IV Therapy Notes.pdf

What are the purposes of IV Therapy? 1. Used to sustain clients who are unable to take substances orally 2. Replaces water, electrolytes, and nutrients more rapidly than oral administration 3. Provides immediate access to the vascular system for the rapid delivery of specific solutions without the...

What are the purposes of IV Therapy? 1. Used to sustain clients who are unable to take substances orally 2. Replaces water, electrolytes, and nutrients more rapidly than oral administration 3. Provides immediate access to the vascular system for the rapid delivery of specific solutions without the time required for gastrointestinal tract absorption 4. Provides a vascular route for the administration of medication or blood components Types of IV Solutions 1. Isotonic solutions a. Same osmolality as body fluids b. Increase extracellular fluid volume c. Do not enter the cells because no osmotic force exists to shift the fluids 2. Hypotonic solutions a. More dilute solutions and have a lower osmolarity than body fluids b. Cause the movement of water into cells by osmosis c. Should be administered slowly to prevent cellular edema 3. Hypertonic solutions a. More concentrated solutions and have a higher osmolality than body fluids b. Cause movement of water from cells into the extracellular fluid by osmosis 4. Colloids a. Plasma expanders b. Pull fluid from the interstitial compartment into the vascular compartment c. Used to increase the vascular volume rapidly, such as in hemorrhage or severe hypovolemia Lactated Ringer’s solution contains potassium and should not be administered to clients with acute kidney injury or chronic kidney disease. Administration of an intravenous (IV) solution or medication provides immediate access to the vascular system. This is a benefit of administering solutions or medications via this route, but it can also present a risk. Therefore, it is critical to ensure that the primary health care provider’s (PHCP’s) prescriptions are checked carefully and that the correct solution or medication is administered as prescribed. Always follow the rights for medication administration. Medication Administration Piggyback- Administer medication through an intravenous tube that is inserted into a patient's vein Antibiotics or another type of medication that needs to be diluted and administered slowly Medication in an IV piggyback is mixed in a small amount of compatible fluid, such as normal saline or dextrose with saline. Buretrol Used in pedi Fluid volume limiter Attach the Buretrol to an IV bag. Slide the lower flow rate adjuster to just under the drip chamber and roll to the zero flow position. (closed) Open the top rate adjuster, the one closest to the IV bag and fill the Buretrol chamber with the desired amount of fluid. Push (IVP) Fast, efficient way to deliver vitamins and nutrients to the body During this treatment, a sterile needle is inserted into a vein then attached to a catheter, from which the desired formula is delivered to the bloodstream from a syringe. Continuous infusion A controlled method of intravenous administration of drugs, fluids, or nutrients given without interruption, instead of by bolus (quick infusion) By adjusting the infusion rate, precise medication dosages or quantities of fluids can be given over time Pumps An infusion pump is a medical device that delivers fluids, such as nutrients and medications, into a patient’s body in controlled amounts Solution and Medication incompatibility-Incompatibility is an undesirable reaction that occurs between the drug and the solution, container or another drug. ALWAYS CHECK DRUG COMPATIBILITY PRIOR TO IV ADMINISTRATION IN THE SAME LINE – Saline flush before and after medication Saline or heparin locked-A saline lock (SL), also known as a heparin lock, is a peripheral intravenous cannula connected to extension tubing with a positive pressure cap (heparin cap) Intravenous Devices 1.Butterfly sets a. The set is a wing-tip needle with a metal cannula, plastic or rubber wings, and a plastic catheter or hub. b. The needle is 0.5 to 1.5 inches in length, with needle gauge sizes from 16 to 26. c. Infiltration is more common with these devices. d. The butterfly infusion set is used commonly in children and older clients, whose veins are likely to be small or fragile. 2. Plastic cannulas: Used primarily for short-term therapy. 3. Needleless infusion devices a. Needleless infusion devices include recessed needles, plastic cannulas, and 1-way valves; these systems decrease the exposure to contaminated needles. b.Do not administer parenteral nutrition or blood products through a 1-way valve. IV gauges (SIZE IS SELECTED BASED ON USE OF IV) A client with diabetes mellitus usually does not receive dextrose (glucose) solutions, because the solution can increase the blood glucose level. IV Tubing 1. IV tubing contains a spike end for the bag or bottle, drip chamber, roller clamp, Y site, and adapter end for attachment to the cannula that is inserted into the client’s vein. 2. Shorter, secondary tubing is used for piggyback solutions, connecting them to the injection sites nearest to the drip chamber 3. Special tubing is used for medication that absorbs into plastic (check specific medication administration guidelines when administering IV medications).  Electronic IV infusion devices 1. IV infusion pumps control the amount of fluid infusing and should be used with central venous lines, arterial lines, solutions containing medication, and parenteral nutrition infusions. Most agencies use IV pumps for the infusion of any IV solution. 2. A syringe pump is used when a small volume of medication is administered; the syringe that contains the medication and solution fits into a pump and is set to deliver the medication at a controlled rate. 3. Patient-controlled analgesia (PCA) a.Self-administer IV medication, such as an analgesic; the client can administer doses at set intervals, and the pump can be set to lock out doses that are not within the preset time frame to prevent overdose. b. The PCA regimen may include a basal rate of infusion along with the demand dosing, basal rate infusion alone, or demand dosing alone. c. A bolus dose can be given prior to any of the settings and should be set based on the PHCP’s prescription. d. PCAs are always kept locked, and setup requires the witness of another registered nurse (RN). Intermittent infusion devices 1. intravascular accessibility is desired for intermittent administration of medications by IV push or IV piggyback. 2. Patency is maintained by periodic flushing with normal saline solution (sodium chloride and normal saline are interchangeable names). 3. Depending on agency policy, when administering medication, flush with 1 to 2 mL of normal saline to confirm placement of the IV cannula; administer the prescribed medication and then flush the cannula again with 1 to 2 mL of normal saline to maintain patency. Equipment Prepare and gather the equipment needed for starting the IV. Always check for the fluid’s expiration date. Inspect solution container for integrity. ○ Glass containers. Hold up to light to look for cracks, clarity, particulate contamination, and expiration date. ○ Plastic containers. Squeeze to check for pinholes, clarity, particulate contamination, and expiration date. Inspect administration set Choose the appropriate set: vented or nonvented Gather venipuncture and dressing supplies Catheter (22 g, 20 g, or 28 g most common) Dressing (gauze or TSM) Tape: 1-inch paper Prepping solution Selection of a peripheral IV site 1. Veins in the hand, forearm, and antecubital fossa are suitable sites 2. Veins in the lower extremities (legs and feet) are not suitable for an adult client because of the risk of thrombus formation and the possible pooling of medication in areas of decreased venous return (Box 69-1). 3. Veins in the scalp and feet may be suitable sites for infants. 4. Assess the veins of both arms closely before selecting a site. 5. Start the IV infusion distally to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs; if infiltration occurs from the antecubital vein, the lower veins in the same arm usually should not be used for further puncture sites. 6. Determine the client’s dominant side, and select the opposite side for a venipuncture site. 7. Bending the elbow on the arm with an IV may easily obstruct the flow of solution, causing infiltration that could lead to thrombophlebitis. 8. Avoid checking the blood pressure on the arm receiving the IV infusion if possible. 9. Do not place restraints over the venipuncture site. 10. Use an armboard as needed when the venipuncture site is located in an area of flexion. Inserting a Peripheral Intravenous Line 1. Check the primary health care provider’s (PHCP’s) prescription, determine the type and size of infusion device, and prepare intravenous (IV) tubing or extension set and solution; prime IV tubing or extension set to remove air from the system; explain procedure to the client. 2. Select the vein for insertion based on vein quality, client size, and indication of IV therapy; apply tourniquet and palpate the vein for resilience. 3. Clean the skin with an antimicrobial solution, using an inner to outer circular motion 4. Stabilize the vein below the insertion site and puncture the skin and vein, observing for blood in the flashback chamber; when observed, lower the catheter so that it is flush with the skin and advance the catheter into the vein (if unsuccessful, a new sterile device is used for the next attempt at insertion). 5. Remove the tourniquet. Apply pressure above the insertion site with the middle finger of the nondominant hand and retract the stylet from the catheter; connect the end of the IV tubing or extension set to the catheter tubing, secure it, and begin IV flow. Ask the client about comfort at the site and assess the site for adequate flow. 6. Tape and secure insertion site with a transparent dressing as specified by agency procedure; label the tubing, dressing, and solution bags clearly, indicating the date and time. 7. Document the specifics about the procedure such as number of attempts at insertion; the insertion site, type and size of device, solution and flow rate, and time; and the client’s response. In addition, follow agency procedure for documentation of procedure. Documentation Document the relevant data, including assessments. Record the start of the infusion on the client’s chart. Include the date and time of the venipuncture The gauge and length of the device Specific name and location of the accessed vein Amount of solution used, including any additives Container number Flow rate Type, length and gauge of the needle or catheter Venipuncture site, how many attempts were made and location of each attempt The type of dressing applied The client’s general response Your signature Removing a Peripheral Intravenous Line 1. Check the primary health care provider’s (PHCP’s) prescription and explain the procedure to the client; ask the client to hold the extremity still during cannula or needle removal. 2. Turn off the intravenous (IV) tubing clamp and remove the dressing and tape covering the site, while stabilizing the catheter. 3. Apply light pressure with sterile gauze or other material as specified by agency procedure over the site and withdraw the catheter using a slow, steady movement, keeping the hub parallel to the skin. 4. Apply pressure for 2 to 3 minutes, using dry sterile gauze (apply pressure for a longer period of time if the client has a bleeding disorder or is taking anticoagulant medication). 5. Inspect the site for redness, drainage, or swelling; check the catheter for intactness. 6. Apply a dressing as needed per agency policy. 7. Document the procedure and the client’s response. Initiation and administration of IV solutions 1. Check the IV solution against the PHCP’s prescription for the type, amount, percentage of solution, and rate of flow; follow the rights for medication administration. 2. Assess the health status and medical disorders of the client and identify client conditions that contraindicate use of a particular IV solution or IV equipment, such as an allergy to cleansing solution, adhesive materials, or latex. Check compatibility of IV solutions as appropriate. 3. Check client’s identification by 2 identifiers and explain the procedure to the client; assess client’s previous experience with IV therapy and preference for insertion site. 4. Wash hands thoroughly before inserting an IV line and before working with an IV line; wear gloves. 5. Use sterile technique when inserting an IV line and when changing the dressing over the IV site. 6. Change the venipuncture site every 72 to 96 hours in accordance with Centers for Disease Control and Prevention (CDC) recommendations and agency policy. 7. Change the IV dressing when the dressing is wet or contaminated, or as specified by the agency policy. 8. Change the IV tubing every 96 hours in accordance with CDC recommendations and agency policy or with a change of the venipuncture site. 9. Do not let an IV bag or bottle of solution hang for more than 24 hours, to diminish the potential for bacterial contamination and possibly sepsis. 10. Do not allow the IV tubing to touch the floor, to prevent potential bacterial contamination. Clients with respiratory, cardiac, renal, or liver disease; older clients; and very young persons are at risk for circulatory overload and cannot tolerate an excessive fluid volume. Also, a client with heart failure or renal failure usually is not given a solution containing saline, because this type of fluid promotes the retention of water and would therefore exacerbate heart failure or renal failure by increasing the fluid overload. Complications of intravenous therapy Complication Description Signs Prevention/Intervention Air Embolism A bolus of air enters the Tachycardia Prime tubing with fluid before vein through an Chest pain and use, and monitor for any air inadequately primed IV dyspnea bubbles in the tubing. line, from a loose Hypotension Secure all connections. connection, during Cyanosis Replace the IV fluid before tubing change, or during Decreased level of the bag or bottle is empty. removal of the IV. consciousness Monitor for signs of air embolism; if suspected, clamp RESPIRATORY the tubing, turn the client on the DISTRESS!!! left side with the head of the bed lowered (Trendelenburg’s position) to trap the air in the right atrium, and notify the PHCP. Infiltration Infiltration is seepage Edema, pain, Avoid venipuncture over an of the IV fluid out of the numbness, and area of flexion. (LIKE THE AC) vein and into the coolness at the site; Anchor the cannula and a surrounding interstitial may or may not have loop of tubing securely with  spaces. a blood return tape. Use an armboard or splint as Infiltration occurs needed if the client is restless when an access device or active. has become dislodged Monitor the IV rate for a or perforates the wall of decrease or a cessation of flow. the vein or when Evaluate the IV site for venous back pressure infiltration by occluding the vein occurs because of a clot proximal to the IV site. If the IV or venospasm. fluid continues to flow, the cannula is probably outside the vein (infiltrated); if the IV flow stops after occlusion of the vein, the IV device is still in the vein. Lower the IV fluid container below the IV site, and monitor for the appearance of blood in the IV tubing; if blood appears, the IV device is most likely in the vein. If infiltration has occurred, remove the IV device immediately; elevate the extremity and apply compresses (warm or cool, depending on the IV solution that was infusing and the PHCP’s prescription and agency procedure) over the affected area. (IMPORTANT) Do not rub an infiltrated area, which can cause hematoma. Document accordingly, including taking pictures of the IV site if indicated by agency policy. Phlebitis and Phlebitis is an Phlebitis: Heat, Use an IV cannula smaller Thrombophlebitis inflammation of the vein redness, tenderness than the vein, and avoid using that can occur from at the site; not very small veins when mechanical or chemical swollen or hard; administering irritating (medication) trauma or intravenous infusion solutions. from a local infection. sluggish Avoid using the lower Thrombophlebitis: extremities (legs and feet) as Phlebitis can cause hard and cord-like an access area for the IV. the development of a vein; heat, redness, Avoid venipuncture over an clot (thrombophlebitis). tenderness at site; area of flexion. intravenous infusion Anchor the cannula and a sluggish. loop of tubing securely with tape Use an armboard or splint as needed if the client is restless or active. If phlebitis occurs, remove the IV device immediately and restart it in the opposite extremity; notify the PHCP if phlebitis is suspected, and apply warm, moist compresses,  as prescribed. If thrombophlebitis occurs, do not irrigate the IV catheter; remove the IV, notify the PHCP, and restart the IV in the opposite extremity. Document accordingly, including taking pictures if indicated by agency policy. Tissue damage Tissues most Skin color changes, Use a careful and gentle (Extravasation) commonly damaged sloughing of the skin, approach when applying a include the skin, veins, discomfort at the site tourniquet. and subcutaneous Avoid tapping the skin over tissue. the vein when starting an IV. Tissue damage can Monitor for ecchymosis when be uncomfortable and penetrating the skin with the can cause permanent cannula. negative effects. Assess for allergies to tape or Extravasation is a dressing adhesives. form of tissue damage Monitor for skin color caused by the seepage changes, sloughing of the skin, of vesicant or irritant or discomfort at the IV site. solutions into the Notify the PHCP if tissue tissues; this occurrence damage is suspected. requires immediate Document accordingly, PHCP notification so including taking pictures if that treatment can be indicated by agency policy. prescribed to prevent tissue necrosis.  Infection Infection occurs from Local—redness, Assess the client for the entry of swelling, and predisposition to or risk for microorganisms into the drainage at the site. infection. body through the Maintain strict asepsis when venipuncture site. Systemic—chills, caring for the IV site. Venipuncture fever, malaise, Monitor for signs of local or interrupts the integrity of headache, nausea, systemic infection. the skin, the first line of vomiting, backache, Monitor white blood cell defense against tachycardia counts. infection. Check fluid containers for The longer the cracks, leaks, cloudiness, or therapy continues, the KNOW SYSTEMIC other evidence of greater the risk for AND LOCAL SIGNS contamination. infection. OF INFECTION!!! Change IV tubing every 96 Infection can occur hours in accordance with CDC locally at the IV recommendations or according insertion site or to agency policy; change IV site systemically from the dressing when soiled or entry of microorganisms contaminated and according to into the body. agency policy. At-risk clients: Label the IV site, bag or Immunocompromised bottle, and tubing with the date clients with diseases and time to ensure that these such as cancer, human are changed on time according immunodeficiency virus to agency policy. or acquired Ensure that the IV solution is immunodeficiency not hanging for more than 24 syndrome, those hours. receiving biological If infection occurs, the PHCP modifier response is notified; discontinue the IV, medications for and place the venipuncture treatment of device in a sterile container for autoimmune conditions, possible culture. or status post organ Prepare to obtain blood transplant are at risk for cultures as prescribed if infection. infection occurs and document Clients receiving accordingly. treatments such as Restart an IV in the opposite chemotherapy who arm differentiate sepsis have an altered or (systemic infection) from local lowered white blood cell infection at the IV site. count are at risk for infection. Document accordingly, including taking pictures of the Older clients, because IV site if indicated by agency aging alters the policy. effectiveness of the immune system, are at risk for infection. Clients with diabetes mellitus are at risk for infection. Educating the Patient Patients must receive information on all aspects of their care. After catheter is stabilized, dressing is applied, and labeling complete:  Inform regarding any limitations of movement or mobility Instruct to call for assistance if venipuncture site becomes tender or sore or if redness or swelling develops Advise that site will be checked every shift by the nurs Central venous catheters a. Deliver hyperosmolar solutions, measure central venous pressure, infuse parenteral nutrition, or infuse multiple IV solutions or medications. b. Catheter position is determined by radiography (Xray) after insertion. c. The catheter may have a single, double, or triple lumen. d. The catheter may be inserted peripherally and threaded through the basilic or cephalic vein into the superior vena cava, inserted centrally through the internal jugular or subclavian veins, or surgically tunneled through subcutaneous tissue. e. With multi lumen catheters, more than 1 medication can be administered at the same time without incompatibility problems, and only 1 insertion site is present. For central line insertion, tubing change, and line removal, place the client in the Trendelenburg’s position if not contraindicated or in the supine position, and instruct the client to perform the Valsalva maneuver to increase pressure in the central veins when the IV system is open. Tunneled central venous catheters a. A more permanent type of catheter, such as the Hickman, Broviac, or Groshong catheter, is used for long-term IV therapy. b. The catheter may be single lumen or multilumen. c. The catheter is inserted in the operating room, and the catheter is threaded into the lower part of the vena cava at the entrance of the right atrium (entrance site) and tunneled under the skin to the exit site where the catheter comes out of the chest; the catheter at the exit site is secured by means of a “cuff” just under the skin at the exit site. d.. Patency is maintained by flushing with a diluted heparin solution or normal saline solution, depending on the type of catheter, per agency policy. Peripherally inserted central catheter (PICC) line a. Long-term IV therapy, frequently in the home. b. The basilic vein usually is used, but the median cubital and cephalic veins in the antecubital area also can be used. c. The catheter is threaded so that the catheter tip may terminate in the subclavian vein or superior vena cava. d. A small amount of bleeding may occur at the time of insertion and may continue for 24 hours, but bleeding thereafter is not expected. e. Phlebitis is a common complication. Parenteral Nutrition (PN) 1. Description a. Parenteral nutrition supplies nutrients via the veins. b. PN consists of both partial parenteral nutrition (PPN) and total parenteral nutrition (TPN). The indication of the type used depends on the client’s nutritional needs. FOCUS ON TPN!!!! c. PN supplies carbohydrates in the form of dextrose, fats in an emulsified form, proteins in the form of amino acids, vitamins, minerals, electrolytes, and water. d. PN prevents subcutaneous fat and muscle protein from being catabolized by the body for energy. e. PN solutions are hypertonic due to the higher concentrations of glucose and addition of amino acids. 2. Indications a. Clients with severely dysfunctional or nonfunctional gastrointestinal tracts who are unable to process nutrients may benefit from PN. b. Clients who can take some oral nutrition but not enough to meet their nutrient requirements may benefit from PN. c. Clients with multiple gastrointestinal surgeries, gastrointestinal trauma, severe intolerance to enteral feedings, or intestinal obstructions, or who need to rest the bowel for healing, may benefit from PN. KNOW WHAT PATIENTS USE TPN VS. EN d. Clients with severe nutritionally deficient conditions such as acquired immunodeficiency syndrome, cancer, burn injuries, or malnutrition, or clients receiving chemotherapy, may benefit from PN. PN is a form of nutrition and is used when there is no other nutritional alternative. Administering nutrition orally or through a nasogastric tube is usually initiated first, before PN is initiated. Administration of PN TPN a. Administered through a CENTRAL VEIN; the use of a PICC is acceptable. Other sites that can be used include the subclavian vein and the internal or external jugular veins. b. If the bag of intravenous solution (the TPN) is empty and the nurse is waiting for the delivery of a new bag of solution from the pharmacy, a 10% dextrose in water solution should be infused at the prescribed rate to prevent hypoglycemia WHY???????; the prescribed solution should be obtained as soon as possible.  The delivery of hypertonic solutions into peripheral veins can cause sclerosis, phlebitis, or swelling. Monitor closely for these complications. Fat emulsion (lipids) a. Lipids provide up to 30% of calorie (energy) needs. b. Lipids provide nonprotein calories and prevent or correct fatty acid deficiency. c. Lipid solutions are isotonic and therefore can be administered through a peripheral or central vein; the solution may be administered through a separate IV line below the filter of the main IV administration set by a Y-connector, or as an admixture to the PN solution (3-in-1 admixture consisting of dextrose, amino acids, and lipids). d. Most fat emulsions are prepared from soybean or safflower oil, with egg yolk to provide emulsification; the primary components are linoleic, oleic, palmitic, linolenic, and stearic acids (assess the client for allergies). e. Glucose-intolerant clients or clients with diabetes mellitus may benefit from receiving a larger percentage of their PN from lipids, which helps control blood glucose levels and lower insulin requirements caused by infused dextrose. f. Examine the bottle for separation of emulsion into layers or fat globules or for the accumulation of froth; if observed, do not use and return the solution to the pharmacy. g. Additives should not be put into the fat emulsion solution. i. Infuse solution at the flow rate prescribed—usually slowly at 1 mL/minute initially—monitor vital signs every 10 minutes, and observe for adverse reactions for the first 30 minutes of the infusion. If signs of an adverse reaction occur, stop the infusion and notify the primary health care provider (PHCP)j. If no adverse reaction occurs, adjust the flow rate to the prescribed rate. k. Monitor serum lipids 4 hours after discontinuing the infusion. Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies. Administration and discontinuation 1. Continuous PN a. Infused continuously over 24 hours b. Most commonly used in a hospital setting 2. Intermittent or cyclic PN a. In general, the nutrient solution infusion regimen varies and is commonly administered overnight. b. Allows clients requiring PN on a long-term basis to participate in activities of daily living during the day without the inconvenience of an IV bag and pump set. c. Monitor glucose levels closely because of the risk of hypoglycemia due to lack of glucose during non infusion times. 3. Discontinuing PN therapy a. Evaluation of nutritional status by a nutritionist is done before PN is discontinued. b. If discontinuation is prescribed, gradually decrease the flow rate for 1 to 2 hours while increasing oral intake (this assists in preventing hypoglycemia). c. After removal of the IV catheter, change the dressing daily until the insertion site heals. Note that central lines should not be left in without a reason due to risk of infection, but in some situations are left in place and used for another necessary reason (venous access, medication administration). d. Encourage oral nutrition. e. Record oral intake, body weight, and laboratory results of serum electrolyte and glucose levels. Complications Complication Cause Signs/Symptoms Intervention Prevention Air Embolism Catheter system opened or IV tubing Apprehension Clamp all ports of Make sure all catheter disconnected Chest pain the IV catheter. connections are secure (use Dyspnea Place the client tape per agency protocol). Air entry on IV tubing changes Hypotension in a left side-lying Clamp the catheter when not Loud churning position with the in use and when changing sound heard over head lower than caps (follow agency protocol pericardium on the feet. for flushing and clamping the auscultation Notify the PHCP. catheter and cap changes). Administer Instruct the client in the Rapid and weak oxygen Valsalva maneuver for tubing pulse and cap changes. For tubing and cap changes, Respiratory distress place the client in the Trendelenburg’s position (if not contraindicated) with the head turned in the opposite direction of the insertion site; client should hold breath and bear down. Hyperglycemia High concentration of dextrose in Restlessness Notify the PHCP. Assess the client for a solution Confusion The infusion rate history of glucose intolerance. Client receiving solution too Weakness may need to be Assess the client’s quickly Diaphoresis slowed. medication history Not enough insulin Elevated blood Monitor blood (corticosteroids increase blood Infection glucose level > 200 glucose levels. glucose). mg/dL (11.1 mmol/L) Administer Begin infusion at a slow rate Excessive thirst regular insulin as as prescribed (usually 40-60 Fatigue prescribed. mL/hr). Kussmaul Monitor blood glucose levels respirations per agency protocol. Coma (when severe) Administer regular insulin as prescribed. Use strict aseptic techniques to prevent infection. Hypoglycemia PN abruptly discontinued Anxiety Notify the PHCP. Gradually decrease PN Diaphoresis Administer IV solution when discontinued. Too much insulin being Hunger dextrose. administered Low blood glucose Monitor blood Infuse 10% dextrose at level < 70 mg/dL (< glucose level. same rate as the PN to 3.9 mmol/L) prevent hypoglycemia for 1-2 Shakiness hours after the PN solution is Weakness discontinued. Monitor glucose levels and check the level 1 hour after discontinuing the PN. Sepsis Poor aseptic technique Chills Notify the PHCP. Use strict aseptic techniques Catheter contamination Fever Remove (PN solution has a high Contamination of solution Elevated white blood catheter. concentration of glucose and is cell count Send a catheter a medium for bacterial growth). Redness or drainage tip to the Monitor temperature (fever at insertion site laboratory for could indicate infection). culture. Assess IV site for signs of Prepare to infection (redness, swelling, obtain blood drainage). cultures. Change site dressing, Prepare for solution, and tubing as antibiotic specified by agency policy. administration. Do not disconnect tubing unnecessarily. Additional nursing considerations 1. Check the PN solution with the PHCP’s prescription to ensure that the prescribed components are contained in the solution; some health care agencies require validation of the prescription by 2 registered nurses. 2. To prevent infection and solution incompatibility, IV medications and blood are not given through the PN line. 3. Blood for testing may be drawn from the central venous access site; a port other than the port used to infuse the PN is used for blood draws after the PN has been stopped for several minutes (per agency procedure), because the PN solution can alter the results of the sample. The client with a central venous access site receiving PN should still have a venipuncture site. 4. Monitor partial thromboplastin time and prothrombin time for clients receiving anticoagulants. 5. Monitor electrolyte and albumin levels and liver and renal function studies, as well as any other prescribed laboratory studies. the results are the basis for the PHCP continuing or changing the PN solution or rate. 6. Monitor blood glucose levels as prescribed (usually every 4 hours) because of the risk for hyperglycemia from the PN solution components. 7. In severely dehydrated clients, the albumin level may drop initially after initiating PN because the treatment restores hydration. 8. With severely malnourished clients, monitor for “refeeding syndrome” (a rapid drop in potassium, magnesium, and phosphate serum levels). 9. The electrolyte shift that occurs in “refeeding syndrome” can cause cardiovascular, respiratory, and neurological problems; monitor for shallow respirations, confusion, weakness, bleeding tendencies, and seizures. If noted, the PHCP is notified immediately. 10. Abnormal liver function values may indicate intolerance to or an excess of fat emulsion or problems with metabolism with glucose and protein. 11. Abnormal renal function tests may indicate an excess of amino acids. 12. PN solutions should be stored under refrigeration and administered within 24 hours from the time they are prepared (remove from refrigerator 0.5 to 1 hour before use). 13. PN solutions that are cloudy or darkened should not be used and should be returned to the pharmacy. 14. Additions of substances such as nutrients to PN solutions should be made in the pharmacy and not in the nursing unit. 15. Consultation with the nutritionist should be done on a regular basis