Chapter 13: Concepts of Infusion Therapy

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? A. Asks the client to both say and spell his or her full name before starting the blood transfusion B. Ensures that another qualified health care professional checks the unit before administering C. Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed D. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

B. Rationale: To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses.Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) A. During insertion, draping the area around the site with a sterile barrier B. Immediately removing the client's venous access device (VAD) when it is no longer needed C. Making certain that observers of the insertion are instructed to look away during the procedure D. Thorough hand hygiene (i.e., no quick scrub) before insertion E. Using chlorhexidine for skin disinfection

B, D, and E Rationale: As soon as the VAD is deemed unnecessary, it needs to be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device. Quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention.During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection.

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? A. Asks the charge nurse about the order B. Contacts the health care provider who ordered it C. Contacts the pharmacy for clarification D. Starts the fluid as ordered, with plans to check it later

B.

Which statement is true about the special needs of older adults receiving IV therapy? A. Placement of the catheter on the back of the client's dominant hand is preferred. B. Skin integrity can be compromised easily by the application of tape or dressings. C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. D. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

B.

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? A. Client states, "It really hurt when the nurse put the IV in." B. The vein feels hard and cordlike above the insertion site. C. Transparent dressing was changed 5 days ago. D. Tubing for the IV was last changed 72 hours ago.

B. Rationale: A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site.It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? A. Change the set immediately. B. Change the set in about 4 hours. C. Change the set in the next 12 to 24 hours. D. Nothing; the set is for long-term use.

B. Rationale: Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? A. Blood pressure B. Capillary refill and pulse C. Neurologic function D. Questioning the client about the pain level at the site

B. Rationale: Capillary refill and pulse should be assessed to ensure that the arterial line is not occluding the artery.Blood pressure and neurologic function are not pertinent to the client's arterial line. Although the client's comfort level is important with an arterial line, it is not a determinant of patency of the line.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? A. Back of the hand for an older adult B. Cephalic vein of the forearm C. Lower arm on the side of a radical mastectomy D. Subclavian vein

B. Rationale: The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters should never be inserted into the lower arm on the same side as a radical mastectomy because they interfere with limited circulation. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? A. Administer 5 mL of a heparinized solution. B. Check for blood return. C. Flush the port with 10 mL of normal saline. D. Palpate the port for stability.

B. Rationale: To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

Length of PICC lines

18-29in

What to blood products require to administer?

2 pt identifiers and 2 RN's

Isotonic solutions

270-300 mOsm/L; do not move water in or out of the cell

How long are midlines for peripheral IV therapy?

3-8 inches long

Length of non-tunneled percutaneous CVC and how many lumens can it have?

7-10 in and up to 5 lumens

Ambulatory pumps

A small, lightweight, portable pump worn by a patient and can be taken home for infusions

he nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? (Select all that apply.) A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine. D. Shave the hair around the area of insertion. E. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

A, B, and C Rationale: Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done.Clipping, rather than shaving, hair around the selected IV site is done. Shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts.

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? A. "I can continue my 20-mile (32-km) running schedule as I have for the past 10 years." B. "I can still go about my normal activities of daily living." C. "I have less chance of getting an infection because the line is not in my hand." D. "The PICC line can stay in for months."

A. Rationale: Excessive physical activity can dislodge the PICC and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have low complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? A. Midline catheter B. Tunneled percutaneous central catheter C. Peripherally inserted central catheter D. Short peripheral catheter

A. Rationale: For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? A. Midline catheter B. Peripherally inserted central catheter (PICC) C. Short peripheral catheter D. Tunneled central catheter

A. Rationale: Midline catheters are the best device for this client. These catheters are used for therapies lasting from 1 to 4 weeks.PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72 to 96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider. Nurses are typically not qualified to start tunneled central catheters.

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? A. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. B. Call the previous hospital to verify the date. C. Immediately discontinue the intraosseous IV. D. Nothing; this is a long-term treatment.

A. Rationale: The admitting nurse would first anticipate an order to discontinue the intraosseous IV and start an epidural IV. 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.The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? A. Assess the insertion site. B. Check connections. C. Check the infusion rate. D. Discontinue the IV and start another.

A. Rationale: The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

Brand names of tunneled CVCs

Broviac, Hickman, and PermCath

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? A. "I hate having IVs started." B. "It hurts when you are inserting the line." C. "My hand tingles when you poke me." D. "My IV lines never last very long."

C.

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? A. 24 B. 22 C. 18 D. 14

C. Rationale: An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? A. Decrease the pressure being used to flush the line. B. Obtain a 10-mL syringe and reattempt flushing the line. C. Stop flushing and try to aspirate blood from the line. D. Use "push-pull" pressure applied to the syringe while flushing the line.

C. Rationale: If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

All central lines should be monitored for what?

CLABSI

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? A. RN who is certified in the administration of oral and infused chemotherapy medications B. RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters C. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions D. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

D. Rationale: The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated.The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? A. Assess the midline IV insertion site. B. Have the client cough and deep-breathe. C. Notify the health care provider about the crackles. D. Slow the rate of the IV infusion.

D. Rationale: The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress.The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site and having the client cough and deep-breathe are not appropriate. Crackles do not disappear with coughing. Notifying the provider may be appropriate, but is not the initial actions for this client.

Dialysis catheters must be....

HEPARINIZED

What type of needle is used to access an implanted port?

Huber needle that is 90 degrees (change it every 7 days!!)

What is the most common type of infusion therapy?

IV therapy

Subcutaneous infusion therapy

LAST RESORT; used for administering pain meds, insulin, and isotonic fluids and may be used to improve absorption of fluids

Can nurses take out/discontinue tunneled and non-tunneled IV therapy?

NO

Which central IV therapy has less risk of CLABSI than the others?

PICC lines

Brand name of non-tunneled percutaneous CVC

Quinton

Who can place a non-tunneled percutaneous CVC?

a trained professional

Central IV therapy

a vascular access device (VAD) that extends into the superior vena cava that ends at the junction of the right atria

Which type of fluid/vesicant can be infused in a PICC?

any type!

Nursing care for IV therapy

assess insertion site, assess and change dressing if needed, changes needless connectors and tubing per protocol, use appropriate syringes for flushing (10mL for CVC), flush line and draw labs per protocol, and discontinue lines per policy after an order is obtained

Thrombosis

blood clot in the vein

How do tunneled CVCs reduce infection risk?

by having a cuff (also keeps it in place)

Intraperitoneal infusion therapy

can be port or catheter; monitor for peritonitis, and can give certain meds or chemotherapy

Placement of a central IV must be verified by what before it is used?

chest X-ray before it is used?

Drug therapy for blood products

confirm 5 rights, monitor for adverse drug events, ensure safe administration, caution with high-alert drugs, and be aware of look alike and sound alike drugs

How often should intermittent sets and TPN tubing be changed?

every 24 hours

How often should blood tubing be changed?

every 4 hours

How often should the site be assessed for short catheters used for peripheral IV therapy?

every 4 hours

Short catheters for peripheral IV therapy

follow protocol on how long they can stay in, use guided insertion if necessary, choose insertion site carefully, and prevent catheter related bloodstream infections (CRBSI)

Containers for infusion systems

glass bottles (require air vents with tubing) and plastic bags

Hypertonic solutions

greater than 300 mOsm/L; move water outside of the cell to the intravascular space

Where is a tunneled CVC placed and taken out?

in interventional radiology; the skin insertion site is separated from the vein insertion site by a tunnel through SubQ tissue to help prevent infection

Where in the hospital are implanted ports placed?

in the OR or interventional radiology with conscious sedation

Where in the body are implanted ports usually placed?

in the subclavian or internal jugular vein

What is the most common complication of intraosseous infusion therapy?

infiltration

Phlebitis

inflammation of the vein due to irritation

Intraspinal infusion therapy

infusion into the epidural space or the subarachnoid space

Intraosseous infusion therapy

infusion through red marrow of bones and shouldn't be used longer than 24 hours

PICC lines are inserted where?

into a deep vein in the upper arm with the use of a guide wire and ultrasound

Where are midlines for peripheral IV therapy inserted?

into the medial antecubital vein or large deep vein

Non-tunneled percutaneous CVCs should be inserted where?

into the subclavian vein or internal jugular vein

Why are tunneled CVCs less of an infection risk than some of the others?

it doesn't have as easy of access into the bloodstream because it is tunneled through subq tissue

Extravasation

leakage of a vesicant solution into the surrounding tissues

Infiltration

leakage of nonvesicant solution into the surrounding tissues

Hypotonic solution

less than 270 mOsm/L; moves water into the cell

PICC lines are indicated for...

long term use at home

Reasons for infusion therapy

maintain fluid balance, maintain electrolyte or acid-base balance, and to administer meds and blood products

Nonvesicant

non damaging fluid to the tissue around the site

Types of blood products to be infused

packed red blood cells (pRBCs), platelets, fresh frozen plasma (FFPs), and albumin

Which central IV access can be used for central venous pressure (CVP) monitoring?

peripherally inserted central catheters (PICCs)

Types of central IV therapy

peripherally inserted central catheters (PICCs), non-tunneled percutaneous central venous catheters (CVCs), tunneled catheters, implanted ports, and hemodialysis catheters

Intra-arterial infusion therapy

placed into the radial, brachial, or femoral arteries

2 parts of an implanted port

port (reservoir) and the catheter (has a silicone rubber center that is capable of many sticks)

Mechanically regulated devices

pressurized with meds in it and can be used to deliver intermittent medications. (slowly drips it to them)

Administration sets for infusion systems

primary and secondary tubing, change intermittent sets and TPN tubing every 24 hours, and change blood tubing every 4 hours

What is required to access and de-access implanted ports?

proper training and heparinization

How long can implanted ports be used?

several years if there are no complications

How long should a non-tunneled percutaneous CVC be used?

short-term, approximately 7-10 days

What lumen can a PICC line be?

single, double, or triple and can include a power PICC

Inserting a midline and dressing changes require what kind of technique?

sterile

What technique is used on insertion of a PICC and how is placement verified?

sterile technique and it is verified with an x-ray

What position should the pt be placed in when putting in a non-tunneled percutaneous CVC?

trendelenburg (placement confirmed by X-ray)

When do we use intraosseous infusion therapy?

when we cannot get venous access

Midlines are used for fluids/meds...

with a pH of 5-9 and osmolarity less than 600 mOsm/L