8B IV Therapy; ATI skills module, pharm book, Igancioius, Article

Extravasation is caused by

leakage of a vesicant IV solution or medication into the extravascular tissue This can occur with both peripheral and central catheters Same as infiltration

To improve your success with venipuncture, use

low angles of 10 to 15 degrees between the skin and catheter

For a poorly controlled diabetic patient, dextrose solutions for dilution may

not be preferred, consult with the pharmacist and prescriber to answer these questions.

Rotate the subcutaneous infusion site at least

once per week.

Administration of IP therapy requires the patient to be in

the semi-Fowler's position for the infusion.

Central Line-Related Bloodstream Infection (CR-BSI) prevention

Maintain sterile technique. Use the recommended CR-BSI prevention bundle.

Fluid overload prevention

Monitor intake and output carefully, and notify physician as soon as an imbalance is noticed between the patient's intake and output.

The phlebitis scale is

0 = No symptoms 1 = Erythema 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 cord 4 = Pain at access site with erythema and/or edema; streak formation; palpable cord more than 1 inch long; purulent drainage

The infiltration scale is

0 = No symptoms 1 = Skin blanched; edema <1 inch in any direction, cool to touch; with or without pain 2 = Skin blanched; edema 1-6 inches in any direction; cool to touch; with or without pain 3 = Skin blanched, translucent; gross edema >6 inches in any direction; cool to touch; mild to moderate pain; possible numbness 4 = Skin blanched, translucent; skin tight, leaking; skin discolored, bruised, swollen; gross edema >6 inches in any direction; deep pitting tissue edema; circulatory impairment; moderate to severe pain; infiltration of any amount of blood product, irritant, or vesicant

Hypodermoclysis should not be used if the fluid replacement needs exceed

2000 to 3000 mL/day, in emergency situations, or if there are bleeding or coagulation problems

Subcutaneous infusion therapy flow rate for hydration begins at

30 mL/hr. After 1 hour, the rate can be increased if the patient has experienced no discomfort. The maximum rate is usually 75 to 80 mL/hr.

Any needle could be used to provide therapy and access the medullary space (marrow). However, 15- or 16-gauge needles specifically designed for IO are preferred because they have:

A removable stylet that screws into the cannula to keep the needle from retracting during insertion A short shaft to eliminate accidental dislodgment after placement An adjustable guard to stabilize the needle at skin level

Catheter (piece) embolism causes

A shaving or piece of catheter breaks off and floats freely in the vessel Anything that damages the catheter—during insertion, dressing change, excessive force with flushing or medication administration

Venous spasm caused by

A sudden contraction of the vein A normal response to irritation or injury of the vein wall

Venous spasm prevention

Allow time for vein diameter to return to normal after tourniquet removal and before advancing catheter. Infuse fluids at room temperature, if possible. For a midline catheter or PICC, gently withdraw the catheter in short segments.

Lumen occlusion prevention

Always flush with normal saline between, before, and after each medication given through the catheter. Use positive-pressure flushing techniques when a negative fluid displacement needleless connector is being used. Use a positive fluid displacement needleless connector. Flush catheters immediately when medication infusion is complete.

Lumen occlusion treatment

Assess history of catheter use. A suddenly developing problem may indicate contact between incompatible medications. A problem that develops over an extended period may indicate a gradual clot formation. For drug precipitate, determine the pH of the precipitated drug. Use hydrochloric acid for acidic drug. Use sodium bicarbonate for alkaline drugs. For blood clot, use thrombolytic enzymes such as alteplase.

Ecchymosis prevention

Avoid veins that cannot be easily seen or palpated. Use extra caution in patients with coagulopathies. Use good venipuncture technique.

'Speed shock' prevention

Be aware of the appropriate infusion rate of medications and adhere to them; use of infusion control devices assists in prevention of speed shock.

Thrombosis is caused by

Blood clot inside the vein Anything that damages the endothelial lining of the intima can initiate clot formation Traumatic venipuncture Multiple venipuncture attempts Use of catheters too large for the chosen vein Hyper-coagulable state and venous stasis

Catheter rupture causes

Catheter is broken, damaged, or separated from hub or port body Forcefully flushing a catheter with any size syringe against resistance Using scissors to remove a dressing Catheter compression of a subclavian inserted catheter between the clavicle and first rib (also known as pinch-off syndrome)

Central Line-Related Bloodstream Infection (CR-BSI) treatment

Change the entire infusion system from solution to IV device; notify physician, obtain cultures, and administer antibiotics as prescribed. If the infusate is the suspected cause, send a specimen to the laboratory for evaluation.

Catheter migration (movement of a properly placed catheter tip to another vein) causes

Changes in intrathoracic pressure caused by coughing, vomiting, sneezing, heavy lifting, and congestive heart failure

Phlebitis prevention

Choose the smallest-gauge catheter for the required therapy. Avoid sites of joint flexion, or stabilize with an armboard. Avoid infusing fluids or medications with a pH below 5 or above 9 through a peripheral vein. Avoid infusing fluids or medications with a final osmolarity above 500 mOsm/L through a peripheral vein. Rotate sites every 72-96 hr according to established policy. Adequately secure the catheter. Use aseptic technique. For PICCs, teach patient to avoid excessive physical activity with the extremity.

Site infection treatment

Clean exit site with alcohol, expressing drainage if present. For short peripheral catheter, midline catheter, or PICC, remove using sterile technique and avoid contact between skin and catheter. Send catheter tip for culture, if requested. Clean site with alcohol, and cover with dry sterile dressing; physician to evaluate for septic phlebitis and need for antimicrobial therapy or surgical intervention.

Venous spasm signs and symptoms

Cramping or pain at or above the insertion site Numbness in the area Slowing of the infusion rate Inability to withdraw midline catheter or PICC

Catheter (piece) embolism treatment

Depending on where the catheter embolizes, this could be life threatening. Cardiopulmonary arrest could occur. Emergently notify the physician. Remove the catheter, and apply a tourniquet high on the limb of the catheter site; inspect catheter to determine how much may have embolized; an x-ray is taken to determine the presence of any catheter piece; surgical intervention may be necessary.

Fluid overload causes

Disruption of fluid homeostasis with excess fluid in the circulatory system Infusion of fluids at a rate greater than the patient's system can accommodate

Central Line-Related Bloodstream Infection (CR-BSI) signs and symptoms

Early symptoms include fever, chills, headache, and general malaise

Ecchymosis is cause by

Ecchymosis from infiltration of blood into the surrounding tissue Hematoma results from uncontrolled bleeding Unskilled or multiple attempts Patients with coagulopathy or fragile veins (e.g., older adults and patients on steroids) Accidental laceration of a large vein or artery

Catheter dislodgement (movement of catheter into or out of the insertion site) signs and symptoms

External catheter length has changed, also changing the internal tip location No other signs or symptoms may be immediately noticed Stop all infusions, and flush catheter.

Catheter rupture signs and symptoms

Fluid leaking from insertion site Pain or swelling during infusion Reflux of blood into the catheter extension Inability to aspirate blood from catheter

'Speed shock' treatment

Immediately discontinue the drug infusion and hang isotonic solution to keep the vein open; monitor vital signs carefully, and notify physician for further treatments.

Nerve damage prevention/treatment

Immediately stop the insertion procedure if the patient reports extreme pain. Remove the catheter if reports of discomfort do not improve when the catheter is secured. Avoid using the cephalic vein near the wrist. Avoid using veins on the palm side of the wrist. Adequately secure the catheter, but avoid tape that is too tight. Support areas of joint flexion with an arm board.

Catheter dislodgement (movement of catheter into or out of the insertion site) causes

Inadequate catheter securement Excessive physical activity with a PICC

Nerve damage caused by

Inadvertent piercing or complete transection of a nerve Venipuncture near known nerve locations Unanticipated nerve locations Reports of tingling or feeling "pins and needles" at or below the insertion site Numbness at or near the insertion site

Lumen occlusion signs and symptoms

Infusion stops or pump alarm sounds Inability or difficulty administering fluids Inability or difficulty drawing blood Increased resistance to flushing of the catheter

Catheter migration (movement of a properly placed catheter tip to another vein) prevention

Instruct patient to perform usual ADLs but to avoid excessive physical activity.

Site infection causes

Invasion of microorganisms at the insertion site in the absence of simultaneous bloodstream infection Infection localized at the insertion site, the port pocket, or subcutaneous tunnel Break in aseptic technique during insertion or the handling of sterile equipment Lack of proper hand hygiene and skin antisepsis

Catheter dislodgement (movement of catheter into or out of the insertion site) treatment

NEVER re-advance the catheter into the insertion site. Determine the amount of external catheter length, and compare with the length documented on insertion. Notify the physician or nurse inserting the catheter for further assessment.

Catheter rupture prevention

NEVER use excessive force when flushing a catheter, regardless of syringe size. On injection, small syringes generate more pressure than larger syringes. Use of a 10-mL syringe is generally recommended for flushing procedures. Insert catheter through jugular or upper extremity sites instead of subclavian site.

Catheter migration (movement of a properly placed catheter tip to another vein) signs and symptoms

No change in the external catheter length For migration to the jugular vein: reports of hearing a running stream or gurgling sound on the side of catheter insertion For migration to the azygos vein: back pain between the shoulder blades Neurologic complications if medications are infused

Central Line-Related Bloodstream Infection (CR-BSI) causes

Pathogenic organisms invade the patient's circulation The CDC has specific criteria to classify these infections Lack of sterile field during insertion Inadequate skin antiseptic agents and application techniques Manipulation of the catheter hub leading to intraluminal contamination Inadequate hand hygiene Long dwell time

'Speed shock' signs and symptoms

Patient may report lightheadedness or dizziness and chest tightness; nurse may note that patient has a flushed face and an irregular pulse; without intervention, patient may lose consciousness and go into shock and cardiac arrest.

Fluid overload signs and symptoms

Patient may report shortness of breath and cough; patient's blood pressure is elevated, and there is puffiness around the eyes and edema in dependent areas; patient's neck veins may be engorged, and nurse may hear moist breath sounds.

Catheter dislodgement (movement of catheter into or out of the insertion site) prevention

Proper catheter securement. Instruct patient to perform normal ADLs but to avoid excessive physical activity.

Phlebitis treatment

Remove short peripheral catheter at the first sign of phlebitis; use warm compresses to relieve pain. Monitor frequently. Document using Phlebitis Scale. Insert a new catheter using the opposite extremity. Mechanical phlebitis occurring in the first week after PICC insertion may be treated without catheter removal. Apply continuous heat; rest and elevate the extremity. Significant improvement is seen in 24 hr, and complete resolution is seen within 72 hr. Remove catheter if treatment is unsuccessful.

Catheter rupture treatment

Repair the damaged segment; depends on the availability of a repair kit designed for the specific brand of catheter being used; repair may be considered a temporary measure instead of a permanent treatment. Remove catheter.

Extravasation prevention

Same as infiltration. Know the vesicant potential before giving any IV medication. Prevention is key

Fluid overload treatment

Slow the IV rate, and notify physician; raise patient to an upright position; monitor vital signs, and administer oxygen as prescribed; administer diuretics as prescribed.

Catheter migration (movement of a properly placed catheter tip to another vein) treatment

Stop all infusions, and flush catheter. Notify physician. Obtain a chest radiograph to assess tip location. Spontaneous repositioning back to the SVC is possible. Repositioning by radiology may be required. Place catheter tip properly in the lower third of the SVC near the junction with the right atrium.

Thrombosis treatment

Stop infusion and remove short peripheral catheter immediately. Apply cold compresses to decrease blood flow and stabilize the clot. Elevate extremity. Surgical intervention may be required. For central venous catheters, notify the physician and obtain requests for a diagnostic study. Low-dose thrombolytic agents can be used to lyse the clot.

Extravasation treatment

Stop infusion, and disconnect administration set. Aspirate drug from short peripheral catheter or port access needle. Leave short peripheral catheter or port access needle in place to deliver antidote, if indicated by established policy. If possible, aspirate residual drug from the exit site of a central venous catheter. Administer antidote according to established policy. Apply cold compresses for all drugs EXCEPT vinca alkaloids and epipodophyllotoxins. Photograph site. Monitor at 24 hr, 1 wk, 2 wk, and as needed. Surgical interventions may be required. Provide written instructions to patient and family.

'Speed shock' causes

Systemic reaction to the rapid infusion of a substance unfamiliar to the patient's circulatory system Rapid infusion of drugs or bolus infusion, which causes the drug to reach toxic levels quickly

Venous spasm treatment

Temporarily slow infusion rate. Apply warm compress. Do not immediately remove short peripheral catheter. If occurring during midline catheter or PICC removal, do not apply tension or attempt forceful removal. Reapply a dressing, apply heat, encourage patient to drink warm liquids, and keep extremity covered and dry. 12-24 hr may be required before catheter can be removed.

Thrombosis prevention

Use evidence-based venipuncture technique. Make only two attempts to perform venipuncture. Choose the smallest-gauge catheter in the largest vein possible. Secure catheter adequately. Use armboards if short peripheral catheters are placed in areas of joint flexion. Ensure adequate hydration to avoid changes in blood composition and flexion of the extremity. Prophylactic low-dose warfarin (Coumadin) may be prescribed for patients with a central venous catheter.

Site infection prevention

Use strict aseptic technique when inserting, maintaining, or removing catheters. Practice good hand hygiene. Ensure dressing remains clean, dry, and adherent to skin at all times.

Catheter (piece) embolism prevention

When inserting over-the-needle catheters, never reinsert the needle into the catheter; avoid pulling a through-the-needle catheter back through the needle during insertion. Avoid scissors near the catheter with dressing changes.

Ecchymosis treatment

When removing device, apply light pressure; excessive pressure could cause other fragile veins in the area to rupture. For hematoma, apply direct pressure until bleeding has stopped. Elevate extremity, apply ice for first 24 hours, then warm compress for comfort.

During the dwell and drainage phases of IP therapy, the patient may need

assistance in frequently moving from side to side to distribute the fluid evenly around the abdominal cavity. After the fluid has drained, the catheter is flushed with normal saline, although heparinized saline may be used in implanted ports. Catheter lumen occlusion is caused by the formation of fibrous sheaths or fibrin clots or plugs inside the catheter or around the tip.

When an arterial site is used for infusion therapy,

be sure catheter equipment is proper to withstand arterial pressure When the carotid artery is involved, perform neurologic assessments. When a femoral catheter is used, apply antiembolic stockings or other measures to prevent deep vein thrombosis. Complications from arterial catheters are similar to those from venous catheters, including infection, bleeding from the insertion site, hemorrhage from a catheter disconnection, catheter migration, infiltration, and catheter lumen or arterial occlusion.

Lumen occlusion causes

catheter lumen is partially or totally blocked Drug or mineral precipitate (calcium, diazepam, and phenytoin are common) Lipid sludge from long-term infusion of fat emulsion Blood clots and fibrin sheath caused by blood reflux into lumen Allowing administration sets to remain connected for extended periods after medication has infused

Fluid overload occurs easily in the older adult and can result in

congestive heart failure

Serum sodium levels should be considered when normal saline is routinely used for

dilution in patients with hypertension or cardiac problems.

Complications of IP therapy include

exit site infection, indicated by redness, tenderness, and warmth of the tissue around the catheter; microbial peritonitis and inflammation of the peritoneal membranes from the invasion of microorganisms evidenced by fever and report abdominal pain, symptoms of abdominal rigidity and rebound tenderness

There are few contraindications for intraosseous infusion. The only absolute contraindication is

fracture in the bone to be used as a site. Conditions such as severe osteoporosis, osteogenesis imperfecta, or other conditions that increase the risk for fracture with insertion of the IO needle and skin infection over the site may also be contraindications for some patients. Repeated attempts to access the same site should be avoided.

The patient undergoing intrathecal or epidural infusion may also exhibit neurologic and systemic signs of infection (e.g., meningitis), such as

headache, stiff neck, or temperature higher than 101° F (38.3° C). Report any neurologic change to the health care provider immediately!

Subcutaneous infusion therapy may be used in palliative care patients who cannot tolerate oral medications, when IM injections are too painful, or when vascular access is not available or is too difficult to obtain. Most often, this type of infusion is used in

hospices for pain management.

The most common complication of IO therapy is

improper needle placement with infiltration into the surrounding tissue evidenced by an accumulation of fluid under the skin at either the insertion site or on the other side of the limb which indicates that the needle either is not far enough in to penetrate the bone marrow or is too far into the limb and has protruded through the other side of the shaft. Needle obstruction occurs when the puncture has been accomplished but flushing has been delayed. This delay may cause the needle to become clotted with bone marrow. Osteomyelitis (bone infection) and compartment syndrome are unusual but serious complications of IO therapy

Phlebitis is caused by

inflammation of the vein Post-infusion phlebitis presents within 48-96 hr after the catheter has been removed Mechanical cause from insertion technique, catheter size, and lack of catheter securement Chemical cause from extremes of pH and/or osmolarity of the fluid or medication Bacterial cause from a break in aseptic technique, poor securement, and extended dwell time

When used for pain management, doses are usually 10 times greater for epidural than for

intrathecal infusion. Assess the patient for response to the drugs being given, level of alertness, respiratory status, and itching.

Hyaluronidase is an enzyme that can be

mixed with each liter of infusion fluid (150 units) to improve the absorption of the infusing fluids from the subcutaneous tissue; requires test dose for allergic reaction. If the enzyme is not used, the infusion may not be well absorbed and redness at the insertion site is more likely

Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area. The decreased circulation to the area leads to hypoxia and pain in the area. Although the complication is rare in IO therapy, the nurse should

monitor the site carefully and alert the physician promptly if the patient exhibits any signs of decreased circulation to the limb, such as coolness, swelling, mottling, or discoloration. Without improvement in perfusion to the limb, the patient could ultimately require amputation of the limb.

Administration of IP therapy may make the patient experience

nausea and vomiting caused by increasing pressure on the internal organs from the infusing fluid. Pressure on the diaphragm may cause respiratory distress. Reducing the flow rate and treatment with antiemetic drugs may be needed. Severe pain may indicate that the catheter has migrated, and an abdominal x-ray is needed to determine its location.

Absorption rates of large-volume parenteral (LVP) infusions and drugs administered via the IO route are similar to those achieved with

peripheral or central venous administration.

Complications of subcutaneous infusion sites include

pooling of the fluid at the insertion site and an uneven fluid drip rate. Both of these problems may be resolved by restarting the infusion in another location. An infusion pump may also be used. Small ambulatory infusion pumps can be used to allow for greater mobility.

Medications commonly contain preservatives such as alcohol, phenols, or sulfites; however, these are toxic to the CNS. All medications used for intraspinal infusion must be free of

preservatives. Alcohol and products containing alcohol should not be applied to the insertion site because the solution could track along the catheter and cause nerve damage. Povidone-iodine solutions are preferred for skin antisepsis before insertion and during catheter dwell, including tunneled catheter exit sites and implanted port pockets.

The IO route should be used only during the immediate period of

resuscitation and should not be used longer than 24 hours. After establishing access, efforts should continue to obtain IV access as well.

When fluid restrictions are required, medications could be diluted in

small quantities and delivered using a syringe pump or a manual IV push. For instance, 1 g of an antibiotic could be diluted in 10 mL normal saline instead of the more common 50 mL. This alternative allows the patient to have more fluid to drink.

Intraperitoneal (IP) therapy is

the administration of chemotherapy agents into the peritoneal cavity through an implanted port for long-term treatment or an external catheter for temporary use. IP therapy is used to treat intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery.

Administration of IP therapy includes three phases:

the instillation phase; the dwell phase, usually 1 to 4 hours; and the drain phase. Because this treatment involves the delivery of biohazardous agents, additional competency is required to handle the infusion properly.

A number of sites can be used for IO, including

the proximal tibia, distal femur, medial malleolus (inner ankle), proximal humerus, and iliac crest. The proximal tibia is the most common site accessed for IO therapy

Hypodermoclysis involves

the slow infusion of isotonic fluids into the patient's subcutaneous tissue; used for short-term fluid volume replacement; must have sufficient sites of intact skin without infection, inflammation, bruising, scarring, or edema; common sites are the front and sides of the thighs and hips, the upper abdomen, and the area under the clavicle because fluid is absorbed more readily from sites with larger stores of adipose tissue. Hydrocortisone cream can be applied to the skin to prevent irritation.

To help prevent the patient from pulling at the dressing or tubing, while allowing easy access to the site. A device such as the I.V. House UltraDome can protect the site. Do not use rolled bandages to cover the extremity because

they prevent insertion site assessment. Complications may progress to an advanced state before they are noticed.

Intraosseous (IO) infusion therapy accesses

to the rich vascular network in the red marrow of bones; previously been regarded as a pediatric procedure, now used in adults for victims of trauma, burns, cardiac arrest, diabetic ketoacidosis, and other life-threatening conditions; IO catheters may be established in the pre-hospital setting when IV access cannot be readily obtained in an emergency.

Assess a subcutaneous infusion site at least

twice daily. Redness, heat, leakage, bruising, swelling, and reports of pain indicate tissue irritation, and the infusion needle should be removed.

Intraspinal Infusion involves

two spaces used for medication infusion directly into CSF: the epidural space between the dura mater and vertebrae and the subarachnoid space. To treat chronic pain, cancers that cross the blood-brain barrier and spasticity of neurologic diseases such as cerebral palsy, multiple sclerosis, reflex sympathetic dystrophy, and traumatic and anoxic acquired brain injuries. The epidural space consists of fat, connective tissue, and blood vessels that protect the spinal cord. Medications infused into the epidural space must diffuse through the dura mater, and there is the possibility that some drug will be absorbed systemically. Intrathecal medications are infused into the subarachnoid space closer to the spinal cord, allowing reduced doses.

Prevention of IP therapy complications includes

using strict aseptic technique in the handling of all equipment and infusion supplies; and antimicrobial therapy administered either IV or intraperitoneally.

Subcutaneous infusion therapy flow rate for medication infusion is

usually 2 or 3 mL/hr. If the infusion is required for adequate pain control, two subcutaneous sites may be needed.