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Chapter 7 Intravenous Therapy

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Intravenous therapy (IV)
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involves inserting a needle into a vein for the purpose of administering fluids and medications. A physician’s order is always necessary for this procedure
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Intravenous solutions and supplies are always sterile
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you must keep all parts of the system sterile to prevent infection, a serious complication. If a piece of intravenous equipment accidentally becomes contaminated, replace it.
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The most commonly used devices are
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catheters that are mounted over needles
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The vein must be large enough to hold the catheter
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a size 20- to 24- gauge catheter is used for most adults. Strict aseptic technique is used for this procedure
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Site Selection:
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The age of the patient and how long the IV is to remain in place may influence your selection. Avoid the veins of the lower extremities. Avoid scalp veins in infants unless you are specially trained in this procedure. Select a vein in the hand or forearm of the non-dominant hand.Selecting a site low on the hand or arm allows for site rotation and subsequent venipuncture higher up on the arm. Avoid veins over joints whenever possible. Choose the largest straightest vein available.
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The selection of an IV needle, or catheter is determined by the patient’s
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diagnosis, length of IV therapy, type of medication or other solution infused, and condition of the veins
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In general the gauge of plastic intravenous catheters is denoted using an
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even number
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The gauge of butterfly and steel needles for intravenous use is listed
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in odd numbers
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Patient comfort is an important
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consideration. Catheters stay in the vein longer than needles, and permit more movement. In most cases, the health care worker selects the device to use. However, the physician may order a specific needle or catheter.
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Most intravenous therapy is infused through flexible, plastic or Teflon catheters, or
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over-the-needle catheters (ONC’s)
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Over-the-needle catheters (ONC’s)
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are used for short or long-term IV therapy, and for restless patients. Many brands are available in assortments of sizes.
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Intravenous Solution:
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intravenous fluid is a prescription item, and must be ordered by a physician. The order must be followed exactly as written.
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To infuse properly, the solution must hang at least 30 to 36 inches above the level of the heart. The solution is attached to an IV pole or IV standard at the patient’s bedside. The standard is adjustable
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Legal Alert: “Six Rights”
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Right solution, right strength, right route, right time, right patient, right documentation
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Administration set or IV tubing / The basic IV administration set
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is a flexible plastic tubing through which the solution flows is attached to the IV solution on one end, and the patient on the other. A basic administration set is usually used with a manual or electronic device pump.
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Piercing pin
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pierces the plastic bag or bottle. The pin is sterile, and is covered with a plastic cap.
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Drop orifice
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is the entry to the drip chamber or drop chamber. The orifice controls the size of the drops of fluid
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Drip chamber
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is a semi-rigid container that is filled halfway with fluid. It allows easy visualization of the flow rate
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Y-sites
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some administration sets have two y-sites and some have only one. This is a connection for administration of medications
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Flow control clamp
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is a roller clamp used to regulate the speed or rte of fluid flow
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Slide clamp
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is a plastic clam used to stop or regulate the flow of fluid. It is used primarily during medication administration, but may be used to stop the fluid quickly, if necessary. Some administration sets do not have this clamp.
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Luer slips
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at the bottom connect the tubing to the needle or IV catheter. The luer mechanism provides a means of locking the tubing and needle or catheter together, making them more difficult to separate. The basic administration set should be made by the same manufacturer as the IV solution you are using.
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Before initiating an IV, always prime the tubing with the IV solution so it is completely full of fluid and free from bubbles
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this will reduce the risk of air entering the vein, which can kill the patient.
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Macrodrip
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is most commonly used for adults. Delivers fluid in a larger volume, typically 10 to 20 drops per milliliter of fluid. The volume delivered in the macrodrip set varies with the manufacturer and the purpost of the tubing.
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Microdrip
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is used for pediatric patients and for certain adults. The microdrip sets deliver fluid in smaller drops, usually 60 drops per milliliter. Always select the macrodrip unless directed otherwise by the RN
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The best way to prevent infection is to use
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standard precautions and strict aseptic technique, including good handwashing.
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Filters
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some facilities attach in-line filters to the administration set. Filters allow fluid to pass, but trap particles. Many agencies do not use them routinely, believing that they increase the infection rate and cause occlusion.
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The junctions of an intravenous infusion must be fastened together
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securely to prevent serious complications
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Marking the container:
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Patient’s name, room number, date and time, container number, flow rate ordered, duration of the infusion, your name or initials. Never write directly on the container with a permanent marker or pen. The ink from a marker will bleed through the plastic container, contaminating the solution. Write on a label, then affix the label to the container. Avoid covering writing or markings on the container with the label.
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Inserting a Peripheral IV in an Adult:
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Straight needles are seldom used, if ever. You will be using an over-the-needle catheter (ONC) or butterfly needle. For most adult fluid infusions, you will use a 20- to 24- gauge ONC. However, if the patient will be receiving blood, a larger gauge is used.
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Catheter Selection Considerations:
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24 g 15 – 25 mL/minute geriatric patients, adults with small veins 22 g 26 – 36 mL/minute geriatric patients, adults with small veins 20 g 50 -65 mL/minute Long-term therapy, radiologic dyes, partial parenteral nutrition 18 g 85 – 105 mL/minute emergency department patients, general surgical pt’s, pt’s w/anticipated blood transfusion 16 g More than 105 mL/minute certain preoperative infusions
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Infiltrates
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the needle pierces the vein and the intravenous fluid flows into the surrounding tissue instead of the vein. The veins below an infiltration may not be used.
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Forearm veins:
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Radial vein, Medial antebrachial vein, accessory cephalic vein, median cubital vein, basilic vein, cephalic vein
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Veins in hand:
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Dorsal metacarpal veins, dorsal venous network, basilic vein, cephalic vein
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Infection Alert:
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An IV infection can be very serious, because once inside the blood vessel, pathogens can move freely about the body. Most IV infections are caused by skin flora that are picked up during or after catheter insertion. Organisms on the skin at the insertion site may migrate on the inside or outside of the catheter. Contamination of the hub or connectors may also migrate into the catheter, causing infection
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Never wipe the skin with alcohol after applying povidone-iodine prep solution. The alcohol eliminates the beneficial effect of the povidone-iodine. Remember to check the patient’s allergies. Iodine allergy is fairly common.
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Catheter embolus
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the sheared piece of the catheter floats freely in the patient’s bloodstream, greatly increasing the risk of complications.
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Immobilizing and Dressing the Insertion Site:
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the needle insertion site must be immobilized with tape to prevent the catheter from moving. Movement is uncomfortable and increases the risk of dislodging the catheter. Position the tape so it does not cover the needle insertion site. The insertion site may be covered with an adhesive bandage, occlusive dressing, or other sterile dressing.
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Age – Appropriate Care Alert:
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When starting an IV on a patient who is elderly, stablilize the vein well, as veins in elderly persons tend to roll upon needle insertion.
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Age – Appropriate Care Alert:
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Immobilize the catheter well to prevent movement, which may cause skin tears and infiltration. However, you must follow your facility policies and documentation for use of restraints. In some situations, the device or method you use for immobilizing the insertion site may be considered a restraint. This is a particular problem with pediatric and elderly patients who do not have the mental capacity to keep from dislodging the IV without additional restraint.
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Heparin lock
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a cap that covers the end, or hub, of the needle or catheter. May be used for patients who are receiving intravenous medications. Two types are available: Male adaptor and a female adaptor. A liquid solution, such as injectable eparin, and anticoagulant, or normal saline is injected into the lock to keep it open when not in use. In adults, the heparin lock is changed every 96 hours, or according to facility policy.
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Inserting an IV using a Butterfly Needle
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In some situations, an intravenous infusion is initiated with a butterfly needle. Butterfly needles are commonly used in elderly patients and in children. They are also useful for short-term therapy in adults, for administering medications, and for certain forms of cancer treatment.
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Apply tape vertically over each wing then horizontally forming an “H” shape
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avoid taping directly over the needle insertion site
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Inserting a Peripheral IV in a Child:
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When selecting a device for IV infusion in children, a 22- or 24- gauge over-the-needle catheter is preferable. Children are active, and a butterfly will easily come out of the vein. Before starting an IV, provide age-appropriate explanation of the procedure. Show him or her the equipment and describe what you will be doing. However, you must be honest. Avoid telling the child that the procedure will not hurt. Have an assistant available to help you, providing the child with distraction and emotional support.
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Centers for Disease Control and Prevention (CDC)
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guidelines recommend using a hand in preference to a leg, arm, or the antecubital space. Try to select a site that will not interfere with the child’s play activities.
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Monitoring Intravenous Flow Rate:
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The IV rate is ordered by the physician, based on length of time the solution will hang. The solution should infuse at a steady rate.
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The RN will calculate the flow rate
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Some facilities attach a piece of tape to the side of the intravenous container. The approximate fluid level for each hour is marked on the tape.
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Sometimes an IV will be administered at a very slow rate, which is just enough to keep the vein open. This may be called:
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KO – keep open, TKO – to keep open, KVO – keep vein open or some other facility abbreviation. When this rate is ordered, the patient does not need fluid. The infusion is used to keep the vein open for emergency use or administration of medications.
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Volumetric intravenous pumps
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regulate the flow of IV fluids electronically. They are used to ensure accurate flow of IV solutions and drugs. Measures flow of fluids in milliliters per hour of solution infused.
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IV controllers
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regulate gravity flow of IV fluids by counting drops of solution. Controllers count drops, which are not always of identical (equal) size. Because of this, they are not as accurate as using a pump
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Complications of IV Therapy:
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Hematoma, infiltration, phlebitis, air embolus, catheter breakage or embolus, infection, fluid overload
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Hematoma
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is a complication that commonly occurs when the vein is injured during venipuncture. This can occur if you puncture the vein, or if inadequate pressure is placed on the insertion site after a needle is withdrawn. A bruise that fills with blood, causing swelling.
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Infiltration
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is also a common complication of IV therapy. This occurs when the catheter or needle comes out of the vein and fluid flows into the surrounding tissue. S/S : Pain / burning at the insertion site, swelling at the insertion site, skin cool to touch; may be lighter in color at the insertion site, rigid, taut skin near the insertion site, infusion rate has slowed or stopped, dressing covering the insertion site is damp or wet, no backflow into IV tubing when the bag is lowered below the insertion site
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Immobilize the extremity using an arm board. Applying a piece of tape to the back of the middle third of each piece of tape will prevent discomfort caused by pulling hair when the tape is removed.
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Phlebitis
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is irritation of the vein. It may be caused by irritation from the IV device, or from the medication. Infection may also cause phlebitis, but this is “less common” that the mechanical reasons listed.
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S/S: redness, warmth, swelling, and pain. The patient may have a red streak extending from the insertion site up the arm.
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The risk of phlebitis can be reduced by suing aseptic technique when
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priming the IV tubing or inserting the catheter or needle and when manipulating the IV system. Many facilities rotate the IV insertion site every 48 to 72 hours to reduce irritation to the wall of the vein.
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Air Embolus
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Length of administration set. Is a serious complication of IV therapy. Air can enter the system from any location, including the bag or bottle, administration set, a syringe, or from connections that become separated. Air embolus can be life-threatening
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S/S: SOB, cyanosis, weak, rapid pulse, decreased blood pressure, loss of consciousness, and cardiac arrest. Turn the patient on the left side. This may trap the air, preventing it from moving into the pulmonary artery.
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Catheter Breakage or Embolus
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loss of part or all of the catheter into the circulatory system causes a catheter embolus. This may be caused by shearing a piece from the catheter with the needle used for insertion. It can also occur if the catheter is not taped securely, causing the catheter to bend and break at the hub.
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S/S: respiratory distress, chest pain, cyanosis, rapid pulse, and decreasedblood pressure. This condition may cause unconsciousness. Stay with patient and notify RN
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Infection
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is caused by contamination somewhere in the IV system, or by improper insertion technique. It may also occur if the connections between the catheter or needle and the administration set separate, allowing contaminants to enter. Prevented by using good hand-washing technique, standard precautions, and aseptic technique.
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S/S: of localized infection are redness, swelling, heat, and pain at the insertion site. Foul-smelling drainage may be present. S/S of systemic infection: fever, chills, headache, and rapid respirations. Later the blood pressure may decrease.
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Fluid Overload
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occurs when fluids infuse too rapidly. This is a serious situation.
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S/S: including respiratory distress and cardiac arrest. Early S/S: rapid respirations, sob, rapid pulse, increased bp, and distended neck veins. Position bed in Fowler’s position. Stay with patient and notify RN
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If the patient c/o pain at the insertion site, has a fever without an obvious cause, or shows signs of a localized or generalized infection
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the dressing should be removed immediately and the site evaluated by the RN. Change the dressing immediately if it becomes wet, because of the high risk of infection.
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Age – Appropriate Care:
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Elderly and pediatric patients are at high risk for circulatory overload when IV fluids are given rapidly making close monitoring necessary.
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S/S: Elevated Bp, rapid respiration’s, coughing, sob, S/S of pulmonary edema: sob, difficulty breathing awakening at night feeling breathlessness, a feeling of suffociation or drowning, wheezing or grunting respirations, a productive cough with frothy, pink sputum, excessive sweating, pale or cyanotic skin color, anxiety, restlessness, weight gain, edema, extremities that are cool to the touch, rapid respirations, tachycardia, elevated Bp, jugular vein distention, retractions use of accessory muscles of respiration.
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Dressings must always be changed when the device is removed or replaced
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or if the dressing becomes soiled, damp, or loose. Frequent dressing changes may be necessary in diaphoretic (sweating) patients. Apply the principles of standard precautions.
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Central intravenous catheter
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is a long catheter that is inserted into a vein in the shoulder or neck area. The tip of the catheter is in the superior vena cava or right atrium of the heart. This type of intravenous catheter is used for long-term IV therapy. Changing the dressing is a sterile procedure. Strict aseptic technique must be maintained.
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The Hickman central intravenous catheter is commonly used
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The central intravenous catheter is threaded through the vein until the tip reaches the superior vena cava or right atrium
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Infection Alert:
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Central intravenous catheters have the greatest risk of infection of all IV’s. Those that are completely implanted (such as ports) have the lowest risk. Catheters with multiple lumens have a higher risk that single-lumen catheters. The triple-lumen catheter has the greatest infection risk. The risk decreases for double and single lumens. The insertion site also affects the risk. These sites are listed respectively from highest to lowest risk for infection: Femoral, Jugular, Subclavian, Peripheral sites.
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Flood or blood products may be administered to patients for many reasons.
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Commonly, patients with blood loss, and those with inadequate oxygen or nutrients in the blood, will receive a transfusion.
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Transfusion
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intravenous administration of blood. Responsibility of RN but may be asked to assist. You must also monitor the patient carefully for signs and symptoms of a transfusion reaction. Complications of this procedure can be life-threatening.
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Blood Groups and Types
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Type A, B, AB, & O. Type O is compatible with all other types of blood it is a “universal donor”. Persons with any blood type may receive type O blood. Persons with type AB blood are considered “universal recipients” because they have no A or B antibodies. Universal donors and recipients are not considered except in emergency situations. Type/Donor A — A, O B — B, O AB — AB, A, B, O O — O
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The Rh factor determines whether the blood is positive or negative for certain antigens, or foreign substances that cause an allergic reaction.
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Allergic reactions can be life-threatening.
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Antigens
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always stimulate an immune response.
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Antibodies
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are a protective mechanism against foreign materials. The antibodies recognize the same substance the next time it is introduced into the body.
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Type and cross-match
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identifies the patient’s blood type and Rh. The cross-match test determines whether the patient’s blood is compatible with the donor blood. Time is often critical,so this procedure must be performed immediately. You may have to pick up the blood from the laboratory. Two employees must check the blood before it leaves the blood bank, to reduce the potential chance for error.
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Transfusion Reactions:
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A transfusion reaction is a serious complication that can occur at any time when blood is being administered. The risk of reaction is greatest in the first 15 minutes of the infusion. However, vital signs are monitored carefully when blood is being administered, and periodically thereafter. In most cases vitals are taken and recorded every 15 to 30 minutes while blood is infusing.
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S/S: c/o heat or burning sensation in the vein through which blood is infusing, fever, chills, rapid pulse, decreased Bp, apprehension and anxiety, flushing of the face, or warm, flushed skin, chest pain, headache, lower back pain, sob, nausea & vomiting, diarrhea, abdominal cramps, coughing, rash or hives, itching, facial or throat edema, asthma reaction muscular pain, blood in the urine, loss of consciousness, cardiac arrest.