Infusion Therapy Overview PDF

Chapter 10 Overview of Infusion Therapy \*\*\*\*\*\*\*\*\*\*\*INTRODUCTION Patients receive infusion therapy in hospitals, extended care facilities, outpatient clinics, infusion centers, and their own homes. "IV resource teams" result in better patient outcomes and reduced costs. However, genera...

Chapter 10 Overview of Infusion Therapy \*\*\*\*\*\*\*\*\*\*\*INTRODUCTION Patients receive infusion therapy in hospitals, extended care facilities, outpatient clinics, infusion centers, and their own homes. "IV resource teams" result in better patient outcomes and reduced costs. However, generalist nurses in all practice settings are involved in the provision of infusion therapy and need to be knowledgeable in the most current evidence related to infusion therapy and competent in the care they provide to their patients. The Infusion Nurses Society (INS) is a national organization that has established evidence-based practice standards of care to guide the delivery of infusion therapy. A professional organization, the Infusion Nurses Certification Corporation, offers a national certification program that recognizes the expertise of nurses specializing in infusion therapy. The designation of Certified Registered Nurse Infusion (CRNI©) is awarded after successfully passing a rigorous examination and completing the required hours of practice in infusion therapy. infusion therapy is needed for a variety of reasons, including fluid and electrolyte replacement, medication administration, blood product administration, and nutritional support. The duration of infusion therapy may be brief periods of hours or days to months or long-term therapy required for a lifetime. Administration of IV fluids is initiated to both maintain and restore fluid and electrolyte balance when it is not possible to maintain this balance with the oral intake of fluids. To maintain fluid balance, adequate amounts of fluid need to be administered to account for sensible and insensible fluid losses. Patients with hemorrhage, surgery, burns, vomiting, or diarrhea. IV administration of medications is indicated when the oral or other routes are not available or appropriate. Certain medications are administered only by the IV route to attain higher blood levels or faster action. When the gastrointestinal tract is unable to absorb sufficient amounts of nutrients, the IV route can be used. Solutions containing protein, lipids, and high concentrations of dextrose can provide the calories and nutrition needed to sustain life. Blood products can be administered only intravenously and include packed red blood cells (RBCs), platelets, plasma, albumin, and clotting factors. They may be needed in acute situations or to correct deficits related to chronic conditions and require special precautions to ensure patient safety. \*\*\*\*\*\*\*\*\*\*\*\*SOLUTIONS USED IN INFUSION THERAPY Infusion therapy requires the specific IV fluid order by a licensed healthcare provider. The order needs to include the solution to be administered, any additives to the solution, and either the rate of infusion or the total dose or volume to be infused over a specific time frame. The two major types of IV solutions are crystalloid solutions and colloidal solutions. Crystalloid solutions are composed of electrolytes dissolved in water and include dextrose solutions, sodium chloride solutions, balanced electrolyte solutions, and alkalizing and acidifying solutions. Colloidal solutions are composed of protein or starch, suspended in fluid and are not a true solution. Colloidal solutions are frequently referred to as plasma volume expanders because the larger molecules do not diffuse through cell membranes and draw fluid into the intravascular space. Colloidal solutions are used to maintain intravascular volume and prevent shock after major blood or fluid losses. Examples of colloidal solutions include albumin, dextran, and mannitol. Osmolarity, a measure of the concentration of the solution. The normal range for serum osmolality is 275 to 295 mOsm/kg. The normal range for the calculated osmolarity for body fluid and plasma is 270 to 300 mOsm/L. It is how water moves between the intracellular and extracellular compartments of the body. Solutions can be isotonic, hypotonic, or hypertonic Isotonic solutions have the same or nearly the same osmolarity as plasma and cause no movement of fluid into or out of cells. Iso means same or equal Tonic is the concentration of a solution remain in the extracellular compartment in either the intravascular or interstitial compartments. The osmolarity of plasma varies from 270 to 300 mOsm/L, and solutions are considered to be isotonic if their osmolarity is between 250 and 375 mOsm/L. Isotonic solutions are administered to dehydrated patients with deficits in intravascular volume because they increase the amount of fluid circulating in the vascular system without causing movement of fluid in and out of cells. Normal Saline D5W LR Used to increase the extracellular fluid volume in your body. Hypotonic solutions -- Hypo means under or beneath and tonic is concentration of a solution. The cell has a low amount of solute extracellularly and it wants to shift inside the cell to get everything back to normal via osmosis. This causes cell swelling which can cause the cell to burst of lyse. ½ NS Hypotonic solutions are used when the cell is dehydrated and fluids need to be put back intracellularly. Administration of hypotonic solutions hydrates cells but results in depletion of intravascular fluid volume. Hypotonic solutions are used in the management of hypernatremia, hyperosmolar conditions, hypertonic dehydration, and diabetic ketoacidosis after initial sodium chloride replacement. Watch for depleting the circulatory system of fluid since you are trying to push extracellular fluid into the cell to rehydrate. Never give hypotonic solutions to patients who are at risk for increased cranial pressure, extensive burns, trauma because you can deplete their fluid volume. Hypertonic solutions -Hyper-Excessive Tonic- concentration of a solution. The cell has an excessive amount of solute extracellularly and osmosis is causing water to rush out of the cell intracellularly to the extracellular areas which will cause the cell to shrink. 3% NS 10% Dextrose 5% dextrose in NS, ½ NS or LR These solutions are given in ICU as the patient needs to have close monitoring because of the quickly arising side effects of PE/Fluid overload. Also, these should be given via a central line because of the risk of infiltration. When administering any IV solution, the nurse needs to carefully monitor the fluid status of the patient regardless of the osmolarity of the solution being administered. This assessment includes respiratory status, vital signs, and skin turgor. Older adults and patients with compromised cardiovascular or renal function require even greater vigilance because of the risk of fluid overload. Most IV solutions are slightly acidic, which increases their stability and shelf life. Fluids or medications with a pH value of less than 5 or greater than 9 should be administered through a central line to avoid damage to the vein. The wrong diluent or incompatible solutions can alter the pH of a medication. Acidic medications are irritating to the walls of the vessels and can cause chemical phlebitis. Antibiotics are also a significant cause of phlebitis because of their low pH. Continually assessing peripheral IV sites where antibiotics are infusing to assess for signs of warmth and tenderness that may indicate phlebitis. The use of the wrong diluents can also alter the pH of a medication, and incompatible solutions can greatly affect the medication's pH. There are three main types of medication incompatibility. Physical incompatibility is the reaction that causes a visible change. This change may be in the form of color, cloudiness, haziness, turbidity, the formation of precipitate, and even the formation of gas. Precipitate formation is the most common physical incompatibility. Calcium in medication or solution increases the risk for precipitate. Ringer's solution is an example of a solution with calcium. The second type is chemical incompatibility, which correlates to the breakdown of the medication. This reaction will most likely not be visible. The most common reaction is the acid--alkaline reaction that results in an unstable pH of one of the medications. The third type of incompatibility is therapeutic incompatibility that causes an increased or decreased therapeutic response. The incompatibility may be undetected until the patient shows no clinical response to the medication. Therapeutic incompatibility may occur with the use of two antibiotics. Nurses must be vigilant about checking compatibility when giving IV medications, whether it is two medications together or the administration of an IV medication by direct IV or IV piggyback with a primary solution. \*\*\*\*\*\*\*\*\*\*\*\*VEINS USED IN INFUSION THERAPY The vein also needs to be large enough to accommodate the vascular access device selected while allowing for blood flow around the device. Nurses need to take into consideration patient condition, characteristics of the solution to be infused, volume and rate of the solution to be infused, and type of intravenous access device when planning infusion therapy. \*\*\*\*\*\*\*\*\*\*TYPES OF INTRAVENOUS ACCESS DEVICES Infusion therapy is divided into two general categories based on the location of the tip of the IVAD, peripheral or central. It is important to understand when peripheral infusion therapy is appropriate and when a CVA is preferred or required. Peripheral Venous Access Peripheral venous access describes when the tip of the IVAD terminates outside of the central vasculature in a peripheral vein. The most common type of peripheral IVAD is the short over-the-needle catheter. The flexible catheter is introduced into the vein over a metal needle that is then removed and discarded. The catheters range in length from 1 to 7.5 cm and in size from 14 to 27 gauge. Standardized catheter hub colors are used to identify catheter gauge Therapies utilizing a short peripheral catheter should be expected to last less than a week, and indications include hydration and administration of pain medications and some antibiotics. Another type of IVAD used for peripheral venous access, the steel-winged device (Fig. 10.4), is indicated only for short-term or single-dose therapy because the rigid steel needle is more likely to puncture the vein and lead to fluid or medication leaking out of the vein. This steel-winged device is often referred to as a butterfly because of the appearance of wings on each side of the needle. Short-term peripheral IV access is established in the superficial veins of the upper extremity It is recommended to start therapy in the most distal available and appropriate vein and move upward with subsequent insertions. Using more distal sites first preserves sites less distal for future insertions. Veins selected for short-term infusion therapy should be soft (nonsclerotic), nontender, and not in an area where a previous infusion has infiltrated. Areas of the vein containing a valve should also be avoided. Veins in areas of flexion such as the wrist and antecubital fossa should be avoided if possible because it is more difficult to stabilize the IVAD in these areas. The movement of an IVAD that is not firmly secured can cause mechanical irritation of the vein. Recommended veins for peripheral infusion therapy include the metacarpal, cephalic, basilic, and median veins. Veins in the lower extremities are not recommended for infusion therapy in the adult patient because of the high risk for thrombophlebitis. Use of a vein in the arm on the side where a patient has had a mastectomy or has dialysis access is also contraindicated because venous return in the extremity may already be compromised. Another type of peripheral infusion device is the midline catheter. Midline catheters are inserted in a peripheral vein in the upper extremities with tips that terminate distal to the shoulder in either the basilic, cephalic, or brachial vein. Midlines are appropriate for therapies expected to last between 1 and 4 weeks. The midline catheter is longer than the short peripheral catheter but is not a central catheter and should not be used to administer therapies when a central line is required, such as vesicants or other irritating solutions, parenteral nutrition solutions, or solutions with a pH of less than 5 or greater than 9 or osmolarity greater than 600 mOsm/L. Central Venous Access Central venous access (CVA) describes when the tip of the IVAD terminates in the central vasculature at the level of the superior vena cava or the inferior vena cava. Central venous catheters are made of silicone or polyurethane and come in many sizes and can have single or multiple lumens. Multiple-lumen catheters (Fig. 10.6) provide separate fluid pathways that make it possible to deliver two or more solutions at the same time. Each lumen, or fluid pathway, is totally separate from the other lumens. The fluid infused in each of the lumens leaves the central venous access device (CVAD) and enters the central venous system at different points along the catheter. These lumens are referred to as proximal, medial, or distal lumens depending on the location of the end of the fluid path on the catheter. Because the lumens are separate, incompatible solutions can be infused using the different ports attached to each of the lumens. Each port of the catheter is attached to a separate lumen that provides a distinct fluid pathway within the catheter. Each lumen requires initial flushing, which fills the catheter with the ordered IV solution, and flushing is also used to maintain the patency of the individual lumens if fluids are not being continuously administered. Manufacturers offer devices coated or impregnated with anti-infective agents and devices that can withstand the pressure created by the power injectors used in imaging studies. Types of IVADs used to obtain central venous access include nontunneled percutaneous central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters (PICCs). The tips of CVADs can be either open or closed. Closed CVADs contain a valve at the end of the catheter that prevents backflow of blood into the catheter when fluid is not being infused and minimizes the risk of the catheter clotting. Another important characteristic of the CVAD that nurses need to understand and communicate is the ability of the CVAD to tolerate the pressure created by the power injectors used during imaging studies. Factors that need to be taken into consideration when the selection of an appropriate CVAD is made include the therapy required by the patient, the projected length of therapy, the condition of the patient's veins, and the resources available to care for the device after insertion. These devices are placed by physicians or advance practice registered nurses. Nontunneled percutaneous central catheters are usually inserted in either the jugular or subclavian veins using venipuncture, and the tip of the catheter is advanced into the superior vena cava. The use of the femoral vein for nontunneled percutaneous catheters is used with caution because of the associated increased risk of infection. This type of CVAD is frequently used in emergency situations when peripheral access is not available. When the catheter is inserted in an emergency situation, it should stay in place no longer than 48 hours because of the risk of infection related to insertion in a less-than-optimal situation. Full barrier precautions (mask, gown, sterile gloves, and sterile drapes) are used for the insertion procedure. A chest radiograph is required before using the nontunneled percutaneous catheter to verify proper tip location and the absence of a pneumothorax that may have been inadvertently caused during insertion. Another disadvantage of this CVAD is easy dislodgement, and it is important to ensure the device is properly secured with an occlusive dressing. Tunneled catheters (Fig. 10.7) exit the skin from a site distal from the site where they enter the vein and are tunneled through the subcutaneous tissue between the exit and insertion site. The tip of the catheter is advanced from the insertion site to the central vascular. The tunneled portion of the catheter contains a Dacron cuff that tissue adheres to after insertion. The cuff stabilizes the catheter and provides a barrier to organisms, minimizing infection. This type of CVAD can be permanent and appropriate for patients requiring long-term therapy. The exit site is usually located on the chest and allows the patient easy access, promoting self-care. Tunneled catheters are inserted in nonemergency situations in sterile environments such as an operating or procedure room. Implanted ports (Mediports) are also used for long-term therapy and offer the added advantage of requiring minimal care when not in use. An implanted port consists of a small reservoir with a septum and an attached catheter (Fig. 10.8). The reservoir is placed under the skin. The preferred site is the upper chest wall because it allows the patient to more easily care for the implanted port. These implanted ports can also be placed in the upper extremity, abdomen, and back. The catheter is inserted in the vein near the reservoir, and the tip is advanced into the central vasculature. The entire device is located internally. In order to use the device, it needs to be accessed with a specially designed noncoring needle that is inserted using sterile technique through the skin and into the septum of the reservoir. Noncoring needles (Fig. 10.9) have a different bevel angle, allowing the septum of the port to be punctured multiple times without damage. Once the implanted port is accessed with the noncoring needle, it needs to either have a continuous infusion maintained or be flushed periodically according to institutional policy. Implanted ports can have one or multiple ports, and each port communicates with a separate lumen in the catheter and needs to be flushed separately. When not accessed, the ports interfere minimally with the patient's daily activities and require only infrequent flushing to maintain patency. Peripherally inserted central catheters (PICCs) are CVADs that are inserted into a peripheral vein and advanced into the central vasculature (Fig. 10.10). Peripherally inserted central catheters are frequently placed by registered nurses trained and competent in their insertion at the bedside with the assistance of ultrasound guidance. These catheters also have the advantage of being more cost-effective and easy to place and are appropriate for therapies of moderate to long-term duration. As with all CVADs, verification of tip placement is required with a chest radiograph before use. Ultrasound guidance can be used to confirm the placement of PICCs. Adjunct use of ultrasound by nurses has been shown to be of particular benefit for peripheral venous catheters when access is difficult. Recent studies show that the technique using electrocardiogram (ECG) guidance for CVADs is more reliable and of lower cost compared with ultrasound guidance. The ECG-guided technique is accurate for the correct positioning in terms of catheter tip--carina distance and catheter tip--tracheobronchial angle. The catheter tip is in ideal position when the P-wave amplitude peaks. If the P-waveform becomes negative, the catheter has passed the distal vena cave and has entered the right atrium of the heart and has lost its position. The veins used for PICC insertion are usually the larger veins in the upper extremities. If infusion therapy using short peripheral therapy with repeated venipunctures has compromised these veins, PICC placement is much more difficult. Early placement of PICCs needs to be considered in patients who require therapies of longer than a few days to maximize the availability of veins that have not previously been accessed. The length of the fluid pathway in a PICC requires special attention to flushing to maintain patency because they need to be flushed before and after each use and periodically when not in use. Care needs to be taken when flushing a PICC so that excess pressure does not damage the thin walls of the catheter. Unless a PICC is specially designed to withstand higher pressures, only 10-mL or larger syringes, or flushing syringes especially designed to limit the amount of pressure they exert, should be used when flushing the PICC or administering medications through the PICC. If there is a possibility of the need for imaging studies requiring power injection, the power PICC is designed to withstand imaging contrast. \*\*\*\*\*\*\*\*\*\*Administration sets are either primary or secondary sets (Fig. 10.13). Primary sets are used to deliver the main IV solution, and secondary sets are attached to the primary set to deliver additional solutions or intermittent medications into a y-site in the primary infusion set. These administration sets use gravity to deliver fluids into the vasculature. Administration sets allow for the control of delivery rates using a roller clamp. The infusion rate is determined by the drip factor of the infusion set. Macrodrop administration sets have drip factors of 10, 15, or 20 drops/mL and are appropriate when delivering higher infusion rates. Microdrop administration sets have drip factors of 60 drops/mL and are appropriate when delivering rates of less than 100 mL/min. To determine the infusion rate, use the following equation: milliliters per minute × drop factor = drops per minute There are situations when more accurate rate control is needed than can be provided by gravity administration set roller clamps, and one possible solution is the use of an electronic infusion device or pump. These infusion pumps can deliver solutions and medications with a greater degree of accuracy and can alert the nurse to situations when the infusion has slowed or stopped because of kinked tubing or increased resistance that can indicate that the IV catheter is clotted or has infiltrated into the subcutaneous tissue. Some electronic infusion devices use standard administration sets, whereas others require administration sets specifically designed for use in the device. Electronic infusion devices assist the nurse in providing accurate infusion therapy, but the nurse is still responsible for monitoring the delivery of the therapy. Smart IV infusion pumps were designed to prevent errors. Although these pumps have Dose Error Reduction Software, the research shows that they fail to prevent certain types of IV medication administration errors, and may in fact cause some IV medication errors themselves. Difficult interfaces and complex programming can create serious human errors. Currently, there is no smart infusion pump manual describing error types and prevention strategies. These safety improvements require input from all disciplines including nurses, physicians, pharmacists, informatics, and safety and regulatory experts. Adherence to clinical practice policies and procedures is crucial to the prevention of medication errors. \*\*\*\*\*\*\*\*\*\*NURSING MANAGEMENT OF INFUSION THERAPY Monitoring and Preventing Complications The fluid status of patients receiving IV fluids needs to be monitored to ensure that the intended outcome of therapy is being achieved; Hypertonic and hypotonic fluids place the patient at the greatest risk for fluid imbalance and require more intense monitoring. Fluid status is monitored with physical assessment, periodic weights, and accurate measurement of intake and output. Laboratory values, particularly serum electrolytes, need to be monitored for further indications of fluid balance. Phlebitis and Infiltration Complications of peripheral infusion therapy include phlebitis and infiltration. Phlebitis, inflammation of the vein, is characterized by pain and erythema along the vein Peripheral sites that show signs of phlebitis should be removed and restarted in another location because phlebitis can progress to more serious conditions, including thrombus formation, cellulitis, and sepsis. The antecubital fossa site has been shown to have the lowest phlebitis rates, whereas hand veins have a high risk of phlebitis. Causative factors of phlebitis are divided into three categories: chemical, mechanical, and bacterial. Chemical phlebitis is the result of the infusion of irritating solutions and medications that occurs when the peripheral vein does not allow for sufficient hemodilution of the IV fluid as it exits the catheter. pH is an important factor in chemical phlebitis. Medications such as vancomycin and potassium can be very irritating to veins and are better tolerated in a central IV catheter. Mechanical phlebitis is the result of the catheter irritating the vein wall and can be caused by introducing a catheter too large for the vein, inadequately securing the catheter, or movement of the catheter placed in an area of flexion such as the elbow or wrist. Bacterial phlebitis is the result of bacteria being introduced into the catheter because of improper IV technique, inadequate site cleaning before venipuncture, failure to clean ports before accessing the administration set, failure to allow alcohol to dry before proceeding, or failure to perform adequate hand hygiene The insertion sites of peripheral vascular access devices need to be assessed at regular intervals. It is important to continue to assess the site after the peripheral catheter has been removed because phlebitis can develop after the infusion has been completed. A rare type of phlebitis is postinfusion phlebitis. This is a late reaction after the IV catheter has been removed. This may occur within 3 to 4 days later, and the patient may have been discharged and home. It occurs due to the damage of the catheter to the internal vein. Before discharge, patient education is important to alert the patient to observe the IV site for pain, swelling, and tenderness, and to notify a healthcare professional if these symptoms persist. Infiltration occurs when a solution or medication is inadvertently infused into the tissue surrounding the vein and is a complication that can occur with any IVAD, peripheral or central. When the solution or medication that infiltrates is a vesicant (able to cause blisters), an extravasation (leakage of IV fluid into subcutaneous tissue) has occurred. Medications that are classified as vesicants include specific antineoplastic agents, antibiotics, and vasoactive medications. Nurses administering vesicants require additional education to ensure competency, and infusion should be routinely assessed for possible infiltration at intervals established by institutional policy. Clinical manifestations of infiltration include blanched skin, skin cool to the touch, edema, unexpected pain or burning at the insertion site or along the path of the vein, and leaking of fluid from the insertion site. Assessment intervals need to take into consideration the patient's condition, type of device, type of therapy, and risk factors. In the case of an extravasation, the infusion needs to be stopped immediately, and corrective action needs to be taken to minimize damage to the tissue. Central Line Complications Complications of central venous infusion therapy can affect the cardiac, vascular, and pulmonary systems. Infection and loss of patency are also issues with central lines. If the guide wire comes in contact with the right atrium, arrhythmias will occur during the procedure. Vascular complications include arterial injury during insertion, and pulmonary complications may include pneumothorax and air embolism. Strategies have been implemented in healthcare institutions to eliminate infections of central venous catheters (CVCs) because of their negative effects on patient outcomes and the high cost of treating central line--associated bloodstream infections. Infections of central lines can result in sepsis and shock sterile barrier precautions, including mask, sterile gown and cap, sterile gloves, and large full-body drapes, while inserting a CVAD is now the standard of practice. Loss of patency, or occlusion, of a CVC can delay the delivery of lifesaving therapies and may also mean the patient is subject to the risk and discomfort of insertion of another CVC. Occlusions can be the result of a thrombotic process when blood or fibrin in or around the catheter interferes with flow. Thrombotic occlusions can result in slowed infusion rate and resistance to flushing or the complete inability to infuse or flush the catheter. Proper flushing before and after use of the catheter and at intervals when the catheter is not in use decreases the occurrence of thrombotic occlusions. Occlusion can also be nonthrombotic (not resulting from a clot) and can result from medication precipitation. Medication precipitation occurs when incompatible medications are administered together or without adequate flushing between administrations of the incompatible medications. Nurses need to verify that medications being administered together by the IV route are compatible with the solution infusing and any other medications that may still be in the line or catheter. An air embolism occurs when air is inadvertently introduced into the venous system. Risk factors may include hypovolemia and central venous access, pressurized infusions, surgical position, and trauma. The pulmonary outflow tract and pulmonary vessels become obstructed by large air bubbles. This causes decreased blood return from the right ventricle, thus causing increased central venous pressure (CVP). Air can be introduced if the catheter is damaged, during insertion and removal of CVCs, and if the connections in the IV delivery system (e.g., catheter hub, tubing, injection caps) are not tightly secured with Luer-locked connections. Nursing actions that can prevent air embolism include proper Trendelenburg positioning during CVC insertion (10--30 degrees), avoiding CVC insertion during inspiration, correcting hypovolemia before CVC insertion, ensuring all IV connections are intact and secure, and ensuring all lumens are capped and/or clamped. Additional actions include using Luer-locking connections, frequently checking the connections, and clamping catheters and injection sites when not in use. Other preventive measures include using infusion pumps, priming (flushing all the air out of the IV tubing with the ordered solution) all IV tubing before connecting to the CVC, expelling air out of all syringes before use, and inspecting all lines and connections. Ensure the central line dressing is intact, and use caution when prepositioning the patient. Symptoms of air embolism may include dyspnea, tachycardia, cough, syncope, and hypotension. The CVC should be removed only by personnel competent to perform this procedure, and removal should be performed with the patient in a supine position. Before removal, the patient should be instructed to perform a Valsalva maneuver or exhale during the removal to prevent the introduction of air into the line. The catheter should be removed slowly, and a sterile occlusive dressing should be placed over the insertion site immediately and left in place for 24 hours. \*\*\*\*\*\*\*\*\*\*\*\*Maintaining Intravenous Access maintain the patency of both peripheral and central IVADs, proper flushing is required, and all IVADs need to be flushed before use to establish that they have been placed properly and are functioning correctly. Single-use vials or prefilled syringes of preservative-free 0.9% saline are the preferred methods of delivering flushes because they require less manipulation and are less likely to be contaminated. Whenever manipulating an IVAD, it is imperative to perform hand hygiene and to clean the injection ports before every entry. The injection port needs to be cleaned with alcohol or chlorhexidine and allowed to dry completely Catheters are flushed with a volume twice that of the catheter and any attached extension tubing recommends a flushing and locking protocol. "Flushing" is the act of moving fluids, medications, blood, blood products, and nutrients out of a vascular access device into the bloodstream, ensuring delivery of these components and verifying device patency. "Locking" is the instillation of a solution into a vascular access device to maintain device patency. The patency of CVADs requires a continuous infusion or periodic flushing. CVADs need to be flushed after the administration of a medication or blood product, when changing from a continuous infusion to an intermittent "locked" device, and also after the withdrawal of blood and when not in use. All IVADs, are dressed with a sterile occlusive dressing to prevent bacterial contamination of the site. Transparent semipermeable dressings offer the advantage of allowing a clear view of the insertion site for assessment, but gauze dressing occluded with tape is acceptable. Dressings should be changed immediately if they are no longer occlusive or become moist. Peripheral IVADs do not require routine dressing changes or site care. Sterile gloves should be worn when changing a CVAD dressing to decrease the risk of infection. Rotating peripheral IV sites every 72 to 96 hours is unpleasant for the patient and expensive in terms of supplies and nursing time peripheral catheters should be replaced when clinically indicated, not at set intervals. Clinical indications for the removal of a peripheral catheter include whenever the patient reports discomfort or pain related to the infusion site and assessment findings indicating possible phlebitis, infiltration, or occlusion. Administration of Intravenous Medications The order of a licensed independent practitioner needs to indicate which method is to be used. Continuous infusion refers to the ongoing administration of a solution and can be ordered as a specific rate per hour (e.g., 125 mL/hr) or a volume over a time period (e.g., 1,000 mL over 8 hours). Clarification needs to be obtained for orders indicating a "keep open rate" or "keep vein open" (KVO) to obtain a more clearly defined rate unless a "keep open rate" is defined in institutional protocols. Veins should never be kept open with solutions containing medications such as potassium because insufficient amounts will be delivered to be therapeutic. Intermittent infusions can be given through the injection port on the administration set of the continuous infusion ("piggyback") or infused into the injection port of the locked IVAD. Intermittent infusions concurrent with a continuous infusion need to be compatible with the continuous infusion. If not compatible, the continuous infusion needs to be stopped while the intermittent infusion infuses and the tubing of the infusion set is cleared or flushed with a compatible solution, usually 0.9% normal saline. Before administration of an intermittent infusion through a locked IVAD, the IVAD device needs to be flushed to ensure proper functioning of the device and clearing of any potentially incompatible solution. When the intermittent infusion is completed, the IVAD then needs to be flushed again and relocked. When intermittent infusions are administered either into a continuous infusion or into a locked IVAD, the IV system needs to remain closed, and the tubing should not be disconnected to prevent the introduction of microorganisms into the IV system. Flushing and administration of intermittent infusions are done through an injection port that has been cleaned with alcohol or chlorhexidine, per institutional protocol, and allowed to completely dry. Bolus infusions are concentrated medications and/or solutions given over a short period of time. This is the method used when administering a "fluid bolus" or "fluid challenge" to a patient who may have a low urine output because of decreased fluid volume status. Boluses are usually administered with small-volume solution containers (250 or 500 mL) in a manner similar to an intermittent infusion but over a shorter time period. Patients receiving bolus infusions need to be monitored closely to ensure they are tolerating the volume infused. IV push, or direct IV, is the manual administration of a medication using a syringe. Special attention needs to be given to the correct concentration and rate of administration of medications given with this method. Some medications need to be diluted before administration to ensure a safe concentration and to more accurately control the rate of administration. IV push medications can be given into a locked IVAD or into an IVAD with a continuous infusion. Before administration, the IVAD and any tubing between the injection port and the IVAD needs to be flushed to ensure proper functioning of the device and clearing of any potentially incompatible solution or medications. Flushing and administration of the IV push are done through an injection port that has been cleaned with alcohol or chlorhexidine and allowed to completely dry. After the IV push medication has been administered, the IVAD needs to be flushed again. Keep in mind that the rate of this flush needs to be at the same rate that is acceptable for the medication administration because the medication that is in the tubing and IVAD will be flushed through and administered to the patient at the flush rate. \*\*\*\*\*\*\*\*\*Administration of Blood Products Transfusion of blood components is a lifesaving therapy that includes risk and requires meticulous adherence to procedures and policies along with close monitoring of the patient. Modern practices for blood collection include multiple screening tests and volunteer donors, rendering the blood supply relatively free of the risk of transmissible diseases such as syphilis, hepatitis, and HIV. Transfusion of whole blood is rare because it is more efficient to administer only the portion of the blood, or component, required by the patient (Table 10.5). Also, 1 unit of donated blood can be separated into individual components that can benefit multiple recipients. Components commonly infused include RBCs, fresh frozen plasma (FFP), platelets, granulocytes, clotting factors, and albumin. Before releasing a blood component for administration to a patient, the blood bank or laboratory carefully matches the intended component to the sample of the patient's blood to ensure that they are compatible Antigens present on the surface of the RBC determine the ABO blood type of the patient. Antibodies to the ABO antigens are in the plasma, which means ABO antigens present on the transfused blood will be attacked by the antigens in the recipient's blood if they do not have the same ABO antigens. This causes a hemolytic transfusion reaction. The Rh antigen is another antigen on the RBC that is either present (Rh-positive) or absent (Rh-negative). Recipients who are Rh-negative should receive only Rh-negative blood, but recipients who are Rh-positive can receive either Rh-positive or Rh-negative blood Patient identification and specimen labeling of blood samples collected from the patient need to be done with extreme care and usually require independent identification by two separate healthcare providers. Because blood components are "living transplants," they need to be stored according to strict standards. Even though most blood components contain preservatives, they are stored in the laboratory until just before their transfusion. There are strict time limits placed on how long blood products can be outside of storage in the laboratory before administration and on the length of time over which they can be infused. Nurses must be knowledgeable of these timelines and follow the guidelines established by the institution where they practice. Each component or unit is accompanied by a unique form that provides information about the blood product. Before the blood component is obtained from the laboratory, the patient's informed consent and an order for the administration of the blood component need to be confirmed. The order should indicate the type of blood component to be administered, the number of units or volume of the blood component to be infused, the flow rate or duration of the infusion, and other parameters for infusion. Because there is a limited amount of time allowed for the component to be outside the controlled storage conditions of the laboratory, the nurse needs to confirm adequate IV access and that all supplies and equipment needed for the transfusion are available before the blood component is released from the laboratory for administration. Once the component is obtained from the laboratory, there needs to be verification performed by two licensed staff members, which includes matching the blood product to the order and matching the patient to the blood product. The blood product should agree with the type of component prescribed, the volume or number of units to be transfused, and the patient's full name and one other patient identifier. The ABO and Rh compatibility of the donor and recipient also needs to be confirmed before the initiation of the transfusion. The expiration date and the date and time the component was released from the laboratory need to be confirmed as acceptable. Immediately before starting the blood transfusion, a patient assessment needs to be completed, including baseline vital signs and respiratory status. The nurse needs to explain the procedure and confirm patient understanding, including clinical manifestations to immediately report. Blood transfusions can be an anxiety-producing situation, and adequate time for explanations and questions needs to be provided. Close observation is required to detect any reaction the patient may have to the blood product (Table 10.7), especially during the first 15 minutes when reactions are most likely to occur. Assessments should continue at least every hour for the duration of the transfusion and should include respiratory status; vital sign status; and any complaints of discomfort, dyspnea, or itching. The type of component ordered determines the method of administration and the type of equipment needed for the infusion. There are special filters and tubing for each type of blood component, but the only type of infusion solution used in flushing administration sets and IVADs, and in the administration of any of the blood components, is 0.9% sodium chloride. The rationale for this fluid is because it is isotonic and does not cause fluids to move into or out of the transfused RBCs. The gauge of the IVAD used for transfusion needs to be large enough to facilitate the required flow rates so that the blood is transfused within the prescribed time frame. An 18- to 20-gauge catheter is recommended for the infusion of packed RBCs in the adult population to prevent RBC lysis. Packed RBCs consist of the cells that remain after the plasma portion of the whole blood is removed. Packed RBCs are the component that is used for most blood replacement therapy, including acute blood loss, and chronic symptomatic anemia that does not respond to pharmacological therapy. In certain situations, RBCs that have undergone special processing are ordered to meet special patient needs. These types of packed RBCs include irradiated and leukocyte-reduced RBCs. Irradiating RBCs inactivates donor lymphocytes and reduces allergic and febrile reactions in some patients. Leukocyte-reduced RBCs decrease febrile reactions in recipients with high levels of leukocyte antibodies. A single unit of packed RBCs has a volume between 225 and 300 mL and is usually infused over 1.5 to 2 hours but no longer than 4 hours. The integrity of blood products infused over periods greater than 4 hours is compromised, and any remaining product not infused in the 4-hour period needs to be returned to the laboratory. Administration sets used to infuse packed RBCs are either a straight or y-type set with a 170- to 260-micron filter. Filters of this size allow for the movement of the RBCs through the filter but stop any small clots or other debris. The tubing is primed with 0.9% sodium chloride before use. \*\*\*\*\*\*\*\*\*\*\*Administration of Total Parenteral Nutrition The use of the intravenous route to provide nutrition is indicated only when it is not possible to provide adequate nutrition using the oral or enteral routes. Intravenous total parenteral nutrition (TPN) is associated with increased risks to the patient and greater costs. Parenteral nutrition solutions provide the major macronutrients (protein, carbohydrates, and lipids) along with required micronutrients (electrolytes, vitamins, and trace minerals) and water. The protein required by the body for growth, maintenance, and repair of tissues is provided in TPN in the form of amino acids in a combination that meets the body's needs. Carbohydrates are supplied by dextrose in the TPN solution. Lipid emulsions may be included to provide an additional source of energy and serve as a source for essential fatty acids. Lipids can either be contained in the primary TPN solution or infused separately. Total parenteral nutrition solutions are prepared in the pharmacy under special conditions to reduce the risk of bacterial contamination. Infusion of additional medications in the TPN solution is institution specific, and the risk of infection and medication incompatibilities needs to be carefully evaluated. Medications that are added in some institutions include insulin, heparin, and H2-receptor antagonists. Because of the high concentrations of dextrose, TPN therapy is initiated gradually, and the patient's glucose and fluid tolerance are evaluated as the infusion rate is gradually increased until the targeted rate is reached. Blood glucose levels may be monitored every 6 hours, and an insulin scale is used to control blood glucose levels. Similarly, when the therapy is being discontinued, the rate of infusion should be gradually decreased as the patient adjusts to decreased amounts of concentrated IV dextrose and fluids. When TPN is infused, special precautions are implemented to prevent complications. Because of the high osmolarity of TPN solutions, they should be infused into a CVAD with the tip placement confirmed in the vena cava. This allows for hemodilution of the TPN solution, decreasing the risk of phlebitis, thrombosis, and pain. The infusion system used to administer TPN should remain a closed and dedicated line and should not be used to administer other medications or access the CVAD for any reason. The administration set used to infuse TPN should be changed every 24 hours to decrease the risk of contamination and infection. \*\*\*\*\*\*\*\*\*\*Patient Teaching One of the most important roles of the professional nurse in infusion therapy is patient and family education because they have the right to be involved in their care. In order to be actively involved and make decisions about the care they receive, patients need to be educated on the alterations in their health that require infusion therapy, the infusion therapies prescribed, and the expected outcomes and possible complications of the therapies. Before the insertion of any IVAD, peripheral or central, the patient needs to be educated and learning verified regarding the rationale for the IVAD, alternatives to the selected device, and expectations during the insertion of the device, including the level of expected discomfort. Patients are also educated on the measures used to decrease discomfort and possible complications. The practice of aseptic techniques needs to be explained to the patients, and return demonstration by the patient, family member, or significant other of aseptic technique in caring for the IV access is included in the education. Patients are informed of the type of IV solution and/or medications to be administered, including the reasons they are being administered, expected outcomes, and possible complications. During therapy, the patient's understanding of the importance of reporting any unexpected outcomes and signs of possible complications is assessed. Patients are taught measures to prevent possible complications, including reporting any discomfort or redness at the insertion site, temperature elevation, and whenever the IVAD dressing is no longer occlusive or is wet. Patients are encouraged to monitor hand washing and proper cleaning of ports in the IV delivery system before entry by all healthcare personnel. It is the professional nurse's responsibility to administer IV solutions and medications as prescribed and know the expected outcomes and possible side effects of the solutions and medications administered. Additionally, it is an expectation that the nurse is competent in the techniques used to provide infusion therapy and in monitoring the patient for responses to therapy and the development of any undesired outcomes or complications. The need for continuous infusion therapy and IV access is evaluated periodically, and discontinuation is considered as soon as therapy can be delivered by other, less invasive routes.