MS CH 7 Nursing Care of Patients Receiving Intravenous Therapy.pdf

4068_Ch07_090-110 15/11/14 12:45 PM Page 90 7 KEY TERMS cannula (KAN-yoo-lah) extravasation (eks-TRAH-vah-ZAY-shun) hematoma (HEE-muh-TOH-mah) infiltration (in-fil-TRAY-shun) intravenous (IN-trah-VEE-nuss) macrodrop (MACK-roh-DROP) microdrop (MIKE-roh-DROP) parenteral (pah-REN-ter-ul) phlebitis (fl...

4068_Ch07_090-110 15/11/14 12:45 PM Page 90 7 KEY TERMS cannula (KAN-yoo-lah) extravasation (eks-TRAH-vah-ZAY-shun) hematoma (HEE-muh-TOH-mah) infiltration (in-fil-TRAY-shun) intravenous (IN-trah-VEE-nuss) macrodrop (MACK-roh-DROP) microdrop (MIKE-roh-DROP) parenteral (pah-REN-ter-ul) phlebitis (fla-BYE-tis) 90 Nursing Care of Patients Receiving Intravenous Therapy LYNN D. PHILLIPS AND DEB RICHARDSON LEARNING OUTCOMES 1. Discuss how the practice of intravenous (IV) therapy is regulated. 2. List indications for IV therapy. 3. Identify common veins used for peripheral IV (PIV) therapy. 4. Describe factors that influence the condition, size, and long-term use of veins. 5. List the steps in the procedure for inserting an IV cannula. 6. Describe methods for locating and/or visualizing difficult veins. 7. Plan nursing interventions to prevent IV therapy complications. 8. Identify common complications associated with IV therapy. 9. Calculate flow and drip rates for IV solutions. 10. Differentiate characteristics of isotonic, hypertonic, and hypotonic solutions. 11. Explain the differences between peripheral and central venous access devices. 12. Describe various types of central venous access devices. 4068_Ch07_090-110 15/11/14 12:45 PM Page 91 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Mrs. Brown, 85 years old, is admitted to the hospital with weight loss of 6% of her total body weight due to gastr oenteritis and diarrhea. Her blood pr essure is 102/80, pulse is 96 beats per minute, and respirations are 14 per minute. Her physical assessment shows decreased skin turgor over the sternum; dry, cracked lips; and a weak, thr eady pulse. The health care provider (HCP) has ordered an IV of 5% dextrose and 0.45% sodium chloride to be started at 100 mL per hour. As you read this chapter, reflect on the challenges of fluid volume deficit in older adults and initiation of infusion therapy. Intravenous (IV) therapy is the administration of fluids or medication via a needle or catheter (also called acannula) directly into the bloodstream. Each state’ s nurse practice act governs the practice of IV therap y in that state. Some states’ nurse practice acts now include IV therapy within the licensed practical nurse/licensed vocational nurse (LPN/LVN) role. Various national and specialty organizations have established and published guidelines or standards of practice related to infusion therapy. The Infusion Nurses Society (INS, www .ins1.org) is recognized as a global authority in infusion nursing and publishes standards of practice for infusion therap y. The INS (2011) standards of practice address the infusion-related scope of practice for LPNs and LVNs. The Centers for Disease Control and Prevention (CDC, www.cdc.gov, 2002) provides guidelines for isolation precautions, hand hygiene, and prevention of intravascular catheter-related infections. The Institute for Healthcare Improvement (IHI, www.ihi.org) provides information related to central line care. The National Institute for Occupational Safety and Health (NIOSH, www.cdc.gov/NIOSH) oversees workplace safety, including safety issues related to IV therapy, and the American Society for Parenteral and Enteral Nutrition (ASPEN, www.nutritioncare.org) provides resources related to IV nutrition. LEARNING TIP National organizations provide guidelines, but you must follow your state Nurse Practice Act to decide which of those guidelines apply to you! INDICATIONS FOR INTRAVENOUS THERAPY A variety of substances can be administered via IV therap y, including fluids, electrolytes, nutrients, blood products, and medications. The solutions and/or medications can be given as a continuous or intermittent infusion (see “Types of Infusions”). Why do patients receive IV therapy? Many medications are faster acting and more effective when given via the IV route. The IV route also allows rapid delivery of medication in an emergency. Other medications can be administered continuously via IV to maintain a therapeutic blood le vel. Patients with anemia or blood loss can recei ve lifesaving IV blood transfusions. P atients can receive life-sustaining 91 fluids, electrolytes, and nutrition via an IV when the y are unable to eat or drink adequate amounts. Patients who are unable to eat for an e xtended period can have their nutritional needs met with peripheral parenteral nutrition (PPN) or total parenteral nutrition (TPN). The term parenteral refers to any medication route other than the digestive tract. When a patient needs intermittent rather than continuous IV therapy, access to the bloodstream can be pro vided by a short peripheral vascular access device, sometimes called a saline lock, in which an IV cannula is inserted and covered with a sterile needleless cap or valve that seals after each use. (See “Intermittent Infusion” later in this chapter.) This provides access to the bloodstream for the prescribed intermittent or emer gency medications, without the need for a continuous fluid infusion. TYPES OF INFUSIONS There are four primary administration modes for IV medications: (1) continuous, (2) intermittent, (3) direct injection, and (4) patient-controlled analgesia. Continuous Infusion A continuous infusion is a large-volume infusion of solution or medications (typically 250 to 1000 mL) administered over 2 to 24 hours. For a continuous infusion, the prescriber orders the infusion in milliliters to be deli vered over a specif ic amount of time, such as 100 mL per hour or 1000 mL o ver 8 hours. The infusion is k ept running at the prescribed rate until ordered to be discontinued. BE SAFE! BE VIGILANT! Always verify that orders are complete and understandable. If you have any questions, contact the RN, prescriber, or pharmacist. Continuous infusions are used when a medication must be highly diluted, a constant plasma concentration of a drug must be maintained, or a lar ge volume of fluids and electrolytes must be administered. Rate control is important in the delivery of continuous infusions and can be achieved by using an electronic infusion de vice (EID), mechanical controller, or roller clamp. Intermittent Infusion Primary Intermittent Infusion These medications/solutions are delivered using a primary intermittent administration set that is connected and disconnected with each use. • WORD • BUILDING • intravenous: intra—within + venous—vein cannula: tube or sheath parenteral: para—beside + enteral—intestines 4068_Ch07_090-110 15/11/14 12:45 PM Page 92 92 UNIT TWO Understanding Health and Illness BE SAFE! BE SAFE! BE VIGILANT! Each time the primary intermittent set is disconnected the tip of the tubing must be kept sterile using a sterile end cap. The intermittent needle is flushed with saline or heparin to keep it patent while it is not in use. BE VIGILANT! The medication in the piggyback must be compatible with any other solution that is in the primary IV tubing. (Check with your pharmacy for compatibilities.) NEEDLELESS CONNECTORS. Needleless connectors are de- Piggyback/Secondary Infusion Some IV medications, such as antibiotics, need to be infused over a short period of time. F or example, an antibiotic may be mixed with 50 mL of 5% dextrose or 0.9% sodium chloride solution and infused over 30 minutes. This is often done as an intermittent infusion. As with any IV therapy, the prescriber orders must specify route, drug, dose, and amount to be infused over a specified time. If the patient already has a primary continuous IV infusing, the antibiotic (secondary) infusion can be “piggybacked” into the primary IV line. This piggyback set is left attached to the primary administration set. For the piggyback medication to infuse, it must hang higher than the primary infusion (Fig. 7.1). Piggyback medications can be infused using a mechanical controller , roller clamp, or an electronic infusion device. vices that allow connection to IV catheters (such as piggybacking into a primary IV line), administration sets, and syringes without using a needle. They are important for avoiding needle stick injuries in nurses. Needleless connector is the current recommended terminology by the INS (2011) and best describes all such devices. Other terms are used as well, such as injection cap, port, or injection valve. The hub or e xtension set of a peripheral cannula that is covered with a needleless connector is sometimes called a saline lock (Fig. 7.2). Intermittent IV lines can be “capped off” with a needleless connector; this mak es them available for intermittent or emergency access. In addition, because the needleless connector does not ha ve to be remo ved to allow access, a sterile closed infusion system is maintained. Intermittent infusions are small v olumes of fluid or medication administered over 15 minutes to 2 hours by IV push or infusion through the needleless connector. Piggyback container BE SAFE! BE VIGILANT! SCRUB THE HUB for 10 to 15 seconds using friction before EACH access to prevent infection! Primary infusion container Clamp The patency (unobstructed flow) of an intermittent cannula must be maintained by flushing at periodic intervals based on institution flushing policy and procedure. Always check for patency of an intermittent de vice before administering a Clamp Check valve FIGURE 7.1 Gravity drip setup with piggyback infusion. FIGURE 7.2 Peripheral IV with needleless connector attached to extension tubing. (Courtesy of Deb Richardson & Associates.) 4068_Ch07_090-110 15/11/14 12:45 PM Page 93 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy medication. Do this by first scrubbing the hub; attach the syringe and draw back to check for backflow of blood; if blood is seen in the syringe, the needle is patent. Once patenc y is confirmed, flush with normal saline (0.9% sodium chloride). To maintain patency of a cannula, flush the cannula after each use, or every 12 hours if not in use or according to institution policy. In addition to ensuring patenc y, flushing with saline also prevents the mixing of incompatible medications and solutions. The INS recommends the use of sodium chloride for maintaining peripheral intermittent de vices, whereas heparin, an anticoagulant, is recommended for flushing central venous access devices (CVADs). Remember that heparin is a medication and may be incompatible with other medications. Check your institution’s policy for specific guidelines. Positive pressure must be maintained in the lumen of the cannula during the administration of the flush solution to prevent a backflow of blood into the cannula lumen, which could lead to occlusion of the lumen with a blood clot.The technique to maintain positive pressure is based on the type of needleless connector that is being used (Hadaway & Richardson, 2010): • Negative fluid displacement—flush, clamp, then disconnect • Positive fluid displacement—flush, disconnect, then clamp • Neutral—no clamping technique required 93 referred to as a bolus, which means “all at once.” IVP provides a rapid effect because it is delivered directly into the patient’s bloodstream. IV push drugs can be dangerous if they are given incorrectly, and a drug reference should al ways be checked to determine the safe amount of time over which the drug can be injected. IVP drugs are usually administered by RNs and are not within the scope of practice of the LPN/LVN in some states. However, you should be aware of the drugs being given so you can assist in observing the patient for desired or adverse effects. Patient-Controlled Analgesia (PCA) PCA is used to deliver analgesic or pain medications. An electronic infusion device (EID) or pump is used to deli ver the analgesic drug. The EID is programmed to administer the prescribed amount to the patient when the patient presses a b utton. PCA administrations are usually done by RNs and may not be within the scope of practice for LPN/LVN. Verify with the state nurse practice act to determine whether PCA administration is within the LPN/LVN scope of practice. Again, you should be aware of the drugs being given so you can assist in observing the patient for desired or adverse effects. METHODS OF INFUSION Gravity Drip BE SAFE! BE VIGILANT! Always be aware of the type of needleless connector you are using, as well as manufacturer guidelines for its use. If resistance is met while a cannula is being flushed, a clot may be occluding the cannula. Do not e xert pressure on the syringe plunger in an attempt to restore patenc y because doing so may dislodge the clot into the v ascular system or rupture the cannula. Gravity can be used to administer a solution into a vein (see Fig. 7.1). The solution is positioned about 3 feet abo ve the infusion site. If it is positioned too high above the patient, the infusion may run too f ast. If positioned too lo w, it may run too slowly. Flow is controlled with a roller , screw, or slide clamp. A mechanical flow device can be added to achie ve accurate delivery of fluid with minimal deviation. Calculating Administration Rates Note: Some states require that registered nurses (RNs) administer medications given by the IV route; be sure to check your state’s nurse practice act re garding the role of the LVN/LPN in administering IV therapy. When using a gravity set, you must calculate the infusion rate and/or the drops (i.e., gtt, L. guttae) required per minute to deliver fluid at the ordered rate. Commercial parenteral administration sets vary in the number of drops delivering 1 mL of fluid. Sets typically deliver 10, 15, 20, or 60 drops per milliliter of fluid. For example, to deliver 100 mL per hour using a set with 10-drop factor tubing, a flow rate of 17 drops per minute is needed. To administer the same amount using a set with 15-drop factor tubing, a flow rate of 25 drops per minute is needed. Check the label on the administration set to determine how many drops per milliliter (drop factor) are delivered by the set. Sets deli vering 10, 15, or 20 drops per milliliter are called macrodrop sets and are used for fluids that need to be infused more quickly. Sets delivering 60 drops per milliliter are called microdrop or minidrop sets and are used for solutions that need to be infused more slowly. To determine drops per minute for IV solution delivery, the nurse needs to know the amount of fluid to be given in a specified time interval and the drop factor of the administration set Direct Injection/IV Push • WORD • BUILDING • BE SAFE! BE VIGILANT! Always check for cannula patency and follow manufacturer’s guidelines for use before injecting any substance into the circulatory system. Forced flushing could cause a clot to dislodge from the cannula into the patient’s circulatory system. An IV push, IVP , or direct injection medication is injected slowly via a syringe into an IV site or port. It is sometimes macrodrop: macro—large + drop microdrop: micro—small + drop 4068_Ch07_090-110 15/11/14 12:45 PM Page 94 94 UNIT TWO Understanding Health and Illness to be used. The formula for determining drops per minute is as follows: mL 1 hr gtt = gtt per minute hr or hrs 60 min 1 mL LEARNING TIP Always round to the nearest whole number when calculating drops per minute. You can’t deliver a fraction of a drop! The formula for determining milliliters per hour is as follows: Total # of mL = mL per hour Total number of hr SAMPLE PROBLEMS. Order: 125 mL of 5% de xtrose and 0.45% sodium chloride per hour Drop factor: 15 gtt/mL 125 mL 1 hr 15 gtt = 31 gtt per minute 1 hr 60 min 1 mL Order: Normal saline 1000 mL over 8 hours HEIGHT OF THE SOLUTION. Because infusions flow by gravity, a change in the height of the infusion bag or bottle or a change in the level of the bed can increase or decrease the flow rate. The flow rate increases as the distance between the solution and the patient increases. A patient may inadv ertently alter the flow rate greatly simply by standing up. The ideal height for a solution is 3 feet abo ve the level of the patient’s heart. PATENCY OF THE CANNULA. A small clot or f ibrin sheath can occlude the cannula lumen and decrease the flow rate or stop the flow completely. A fibrin sheath begins developing within the first twenty-four hours of the cannula insertion. Clot formation can result from irritation, v ein wall injury from the insertion or tip position, increased venous pressure, or backup of blood into the cannula. Avoid use of a blood pressure cuff on the affected limb because of the resulting transient increase in venous pressure. A regular flush schedule helps maintain patency. BE SAFE! BE VIGILANT! NEVER exert pressure with a saline or heparin flush in an attempt to restore patency; doing so could dislodge a clot into the vascular system or rupture the cannula. 1000 mL = 125 mL per hour 8 hours Mechanical and Electronic Infusion Devices LEARNING TIP If you are having trouble with IV and drug calculations, check out the Calculating Drug Doses tutorial on your Student CD! Factors Affecting Flow Rates of Gravity Infusions CHANGE IN CANNULA POSITION. A change in the position of the cannula’s tip can affect the infusion flow rate. If the bevel is against the w all of the v ein, the flow rate will decrease; if it is a way from the w all of the v ein the flow rate can increase. Placement of a PIV in a joint area (wrist or elbow) can cause a kink in the cannula or change the tip position, which can cause a change in the flow rate. Careful cannula securement and a voiding areas of joint fle xion will minimize this problem. Patients may need to be reminded to keep flexion to a minimum when an IV is placed near a joint. Flow-control devices, such as electronic infusion de vices (EIDs) and mechanical controllers regulate the rate of infusion and are used in all healthcare settings (Fig. 7.3). Mechanical controllers measure the amount of solution delivered and depend on gravity to deliver the infusion. Electronic infusion devices, sometimes called pumps, use positi ve pressure to deliver the solution. Pumps and controllers are used for infusing precise v olumes and rates of solution. Institution polic y often dictates use of controllers for infusion of potent medications, such as BE SAFE! BE VIGILANT! If the only useable vein is in an area of flexion, secure PIV appropriately; remind patients to keep flexion to minimum; closely monitor PIV site and flow rate. FIGURE 7.3 Infusion pump. 4068_Ch07_090-110 15/11/14 12:45 PM Page 95 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy 95 heparin, concentrated morphine, and chemotherapy solutions, and for very fast or slow rates. Some electronic infusion devices are portable and designed to be worn on the body. These are called ambulatory infusion devices. It is important to know the type of pump being used and to follo w its manufacturer’s guidelines. Sodium Chloride Solutions Filters • Sodium chloride solutions are used for fluid replacement; treatment of shock, hyponatremia, and metabolic acidosis; as a primer for blood transfusions and during resuscitation after trauma. According to the American Association of Blood Banks, blood component administration sets can be primed only with 0.9% sodium chloride solution (Roback et al, 2008). • Combination dextrose and sodium chloride solutions, such as 5% dextrose with 0.45% sodium chloride (often referred to as “D5 and a half”), are commonly used for hydration and to check for kidney function before administration of potassium replacement therapy. Filters can either be add-on devices to administration sets or built into the set during manufacturing. Various types of filters are available. The INS standards (2011) address the use of inline filters to remove bacteria, fungi, particulate matter, air, and some endotoxins from IV fluids. A 0.22-micron filter that removes air, bacteria, fungi, and particulate matter from IV fluids is to be used for nonlipid solutions. Blood infusions generally use a standard 170-micron filter, which is built into the Y-administration set. Leukocytedepleting filters are available for blood administration sets when concern for febrile reactions to leukocytes is anticipated (INS 2011; Roback, Combs, Grossman, & Hillyer , 2008). Other types of filters (i.e., 1.2-micron) are used for nutritional products such as parenteral nutrition and f at emulsions. Check institution policy and manufacturers’ guidelines for use of filters. TYPES OF FLUIDS There are three basic types of IV solutions: isotonic, hypotonic, and hypertonic (see Chapter 6). Fluids and electrolytes administered intravenously pass directly into the plasma space of the extracellular fluid compartment. They are then absorbed based on the characteristics of the fluid and the hydration status of the patient. The most commonly infused fluids are de xtrose and sodium solutions. These are called crystalloid solutions. Crystalloid Solutions Dextrose Solutions Dextrose in water is available in many concentrations (2.5%, 5%, 10%) and is typically used for continuous peripheral infusions. Concentrations exceeding 10% and above must be infused via a central line into a large vein. Advantages of dextrose solutions are as follows: • Dextrose solutions provide carbohydrates in a readily usable form and calories for energy, reducing breakdown of glycogen and catabolism of protein to help prevent negative nitrogen balance. • They are nonelectrolyte and well metabolized by all tissues. • High concentrations can be used for treating hypoglycemia or in combination with TPN because they supply a large number of calories. Disadvantages of dextrose solutions are as follows: • Vein irritation, damage, and thrombosis may result when hypertonic dextrose solutions are administered in a peripheral vein. Sodium chloride solutions are available in concentrations of 0.25%, 0.33%, 0.45%, 0.9% (normal saline), 3%, and 5%. Sodium chloride 0.9% and 0.45% solutions are used most commonly. Advantages of sodium chloride solutions are as follows: Disadvantages of sodium chloride solutions are as follows: • They can cause circulatory overload if the prescribed rate is not monitored. • If the patient is unable to excrete excess sodium (due to kidney disease or hormonal imbalance, for example) hypernatremia can result. Balanced Electrolyte Solutions Electrolyte solutions are used to replace lost fluids and electrolytes. A variety of balanced electrolyte solutions are available commercially. Maintenance electrolyte solutions, such as lactated Ringer’s solution, approximate normal body electrolyte needs. Balanced solutions often contain lactate or acetate (yielding bicarbonate), which helps combat acidosis and provide a truly balanced solution. Potassium is an electrolyte that is commonly added to balanced solutions to replace potassium deficits. The patient must be monitored for signs and symptoms related to potassium imbalance (see Chapter 6). BE SAFE! BE VIGILANT! Be sure to review institution guidelines for potassium administration before administration of any potassium-containing solution. An inappropriate rate or amount can cause a life-threatening cardiac dysrhythmia! Osmolarity of IV Solutions The osmolarity of an IV solution refers to its osmotic activity. As noted previously, IV fluids may be classified as isotonic, hypotonic, or hypertonic. (See Chapter 6 to review these concepts.) Isotonic fluids have the same concentration of solutes to water as body fluids. Hypertonic solutions ha ve more solutes (are more concentrated) than body fluids. Hypotonic solutions have fewer solutes (are less concentrated) than body 4068_Ch07_090-110 15/11/14 12:45 PM Page 96 96 UNIT TWO Understanding Health and Illness fluids. Water moves from areas of lesser concentration to areas of greater concentration. Therefore, hypotonic solutions send water into areas of greater concentration (cells), and hypertonic solutions pull water from the more highly concentrated cells. Isotonic Solutions Normal saline (0.9% sodium chloride) solution is an isotonic solution that has the same tonicity as body fluid. When administered to patients requiring w ater, it neither enters cells nor pulls water from cells; it therefore expands the extracellular fluid volume. A solution of 5% de xtrose in water (D5W) is also isotonic when infused, b ut the dextrose is quickly metabolized, making the solution hypotonic. Lactated Ringer’s and 5% alb umin are other examples of isotonic solutions. INTRAVENOUS ACCESS IV therapy can be administered into the systemic circulation via the peripheral or central v eins. Peripheral v eins lie beneath the epidermis, dermis, and subcutaneous tissue of the skin. They usually provide easy access to the venous system. Central veins are deeper and located closer to the heart. Special catheters with a tip that ends in a large vessel (i.e., superior vena cava) near the heart are CVADs. This chapter primarily focuses on short peripheral catheters. The definitions of the various types of CVADs are discussed briefly at the end of the chapter. INITIATING PERIPHERAL INTRAVENOUS THERAPY Starting a Peripheral (Short-Cannula) Infusion (Phillips, 2010) BE SAFE! BE VIGILANT! Since isotonic solutions expand the extracellular fluid volume be vigilant for signs of fluid overload. Hypotonic Solutions Hypotonic fluids are used when fluid is needed to enter the cells, as in the patient with cellular dehydration.They are also used as fluid maintenance therap y. Examples of hypotonic solutions are De xtrose 2.5% w ater and 0.33% or 0.45% sodium chloride solution. The following steps are adapted from: Phillips, L. D. (2010). Manual of IV therapeutics (5th ed.). Philadelphia: F.A. Davis. Precannulation (Steps 1–5) STEP 1: CHECK AUTHORIZED PRESCRIBER’S ORDER. A physi- cian or authorized prescriber’ s order is needed to start IV therapy. The order should include patient identif ication, solution and type, dosage, volume, rate, route, frequency, and anything requiring significant attention. STEP 2: PERFORM HAND HYGIENE. Hand hygiene has been shown to significantly decrease the risk of contamination. Before beginning the procedure, w ash your hands for a minimum of 15 to 20 seconds with antimicrobial soap and running water or alcohol-based hand rub. STEP 3: GATHER, INSPECT, AND PREPARE EQUIPMENT. BE SAFE! BE VIGILANT! Hypotonic solutions, because they enter cells, can cause cardiovascular collapse and increase intracranial pressure (ICP). Hypertonic Solutions Examples of hypertonic solutions include 5% de xtrose in 0.9% sodium chloride, 3% sodium chloride, calcium chloride 10%, and 5% dextrose in lactated Ringer’s solution. Hypertonic solutions are used to e xpand the plasma volume, for example, in a hypo volemic patient. They are also used to replace electrolytes. BE SAFE! Monitor the patient receiving a hypertonic solution for circulatory overload. • Clean gloves • Skin prepping solution (i.e., 70% isopropyl alcohol, chlorhexidine gluconate, or chlorhexidine gluconate/ alcohol combination) • Sterile 2" × 2" gauze pads • Towel or drape to place under selected IV site • Alcohol prep pads • Securement device • Prefilled saline syringe (10 mL) or normal saline vial with 10-mL syringe and 20-gauge needle • Sterile extension set to attach to cannula hub • Dressing material • Disposable nonlatex, single-use tourniquet • PIV cannulas (over-the-needle sizes 18, 20, 22, and 24 are the most common) • Appropriate administration set, if indicated • IV solution, if indicated (Inspect and gently squeeze soft plastic bags for puncture holes or breaks; check expiration date; inspect solution for visible contamination or particles; ensure that outer wrap is dry.) • Needleless connector • IV pole, if needed • Infusion pump, if needed 4068_Ch07_090-110 15/11/14 12:45 PM Page 97 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Some institutions have IV start kits that contain supplies needed. STEP 4: IDENTIFY, ASSESS, AND PREPARE THE PATIENT. Patient Identification. The 2014 National Patient Safety Goals established by the Joint Commission (© The Joint Commission, 2013. Reprinted with permission) specify that two patient identifiers should be used when administering medications, blood, or blood components. The patient’s room number or physical location should not be used as an identifier. Patient Assessment. Several factors must be considered be- fore venipuncture: type of solution to be infused, condition of vein, duration of therap y, cannula size needed, patient age, patient activity, presence of disease or previous surgery, presence of a dialysis shunt or graft, medications being taken by the patient (such as anticoagulants), allergies, and patient preference for site. In addition, be sure to assess specific needs related to the patient’ s culture (see “Cultural Considerations”). Psychological Preparation. Provide privacy, explain the procedure and the reason why the IV is needed, and evaluate the patient’s knowledge of the procedure before assessing the patient’s arms for suitable venipuncture sites. Ask if the patient has had experience with infusions before and if he or she experienced any difficulties with venipuncture or the infusion. Make sure the patient is comfortable. Distraction techniques or music therapy may assist in reducing anxiety. STEP 5: SELECT SITE AND DILATE VEIN. Site Selection. Proper vein/site selection is crucial to the suc- cess of the procedure and the infusion treatment (INS 2011; Box 7-1). Avoid use of an arm on the side where the patient has had a mastectomy, has a dialysis access site, or is scheduled for a surgical procedure. The patient’s condition and diagnosis; age; vein condition, size, and location; type/duration of therapy; and experience of the inserter should be considered before starting IV therapy (Box 7-2). The PIV cannula selected should be the least invasive with the smallest gauge and length needed to accommodate the ordered therapy (INS, 2011). The first cannula should be started in the most distal site that supports therapy. This allows each successive venipuncture to be made proximal to the site of the pre vious one, which eliminates the passage of irritating fluids through a previously injured vein and minimizes leakage through old puncture sites. Hand veins can be used successfully for most hydrating Box 7-1 97 Considerations for Vein Selection • Age of patient • Availability of sites • Size of cannula to be used • Purpose of infusion therapy • Osmolarity and pH of solution to be infused • Volume, rate, and length of infusion • Degree of mobility desired Box 7-2 General Considerations for Initiating IV Therapy 1. Use veins in the upper extremities. Avoid lower extremity veins in adults. 2. When multiple sticks are anticipated, make the first venipuncture distally and work proximally with subsequent punctures. Make no more than two attempts at venipuncture before getting help. 3. Use only one cannula per cannulation attempt. 4. If therapy will be prescribed for longer than 6 days, a peripherally inserted central catheter (PICC) or other type of CVAD should be considered. 5. Avoid using venipunctures in affected arms of patients with radical mastectomy or a dialysis access site. 6. If possible, avoid taking a blood pressure on the arm receiving an infusion because the cuff interferes with blood flow and forces blood back into the cannula. This may cause a clot or cause the vein or cannula to rupture. 7. Select the smallest cannula in gauge and length that supports prescribed therapy. All cannulas should be radiopaque. 8. All peripheral cannulas should be stabilized with a stabilization device to preserve the integrity of the access device and prevent migration. solutions, but they are best avoided when irritating solutions of potassium or antibiotics are anticipated. Vein size must also be considered. Small veins do not tolerate large volumes of fluid, high infusion rates, or irritating solutions. Cultural Considerations Among the Vietnamese, the head is considered sacred. Thus, the practice of starting IV lines in the scalp may cause a Vietnamese patient significant anxiety. Consider other sites first. If the patient must have an IV line in the scalp, carefully explain why it is needed. 4068_Ch07_090-110 15/11/14 12:45 PM Page 98 98 UNIT TWO Understanding Health and Illness Large veins should be used for these purposes. Figure 7.4 shows peripheral veins that can be used for IV therapy. BE SAFE! BE VIGILANT! Pay attention to the vein when choosing a cannula size. A smaller gauge cannula takes up less space within the vein, allows for better blood flow around the cannula, and decreases trauma to the vein wall. A tourniquet helps to dilate and stabilize the vein, easing venipuncture and threading of the cannula. Place the tourniquet 6 to 8 inches abo ve the insertion site. If the tourniquet is too close to the insertion site, it can create too much pressure and cause a hematoma, which is a localized collection of blood in the subcutaneous tissue. The tourniquet should be tight enough to impede v enous flow while maintaining arterial flow. A tourniquet should be at least 1 inch wide and should not be left on for more than 3 minutes to prevent impaired blood flow to the extremity. Use a nonlatex, single-use tourniquet. Tourniquets should be applied loosely or not used at all in patients with fragile v eins or who bruise easily. Vein Dilation. If veins are constricted, venipuncture is more difficult. Fever, anxiety, and cold temperatures can cause veins to constrict. Smoking before the insertion of an IV line also causes veins to constrict. Basilic vein Cephalic vein NURSING CARE TIP Many patients know from experience whether their veins are difficult to access. Asking a patient to indicate his or her “best vein” may decrease the number of attempts before successful IV cannulation. When selecting a hand vein, avoid the patient’s dominant hand, if at all possible, to avert accidental removal of the IV by the patient. Dorsal venous arch Metacarpal veins Digital veins Cephalic vein Occasionally, additional techniques are needed to distend a vein. Placing the arm in a dependent position or placing a warm towel over the site for several minutes before applying the tourniquet helps to dilate a v ein. The whole extremity must be warmed to improve blood flow to the area. Opening and closing the f ist pumps blood to the e xtremity and increases blood flow to help dilate the v ein. Lightly stroking downward on the vein may also help. A blood pressure cuff inflated to 30 mm Hg is another appropriate method for vein dilation, especially with fragile veins in older adults. Box 7-3 lists additional tips for difficult-to-find veins. Basilic vein Brachial artery Accessory cephalic vein Radial artery Median cubital vein Basilic vein Ulnar artery Cephalic vein Median antebrachial vein BE SAFE! Use a tourniquet only once to avoid crosscontamination between patients. Tourniquets may also be sources of latex exposure; use a nonlatex tourniquet or blood pressure cuff technique for patients whenever appropriate. Cannulation (Steps 6–10) STEP 6: SELECT CANNULA. Needles have been largely re- placed with fle xible plastic catheters (cannulas) that are inserted over a needle (Fig. 7.5). The needle (or stylet) is removed or retracted after the cannula is in place. FIGURE 7.4 Peripheral veins used for IV therapy. (Modified from Phillips, L. D. [2010]. Manual of IV therapeutics [5th ed.]. Philadelphia: F.A. Davis.) • WORD • BUILDING • hematoma: hemat—blood + oma—tumor 4068_Ch07_090-110 15/11/14 12:45 PM Page 99 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy BE SAFE! A PIV technology has been designed to prevent or decrease the risk of needlestick injury and blood exposure. Safety (passive or active) PIVs provide protection against needlestick injury (see Fig. 7.5). Other safety PIV devices have been designed not only to prevent needlestick injury but to control or prevent blood leakage, spill, or splatter at the time of insertion and/or maintenance. B Box 7-3 Techniques for Patients With Difficult Venous Access Impaired skin integrity related to lesions, burns, or disease process • Use light directed toward the side of the patient’s extremity (tangential lighting) to illuminate blue veins. (This technique can also be used on dark-skinned people.) • Do not flatten veins or cause damage to skin. • Use a vein illumination device, which uses technology that shines a special light to identify veins beneath the surface of the skin. C Hard sclerosed vessels related to disease process, personal misuse, frequent drug therapy • Assess for collateral circulation. • Use multiple tourniquet technique to increase oncotic pressure inside the tissue, forcing small vessels of periphery to be visualized: • Place one tourniquet high on arm for 2 minutes and leave in place; stroke downward toward hand. • After 2 minutes, place a second tourniquet at midarm just below the antecubital fossa; leave along with first tourniquet for 2 minutes. • This should bring peripheral veins into view; if needed, place a third tourniquet at wrist. • Do not leave on for more than 6 minutes total. • Use a vein illumination device. Obesity or edema • Use a 2-inch cannula. • Use multiple tourniquet technique. • Press down on tissue to displace edema to side to visualize veins. Source: Phillips, L. D. (2010). Manual of IV therapeutics (5th ed.). Philadelphia: F.A. Davis. D FIGURE 7.5 (A) Insyte Autoguard. (B) BD Nexiva Closed IV Catheter System. (C) BD Insyte Autoguard BC Shielded IV Catheter. (D) BD SAF-T-EZ set. (Courtesy and © Becton, Dickinson and Company. Reprinted with permission.) 99 4068_Ch07_090-110 15/11/14 12:45 PM Page 100 100 UNIT TWO Understanding Health and Illness For patient comfort, choose the smallest gauge cannula that will work for the intended purpose. Use smaller gauge cannulas (22–24 gauges) for fluids and slo w infusion rates. Use larger cannulas (18–20 gauges) for rapid fluid administration and viscous solutions such as blood. Also consider vein size when choosing a cannula gauge. Refer to institution polic y and equipment stock for specific recommendations. For adult and pediatric patients, the INS (2011) recommends that short peripheral cannulas be removed only when clinically indicated and immediately upon suspected contamination. INS also instructs clinicians to replace or remove any PIV cannula placed in an emergency situation within 48 hours of the insertion or as soon as possible (INS, 2011). STEP 7: PUT ON GLOVES. The INS (2011) and the Occupa- tional Safety and Health Administration (2009) recommend following standard precautions whenever exposure to blood or body fluids is lik ely: wear clean late x or vinyl gloves to provide basic minimal protection from blood and body fluids. Remove gloves after contact with a patient, using proper technique to pre vent hand and en vironmental contamination; wash hands after glove removal. STEP 8: PREPARE THE SITE. Some agency policies allow the use of a local anesthetic agent before insertion of a peripheral IV cannula to minimize pain during the insertion. Be sure to check your agency’s policy. Local anesthetic agents include lidocaine, iontophoresis low-frequency ultrasonification, pressureaccelerated lidocaine, and topical transdermal agents. Clean the insertion site with an antiseptic/antimicrobial solution before cannula placement. If the patient’s skin is visibly dirty, wash it with soap and water before applying the solution. If the patient has e xcess hair, it can be clipped with scissors or disposable-head sur gical clippers. Avoid using a razor , which can cause skin irritation. Acceptable solutions include, but are not limited to, 70% alcohol or alcohol/chlorhe xidine gluconate combination (A & CHG). CHG is the preferred prep solution of choice based on scientif ic evidence (O’Grady et al, 2011, INS, 2011). Avoid using alcohol after an antimicrobial preparation because alcohol negates the antimicrobial action of the skin prep agent. Follow manufacturers’ instructions for your chosen solution. Typically alcohol and povidone-iodine (PI) are applied in a circular motion, starting at the intended site and working outward to clean an area 2 to 3 inches in diameter. A & CHG combination solution is applied using a back-and-forth technique. Regardless of antiseptic solution used, it should be applied with friction for at least 30 seconds. Blotting of excess solution at the insertion site is not recommended. Let the solution air dry completely before inserting the PIV cannula. bacteria as possible. It also decreases the risk of tracking the solution into the vein during insertion, which can lead to phlebitis. 2. Do not repalpate the site after prepping it. If you need to repalpate after cleaning, you must change to sterile gloves to perform this step (INS, 2011). STEP 9: INSERT THE CANNULA. Make sure you have good lighting to visualize the vein. Venipuncture can be performed using a direct (one-step) or indirect (two-step) approach. For the direct approach, the cannula enters the skin directly abo ve the vein. Small, fragile veins can be bruised more easily with the direct method. In the indirect approach, the cannula is inserted through the skin, the vein is located and the cannula is then inserted into the vein. This method is useful when cannulating small, fragile veins as bruising is less likely to occur. Hold the cannula with the be vel (slanted opening) of the needle facing up. With the tourniquet in place, pull down on the skin to help stabilize the vein and then enter the skin/vein at a 10- to 30-degree angle using either the direct or indirect approach (Fig. 7.6). NURSING CARE TIP Use traction (a downward pulling motion that makes the skin taut below the puncture site) to stabilize the skin and prevent the vein from rolling during venipuncture (Fig. 7.7). Once the skin is punctured, lower the needle angle and locate and puncture the vein. Depending on the type of device used, a small flash of blood may be seen in the tubing or at 30° 10° BE SAFE! BE VIGILANT! 1. It is important to allow the skin prep to dry completely. This allows the prep to do its job, which is to kill off as much skin FIGURE 7.6 Insert the needle of choice bevel up at a 10- to 30-degree angle, depending on the vein location and catheter. 4068_Ch07_090-110 15/11/14 12:45 PM Page 101 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Box 7-4 FIGURE 7.7 Pull skin below the intended puncture site using a downward motion to stabilize the skin and prevent the vein from rolling. the hub of the cannula when the needle is in the v ein. With the angle of the needle lowered so that it is parallel with the skin, thread it into the lumen of the v ein. If a cannula-overneedle device is used, advance the cannula device 1/16th of an inch and then advance the cannula gently into the vein for its remaining length. Once the cannula is threaded into the vein, engage the safety mechanism according to de vice instructions to withdraw the needle out of the plastic cannula. Once the cannula is in place, release the tourniquet and connect the preflushed extension set and needleless connector to the cannula hub. Blood may ooze from the hub at this time, so be sure to follow precautions against exposure. Clean the needleless connector and check for patency by aspirating for a blood return and flushing the cannula with 0.9% sodium chloride solution. A smooth, easy flush and good blood return along with no signs of inf iltration or pain indicate that the cannula is patent and that the prescribed solution can be administered. If an IV solution is to be infused, clean the needleless connector, connect the IV tubing and initiate the infusion. Box 7-4 lists troubleshooting tips for peripheral cannula insertions. STEP 10: STABILIZE THE CANNULA AND DRESS THE SITE. The purpose of cannula stabilization is to (1) preserve the integrity of the access de vice, (2) prevent cannula mo vement, and (3) decrease potential complications such as phlebitis, inf iltration, or loss of the de vice. The stabilization technique should not interfere with visualization and evaluation of the insertion site or affect circulation. Several methods may be used to stabilize the cannula hub, including transparent dressings, tape, and specialized securement devices. A transparent semipermeable membrane (TSM) dressing allows the venipuncture site to be monitored for redness or swelling and provides an occlusive dressing for the site. Other choices include sterile gauze or hydrocolloidal dressings. The dressing choice should be based on the patient’s needs. BandAids® are not acceptable dressings over cannulas. Arm boards, finger splints, or limb splints can be used to stabilize cannulas that are placed near joints. These devices should only be used to assist in the deli very of the infusion and to decrease the risk of complications. Ho wever, if a 101 Troubleshooting Tips for Peripheral IV Therapy Common reasons for failure of venipuncture include: • Failure to release the tourniquet promptly when the vein has been successfully cannulated • Use of a “stop and start” technique by beginners who lack confidence—a tentative approach that can injure the vein, causing a hematoma • Inadequate vein stabilization, as can occur when traction is not used to hold the vein, causing the stylet to push the vein aside • Failure to recognize that the cannula has gone through the opposite vein wall • Stopping too soon after insertion of only the stylet so that the cannula does not enter the lumen of the vein (causing blood return to disappear when the stylet is removed because the cannula is not in the lumen of the vein) • Attempting to insert the cannula too close to a bifurcation • Inserting the cannula too deep, below the vein • Failure to penetrate the vein wall because of improper insertion angle (too steep or not steep enough), causing the cannula to ride on top of or below the vein • Poor venous access Source: Phillips, L. D. (2010). Manual of IV therapeutics (5th ed.). Philadelphia: F.A. Davis. confused patient places the IV site in danger, the extremity can be immobilized as a last resort; this requires a HCP’s order. If a joint stabilization device is used, make sure the insertion site and vein path can be seen and that placement of the device does not affect circulation or cause skin or nerve damage. NURSING CARE TIP Dressing changes for PIV catheters are only done if the dressing is dirty or no longer intact. CVAD dressings should be changed every 2 days for a gauze dressing and every 5 to 7 days for a transparent semipermeable membrane dressing—sooner if it is dirty or no longer intact or if bleeding, drainage, or infection is noted (INS, 2011). Post-Cannulation (Steps 11–15) STEP 11: LABEL THE SITE. The IV setup should be labeled in three areas: the insertion site, the tubing, and the solution container. Once the venipuncture procedure is completed, label the insertion site dressing with the date, time, cannula type/size and length, and your initials; label tubing and solution (if applicable) with date, time, and initials. 4068_Ch07_090-110 15/11/14 12:45 PM Page 102 102 UNIT TWO Understanding Health and Illness STEP 12: DISPOSE OF EQUIPMENT AND PERFORM HAND HYGIENE. Equipment disposal should follow CDC guidelines and INS standards of practice for biohazards. All needles, cannulas, and blood-contaminated equipment should be disposed of according to institution policy in tamper-proof, nonpermeable, biohazard waste containers. Remove gloves and wash your hands. STEP 13: EDUCATE THE PATIENT. Patients have the right to receive information on all aspects of their care in a manner they can understand. They also have the right to accept or refuse treatment. The following information should be included in education and documentation: • Reason IV is needed and for how long. • Limitations on mobility that result from the IV placement. • Medications ordered and why; side effects to report. • Meaning of alarms if an electronic infusion device is used. • How to call for assistance if the venipuncture site becomes tender or sore or if redness or swelling develops. STEP 14: CALCULATE DRIP RATE. All IV infusions should be monitored frequently for accurate flo w rates and complications associated with infusion therap y. See the section on calculating drip rates earlier in this chapter. STEP 15: DOCUMENT. After implementation of infusion therapy, the procedure must be documented in the medical record. Document your actions and the patient’s response according to institution policy. All IV solutions are also documented on the medication administration record. Include the following: • Date and time of insertion • Manufacturer’s brand name and style of device • Gauge and length of the device • Location of the accessed vein • Presence of good blood return and patency of device • Solution infusing and rate of flow • Application of stabilization technique and dressing applied • Method of infusion (gravity or pump) • Flush solution-heparin or saline and amount used, if applicable • Number of attempts needed for a successful IV start • Patient’s response and specific comments related to the procedure • Patient education related to the procedure • Signature CRITICAL THINKING Mrs. Green ■ Mrs. Green is admitted with a diagnosis of symptomatic anemia and has an atrio ventricular (AV) dialysis shunt in her left arm. An IV line is ordered for administration of 2 units of pack ed red blood cells. What must be taken into consideration when assessing Mrs. Green for an appropriate venipuncture site? Suggested answers are at the end of the chapter. NURSING PROCESS FOR THE PATIENT RECEIVING IV THERAPY IV therapy is a medical intervention, and the nurse is responsible for appropriate assessment, monitoring, documentation, and reporting related to the therapeutic goals. Data Collection Some institutions require assessment as often as every hour. An INS Position P aper (Gorski et al, 2012) pro vides some guidance on frequenc y of site assessment including the following recommendations: • At least every 4 hours for patients not getting an irritant or vesicant and who are alert and oriented • Every 2 hours for critically ill patients and adult patients with cognitive sensory deficits; receiving sedative medications or unable to notify the nurse of any problems; or if IV is placed in a joint area or external jugular vein • Every hour for pediatric or neonatal patients Assessment should be systematic and thorough and include physiological and psychosocial data, critical laboratory values, allergies and environmental issues, and presence of adverse reactions or complications related to infusion therapy. Older adults are at increased risk for complications, making careful assessment essential (see “Gerontological Issues”). Gerontological Issues Care of the Older Adult Receiving Intravenous Therapy When an older patient is receiving IV fluids, the nurse must regularly assess the patient for potential fluid volume excess. Symptoms of fluid volume excess include the following: • Elevated blood pressure • Increasing weight • Full bounding pulse • Shallow, rapid respirations • Jugular venous distention • Increased urine output • Development of moist crackles in the lungs. If these signs are present: • Immediately notify the RN or turn down the IV to a minimum drip rate (1 mL per minute); do not discontinue the IV because the HCP may want to order IV diuretics. • Position the patient to maximize lung expansion. • Check peripheral oxygen saturation with an oximeter. • Apply oxygen by mask or nasal cannula if indicated and per institution guidelines. • Closely monitor patient’s vital signs, level of consciousness, and oxygen saturation along with fluid output. • Assist the HCP or RN with IV push administration of diuretic medication such as furosemide if ordered. 4068_Ch07_090-110 15/11/14 12:45 PM Page 103 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Physical assessments such as daily weights and measurement of intake and output (I&O) help determine whether the patient is retaining too much fluid. Skin turgor, mucous membrane moisture, vital signs, and le vel of consciousness also 103 indicate hydration status. New onset of f ine crackles in the lungs can indicate fluid retention. Table 7.1 lists other symptoms of complications, along with prevention and treatment strategies. TABLE 7.1 COMPLICATIONS OF PERIPHERAL IV THERAPY Complication Signs and Symptoms Local Complications of IV Therapy • Ecchymoses Hematoma • Swelling • Inability to advance cannula • Resistance during flushing Prevention Treatment Use indirect method of venipuncture. Choose smallest cannula appropriate. Apply tourniquet just before venipuncture. Remove cannula. Apply pressure with 2" × 2" gauze. Elevate extremity. Thrombosis • Slowed or stopped infusion • Fever/malaise • Inability to flush or aspirate cannula Use an electronic infusion device (EID). Choose microdrop sets with gravity flow if rate is less than 50 mL/hr. Avoid use of flexion areas for insertion site. Discontinue cannula. Apply cold compress to site. Assess for circulatory impairment. Insert new cannula at another site. Phlebitis • • • • • Redness/warmth at site Local swelling Pain Palpable cord Sluggish infusion rate Use larger veins for hypertonic solutions. Choose smallest cannula appropriate. Use good hand hygiene. Add buffer to irritating solutions. Change solutions and containers every 24 hours. Assess PIV site per institution policy. Remove cannula when clinically indicated. Discontinue cannula. Apply cold compress initially; then warm. Consult RN or provider if severe. Infiltration or Extravasation • • • • • • Coolness of skin at site Taut skin Dependent edema Absent backflow of blood Sluggish infusion rate Pain or burning (depending on solution used) Place cannula in appropriate site. Avoid antecubital fossa. Stabilize cannula carefully. Monitor PIV site per policy. Instruct patient to notify nurse immediately if any pain, burning or swelling occurs. Discontinue cannula. Apply cool compress if appropriate. Elevate extremity slightly. Notify RN/provider. Follow agency infiltration/ extravasation guidelines. Have antidote available (if medication extravasates). Local Infection • Redness and swelling at site • Possible exudate • Elevated white blood cell (WBC) count • Elevated T lymphocytes Inspect all solutions. Use sterile technique during venipuncture and site maintenance. Discontinue cannula. Culture site and cannula. Apply sterile dressing over site. Notify RN/HCP. Administer antibiotics if ordered. Continued 4068_Ch07_090-110 15/11/14 12:45 PM Page 104 104 UNIT TWO Understanding Health and Illness TABLE 7.1 COMPLICATIONS OF PERIPHERAL IV THERAPY—cont’d Complication Venous Spasm Signs and Symptoms • Sharp pain at site • Sluggish infusion Systemic Complications of Peripheral IV Therapy Septicemia • Fluctuating temperature • Profuse sweating • Nausea/vomiting • Diarrhea • Abdominal pain • Tachycardia • Hypotension • Altered mental status Circulatory Overload • • • • • • • • • Weight gain Puffy eyelids Edema Hypertension Changes in input and output (I&O) Rise in central venous pressure (CVP) Shortness of breath Crackles in lungs Distended neck veins Prevention Take thorough history. Verify allergies. Use proper patient identification. Reduce infusion rate. Warm solutions with appropriate warming device if appropriate. Treatment Apply warm compress to site. Restart infusion in new site if spasm continues. Notify RN. Use good hand hygiene. Use aseptic techniques for insertion/maintenance of cannula, needleless connector, IV tubing and solutions. Carefully inspect fluids. Use Luer-Lok devices. Cover infusion sites with appropriate dressings. Follow standards of practice related to assessment and monitoring of PIV and hang time of infusions/IV tubing. Use appropriate preparation solutions. Restart new IV system. Obtain cultures. Notify RN/HCP. Initiate antimicrobial therapy as ordered. Monitor patient closely. Monitor infusion. Maintain flow at prescribed rate. Monitor I&O. Know patient’s cardiovascular history. Do not “catch up” infusion if behind schedule. Be alert that older patients are more prone to this and monitor closely. Decrease IV flow rate. Place patient in high Fowler’s position. Keep patient warm. Monitor vital signs. Administer oxygen. Use a microdrop set or an EID. Notify RN/provider. Venous Air Embolism • Lightheadedness • Dyspnea, cyanosis, tachypnea, expiratory wheezes, cough • Mill wheel murmur, chest pain, hypotension • Changes in mental status Remove all air from administration sets. Use Luer-Loks. Attach piggyback to appropriate port. CALL FOR HELP! Place patient in Trendelenburg position on left side. Administer oxygen. Monitor vital signs. Notify RN/HCP. Speed Shock • • • • • • • Reduce the size of drops by using microdrop set. Use an EID. Monitor infusion sites. Dilute IV push mediations if possible; give slowly. CALL FOR HELP! Notify RN/HCP. Give antidote or resuscitation medications as ordered. Dizziness Facial flushing Headache Tightness in chest Hypotension Irregular pulse Progression of shock Source: Adapted from Phillips, L. D. (2010). Manual of IV therapeutics (5th ed.). Philadelphia: F.A. Davis. 4068_Ch07_090-110 15/11/14 12:45 PM Page 105 Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy CRITICAL THINKING Mr. Rick ■ Mr. Rick’s IV has blood back ed up in the tubing. When you open the clamp to increase the flow, nothing happens. What should you do? Suggested answer is at the end of the chapter. Inspect the insertion site for redness or swelling, evaluate the integrity of the dressing, and document your findings. Inspect the tubing to ensure tight connections and the absence of kinks or defects. Inspect the solution container and compare it with the HCP’ s order for type, amount, and rate. Report abnormal findings to the RN or HCP. Nursing Diagnoses, Planning, and Implementation Priority nursing diagnoses for IV-related issues may include the following. Fear related to insertion of IV cannula EXPECTED OUTCOME: The patient will have minimal fear as evidenced by cooperation with the procedure and verbalizing minimal fear. • Explain the IV therapy (rationale for therapy, insertion procedure, care of the IV, and importance of reporting pain, swelling, or pump alarm) to the patient. Lack of knowledge is associated with fear. • Use techniques to minimize discomfort. Pain may increase fear. Impaired Physical Mobility related to placement and maintenance of IV cannula EXPECTED OUTCOME: The patient will maintain mobility as evidenced by full range of motion and avoidance of complications related to immobility. • Avoid insertion site close to joints if at all possible. Joint areas are mobile, making it difficult to maintain an intact site. • If you must use a mobile site, such as the antecubital fossa or wrist area, immobilize the joint with arm board or other immobilizer to reduce cannula movement. (Remember to get an order for this.) • If site must be wrapped to prot