.

hat i"0

Si$ns and s#%'to%s o" VE as short o" !reath or crac6les occurs000

Sto' or slo the in"usion

Elevate the HO)

Vital si$ns

+oti"# 3

Antici'ate 3iuretic; or'hine sul"ate

O#$en

Aller$ic Trans"usion Reaction see Techni7ues C.

re7uenc# 1Q

S 2 S: Urticaria& "lushin$& itchin$& @no "ever

$t: antihista%ines& trans"usion %a# continue

Prevention: treat 'ro'h#lacticall# ith antihista%ines 2 aceta%ino'hine

e'ine'hrine& corticosteroids "or severe reaction

e!rile Trans"usion Reaction

re7uenc#: G.9-1Q

S 2 SN: "ever and;or 'ul%onar# s#%'to%s& sudden chills and "ever& HA& "lushin$& aniet#&

%uscle 'ain

$t: I" "ever and;or 'ul%onar# s#%'to%s- 3O +OT resu%e in"usion& treat shoc6& $ive

anti'#retics

Prevention: (onsider leu6oc#te 'roducts hich have !een "iltered& ashed or "ro*en.

Acute He%ol#tic Trans"usion Reaction

re7uenc#: 1:89&GGG

S 2 SN: chills& "ever& )P& "lushin$& tach#cardia& tach#'nea& h#'otension& vascular colla'se&


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hat i"0000

I" reaction is sus'ected& should nurse turn saline on and allo saline to "lo throu$h tu!in$0

h# han$ saline ith !lood trans"usion and not detrose0

Anser: 3etrose cause coa$ulatio o" donor !lood.

Ana'h#lactic Trans"usion Reaction

re7uenc#: 1:19G&GGG

S 2 SN: aniet#& urticaria& hee*in$& d#s'nea

'ro$ressin$ to c#anosis& shoc6& cardiac arrest

$t: Sto' trans"usion& (PR i" needed& have E'ine'hrine read# "or in/ection

Prevention: >iven !lood "ro% I$A de"icient donors or 'las%a ash

3O +OT restart trans"usion

3ela#ed trans"usion reactions

3ela#ed he%ol#tic

He'atitis ) and (

HIV

Iron Overload

est +ile Virus

a# occur ee6s to %onths a"ter the trans"usion.

)lood (ollection

)lood s'eci%en collection

ost co%%onl# used dia$nostic aids in the care and evaluation o" clients

Yield valua!le in"or%ation a!out nutritional& he%atolo$ical& %eta!olic& i%%une and !ioche%ical

status

Screen "or earl# si$ns o" disease& 'lot current treat%ent course& and %onitor res'onse to thera'#

a# !e 'er"or%ed !# R+& or other trained 'ersonnel


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)lood tu!es

I3 la!els "or tu!es

A !utter"l#

Sterile s#rin$e

Vaccutainer tu!e

Sterile dou!le ended needle 8G-89>A

Anaero!ic and aero!ic culture !ottles

Su''lies de'end on hat !lood tests are ordered

(onsider- !e"ore #ou stic6

Antici'ate client?s aniet#

Assess "or an# 'ossi!le ris6s

Is the 'atient a!le to coo'erate0

(ontraindicated sites0

So%e s'eci%ens re7uire s'ecial collection re7uire%ents- 6no "acilit# 'olic#

hich tu!e do I use0

Pur'le - !lood cell counts @()(

Solid red - dru$ levels in !lood

S'ec6led red - che%istr#; electrol#te levels

)lue - clottin$ ti%es

>reen - cardiac s'eci"ic

ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ

555THIS VARIES RO A(I


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>ather su''lies

ash hands

Provide 'rivac#& 'osition 'atient

A''l# tourni7uet @1 %in %a

A''l# $loves

3eter%ine !est site- strai$ht& 'ro%inent vein

(leanse site and allo to dr#

Pull s6in taut& hold needle at 19-FG de$ree an$le ith !evel u'

Procedure cont.

Slol# insert into vein- "eel the 'o'J

ithdra !lood hile 6ee'in$ needle sta!ili*ed

Release tourni7uet hen !lood collected

A''l# sterile 'ressure dressin$

3is'ose o" su''lies 'ro'erl#

The )lood dra and the IV line

I" ne IV& dra !lood "ro% hu! !e"ore "lushin$

I" it is an old IV line- TOO )A3

hen drain$ !lood "or la!& avoid the ar% ith the IV 4 it %a# alter la! results

I" have to use sa%e ar%& turn o"" "luids "or 1G %inutes and use site distal to IV i" 'ossi!le

Handlin$ )lood S'eci%ens

Rotate !lood tu!es $entl# a"ter dra


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3is'osal o" %aterials

+eedles- shar's

I" not saturated ith !lood %a# $o into re$ular $ar!a$e. I" saturated ith !lood %ust $o into

!ioha*ard rece'tacle.

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53991583 Overview IV Therapy

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