M1 N244 CHAPTER 13 INFUSION THERAPY

24-26 gauge Smallest, shortest (3 4-inch length)

24 yellow & 26 butterfly 24 mL/min (1440 mL/hr) Not ideal for viscous infusions Expect blood transfusion to take longer Preferred for infants and small children

The nurse is attending to a client with a peripherally inserted central catheter (PICC). What action does the nurse take to maintain patency of the PICC? 1 Flush the PICC line not actively used with 2.5 mL heparin (10 units/mL) daily. 2 Use 5 mL sterile saline to flush the PICC line before and after medication is administered. 3 Flush the PICC line with 10 mL of sterile saline after drawing blood. 4 Use 10-mL barrel syringes to flush all PICC lines.

A 10-mL barrel syringe should be used to flush PICC lines because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter. When the PICC line is not actively used, it should be flushed with 5 mL of heparin (10 units/mL) in a 10-mL syringe at least daily. 10 mL of sterile saline should be used to flush the line before and after medication administration. 20 mL of sterile saline should be used to flush the line after drawing blood.

A client receiving vancomycin intravenously reports that the periph- eral IV insertion site has become painful and reddened. What is the nurse's first action? A. Report the change to the health care provider. B. Document the findings in the electronic patient record. C. Change the IV insertion site to a new location. D. Stop the infusion of the drug.

DACB

"locking" or "de-accessing.

Flushing with 5 mL of 100 units heparin/mL

Which catheter types are more likely to cause venospasms when removed forcefully?

Peripherally inserted central midline

A 22-gauge catheter

has a flow rate of 38 mL/min. It is used in the transfusion of blood without any damage.

VASCULAR ACCESS DEVICES

infusion catheter is a plastic tube placed in a blood vessel to deliver fluids and medications.

Drug Therapy

knowledge of proper dilution, rate of infusion pH Osmolarity compatibility w/ other IV meds appropriate site potential for vesicant specific aspect of monitoring (stat effect)

Intravenous Soultions

more than 200 IV fluids Isotonic 270-300 Hypertonic 300+ Hypotonic <270

intraosseous route

The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management.

butterfly needles

easy to insert associated with a high frequency of infiltration. commonly used for injection of single-dose drugs or for drawing blood samples

18 gauge

green 110 mL/min (6600 mL/hr Preferred size for surgery Vein needs to be large enough to accommodate

22 gauge

blue 38 mL/min (2280 mL/hr) Adequate for most therapies, blood can infuse without damage

Prolonged parenteral nutrition

requires the placement of a tunneled CVC.

PERIPHERAL INTRAVENOUS THERAPY

*Short infusion catheters are the most commonly used usually placed in the veins of the arm. *Another catheter used for peripheral IV therapy is a midline catheter.

Short peripheral catheters

- composed of a plastic cannula built around a sharp stylet extending slightly beyond the cannula - allows for the veni- puncture, and the cannula is advanced into the vein. - Once the cannula is advanced into the vein, the stylet is withdrawn - These stylets are hollow-bore, blood-filled needles that carry a high risk for exposure to bloodborne pathogens if needle stick injury occurs

Choose catheter and site

- smallest gauge catheter capable of delivering the prescribed therapy. - dwell (stay in) 72 to 96 hours(213/7ed) /do not include a specific time (pg 190/8ed) require rotation of insertion at another venous site. - therapy is expected to be longer than 6 days, a midline catheter or PICC should be chosen -When selecting the site, consider the patient's age, history, diagnosis; the type and duration of the prescribed therapy; whenever possible, the patient's preference.

Midline Catheters

-3 to 8 inches long, 3 to 5 Fr, and double or single lumen. -The median antecubital vein is used most often -With ultrasound guidance, deeper veins can be accessed and the insertion site can be further above the antecubital fossa. -The basilic vein is preferred over the cephalic vein larger diameter straighter path greater hemodilution -catheter tip is located in the upper arm with the tip residing no further into the venous network than the axillary vein -therapies lasting from 1 to 4 weeks; however, there are no recommendations for the optimal dwell time. Avg 6.9 days

topical anesthetic agent or intradermal lidocaine HCl 1%

-Obtain a health care provider's order -check for patient allergies before administering -decrease patient discomfort.

Site Selection and Skin Preparation

most appropriate veins for peripheral catheter placement include the: -dorsal venous network, ***cannulation of veins on the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition and for active patients receiving infusion therapy in an ambulatory clinic or home care. Use of veins on the dorsal surface of the hands should be reserved for short-term infusion of non-vesicant and non-irritant solutions. -basilic, -cephalic, -median veins, -as well as their branches

Ultrasound-guided peripheral IV

-allow insertion into deeper veins. cannulation **Arteries and nerves lie parallel to deep veins, and special training is needed to learn to identify these structures and avoid damaging them. ** infiltration may go undetected until a significant amount of fluid has collected in the tissues. -devastating if the solution is an irritant or vesicant.

vein transilluminators

-tools to assist in IV line placement. -Several different types : VeinViewer, Veinlite LED, and AccuVein -some using infrared light and some using laser -these devices penetrate only up to approximately 10 mm and so are limited to finding superficial veins.

Insertion and Placement Methods

-usually inserted into superficial veins of the forearm using sterile technique. -In emergent situations, can be used also in the external jugular vein of the neck. ***Avoid the use of veins in the lower extremities of adults, if possible, because of an increased risk for deep vein thrombosis and infiltration. -

International Society of Blood Transfusion ISBT

1) a unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor.

14-16 gauge

14 gray & 16 orange For trauma and surgical patients requiring rapid fluid resuscitation Needs to be in a vein that can accommodate it

7 major VAD

• Short peripheral catheters • Midline catheters • Peripherally inserted central catheters (PICC) • Nontunneled percutaneous central venous catheters (CVCs) • Tunneled catheters • Implanted ports • Hemodialysis catheters

Implanted ports

BEFORE GIVING DRUG always check for blood return. - NO BLOOD - HOLD DRUG until patency and adequate noncoring needle placement of the port are establisted extravasations of vesicant drugs can occur because a fibrin sheath (flap or tail) may occur at the tip of the catheter, clot it, and cause retrograde subcutaneous leakage. - need to be flushed after each use and at least once a month between courses of therapy.

Blood & Blood Products

Blood transfusion given using: -packed red blood cells -platlets -fresh frozen plasma -albumin -specific clotting factors 2 pt identifiers and 2 healthcare verify before compatibility and acceptability --------------------------------------------------

A drug prescription should include

Drug name, preferably by generic name • Specific dose and route - Frequency of administration - Time of administration - length of time for infusion _ Purpose (required in some health care agencies, esecially nursing homes)

What manifestations of catheter-related complications does the nurse observe in a client undergoing intraspinal infusion therapy?

Infection Bleeding

Which devices allow the visualization of a vein for a client who is prescribed infusion therapy? Select all that apply. 1 X-ray 2 Drugs 3 Infrared 4 Laser beam 5 Transilluminator

Several illuminating devices are available for the visualization of veins. The use of infrared and laser beams are employed for the visualization of superficial veins. Transilluminators include portal vein transilluminators such as VeinViewer, Veinlite LED, and AccuVein for the detection of deeper veins. X-rays and drugs are not employed for the visualization of veins. X-ray is used to confirm catheter placement.

prescription need to include

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 (e.g., 125 mL/hr or 1000 mL/8 hr) • - Drugs and the specific dose to be added to the solution, such as electrolytes or vitamins

non-tunneled percutaneous central venous catheter (CVC)

The subclavian and internal jugular veins are the sites of choice for placing They are mostly used during emergency situations like surgery and critical care or trauma to administer IV infusions.

conditions require a physician's request

Using veins in the extremity affected -Mastectomy, -axillary lymph node dissection, -lymphedema, -paralysis of the upper extremity, -presence of dialysis grafts or fistulas they alter the normal pattern of blood flow through the arm.

Avoid veins ...

on the palmar side of the wrist because the median nerve is located close to veins in this area,= painful and difficult to stabilize. The cephalic vein begins above the thumb and extends up the entire length of the arm. This vein is usually large and prominent, appearing as a prime site for catheter insertion. However, the sensory branch of the median nerve can intersect with the cephalic vein up to three times from its origin to about 4 to 5 inches up the lateral aspect of the arm. Damage to the nerve can result in permanent loss of function or complex regional pain syndrome. Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.

20 gauge (1-114-inch length)

pink 65 mL/min (3900 mL/hr) Adequate for all therapies Most anesthesiologists prefer not to use a smaller size than this for surgery cases

PERSCRIBING INFUSION THERAPY

prescription need to include - 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 (e.g., 125 mL/hr or 1000 mL/8 hr) • - Drugs and the specific dose to be added to the solution, such as electrolytes or vitamins A drug prescription should include - Drug name, preferably by generic name • Specific dose and route - Frequency of administration - Time of administration - length of time for infusion _ Purpose (required in some health care agencies, esecially nursing homes)

Aseptic skin preparation and technique before IV inser- tion

• Perform hand hygiene before palpating the insertion site. • Clip hair—do not shave. • Ensure that skin is clean. • Wear clean gloves for peripheral IV insertion; do not touch the access site after application of antiseptics. • Prepare clean skin with 70% alcohol 70% isopropylalchol (or 2% chlorhexidine) back and fourth for 30 sec allow to dry

Placement of Short Peripheral Venous Catheters

• Verify that the prescription for infusion therapy is complete and appropriate for infusion through a short peripheral catheter. • For 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 proxi- mal to previous sites. • 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 catheter sites. • Choose a vein of appropriate length and width to fit the size of the catheter required for infusion.