Infusion Therapy Chapter 10 PDF

INTRODUCTION In today's healthcare environment, infusion therapy is delivered to patients across the continuum of care. Patients receive infusion therapy in hospitals, extended care facilities, outpatient clinics, infusion centers, and their own homes. Infusion therapy is undergoing rapid advanceme...

INTRODUCTION In today's healthcare environment, infusion therapy is delivered to patients across the continuum of care. Patients receive infusion therapy in hospitals, extended care facilities, outpatient clinics, infusion centers, and their own homes. Infusion therapy is undergoing rapid advancements as new evidence is constantly emerging to improve outcomes through improved techniques, equipment, and technologies. Research demonstrates that specialized "IV resource teams" result in better patient outcomes and reduced costs. However, generalist nurses in all practice settings are involved in the provision of infusion therapy and need to be knowledgeable in the most current evidence related to infusion therapy and competent in the care they provide to their patients. The Infusion Nurses Society (INS) is a national organization that has established evidence-based practice standards of care to guide the delivery of infusion therapy. The standards were last revised in 2021 and are based on ranked evidence. A professional organization, the Infusion Nurses Certification Corporation, offers a national certification program that recognizes the expertise of nurses specializing in infusion therapy. The designation of Certified Registered Nurse Infusion (CRNI©) is awarded after successfully passing a rigorous examination and completing the required hours of practice in infusion therapy. Patients require infusion therapy for a variety of reasons, including fluid and electrolyte replacement, medication administration, blood product administration, and nutritional support. The duration of infusion therapy may be brief periods of hours or days to months or long-term therapy required for a lifetime. Administration of IV fluids is initiated to both maintain and restore fluid and electrolyte balance when it is not possible to maintain this balance with the oral intake of fluids. To maintain fluid balance, adequate amounts of fluid need to be administered to account for sensible and insensible fluid losses. Fluid and electrolyte replacement may also be required because of losses related to hemorrhage, surgery, burns, vomiting, or diarrhea. IV administration of medications is indicated when the oral or other routes are not available or appropriate. Certain medications are administered only by the IV route because of their pharmacological composition or because of the need to be given intravenously to attain higher blood levels or faster action. When the gastrointestinal tract is unable to absorb sufficient amounts of nutrients, the IV route can be used. Solutions containing protein, lipids, and high concentrations of dextrose can provide the calories and nutrition needed to sustain life. Blood products can be administered only intravenously and include packed red blood cells (RBCs), platelets, plasma, albumin, and clotting factors. They may be needed in acute situations or to correct deficits related to chronic conditions and require special precautions to ensure patient safety; they are presented later in the chapter. Connection Check 10.1 The nurse recognizes that which patient may need infusion therapy? (Select all that apply.) A.  Patient who sustained trauma presenting to the emergency department B.  Patient with osteomyelitis receiving IV antibiotics at home C.  High school teacher during an annual health appraisal D.  Patient with cancer receiving parenteral chemotherapy E.  Patient with multiple sclerosis in remission SOLUTIONS USED IN INFUSION THERAPY Infusion therapy requires the specific IV fluid order by a licensed healthcare provider. The order needs to include the solution to be administered, any additives to the solution, and either the rate of infusion or the total dose or volume to be infused over a specific time frame. The two major types of IV solutions are crystalloid solutions and colloidal solutions. Crystalloid solutions are composed of electrolytes dissolved in water and include dextrose solutions, sodium chloride solutions, balanced electrolyte solutions, and alkalizing and acidifying solutions. Colloidal solutions are composed of larger molecules, usually protein or starch, suspended in fluid and are not a true solution. Colloidal solutions are frequently referred to as plasma volume expanders because the larger molecules do not diffuse through cell membranes and draw fluid into the intravascular space. Colloidal solutions are used to maintain intravascular volume and prevent shock after major blood or fluid losses. Examples of colloidal solutions include albumin, dextran, and mannitol. An important characteristic of IV solutions is osmolarity, a measure of the concentration of the solution that is expressed in terms of the number of particles (osmoles) per liter of solution (mOsm/L). Osmolality is the number of particles in a kilogram (mOsm/kg). Because 1 liter of fluid weighs approximately 1 kilogram, osmolarity and osmolality are essentially the same in human body fluids. The normal range for serum osmolality is 275 to 295 mOsm/kg. The normal range for the calculated osmolarity for body fluid and plasma is 270 to 300 mOsm/L. The concentration of the intravenous solution influences how water moves between the intracellular and extracellular compartments of the body. Solutions can be isotonic, hypotonic, or hypertonic (Table 10.1). Isotonic solutions (Fig. 10.1A) have the same or nearly the same osmolarity as plasma and cause no movement of fluid into or out of cells. Isotonic solutions remain in the extracellular compartment in either the intravascular or interstitial compartments. The osmolarity of plasma varies from 270 to 300 mOsm/L, and solutions are considered to be isotonic if their osmolarity is between 250 and 375 mOsm/L. Isotonic solutions are administered to dehydrated patients with deficits in intravascular volume because they increase the amount of fluid circulating in the vascular system without causing movement of fluid in and out of cells. Hypotonic solutions (Fig. 10.1B) have a lower solution concentration than plasma and cause fluid to move from the intravascular space into both the intracellular and interstitial spaces. Administration of hypotonic solutions hydrates cells but results in depletion of intravascular fluid volume. Hypotonic solutions are used in the management of hypernatremia, hyperosmolar conditions, hypertonic dehydration, and diabetic ketoacidosis after initial sodium chloride replacement. Dextrose 5% in Water (D5W) is initially an isotonic solution that becomes hypotonic as the dextrose (glucose) is metabolized by the body. Extreme caution needs to be exercised when solutions that are not isotonic are administered because of resulting fluid shifts, and they should be administered only for brief periods. Hypertonic solutions (Fig. 10.1C) have concentrations higher than plasma and cause fluid to move from the cells into the intravascular space. Because of the danger of circulatory overload, these solutions are given only in critical situations. Solutions with a concentration greater than 600 mOsm/L should be administered only via central venous access (CVA), commonly referred to as a central line, where there is adequate blood flow to dilute the solution and prevent damage to the vein as the hypertonic solution infuses. Table 10.1 Osmolarity of Intravenous Solutions Isotonic Hypotonic Hypertonic 250--375 mOsm/L Less than 250 mOsm/L Greater than 375 mOsm/L Examples: Examples: Examples: 0.9% sodium chloride (0.9% NaCl, normal saline \[NS\]) Lactated Ringer's solution (LR) 0.45% sodium chloride (0.45% NaCl, 1/2 NS) 2.5% dextrose in water 0.33% sodium chloride 5% dextrose in water (D5W)---initially isotonic, but changes to hypotonic solution as dextrose (glucose) is metabolized in the body 3% sodium chloride 5% dextrose in lactated Ringer's 20% dextrose in water 10% dextrose in water Dextrose 5% in 1/2 NSS Dextrose 5% NSS Albumin 25% Indications: Fluid deficits Dehydration Fluid challenges Indications: Diabetic ketoacidosis Hyperosmolar hyperglycemia Hypertonic dehydration D5W Hypoglycemia Insulin shock Dehydration Indications: Severe dehydration Severe electrolyte imbalance Hypotonic dehydration FIGURE 10.10 Effects of osmolarity on fluid movement. A, Isotonic. The osmolarity is the same in both the intracellular fluid (ICF) and extracellular fluid (ECF). There is typically no movement of fluid from cells when an isotonic solution is administered. If there is movement, it is equal between the two compartments due to the same osmolarity. B, Hypotonic. With the administration of hypotonic solutions, fluid moves from the intravascular into the intracellular space. C, Hypertonic. With the administration of hypertonic solutions, fluids move from the cells into the intravascular space. When administering any IV solution, the nurse needs to carefully monitor the fluid status of the patient regardless of the osmolarity of the solution being administered. This assessment includes respiratory status, vital signs, and skin turgor. Older adults and patients with compromised cardiovascular or renal function require even greater vigilance because of the risk of fluid overload. The pH is a measure of the concentration of hydrogen ions in a solution and indicates the acidity or alkalinity of the solution. Most IV solutions are slightly acidic, which increases their stability and shelf life. Medications with a pH of less than 7 are acidic; those with a pH of greater than 7 are basic, or alkaline. Fluids or medications with a pH value of less than 5 or greater than 9 should be administered through a central line to avoid damage to the vein. (Acid--base disorders are discussed in more detail in Chapter 9.) The wrong diluent or incompatible solutions can alter the pH of a medication. Acidic medications are irritating to the walls of the vessels and can cause chemical phlebitis, which is irritation of the vein wall caused by the medication. Antibiotics are also a significant cause of phlebitis because of their low pH. Nurses need to be attentive to continually assessing peripheral IV sites where antibiotics are infusing to assess for signs of warmth and tenderness that may indicate phlebitis. The use of the wrong diluents can also alter the pH of a medication, and incompatible solutions can greatly affect the medication's pH. Incompatibility is an undesirable reaction occurring between two medications or a medication and its diluent. There are three main types of medication incompatibility. Physical incompatibility is the reaction that causes a visible change. This change may be in the form of color, cloudiness, haziness, turbidity, the formation of precipitate, and even the formation of gas. Precipitate formation is the most common physical incompatibility. Calcium in medication or solution increases the risk for precipitate. Ringer's solution is an example of a solution with calcium. The second type is chemical incompatibility, which correlates to the breakdown of the medication. This reaction will most likely not be visible. The most common reaction is the acid--alkaline reaction that results in an unstable pH of one of the medications. The third type of incompatibility is therapeutic incompatibility that causes an increased or decreased therapeutic response. The incompatibility may be undetected until the patient shows no clinical response to the medication. Therapeutic incompatibility may occur with the use of two antibiotics. For example, aminoglycosides may be inactivated when given with penicillins or cephalosporins. Therefore, they must be given in separate sites, 1 hour apart. Also, if the medication requires peak and trough levels (measurements of medication levels before and after administration), the levels may show no therapeutic response. Nurses must be vigilant about checking compatibility when giving IV medications, whether it is two medications together or the administration of an IV medication by direct IV or IV piggyback with a primary solution. Compatibility charts are readily available in most facilities, and many healthcare facilities utilize IBM Micromedex© as the standard for checking the compatibility of medications. The pharmacist is also an additional resource for information about medication incompatibility. According to the journal Pharmaceutical Technology in Hospital Pharmacy (2019) and the Journal of Pharmaceutical Sciences and Research (2021), incompatibilities are the most common intravenous medication errors in hospitals with an incidence of 25% and with 2% having a severe clinical significance. Medication incompatibilities may cause IV catheter obstruction, venous irritation, decreased potency of medication, pulmonary or renal emboli, multisystem failure, or even death. Connection Check 10.2 The nurse anticipates which fluid movement when administering an isotonic IV fluid to a patient? A.  Causes fluid to move from the cells into the intravascular space B.  Causes fluid to move from the intravascular space into the intracellular space C.  Causes no or equal movement of fluid into or out of cells D.  Causes fluid to move from the intravascular space into the interstitial spaces VEINS USED IN INFUSION THERAPY Veins are the low-pressure blood vessels that return deoxygenated blood to the heart. Vein walls consist of three layers: the tunica intima (innermost layer), tunica media (middle layer), and tunica adventitia (outer layer) (Fig. 10.2A). The innermost layer consists of a single layer of endothelial cells lining the lumen of the vein. The middle layer contains smooth muscles that surround the vein, and the outer layer contains connective fibers that support the vein and nerve endings. Veins contain valves that aid the return of blood to the heart by preventing backflow of blood as veins are compressed by the surrounding skeletal muscles, thus facilitating blood return back to the central circulation. Geriatric/Gerontological Considerations Physiological changes in older adults can be a challenge for infusion therapy due to the changes in skin and veins. Because of these changes, nurses must consider catheter design and gauge size before IV catheter insertion. The loss of thickness of the dermal layer may affect the placement of peripheral catheters and can result in decreased pain perception for possible complications of infiltration or phlebitis. Also, due to the fragile dermal and subcutaneous vessels, purpura and ecchymoses may occur. Frequent monitoring is required to prevent complications. The diameter of the veins and blood flow within the veins increase as the veins get closer to the heart. Larger veins with greater blood flow are appropriate when infusing larger volumes of fluid and when the osmolarity of the solution is high or the pH is outside the normal range. The vein also needs to be large enough to accommodate the vascular access device selected while allowing for blood flow around the device. Nurses need to take into consideration patient condition, characteristics of the solution to be infused, volume and rate of the solution to be infused, and type of intravenous access device (IVAD) available when planning infusion therapy. FIGURE 10.2 Layers of the vein. A, Vein walls consist of three layers: the tunica intima (innermost layer), the tunica media (middle layer), and the tunica adventitia (outer layer). B, Valves in vein wall. TYPES OF INTRAVENOUS ACCESS DEVICES Infusion therapy is divided into two general categories based on the location of the tip of the IVAD, peripheral or central. It is important to understand when peripheral infusion therapy is appropriate and when a CVA is preferred or required. The IVAD should be of the smallest gauge (size) and length with the fewest number of lumens and be the least invasive to provide the ordered infusion therapy. Peripheral Venous Access Peripheral venous access describes when the tip of the IVAD terminates outside of the central vasculature in a peripheral vein. The most common type of peripheral IVAD is the short over-the-needle catheter (Fig. 10.3). The flexible catheter is introduced into the vein over a metal needle that is then removed and discarded. The catheters range in length from 1 to 7.5 cm and in size from 14 to 27 gauge. Standardized catheter hub colors are used to identify catheter gauge (Table 10.2). Therapies utilizing a short peripheral catheter should be expected to last less than a week, and indications include hydration and administration of pain medications and some antibiotics (Table 10.3). Another type of IVAD used for peripheral venous access, the steel-winged device (Fig. 10.4), is indicated only for short-term or single-dose therapy because the rigid steel needle is more likely to puncture the vein and lead to fluid or medication leaking out of the vein. This steel-winged device is often referred to as a butterfly because of the appearance of wings on each side of the needle. FIGURE 10.3 Over-the-needle peripheral catheter. The flexible catheter is introduced into the vein over a metal needle that is then removed and discarded. The Flashback chamber fills with blood when the vein is accessed, and the activation button progresses the catheter over the needle. The safety chamber protects the needle once the catheter is inserted to prevent inadvertent needle stick. Table 10.2 Standard Colors Used to Identify Catheter Gauge Gauge Color 16 Gray 18 Green 20 Pink 22 Blue 24 Yellow Table 10.3 Peripheral Catheter Gauge Selections Catheter Gauge Clinical Indications 14, 16, 18 Trauma, surgery, blood transfusion, need for rapid administration of large volumes 20 Continuous or intermittent infusions, blood transfusions 22 Continuous or intermittent infusions in small veins 24 Continuous or intermittent infusions in fragile veins FIGURE 10.4 Steel-winged infusion set. Short-term peripheral IV access is established in the superficial veins of the upper extremity (Fig. 10.5; Box 10.1). It is recommended to start therapy in the most distal available and appropriate vein and move upward with subsequent insertions. Using more distal sites first preserves sites less distal for future insertions. Veins selected for short-term infusion therapy should be soft (nonsclerotic), nontender, and not in an area where a previous infusion has infiltrated. Areas of the vein containing a valve should also be avoided. Veins in areas of flexion such as the wrist and antecubital fossa should be avoided if possible because it is more difficult to stabilize the IVAD in these areas. The movement of an IVAD that is not firmly secured can cause mechanical irritation of the vein. Recommended veins for peripheral infusion therapy include the metacarpal, cephalic, basilic, and median veins. Veins in the lower extremities are not recommended for infusion therapy in the adult patient because of the high risk for thrombophlebitis. Use of a vein in the arm on the side where a patient has had a mastectomy or has dialysis access is also contraindicated because venous return in the extremity may already be compromised. Another type of peripheral infusion device is the midline catheter. Midline catheters are inserted in a peripheral vein in the upper extremities with tips that terminate distal to the shoulder in either the basilic, cephalic, or brachial vein. Midlines are appropriate for therapies expected to last between 1 and 4 weeks. The midline catheter is longer than the short peripheral catheter but is not a central catheter and should not be used to administer therapies when a central line is required, such as vesicants or other irritating solutions, parenteral nutrition solutions, or solutions with a pH of less than 5 or greater than 9 or osmolarity greater than 600 mOsm/L. FIGURE 10.5 Veins of the upper extremities. Box 10.1 Obtaining Peripheral IV Access Verify the order. Explain the procedure to the patient. Select the needed catheter and equipment on the basis of the prescribed therapy and the patient's age and condition. Wash hands and put on gloves. Apply the tourniquet proximal to the venipuncture site. Select site for venipuncture. Clean the site with an antiseptic agent and allow it to dry completely. Perform venipuncture and obtain positive blood return. Advance catheter into vein. Release tourniquet. Activate the safety release for the needle. Attach primed administration set or extension set. Apply sterile occlusive dressing. Discard used equipment in appropriate containers. Remove gloves and wash hands. Assess patient's tolerance of the procedure and the security of the catheter. Document per institutional policy. Connection Check 10.3 A patient is admitted with osteomyelitis and is going to require 3 to 4 weeks of IV antibiotics. Which IVAD is most appropriate for this patient? A.  16-gauge central venous catheter B.  18-gauge over-the-needle IVAD C.  20-gauge midline catheter D.  22-gauge steel-winged device Central Venous Access Central venous access (CVA) describes when the tip of the IVAD terminates in the central vasculature at the level of the superior vena cava or the inferior vena cava. Central venous catheters are made of silicone or polyurethane and come in many sizes and can have single or multiple lumens. Multiple-lumen catheters (Fig. 10.6) provide separate fluid pathways that make it possible to deliver two or more solutions at the same time. Each lumen, or fluid pathway, is totally separate from the other lumens. The fluid infused in each of the lumens leaves the central venous access device (CVAD) and enters the central venous system at different points along the catheter. These lumens are referred to as proximal, medial, or distal lumens depending on the location of the end of the fluid path on the catheter. Because the lumens are separate, incompatible solutions can be infused using the different ports attached to each of the lumens. Each port of the catheter is attached to a separate lumen that provides a distinct fluid pathway within the catheter. Each lumen requires initial flushing, which fills the catheter with the ordered IV solution, and flushing is also used to maintain the patency of the individual lumens if fluids are not being continuously administered. Manufacturers offer devices coated or impregnated with anti-infective agents and devices that can withstand the pressure created by the power injectors used in imaging studies. Types of IVADs used to obtain central venous access include nontunneled percutaneous central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters (PICCs). The tips of CVADs can be either open or closed. Closed CVADs contain a valve at the end of the catheter that prevents backflow of blood into the catheter when fluid is not being infused and minimizes the risk of the catheter clotting. Another important characteristic of the CVAD that nurses need to understand and communicate is the ability of the CVAD to tolerate the pressure created by the power injectors used during imaging studies. Factors that need to be taken into consideration when the selection of an appropriate CVAD is made include the therapy required by the patient, the projected length of therapy, the condition of the patient's veins, and the resources available to care for the device after insertion. These devices are placed by physicians or advance practice registered nurses. Nontunneled percutaneous central catheters are usually inserted in either the jugular or subclavian veins using venipuncture, and the tip of the catheter is advanced into the superior vena cava. The use of the femoral vein for nontunneled percutaneous catheters is used with caution because of the associated increased risk of infection. This type of CVAD is frequently used in emergency situations when peripheral access is not available. When the catheter is inserted in an emergency situation, it should stay in place no longer than 48 hours because of the risk of infection related to insertion in a less-than-optimal situation. Full barrier precautions (mask, gown, sterile gloves, and sterile drapes) are used for the insertion procedure. A chest radiograph is required before using the nontunneled percutaneous catheter to verify proper tip location and the absence of a pneumothorax that may have been inadvertently caused during insertion. Another disadvantage of this CVAD is easy dislodgement, and it is important to ensure the device is properly secured with an occlusive dressing. FIGURE 10.6 Multiple-lumen central venous catheter. Multiple-lumen catheters provide separate fluid pathways to deliver two or more solutions at the same time. The lumens are referred to as proximal, medial, or distal lumens depending on the location of the end of the fluid path on the catheter, and the corresponding exit ports are noted on the distal end of the catheter. Tunneled catheters (Fig. 10.7) exit the skin from a site distal from the site where they enter the vein and are tunneled through the subcutaneous tissue between the exit and insertion site. The tip of the catheter is advanced from the insertion site to the central vascular. The tunneled portion of the catheter contains a Dacron cuff that tissue adheres to after insertion. The cuff stabilizes the catheter and provides a barrier to organisms, minimizing infection. This type of CVAD can be permanent and appropriate for patients requiring long-term therapy. The exit site is usually located on the chest and allows the patient easy access, promoting self-care. Tunneled catheters are inserted in nonemergency situations in sterile environments such as an operating or procedure room. Implanted ports (Mediports) are also used for long-term therapy and offer the added advantage of requiring minimal care when not in use. An implanted port consists of a small reservoir with a septum and an attached catheter (Fig. 10.8). The reservoir is placed under the skin. The preferred site is the upper chest wall because it allows the patient to more easily care for the implanted port. These implanted ports can also be placed in the upper extremity, abdomen, and back. The catheter is inserted in the vein near the reservoir, and the tip is advanced into the central vasculature. The entire device is located internally. In order to use the device, it needs to be accessed with a specially designed noncoring needle that is inserted using sterile technique through the skin and into the septum of the reservoir. Noncoring needles (Fig. 10.9) have a different bevel angle, allowing the septum of the port to be punctured multiple times without damage. Once the implanted port is accessed with the noncoring needle, it needs to either have a continuous infusion maintained or be flushed periodically according to institutional policy. Implanted ports can have one or multiple ports, and each port communicates with a separate lumen in the catheter and needs to be flushed separately. When not accessed, the ports interfere minimally with the patient's daily activities and require only infrequent flushing to maintain patency. FIGURE 10.7 Tunneled central venous catheter. Tunneled catheters exit the skin from a site distal from the site where they enter the vein and are tunneled through the subcutaneous tissue between the exit and insertion site. The tip of the catheter is located in the central vasculature. The tunneled portion of the catheter contains a Dacron cuff that tissue adheres to after insertion. FIGURE 10.8 Implanted port. The implanted port consists of a small reservoir with a septum and an attached catheter. The reservoir is placed under the skin. The catheter is inserted in the vein near the reservoir, and the tip is advanced into the central vasculature. The entire device is located internally. Peripherally inserted central catheters (PICCs) are CVADs that are inserted into a peripheral vein and advanced into the central vasculature (Fig. 10.10). Peripherally inserted central catheters are frequently placed by registered nurses trained and competent in their insertion at the bedside with the assistance of ultrasound guidance. These catheters also have the advantage of being more cost-effective and easy to place and are appropriate for therapies of moderate to long-term duration. As with all CVADs, verification of tip placement is required with a chest radiograph before use. Ultrasound guidance can be used to confirm the placement of PICCs. Adjunct use of ultrasound by nurses has been shown to be of particular benefit for peripheral venous catheters when access is difficult. Recent studies show that the technique using electrocardiogram (ECG) guidance for CVADs is more reliable and of lower cost compared with ultrasound guidance. The ECG-guided technique is accurate for the correct positioning in terms of catheter tip--carina distance and catheter tip--tracheobronchial angle. The catheter tip is in ideal position when the P-wave amplitude peaks. If the P-waveform becomes negative, the catheter has passed the distal vena cave and has entered the right atrium of the heart and has lost its position. FIGURE 10.9 Straight and right-angle noncoring needles. Noncoring needles have a different bevel angle, allowing the septum of the port to be punctured multiple times without damage. The veins used for PICC insertion are usually the larger veins in the upper extremities. If infusion therapy using short peripheral therapy with repeated venipunctures has compromised these veins, PICC placement is much more difficult. Early placement of PICCs needs to be considered in patients who require therapies of longer than a few days to maximize the availability of veins that have not previously been accessed. The length of the fluid pathway in a PICC requires special attention to flushing to maintain patency because they need to be flushed before and after each use and periodically when not in use. Care needs to be taken when flushing a PICC so that excess pressure does not damage the thin walls of the catheter. Unless a PICC is specially designed to withstand higher pressures, only 10-mL or larger syringes, or flushing syringes especially designed to limit the amount of pressure they exert, should be used when flushing the PICC or administering medications through the PICC. If there is a possibility of the need for imaging studies requiring power injection, the power PICC is designed to withstand imaging contrast. FIGURE 10.10 Peripherally inserted central catheter. Peripherally inserted central catheters (PICCs) are central venous access devices (CVADs) that are inserted into a peripheral vein and advanced into the central vasculature. Access to the central venous system is also possible using the intraosseous (IO) (into bone marrow) route (Fig. 10.11). Using a handheld driver, the IO device is inserted into the vasculature of the bone marrow, allowing for infusion of fluids and medications. The insertion site is covered with a sterile occlusive dressing to decrease the risk of infection. Infusion rates of up to 1,800 mL per hour are possible, and the patient may require pain medications if experiencing discomfort and pressure during rapid infusions. The IO route is acceptable for any medication that requires a central venous route, and any medication or fluid that is administered by the IV route can be administered by this route. Intraosseous access requires less skill than other types of venous access and can be accomplished in under 1 minute. It is especially useful in severely dehydrated patients and for prehospital vascular access. It is becoming more common for IO lines to be placed by emergency medical technicians before arrival to the hospital. Frequently used sites in the adult include the proximal humerus, proximal tibia, and distal tibia. The IO route provides rapid central venous access in emergency situations and is recommended as an alternative route in cardiopulmonary resuscitation by the American Heart Association. EQUIPMENT USED IN INFUSION THERAPY Infusion systems consist of the containers and the tubing or administration sets that deliver solutions and medications to the IV access device. Needleless systems have been developed and are mandated by the Occupational Safety and Health Administration (OSHA) to reduce the number of needle-stick injuries and exposure to blood-borne pathogens, and there are several types of needleless systems available to nurses. One type of needleless system makes use of a port that contains a valve that is accessed with a male Luer lock on the end of a syringe or administration set (Fig. 10.12). There are also Luer access valve systems available with a positive displacement feature that prevents blood from backflowing into the IV catheter after use. All needleless connectors are activated by pressure in the syringe Luer. This pressure facilitates the syringe Luer to enter an already-split septum to open or depress the septum/plunger. The needleless system aims to prevent microorganisms on the system surface from gaining access into the bloodstream. A 2018 study researched reports of increased bloodstream infections associated with needleless connectors. It was suggested that healthcare worker noncompliance with infection control policies and manufacturer instructions may be the contributing factor. A nurse survey was developed and the responses determined that there is still a lack of knowledge regarding needleless connector types, care, disconnecting syringe from the connector, and cleaning. Ongoing nursing education concerning needleless connectors should continue to be implemented. Disinfection of the needleless system surface is of primary importance before use. Disinfection/alcohol caps can be used for continuous disinfectant contact. Even with these caps, the needleless system must be cleaned with an alcohol wipe. The Joint Commission recommends a 10- to 15-second scrub. Allow the disinfectant to dry before accessing the system. FIGURE 10.11 Obtaining intraosseous (IO) access. A, A handheld driver is used to access the bone marrow to place the IO device. B, The IO device is inserted into the vasculature of the bone marrow, allowing for infusion of fluids and medications. FIGURE 10.12 Luer-activated injection cap. This is a needleless system that uses a port that contains a valve that is accessed with a male Luer lock on the end of a syringe or administration set. Administration sets are either primary or secondary sets (Fig. 10.13). Primary sets are used to deliver the main IV solution, and secondary sets are attached to the primary set to deliver additional solutions or intermittent medications into a y-site in the primary infusion set. These administration sets use gravity to deliver fluids into the vasculature. Administration sets allow for the control of delivery rates using a roller clamp. The infusion rate is determined by the drip factor of the infusion set. Macrodrop administration sets have drip factors of 10, 15, or 20 drops/mL and are appropriate when delivering higher infusion rates. Microdrop administration sets have drip factors of 60 drops/mL and are appropriate when delivering rates of less than 100 mL/min. To determine the infusion rate, use the following equation: milliliters per minute × drop factor = drops per minute There are situations when more accurate rate control is needed than can be provided by gravity administration set roller clamps, and one possible solution is the use of an electronic infusion device or pump. These infusion pumps can deliver solutions and medications with a greater degree of accuracy and can alert the nurse to situations when the infusion has slowed or stopped because of kinked tubing or increased resistance that can indicate that the IV catheter is clotted or has infiltrated into the subcutaneous tissue. Some electronic infusion devices use standard administration sets, whereas others require administration sets specifically designed for use in the device. Electronic infusion devices assist the nurse in providing accurate infusion therapy, but the nurse is still responsible for monitoring the delivery of the therapy. FIGURE 10.13 Primary administration set. Primary sets are used to deliver the main IV solution and consist of a spike that goes into the IV bag, a roller clamp that allows control of flow/infusion rate, ports for secondary access, and the end that connects to the IV catheter. Smart IV infusion pumps were designed to prevent errors. Although these pumps have Dose Error Reduction Software, the research shows that they fail to prevent certain types of IV medication administration errors, and may in fact cause some IV medication errors themselves. According to the Agency for Healthcare Research (AHRQ), 88% of U.S. hospitals use smart infusion pumps. Although these pumps offer advantages such as a drug library, there are also challenges for the healthcare professional. Despite the use of smart pumps, one study found that 67% of infusions involved one or more discrepancies. Difficult interfaces and complex programming can create serious human errors. Currently, there is no smart infusion pump manual describing error types and prevention strategies. With smart infusion pumps interoperability with Electronic Health Records (EHR), many resources are required to keep this system working. Those resources include standardization across all care areas and devices, as well as data collection and ongoing quality improvement. These safety improvements require input from all disciplines including nurses, physicians, pharmacists, informatics, and safety and regulatory experts. Adherence to clinical practice policies and procedures is crucial to the prevention of medication errors. Connection Check 10.4 In order to deliver 0.9% sodium chloride at 125 mL/hr, the nurse has selected an infusion set with a drop factor of 15 drops/mL. What is the correct drop rate required to deliver this volume? A.  15 drops/min B.  31 drops/min C.  60 drops/min D.  125 drops/min NURSING MANAGEMENT OF INFUSION THERAPY Monitoring and Preventing Complications The fluid status of patients receiving IV fluids needs to be monitored to ensure that the intended outcome of therapy is being achieved; therapy should provide adequate amounts of fluid to maintain a euvolemic or normovolemic (having normal blood volume) state. Hypertonic and hypotonic fluids place the patient at the greatest risk for fluid imbalance and require more intense monitoring. Fluid status is monitored with physical assessment, periodic weights, and accurate measurement of intake and output. Laboratory values, particularly serum electrolytes, need to be monitored for further indications of fluid balance. Phlebitis and Infiltration Complications of peripheral infusion therapy include phlebitis and infiltration. Phlebitis, inflammation of the vein, is characterized by pain and erythema along the vein and is graded using a standardized Visual Infusion Phlebitis scale according to signs, symptoms, and severity (Table 10.4). Peripheral sites that show signs of phlebitis should be removed and restarted in another location because phlebitis can progress to more serious conditions, including thrombus formation, cellulitis, and sepsis. The antecubital fossa site has been shown to have the lowest phlebitis rates, whereas hand veins have a high risk of phlebitis. Phlebitis is the most common complication of peripheral venous catheters. Nurses must be vigilant in assessing the patient for fever and the insertion site for heat, pain, erythema, and swelling. Causative factors of phlebitis are divided into three categories: chemical, mechanical, and bacterial. Chemical phlebitis is the result of the infusion of irritating solutions and medications that occurs when the peripheral vein does not allow for sufficient hemodilution of the IV fluid as it exits the catheter. pH is an important factor in chemical phlebitis. Medications such as vancomycin and potassium can be very irritating to veins and are better tolerated in a central IV catheter. Mechanical phlebitis is the result of the catheter irritating the vein wall and can be caused by introducing a catheter too large for the vein, inadequately securing the catheter, or movement of the catheter placed in an area of flexion such as the elbow or wrist. Bacterial phlebitis is the result of bacteria being introduced into the catheter because of improper IV technique, inadequate site cleaning before venipuncture, failure to clean ports before accessing the administration set, failure to allow alcohol to dry before proceeding, or failure to perform adequate hand hygiene (see Evidence-Based Practice: Nursing Interventions and Management in the Prevention and Treatment of PVC Phlebitis). The insertion sites of peripheral vascular access devices need to be assessed at regular intervals for phlebitis, as defined by institutional policies. It is important to continue to assess the site after the peripheral catheter has been removed because phlebitis can develop after the infusion has been completed. A rare type of phlebitis that occurs in 2% of the patient population is postinfusion phlebitis. This is a late reaction after the IV catheter has been removed. This may occur within 3 to 4 days later, and the patient may have been discharged and home. It occurs due to the damage of the catheter to the internal vein. Before discharge, patient education is important to alert the patient to observe the IV site for pain, swelling, and tenderness, and to notify a healthcare professional if these symptoms persist. Phlebitis increases healthcare expenses, prolongs hospitalizations and treatments, and may lead to other complications such as pain, sepsis, thrombophlebitis, and embolism. Table 10.4 Infusion Nurses Society Visual Infusion Phlebitis Scale Grade Clinical Criteria 0 No clinical symptoms 1 One of the following is evident: Slight Erythema at access site, OR Slight pain near the IV site 2 Two are evident: Pain at access site, Erythema, OR Swelling 3 All are evident: Pain along cannula path AND Induration (hardened tissue) 4 All are evident and extensive: Pain along cannula path, Erythema, Induration, AND Palpable venous cord 5 All are evident and extensive: Pain along cannula path, Erythema, Induration, Palpable venous cord, AND Fever Data from Infusion Nurses Society. (2021). Infusion therapy standards of practice (8th ed.). Norwood, MA: Author. Infiltration occurs when a solution or medication is inadvertently infused into the tissue surrounding the vein and is a complication that can occur with any IVAD, peripheral or central. When the solution or medication that infiltrates is a vesicant (able to cause blisters), an extravasation (leakage of IV fluid into subcutaneous tissue) has occurred. Medications that are classified as vesicants include specific antineoplastic agents, antibiotics, and vasoactive medications. Nurses administering vesicants require additional education to ensure competency, and infusion should be routinely assessed for possible infiltration at intervals established by institutional policy. Clinical manifestations of infiltration include blanched skin, skin cool to the touch, edema, unexpected pain or burning at the insertion site or along the path of the vein, and leaking of fluid from the insertion site. Assessment intervals need to take into consideration the patient's condition, type of device, type of therapy, and risk factors. In the case of an extravasation, the infusion needs to be stopped immediately, and corrective action needs to be taken to minimize damage to the tissue. Central Line Complications Complications of central venous infusion therapy can affect the cardiac, vascular, and pulmonary systems. Infection and loss of patency are also issues with central lines. If the guide wire comes in contact with the right atrium, arrhythmias will occur during the procedure. Vascular complications include arterial injury during insertion, and pulmonary complications may include pneumothorax and air embolism. Strategies have been implemented in healthcare institutions to eliminate infections of central venous catheters (CVCs) because of their negative effects on patient outcomes and the high cost of treating central line--associated bloodstream infections. Infections of central lines can result in sepsis and shock, and studies show that the patient mortality rate is 12% to 25% with this complication. The use of maximal sterile barrier precautions, including mask, sterile gown and cap, sterile gloves, and large full-body drapes, while inserting a CVAD is now the standard of practice. To ensure compliance, audits must be implemented on physicians who insert central lines and nurses who monitor the lines for infection. Both play a key role in preventing these infections by following evidence-based best practices (see Safety Alert). Evidence-Based Practice Nursing Interventions and Management in the Prevention and Treatment of PVC Phlebitis Because of the risk of phlebitis associated with IV fluid administration, a systematic review of the literature was conducted in December 2020 to January 2021. The documents searched were from 2015 to 2020. The purpose of the review was to identify available evidence on nursing interventions for treatment and prevention of phlebitis and to ensure proper catheter care. Presently, according to the Infusion Nurses Society (INS), the incidence of phlebitis is 5% to 59.1%. The INS suggests that the accepted phlebitis rate should be 5% or less. The review examined the effects of asepsis to prevent phlebitis and aloe vera and other non--aloe vera agents to prevent and treat phlebitis. There was a total of 52 studies, reviewing nursing interventions for the treatment and prevention of phlebitis. One of the studies was from 32 different hospitals and 1,344 medical records, where 377 patients developed phlebitis and/or extravasation at a rate of 25.1%. In this study one of the main sources of evidence to prevent phlebitis was asepsis by hygienic hand washing, the use of topical \>0.5% chlorhexidine preparation with 70% alcohol or 2% aqueous chlorhexidine, and the use of clean gloves when handling IV connections and devices. Routine dressing changes are not recommended due to the risk of moving the catheter. To prevent and treat phlebitis, topical treatments with aloe vera or matricaria chamomilla (chamomile) were found to be effective. When reviewing if a site change made a difference, there were no significant findings in phlebitis in PVCs that were inserted less than 96 hours or more than 96 hours. Assessment was found to be crucial to identify signs of phlebitis and to remove the catheter immediately. The authors note that this review may contain limitations inherent to the search and selection process. Guanche-Sicilia, A., Sánchez-Gómez, M. B., Castro-Peraza, M. E., Rodríguez-Gómez, J. Á., Gómez-Salgado, J., & Duarte-Clíments, G. (2021). Prevention and treatment of phlebitis secondary to the insertion of a peripheral venous catheter: A scoping review from a nursing perspective. Healthcare (Basel, Switzerland), 9(5), 611. https://doi.org/10.3390/healthcare9050611 2019 National Patient Safety Goal: Implement best practices or evidence-based guidelines to prevent central line--associated bloodstream infections. Perform hand hygiene before line manipulation and dressing changes; use aseptic technique. Disinfect catheter hub and injection port with a standardized protocol when accessing. If assisting or supervising line insertion, maintain sterile technique, and speak up if sterile technique is broken; complete or collect line insertion checklist. Educate patient and/or family before insertion regarding prevention of central line infection. Educate all staff when hired, who are involved with managing central lines, about the prevention of central line--associated bloodstream infections; and monitor compliance with evidence-based practices. Evaluate all CVCs routinely and remove nonessential catheters. Loss of patency, or occlusion, of a CVC can delay the delivery of lifesaving therapies and may also mean the patient is subject to the risk and discomfort of insertion of another CVC. Occlusions can be the result of a thrombotic process when blood or fibrin in or around the catheter interferes with flow. Thrombotic occlusions can result in slowed infusion rate and resistance to flushing or the complete inability to infuse or flush the catheter. Proper flushing before and after use of the catheter and at intervals when the catheter is not in use decreases the occurrence of thrombotic occlusions. There are injection caps specially designed to prevent thrombotic occlusions; these caps create a positive pressure that prevents blood from refluxing into the catheter when not in use. Occlusion can also be nonthrombotic (not resulting from a clot) and can result from medication precipitation. Medication precipitation occurs when incompatible medications are administered together or without adequate flushing between administrations of the incompatible medications. Nurses need to verify that medications being administered together by the IV route are compatible with the solution infusing and any other medications that may still be in the line or catheter. An air embolism occurs when air is inadvertently introduced into the venous system. Risk factors may include hypovolemia and central venous access, pressurized infusions, surgical position, and trauma. The pulmonary outflow tract and pulmonary vessels become obstructed by large air bubbles. This causes decreased blood return from the right ventricle, thus causing increased central venous pressure (CVP). Air can be introduced if the catheter is damaged, during insertion and removal of CVCs, and if the connections in the IV delivery system (e.g., catheter hub, tubing, injection caps) are not tightly secured with Luer-locked connections. Nursing actions that can prevent air embolism include proper Trendelenburg positioning during CVC insertion (10--30 degrees), avoiding CVC insertion during inspiration, correcting hypovolemia before CVC insertion, ensuring all IV connections are intact and secure, and ensuring all lumens are capped and/or clamped. Additional actions include using Luer-locking connections, frequently checking the connections, and clamping catheters and injection sites when not in use. Other preventive measures include using infusion pumps, priming (flushing all the air out of the IV tubing with the ordered solution) all IV tubing before connecting to the CVC, expelling air out of all syringes before use, and inspecting all lines and connections. Ensure the central line dressing is intact, and use caution when prepositioning the patient. Symptoms of air embolism may include dyspnea, tachycardia, cough, syncope, and hypotension. The CVC should be removed only by personnel competent to perform this procedure, and removal should be performed with the patient in a supine position. Before removal, the patient should be instructed to perform a Valsalva maneuver or exhale during the removal to prevent the introduction of air into the line. The catheter should be removed slowly, and a sterile occlusive dressing should be placed over the insertion site immediately and left in place for 24 hours. Connection Check 10.5 The nurse recognizes the presence of pain along the cannula path and induration at the site of a peripheral IV site as what grade of phlebitis? A.  1 B.  2 C.  3 D.  4 Maintaining Intravenous Access In order to maintain the patency of both peripheral and central IVADs, proper flushing is required, and all IVADs need to be flushed before use to establish that they have been placed properly and are functioning correctly. Single-use vials or prefilled syringes of preservative-free 0.9% saline are the preferred methods of delivering flushes because they require less manipulation and are less likely to be contaminated. Whenever manipulating an IVAD, it is imperative to perform hand hygiene and to clean the injection ports before every entry. The injection port needs to be cleaned with alcohol or chlorhexidine and allowed to dry completely; the nurse follows institutional protocols regarding which agent is used to clean the port. Catheters are flushed with a volume twice that of the catheter and any attached extension tubing (Box 10.2). The INS recommends a flushing and locking protocol. "Flushing" is the act of moving fluids, medications, blood, blood products, and nutrients out of a vascular access device into the bloodstream, ensuring delivery of these components and verifying device patency. "Locking" is the instillation of a solution into a vascular access device to maintain device patency. According to the CDC and the Institute for Safe Medication Practices (ISMP), to prevent IV catheter bloodstream infections, the reuse of syringes and needles is unsafe practice. This also applies to prefilled saline syringes. To remain safe, discard all needles and syringes after one use. The patency of CVADs requires a continuous infusion or periodic flushing. As with peripheral catheters, CVADs need to be flushed after the administration of a medication or blood product, when changing from a continuous infusion to an intermittent "locked" device, and also after the withdrawal of blood and when not in use. The frequency of periodic flushing is determined by the type of CVAD and institutional policies. The volume used to flush the CVAD needs to be at least twice the volume of the catheter to be sure all contents of the IVAD are cleared with the flush. Institutional policy determines which CVADs used intermittently are "locked" with saline or with a heparin solution. Studies have shown that the patency of some catheters can be maintained without heparin, which decreases the bleeding complications associated with this anticoagulant. Box 10.2 Centers for Disease Control and Prevention (CDC) Protocol for Flushing Central Venous Lines Positive-pressure technique (may not apply to neutral-displacement or positive-displacement needleless connectors): Flush the catheter, continue to hold the plunger of the syringe while closing the clamp on the catheter, and then disconnect the syringe. For catheters without a clamp, withdraw the syringe as the last 0.5 to 1 mL of fluid is flushed. From Centers for Disease Control and Prevention. (2017). Guidelines for the prevention of intravascular catheter-related infections. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html All IVADs, with the exception of well-healed tunneled catheters, are dressed with a sterile occlusive dressing to prevent bacterial contamination of the site. Transparent semipermeable dressings offer the advantage of allowing a clear view of the insertion site for assessment, but gauze dressing occluded with tape is acceptable. Dressings should be changed immediately if they are no longer occlusive or become moist. Peripheral IVADs do not require routine dressing changes or site care. The frequency of CVAD dressing changes and site care is determined by institutional policy, type of CVAD, and type of dressing. Sterile gloves should be worn when changing a CVAD dressing to decrease the risk of infection. A recent meta-analysis performed by the Cochrane Collaboration found no clear evidence for routine replacement of peripheral IV catheters. Rotating peripheral IV sites every 72 to 96 hours is unpleasant for the patient and expensive in terms of supplies and nursing time. The 2021 INS Infusion Nursing Standards of Practice note that peripheral catheters should be replaced when clinically indicated, not at set intervals. Clinical indications for the removal of a peripheral catheter include whenever the patient reports discomfort or pain related to the infusion site and assessment findings indicating possible phlebitis, infiltration, or occlusion. IV tubing is changed according to institutional policy; there is no evidence that changing IV tubing more frequently than every 96 hours decreases the risk of infection (see Evidence-Based Practice: Peripheral IV Site Rotation Based on Assessment Findings). Routine replacements or exchanges of CVADs are not necessary if the catheter is functioning and there is no evidence of complications. The continued need for a short-term central catheter (PICCs and nontunneled percutaneous central catheters) needs to be evaluated daily by the interprofessional team to determine if the catheter is required. Consideration needs to be made to possibly administering infusion therapies by a less invasive peripheral approach or by other routes, such as oral. Evidence-Based Practice Peripheral IV Site Rotation Based on Assessment Findings There are variations in practice related to the length of time that peripheral IV catheters may remain in place before changing sites. In many healthcare settings, agency policies require that sites be changed at specific time intervals (usually 72--96 hours), despite the absence of complications such as phlebitis and infiltration. A yearlong quantitative study was conducted from 2017 to 2018 with a sample of 473 medical records from a critical care unit, a step-down unit, and an oncology unit. The purpose of the study was to examine the outcome of only changing peripheral IV sites when clinically necessary, and utilizing chlorhexidine dressings. These units were chosen because of the high risk of catheter-related bloodstream infections (CRBSI). The criteria included a length of stay greater than 2 days, peripheral IV catheters inserted according to policy, and a new chlorhexidine dressing. A total of 737 peripheral IV sites and two nursing surveys were included in the study. The results indicated that after a 7-day catheter dwell time, there was a 3% phlebitis rate, no CRBSI, 2 skin tears, a 94.2% nurse satisfaction rate, and a cost savings of \$17,100 in supplies in 1 year. Olivier, R., Wickman, M. Skinner, C., & Ablir, L. (2021). The impact of replacing peripheral intravenous catheters when clinically indicated on infection rate, nurse satisfaction, and costs in CCU, step-down, and oncology units. American Journal of Infection Control, 49(3), 327--332. CASE STUDY: EPISODE 2 Upon Jason's arrival in the emergency department, the IV lines started in the field are discontinued, and two large-bore (18-gauge) peripheral IV catheters are placed in his left forearm. The 0.9% normal saline infusion continues in one of the new peripheral IV sites. The nurse practitioner also inserts a nontunneled percutaneous central catheter. Blood samples are obtained for serum chemistries, complete blood count, and toxicology, and samples are also sent for type and crossmatch in the event Jason requires blood products. He is taken to the operating room for an emergency exploratory laparotomy where he received 2 units of packed RBCs. In the postanesthesia care unit (PACU), the nurse anesthetist places a triple-lumen CVAD for the anticipated need for additional administration of blood products, IV fluids, and antibiotics. The two large-bore peripheral IV catheters and the nontunneled percutaneous central catheter are removed. He is transferred to the surgical intensive care unit for postoperative management... Administration of Intravenous Medications Terms used to describe the method used to administer medications or solutions include continuous infusion, intermittent infusion, bolus (a specific amount of fluid over a short time period) infusion, and IV push (direct IV administration). The order of a licensed independent practitioner needs to indicate which method is to be used. Continuous infusion refers to the ongoing administration of a solution and can be ordered as a specific rate per hour (e.g., 125 mL/hr) or a volume over a time period (e.g., 1,000 mL over 8 hours). Clarification needs to be obtained for orders indicating a "keep open rate" or "keep vein open" (KVO) to obtain a more clearly defined rate unless a "keep open rate" is defined in institutional protocols. Interpretation of such orders can vary greatly, particularly depending on the age and weight of the patient, and can lead to possible fluid overload. Veins should never be kept open with solutions containing medications such as potassium because insufficient amounts will be delivered to be therapeutic. Intermittent infusions can be given through the injection port on the administration set of the continuous infusion ("piggyback") or infused into the injection port of the locked IVAD. Intermittent infusions concurrent with a continuous infusion need to be compatible with the continuous infusion. If not compatible, the continuous infusion needs to be stopped while the intermittent infusion infuses and the tubing of the infusion set is cleared or flushed with a compatible solution, usually 0.9% normal saline. Before administration of an intermittent infusion through a locked IVAD, the IVAD device needs to be flushed to ensure proper functioning of the device and clearing of any potentially incompatible solution. When the intermittent infusion is completed, the IVAD then needs to be flushed again and relocked. When intermittent infusions are administered either into a continuous infusion or into a locked IVAD, the IV system needs to remain closed, and the tubing should not be disconnected to prevent the introduction of microorganisms into the IV system. Flushing and administration of intermittent infusions are done through an injection port that has been cleaned with alcohol or chlorhexidine, per institutional protocol, and allowed to completely dry. Bolus infusions are concentrated medications and/or solutions given over a short period of time. This is the method used when administering a "fluid bolus" or "fluid challenge" to a patient who may have a low urine output because of decreased fluid volume status. Boluses are usually administered with small-volume solution containers (250 or 500 mL) in a manner similar to an intermittent infusion but over a shorter time period. Patients receiving bolus infusions need to be monitored closely to ensure they are tolerating the volume infused. IV push, or direct IV, is the manual administration of a medication using a syringe. Special attention needs to be given to the correct concentration and rate of administration of medications given with this method. Some medications need to be diluted before administration to ensure a safe concentration and to more accurately control the rate of administration. IV push medications can be given into a locked IVAD or into an IVAD with a continuous infusion. Before administration, the IVAD and any tubing between the injection port and the IVAD needs to be flushed to ensure proper functioning of the device and clearing of any potentially incompatible solution or medications. Flushing and administration of the IV push are done through an injection port that has been cleaned with alcohol or chlorhexidine and allowed to completely dry. After the IV push medication has been administered, the IVAD needs to be flushed again. Keep in mind that the rate of this flush needs to be at the same rate that is acceptable for the medication administration because the medication that is in the tubing and IVAD will be flushed through and administered to the patient at the flush rate. Administration of Blood Products Transfusion of blood components is a lifesaving therapy that includes risk and requires meticulous adherence to procedures and policies along with close monitoring of the patient. Modern practices for blood collection include multiple screening tests and volunteer donors, rendering the blood supply relatively free of the risk of transmissible diseases such as syphilis, hepatitis, and HIV. Transfusion of whole blood is rare because it is more efficient to administer only the portion of the blood, or component, required by the patient (Table 10.5). Also, 1 unit of donated blood can be separated into individual components that can benefit multiple recipients. Components commonly infused include RBCs, fresh frozen plasma (FFP), platelets, granulocytes, clotting factors, and albumin. Before releasing a blood component for administration to a patient, the blood bank or laboratory carefully matches the intended component to the sample of the patient's blood to ensure that they are compatible using ABO, Rhesus (Rh), and human leukocyte antigen (HLA) testing. Antigens present on the surface of the RBC determine the ABO blood type of the patient. Antibodies to the ABO antigens are in the plasma, which means ABO antigens present on the transfused blood will be attacked by the antigens in the recipient's blood if they do not have the same ABO antigens. This causes a hemolytic transfusion reaction. The Rh antigen is another antigen on the RBC that is either present (Rh-positive) or absent (Rh-negative). Recipients who are Rh-negative should receive only Rh-negative blood, but recipients who are Rh-positive can receive either Rh-positive or Rh-negative blood (Table 10.6). Patient identification and specimen labeling of blood samples collected from the patient need to be done with extreme care and usually require independent identification by two separate healthcare providers. The HLA system relates to proteins located on the surface of white blood cells and other tissues. Important to immune function, HLAs form in response to exposure to foreign substances. In blood transfusions and organ transplants, the immune system recognizes these cells or tissues as foreign substances, activating the HLA system and leading to transfusion reactions and organ rejection. Table 10.5 Indications for Blood Component Transfusion Blood Component Indication Packed red blood cells (volume 225--350 mL) Symptomatic anemia Acute and chronic blood loss Plasma (fresh frozen plasma) (volume 200--250 mL) Deficiency of plasma coagulation factors Massive transfusion in trauma Need for emergency reversal of elevated prothrombin time and international normalized ratio (PT/INR) that indicates increased risk of bleeding Disseminated intravascular coagulation (DIC) Platelets (volume 40--70 mL) Bleeding due to thrombocytopenia or platelet abnormalities Granulocytes (volume 200--300 mL) Neutropenia with infection, unresponsive to appropriate antibiotics Albumin (volume varies) Volume expansion when crystalloid solutions are not adequate Because blood components are "living transplants," they need to be stored according to strict standards. Even though most blood components contain preservatives, they are stored in the laboratory until just before their transfusion. There are strict time limits placed on how long blood products can be outside of storage in the laboratory before administration and on the length of time over which they can be infused. Nurses must be knowledgeable of these timelines and follow the guidelines established by the institution where they practice. Compliance with these standards is monitored on the blood product administration forms required with the administration of each individual component. Each component or unit is accompanied by a unique form that provides information about the blood product. Table 10.6 ABO Compatibilities Blood Component Type-Specific Compatibilities Red blood cells (RBCs) and platelets Donor O A B AB Recipient O, A, B, AB A, AB B, AB AB Fresh frozen plasma Donor O A B AB Recipient O A, O B, O AB, B, A, O Before the blood component is obtained from the laboratory, the patient's informed consent and an order for the administration of the blood component need to be confirmed. The order should indicate the type of blood component to be administered, the number of units or volume of the blood component to be infused, the flow rate or duration of the infusion, and other parameters for infusion. Because there is a limited amount of time allowed for the component to be outside the controlled storage conditions of the laboratory, the nurse needs to confirm adequate IV access and that all supplies and equipment needed for the transfusion are available before the blood component is released from the laboratory for administration. Once the component is obtained from the laboratory, there needs to be verification performed by two licensed staff members, which includes matching the blood product to the order and matching the patient to the blood product. The blood product should agree with the type of component prescribed, the volume or number of units to be transfused, and the patient's full name and one other patient identifier. The ABO and Rh compatibility of the donor and recipient also needs to be confirmed before the initiation of the transfusion. The expiration date and the date and time the component was released from the laboratory need to be confirmed as acceptable. The National Quality Forum has identified mismatched blood transfusions as an event that should never happen. Patient identification is the most important process in the safe administration of blood components. Fatal errors can occur because of mislabeled specimens or blood components and patient identification. Immediately before starting the blood transfusion, a patient assessment needs to be completed, including baseline vital signs and respiratory status. The nurse needs to explain the procedure and confirm patient understanding, including clinical manifestations to immediately report. Blood transfusions can be an anxiety-producing situation, and adequate time for explanations and questions needs to be provided. Close observation is required to detect any reaction the patient may have to the blood product (Table 10.7), especially during the first 15 minutes when reactions are most likely to occur. Assessments should continue at least every hour for the duration of the transfusion and should include respiratory status; vital sign status; and any complaints of discomfort, dyspnea, or itching. Table 10.7 Types of Transfusion Reactions Transfusion Reaction Cause Clinical Manifestations Interventions if Suspected Acute hemolytic reaction Infusion of ABO-incompatible blood Fever Chills Hypotension Flank pain Vascular collapse Stop the transfusion immediately. Notify the provider. Maintain blood pressure. Febrile nonhemolytic reaction Antibody reaction to granulocytes or platelets in infused blood component Temp increase of 1°C or 2°F Chills Headache Chest pain Stop transfusion; notify provider. Monitor vital signs. Possible administration of antipyretics. Restart transfusion slowly. Allergic reaction Sensitivity to donor's plasma proteins Itching Hives Facial flushing Anxiety Dyspnea Stop transfusion; notify provider. Monitor vital signs. Possible administration of antihistamines. Restart transfusion slowly. Circulatory overload Administration rate higher than patient tolerance Headache Dyspnea JVD Edema Increased BP Stop transfusion; notify provider. Monitor vital signs. Elevate HOB. Possible administration of diuretics and oxygen. Restart transfusion slowly. BP, Blood pressure; HOB, head of bed; JVD, jugular venous distention. The type of component ordered determines the method of administration and the type of equipment needed for the infusion. There are special filters and tubing for each type of blood component, but the only type of infusion solution used in flushing administration sets and IVADs, and in the administration of any of the blood components, is 0.9% sodium chloride. The rationale for this fluid is because it is isotonic and does not cause fluids to move into or out of the transfused RBCs. The gauge of the IVAD used for transfusion needs to be large enough to facilitate the required flow rates so that the blood is transfused within the prescribed time frame. An 18- to 20-gauge catheter is recommended for the infusion of packed RBCs in the adult population to prevent RBC lysis. Packed RBCs consist of the cells that remain after the plasma portion of the whole blood is removed. Packed RBCs are the component that is used for most blood replacement therapy, including acute blood loss, and chronic symptomatic anemia that does not respond to pharmacological therapy. In certain situations, RBCs that have undergone special processing are ordered to meet special patient needs. These types of packed RBCs include irradiated and leukocyte-reduced RBCs. Irradiating RBCs inactivates donor lymphocytes and reduces allergic and febrile reactions in some patients. Leukocyte-reduced RBCs decrease febrile reactions in recipients with high levels of leukocyte antibodies. A single unit of packed RBCs has a volume between 225 and 300 mL and is usually infused over 1.5 to 2 hours but no longer than 4 hours. The integrity of blood products infused over periods greater than 4 hours is compromised, and any remaining product not infused in the 4-hour period needs to be returned to the laboratory. Administration sets used to infuse packed RBCs are either a straight or y-type set with a 170- to 260-micron filter. Filters of this size allow for the movement of the RBCs through the filter but stop any small clots or other debris. The tubing is primed with 0.9% sodium chloride before use. Connection Check 10.6 A patient is ordered to receive a blood transfusion because of anemia. What is the recommended minimum gauge of the IV catheter to administer blood? A.  16 B.  18 C.  20 D.  22 Administration of Total Parenteral Nutrition The use of the intravenous route to provide nutrition is indicated only when it is not possible to provide adequate nutrition using the oral or enteral routes. Intravenous total parenteral nutrition (TPN) is associated with increased risks to the patient and greater costs. Parenteral nutrition solutions provide the major macronutrients (protein, carbohydrates, and lipids) along with required micronutrients (electrolytes, vitamins, and trace minerals) and water. The protein required by the body for growth, maintenance, and repair of tissues is provided in TPN in the form of amino acids in a combination that meets the body's needs. Carbohydrates used to generate energy for the body are supplied by dextrose in the TPN solution. Lipid emulsions may be included to provide an additional source of energy and serve as a source for essential fatty acids. Lipids can either be contained in the primary TPN solution or infused separately. An interprofessional approach is required to design a TPN program that meets the needs of the individual patient, including the primary healthcare provider (physician, advanced practice registered nurse, physician's assistant), registered nurses, pharmacists, and dietitians. Total parenteral nutrition solutions are prepared in the pharmacy under special conditions to reduce the risk of bacterial contamination. Infusion of additional medications in the TPN solution is institution specific, and the risk of infection and medication incompatibilities needs to be carefully evaluated. Medications that are added in some institutions include insulin, heparin, and H2-receptor antagonists. Because of the high concentrations of dextrose, TPN therapy is initiated gradually, and the patient's glucose and fluid tolerance are evaluated as the infusion rate is gradually increased until the targeted rate is reached. Blood glucose levels may be monitored every 6 hours, and an insulin scale is used to control blood glucose levels. Similarly, when the therapy is being discontinued, the rate of infusion should be gradually decreased as the patient adjusts to decreased amounts of concentrated IV dextrose and fluids. When TPN is infused, special precautions are implemented to prevent complications. Because of the high osmolarity of TPN solutions, they should be infused into a CVAD with the tip placement confirmed in the vena cava. This allows for hemodilution of the TPN solution, decreasing the risk of phlebitis, thrombosis, and pain. The infusion system used to administer TPN should remain a closed and dedicated line and should not be used to administer other medications or access the CVAD for any reason. The administration set used to infuse TPN should be changed every 24 hours to decrease the risk of contamination and infection. Connection Check 10.7 The nurse recognizes the prevention of which complication as the primary rationale for initiating total parenteral nutrition at a slow rate? A.  Infection B.  Hyperglycemia C.  Discomfort D.  Air embolism Patient Teaching One of the most important roles of the professional nurse in infusion therapy is patient and family education because they have the right to be involved in their care. In order to be actively involved and make decisions about the care they receive, patients need to be educated on the alterations in their health that require infusion therapy, the infusion therapies prescribed, and the expected outcomes and possible complications of the therapies. Before the insertion of any IVAD, peripheral or central, the patient needs to be educated and learning verified regarding the rationale for the IVAD, alternatives to the selected device, and expectations during the insertion of the device, including the level of expected discomfort. Patients are also educated on the measures used to decrease discomfort and possible complications. The practice of aseptic techniques needs to be explained to the patients, and return demonstration by the patient, family member, or significant other of aseptic technique in caring for the IV access is included in the education. Patients are informed of the type of IV solution and/or medications to be administered, including the reasons they are being administered, expected outcomes, and possible complications. During therapy, the patient's understanding of the importance of reporting any unexpected outcomes and signs of possible complications is assessed. Patients are taught measures to prevent possible complications, including reporting any discomfort or redness at the insertion site, temperature elevation, and whenever the IVAD dressing is no longer occlusive or is wet. Patients are encouraged to monitor hand washing and proper cleaning of ports in the IV delivery system before entry by all healthcare personnel. Connection Check 10.8 The nurse recognizes that education for patients receiving infusion therapy should include which information? (Select all that apply.) A.  Precautions for preventing infection B.  Signs and symptoms to report C.  Manufacturer of the IVAD D.  Purpose of infusion therapy E.  Calculation of infusion rates It is the professional nurse's responsibility to administer IV solutions and medications as prescribed and know the expected outcomes and possible side effects of the solutions and medications administered. Additionally, it is an expectation that the nurse is competent in the techniques used to provide infusion therapy and in monitoring the patient for responses to therapy and the development of any undesired outcomes or complications. The need for continuous infusion therapy and IV access is evaluated periodically, and discontinuation is considered as soon as therapy can be delivered by other, less invasive routes. Making Connections CASE STUDY: WRAP-UP Four days postoperatively, Jason develops a peritoneal abscess requiring IV antibiotics and analgesics, blood products, and TPN. While in the surgical intensive care unit, he receives 4 more units of packed RBCs. Seven days postoperatively, he is transferred to the surgical intermediate care unit. He is then transferred to a short-term acute rehabilitation facility until he can be discharged home. Case Study Questions 1\. The nurse should be prepared to administer what IV solution to Jason as a result of the injuries he sustained in the motor vehicle accident? A. 5% dextrose in lactated Ringer's B. 5% dextrose in normal saline C. 0.45% normal saline D. 0.9% normal saline 2\. What is the rationale for the placement of a nontunneled percutaneous central catheter for Jason? A. The catheter allows easy care of the catheter by Jason after discharge. B. There is a lower risk of infection and other complications. C. Jason prefers to not have an IV in his hand. D. There is an urgent need for fluid and medication administration. 3\. The nurse recognizes that the multiple units of packed RBCs Jason received for blood loss after his motorcycle accident did not contain clotting factors and anticipates that which blood component may be required? A. Fresh frozen plasma B. Granulocytes C. Platelets D. Whole blood 4\. Into which port of his triple-lumen CVAD can the nurse infuse the next dose of antibiotics? (Select all that apply.) A. Port with the parenteral nutrition infusion B. Port with the packed RBCs infusing C. Port where the patient-controlled analgesia is attached D. Port that is saline locked E. Port with 0.9% normal saline infusing 5\. On assessing Jason's central line, the nurse notes that the Luer lock on one of the lumens is not tight and recognizes that this places him at risk for which complication? A. Air embolism B. Clotting of the catheter C. Infection D. Fluid loss Making Connections to Clinical Judgment 1\. Recognizing Cues: What clinical manifestations are observed in this patient? 2\. Analyzing Cues: How do the clinical manifestations correlate to the underlying pathophysiology? 3\. Prioritizing Hypotheses: What could happen if this patient's symptoms are not effectively managed? 4\. Generating Solutions: What treatments are included to manage this patient's condition? 5\. Taking Actions: What are the priority interventions for this patient? 6\. Evaluating Outcomes: What findings demonstrate that the treatment plan is effective? What follow-up data are needed? CHAPTER SUMMARY Infusion therapy is an important part of the care provided to patients with a wide variety of conditions in many settings across the continuum of care. In order to provide safe and effective infusion therapy, nurses require specialized skills and knowledge of current evidence to guide their practice. Infusion therapy is utilized to maintain fluid and electrolyte balances, administer medication and blood products, and provide nutritional support. In order to provide the safest care and prevent complications, nurses need to have knowledge of the anatomy and physiology of the vascular system, correct selection and care of various IV access devices, and the pharmacology of the medications and solutions administered intravenously. Nurses need to be alert to possible complications and perform interventions that minimize their occurrence and detect complications early when they do occur. Intravascular devices selected to deliver infusion therapy should be the least invasive, with the smallest gauge and fewest number of lumens to provide the therapy prescribed. More invasive CVADs are indicated when larger volumes of fluid need to be delivered and for certain medications and solutions that require the greater hemodilution provided in the central vasculature. Specially designed CVADs are available to meet the needs of a variety of patients, including tunneled devices, ports, PICCs, and IO devices. CVADs are required for the administration of TPN due to the high osmolarity and glucose levels.