Chapter 13 Notes: Infusion Therapy

Contraindications for hypotonic solutions

Low blood pressure (because it pulls fluid from blood into cells)

What to do if air embolism occurs

turn patient on left side with head down, notify the MD

Veins to avoid (6)

1. Those in areas of flexion 2. highly visible, may roll 3. damaged from previous use 4. those that have been knotted or tortuous 5. veins of injured extremities or AV device 6. veins that bifurcate

Why should isotonic solutions be used with caution? (3)

1. circulatory overload 2. dilute concentration of Hgb 3. decrease Hct

Air embolism symptoms

1. cyanosis 2. hypotension 3. weak rapid pulse 4. increase venous pressure 4. loss of consciousness

Most appropriate placement for peripheral catheter placement (4)

1. dorsal venous network 2. basilic 3. cephalic 4. median veins

Symptoms of infiltration (5)

1. edema at injection site 2. skin blanches 3. no blood return 4. pain 5. decrease or stoppage of IV flow

Extension for tubing may be required to

1. increase mobility and facilitate changes in position 2. decrease manipulation 3. decrease potential contamination at insertion site

Complications for infusion therapy (8)

1. infiltration 2. hematoma 3. infection 4 & 5. phlebitis & thrombophlebitis 6 & 7. embolism & air embolism 8. circulatory overload

Post insertion care for tunneled catheters (6)

1. keep arm still for 30 minutes and limit use for 24 hours 2. apply warm compress for 20-30 mins for 24 hours, then prn 3. observe site Q4h 4. cannot check BP 5. sterile dressing change 6. daily flushing

Most common reasons for infusion therapy (4)

1. maintain *fluid balance* or correct imbalance 2. maintain *electrolyte* or *acid-base* balance or correct imbalance 3. administer *medications* 4. replace *blood* or blood products

Thrombophlebitis symptoms (3)

1. pain along the vein 2. redness & edema at injection site 3. arm is warm to touch

Most common complications with PICC lines

1. phlebitis 2. thrombophlebitis 3. DVT

Advantages to infusion therapy (4)

1. rapid treatment 2. dosage accuracy 3. painless 4. immediate withdrawal

Contraindications for Nontunneled percutaneous CVCs

1. respiratory conditions 2. spinal curvatures 3. Intra-cranial pressure 4. neck trauma, surgery, or radiation

Types of catheters used for peripheral IV therapy

1. short infusion catheters 2. midline catheters

Hypertonic solution other uses (4)

1. stabilize blood pressure (pulls water from cells into blood) 2. increase urine output (pulls water from cells into blood) 3. reduce edema (Pulls water from interstitial space) 4. parenteral nutrition

What do you do if infiltration occurs? (4)

1. stop infusion immediately 2. restart IV in another vein 3. elevate extremity 4. apply warm, moist compress

Goals for infusion therapy (3)

1. to correct or prevent fluid/electrolyte disturbances 2. allow access to vascular system permitting continuous IV therapy 3. maintain access to blood system in case of emergency

Circulatory overload symptoms (4)

1. venous distention 2. coughing 3. increased BP 4. SOB

Examples of conditions in which a hypotonic solution would be used (2)

1. when cells are dehydrated such as a dialysis patient on diuretic therapy 2. hyperglycemic conditions such as DKA in which high serum glucose levels draw fluid out of the cells and into vascular compartments

pH of IV solutions

3.5-6.2

Microdrip tubing

60 gtt/mL

Blood Flow in the superior vena cava compared to axillary vein.

About 2 L/min compared with about 200 mL/min (.2L/min) in the axillary vein.

Infiltration

IV solution leaks into tissues around the vein and the solution goes into subcu tissue

Phlebitis

Inflammation of a vein caused by mechanical, chemical, or bacterial irritation

Types of infusion therapy fluids (3)

Iv solutions such as... 1. parenteral nutrition 2. blood components 3. drug therapy

Nursing considerations for potassium

NEVER GIVE IV

Flushing PICC lines

The INS recommendation for flushing PICC lines not actively used is 5 mL of heparin in a 10-mL syringe at least daily when using a non-valved catheter and at least weekly with a valved catheter. Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline is flushed after drawing blood. Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.

Why do you do this?

to keep air in the apex of the right ventricle, trapped air will slowly dissipate through the pulmonary system

Implanted ports

This type of device is chosen for patients who are expected to require IV therapy for more than a year. Consists of a portal body, a dense septum over a reservoir, and a catheter.

What position must the patient be in for Nontunneled CVCs

Trendelenburg

Tunneled CVCs

VADs that have a portion of the catheter in a subcutaneous tunnel; separating the points where the catheter enters the vein from where it exits the skin; used when therapy is frequent and long term (1-6 months) and PICC line is not a good choice

Remove dressing over catheter site

When changing the dressing, remove it by pulling laterally from side to side. It can also be removed by holding the external catheter and pulling it off toward the insertion site. Never pull it off by pulling away from the insertion site because this could dislodge the catheter!

If patient therapy is expected to be longer than 6 days...

a midline catheter or PICC should be chosen

Air Embolism

air entering by way of IV tubing, tubing was not cleared before infusion

Larger sized gauges

allow for faster flow but also cause phlebitis more often

Fluid and medications with a pH value less than 5 or greater than 9 and with an osmolarity greater than 600...

are best infused in central circulation where greater blood flow provides adequate hemodilution and maintains perfusion (ex: TPN 1400 mOsm/L)

Each solution is classified by its _________ and ________

tonicity (concentration) and pH

Treatment for thrombophlebitis

based on MD order

Veins of the dorsal network

can accommodate large needles but there is an increased risk of DVT and impaired circulation

Midline Catheters size and insertion site

can be anywhere from 3-8 inches; inserted in the upper arm (preferably median antecubital to the basilic vein)

Why should hypotonic solutions be used with caution?

can cause circulatory depletion as water moves from vascular space into the cells

Tonicity is categorized by...

comparison with normal blood plasma as osmolarity (mOsm/L)

Hypertonic solutions main purpose

correct F&E and A&B imbalances by moving water out of cells/interstitial spaces to blood plasma; electrolytes also move across the gradient (replacement)

Infusion therapy

delivering of medications in solutions and fluids by parenteral route through a large variety of catheter types and locations using multiple procedures

Most frequently used in...

dialysis patients and those who require ongoing nutrition via veins

20-25 gauge

less viscous solutions

Hypotonic osmolarity

fluids <250 mOsm/L

Hypertonic osmolarity

fluids >375 mOsm/L

Midline catheter indications

fluids for hydration and drug therpy that last longer than 1-4 weeks; must have a pH 5-9 and osmolarity less than 600

Isotonic osmolarity

fluids that are within normal range

Peripherally Inserted Central Catheter (PICC)

long catheter (18-29 inches) inserted through the antecubital fossa through the basilic vein with the tip resting in superior vena cava, can be used over long periods of time

Winged needles or butterfly needles

most commonly used for single dose drugs or drawing blood samples

Hypotonic solutions purpose

moves water into the cell to expand and hydrate cells (cells swell); decreases serum osmolality, body fluids shift out of blood vessels into interstitial spaces

Solutions given rapidly

need to be infused with a macrodrip tubing (large drops), 10-15 gtt/mL

25-27 gauge

neonates

Advantages to PICC lines

no limitations of pH and osmolarity because medication can quickly be diluted due to placement; can be used long term

Short peripheral catheters are not recommended for...

obtaining routine blood samples

21-25

older children

Contraindications for PICC lines

parapalegics who rely on arms for mobility and those who use crutches

Circulatory overload

patient has received too much fluid (watch for cardiac patients)

Patients receiving hypertonic or hypotonic fluids are at risk for...

phlebitis

Parenteral route

piercing skin or mucous membranes

Tunneled cath advantages

prevent the spread of bacteria along the pathway of the catheter and enable "scarring in" of the catheter to help it in place

Prevention of air embolism

properly prime the tubing; change the bottles or hang another one before the first one is completely emptied

Dextrose 5%

rapidly metabolized and has no osmolatically active particle after it is in the plasma; used for dehydration

When selecting a vein, they should be free of...

sclerosis or hematomas

What do you do is circulatory overload occurs?

stop or slow infusion and raise the head of the bed

Disadvantages of nontunneled percutaneous CVCs

tracheostomy increases risks; CR-BSI is more common

Isotonic solutions purpose

used to expand extra cellular fluid

Nontunneled Percutaneous CVCs

usually 7-10 inches; inserted through subclavian vein in the upper chest or internal jugular in the neck and empties into the right atria; used for emergent situations for short term

Short infusion catheter

usually inserted into superficial veins of the forearm; can be inserted into jugular in emergencies 3/4-1 1/4 inch; 26-14 gauge

Midline catheters should not be used for

vesicant medications (cause tissue damage, blistering), drawing blood, or osmolarities greater than 600

16-19 gauge

viscous solutions