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What is the delivery of medications in solution and fluids by parenteral route through a wide variety of catheter types and locations using multiple procedures?
Most common reasons for using infusion therapy:
- maintain fluid balance/correct imbalance
- correct or maintain electrolyte/acid base balance/imbalance
- administer meds
- replace bood
Types of infusion therapy are:
- IV solutions, including parenteral nutrition
- blood and blood components
- drug therapy
Tonicity is typically characterized by:
comparison with normal blood plasma as osmolarity (mOsm/L)
Normal serum osmolarity for adults is between:
Parental fluids within normal range are:
Fluids greater than 300 mOsm/L are:
Fluids less than 270 mOsm/L are:
When ____________ is used, water does not move into or out of the body's cells.
*therefore patients receiving isotonic solutions are at risk for fluid overload, especially older adults
__________ fluids are used to correct fluid, electrolyte, and acid-base imbalances by moving water out of the bodys cells and into the blood stream.
*parenteral nutrition solutions are also hypertonic
Instead of moving water out of the cells, ______ infusates move water into cells to expand them.
*patients receiving either hypertonic or hypotonic fluids are at arisk for phlebitis and infiltration
the inflammation of a vein caused by mechanical, chemical or bacterial irritation.
_____ occurs when IV solution leaks into the tissues around the vein.
The pH of IV solutions measures the acidity and alkalinity and usually ranges from:
3.5 and 6.2.
a blood clot in the vein is called
*extremes of both osmolarity and pH can cause vein damage, thus, fluids and meds with a pH value of less than 5 and more than 9 and with an osmolarity of more than 600 mOsm/L are best infused in the central circulation where greater blood flow provides adequate hemodilution.
*TPN solutions have an osmolarity greater than 1400 mOsm/L and should NOT be infused in peripheral circulation because it can damage blood cells and the endothelial lining of veins.
Venous irritants that have a pH less than 5:
- amiodarone (Cardarone)
- vancomycin (Vancocin)
- ciproflaxacin (Cipro I.V.)
Drugs with vasoconstrictive action:
- chemotherapeutic agens ie: vinblastine
*vescicants that cause exstravasation which results in severe tissue damage as manifested by blistering, tissue sloughing, or necrosis from infiltration into the surrounding tissues.
Nursing Safety Priority:
Monitor the IV insertion site carefully for early manifestations of infiltration, including swelling, coolness, or redness. If any of these symptoms are present, discontinue the drug immediately and notify the infusion therapy team, if available. If an infusion specialist is not available, plan to remove the IV catheter and consider central line placement.
The ISBT system (International Society of Blood Transfusion) includes 4 components theat must be present on the blood label both in bar code and in eye-readable format.
- a unique facility identifier
- the lot number relating to the donor
- the product code
- the ABO group and Rh type of the donor
An acute hemolytic transfusion reaction caused by an incompatible blood transfusion is a ____.
IV administration requires several things:
- knowledge of appropriate dilution
- rate of infusion
- pH and osmolarity
- compatibility with other IV meds
- appropriate site
- potential for vesican effects
- drug indications
- proper dosage
One major goal of the TJC is :
improving the safety of high alert drugs. ie: concentrated electrolyte solutions (potassium, chloride), which require restricted access, prominent warnings about the concentration, and storage in a secured location
Nursing Safety Alert:
Be sure to check for the accuracy and completeness of the treatment prescription. ie of incomplete prescription is "5% dextrose in water to keep the vein open". This statement doesn't specify the rate of infusion and is not considered complete
a plastic tube placed in a blood vessel to deliver fluids and medications is called a
vascular access device or infusion catheter
Seven major types of infusion catheters are:
- short perifpher catheters
- midline caths
- Nontunneled percutaneous central venous access cath
- tunneled caths
- implanted ports
- hemodialysis cath
Topical anethesthetic agents such as ____ can be used to decrease patient discomfort during insertion.
intradermal lidocaine 1%
__________ catheters are the most commonly used vascular access devices used for peripheral IV therapy
short peripheral cath
- *usually inserted into superficial veins fo the dorsal surface of the hand and the forearm using sterile technique. also the jugular vein in emergent situations.
- *avoid use of veins in lower extremities in adults because of increased risk for deep vein thrombosis and infiltration
- *range in length from 3/4 inch to 1 1/4 inch with gauge sizes from 26 gauge (the smallest) to 14 gauge (large bore)
Choosing the gauge for peripheral catheter:
24-26 gauge: smallest, not ideal for viscous infusions, expect blood transfusion to take longer; preferred for infants and small children; flow rate 24 mL/min
22 gauge: adequate for most therapies, blood can infuse without damage; flow rate 38 mL/min
20 gauge: adequate for all therapies; most anethesiologists prefer not to use a smaller size than this for surgery cases; flow rate 65 mL/min
18 gauge: preferred size for surgery; vein needs to be large enough to accommodate the catheter; flow rate 110 mL/min
14-16 gauge: For trauma and surgical patients requiring rapid fluid resuscitation; Needs to be in a vein that can accommodate
When selecting a site for a peripheral catheter consider the patients:
- type and duration of therapy
- patients preference when possible
3 different types of transilluminators:
- Veinlite LED
Placement of short peripheral venous cath:
- verify that the Rx for infusion therapy is complete and appropriate for infusion through a short peripheral catherter
- adults; choose a site for placement in the upper extremity. Do not use the wrist
- choose the patient's nondominant arm when possible
- choose a distal site, and make all subsequent venipunctures proximal to venous site
- do not use the arm on the side of a mastectomy, lymph node dissection, arteriovenous shunt or fistula or paralysis
- avoid choosing a site in an area of joint flexion
- avoid choosing a site in a vein that feels hard or cordlike
- avoid choosing a site close to areas of cellulitis, dermatitis, or complications from previous cath sites
- choose a vein of appropriate length and width to fit the size of the cath
The most appropriate veins for peripheral cath placement include:
- dorsal venous network
- median veins
- as well as their branches
Winged needles are easy to insert but associated with a high frequency of:
- *they are most commonly used for injection of single-dose drugs or for drawing blood samples.
- *like short peripheral caths, these should also have an engineered safety mechanism to house the needle when removed
_________ _____ ____ and technique before IV insertion are crucial.
aseptic skin prep
CDC recommendations to prevent blood stream infection during insertion:
- perform hand hygiene
- Clip hair do not shave
- ensure skin is clean
- wear clean gloves for peripheral IV insertion; do not touch access site after application of antiseptics
- prepare clean skin with 70% alcohol or chlorhexidine before peripheral venous catheter insertion
- apply povidone-iodine to the skin and allow to dry for at least two minutes
Common IV sites of the inner arm:
- Cephalic vein
- axillary vein
- brachial vein
- basilic vein
- median cephalic vein
- radial vein
- median vein
- median basilic
- ulnar vein
A patient is in the hospital for his first chemo therapy treament forlung cancer. Which IV access methods are appropriate for this patient? (Select all that apply)
- a. Peripheral access
- b. PICC
- c. Dialysis cath
- d. tunneled central venous cath
- e. implanted port
answer: b, d, e
______ can be anywhere from three to eight inches long and double or single lumen
- Midline catheters
- *inserted through veins of the upper arm; most often medial antecubital vein if done without ultrasound guidance
- *with ultrasound guide deeper veins can be accessed; basilic preferred over cephalic because of its larger diameter and straighter path
Midline caths can be use when:
- skin integrity or limited peripheral veins make it difficult to maintain a short peripheral catheter
- fluids for hydration
- Longer than six days and up to 4 weeks of therapy such as: antibiotics, heparin infusions for deep vein thrombosis, bronchodilators such as aminophylline and steroids
Drugs that cause severe tissue damange if they escape into the subcutaneous tissue (extravasation)
The DO NOTS:(midline cath)
- do not infuse parenteral nutrition formulas, including those with low concentrations of dextrose and all solutions that have an osmolarity greater than 600 mOsm/L
- Do not draw blood from midline catheters routinely
- Do not place in extremities affected by mastectomy with lymphedema, paralysis or dialysis grafts and fistulas
- Do Not administer incompatible drugs simultaneously administered through both lumens when using and double lumen because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein.
In ____ ______ ____ the vascular access device is placed inthe central circulation, specifically within the superior vena cava near its junction with the right atrium.
Central IV therapy
Blood flow in the SVC is approximately:
All central vascular devices require confirmation of placement in the vein by:
types of CVADs:
- Nontunneled percutaneous central venous catheters (CVCs)
- Tunnelled Central Venous Catheters
- Implanted cath
- hemodialysis cath
A long catheter inserted through a vein of the antecubital fossa or the middle of the upper arm
PICC: periperally inserted central catheter
In adults, the PICC legth ranges from:
- 18 to 29 inches with the tip residing in teh superior vena cava; placement of the tip in veins distal to the SVC is avoided due to higher rates of thrombosis.
- * the basilic vein is the preferred site for insertion of the PICC; the cephalic vein can be used if necessary
______ technique is used for insertion to reduce the risk for cath related bloodstream infections.
*before the cath can be used for infusion, a chest xray indicating that the tip resides inthe lower SVC is required when the catheter is not placed under fluoroscopy
What lumens are PICCs available in?
PICCs are available as:
- Groshong valve and pressure activated safety valve (PASV)
- Power PICCs; which can be used for contrast inujectino at a maximum of 5 ml/sec and a max pressure of 300 psi
Most common complications from PICC lines include:
- CR-BSIs (catheter related blood stream infections)
A patient has a PICC inserted and is ordered to received IV cisplatin (Platinol). the drug has infiltrated into the tissue and redness is observed in the right lower side of the neck. What interventions, in order of priority, will the nurse perform?
- a. Apply cold compresses to the site of swelling
- b. Stop infusion and disconnect the IV line from the admin set.
- c. Aspirate the drug from the IV access device
- d. Monitor the patient and document.
Answer: B, C, A, then D
The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug? (Select all that apply)
- a. indications, contraindications, precautions for IV therapy
- b. appropriate dilution, pH and osmolarity of solution
- c. rate of infusion and dosage
- d. generic, chemical, brand name of the drug
- e. compatibility with other IV meds
- f. percentage of adverse events for the drug
- g. specifics of monitoring because of immediate effect
answer: A, B, C, E, G
The charge nurse is reviewing IV therapy orders. what information is included in each order? (All that apply)
- a. specific type of solution
- b. rate
- c. specific drug dose to be added to solution
- d. method for diluting drugs for the solution
- e. specific type of administration equipment
answer: A, B, C
The nurse must insert a short peripheral IV catheter. In order to decrease teh risk of deep vein thrombosis or phlebitis, which vein does the nurse choose for the infusion site?
- a. Hand
- b. foot
- c. forearm
- d. antecubital
Which items does the nurse include in the documentation after completing the insertion of a PICC?
- a. type of dressing applied
- b. response of the family to IV Access
- c. type of IV access device used
- d. how long it took to place
- e. location and vein used for insertion
anser: A, C, E
A patient has a PICC placed by an advanced practice nurse at the bedside. Before using the cath, how is it's placement verified?
A chest x-ray is taken which shows the catheter tip in the lower superior vena cava
A patient requires a 2 month course of antibiotics to treat a resistant infection. Which device is chosen for this therapy?
The nurse is attempting to remove a PICC line and feels resistance. What techniques does the nurse use first to attempt to resolve this problem?
Use simple distraction techniques and deep breathing
PICCs can be use for blood sampling; however, a lumen size of ____ or larger are recommended
Patient teaching with a PICC line:
- teach patients to perform usual ADLs; they should avoid excessive physical activity
- PICCs may be contraindicated in paraplegic patients who rely on their arms for mobility
Recommendation for flushing PICC lines:
- 5 ml of heparin in a 10 ml syringe at least once daily if not actively used
- 10 ml of sterile saline is used to flush before and after med admin
- 20 ml of sterile saline is flushed after drawing blood.
- always use 10 ml barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the cath
__________ are inserted by a physician through the subclavian vein in the upper chest or the internal jugular veins in the neck using sterile tech.
nontunneled percutaneous central venous cath
*occassionally the patients condition may require insertion in a femoral vein, but the rate of infection is very high.
Nontunneled percutaneous cvc
- usually 7 to 10 inches long and have one to as many as five lumens.
- also available with antimicrobial coatings
- tip resides inthe superior vena cava and is confirmed by chest xray
- most commonly used for emergen, trama, critical care and surgery situations
Insertion of the nontunneled perc cvc requires the patient to be placed in the _____ position.
- Trendelenburg position
- *usually with a rolled towel between the shoulder blades
- this positioin may be difficult or contraindicated for patiens with respiratory conditions, spinal curvatures and ICP