College of Nursing ABSN Program Adult Health Nursing II Block 7.0 Topic: Infusion Therapy Module: 1.1
Feb 23, 2016
College of NursingABSN ProgramAdult Health Nursing II
Block 7.0
Topic: Infusion Therapy Module: 1.1
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Assignment: Complete the Dosage Calculation Workbook,
DOC 1.20 Complete the Dosage Calculation Assessment
with a grade of 90% or greater.
Dosage Calculation
A thought to remember regarding dosage calculations:
“If you get a 90% on the dosage calculation assessment, it is an “A” or “Pass.”
“If you do dosage calculations at work as a nurse @ a 90% accuracy level, that could lead to the worst day of your life, and the last day of your
patient’s life!”
YOU MUST ENSURE 100% ACCURACY.
Block 7.0 Module 1.1
Infusion Therapy
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Adult Health II Block 7.0
IV Therapy
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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
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Learning Outcomes1. Discuss the purpose and goals for infusion therapy.
2. Verbalize & Demonstrate all appropriate steps when initiating intravenous therapy using a short peripheral IV catheter and discontinuing the IV access.
3. Verbalize & Demonstrate the procedure for changing intravenous solutions and intravenous tubing.
4. Analyze & Prioritize nursing responsibilities for the patient with an IV access, including short peripheral catheter, PICC line, tunneled catheter, & implanted port.
5. Analyze & Demonstrate the procedure for a central line dressing change.
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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.
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Some Key Terms 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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Infusion TherapyDelivery of parenteral medications and fluids through a wide variety of catheters and locationsVirtually all clients will have some type of infusion therapy during their hospital stay.Infusion therapy is also delivered in all types of healthcare settings.pH of IV solutions range from 3.5-6.2 extremes of both osmolarity (normal range 270-300) & pH can cause damage to vein fluids & meds with pH <5 & >9 & with osmolarity >500 should not be infused through a peripheral vein
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Goals of Infusion TherapyMaintain or correct fluid and electrolyte balance
Maintain or correct acid-base balance
Administer parenteral (IV) nutrition
Administer blood or blood products
Administer medications
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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
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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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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
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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
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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
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Never Use
Fluids past date of expiration
Outer Wrapping Removed
Fluid Discolored
Bag Leaking
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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.
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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
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Peripheral IV Catheters
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Short Peripheral IV Caths1. Plastic cannula built around a sharp stylet2. Length ¾-1 ¼ inches3. Dwell time 72 to 96-hours, then they are removed, and changed to another site4. If patient requires therapy longer than 6-days, a PICC or central line should be considered5. Highest risk of exposure to blood borne pathogens if accidental needle stick occurs
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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
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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
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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
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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
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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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Gauge Size for Peripheral Catheters Use the shortest length and smallest gauge to
deliver prescribed therapy 14-to-16 gauge: multiple trauma, heart surgery 18-20 gauge: major trauma or surgery, blood
administration 20-22 gauge: fluids & medications 22-24 gauge: used for all types of standard IV
solutions and clear IV meds; best for patients >65 years old
See Iggy, Table 15-1, p.216
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Site Preparation• If excessive hair to area, remove
only with clippers or scissors– Shaving not recommended
• Cleanse site with antimicrobial solution– Follow facility policy– Use of a 2% chlorhexidine and
alcohol solution, like ChloraPrep has been associated with reduced infections
– Povidone iodine—assess for allergies
– Alcohol—use before povidone-iodine
– Cleanse site in circular motion out or follow manufacturer's recommendation
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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
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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
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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
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IV with Transparent Dressing
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Patient Education Inform on any limits on movement
Explain alarms for controller/pump
Instruct the patient to report any redness, swelling, pain
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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)
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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
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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
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PICCs1. Inserted by RN with special training2. 18-29 inches long w/1-3 lumens3. Inserted in basilic or cephalic vein4. Tip rests in superior vena cava5. CXR required to check placement
before use6. Initial gauze dressing should be
replaced with transparent dressing within 24 hr
7. Ideal for long-term IV therapy8. Dwell time can be months or years9. RNs can draw blood specimens from
PICC port10. Low incidence of infection, other
complications
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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)
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Tunneled IV Catheters1. Trade names: Hickman,
Broviac, Groshong2. Indicated for frequent, long-
term therapy3. Used when PICC not best
choice (e.g., paraplegics) or when implanted port not desired d/t frequent needle sticks for access
4. No dressing required5. Dwell time: years6. Flushed with NS or heparin
after each use
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Implanted Ports1. Used when long-term (>year) access is
required. Used for chemotherapy. 2. Surgically placed under the skin. No
portion is visible.3. Usually placed on upper chest.4. Available in single or dual port.5. Catheter enters either subclavian or
internal jugular vein.6. Port access using Huber needle to
puncture the skin & port7. Remove Huber needle carefully --
needle stick frequently occurs to RN8. Flush after each use & at least monthly
w/NS &/or heparin per facility protocol
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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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Administration Sets•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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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
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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
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Intermittent Administration Sets Used to infuse multiple meds when no
primary continuous fluid is needed Replace tubing every 24 hr d/t greater
potential for contamination of both ends of this tubing
The IV catheter is capped with a needless connection device or “hep-lock”
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Pump Specific Administration Sets Made specifically for use with electronic infusion
devices
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Review: Administration Sets Primary Secondary Intermittent Pump-specific
What is their purpose? How often are they changed?
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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
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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
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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.
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PCA (Patient Controlled Analgesia) Pump
Provide an important mechanism for delivering analgesia
Embedded computer is programmed by RN to give a specified amount of opiate intravenously every time the patient pushes a button.
To help prevent excessive drug administration, the onboard computer ignores further patient demands until a lockout period (usually set for 5–10 minutes) has passed.
Can result in respiratory depression; requires routine monitoring of respiratory status is required. Consider continuous pulse ox monitoring.
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Prepare Equipment: Sterile Technique
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Prepare Equipment: Prime Tubing & Remove Air Bubbles
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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
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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
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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
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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
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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
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Local Complications of IV
Therapy
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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
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Infiltration & Extravasation: Leakage of Vesicant Fluid
InfiltrationTissue destruction d/t
extravasation of vesicant fluid
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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
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InfiltrationScale Grade
0
1
2
3
4
Grade Clinical Criteria0 No symptoms
1 Skin blanchedEdema < 1 inch in any directionCool to touchWith or without pain
2 Skin blanched, translucentEdema 1-6 inch in any directionCool to touchWith or without pain
3 Skin blanched, translucentGross edema > 6 inches in any directionCool to touchMild-moderate painPossible numbness
4 Skin blanched, translucentSkin tight, leakingSkin discolored, bruised, swollenGross edema > 6 inches in any directionDeep pitting tissue edemaCirculatory impairmentModerate—severe painInfiltration of any amount of blood product, irritant, or vesicant
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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
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Phlebitis ScaleGrade Clinical Criteria
0 No symptoms
1 Erythema at access site, with or without pain
2 Pain at access site with erythema and/or edema
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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Systemic Complications
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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
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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
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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
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InfectionLocal Site red, swollen, warm, may
have purulent drainage Caused by break in aseptic
technique during insertion or handling of equipment. Or lack of proper hand hygiene or skin antisepsis
Treatment: Clean site, save catheter tip in sterile container for culture, notify physician
Prevention: STRICT aseptic technique! Hand hygiene! Maintain dressing
Systemic Fever, chills, headache,
general malaise. If severe, vascular collapse and death
Cause: Same as local Treatment: Save entire
IV set and sample of IV fluid, notify physician, blood culture, IV antibiotics
Prevention: Same as local
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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
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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