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