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College of Nursing ABSN Program Adult Health Nursing II Block 7.0

College of Nursing ABSN Program Adult Health Nursing II Block 7.0. Topic: Infusion Therapy Module: 1.1. A thought to remember regarding dosage calculations: “If you get a 90% on the dosage calculation assessment, it is an “A” or “Pass.”

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College of Nursing ABSN Program Adult Health Nursing II Block 7.0

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

  2. 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. Dosage Calculation • 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

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

  4. 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

  5. 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.

  6. 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

  7. 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

  8. 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 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 Block 7.0 Module 1.1

  9. 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

  10. 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 7.0 Module 1.1

  11. 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

  12. 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

  13. 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

  14. 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

  15. Never Use • Fluids past date of expiration • Outer Wrapping Removed • Fluid Discolored • Bag Leaking Block 7.0 Module 1.1

  16. 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 7.0 Module 1.1

  17. 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

  18. Peripheral IV Catheters Block 7.0 Module 1.1

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. Block 7.0 Module 1.1

  25. 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

  26. 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,bloodadministration • 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

  27. 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 7.0 Module 1.1

  28. 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

  29. 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

  30. 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

  31. IV with Transparent Dressing Block 7.0 Module 1.1

  32. Block 7.0 Module 1.1

  33. 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

  34. 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

  35. 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 7.0 Module 1.1

  36. 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 7.0 Module 1.1

  37. 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 7.0 Module 1.1

  38. 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 7.0 Module 1.1

  39. 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 7.0 Module 1.1

  40. 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 7.0 Module 1.1

  41. Implanted Ports Block 7.0 Module 1.1

  42. 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

  43. Administration Sets • Each type of set has a drip chamber • And a drip system: macrodrip or microdrip *60 gtt/mL *15 gtt/mL Block 7.0 Module 1.1

  44. 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

  45. Large volume IV infusion bag Piggyback bag Drip chamber IV catheter ports IV pump IV catheter Block 7.0 Module 1.1

  46. 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

  47. 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

  48. Pump Specific Administration Sets • Made specifically for use with electronic infusion devices Block 7.0 Module 1.1

  49. Review: Administration Sets • Primary • Secondary • Intermittent • Pump-specific • What is their purpose? • How often are they changed? Block 7.0 Module 1.1

  50. 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 7.0 Module 1.1

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