IV Therapy Lecture Overview PDF

Welcome to week two of IV Therapy Lecture. Today we're covering an overview of infusion therapies. Our objectives for this lecture will be discussing reasons patients require IV infusion. Describing the characteristics of common IV solutions. Comparing peripheral and central venous access. Describin...

Welcome to week two of IV Therapy Lecture. Today we're covering an overview of infusion therapies. Our objectives for this lecture will be discussing reasons patients require IV infusion. Describing the characteristics of common IV solutions. Comparing peripheral and central venous access. Describing the equipment used to provide infusion therapy, and describing potential complications of infusion therapy, as well as strategies to prevent these complications. We will also develop a teaching plan for a patient receiving infusion therapy. Concepts covered in this lecture will be assessment. Fluid and electrolyte balance. Medications. Nutrition and skin integrity. In today's healthcare environment, infusion therapy is delivered to patients across the continuum of care. Patients receive infusion therapy in hospitals, extended care facilities, outpatient clinics, infusion centers, and at their homes. The Infusion Nurses Society, or I.n.s., will be referenced many times throughout this class. It's a national organization that has established evidence based practice standards of care to guide the delivery of infusion therapy. Patients require infusions 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 even long term therapy required for a lifetime. Solutions used in infusion therapy require specific I.V. fluid order by a licensed health care provider. The order needs to include solution to be administered, any additives to the solution, and either the rate of infusion, or a total dose or volume to be infused over a specific time frame. The two major types of I.V. solutions are crystalloid solutions and colloidal solutions. crystalloid solutions are composed of electrolytes dissolved in water. This includes dextrose solution, sodium chloride, balanced electrolyte solutions, and alkalizing and acidifying solutions. Colloidal solutions are composed of larger molecules, usually a protein or starch, and suspended in fluid. Colloidal solutions are frequently referred to as plasma volume expanders because the larger molecules are not diffused through the cell membrane, and they draw fluid into the intravascular space. These solutions are used to maintain intravascular volume and to prevent shock after major blood or fluid losses. An important characteristic of IV solutions in general is their osmolarity. This is a measure of concentration of the solution. It's expressed in terms of the number of particles or osmoles per liter of solution. The concentration of the solution influences how water moves between the intracellular and extracellular compartments of the body. Normal blood and body solutions have a calculated osmolarity of 270 to 300, and depending on their osmolarity, solutions can be categorized into isotonic, hypotonic or hypertonic solutions. There's a table in your book that has the osmolarity of intravenous solutions that you should review. So isotonic solutions have the same osmolarity as plasma. They cause no movement of fluid into or out of the cells. Isotonic solutions remain in that extracellular compartment in either the intravascular or interstitial compartments. The osmolarity of plasma varies from 270 to 300, and solutions are considered to be isotonic if their osmolarity is between 250 and 375. Isotonic solutions are administered to dehydrated patients with deficits in intravascular volume because they increase the amount of circulating fluid in the vascular system without causing movement of fluid in and out of cells. Common isotonic fluids that you will see in practice is 0.9% sodium chloride, which you will hear is often referred to as NS and then lactated ringers, which you will hear as LR. Hypotonic solution are lower solution concentration in plasma, and cause fluid to move from the intravascular space into both the intracellular and interstitial spaces. This hydrates the cells but results in depletion of intravascular fluid volume. An example of this type of solution would be 0.45% sodium chloride or half sodium chloride, half NS. Hypotonic solutions are used in the management of hypernatremia, as well as in conditions like diabetic ketoacidosis after initial sodium chloride replacement. Extreme caution needs to be exercised when solutions that are not isotonic are being administered because of these resulting fluid shifts, and they should be administered for only brief periods of time. Hypertonic solutions have a concentration higher than plasma and cause fluid to move from this cells into the intravascular space. This will cause your cells to shrink. Because of the danger of circulatory overload. These solutions are given only in critical situations. Solutions with a concentration of greater than 600 mili osmoles per liter should be administered only via a central venous access, where there is adequate blood flow to dilute the solution and prevent damage to the vein as the hypertonic solution infuses. So a common example of a hypertonic solution that you may see is 3% sodium chloride. Careful monitoring of fluid status, regardless of what solution is being administered, is important. Assessment includes vital signs, respiratory status, and skin trigger. Older adults and patients with compromised cardiovascular or renal function require even greater vigilance because of the risk of fluid overload. Most I.V. solutions are slightly acidic. This increases their stability and shelf life. Medications with a pH of less than seven are acidic. If the pH is greater than seven, they are considered basic or alkaline. Fluids or medications with a pH less than five or greater than nine should be administered through a central line to avoid damage to the vein. Important nursing implications to remember is that the wrong dilutent or incompatible solution can alter the pH of a medication. Acidic medications are irritating to the walls of the vessels. They can cause chemical phlebitis, which is irritation of the vein wall. Antibiotics are also a significant cause of phlebitis because they have a lower PH Nurses need to be attentive to continually assessing peripheral IV sites where antibiotics are infusing, to assess for signs of warmth and tenderness that may indicate phlebitis. The use of the wrong dilutents can also alter the pH of a medication, and incompatible solutions can greatly affect the medications pH as well. Incompatibility is the undesirable reaction occurring between two medicines or a medication in its diluent. There are three main types of medication incompatibility, there are physical, chemical, and therapeutic. Physical incompatibility is the reaction and it causes a visible change. This change may be in the form of color, cloudiness, haziness, turbidity, and the formation of a 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. Ringers solution as an example of a solution with calcium. The second type of incompatibility is chemical. This 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 just an unstable pH of one of the medications. The third type of incompatibility is therapeutic, which causes an increased or decreased therapeutic response. The incompatibility may be undetected until the patient shows no clinical response to the medication. Therapeutic incompatibility may occur with the use of two antibiotics. For example, aminoglycosides may be inactivated when given with penicillin or cephalosporins. Therefore, they must be given in separate sites one hour apart. Nurses must be vigilant about checking compatibility when giving IV medications. Whether it is two medications together, or the administration of an IV medication by direct IV or IV piggyback with a primary solution. Compatibility charts are readily available in those facilities, and many health care facilities utilize micromedex as a standard for checking compatibility of medications and solutions. The pharmacist is also an additional resource for information about medication compatibility. When we talk about the veins used in I.V. therapy, the diameter of the vein and the blood flow within the veins increases as the veins get closer to the heart. Larger veins with greater blood flow are appropriate when infusing larger volumes of fluid, or when the osmolarity of a solution or the pH is outside normal range. The vein also needs to be large enough to accommodate the vascular access device selected, while allowing for the blood to flow around the device. The nurse needs to take into consideration the patient condition. The characteristics of the solution being infused. The volume and rate of the solution and the type of access device available. When planning infusion therapy. This is just a review of the layers of the vein. The vein wall consists of three layers the innermost, middle, and outer layers. Remember that our veins also have valves, and valves aid in the return of blood to the heart by preventing backflow of blood, as veins are compressed by the surrounding skeletal muscles. So when we're initiating an IV. Sometimes you're able to visualize these valves on a patient. You want to avoid these areas because you won't be able to get your needle or your plastic catheter past these valves. Infusion therapy is divided into two general categories based on the location of the tip of the access device. They may be peripheral or central. It is important to understand when peripheral infusion is appropriate and when central venous access is preferred or even required. The access device should be the smallest gauge in length with the fewest number of lumens. It should be the least invasive to provide the ordered infusion therapy. In your book, there's a box for obtaining peripheral IV access that I would like you to review. Peripheral venous access terminates outside of the central vasculature in the peripheral vein, the most common type of peripheral IVAD, that is the short over the needle catheter. The flexible catheter is introduced into the vein over a metal needle and then that is removed and discarded. The catheters range in length from 1 to 7.5 centimeters in size, and from 14 to 27 gauge. There is standardized catheter hub color used to identify the different sized needles. The bigger the gauge, the smaller the needle diameter, so a 24 peripheral I.V. catheter is going to be significantly smaller than an 18 gauge peripheral IV catheter. The steel wing device is indicated only for short term or single dose therapy. Because of the rigid steel needle, it's more likely to puncture through the vein and lead to fluid or medication leaking out of the vein. The steel-winged device is often referred to as a butterfly. I feel like that is commonly how you would probably hear it in practice, because of the appearance on the wings on each side. I would say this is often what you're going to see if someone is just needing a lab draw and we're not drawing from the IV. You're probably going to be using a butterfly needle to collect your labs. In your book, there's a table for peripheral catheter gauge selections and clinical indications that I would like you to review. When selecting a site for short term peripheral I.V. access. Using more distal sites, first preserve sites less distal for feature insertion, so you want to start down lower on the arm. Veins selected should be soft or non sclerotic. They should be non tender and not in an area where a previous infusion has infiltrated. Areas of the vein containing a valve should be avoided. Veins in areas of flexion like their wrist in antecubital fossa or AC should be avoided if possible because it is more difficult to stabilize the area. Veins in the lower extremities are not recommended for infusion therapy in the adult, because they're a high risk for thrombophlebitis this way. The 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 the venous return in the extremity may already be compromised. These patients, if you're inpatient in the hospital, often also have a limit alert bracelet on that will help to alert you. We should be avoiding that side. So a midline catheter is another type of peripheral infusion device. Midline catheters are inserted in the peripheral vein in the upper extremities, with a tip that terminates distal to the shoulder. So we're not quite to the shoulder yet. And either the basillic cephallic or brachial vein. The midline catheter is longer than a short peripheral catheter, but it is not a central catheter, so it should not be used to administer therapies where a central line is indicated, such as a vesicant or other irritating solution. That may be TPN, solutions with the pH of less than five or greater than nine, or solutions within osmolarity greater than 600. Therapy with mid lines is expected to last between 1 and 4 weeks. So we'll move on to central venous access. The tip of these terminate in the central vasculature at the level of the superior vena cava, or the inferior vena cava. They come in many sizes. They have single or multiple lumens. Multiple lumen catheters provide a separate fluid pathway that makes 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 and enters the central venous system at different points along the catheter. These lumens are referred to as proximal, medial, and distal 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 different ports attached to each of the lumens. So if you have two incompatible meds, you can infuse one in blue and one in red. They're right next to each other, but they have separate fluid pathways. So as long as they're in separate ports, it is okay to be infusing at the same time. Each lumen requires initial flushing, which fills the catheter with the ordered I.V. solution, and flushing is also used to maintain patency of the individual lumen if fluid is not being continuously administered. Manufacturers offer devices coated or impregnated with anti-infective agents that can be placed on ports that are not in use. These are often green caps that you'll see in the hospital. They also have devices that can withstand the pressure created by the power injectors you use in imaging studies. An example of this would be a CT that requires I-V contrast. The pressure of the I.V. contrast is significant, so you need to make sure that your I.V. access can withstand the pressure. Often, almost always, the central venous access and larger gauge peripheral accesses can withstand that pressure. The types of CVADs that we're going to talk about are non tunneled percutaneous central catheters, tunnel catheters, implanted ports and peripherally inserted central catheters, also referred to as PICCs. The tips of the CVAD can be 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. Non tunneled percutaneous central catheters are usually inserted in either of the jugular or subclavian veins using veinipuncture and the tip of the catheter is advanced into the superior vena cava. The use of the femoral vein for non tunneled percutaneous catheters is used with caution, because of the associated risk of infection, just on where it is anatomically on your body. 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 for no longer than 48 hours because of the risk of infection related to the insertion in a less than optimal situation. When these are inserted, everyone is wearing full barrier precautions. The provider inserting is wearing a mask, gown, sterile gloves and sterile drapes are used during the insertion procedure. A chest X-ray is required prior to using this catheter to verify proper tip location. and the absence of a pneumothorax that may have inadvertently been, um, caused during the insertion. A disadvantage of this CVAD is easy dislodgement, and it is important to ensure that the device is properly secured with an occlusive dressing. Tunnel catheters exit the skin from a site distal from the site where they enter the vein, and are tunneled through the subcutaneous tissue between the exit and insertion site. The tip of the catheter is advanced from the insertion site to the central vasculature. The tunneled portion of the catheter contains a cuff that tissue adheres to after insertion. This cuff stabilizes the catheter and provides a barrier to organisms minimizing infection. The exit site is usually located on the chest and allows for the patient easy access, promoting self care. Tunnel catheters are inserted in non-emergency situations in sterile environments, such as the operating or procedure room. Implanted ports are also used for long term therapy, and have the other added advantage of requiring minimal care when they're not in use. An implanted port consists of a small reservoir with the septum and an attached catheter. 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 ports can also be placed in the upper extremity or abdomen, or even the 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, so it's all underneath the skin. In order to use this device, it needs to be accessed with a specially designed non coring needle that is inserted using sterile technique. This can be done by a nurse. Once you're trained on it, it goes through the skin and into the septum of the reservoir. Once the implanted port is accessed with the needle, it needs to either have a continuous infusion maintained or to be flushed periodically according to institutional policy. Implanted ports can have one or multiple ports. Each port communicates with a separate lumen in the catheter, and all need to be flushed separately. When not accessed, ports interfere minimally with the patient's daily activities and require only infrequent flushing to maintain patency. Peripherally inserted central catheters or PICC lines are CVADs that are inserted into a peripheral vein and advanced into the central vasculature. Peripherally inserted central catheters are frequently placed by registered nurses, trained and competent in their insertion at the bedside with the assistance of ultrasound. As with all central lines, verification of tip placement is required with a chest X-ray prior to use. Ultrasound guidance can also be used to confirm the placement of PICCs. The length of the fluid pathway in the PICC requires special attention. You can see how long it is in that image there. They need to be flushed before and after each use, just like any line, and then 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. If there is a possibility of the need for imaging studies requiring power injection, the power PICC is designed to withstand imaging contrast. Access to the central venous system is also possible using the intra osseous access. This is accomplished using a handheld driver. The IO device is inserted into the vasculature of the bone marrow, allowing for infusion of fluids and medications. Any medication or fluid that is administered by IV can be administered IO. The insertion site is covered with a sterile occlusive dressing to decrease the risk of infection. The patient, if conscious, will require pain medicine if experiencing discomfort and pressure during rapid infusions. It is often not the insertion that is painful. It is the infusion of medicine or fluids that is painful. Inter osseous access can be accomplished in under one minute. It is especially useful in severely dehydrated patients and for prehospital vascular access. It is becoming more common for IO lines to be placed by EMTs prior to arrival to the hospital. Frequently used sites in adults include proximal humerus, proximal tibia, and distal tibia. The IO provides rapid central venous access in emergency situations, and is recommended as an alternative route in cardiopulmonary resuscitation by the American Heart Association. Electronic infusion devices assist the nurse in providing accurate infusion therapy, but the nurse is still responsible for monitoring the delivery of the therapy. Alarms may be related to kink tubing or increased resistance, which may indicate that the IV catheter is clotted or has infiltrated into the subcutaneous tissue. One of the most important safety features offered by many electronic infusion devices is the ability to enforce parameters for safe administration of medications through the use of a medication library that sets highs and low limits for medication administration. The infusion systems consist of containers, tubing, and administration sets that deliver solutions and medications to the IV access device. Needless systems reduce needle sticks. Remember to disinfect needless systems prior to use with a 10 to 15 second scrub of alcohol. Administration sets are either primary or secondary tubing sets. 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 on the primary infusion set. And this will all make much more sense when we're looking at it in the lab. Monitoring and preventing complications is an important nursing implication for I.V. therapy. The fluid status of patients receiving IV fluids needs to be monitored to ensure that the intended outcome of therapy is being achieved. Therapy should provide adequate amounts of fluid to maintain a euvolemic or normovolemic fluid state. Fluid status is monitored with physical assessment, periodic weights, accurate measurement of intake and output, and laboratory values, particularly your serum electrolytes that we need to monitor for further indications of fluid balance. Remember that our hypertonic and hypotonic fluids place the patient at greater risk for fluid imbalance, and they require more intense monitoring. We also need to be monitoring for phlebitis and infiltration. Phlebitis is inflammation of the vein. It is characterized by pain and erythema along the vein. It is graded using a standardized scale according to signs, symptoms, and severity. In your book you have an infusion nurses society phlebitis scale that you'll want to look at peripheral sites that show signs of phlebitis should be removed. They need to be restarted in another location because phlebitis can progress to more serious conditions, including thrombus formation, cellulitis and sepsis. The antecubital fossa site has shown to have the lowest phlebitis rates, whereas hand veins have the highest risk for phlebitis. There are different causative factors for a phlebitis that includes chemical, mechanical and bacterial. Chemical phlebitis is the result of the infusion of irritating solutions and medications that occurs when a peripheral vein does not allow for sufficient hemo dilution of the IV fluid as it exits the catheter. Mechanical phlebitis is the result of the catheter irritating the vein wall, and can be caused by introducing a catheter that is too large for the vein. So if you put an 18 gauge in a vein that really needs a 22, you could potentially cause a mechanical phlebitis. It also can occur by inadequately securing the catheter or movement of the catheter placed in an area of flexion, such as the elbow or the wrist. Bacterial phlebitis is the result of bacteria being introduced into the catheter because of improper site cleaning prior to starting the IV, failure to clean the port prior to accessing the IV or administration set, or failure to perform adequate hand hygiene. Infiltration occurs when a solution or medication is inadvertently infused into the tissue surrounding the vein. This can occur peripherally and centrally. You're going to see blanched skin. Skin that's cool to the touch, edema or swelling, unexpected pain or burning at the insertion site or along the path of the vein and leaking fluid from the insertion site. When a solution or medicine that infiltrates is a vesicant an extravasation or leaking of fluid into the subcutaneous tissue that is able to cause blisters has occurred. Medications that are classified as vesicants include specific anti neoplastic agents, antibiotics, and vaso active medications. 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. This will often look like stopping the infusion, immediately notifying the provider, and perhaps getting an order for some kind of potential antidote. To minimize the tissue damage. There are central line complications that you need to be aware of infection, loss of patency, and air embolism. Infection. We're looking specifically at central line associated bloodstream infections, otherwise known as CLABSIs. The use of maximal sterile barrier precautions are used when inserting. This is now standard practice. Loss of patency or occlusion of CVCs can delay the delivery of lifesaving therapies, and may also mean the patient is subject to the risk and discomfort of another central line insertion. If theirs becomes occluded and stops working, occlusions can be the result of a thrombotic process. When the blood or fibrin in or around the catheter interferes with the flow. Thrombic occlusions can result in a slowed infusion rate or resistance when flushing, or the complete inability to infuse or flush the catheter at all. Proper flushing before and after the use of a catheter and at intervals when the catheter is not in use decreases the occurrence of thrombic occlusions. There are injection caps specifically designed to prevent thrombotic occlusions. These caps create a positive pressure that prevent blood from refluxing into the catheter when not in use. Occlusions can also be non thrombotic or 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 administration of the incompatible medicines. And the final complication is an air embolism. This is when air is inadvertently introduced into the venous system. Nursing actions to prevent air embolisms include frequently checking the central line connections to ensure that your caps are on tight, and clamping injection sites when not in use. Other preventative measures include using infusion pumps, priming your I.V. tubing prior to connecting, expelling out air of all syringes prior to use, and frequently inspecting all lines and connections. You want to ensure your central line dressing is intact. The central line should only be removed by personnel competent to perform this procedure, and the removal should be performed with the patient in the supine position prior to the removal, the patient to be instructed to perform the vessel by maneuver or exhale during their 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. Whenever we're maintaining our intravenous access, remember to perform hand hygiene and clean injection ports prior to every entry. Always flush prior to use to establish proper placement and functioning. You want to flush with the volume twice that of the catheter and any attached extension tubing. Flushing is the act of moving fluids, medications, blood, blood products, and nutrients out of the vascular access device into the bloodstream, ensuring delivery of these components and verifying device patency. Locking is the installation of a solution into the vascular access device to maintain device patency. Frequency and periodic flushing for central lines is determined by the type of line and institutional policies. Sterile occlusive dressings must be changed immediately if they are no longer occlusive or become moist. Peripheral IVs do not require routine site dressing changes or site care. However, that does not mean that you're not assessing them every shift. You must document on them every shift and every time you initiate or discontinue an IV. Frequency of central dressing changes in site care is determined by institutional policy. The type of central line that it is, the type of dressing that is on and with central lines, sterile gloves should be worn when changing a dressing. Various methods to administer medications or solutions include continuous infusion, intermittent infusion bullets, and IV push. Intermittent infusions concurrent with a continuous infusion need to be compatible. If not compatible, the continuous infusion needs to be stopped while the intermittent infusion runs and the tubing of the infusion set must be cleared or flushed with a compatible solution. Usually this is normal saline prior to resuming your continuous infusion. Prior to administration of an intermittent infusion through a locked access, the access device needs to be flushed to ensure proper functioning of the device and clearing out any potential incompatible solutions when the intermittent infusion is complete. The access device needs to be flushed again and re locked. 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 medicines given with this method. Some medications need to be diluted prior to administration to ensure safe concentration, and to more accurately control the rate of administration. IV push medications can be given into a locked access or into an access with a continuous infusion. Keep in mind that the rate of this flush after giving your medicine needs to be at the same rate that is acceptable for the medication administration, because the medication that is in the tubing and the IV will be flushed through and administered to the patient at the flush rate. Prior to insertion of any access, peripheral or central, the patient needs to be educated and learning verified regarding the rationale for the access alternatives to the selected device and the 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 technique needs to be explained to the patients and return demonstration by the patient, family member, or significant other of aseptic technique and caring for the I.V. access is included in this education. Patients are informed of the type of I.V. solution and or medications to be administered, including the reason they are being administered. Expected outcome 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 access dressing is no longer occlusive or becomes wet. Patients are encouraged to monitor hand washing and proper cleaning of ports to the I.V. delivery system prior to access by all health care personnel. So now briefly we will go through a case study. Jason Blair is a 21 year old male who was involved in a motor vehicle accident and arrived to the emergency department with abdominal and lower extremity injuries upon arrival. He is tachycardic and hypotensive. He has one peripheral I.V. in his left forearm that is infusing at 200ml per hour. The emergency department provider and general surgeon will be evaluating his injuries. Jason is a Well-conditioned professional hockey player in excellent health. Question one the nurse should prepare to administer. What IV solution to Jason. As a result of the injuries he sustained in the motor vehicle accident. A 5% dextrose in lactated Ringer's B 5% dextrose in normal saline, C 0.45%. Normal saline, or D 0.9% normal saline. The answer for question one is D. 0.9%. Normal saline is isotonic and indicated for fluid resuscitation, and is the only fluid with which blood products can be administered. And this is important to consider for Jason because he is a trauma patient and may likely receive blood products. Upon Jason's arrival, the emergency department placed two large bore IVs in his forearm, and the I.V. line started in the field are discontinued. The nurse practitioner also inserts a non tunneled percutaneous central catheter. Blood samples are obtained for serum chemistries. Complete blood count and toxicology, and samples are also sent for the type and cross match in the event Jason requires blood products. Question two. What is the rationale for the placement of the non tunneled percutaneous central catheter for Jason? A the catheter allows for easy care of the catheter by Jason after discharge. B there is a lower risk for infection and other complications. C Jason prefers to not have the IV in his hand. And D There is an urgent need for fluid and medication administration. So the answer to question two is D. Non tunneled percutaneous catheters can be placed quickly and provide a large gauge catheter for large volumes of fluid. This catheter would not be used after discharge and does not have a lower infection or other complication rate. He is taken to the operating room for an emergency exploratory laparotomy, and in the post anesthesia care unit, the nurse anesthetist places a triple lumen central catheter for the anticipated need of administration of blood products, I.V. fluids, and antibiotics. He is transferred to the surgical Intensive Care Unit for post-operative management. Question three. The nurse recognizes that the multiple units of packed red blood cells Jason received for blood loss after his motorcycle accident did not contain clotting factors and anticipates which of the following blood components. This one. We'll just talk through and we will talk about blood products in a later lecture. The answer to this one is a. Fresh frozen plasma. FFP contains clotting factors that are not replaced when the patient receives only packed red blood cells. Oftentimes blood transfusions are separated into various components, not whole blood. So if you're replacing a lot of packed red blood cells, you're going to need additional components to kind of complement what you're missing when you're only receiving the packed red blood cells. But again, we'll talk about that at a later date. Question four into which port of is triple lumen central line can the nurse infuse the next dose of antibiotics? This is a select all. A the port with the parenteral nutrition infusion. B the port with packed red blood cells, infusing C the port where the patient controlled analgesia is attached. D the port that is sailing locked, and E the port with 0.9% normal saline infusing. The correct answers for question four are C, D, and E. The port with PN infusing is a dedicated line that should not be infused with anything else, and nothing can be co-infused with blood products. If the antibiotic is compatible with the PCA, it can be co-infused or flushed, and the PCA could be temporarily stopped, or the saline locked port can be used as well as the port infusing normal saline. Four days Postoperatively Jason develops a peritoneal abscess requiring IV antibiotics and analgesics, blood products and TPN. He remains in the surgical intensive care unit for three days and receives four more units of packed red blood cells. On day four, he is transferred to the surgical intermediate care unit, and ten days after admission, he is transferred to a short term acute rehab facility until he can be discharged home. So last question. Question five. On assessing Jason central line, the nurse notes that the luer lock on one of the lumens is not tight and recognize that this places him at risk, for which complication A air embolism, B clotting of the catheter C infection, or D fluid loss. The correct answer for question five is A. An air embolism occurs when air is inadvertently introduced into the venous system, and it can occur if the catheter is damaged during insertion or removal of the central line, and if the connections in the IV delivery system are not tightly secured with luer locked connections. And this concludes our lecture for week two of I.V. therapy.