Module 5 Chapter 28 PDF

CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to fluid, electrolyte, acid–base balance, and blood transfusions necessary to care for the following patients: Simon Lawrence, age 3 years, has been admitted to...

CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to fluid, electrolyte, acid–base balance, and blood transfusions necessary to care for the following patients: Simon Lawrence, age 3 years, has been admitted to the pediatric floor with dehydration after vomiting for 2 days. He needs intravenous fluids to become rehydrated. Melissa Cohen, age 32, was just involved in a motor vehicle crash. She has lost a large amount of blood and needs a blood transfusion. Jack Tracy, age 67, is undergoing chemotherapy. He is to be discharged and needs his port deaccessed. LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Initiate a peripheral venous access IV infusion. 6. Administer a blood transfusion. 2. Change IV solution container and administration set. 7. Change the dressing and flushing a central venous access device. 3. Monitor an IV site and infusion. 8. Access an implanted port. 4. Change a peripheral venous access dressing. 9. Deaccess an implanted port. 5. Cap for intermittent use and flush a peripheral venous access device. 10. Remove a peripherally inserted central catheter (PICC). KEY TERMS autologous transfusion: a blood transfusion donated by the patient in anticipation that he or she may need the transfusion during a hospital stay central venous access device (CVAD): a venous access device in which the tip of the catheter terminates in the central venous circulation, usually in the superior vena cava just above the right atrium crossmatching: determining the compatibility of two blood specimens dehydration: decreased fluid volume continued 779 LWBK545_C15_p779-829.qxd 8/6/10 10:34 PM Page 780 Aptara 780 UNIT II KEY TERMS Promoting Healthy Physiologic Responses continued edema: accumulation of fluid in body tissues hypertonic: having a greater concentration of solutes than the solution with which it is being compared hypervolemia: excess of isotonic fluid (water and sodium) in the extracellular space hypotonic: having a lesser concentration than the solution with which it is being compared hypovolemia: deficiency of isotonic fluid (water and sodium) from the extracellular space implanted port: a type of CVAD; subcutaneous injection port attached to a catheter; distal catheter tip dwells in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium (Infusion Nurses Society [INS], 2006), and the proximal end or port is usually implanted in a subcutaneous pocket of the upper chest wall. Implanted ports placed in the antecubital area of the arm are referred to as peripheral access system ports isotonic: having about the same solute concentration as the solution with which it is being compared nontunneled percutaneous central venous catheters: a type of CVAD that has a short dwell time (3 to 10 days); may have double, triple, or quadruple lumens; are more than 8 cm, depending on patient size; introduced through the skin into the internal jugular, subclavian, or femoral veins and sutured into place; and are mainly used in critical care and emergency settings (Gabriel, 2008a) overhydration: increased fluid volume peripherally inserted central catheter (PICC): a type of CVAD, more than 20 cm, depending on patient size, that can be introduced into a peripheral vein (usually the basilic, brachial, or cephalic vein), and advanced so the distal tip dwells in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium (INS, 2006) peripheral venous access device: a short (less than 3 inches) peripheral catheter placed in a peripheral vein for short-term therapy. This device is not appropriate for certain therapies, such as vesicant chemotherapy, drugs that are classified as irritants, or TPN. personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear tunneled central venous catheter: a type of CVAD; intended for long-term use; implanted into the internal or external jugular, or subclavian vein; length of this catheter is more than 8 cm (approximately 90 cm on average), depending on patient size; tunneled in subcutaneous tissue under the skin (usually the midchest area) for 3 to 6 inches to its exit site typing: determining a person’s blood type (A, B, AB, or O) This chapter discusses the skills needed to care for patients with fluid, electrolyte, and acid–base balance needs. Because fluid is the main constituent of the body, the body’s fluid balance is very important. The balance, or homeostasis, of water and dissolved substances (electrolytes) is maintained through the functions of almost every organ of the body. In a healthy individual, fluid intake and fluid losses are about equal. Fundamentals Review 15-1 lists the average adult daily fluid sources and losses. A common form of therapy for handling fluid and electrolyte disturbances is the use of various solutions infused intravenously. The primary care provider is responsible for prescribing the kind and amount of solution to be used. The contents of selected IV solutions are listed, along with comments about their use, in Fundamentals Review 15-2. The nurse is responsible for initiating, monitoring, and discontinuing the therapy. As is the case with other therapeutic agents, the nurse must understand the patient’s need for IV therapy, the type and desired effect of solution being used, and untoward reactions that may occur (Fundamentals Review 15-3). LWBK545_C15_p779-829.qxd 8/6/10 10:34 PM Page 781 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance 781 Fundamentals Review 15-1 AVERAGE ADULT DAILY FLUID SOURCES AND LOSSES Fluid Intake (mL) Fluid Output (mL) Ingested water Ingested food Metabolic oxidation 1,300 1,000 300 Total 2,600 Kidneys Skin Lungs Gastrointestinal 1,500 600 300 200 Total 2600 Fundamentals Review 15-2 SELECTED INTRAVENOUS SOLUTIONS Solution Isotonic 5% dextrose in water (D5W) Comments Supplies about 170 cal/L and contains 50 g of glucose Should not be used in excessive volumes because it does not contain any sodium; thus, the fluid dilutes the amount of sodium in the serum. Brain swelling, or hyponatremic encephalopathy, can develop rapidly and cause death unless it is recognized and treated promptly. 0.9% NaCl (normal saline) Not desirable as routine maintenance solution because it provides only Na and Cl–, which are provided in excessive amounts. May be used to expand temporarily the extracellular compartment if circulatory insufficiency is a problem; also used to treat diabetic ketoacidosis. Lactated Ringer’s solution A roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2 and PO43–) Used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea Useful in treating mild metabolic acidosis Hypotonic 0.33% NaCl (1⁄3-strength normal saline) 0.45% NaCl (1⁄2-strength normal saline) A hypotonic solution that provides Na, Cl–, and free water Na and Cl– allows kidneys to select and retain needed amounts Free water desirable as aid to kidneys in elimination of solutes A hypotonic solution that provides Na, Cl– and free water Often used to treat hypernatremia (because this solution contains a small amount of Na, it dilutes the plasma sodium while not allowing it to drop too rapidly) Hypertonic 5% dextrose in 0.45% NaCl A common hypertonic solution used to treat hypovolemia; used to maintain fluid intake 10% dextrose in water (D10W) Supplies 340 cal/L Used for peripheral parenteral nutrition (PPN) 5% dextrose in 0.9% NaCl (normal saline) Replaces nutrients and electrolytes Can temporarily be used to treat hypovolemia if plasma expander is not available (Data from Portable fluids & electrolytes.. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins, with permission.) LWBK545_C15_p779-829.qxd 8/6/10 10:34 PM Page 782 Aptara 782 UNIT II Promoting Healthy Physiologic Responses Fundamentals Review 15-3 COMPLICATIONS ASSOCIATED WITH INTRAVENOUS INFUSIONS Complication/Cause Signs and Symptoms Nursing Considerations Infiltration: the escape of fluid into the subcutaneous tissue Dislodged needle Penetrated vessel wall Swelling, pallor, coldness, or pain around the infusion site; significant decrease in the flow rate Check the infusion site several times every hour for signs/symptoms. Discontinue the infusion if symptoms occur. Restart the infusion at a different site. Limit the movement of the extremity with the IV. Sepsis: microorganisms invade the bloodstream through the catheter insertion site Poor insertion technique Multilumen catheters Long-term catheter insertion Frequent dressing changes Red and tender insertion site Fever, malaise, other vital sign changes Assess catheter site daily. Notify physician immediately if any signs of infection. Follow agency protocol for culture of drainage. Use scrupulous aseptic technique when starting an infusion. Phlebitis: an inflammation of a vein Mechanical trauma from needle or catheter Chemical trauma from solution Septic (due to contamination) Local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site Discontinue the infusion immediately. Apply warm, moist compresses to the affected site. Avoid further use of the vein. Restart the infusion in another vein. Thrombus: a blood clot Tissue trauma from needle or catheter Symptoms similar to phlebitis IV fluid flow may cease if clot obstructs needle Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site. Do not rub or massage the affected area. Speed shock: the body’s reaction to a substance that is injected into the circulatory system too rapidly Too rapid a rate of fluid infusion into circulation Pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea If symptoms develop, discontinue the infusion immediately. Report symptoms of speed shock to the primary care provider immediately. Monitor vital signs if symptoms develop. Use the proper IV tubing. Carefully monitor the rate of fluid flow. Check the rate frequently for accuracy. A time tape is useful for this purpose. Fluid overload: the condition caused when too large a volume of fluid infuses into the circulatory system Too large a volume of fluid infused into circulation Engorged neck veins, increased blood pressure, and difficulty in breathing (dyspnea) If symptoms develop, slow the rate of infusion. Notify the primary care provider immediately. Monitor vital signs. Carefully monitor the rate of fluid flow. Check the rate frequently for accuracy. Air embolus: air in the circulatory system Break in the IV system above the heart level allowing air in the circulatory system as a bolus Respiratory distress Increased heart rate Cyanosis Decreased blood pressure Change in level of consciousness Pinch off catheter or secure system to prevent entry of air. Place patient on left side in Trendelenburg position. Call for immediate assistance. Monitor vital signs and pulse oximetry. 783 CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance 15-1 Initiating a Peripheral Venous Access IV Infusion Administering and monitoring IV fluids is an essential part of routine patient care. The primary care provider often orders IV therapy to prevent or correct problems in fluid and electrolyte balance. For IV therapy to be administered, an IV must be inserted. Please review Figure 15-1, which illustrates potential infusion sites for peripheral venous catheters. The nurse must also verify the amount and type of solution to be administered, as well as the prescribed infusion rate. Follow the facility’s policies and guidelines to determine if the infusion should be administered by electronic pump or by gravity. Refer to Box 15-1 for guidelines to calculate flow rate for gravity infusion. Cephalic vein Cephalic vein Basilic vein Dorsal metacarpal veins Median cubital vein Basilic vein Medial antebrachial vein Accessory cephalic veins Superficial temporal vein Frontal or metopic vein Radial vein Occipital vein Posterior auricular vein A B FIGURE 15-1. Infusion sites. (A) Ventral and dorsal aspects of lower arm and hand. (B) Scalp. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:34 PM Page 784 Aptara 784 UNIT II Promoting Healthy Physiologic Responses 15-1 BOX 15-1 Initiating a Peripheral Venous Access IV Infusion continued REGULATING IV FLOW RATE Follow agency’s guidelines to determine if infusion should be administered by electronic pump or by gravity. Check physician’s order for IV solution. Check patency of IV line and needle. Verify drop factor (number of drops in 1 mL) of the equipment in use. Calculate the flow rate: EXAMPLE—Administer 1000 mL D5W over 10 hours (set delivers 60 gtt/1 mL). a. Standard formula gtt/min  gtt/min   volume (mL)  drop factor (gtt/mL) time (in minutes) 1000 mL  60 600 (60 min  10 h) b. Short formula using milliliters per hour gtt/min  milliliters per hour  drop factor (gtt/mL) time (60 min) Find milliliters per hour by dividing 1000 mL by 10 hours: 1000  100 mL/hr 10 gtt/min   100 mL  60 60 min 6,000 60  100 gtt/min 60,000 600  100 gtt/min EQUIPMENT ASSESSMENT Review the patient’s record for baseline data, such as vital signs, intake and output balance, and pertinent laboratory values, such as serum electrolytes. Assess the appropriateness of the solution for the patient. Review assessment and laboratory data that may influence solution administration. Assess arms and hands for potential sites for initiating the IV. Keep in mind the following guidelines related to peripheral venous catheters and access sites: Determine the most desirable accessible vein. The cephalic vein, accessory cephalic vein, metacarpal, and basilic vein are appropriate sites for infusion (INS, 2006). The superficial veins on the dorsal aspect of the hand can also be used successfully for some people, but can be more painful (I.V. Rounds, 2008). Initiate venipuncture at least 2 inches (5 cm) above the crease of the IV solution, as prescribed Medication administration record (MAR) or computer-generated MAR (CMAR) Towel or disposable pad Nonallergenic tape IV administration set Label for infusion set (for next change date) Transparent site dressing Electronic infusion device (if appropriate) Tourniquet Time tape and/or label (for IV container) Cleansing swabs (chlorhexidine preferred) IV securement/stabilization device, as appropriate Clean gloves Additional personal protective equipment (PPE), as indicated IV pole Local anesthetic (if ordered) IV catheter (over the needle, Angiocath) or butterfly needle Short extension tubing End cap for extension tubing Alcohol wipes Skin protectant wipe (e.g., SkinPrep) Prefilled 2-mL syringe with sterile normal saline for injection LWBK545_C15_p779-829.qxd 8/6/10 10:34 PM Page 785 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance 785 wrist in an adult patient (Masoorli, 2007). Initiate venous access in the distal areas of the upper extremities; this allows for future sites proximal to the previous insertion site (INS, 2006). Either arm may be used for IV therapy. If the patient is right-handed and both arms appear equally usable, select the left arm to free the right arm for the patient’s use. Determine accessibility based on the patient’s condition. For example, a person with severe burns on both forearms does not have vessels available in these areas, or a patient with a history of axillary node dissection should not have venipuncture in the affected arm. Do not use the antecubital veins if another vein is available. They are not a good choice for infusion because flexion of the patient’s arm can displace the IV catheter over time. By avoiding the antecubital veins for peripheral venous catheters, a PICC line may be inserted at a later time, if needed. Do not use veins in the leg, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications. The cannulation of the lower extremities is associated with risk of embolism and thrombophlebitis (INS, 2006). Some institutions require a physician’s order to insert an IV catheter in an adult patient’s lower extremity. Do not use veins in surgical areas. For example, infusions in the arm should not be given on the same side as recent extensive breast surgery, because of vascular disturbances in the area, or in an arm that has a device inserted for dialysis (e.g., fistula or shunt). NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Deficient Fluid Volume Impaired Skin Integrity Risk for Injury Risk for Deficient Fluid Volume Risk for Infection OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when initiating a peripheral venous access IV infusion is that the access device is inserted using sterile technique on the first attempt. Also, the patient experiences minimal trauma, and the IV solution infuses without difficulty. IMPLEMENTATION ACTION R AT I O N A L E 1. Verify the IV solution order on the MAR/CMAR with the medical order. Clarify any inconsistencies. Check the patient’s chart for allergies. Check for color, leaking, and expiration date. Know techniques for IV insertion, precautions, purpose of the IV administration, and medications if ordered. This ensures that the correct IV solution and rate of infusion, and/or medication will be administered. This knowledge and skill is essential for safe and accurate IV and medication administration. 2. Gather all equipment and bring to the bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about allergies to medications, tape, or skin antiseptics, as appropriate. If considering using a local anesthetic, inquire about allergies for these substances as well. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Possible allergies may exist related to medications, tape, or local anesthetic. Injectable anesthetic can result in allergic reactions and tissue damage. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:34 PM Page 786 Aptara 786 UNIT II 15-1 Promoting Healthy Physiologic Responses Initiating a Peripheral Venous Access IV Infusion continued ACTION 6. If using a local anesthetic, explain the rationale and procedure to the patient. Apply the anesthetic to a few potential insertion sites. Allow sufficient time for the anesthetic to take effect. R AT I O N A L E Explanations provide reassurance and facilitate the patient’s cooperation. Local anesthetic decreases the degree of pain felt at the insertion site. Some of the anesthetics take up to an hour to become effective. Prepare the IV Solution and Administration Set 7. Compare the IV container label with the MAR/CMAR. Remove IV bag from outer wrapper, if indicated. Check expiration dates. Scan bar code on container, if necessary. Compare on patient identification band with the MAR/CMAR. Alternately, label the solution container with the patient’s name, solution type, additives, date, and time. Complete a time strip for the infusion and apply to IV container. Checking the label with MAR/CMAR ensures the correct IV solution will be administered. Identifying the patient ensures the right patient receives the medications and helps prevent errors. Time strip allows for quick visual reference by the nurse to monitor infusion accuracy. 8. Maintain aseptic technique when opening sterile packages and IV solution. Remove administration set from package (Figure 1). Apply label to tubing reflecting the day/date for next set change, per facility guidelines. Asepsis is essential for preventing the spread of microorganisms. Labeling tubing ensures adherence to facility policy regarding administration set changes and reduces the risk of spread of microorganisms. In general, IV tubing is changed every 72 to 96 hours. 9. Close the roller clamp or slide clamp on the IV administration set (Figure 2). Invert the IV solution container and remove the cap on the entry site, taking care not to touch the exposed entry site. Remove the cap from the spike on the administration set. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container (Figure 3). Alternately, follow the manufacturer’s directions for insertion. Clamping the IV tubing prevents air and fluid from entering the IV tubing at this time. Inverting the container allows easy access to the entry site. Touching the opened entry site on the IV container and/or the spike on the administration set results in contamination and the container/administration set would have to be discarded. Inserting the spike punctures the seal in the IV container and allows access to the contents. 10. Hang the IV container on the IV pole. Squeeze the drip chamber and fill at least halfway (Figure 4). Suction causes fluid to move into drip chamber. Fluid prevents air from moving down the tubing. FIGURE 1. Basic administration set for gravity infusion. (Photo by FIGURE 2. Closing clamp on administration set. B. Proud.) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 787 Aptara 787 CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION FIGURE 3. Inserting administration set spike into entry site of IV R AT I O N A L E FIGURE 4. Squeezing drip chamber to fill at least halfway. fluid container. 11. Open the IV tubing clamp, and allow fluid to move through tubing. Follow additional manufacturer’s instructions for specific electronic infusion pump, as indicated. Allow fluid to flow until all air bubbles have disappeared and the entire length of the tubing is primed (filled) with IV solution (Figure 5). Close the clamp. Alternately, some brands of tubing may require removal of the cap at the end of the IV tubing to allow fluid to flow. Maintain its sterility. After fluid has filled the tubing, recap the end of the tubing. This technique prepares for IV fluid administration and removes air from the tubing. If not removed from the tubing, large amounts of air can act as an embolus. Touching the open end of the tubing results in contamination and the administration set would have to be discarded. 12. If an electronic device is to be used, follow manufacturer’s instructions for inserting tubing into the device (Figure 6). This ensures proper use of equipment. FIGURE 5. Priming administration set. FIGURE 6. Inserting administration set into electronic infusion device. Initiate Peripheral Venous Access 13. Place patient in low Fowler’s position in bed. Place protective towel or pad under patient’s arm. The supine position permits either arm to be used and allows for good body alignment. Towel protects underlying surface from blood contamination. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 788 Aptara 788 UNIT II 15-1 Promoting Healthy Physiologic Responses Initiating a Peripheral Venous Access IV Infusion continued ACTION R AT I O N A L E 14. Provide emotional support, as needed. Patient may experience anxiety because he/she may, in general, fear needlestick or IV infusion. 15. Open the short extension tubing package. Attach end cap, if not in place. Clean end cap with alcohol wipe. Insert syringe with normal saline into extension tubing. Fill extension tubing with normal saline and apply slide clamp. Remove the syringe and place extension tubing and syringe back on package, within easy reach. Priming the extension tubing removes air from the tubing and prevents administration of air when connected to venous access. Having tubing within easy reach facilitates accomplishment of procedure. 16. Select and palpate for an appropriate vein. Refer to guidelines in previous Assessment section. The use of an appropriate vein decreases discomfort for the patient and reduces the risk for damage to body tissues. 17. If the site is hairy and agency policy permits, clip a 2-inch area around the intended entry site. Hair can harbor microorganisms and inhibit adhesion of site dressing. 18. Put on gloves. Gloves prevent contact with blood and body fluids. 19. Apply a tourniquet 3 to 4 inches above the venipuncture site to obstruct venous blood flow and distend the vein (Figure 7). Direct the ends of the tourniquet away from the entry site. Make sure the radial pulse is still present. Interrupting the blood flow to the heart causes the vein to distend. Distended veins are easy to see, palpate, and enter. The end of the tourniquet could contaminate the area of injection if directed toward the entry site. Tourniquet may be applied too tightly so assessment for radial pulse is important. Checking radial pulse ensures arterial supply is not compromised. FIGURE 7. Applying tourniquet. 20. Instruct the patient to hold the arm lower than the heart. Lowering the arm below the heart level helps distend the veins by filling them. 21. Ask the patient to open and close the fist. Observe and palpate for a suitable vein. Try the following techniques if a vein cannot be felt: Contracting the muscles of the forearm forces blood into the veins, thereby distending them further. a. Massage the patient’s arm from proximal to distal end and gently tap over intended vein. Massaging and tapping the vein help distend veins by filling them with blood. b. Remove tourniquet and place warm, moist compresses over intended vein for 10 to 15 minutes. Warm, moist compresses help dilate veins. 22. Cleanse site with an antiseptic solution such as chlorhexidine or according to facility policy. Press applicator against the skin and apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow to dry completely. Scrubbing motion and length of time (minimum 30 seconds) is necessary for chlorhexidine to be effective (Infection Control Today [ICT], 2005). Organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Chlorhexidine is the preferred antiseptic solution, but iodine, povidone-iodine, and 70% alcohol are considered acceptable alternatives (INS, 2006). LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 789 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 789 R AT I O N A L E 23. Use the nondominant hand, placed about 1 or 2 inches below the entry site, to hold the skin taut against the vein. Avoid touching the prepared site. Ask the patient to remain still while performing the venipuncture. Pressure on the vein and surrounding tissues helps prevent movement of the vein as the needle or catheter is being inserted. The needle entry site must remain untouched to prevent contamination from unsterile hands. Patient movement may prevent proper technique for IV insertion. 24. Enter the skin gently, holding the catheter by the hub in your dominant hand, bevel side up, at a 10- to 15-degree angle (Figure 8). Insert the catheter from directly over the vein or from the side of the vein. While following the course of the vein, advance the needle or catheter into the vein. A sensation of “give” can be felt when the needle enters the vein. This allows the needle or catheter to enter the vein with minimal trauma and deters passage of the needle through the vein. FIGURE 8. Stretching skin taut and inserting needle. 25. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance either device into the vein until the hub is at the venipuncture site. The exact technique depends on the type of device used. The tourniquet causes increased venous pressure, resulting in automatic backflow. Placing the access device well into the vein helps to prevent dislodgement. 26. Release the tourniquet. Quickly remove the protective cap from the extension tubing and attach it to the catheter or needle. Stabilize the catheter or needle with your nondominant hand. Bleeding is minimized and the patency of the vein is maintained if the connection is made smoothly between the catheter and tubing. 27. Continue to stabilize the catheter or needle and flush gently with the saline, observing the site for infiltration and leaking. Infiltration and/or leaking and patient reports of pain and/or discomfort indicate that the insertion into the vein is not successful and should be discontinued. 28. Open the skin protectant wipe. Apply the skin protectant to the site, making sure to apply—at minimum—the area to be covered with the dressing. Place sterile transparent dressing or catheter securing/stabilization device over venipuncture site. Loop the tubing near the site of entry, and anchor with tape (nonallergenic) close to the site. Skin protectant aids in adhesion of the dressing and decreases the risk for skin trauma when the dressing is removed. Transparent dressing allows easy visualization and protects the site. Stabilization/securing devices preserve the integrity of the access device and prevent catheter migration and loss of access (INS, 2006, p. S44). Some stabilization devices act as a site dressing also. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. 29. Label the IV dressing with the date, time, site, and type and size of catheter or needle used for the infusion (Figure 9). Other personnel working with the infusion will know what type of device is being used, the site, and when it was inserted. IV insertion sites are changed every 48 to 72 hours or according to agency policy (Lavery, 2005). (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 790 Aptara 790 UNIT II 15-1 Promoting Healthy Physiologic Responses Initiating a Peripheral Venous Access IV Infusion continued ACTION R AT I O N A L E 30. Using an antimicrobial swab, cleanse the access cap on the extension tubing. Remove the end cap from the administration set. Insert the end of the administration set into the end cap (Figure 10). Loop the administration set tubing near the site of entry, and anchor with tape (nonallergenic) close to the site. Remove gloves. Inserting the administration set allows initiation of the fluid infusion. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. Removing gloves properly reduces the risk for infection transmission and contamination of other items. FIGURE 9. Venous access site with labeled dressing. FIGURE 10. Inserting administration set into the end cap of venous access device. 31. Open the clamp on the administration set. Set the flow rate and begin the fluid infusion (Figure 11). Alternately, start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the solution and function of the infusion device. Inspect the insertion site for signs of infiltration (Figure 12). Verifying the rate and device settings ensures the patient receives the correct volume of solution. If the catheter or needle slips out of the vein, the solution will accumulate (infiltrate) into the surrounding tissue. FIGURE 11. Initiating IV fluid infusion. FIGURE 12. Inspecting insertion site. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 791 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 791 R AT I O N A L E 32. Apply an IV securement/stabilization device if not already in place as part of dressing, as indicated, based on facility policy. Explain to patient the purpose of the device and the importance of safeguarding the site when using the extremity. These systems are recommended for use on all venous access sites, and particularly central venous access sites, to preserve the integrity of the access device and to prevent catheter migration and loss of access (INS, 2006, p. S44). Some devices act as a site dressing also and may already have been applied. 33. Remove equipment and return the patient to a position of comfort. Lower bed, if not in lowest position. Promotes patient comfort and safety. 34. Remove additional PPE, if used. Perform hand hygiene. 35. Return to check flow rate and observe IV site for infiltration 30 minutes after starting infusion, and at least hourly thereafter. Ask the patient if he or she is experiencing any pain or discomfort related to the IV infusion. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. Continued monitoring is important to maintain correct flow rate. Early detection of problems ensures prompt intervention. The expected outcome is met when the IV access is initiated on the first attempt; fluid flows easily into the vein without any sign of infiltration; and the patient verbalizes minimal discomfort related to insertion and demonstrates an understanding of the reasons for the IV. DOCUMENTATION Guidelines Sample Documentation Document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, and the rate of the IV infusion, as well as the use of a securing or stabilization device. Additionally, document the condition of the site, such as presence of redness, swelling, or drainage. Record the patient’s reaction to the procedure and pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from the IV or notices any swelling at the site. If necessary, document the IV fluid solution on the intake and output record. 11/02/12 0830 20G IV started in L hand via the dorsal metacarpal vein. Transparent dressing applied. Site without redness, drainage, or edema. D51/2 NS with 20 mEq KCl begun at 110 mL/hour. Patient instructed to call with any pain or swelling. —S. Barnes, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Fluid does not easily flow into the vein: Reposition the extremity because certain positions that the patient may assume may prevent the IV from infusing properly. If the IV is a free-flowing IV, raise the height of the IV pole. This may promote an increase in IV flow. Attempt to flush the IV with 2 to 3 mL of saline in a syringe. Check the IV connector to ensure that clamp is fully open. If fluid still does not flow easily, or if resistance is met while flushing, the IV may be against a valve and may need to be restarted in a different location. Fluid does not flow easily into the vein, and the skin around the insertion site is edematous and cool to the touch: IV has infiltrated. Put on gloves and remove the catheter. Apply pressure with a sterile gauze pad. Secure gauze with tape over the insertion site and restart IV in a new location. A small hematoma is forming at the site while you are inserting the catheter: The vein is “blowing”: a small hole has been made in the vein and blood is leaking out into the tissues. Remove and discard the catheter and choose an alternate insertion site. Fluids are leaking around the insertion site: Change dressing on IV. If site continues to leak, remove IV to decrease risk of infection and restart it in a new location. IV infusion set becomes disconnected from IV: Discard IV tubing to prevent infection. Attempt to flush IV with 3 mL of normal saline. If the IV is still patent, the site may still be used, as long as the catheter hub has not been contaminated. IV catheter is partially pulled out of insertion site: Do not reinsert the catheter. Whether the IV is salvageable depends on how much of the catheter remains in the vein. If this catheter is not removed, monitor it closely for signs of infiltration. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 792 Aptara 792 UNIT II Promoting Healthy Physiologic Responses 15-1 Initiating a Peripheral Venous Access IV Infusion continued SPECIAL CONSIDERATIONS General Considerations Make only two venipuncture attempts when initiating venous access for a patient. If unsuccessful after two attempts, a colleague with advanced skills, such as a member of the nurse IV team, should attempt to initiate the venous access (Arbique & Arbique, 2007). Infant and Child Considerations Hand insertion sites should not be the first choice for children because nerve endings are very close to the surface of the skin, and such an insertion is more painful. Once the child can walk, do not use the feet as insertion sites. Other potential sites for neonates and children include veins of the head, neck, and lower extremities (INS, 2006). Scalp arteries in infants are visible. Carefully palpate the site before insertion. If the site is pulsating, do not use. Do not replace peripheral catheters in children unless clinically indicated (Centers for Disease Control and Prevention, 2002). For neonates, isopropyl alcohol or products containing isopropyl alcohol are not recommended for access site preparation. Povidone-iodine or chlorhexidine solution is recommended, but requires complete removal after the preparatory procedure with sterile water or sterile saline to prevent product absorption (INS, 2006, p. S42). Chlorhexidine has been associated with contact dermatitis when used for infants weighing less than 1000 g. It should be used with caution with this patient population (INS, 2006). Older Adult Considerations Avoid using vigorous friction and too much alcohol at the insertion site. Both can traumatize fragile skin and veins in the elderly. To decrease the risk for trauma to the vessel, experienced nurses may omit use of a tourniquet if the patient has prominent but especially fragile veins. Catheter stabilization/securing devices should be used routinely with older adults to preserve the integrity of the access device and to prevent catheter migration and loss of access (INS, 2006, p. S44; Smith & Hannum, 2008). EVIDENCE FOR PRACTICE Infusion Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), S1–S92. The Infusion Nurses Society is recognized as the global authority in infusion therapy. The Infusion Nursing Standards of Practice is an evidence-based document, providing guidelines for nurses related to infusion therapy. All nurses involved in the delivery of infusion therapies are responsible for ensuring the incorporation and dissemination of these Standards of Practice into current practice in all healthcare settings (INS, 2006, p. S3). Needle insertion for venipuncture or IV cannulation is painful, frightening, and distressful for children. Topical anesthetics have been used to provide effective local anesthesia for venipuncture. These products require 30 to 90 minutes after application to reach maximal effectiveness. This limits usefulness in acute care situations. Iontophoresis (application of electric current to carry ionized lidocaine through the skin) has also been shown to be an effective analgesic for children undergoing these procedures. It also requires a waiting period, up to 15 minutes, for onset of effect. New systems are being investigated to decrease the wait for onset of effect and provide effective pain relief for venipuncture. Related Research Migdal, M., Chudzynska-Pomianowska, E., Vause, E., et al. (2005). Rapid, needle-free delivery of lidocaine for reducing the pain of venipuncture among pediatric subjects. Pediatrics, 115(4), e393–e398. This study evaluated an investigational, needle-free, single-use, prefilled, disposable system that delivers a fine, dry powdered lidocaine into the epidermis which results in rapid local anesthetic effect (within 1 to 3 minutes). The purpose of the study was to determine the optimal dosing for the drug using this delivery system. This application method of lidocaine, at two different doses (0.25 and 0.5 mg), was compared with a placebo among children (3 to 18 years of age), 2 to 3 minutes before venipuncture. The authors concluded that both doses were safe and well tolerated. The 0.5-mg dose administered 2 to 3 minutes before venipuncture produced significantly lower pain scores, compared with the placebo. The 0.25-mg dose did not achieve a statistically significant reduction in pain. Relevance for Nursing Practice Nurses are often responsible for initiating venous access and obtaining blood samples from their patients, including children. Using the most efficient techniques can result in decreased pain and anxiety for both the children and their parents. Many adult patients also experience pain and stress related to initiation of venous access. Nurses should consider the use of this technique with adult patients. CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance 15-2 793 Changing an IV Solution Container and Administration Set Intravenous fluid administration frequently involves multiple bags or bottles of fluid infusion. Verify the amount and type of solution to be administered, as well as the prescribed infusion rate. Follow the facility’s policies and guidelines to determine if the infusion should be administered by electronic pump or by gravity. Refer to Box 15-1 for guidelines to calculate flow rate for gravity infusion. In addition, monitor these fluid infusions and replace the fluid containers, as needed. Focus on the following points: If more than one IV solution or medication is ordered, check facility policy and appropriate literature to make sure that the additional IV solution can be attached to the existing tubing. As one bag is infusing, prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Ongoing assessments related to the desired outcomes of the IV therapy, as well as assessing for both local and systemic IV infusion complications, are required. Before switching the IV solution containers, check the date and time of the infusion administration set to ensure it does not also need to be replaced. Check facility policy for guidelines for changing IV administration sets. For simple IV solutions, every 72 to 96 hours is recommended. EQUIPMENT For solution container change: IV solution, as prescribed MAR//CMAR Time tape and/or label (for IV container) PPE, as indicated For tubing change: Administration set Label for administration set (for next change date) Sterile gauze Nonallergenic tape IV securement/stabilization device, as appropriate Clean gloves Additional PPE, as indicated Alcohol wipes ASSESSMENT Review the patient’s record for baseline data, such as vital signs, intake and output balance, and pertinent laboratory values, such as serum electrolytes. Assess the appropriateness of the solution for the patient. Review assessment and laboratory data that may influence solution administration. Inspect the IV site. The dressing should be intact, adhering to the skin on all edges. Check for any leaks or fluid under or around the dressing. Inspect the tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. Also inspect the site for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site. Ask the patient if he/she is experiencing any pain or discomfort related to the IV line. Pain or discomfort is sometimes associated with both infiltration and phlebitis. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. An appropriate nursing diagnosis is Risk for Injury. Other nursing diagnoses that may be appropriate include: Deficient Fluid Volume Risk for Infection Risk for Deficient Fluid Volume Impaired Skin Integrity OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when changing an IV solution container and tubing is that the prescribed IV infusion continues without interruption and no infusion complications are identified. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 794 Aptara 794 UNIT II 15-2 Promoting Healthy Physiologic Responses Changing an IV Solution Container and Administration Set continued IMPLEMENTATION ACTION R AT I O N A L E 1. Verify IV solution order on MAR/CMAR with the medical order. Clarify any inconsistencies. Check the patient’s chart for allergies. Check for color, leaking, and expiration date. Know the purpose of the IV administration and medications if ordered. This ensures that the correct IV solution and rate of infusion, and/or medication will be administered. This knowledge and skill is essential for safe and accurate IV and medication administration. 2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about allergies to medications or tape, as appropriate. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Possible allergies may exist related to IV solution additive or tape. 6. Compare IV container label with the MAR/CMAR (Figure 1). Remove IV bag from outer wrapper, if indicated. Check expiration dates. Scan bar code on container, if necessary. Compare patient identification band with the MAR/CMAR. Alternately, label solution container with the patient’s name, solution type, additives, date, and time. Complete a time strip for the infusion and apply to IV container. Checking label with MAR/CMAR ensures the correct IV solution will be administered. Identifying the patient ensures the right patient receives the medications and helps prevent errors. Time strip allows for quick visual reference by the nurse to monitor infusion accuracy. FIGURE 1. Comparing IV fluid container label with MAR/CMAR. 7. Maintain aseptic technique when opening sterile packages and IV solution. Remove administration set from package. Apply label to tubing reflecting the day/date for next set change, per facility guidelines. Asepsis is essential for preventing the spread of microorganisms. Labeling tubing ensures adherence to facility policy regarding administration set changes and reduces risk of spread of microorganisms. In general, IV tubing is changed every 72 to 96 hours. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 795 Aptara 795 CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION R AT I O N A L E To Change IV Solution Container 8. If using an electronic infusion device, pause the device or put on “hold.” Close the slide clamp on the administration set closest to the drip chamber. If using gravity infusion, close the roller clamp on the administration set. The action of the infusion device needs to be paused while the solution container is changed. Closing the clamps prevents the fluid in the drip chamber from emptying and air from entering the tubing during the procedure. 9. Carefully remove the cap on the entry site of the new IV solution container and expose the entry site, taking care not to touch the exposed entry site. Touching the opened entry site on the IV container results in contamination and the container would have to be discarded. 10. Lift empty container off IV pole and invert it. Quickly remove the spike from the old IV container, being careful not to contaminate it. Discard old IV container. Touching the spike on the administration set results in contamination and the tubing would have to be discarded. 11. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container. Alternately, follow the manufacturer’s directions for insertion. Hang the container on the IV pole. Inserting the spike punctures the seal in the IV container and allows access to contents. 12. Alternately, hang the new IV fluid container on an open hook on the IV pole. Carefully remove the cap on the entry site of the new IV solution container and expose the entry site, taking care not to touch the exposed entry site. Lift empty container off the IV pole and invert it. Quickly remove the spike from the old IV container, being careful not to contaminate it (Figure 2). Discard old IV container. Using a twisting and pushing motion, insert the administration set spike into the entry port of the new IV container as it hangs on the IV pole (Figure 3). Touching the opened entry site on the IV container or the administration set spike results in contamination and both would have to be discarded. Inserting the spike punctures the seal in the IV container and allows access to contents. FIGURE 2. Removing administration spike from empty IV fluid FIGURE 3. Inserting administration set spike into entry port of container. new IV fluid container. 13. If using an electronic infusion device, open the slide clamp, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to “run” or “infuse.” Verifying the rate and device settings ensures the patient receives the correct volume of the solution. 14. If using gravity infusion, slowly open the roller clamp on the administration set and count the drops. Adjust until the correct drop rate is achieved (Figure 4). Opening the clamp regulates the flow rate into the drip chamber. Verifying the rate ensures patient receives the correct volume of solution. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 796 Aptara 796 UNIT II 15-2 Promoting Healthy Physiologic Responses Changing an IV Solution Container and Administration Set continued ACTION R AT I O N A L E FIGURE 4. Reopening clamp and adjusting flow rate. To Change IV Solution Container and Administration Set 15. Prepare the IV solution and administration set. Refer to Skill 15-1, Steps 7–11. 16. Hang the IV container on an open hook on the IV pole. Close the clamp on the existing IV administration set. Also, close the clamp on the short extension tubing connected to the IV catheter in the patient’s arm. Clamping the existing IV tubing prevents leakage of fluid from the administration set after it is disconnected. Clamping the tubing on the extension set prevents introduction of air into the extension tubing. 17. If using an electronic infusion device, remove the current administration set from device. Following manufacturer’s directions, insert a new administration set into infusion device. Administration set has to be removed in order to insert new tubing into device. 18. Put on gloves. Remove the current infusion tubing from the access cap on the short extension IV tubing. Using an antimicrobial swab, cleanse access cap on extension tubing. Remove the end cap from the new administration set. Insert the end of the administration set into the access cap. Loop the administration set tubing near the entry site, and anchor with tape (nonallergenic) close to site (Figure 5). Cleansing the cap or port reduces the risk of contamination. Inserting the administration set allows initiation of the fluid infusion. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. 19. Open the clamp on the extension tubing. Open the clamp on the administration set. Opening clamps allows solution to flow to patient. 20. If using an electronic infusion device, open the slide clamp, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to “run” or “infuse.” Verifying the rate and device settings ensures the patient receives the correct volume of solution. 21. If using gravity infusion, slowly open the roller clamp on the administration set and count the drops. Adjust until the correct drop rate is achieved. Opening the clamp regulates flow rate into the drip chamber. Verifying the rate ensures the patient receives the correct volume of solution. 22. Remove equipment. Ensure patient’s comfort. Remove gloves. Lower bed, if not in lowest position. Promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 797 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 797 R AT I O N A L E FIGURE 5. Making sure clamp is open on new tubing, with short extension tubing taped in place. 23. Remove additional PPE, if used. Perform hand hygiene. 24. Return to check flow rate and observe IV site for infiltration 30 minutes after starting infusion, and at least hourly thereafter. Ask the patient if he or she is experiencing any pain or discomfort related to the IV infusion. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. Continued monitoring is important to maintain the correct flow rate. Early detection of problems ensures prompt intervention. The expected outcome is achieved when the IV solution container and administration set are changed; the IV infusion continues without interruption; and no infusion complications are identified. DOCUMENTATION Guidelines Sample Documentation Document the type of IV solution and the rate of infusion; and the presence of redness, swelling, or drainage. Record the patient’s reaction to the procedure and pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from the IV or notices any swelling at the site. If necessary, document the IV fluid solution on the intake and output record. 11/3/12 1015 IV fluid changed from D51/2 NS with 20 mEq KCl/L at 125 mL/hour to D50.9% NS with 20 mEq KCl/L at 80 mL/hour. IV site intact; no swelling, redness, or drainage noted. —S. Barnes, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Infusion does not flow or flow rate changes after bag and tubing is changed: Make sure that the flow clamp is open and the drip chamber is approximately half full. Check the electronic device for proper functioning. Check the IV site for possible problems with the catheter, such as bending of the catheter or position of the patient’s extremity, and inspect the IV site for signs and symptoms of complications. Readjust the flow rate. After attaching new IV tubing, you note air bubbles in the tubing: If the bubbles are above the roller clamp, you can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with your finger so the bubbles rise to the drip chamber. If there is a larger amount of air in the tubing, swab the medication port on the tubing below the air with an antimicrobial solution and attach a syringe to the port below the air. Clamp the tubing below the access port. Aspirate the air from the tubing via the syringe. Remember that air bubbles in the tubing can be reduced if the tubing is primed slowly with fluid instead of allowing a wide-open flow of the solution. EVIDENCE FOR PRACTICE Infusion Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), S1–S92. Refer to details in Skill 15-1, Evidence for Practice. 798 UNIT II Promoting Healthy Physiologic Responses 15-3 Monitoring an IV Site and Infusion The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial patient assessment and at the beginning of a work shift. In addition, IV sites are checked at specific intervals and each time an IV medication is given, as dictated by the institution’s policies. It is common to check IV sites every hour, but it is important to be familiar with the requirements of your institution. Monitoring the infusion rate is a very important part of the patient’s overall management. If the patient does not receive the prescribed rate, he or she may experience a fluid volume deficit. In contrast, if the patient is administered too much fluid over a period of time, he or she may exhibit signs of fluid volume overload. Other responsibilities involve checking the IV site for possible complications and assessing for both the desired effects of an IV infusion as well as potential adverse reactions to IV therapy. EQUIPMENT PPE, as indicated ASSESSMENT Inspect the IV infusion solution for any particulates and check the IV label. Confirm it is the solution ordered. Assess the current rate of flow by timing the drops if it is a gravity infusion or verifying the settings on the electronic infusion device. Check the tubing for kinks or anything that might clamp or interfere with the flow of the solution. Inspect the IV site. The dressing should be intact, adhering to the skin on all edges. Assess fluid intake and output. Assess for complications associated with IV infusions. Assess the patient’s knowledge of IV therapy. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Excess Fluid Volume Risk for Infection Deficient Fluid Volume Risk for Deficient Fluid Volume Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to be met when monitoring the IV infusion and site is that the patient remains free from complications and demonstrates signs and symptoms of fluid balance. IMPLEMENTATION ACTION R AT I O N A L E 1. Verify IV solution order on the MAR/CMAR with the medical order. Clarify any inconsistencies. Check the patient’s chart for allergies. Check for color, leaking, and expiration date. Know purpose of the IV administration and medications, if ordered. This ensures that the correct IV solution and rate of infusion, and/or medication will be administered. This knowledge and skill is essential for safe and accurate IV and medication administration. 2. Monitor IV infusion every hour or per agency policy. More frequent checks may be necessary if medication is being infused. Promotes safe administration of IV fluids and medication. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do to the patient. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. 6. If an electronic infusion device is being used, check settings, alarm, and indicator lights. Check set infusion rate (Figure 1). Note position of fluid in IV container in relation to time tape. Teach patient about the alarm features on the electronic infusion device. Observation ensures that infusion control device and the alarm are functioning. Lack of knowledge about “alarms” may create anxiety for patient. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 799 Aptara 799 CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 7. If IV is infusing via gravity, check the drip chamber and time the drops (Figure 2). Refer to Box 15-1 to review calculation of IV flow rates for gravity infusion. FIGURE 1. Checking the settings of the infusion device. R AT I O N A L E This ensures that the flow rate is correct. Use a watch with a second hand for counting the drops in regulating a gravity drip IV infusion. FIGURE 2. Checking the drip chamber and timing drops. 8. Check tubing for anything that might interfere with flow (Figure 3). Be sure clamps are in the open position. Any kink or pressure on tubing may interfere with flow. 9. Observe dressing for leakage of IV solution. Leakage may occur at the connection of the tubing with the hub of the needle or the catheter and allow for loss of IV solution. 10. Inspect the site for swelling, leakage at the site, coolness, or pallor, which may indicate infiltration (Figure 4). Ask if patient is experiencing any pain or discomfort. If any of these symptoms are present, the IV will need to be removed and restarted at another site. Check facility policy for treating infiltration. See Fundamentals Review 15-3 and Box 15-2. Catheter may become dislodged from the vein, and IV solution may flow into subcutaneous tissue. FIGURE 3. Checking the tubing for anything that might interfere FIGURE 4. Inspecting IV site. with the flow rate. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 800 Aptara 800 UNIT II 15-3 Promoting Healthy Physiologic Responses Monitoring an IV Site and Infusion ACTION BOX 15-2 continued R AT I O N A L E INFILTRATION SCALE Grade and document infiltration according to the most severe presenting indicator. Grade Clinical Criteria Grade Clinical Criteria 0 1 No symptoms Skin blanched Edema 1 inch in any direction Cool to touch With or without pain Skin blanched Edema 1 to 6 inches in any direction Cool to touch With or without pain Skin blanched, translucent Gross edema 6 inches in any direction Cool to touch Mild–moderate pain Possible numbness 4 Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema 6 inches in any direction Deep pitting tissue edema Circulatory impairment Moderate–severe pain Infiltration of any amount of blood product, irritant or vesicant 2 3 (From Infusion Nurses Society.. Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), p. S60, with permission.) 11. Inspect site for redness, swelling, and heat. Palpate for induration. Ask if patient is experiencing pain. These findings may indicate phlebitis. Notify primary care provider if phlebitis is suspected. IV will need to be discontinued and restarted at another site. Check facility policy for treatment of phlebitis. Refer to Fundamentals Review 15-3 and Box 15-3. BOX 15-3 Chemical irritation or mechanical trauma causes injury to the vein and can lead to phlebitis. Phlebitis is the most common complication related to IV therapy (Lavery, 2005). PHLEBITIS SCALE Grade and document phlebitis according to the most severe presenting indicator. Grade Clinical Criteria Grade Clinical Criteria 0 1 2 No symptoms Erythema at access site with or without pain Pain at access site with erythema and/or edema Pain at access site with erythema and/or edema Streak formation Palpable venous cord 4 Pain at access site with erythema and/or edema Streak formation Palpable venous cord 1 inch in length Purulent drainage 3 (From Infusion Nurses Society.. Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), p. S59, with permission.) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 801 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 801 R AT I O N A L E 12. Check for local manifestations (redness, pus, warmth, induration, and pain) that may indicate an infection is present at the site, or systemic manifestations (chills, fever, tachycardia, hypotension) that may accompany local infection at the site. If signs of infection are present, discontinue the IV and notify the primary care provider. Be careful not to disconnect IV tubing when putting on patient’s hospital gown or assisting the patient with movement. Poor aseptic technique may allow bacteria to enter the needle, catheter insertion site, or tubing connection and may occur with manipulation of equipment. 13. Be alert for additional complications of IV therapy. a. Fluid overload can result in signs of cardiac and/or respiratory failure. Monitor intake and output and vital signs. Assess for edema and auscultate lung sounds. Ask if patient is experiencing any shortness of breath. Infusing too much IV solution results in an increased volume of circulating fluid volume. Elderly patients are most at risk for this complication due to possible decrease in cardiac and/or renal functions. b. Check for bleeding at the site. Bleeding may be caused by anticoagulant medication. Bleeding at the site is most likely to occur when the IV is discontinued. 14. If possible, instruct patient to call for assistance if any discomfort is noted at site, solution container is nearly empty, flow has changed in any way, or if the electronic pump alarm sounds. EVALUATION This facilitates patient cooperation and safe administration of IV solution. The expected outcome is achieved when the patient remains free of injury (specifically, complications related to IV therapy), exhibits patent IV site, and the IV solution infuses at the prescribed flow rate. DOCUMENTATION Guidelines Sample Documentation Document the type of IV solution as well as the infusion rate. Note the insertion site location and site assessment. Document the patient’s reaction to the IV therapy as well as the absence of subjective reports that he/she is not experiencing any pain or other discomfort, such as coolness or heat associated with the infusion. Additionally, record that the patient is not demonstrating any other IV complications, such as signs or symptoms of fluid overload. Record on the intake and output documents, as needed. 11/6/12 1020 IV site right forearm/cephalic vein intact without swelling, redness, or drainage. D5 0.9% NS with 20 mEq KCl continues to infuse at 110 mL/hour. Patient instructed to call nurse with any swelling or pain. —S. Barnes, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient’s lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify primary care provider immediately. The patient may be exhibiting signs of fluid overload. Be prepared to tell the healthcare provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the patient. IV is not flowing as easily as it previously had been: Check all clamps on the tubing and check tubing for any kinking. Check that the patient is not lying on the tubing. If the IV is over a joint, reposition the extremity and see if this helps the flow. An arm board may need to be applied. Attempt to flush the IV with 2 to 3 mL of normal saline. If the IV is painful or you meet resistance when attempting to flush, discontinue the IV and restart in another place. EVIDENCE FOR PRACTICE Infusion Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), S1–S92. Refer to details in Skill 15-1, Evidence for Practice. 802 UNIT II Promoting Healthy Physiologic Responses 15-4 Changing a Peripheral Venous Access Dressing The IV site is a potential entry point for microorganisms into the bloodstream. To prevent this, sealed IV dressings are used to occlude the site and prevent complications. Whenever these dressings need to be changed, it is important to observe meticulous aseptic technique to minimize the possibility of contamination. The particular facility’s policies determine the type of dressing used and when these dressings are changed. Peripheral venous access site dressing changes often coincide with site rotations. However, dressing changes might be required more often, based on nursing assessment and judgment. Any access site dressing that is damp, loosened, or soiled should be changed immediately. EQUIPMENT ASSESSMENT Assess IV site. Note any drainage, redness, leakage, or other indications that the dressing needs to be changed. Note the insertion date and date of last dressing change, if different from insertion date. Also assess the patient’s need to maintain venous access. If patient does not need the access, discuss the possibility of discontinuation with the primary care provider. Ask the patient about any allergies. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when changing an peripheral venous access dressing is that the patient will exhibit an access site that is clean, dry, and without evidence of any signs and symptoms of infection, infiltration, or phlebitis. In addition, the dressing will be clean, dry, and intact and the patient will not experience injury. Transparent occlusive dressing 2% chlorhexidine, povidone-iodine, 70% alcohol Adhesive remover (optional) Alcohol swabs Tape Clean gloves Towel or disposable pad Masks for nurse and patient; sterile gloves (used for catheter with extended dwell time or if patient is immunocompromised [INS, 2006, p. S57]) Additional PPE, as indicated IMPLEMENTATION ACTION 1. Determine the need for a dressing change. Check facility policy. Gather all equipment and bring to bedside. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. R AT I O N A L E The particular facility’s policies determine the type of dressing used and when these dressings are changed. Dressing changes might be required more often, based on nursing assessment and judgment. Immediately change any access site dressing that is damp, loosened, or soiled. Having equipment available saves time and facilitates accomplishment of procedure. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 803 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 803 R AT I O N A L E 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about allergies to tape and skin antiseptics. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Possible allergies may exist related to tape or antiseptics. 5. Put on mask and place a mask on patient, if indicated. Put on gloves. Place towel or disposable pad under the arm with the venous access. If solution is currently infusing, temporarily stop the infusion. Hold the catheter in place with your nondominant hand and carefully remove old dressing and/or stabilization/securing device (Figure 1). Use adhesive remover as necessary. Discard dressing. Masks should be used for catheter with extended dwell time or if patient is immunocompromised (INS, 2006, p. S57). Gloves prevent contact with blood and body fluids. Pad protects underlying surface. Proper disposal of dressing prevents transmission of microorganisms. 6. Inspect IV site for presence of phlebitis (inflammation), infection, or infiltration. Discontinue and relocate IV, if noted. Refer to Fundamentals Review 15-3, Box 15-2, and Box 15-3. Inflammation (phlebitis), infection, or infiltration causes trauma to tissues and necessitates removal of the venous access device. 7. Cleanse site with an antiseptic solution such as chlorhexidine or according to facility policy. Press applicator against the skin and apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow to dry completely. Scrubbing motion and length of time (minimum 30 seconds) is necessary for chlorhexidine to be effective (ICT, 2005). Organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Chlorhexidine is the preferred antiseptic solution, but iodine, povidone-iodine, and 70% alcohol are considered acceptable alternatives (INS, 2006). 8. Open the skin protectant wipe. Apply the skin protectant to the site, making sure to cover at minimum the area to be covered with the dressing (Figure 2). Allow to dry. Place sterile transparent dressing or catheter securing/stabilization device over venipuncture site (Figure 3). Skin protectant aids in adhesion of the dressing and decreases the risk for skin trauma when the dressing is removed. Transparent dressing allows easy visualization and protects the site. Stabilization/securing devices preserve the integrity of the access device and prevent catheter migration and loss of access (INS, 2006, p. S44). Some stabilization devices act as a site dressing also. FIGURE 1. Carefully removing old dressing. 9. Label dressing with date, time of change, and initials. Loop the tubing near the entry site, and anchor with tape (nonallergenic) close to site (Figure 4). Resume fluid infusion, if indicated. Check that IV flow is accurate and system is patent. Refer to Skill 15-3. 10. Remove equipment. Ensure patient’s comfort. Remove gloves. Lower bed, if not in lowest position. FIGURE 2. Applying skin protectant to site. Labeling helps ensure communication about venous access site dressing change. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. Promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 804 Aptara 804 UNIT II 15-4 Promoting Healthy Physiologic Responses Changing a Peripheral Venous Access Dressing ACTION R AT I O N A L E FIGURE 3. Applying transparent dressing to site. 11. Remove additional PPE, if used. Perform hand hygiene. EVALUATION continued FIGURE 4. Site dressing with label and anchored tubing. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. The expected outcome is met when the patient remains free of any signs and symptoms of infection, phlebitis, or infiltration at the venous access site. In addition, the access site dressing is clean, dry, and intact; and the patient has not experienced injury. DOCUMENTATION Guidelines Sample Documentation Document the location of the venous access as well as the condition of the site. Include the presence or absence of signs of erythema, redness, swelling, or drainage. Document the clinical criteria for site complications. Refer to Fundamentals Review 15-3, Box 15-2, and Box 15-3. Record the subjective comments of the patient regarding the absence or presence of pain at the site. Record the patient’s reaction to the procedure and pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from the IV or notices any swelling at the site. 11/15/12 1120 Dressing change to IV site in L hand (dorsal metacarpal) complete. Site without erythema, redness, edema, or drainage. D5 NS infusing at 75 mL/hour. Patient instructed to call nurse with any pain, swelling, or questions. —S. Barnes, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient complains that IV site feels “funny” and hurts: Observe venous access site for redness, edema, and warmth. If present, clamp the tubing to stop the IV solution flow, remove the catheter, and apply a gauze dressing. Initiate a new venous access in a different site. Record site assessment and interventions, as well as site for new venous access. SPECIAL CONSIDERATIONS Infant and Child Considerations For neonates, isopropyl alcohol or products containing isopropyl alcohol are not recommended for access site preparation. Povidone-iodine or chlorhexidine solution is recommended but requires complete removal after the preparatory procedure with sterile water or sterile saline to prevent product absorption (INS, 2006, p. S42). Chlorhexidine has been associated with contact dermatitis when used for infants weighing less than 1000 g. It should be used with caution with this patient population (INS, 2006). EVIDENCE FOR PRACTICE Infusion Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), S1-S92. Refer to details in Skill 15-1, Evidence for Practice. CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance 15-5 805 Capping for Intermittent Use and Flushing a Peripheral Venous Access Device When the continuous infusion of an IV solution is no longer necessary, it is often converted to an access point for intermittent or emergency use. A capped line consists of the IV catheter connected to a short length of extension tubing sealed with a cap. This can be accomplished in different ways. Refer to facility policy for the procedure to convert to an access for intermittent use. Intermittent peripheral venous access devices are flushed at periodic intervals with normal saline to keep the IV catheter patent and to prevent clots from forming in the catheter. Flushing with normal saline solution is generally done at least every 12 hours and before and after administering an IV medication. Refer to facility policy for specific guidelines. The following skill describes converting a primary line when extension tubing is present; the accompanying skill variation describes converting a primary line when the administration set is connected directly to the hub of the IV catheter, without extension tubing. EQUIPMENT ASSESSMENT Assess insertion site for signs of any IV complications. Refer to Fundamentals Review 15-3, Box 15-2, and Box 15-3. Verify the medical order for discontinuation of IV fluid infusion. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when converting a primary peripheral IV line is that the patient will remain free of injury and any signs and symptoms of IV complications. In addition, the capped venous access device will remain patent. End cap device Clean gloves Additional PPE, as indicated 4  4 gauze pad Normal saline flush prepared in a syringe (1 to 3 mL) according to facility policy Antimicrobial wipe Tape IMPLEMENTATION ACTION 1. Determine the need for conversion to an intermittent access. Verify medical order. Check facility policy. Gather all equipment and bring to bedside. R AT I O N A L E Ensures correct intervention for correct patient. Having equipment available saves time and facilitates accomplishment of procedure. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about allergies to tape and skin antiseptics. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Possible allergies may exist related to tape or antiseptics. 5. Assess the IV site. Refer to Skill 15-3. Complications, such as infiltration, phlebitis, or infection, necessitate discontinuation of the IV infusion at that site. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 806 Aptara 806 UNIT II 15-5 Promoting Healthy Physiologic Responses Capping for Intermittent Use and Flushing a Peripheral Venous Access Device continued ACTION R AT I O N A L E 6. If using an electronic infusion device, stop the device (Figure 1). Close the roller clamp on the administration set. If using gravity infusion, close the roller clamp on the administration set. The action of the infusion device needs to be stopped and clamps closed to prevent leaking of fluid when tubing is disconnected. 7. Put on gloves. Close the clamp on the short extension tubing connected to the IV catheter in the patient’s arm. Clamping the tubing on the extension set prevents introduction of air into the extension tubing. 8. Remove the administration set tubing from the extension set. Cleanse the end cap with an antimicrobial swab. Removing the infusion tubing discontinues the infusion. Cleaning the cap reduces the risk for contamination. 9. Insert the saline flush syringe into the cap on the extension tubing. Pull back on the syringe to aspirate the catheter for positive blood return. If positive, instill the solution over 1 minute or flush the line according to facility policy (Figure 2). Remove syringe and reclamp the extension tubing. Positive blood return confirms patency before administration of medications and solutions (INS, 2006, p. S56). Flushing maintains patency of the IV line. Action of positive pressure end cap is maintained with removal of syringe before clamp is engaged. Clamping prevents air from entering the extension set. FIGURE 1. Stopping IV fluid infusion. FIGURE 2. Flushing venous access device. 10. If necessary, loop the extension tubing near the entry site and anchor it with tape (nonallergenic) close to site. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. 11. Remove equipment. Ensure patient’s comfort. Remove gloves. Lower bed, if not in lowest position. Promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. 12. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. The expected outcome is met when the peripheral venous access device flushes without resistance; the patient exhibits an access site that is intact, free of the signs and symptoms of infection, phlebitis, or infiltration; and the site dressing is clean, dry, and intact. DOCUMENTATION Guidelines Document discontinuation of IV fluid infusion. Record the condition of the venous access site. Document the flushing of the venous access device. This is often done in the MAR. Record the patient’s reaction to the procedure and any patient teaching that has occurred. 807 CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Peripheral venous access site leaks fluid when flushed: To prevent infection and other complications, remove from site and restart in another location. IV does not flush easily: Assess insertion site. Infiltration and/or phlebitis may be present. If present, remove and restart in another location. In addition, the catheter may be blocked or clotted due to a kinked catheter at the insertion site. Aspirate and attempt to flush again. If resistance remains, do not force. Forceful flushing can dislodge a clot at the end of the catheter. Remove and restart in another location. If assessment reveals the catheter has pulled out a short distance, do not reinsert it; it is no longer sterile. Remove and restart in another location. SPECIAL CONSIDERATIONS Some facilities may use end caps for venous access devices that are not positive pressure devices. In this case, flush with the recommended volume of saline, ending with 0.5 mL of solution remaining in the syringe. While maintaining pressure on the syringe, clamp the extension tubing. This provides positive pressure, preventing backflow of blood into the catheter, decreasing risk for occlusion. Skill Variation Capping a Primary Line When No Extension Tube is in Place It is good practice to add a short extension tubing to decrease the risk of contact with blood, and for infection-control purposes if one was not placed during initiation of the peripheral venous access. After checking the medical order to convert the peripheral venous access, the nurse brings the end cap and the extension tubing to the bedside, as well as other required equipment. 1. Gather equipment and verify medical order. 2. Perform hand hygiene. 8. Put on gloves. 9. Place gauze 4  4-inch sponge underneath IV connection hub, between IV catheter and tubing. 10. Stabilize hub of IV catheter with nondominant hand. Use dominant hand to quickly twist and disconnect IV tubing from the catheter. Discard it. Attach the extension tubing to the IV catheter hub using aseptic technique. 11. Cleanse cap with an antimicrobial solution. 12. Insert the syringe into the cap and gently flush with saline per facility policy. Remove syringe. Engage slide clamp on extension tubing. 3. Put on PPE, as indicated. 13. Remove gloves. 4. Identify the patient. 14. Loop the extension tubing near the entry site and anchor with tape (nonallergenic) close to the site. 15. Ensure that the patient is comfortable. Perform hand hygiene. 5. Explain the procedure to the patient. 6. Fill the cap and extension tubing with normal saline. 7. Assess IV site. EVIDENCE FOR PRACTICE 15-6 16. Chart on IV administration record, MAR, or CMAR, per institutional policy. Infusion Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), S1–S92. Refer to details in Skill 15-1, Evidence for Practice. Administering a Blood Transfusion A blood transfusion is the infusion of whole blood or a blood component, such as plasma, red blood cells, or platelets, into a patient’s venous circulation (Table 15-1). Before a patient can receive a blood product, his or her blood must be typed to ensure that he or she receives compatible blood. Otherwise, a serious and life-threatening transfusion reaction may occur involving clumping and hemolysis of the red blood cells and, possibly, death (Table 15-2). The nurse must also verify the infusion rate, based on facility policy or medical order. Follow the facility’s policies and guidelines to determine if the transfusion should be administered by electronic pump or by gravity. Refer to Box 15-1 for guidelines to calculate flow rate for gravity infusion. (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 808 Aptara 808 UNIT II Promoting Healthy Physiologic Responses 15-6 T A B L E 15-1 Administering a Blood Transfusion continued BLOOD PRODUCTS ABO Compatibility Double-Checked by Two People 1 unit over 2–3 hours; no longer than 4 hours Yes Yes Yes (in tubing provided) As fast as patient can tolerate No Yes Cryoprecipitate No IV push over 3 minutes Recommended Yes Fresh-frozen plasma No 200 mL/hr Yes Yes Albumin In tubing provided 1–10 mL/min (5%) 0.2–0.4 mL/min (25%) No No Blood Product Filter Rate of Administration Packed red blood cells Yes Platelets T A B L E 15-2 TRANSFUSION REACTIONS Reaction Signs and Symptoms Allergic reaction: allergy to transfused blood Hives, itching Anaphylaxis Stop transfusion immediately and keep vein open with normal saline. Notify physician stat. Administer antihistamine parenterally, as necessary. Febrile reaction: fever develops during infusion Fever and chills Headache Malaise Stop transfusion immediately and keep vein open with normal saline. Notify physician. Treat symptoms. Hemolytic transfusion reaction: incompatibility of blood product Immediate onset Facial flushing Fever, chills Headache Low back pain Shock Stop infusion immediately and keep vein open with normal saline. Notify physician stat. Obtain blood samples from site. Obtain first voided urine. Treat shock if present. Send unit, tubing, and filter to lab. Draw blood sample for serologic testing and send urine specimen to the lab. Circulatory overload: too much blood administered Dyspnea Dry cough Pulmonary edema Bacterial reaction: bacteria present in blood Fever Hypertension Dry, flushed skin Abdominal pain Stop infusion immediately. Obtain culture of patient’s blood and return blood bag to lab. Monitor vital signs. Notify physician. Administer antibiotics stat. Nursing Activity Slow or stop infusion. Monitor vital signs. Notify physician. Place in upright position with feet dependent. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 809 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance 809 EQUIPMENT ASSESSMENT Obtain a baseline assessment of the patient, including vital signs, heart and lung sounds, and urinary output. Review the most recent laboratory values, in particular, the complete blood count (CBC). Ask the patient about any previous transfusions, including the number he or she has had and any reactions experienced during a transfusion. Inspect the IV insertion site, noting that the gauge of the IV catheter is a 20 gauge or larger. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Injury Excess Fluid Volume Deficient Fluid Volume Ineffective Peripheral Tissue Perfusion Decreased Cardiac Output OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when administering a blood transfusion is that the patient will remain free of injury and any signs and symptoms of IV complications. In a ddition, the capped venous access device will remain patent. Blood product Blood administration set (tubing with in-line filter and Y for saline administration) 0.9% normal saline for IV infusion IV pole Venous access; if peripheral site, preferably initiated with a 20-gauge catheter or larger Clean gloves Additional PPE, as indicated Tape (hypoallergenic) Second nurse to verify blood product and patient information IMPLEMENTATION ACTION R AT I O N A L E 1. Verify the medical order for transfusion of a blood product. Verify the completion of informed consent documentation in the medical record. Verify any medical order for pretransfusion medication. If ordered, administer medication at least 30 minutes before initiating transfusion. Verification of order ensures the patient receives the correct intervention. Premedication is sometimes administered to decrease the risk for allergic and febrile reactions for patients who have received multiple previous transfusions. 2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about previous experience with transfusion and any reactions. Advise patient to report any chills, itching, rash, or unusual symptoms. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Previous reactions may increase the risk for reaction to this transfusion. Any reaction to the transfusion necessitates stopping the transfusion immediately and evaluating the situation. 6. Prime blood administration set with the normal saline IV fluid. Refer to Skill 15-2. Normal saline is the solution of choice for blood product administration. Solutions with dextrose may lead to clumping of red blood cells and hemolysis. 7. Put on gloves. If patient does not have a venous access in place, initiate peripheral venous access. (Refer to Skill 15-1.) Connect the administration set to the venous access device via Gloves prevent contact with blood and body fluids. Infusion of fluid via venous access maintains patency until the blood product is administered. Start an IV before obtaining the blood product in (continued) LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 810 Aptara 810 UNIT II 15-6 Promoting Healthy Physiologic Responses Administering a Blood Transfusion ACTION the extension tubing. (Refer to Skill 15-1.) Infuse the normal saline per facility policy. continued R AT I O N A L E case the initiation takes longer than 30 minutes. Blood must be stored at a carefully controlled temperature (4C) and transfusion must begin within 30 minutes of release from blood bank. 8. Obtain blood product from blood bank according to agency policy. Scan for bar codes on blood products if required. Bar codes on blood products are currently being implemented in some agencies to identify, track, and assign data to transfusions as an additional safety measure. 9. Two nurses compare and validate the following information with the medical record, patient identification band, and the label of the blood product: Medical order for transfusion of blood product Informed consent Patient identification number Patient name Blood group and type Expiration date Inspection of blood product for clots Most states/agencies require two registered nurses to verify the following information: unit numbers match; ABO group and Rh type are the same; expiration date (after 35 days, red blood cells begin to deteriorate). Blood is never administered to a patient without an identification band. If clots are present, return blood to the blood bank. 10. Obtain baseline set of vital signs before beginning transfusion. Any change in vital signs during the transfusion may indicate a reaction. 11. Put on gloves. If using an electronic infusion device, put the device on “hold.” Close the roller clamp closest to the drip chamber on the saline side of the administration set. Close the roller clamp on the administration set below the infusion device. Alternately, if using infusing via gravity, close the roller clamp on the administration set. Gloves prevent contact with blood and body fluids. Stopping the infusion prevents blood from infusing to the patient before completion of preparations. Closing the clamp to saline allows blood product to be infused via electronic infusion device. 12. Close the roller clamp closest to the drip chamber on the blood product side of the administration set. Remove the protective cap from the access port on the blood container. Remove the cap from the access spike on the administration set. Using a pushing and twisting motion, insert the spike into the access port on the blood container, taking care not to contaminate the spike. Hang blood container on the IV pole. Open the roller clamp on the blood side of the administration set. Squeeze drip chamber until the in-line filter is saturated (Figure 1). Remove gloves. Filling the drip chamber prevents air from entering the administration set. The filter in the blood administration set removes particulate material formed during storage of blood. If the administration set becomes contaminated, the entire set would have to be discarded and replaced. 13. Start administration slowly (no more than 25 to 50 mL for the first 15 minutes). Stay with the patient for the first 5 to 15 minutes of transfusion. Open the roller clamp on the administration set below the infusion device. Set the rate of flow and begin the transfusion. Alternately, start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the blood and function of the infusion device. Inspect the insertion site for signs of infiltration. Transfusion reactions typically occur during this period, and a slow rate will minimize the volume of red blood cells infused. Verifying the rate and device settings ensures patient receives correct volume of solution. If the catheter or needle slips out of the vein, the blood will accumulate (infiltrate) into the surrounding tissue. 14. Observe patient for flushing, dyspnea, itching, hives or rash, or any unusual comments. These signs and symptoms may be an early indication of a transfusion reaction. 15. After the observation period (5 to 15 minutes) increase the infusion rate to the calculated rate to complete the infusion within the prescribed time frame, no more than 4 hours. If no adverse effects occurred during this time, the infusion rate is increased. If complications occur, they can be observed and the transfusion can be stopped immediately. Verifying the rate and device settings ensures patient receives correct volume of solution. Transfusion must be completed within 4 hours due to potential for bacterial growth in blood product at room temperature. 16. Reassess vital signs after 15 minutes (Figure 2). Obtain vital signs thereafter according to facility policy and nursing assessment. Vital signs must be assessed as part of monitoring for possible adverse reaction. Facility policy and nursing judgment will dictate frequency. LWBK545_C15_p779-829.qxd 8/6/10 10:35 PM Page 811 Aptara CHAPTER 15 Fluid, Electrolyte, and Acid–Base Balance ACTION 811 R AT I O N A L E FIGURE 1. Starting transfusion slowly. FIGURE 2. Assessing vital signs after 15 minutes. 17. Maintain the prescribed flow rate as ordered or as deemed appropriate based on the patient’s overall condition, keeping in mind the outer limits for safe administration. Ongoing monitoring is crucial throughout the entire duration of the blood transfusion for early identification of any adverse reactions. Rate must be carefully controlled, and patient’s reaction must be monitored frequently. 18. During transfusion, assess frequently for transfusion reaction. Stop blood transfusion if you suspect a reaction. Quickly replace the blood tubing with a new administration set primed with normal saline for IV infusion. Initiate an infusion of normal saline for IV at an open rate, usually 40 mL/hour. Obtain vital signs. Notify physician and blood bank. If a transfusion reaction is suspected, the blood must be stopped. Do not infuse the normal saline through the blood tubing because you would be allowing more of the blood into the patient’s body, which could complicate a reaction. Besides a serious life-threatening blood transfusion reaction, the potential for fluid–volume overload exists in elderly patients and patients with decreased cardiac function. 19. When transfusion is complete, close roller clamp on blood side of the administration set and open the roller clamp on the normal saline side of the administration set. Initiate infusion of normal saline. When all of blood has infused into the patient, clamp the administration set. Obtain vital signs. Put on gloves. Cap access site or resume previous IV infusion. (Refer to Skill 15-1 and Skill 15-5.) Dispose of blood-transfusion equipment or return to blood bank, according to facility policy. Saline prevents hemolysis of red blood cells and clears remainder of blood in IV line. Proper disposal of equipment reduces transmission of microorganisms and potential contact with blood and body fluids. 20. Remove equipment. Ensure patient’s comfort. Remove gloves. Lower bed, if not in lowest position. Promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. 21. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene pre