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Med/Surg Chapter 13 infusion therapy

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Infusion therapy
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is the delivery of medications in solution and fluids by the parenteral (piercing of skin or mucous membranes) route through a wide variety of catheter types and locations using multiple procedures. • Intravenous (IV) therapy is the most common route for infusion therapy. • Infusion therapy is used for maintaining or correcting FLUID AND ELECTROLYTE BALANCE, correcting acid-base imbalance, achieving optimum nutrition, maintaining homeostasis, infusing blood or blood products, and treating or preventing illnesses with medications. • A specialized team of infusion nurses often initiates and maintains infusion therapy to reduce complications of therapy. • Infusion nurses may develop evidence-based policies and procedures; insert several types of peripheral and central venous catheters; provide therapies, including blood withdrawal, hypodermoclysis, intraosseous infusions, and administering medications, including chemotherapy; monitor patient outcomes; educate staff, patients, and families; and consult on product selection and purchasing decisions. • Orders for infusion fluids should include the specific type of fluid; rate of administration written in milliliters per hour, or the total amount of fluid and the total number of hours for infusion; drugs; and the specific dose to be added to the solution, such as electrolytes or vitamins. • Nurses are responsible for determining that the correct device is used and the order is appropriate for the patient, and for clarifying any questions before administration.
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Intravenous fluids
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are categorized according to osmolarity and tonicity as isotonic, hypertonic, and hypotonic.
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isotonic normal saline solution (0.9%)
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o Only isotonic normal saline solution (0.9%) is given with blood products.
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dextrose 5% in water (D5W)
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o Although dextrose 5% in water (D5W) is considered isotonic, it quickly becomes hypotonic as the dextrose is taken up by the cells. o Because of its high osmolarity, total parenteral nutrition is best infused into a central line for rapid dilution in a high-volume vein.
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turbidity
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o Always observe the fluid for turbidity (cloudiness) or any unusual color that could indicate contamination and INFECTION
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Blood and Blood Components
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o Whole blood, packed red blood cells, platelets, fresh-frozen plasma, albumin, and clotting factors can be transfused via the blood. o To ensure that the right blood products are given to the right patient, the patient is identified using two identifiers by two qualified health care professionals to ensure patient safety. o The International Society of Blood Transfusion system requires four components to be verified: the unique facility identifier, donor lot number, product code, and ABO group and Rh type of donor.
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sentinel event
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o An acute hemolytic transfusion reaction caused by an incompatible blood transfusion is called a “sentinel event.”
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PERIPHERAL IV THERAPY
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• Use best practice for placement of short peripheral vascular access devices (VADs), including avoiding the small veins of the hands. • Choose the appropriate peripheral catheter gauge size of the VAD depending on its purpose.
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CENTRAL IV THERAPY
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• Peripherally inserted central catheters (PICCs), tunneled central venous catheters, and implanted ports are commonly used for long-term infusion therapy.
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Vascular access devices (VADs)
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are catheters that are used to deliver fluids, electrolytes, and medications into the intravascular space. • The type of VAD that is used depends on the reason for infusion therapy, the patient’s condition, and the length of therapy. • Common types of VADs include short peripheral catheters, midline catheters, peripherally inserted central catheters (PICCs), nontunneled percutaneous central venous catheters (CVCs) and tunneled central venous catheters, implanted ports, and hemodialysis catheters. • Document care for the patient receiving IV therapy, including the type of VAD inserted. • Infusion controllers and pumps are electronic devices used to regulate the flow of infusion fluids and medications, but be sure to monitor the infusion rate.
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NURSING CARE FOR PATIENTS RECEIVING IV THERAPY
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• Nursing assessment for all types of infusion systems should be systematic, beginning with the insertion site and working up toward the tubing. • Nursing care for patients receiving IV therapy includes using sterile technique when starting the therapy and when changing components of the infusion system, changing and securing the site dressing, and assessing the site for local complications. • Use normal saline to flush IV catheters on a periodic basis per organizational policy. • Assess, prevent, and manage systemic complications related to intravenous therapy, which can cause INFECTION and reduce PERFUSION. • Older adults present special challenges when infusion therapy is used—physiologic changes of the skin (TISSUE INTEGRITY) and cardiac/renal systems must be considered. • Use small IV catheters for older adults and insert using a 10- to 15-degree angle to prevent rolling of the vein. • Check intravenous administration orders for accuracy and completeness before implementing them. • Prevent IV administration errors by using smart pumps and other safety infusion systems. • Devices engineered with safety mechanisms are required by the Occupational Safety and Health Administration to prevent staff injuries from needles by preventing bloodborne pathogen hazards. • Conscientiously document care for the patient receiving IV therapy, before and after VAD insertion and during the course of IV therapy. • Teach the patient and family about care of the patient receiving infusion therapy, including purpose and safety precautions.
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piggybacking
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• Use best practice for administering intermittent IV medications by either of the two methods of piggybacking or backpriming.
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COMPLICATIONS OF IV THERAPY
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• Use the evidence-based catheter-related bloodstream infection prevention bundle during insertion and care of central lines. • Assess and document the presence of phlebitis using the Infusion Nurses Society Phlebitis Scale. • Assess, prevent, and manage systemic complications related to IV therapy, including INFECTION. • Assess for common complications associated with central VAD insertion. • Assess, prevent, and manage complications during the course of central IV therapy. • Particularly in the older adult, maintain skin integrity (TISSUE INTEGRITY) when applying and removing adhesive tape or dressings.
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phlebitis
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inflammation of a vein
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Arterial therapy
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is used primarily for the administration of chemotherapy agents directly into a tumor site; the liver is the most common arterial site for this purpose.
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Intraperitoneal (IP) infusion therapy
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is used for antineoplastic agent administration into the peritoneal cavity, especially for ovarian and gastrointestinal tumors that have metastasized into the peritoneum.
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Subcutaneous infusion therapy
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with fluids (hypodermoclysis) involves a slow infusion for a short time; the thighs, hips, and abdomen are commonly used sites
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intraspinal infusion.
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• Epidural and intrathecal administration of medications is the common use for intraspinal infusion. o Epidural infusions are usually for pain management.
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Intrathecal infusions
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are usually for antineoplastic agents used for cancers that cross the blood-brain barrier into the central nervous system.
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Intraosseous (IO) therapy
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allows fluids and medications to be absorbed by the rich vascular network of the long bones; it is used for both children and adults, particularly in emergency situations.
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Intravenous Solutions
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Normal serum osmolarity (adults) = 270 to 300 mOsm/L: Isotonic = 270 to 300 mOsm/L Hypertonic = Fluids >300 mOsm/L Hypotonic = Fluids <270 mOsm/L
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Isotonic Infusate
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Water does not move into or out of body’s cells Risk for fluid overload, especially older adults
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Hypertonic Infusate
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Corrects fluid, electrolyte, and acid-base imbalances by moving water out of body’s cells, into bloodstream Parenteral nutrition is example
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Hypotonic Infusate
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Moves water into cells and expands them
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Osmolarity/TPN
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If osmolarity is >600 mOsm/L, best infused in central circulation where greater low provides adequate hemodilution TPN has osmolarity >1400 mOsm/L TPN should never be infused in peripheral circulation – can damage blood cells and endothelial lining of vein
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Blood Transfusions and Other Components
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Packed red blood cells Platelets Fresh frozen plasma Albumin Several specific clotting factors
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Limb Alert
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Veins cannot be used in patients with: Mastectomy Axillary lymph node dissection Lymphedema Paralysis of upper extremities Dialysis graft or fistulas
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Infection Control
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CDC recommends aseptic preparation and technique including: Hand hygiene Clip hair; do not shave Ensure skin is clean Wear gloves Prepare skin with 70% alcohol or chlorhexidine
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Midline Catheter
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3 to 8 inches long, 3 to 5 Fr, double or single lumen Inserted through vein in upper arm Used for therapies lasting 1 to 4 wk Do not use for vesicant drugs; can cause tissue damage if extravasation occurs Do not use to draw blood
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Central IV Therapy
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Vascular access device (VAD) placed in central circulation, specifically within superior vena cava (SVC) near junction with right atrium Chest x-ray to confirm placement
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Peripherally Inserted Central Catheter (PICC)
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Length of 18 to 29 inches (45 to 72 cm) Chest x-ray determines placement Power ICCs used for contrast injection; can also attach to transducers for CVP monitoring
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Nontunneled Percutaneous Central Venous Catheter
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Inserted through subclavian vein in upper chest or jugular veins in neck May require insertion in femoral vein – Rate of infection is high 7 to 10 inches (15 to 25 cm) long; up to 5 lumens Tip resides in superior vena cava Chest x-ray confirms placement
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Tunneled Central Venous Catheter
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Portion lies in subcutaneous tunnel Used for frequent and long-term infusion therapy Has cuff of antibiotic-containing material to help reduce infection
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Implanted Port
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Consists of portal body, dense septum over a reservoir, and catheter Single or double Surgically created subcutaneous pocket houses the port body Usually placed in upper chest/extremity Not visible externally Flushing after each use and at least once per month between therapies prevents clot formation in internal chamber
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Hemodialysis Catheter
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Large lumens accommodate hemodialysis or pheresis procedure (harvests specific blood cells) Catheter-related bloodstream infections (CR-BSI), vein thrombosis are common problems Do not use for administering other fluids/medications (except in emergency)
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Infusion System
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Containers – Plastic (PVC-free or DEHP-free), glass Administration sets – Secondary, intermittent Add-on systems Needleless connection devices Rate-controlling infusion devices Use of IV pumps does not decrease the nurse’s responsibility to carefully monitor the patient’s infusion rate and site!
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Important regarding IV tubing
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Change lipid tubing every 24 hr Change blood tubing within 4 hr Change propofol (Diprovan) tubing every 6 to 12 hr Always Check facility protocol for possible deviations
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Local Complications of IV Therapy
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Infiltration Phlebitis and post-infusion phlebitis Thrombosis Thrombophlebitis Ecchymosis and hematoma Site infection Venous spasm Nerve damage
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Systemic Complications of IV Therapy
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Circulatory overload Speed shock Allergic reaction Catheter embolism
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Interventions to reduce infection risk
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Clean needleless system connections before use with antimicrobial for 30 seconds Do not tape connections between tubing sets Use evidence-based hand hygiene guidelines from CDC and OSHA
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Alternative Sites for Infusion
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Intra-arterial therapy Intraperitoneal (IP) infusion Subcutaneous infusion Intraspinal infusion Intraosseous therapy
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Compartment Syndrome
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When increased tissue perfusion in a confined space causes decreased flow to the area
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Older Adult Care
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Skin care Vein and catheter selection Cardiac and renal changes
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What is the primary intervention the nurse can implement to prevent a central catheter-related bloodstream infection (CR-BSI) for a patient having IV therapy?
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A. Perform hand hygiene. (correct answer) B. Ensure the dressing remains intact. C. Question the need for a central line. D. Clean the hub for 15 seconds before accessing the port. Rationale: Prevention of CR-BSI involves multiple interventions; however, consistent hand hygiene with soap and water or an alcohol-based hand rub remains the primary mechanism for prevention of infection. Cleaning the hub prior to access, maintaining the dressing integrity, and removing the central line when it is no longer needed are also important interventions to prevention
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A man with severe burns over 90% of his body has been brought to the ED. The rescue personnel were unable to establish IV access during transport to the hospital. Which type of IV device would be most appropriate at this time?
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A. PICC line B. Central line C. Intraosseous catheter (correct answer) D. Subcutaneous infusion Rationale: Intraosseous (IO) therapy allows access to the rich vascular network located in the long bones. Victims of trauma, burns, cardiac arrest, and other life-threatening conditions benefit from this therapy because often clinicians are unable to access these patients’ vascular systems for traditional IV therapy. If IV access cannot be obtained within the first few minutes of resuscitation procedures, IO may be attempted. After establishing IO access, efforts should continue to obtain IV access as well.
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During the insertion of an IV catheter, a patient with dehydration reports feeling “pins and needles” in his arm. The nurse is aware that this sensation may have been caused by what?
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A. Nerve puncture may have occurred. (correct answer) B. The patient’s dehydration caused this sensation. C. The vein has collapsed during the catheter insertion. D. The vein has been accessed properly for the infusion. Rationale: Reports of tingling, feeling “pins and needles” in the extremity, or numbness during the venipuncture procedure, can indicate nerve puncture. The procedure should be stopped immediately, the catheter removed, and a new site chosen. Transsection of the nerve can result in permanent loss of function, and local nerve damage can become a chronic systemic pain syndrome.