Central Venous Catheter risks and Intravenous Therapy

Risks of a Central Venous Catheter

• Breaking of the catheter
• Dislodgment of a thrombus
• Entry of air into circulation, leading to embolism.

Signs and Symptoms of Embolism

• Sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia

Nursing Interventions for Embolism due to Central Venous Catheter

• Clamp the catheter
• Place client on left side with head lower than feet
• Administer oxygen
• Notify health care provider.

Intravenous Therapy Uses

• Sustaining clients unable to take substances orally
• Rapid replacement of water, electrolytes, and nutrients
• Immediate access to the vascular system for rapid delivery of specific solutions without absorption delays.
• Providing a vascular route for medication or blood component administration.

Intravenous Solutions and Osmolality

• Isotonic solutions have the same osmolality as body fluid.
• Isotonic solutions increase extracellular fluid volume.
• Isotonic solutions do not cause fluid shift into cells due to osmotic force

Hypotonic Solutions

• More dilute with lower osmolality than body fluids.
• Cause water movement into cells by osmosis.
• Should be administered slowly to prevent cellular edema.

Hypertonic Solutions

• More concentrated with higher osmolality than body fluid.
• Cause water movement from cells into the extracellular fluid by osmosis.

Colloid Solutions

• Also called plasma expanders.
• Pull fluid from the interstitial compartment into the vascular compartment.
• Used to rapidly increase vascular volume in cases such as hemorrhage or severe hypovolemia.

Butterfly IV Cannulas

• Wing-tip needle with a metal cannula, plastic or rubber wings, and a plastic catheter or hub.
• Needle length is 0.5 to 1.5 inches, with gauge sizes 16-26.
• More prone to infiltration.
• Commonly used for children and older clients with fragile or small veins.

Plastic IV Cannulas

• May be over-the-needle or in-needle devices
• Primarily for short-term therapy
• Over-the-needle device is preferred in plastic cannulas due to comfort and rapid infusion.
• Broken tips of needle catheters can cause catheter embolism.

IV Gauge

• An indication of the diameter of the lumen of the needle or cannula.
• Smaller gauge number means a larger diameter of the lumen.
• The gauge size depends on the solution to be administered and the diameter of the available vein.

IV Flow Rate

• Smaller gauge results in a higher fluid rate than larger gauges.
• Larger diameter lumens allow a higher fluid rate than smaller diameter lumens.
• Larger diameter lumens are used for higher solution concentrations

IV Administration

• Large diameter lumen needles or cannulas are used for rapid emergency fluid, blood, or anesthetic administration.
• Use 14, 16, 18, or 19 gauge needles for rapid emergency infusions.
• Use 20 or 21 gauge lumen/cannula for peripheral fat emulsion (lipids) infusions.
• Use 22 or 24 gauge lumen/cannula for standard IV fluids and clear liquid IV medications.
• Use 24 or 25 gauge lumen/cannula when the client has very small veins.

IV Containers

• Intravenous containers can be made of glass or plastic.
• Plastic IV bags should be squeezed to ensure intactness.
• Glass IV bottles should be assessed for cracks before hanging.
• Do not write on plastic IV bags with a marking pen as the ink may be absorbed into the solution. Write on a plastic IV bag using a label and a ballpoint pen, then place the label into the bag.

Isotonic IV Solutions

• 0.9% sodium chloride (0.9% NS) is an isotonic solution.
• 5% dextrose in water (D5W) is isotonic but physiologically hypotonic.
• 5% dextrose in 0.225% saline (D5 W/ 1/4 NS) is isotonic.
• Lactated Ringer's (LR) is isotonic.

Hypotonic IV Solutions

• 0.45% sodium chloride (normal saline); (1/2 NS) is hypotonic.
• 0.225% sodium chloride (normal saline); (1/4 NS) is hypotonic.
• 0.33% sodium chloride (normal saline); (1/3 NS) is hypotonic.

Hypertonic IV Solutions

• 3% sodium chloride (normal saline); (3% NS) is hypertonic.
• 5% sodium chloride (normal saline); (5% NS) is hypertonic.
• 10% dextrose in water (D10 W) is hypertonic.
• 5% dextrose in 0.9% sodium chloride (normal saline); D5 W/NS is hypertonic.
• 5% dextrose in lactated ringer's (D5 LR) is hypertonic.

Colloid IV Solutions

• Dextran is a colloid.
• Albumin is a colloid.

Vented IV Tubing

• Tubing allows air to enter the IV container as the fluid leaves acting as a vent.
• An adapter can be added to nonvented IV tubing to create a vent.
• Use nonvented tubing for flexible containers.
• Use vented tubing for glass or rigid plastic containers.
• Fluid will not flow from a rigid IV container unless it is vented.

IV Tubing Considerations

• Add extension tubing for children, restless clients, or those with special mobility needs.
• Macrodrip chambers are used for thick solutions or rapid infusions.
• Macrodrip chamber drop factor varies from 10-20 drops (gtt)/mL, depending on the manufacturer.
• The tubing package indicates how many drops per milliliter are delivered (drop factor).
• Microdrip chambers have a short vertical metal piece (stylet) where the drops form.
• Microdrip chambers deliver about 60 gtt/mL
• Microdrip chambers are used for slow infusions, less than 50mL/hour.
• Microdrip chambers are used when solution contains potent medication that needs titration, in critical care or pediatric settings.

Colloids

• Used to rapidly increase vascular volume in hemorrhage or severe hypovolemia cases.
• Examples include Dextran and Albumin.

IV Tubing Actions

• Close the roller clamp on the IV tubing before spiking the IV bag.
• Use special tubing for medications that absorb into plastic.
• Use shorter tubing for piggyback solutions, connecting them to the injection site, nearest to the drip chamber, or secondary.
• Hang piggyback medication bags higher than the primary IV.
• Filters prevent particles from entering the client's veins.
• Change filters every 24 to 72 hours to prevent bacterial growth, depending on agency policy.

Intermittent Infusion Devices

• Used when intravascular accessibility is required for intermittent medication administration (IV push or piggyback).
• Patency is maintained by periodic flushing with normal saline solution.

Latex Allergies

• IV supplies containing latex include multidose vials, catheters, IV tubing, IV ports, rubber stoppers, and adhesive tape.
• Assess clients for latex allergies before IV insertion.

Peripheral IV Site Selection

• Veins in the hand, forearm, and antecubital fossa are suitable sites.
• Lower extremities (legs and feet) are not suitable due to the risk of thrombus formation and possible medication pooling.
• Scalp and feet veins may be suitable for infants.
• Assess veins in both arms before selecting a site.
• Start the IV infusion distally, allowing options to proceed up the extremity if infiltration or vein rupture occurs.
• If infiltration occurs from the antecubital vein, lower veins cannot be used for further puncture sites.

Venipuncture

• Select the side opposite the client's dominant side for venipuncture.
• Avoid bending the elbow on the arm with an IV to prevent obstructing solution flow or causing infiltration/thrombophlebitis.
• Avoid checking blood pressure on the arm receiving the IV infusion.
• Do not place restraints over the venipuncture site.
• Use an armboard when the venipuncture site is in an area of flexion.

IV Insertion Sites to Avoid

• Edematous extremity
• An arm that is weak/traumatized/paralyzed
• The arm on the same side as a mastectomy
• An arm with an arteriovenous fistula or shunt for dialysis
• An area of skin infection
• Veins of the forearm are preferred in adults because they act as support and splints.

Medication Adminstration

• Assess IV solution for compatibility before adding medication.
• Mix the bag end-to-end several times to disperse the medication.

Medications

• Some medications should only be mixed in glass as medications can absorb into soft plastic.
• Wash hands thoroughly before IV insertion and when working with an IV.
• Use sterile technique when inserting an IV and changing the dressing over the IV site.
• Change the venipuncture site every 72 to 96 hours, in accordance with CDC guidelines.
• Do not let an IV bag or bottle hang for more than 24 hours because of sepsis potential.
• Prevent bacterial contamination by not allowing the IV tubing to touch the floor.
• Swab access ports with 70% alcohol or another effective solution before adding medications/solutions.

Risks of IV Use

• IV puncture offers a route of entry for microorganisms.
• Administering medications via IV can quickly result in adverse or allergic reactions.

Solution Considerations

• Clients with congestive heart failure or heart failure are usually not given saline solutions due to fluid retention exacerbating fluid overload.
• Clients with diabetes mellitus do not typically receive dextrose (glucose) solutions.
• Lactated Ringer's solution contains potassium and should not be administered to clients with renal failure.

Air Embolism

• Caused by a bolus of air entering the vein through an inadequately primed IV line, a loose connection, or during tubing/IV removal.
• Clinical manifestations include tachycardia, chest pain and dyspnea, hypotension, cyanosis, and decreased LOC.
• Prevent through fluid-priming of the tubing, secure connections, and replacing the IV before the bag/bottle is empty.
• If suspected, clamp the tubing and turn the client to the left side with the head of the bed lowered to trap the air in the right atrium; notify the health care provider.

Trendelenburg Position

• Place client on the left side with the head of the bed lowered.

Catheter Embolism

• Breakage of the catheter tip during IV insertion or removal.
• Clinical manifestations include decreased blood pressure, pain along the vein, weak/rapid pulse, cyanosis of the nail beds, and loss of consciousness.
• Prevent by carefully removing the catheter and inspecting it.
• If suspected, place a tourniquet proximally to the IV site on the affected limb and notify the health care provider immediately. Prepare for X-rays and possible surgery.

Circulatory Overload

• Results when fluids are administered too rapidly.
• Clinical manifestations include increased blood pressure, distended jugular veins, rapid breathing, dyspnea, moist cough, and crackles.
• Prevent by identifying at-risk clients (respiratory, cardiac, renal, or liver disease; young and old) and using an IV infusion pump.
• Actions for suspected circulatory overload include decreasing the flow rate to KVO, elevating the head of the bed, keeping the client warm, assessing lungs, assessing for edema, and notifying the healthcare provider.

Hematoma

• Collection of blood in the tissues after an unsuccessful IV or after IV discontinued.
• Clinical manifestations include ecchymosis, immediate swelling, blood leakage, and hard/painful lumps at the site.
• Ecchymosis is a discoloration of the skin (bruising) caused by bleeding underneath.
• To prevent, avoid piercing the posterior wall of the vein when starting the IV.
• Do not apply a tourniquet immediately after an unsuccessful venipuncture.
• When removing IV, apply pressure for 2-3 minutes and elevate the extremity, longer for anticoagulants.
• If a hematoma develops, apply pressure and ice.

Complications of IV Therapy

• Infection, infiltration, phlebitis, and thrombophlebitis

Infection

• Entry of microorganisms into the body through IV or systemically
• Infiltration; seepage of IV fluid outside of the vein and into the surrounding tissue
• Phlebitis; inflammation of a vein, can occur from mechanical or chemical trauma and/or local infection
• Thrombophlebitis; phlebitis that causes development of a clot

Local Indications of Infusion

• Redness, tenderness, purulent drainage, warmth, edema

System Indications of Infusion

• Fever, chills, malaise, tachycardia, headache, nausea

Clinical Manifestation of Infiltration

• Edema, pain, coolness, and possible/not-possible blood return

Phlebitis

• Heat, redness, tenderness, and sluggish IV infusion

Thrombophlebitis

• Heat, redness, tenderness, sluggish IV infusion, and a hard/cordlike vein

Preventing Infections

• Assess for clients at risk and maintain strict asepsis when caring for an IV site.
• Monitor for local and systemic infection signs.
• Monitor the patient's white blood cell counts.
• Check fluid containers for cracks, leaks, cloudiness, or contamination.
• Change IV tubing at least every 96 hours per agency policy. Change IV dressing when soiled or contaminated.
• Ensure IV solutions are not hanging longer than 24 hours.
• For local infections, remove the catheter if indicated, culture drainage, and apply warm/moist compresses.
• For systemic infections, blood cultures, antibiotic therapy, antipyretic therapy, and catheter removal if indicated may be needed.
• Prevent infiltration by avoiding venipuncture over areas of flexion and anchoring the cannula with a tubing loop securely taped.
• If you suspect infiltration, remove IV (do not rub the site) and elevate extremity; apply warm or cold compress depending on the solution.

Additional Preventative Measures

• Do not rub, as it could cause a hematoma.
• Use an IV cannula smaller than the vein. Avoid using very small veins and/or lower extremities when administering solutions through an IV. Avoid venipuncture in an area of flexion to prevent phlebitis.
• For suspected cases of phlebitis, remove IV, restart in the opposite extremely, notify the physician, and apply a warm, moist compress.
• To prevent thrombophlebitis, use an IV cannula smaller than the vein. Use only small veins when administering solutions through an IV. Avoid venipuncture in an area of flexion or using the lower extremities as an IV site.
• To treat thrombophlebitis, do not irrigate the IV catheter, remove the IV, and restart in the opposite extremity.