Maintaining Fluid Balance PDF

CHAPTER 7 Maintaining fluid balance Barbara Workman Aims and learning outcomes This chapter considers the intake of fluids by the oral and parenteral routes, and details practices to be followed to ensure safe administra- tion of fluids and blood by the intravenous route. By the en...

CHAPTER 7 Maintaining fluid balance Barbara Workman Aims and learning outcomes This chapter considers the intake of fluids by the oral and parenteral routes, and details practices to be followed to ensure safe administra- tion of fluids and blood by the intravenous route. By the end of the chapter you will be able to: assist a patient to increase their oral fluid intake accurately complete a fluid intake and output chart discuss factors that affect fluid balance identify common intravenous fluids and their uses prepare equipment for an intravenous infusion, monitor its progress and discontinue when appropriate recognize complications of IV therapy and take appropriate actions to prevent or relieve complications discuss the precautions that are used during a blood transfusion to ensure a safe transfusion. Monitoring fluid balance This is an essential aspect of nursing care because it can make a great deal of difference to the patient’s comfort and recovery but requires few 134 Maintaining fluid balance highly technical nursing skills. To be effective it should be accurate, otherwise assessment of the patient’s condition is based on false infor- mation and may result in a patient’s condition deteriorating unneces- sarily (Morrison 2000). Homeostasis is the term used to describe the balance that the body maintains between fluid intake and fluid output. It is estimated that a healthy person requires at least 2–2.5 litres, intake of fluid daily (Edwards 2001) which, together with food and metabolic pro- cesses, results in an intake of approximately 3 litres of fluid daily. Patients will vary as to how much and how often they like to drink, and some will need more encouragement than others to maintain or increase a satisfactory fluid intake. Fluid intake can be by oral drinks, food, tube feeds and intravenous fluids. Fluid output may occur via urine, vomiting, faeces and diarrhoea, sweat, gastric secretions, or wound drainage. The lack of adequate fluid intake can lead to dehydration which presents (Morrison 2000) as: dry mouth and lips dry skin with loss of elasticity (turgor) weakness and lethargy thirst sunken eyes small concentrated urine output (oliguria) confusion tachycardia poor peripheral perfusion leading to pallor. Accurate measurement of a patient’s fluid intake and output will iden- tify those patients at risk of becoming dehydrated or overhydrated. Particularly vulnerable patients are: the elderly, who may have lost their thirst stimulus and neglect to drink the confused or neurologically disordered, who may fail to respond to thirst those whose conditions are deteriorating, e.g. with renal or car- diac failure post-operative patients 135  Key Nursing Skills emergency admissions as their fluid needs may be initially under- estimated those who are nil by mouth. Patients’ fluid requirements will increase: in hot weather with a pyrexia (high temperature) if a urinary catheter is in situ if constipated if there is fluid loss from the gastro-intestinal tract, such as diar- rhoea, vomiting, or nasogastric or wound drainage. Patient history Mrs May is a 79-year-old lady who has been admitted following a fall at home. Her daughter normally drops in to see her most days, but had been away for the weekend, and found Mrs May on the floor when she came home. Her daughter says that Mrs May is very independent but has become increasingly forgetful recently, and would sometimes forget when she last had a meal. Mrs May has facial bruising and a possible head injury so has been admitted for observation. NURSING PROBLEM 7.1 Problem: Mrs May is dehydrated. Goal: Mrs May is to be rehydrated and to maintain an oral fluid intake of at least 2 litres per day. Intervention: increase oral fluid intake Commence Mrs May on an accurate fluid balance chart. Ensure she understands that all fluid intake and output are to be measured and recorded. Plan to give her a drink of at least 100 ml (approximately half a glass or cup of fluid) per waking hour in addition to regular drinks provided at mealtimes, over 24 hours. 136  Maintaining fluid balance TIP! Specifying a specific amount to be consumed in a period of time will make it easier to monitor and spread the intake over the 24-hour period, and so be achievable. The equivalent of 1.5 litres is about 8 cups or 5 mugs of fluid a day (Morrison 2000). Ensure the drink is placed within the reach of Mrs May, and that she can pick up and hold it and is in a safe and comfortable position to consume it. Offer a feeding beaker if necessary. Assist drinking if the fluid is very hot and there is a danger of scalding. Offer a wide range of fluids to improve incentive to drink. TIP! Patients who are reluctant to drink may enjoy: – sucking ice cubes or frozen fruit juices – very hot or very cold water in preference or in addition to tea or coffee – savoury drinks such as diluted hot stock cubes (ensure the patient is not on a low-salt diet before offering this) – carbonated water to relieve nausea – fizzy drinks, which may be more palatable than tepid water that has been sitting beside a bed for a while. Ensure that the patient does not have a high intake of sugar through fluids as this will increase dehydration – fluids drunk from a feeding beaker, which may be easier for patients with restricted movement – fluids drunk through a straw, to relieve hiccoughs – milk, poured on cereals or taken as milkshakes – jellies, ice-cream, soups and thickened fluids to increase fluid intake. All of these may assist swallowing for patients with dysphagia (Leech and McDonnell 1999) – proprietary fluid or food supplements, particularly if they are not consuming a full diet. Teach Mrs May about the importance of maintaining oral fluid intake to 1.5–2 litres per day. She may be reluctant to continue on this regime if she suffers from urinary urge or incontinence, so she needs to understand the importance of adequate fluid intake in preventing the urgency and frequency resulting from concentrat- ed urine (Addison 1999). 137  Key Nursing Skills Record fluid intake on fluid balance chart by documenting each drink after it has been consumed, to accurately reflect intake. Ensure the fluid balance sheet is completed accurately at the end of each shift, and totalled every 24 hours. TIP! Record the amount of fluid contained in: a teacup a glass a mug an ice cube a soup bowl a glass of fruit juice. Use this to accurately monitor and record fluid intake. Evidence suggests that nurses are not sure about the quanti- ties contained in these common containers (Morrison 2000). Evaluation Mrs May is no longer dehydrated, and is able to maintain a satisfactory fluid intake. NURSING PROBLEM 7.2 Problem: Mrs May is dehydrated and has a reduced urine output. Goal: Mrs May will be rehydrated within 24 hours, demonstrated by a urinary output of approximately 1500 ml per day. Urine output in health is approximately 1.5–2 litres per day (Edwards 2001). When measuring urine output hourly a patient is expected to excrete a minimum of 30 ml per hour (720 ml/day). Failure to excrete this amount per hour will have a significant impact on a patient’s fluid and electrolyte balance and therefore monitoring of urine output is essential, particularly in serious illness. Intervention: record fluid output Inform Mrs May that you are monitoring all her fluid intake and output to gain her cooperation. 138  Maintaining fluid balance If Mrs May is able to use the toilet, ask if she is able to pass water directly into the measuring jug. She may find it more acceptable to pass water into a bedpan on the toilet, or use a bedpan or com- mode. Dispose of toilet tissue in clinical waste bag. Wear clean gloves and apron and use an individual measuring jug when measuring urine to prevent cross-infection (Ayliffe et al. 1999). Empty fluid contents of bedpan or commode into jug. Some fluid may be lost when the toilet tissue is discarded. In addition all fluid excreta should be monitored. Vomit should be poured into the jug to be measured. If measuring gastric aspirate, the nasogastric tube should be fully aspirated and the contents poured from the bladder syringe into the measuring jug. When no more fluid can be aspirated the amount may be measured. If small amounts of any fluid, particularly urine, are passed, accurate meas- urement in a jug will not be possible under 50 ml. A bladder syringe or calibrated urinometer should be used to ensure accurate measurement of small quantities. TIP! Place jug on a level surface to read amount accurately. Record on fluid balance chart (see example below), and report any abnormalities to senior staff. TIP! Contamination with solid faeces will give an inaccurate read- ing. Passing liquid faeces will inevitably increase fluid output; where possible the output may be measured, although accu- racy will be difficult – recording of frequency alone may only be possible. If large amounts of faecal matter are lost but are essential to monitor, it is possible to record faecal weight in grams. This may be weighed by using special cartons or dis- posable waterproof pads. As 1 g = 1 ml, this will give some guide as to the fluid loss. A clean pad or carton should be weighed, the faeces should be poured into it from the bedpan or commode, and the pad or carton should then be weighed again. The difference in weight will equal the amount of fluid lost. Scales designated for this purpose only should be used to limit cross-infection. 139 Key Nursing Skills Evaluation Mrs May’s urine output has returned to and is maintained at 1.5 litres a day. Example of a fluid balance chart This chart shows the patient is in a positive balance of 1 620 ml. The oral intake is low but the intravenous fluid compensates for this. As can be seen, the amount of intravenous fluid is being reduced towards the end of the day and then discontinued at midnight. Oral fluids should be encouraged hourly when the patient is awake to compensate for the reduction in IV fluids. Patient name A.N. Other............. Hospital Number....H54321P INTAKE OUTPUT Time Oral IV Urine Vomit Drainage Other Balance (hours) 01.00 1 litre D/Saline start 02.00 03.00 04.00 350 05.00 06.00 07.00 08.00 tea 100 D/Saline 200 +1160 juice 60 1 000 ml –550 given. 5% = +610 Dext 1 litre start 09.00 10.00 coffee 250 25 drain 60 ml removed 11.00 140 Maintaining fluid balance Patient name A.N. Other............. Hospital Number....H54321P INTAKE OUTPUT Time Oral IV Urine Vomit Drainage Other Balance (hours) 12.00 soup 100 13.00 14.00 15.00 16.00 tea 200 5% Dext 250 +2 520 finish 1 000 –1 075 ml given. = +1 445 500 ml 0.9% Saline start 17.00 18.00 tea 100 300 19.00 20.00 21.00 22.00 water 100 23.00 225 24.00 water 100 0.9% Saline +3220 400 ml –1600 given. IVI = +1 620 discontinued Total 820 2 400 1 575 Nil 25 Nil Balance +3 220 –1 600 +1620 Fluid overload It is possible to overhydrate a patient, particularly when administering intravenous fluids. The patient may present with the following symp- toms (Perry and Potter 1997; Edwards 2000): 141 Key Nursing Skills feeble, weak, irregular pulse breathlessness and cough, expectorating white or pink frothy sputum discomfort and restlessness oedema, particularly around ankles and sacrum lethargy anxiety distended neck veins raised blood pressure raised fluid intake and insufficient output on fluid balance chart. Careful monitoring of a patient’s fluid intake should detect these signs and symptoms early so that the fluid intake can be reduced and the fluid overload reversed. Report your observations to senior staff and medical practitioner immediately. Peripheral intravenous therapy Intravenous therapy (IVT) is a very common clinical intervention in modern acute care, and at least 50 per cent of patients admitted in the UK may have intravenous interventions during their stay (Wilkinson 1996). Patients receiving IVT are either unable to take fluids and med- ications orally to meet their needs, or these substances are not suitable to be given by the oral route. IVT by the peripheral route is an in- vasive procedure and all IVT care should follow aseptic principles to prevent infection. The patient’s comfort and safety are of central importance during the infusion. Spencer (1996) identifies some uses of IVT as: fluid and electrolyte replacement blood transfusion therapy drug administration parenteral nutrition. Fluids commonly used in intravenous therapy include the following. 0.9% sodium chloride in water This is isotonic and therefore does not encourage fluid to move from the intracellular compartments (cells) to the extracellular compartments (plasma and interstitial fluid), but replaces fluid lost from the circula- tion such as that lost by haemorrhage or dehydration. 142  Maintaining fluid balance Sodium chloride can be infused in other strengths to correct elec- trolyte imbalance, e.g. 1.8% or 3%. These concentrations are hyper- tonic and so draw fluid from the cells into the plasma and interstitial fluid compartments, thus increasing the fluid in circulation. Hypotonic sodium chloride 0.45% This can be used to correct severe dehydration arising from conditions such as diabetic ketoacidosis, and returns fluid to the cells. Too much sodium chloride by infusion can result in fluid and sodium overload, and potassium imbalance (Hand 2001), and therefore should be mon- itored closely. 5% dextrose in water This isotonic fluid provides fluid replacement without disturbing the electrolyte balance and provides energy up to 170 calories in 1 litre (Hand 2001). Stronger concentrations of dextrose such as 10% or 20% may be used to provide calorie intake for patients who are temporarily unable to eat. Dextrose infusions, especially when containing potassi- um, are acidic and may irritate a patient’s veins causing phlebitis after several days, use. Other substances may be used to expand intravascular volume, such as: blood and its derivatives (see ‘Blood transfusion’, page 168) artificial colloids such as dextrans, hydroxyethyl starch (HES) and gelatin derivatives. These are used to expand the plasma volume when there have been large blood losses. NURSING PROBLEM 7.3 Patient history: Mr Elliot is a 53-year-old man, who has been admitted with abdominal pain. He is not to have any oral food or fluids (nil by mouth) while the cause of his pain is investigated. Problem: Mr Elliot is nil by mouth so requires fluids by intravenous infusion. Goal: Mr Elliot will have a peripheral cannula sited and intravenous infusion administered safely. 143  Key Nursing Skills Intervention: commencing intravenous therapy Equipment Cannula – green (21G) or pink (23G) are the commonest sizes. Use the smallest size as possible, depending on the patient’s treat- ment needs, to reduce trauma to the vein (RCN 1999). Antiseptic skin preparation, e.g. 2% chlorhexidine solution or 70% alcohol wipes (Ayliffe et al. 1999). Sterile tape and sterile dressing or designated IV dressing. Sterile gloves (correct size for the trained nurse or doctor insert- ing the cannula). Towel or disposable waterproof pad to protect the bed. Tourniquet. Intravenous infusion administration set. IV fluid as prescribed. Prescription sheet. 10 ml 0.9% saline solution to flush cannula; needle and 10 ml syringe to administer. Disinfectant hand rub. IV pole – this may be portable with casters, or fixed to the bed. Receiver. Procedure Explain the rationale for the procedure to Mr Elliot to gain his consent and cooperation. Mr Elliot may be very anxious about this treatment since he may perceive it to mean that he is seriously ill. Information gleaned from relatives or friends may increase his anxiety (Dougherty 1996) so a clear explanation of the procedure and the expected length of therapy should be given to help to reduce his worries. Wash hands. Gather equipment in a clean tray. TIP! Some local policies advocate the use of local anaesthetic prior to insertion of IV cannula. Anaesthetic cream should be applied at least 20–90 minutes before procedure (depending on the type used) to allow for full effect; check the manufac- turer’s instructions regarding this. Local anaesthetic cream 144  Maintaining fluid balance may be particularly useful for patients who are afraid of needles. Injecting local anaesthetic may be as painful as siting the cannula, and the resultant localized swelling may obscure the vein (Dougherty 1998). Take equipment to the bedside and position the patient comfort- ably with easy access to the non-dominant arm. This arm should be chosen in preference, so that Mr Elliot may use his dominant arm and maintain some independence during treatment. TIP! Avoid arms which are swollen (lymphoedema), or with open wounds. Consider cultural preferences for a ‘clean’ and ‘dirty’ hand when helping to select a vein. Check prescribed fluid against prescription sheet and follow the five Rs for right drug administration – Right patient, Right drug (fluid), Right route, Right time, and Right dose. Wash hands. Open the outer wrapper of the prescribed fluid. Check the con- tainer for cracks, leaks or breakage in sterility; expiry date; and check that the fluid is clear – any discolouration, particles or cloudi- ness indicates contamination. Invert the bag several times gently – but do not shake – to ensure the solution is well mixed. This is particularly important if potassium or other drugs have been added to prevent layers forming (Metheny 1990). Open the administration set pack and close the clamp. See Figure 7.1 for different types of clamps. Place the bag on a flat surface and break the protective cap off the port. Remove the protective cap from the administration set spike. Holding the connection port firmly in one hand, insert the spike into the port with the other hand, ensuring that the connections do not touch anything (Figure 7.2). Hang the bag on the IV pole and squeeze the administration set chamber to half full. Open the roller clamp and allow the fluid to run through the administration set into a receiver until it emerges at the end (Figure 7.3). Ensure all air bubbles are removed. Clip the end of the tubing of the administration set into the roller clamp to prevent it from being contaminated. 145 Key Nursing Skills Figure 7.1 Types of IV clamp. Roller clamp. Slide clamp. Figure 7.2 Connecting IV bag and administration set aseptically. Figure 7.3 Running through administration set. 146  Maintaining fluid balance TIP! Position the roller clamp just under the chamber before attaching the administration set to the bag. This will allow you to fill the chamber and run the fluid through the administra- tion set with the minimum of air entering the system, saving time and fluid. Air bubbles may not flush out easily and a lot of fluid may be lost as you try to remove them. Once the administration set is full, if there are air bubbles still in the tubing, give the tubing a gentle shake to dislodge the bubbles. Allow them to rise up in the tubing. Prepare the flush solution by drawing up the prescribed amount of 0.9% saline into a 10 ml syringe. Studies have not yet determined the optimum amount of flush solution, but experience suggests that 2–5 ml is sufficient. Place on the tray, protecting the syringe connection from contamination, and enabling the person who is cannulating to retrieve it safely and easily when ready. Prepare the skin for cannulation. Adequate cleansing and disinfec- tion of the site should be undertaken by alcohol swab or using 2% aqueous chlorhexidine solution by cleansing for 30 seconds and allowing to dry for up to 1 minute (Ayliffe et al. 1999). This has been shown to be most effective at preventing cannula-related infection. If the patient is very hairy, clipping or depilatory (hair removing) cream rather than shaving is preferable as these meth- ods do not cause skin abrasions. Following skin preparation the area should not be touched again (RCN 1999). To confirm patency the trained practitioner should flush the can- nula with 0.9% saline solution. When the doctor or trained nurse has successfully cannulated the vein, remove protector from administration set and connect it to the cannula. TIP! As connection is likely to involve contact with blood, gloves should be worn. To reduce contamination during manipulation of the IV, it is preferable for one person only to touch the area during the procedure. To reduce blood loss, press on the vein just above the cannula. Secure the cannula. Cannulas may be secured by sterile tape (Figure 7.4), which can be achieved by using a new roll and 147 Key Nursing Skills cutting with scissors that have been cleaned using an alcohol wipe (Workman 1999), and dressing the site with sterile gauze. (See ‘Securing a cannula’, page 150.) However, the usual, and increas- ingly preferred, method is to use a specific IV dressing which is semi-permeable to allow the site to ‘breathe’ and remain dry with- out admitting micro-organisms. It should be applied to clean dry skin, maintaining aseptic technique and not touching the sterile surface. The dressing is applied directly over the insertion site and Figure 7.4.1 Place strip under cannula wings. Figure 7.4.2 Secure each wing parallel to cannula. Figure 7.4.3 Tuck strip arond cannula hub. Figure 7.4.1–3 Taping cannula. 148 Maintaining fluid balance Figure 7.5 Transparent dressing to cannula and securing IV set to arm. tucked around the hub of the cannula to ensure a firm seal, and prevent movement of the cannula (Figure 7.5). Secure the administration set by taping the tubing to Mr Elliot’s arm (Figure 7.5) to prevent pulling on the cannula site. Bandages and/or splints should only be used in exceptional circumstances, for example, if the patient is a child or confused. If secured too tightly they can prevent the infusion from running satisfactorily, prevent regular observation of the limb, and cause stiffness and discomfort. Commence the infusion at the prescribed rate. Check again with- in the hour that the infusion is running as previously set. Label the administration set with the date and time of com- mencement, and your initials. Make Mr Elliot comfortable, and ensure that he has all he requires, including the call bell. Dispose of all equipment and wash hands. In the nursing notes, document: the site and size of cannula; time and date of commencement of infusion – and set rate on the fluid balance chart; and the batch number, start date, time and signa- tures of administering staff on the prescription sheet. Securing a cannula The entry site of the cannula should not come into contact with the tape as it has been found to predispose to infection. Use a clean or new roll of tape, and cut with scissors that have been cleaned, or are sterile. Using the H method, as illustrated, for cannulas with wings will secure 149 Key Nursing Skills the cannula firmly and be easy to remove, and keep the tape well away from the cannula site. This method should only be used if the patient is allergic to a transparent dressing, or if there are none available. Procedure Cut four short strips of tape (about 5 cm long). Place one under the cannula wings – this protects the skin under the plastic wings (Figure 7.4.1). Place a strip of tape lengthways, parallel to the cannula and on each side of the cannula, securing each wing (Figure 7.4.2). Place the final strip of tape across the wings, tucking it around the cannula hub to secure it firmly (Figure 7.4.3). Apply a sterile gauze dressing over the cannula site. Write the date, time of insertion and your initials on a piece of tape and use it as a label on the dressing. Change the dressing daily, or more frequently if it becomes soiled or wet. Applying a transparent semi-permeable IV dressing The advantage of a transparent dressing is that the IV site can be observed without removing the dressing. If not applied correctly, the cannula may become loose and cause irritation to the vein. Manu- facturers of sterile IV dressings do not advocate the use of tape in addition to their dressings. Make sure the site is clean and dry. Open the packaging and use aseptic technique to apply it. Peel the backing paper off the transparent end, leaving the port backing paper on. Position the transparent film over the entry site and apply tension to the sides of the dressing to place it smoothly in situ, tucking the film around the cannula hub to hold it firm (Figure 7.5). Take the rest of the backing film off and stick the wings down, allowing the film to conform to the shape of the cannula, before securing it to the skin. This will hold it firmly in place, and not pull on the skin surface. 150  Maintaining fluid balance Change the dressing if it becomes wet underneath, soiled or loose (RCN 1999). Removing it without dislodging the cannula is very tricky. If the cannula does move while removing the dressing it will need to be resited. Do not try to push the cannula back into the vein as it may snap causing an embolus, may introduce infec- tion, or may pierce the vein. Management of an IV infusion Intervention: regulation of flow rate The flow rate of an infusion is determined by the amount of fluid to be given over a prescribed time. Fluid rate can be controlled manually by using a slide or roller clamp, which can be adjusted to deliver fluid at a number of drops per minute by a gravity administration set. This method will deliver approximate amounts, and therefore will not be suitable for all IV fluids. Fluids that require an exact delivery rate should be given by a syringe driver, electronic pump or mechanical pump. It is important to deliver fluids as prescribed to prevent fluid overload, and to ensure accurate drug doses. To accurately deliver fluids the correct administration set should be selected. Check the label on the packaging to determine how many drops per minute it will deliver and the compatible type of electronic infusion device: standard administration set = 20 drops per ml for aqueous solu- tions: this set may be used with or without a compatible electron- ic device blood administration set = 15 drops per ml: this has an integral filter system but particular treatments may require additional filtration paediatric administration set (burette) = 60 drops per ml: a burette may also be used for adults when delivering some intravenous drugs or small amounts of fluid. To help you understand the flow rate, when setting an IV rate, TIP! try to visualize the drops going into a teaspoon. For example, a teaspoon holds 5 ml, so an administration set giving 20 drops a ml would produce a very small amount. 151  Key Nursing Skills Calculating flow rates The formula for calculating IV infusion rates is as follows: amount of fluid drops per ml × = drops per minute number of hours 60 (minutes) If calculated as in the following stages this formula uses simple figures and can be used without relying on a calculator. 1. To find out the number of ml per hour. Divide the total amount of fluid by the number of hours: e.g. 1000 ml = 125 ml/hour 8 hours TIP! This is useful to know straight away because if you are using an electronic device it usually needs to have the amount of fluid per hour set. If an electronic device is not being used, knowing how much fluid per hour is to be delivered means that you can observe the amount on the calibrations of the IV bag to monitor the accuracy of flow. 2. To calculate the number of drops per minute (dpm). A standard administration set gives 20 dpm, therefore divide 60 minutes by 20: 60 ÷ 20 = 3 A blood administration set gives 15 dpm; therefore 60 minutes ÷ 15 dpm = 4. A burette set gives 60 minutes ÷ 60 dpm = 1. 3. Divide the ml per hour by dpm: 125 ml ÷ 3 = 41.6 = 42 dpm If using the blood administration set: 125 ml ÷ 4 = 31 dpm 152  Maintaining fluid balance If using a burette set: 125 ml ÷ 1 = 125 dpm When calculating the rate per hour the number should be rounded down to the nearest whole number if the answer is below 0.5 dpm, or rounded up to the next whole number if the amount is greater than 0.5 dpm. Examples to try Calculate the infusion rates for the following: 1. 500 ml 5% dextrose infusion in 4 hours. What should be the rate in ml per hour and drops per minute? 2. 420 ml blood. How many ml per hour and drops per minute? TIP! Ifanswers you are uncertain about calculating flow rates, check your with a calculator. If you know another way to calcu- late the flow rates make sure that the answers are consis- tent, and that you can explain it to another nurse to make sure you are administering doses safely. Intervention: setting the flow rate manually Equipment Watch with second hand. Prescription sheet to calculate required rate. IV administration set and IV fluid. Procedure Calculate required rate. Hold the watch with the second hand next to the IV administra- tion chamber (Figure 7.6). Use your other hand to adjust the flow by opening or closing the roller clamp. Set the clamp to allow fluid to flow at an approximate rate and count the drops over 15 seconds. Multiply by 4 to get an idea how 153 Key Nursing Skills Figure 7.6 Setting flow rate. fast the infusion is running per minute (4 × 15 = 60 seconds). Adjust the rate of flow faster or slower as required, checking the rate by the watch. Before leaving the patient, confirm that the infusion is running as you have set it. Ensure the patient understands that the flow rate should only be adjusted by medical or nursing staff and that speeding it up will not result in early discontinuation of IVT (Wilkinson 1996). Check flow rates: after the first hour of commencing an infusion; when administering a patient’s drugs (by any route); and when undertaking any care that has involved moving the patient’s posi- tion, such as turning him or providing toilet facilities. Movement may cause the cannula to change position and affect the rate of flow. Intervention: delivering fluids by IV pump or syringe driver When IV fluids require accurate delivery, IV pumps and syringe driv- ers are used. Every Trust has a variety of types in use for different pur- poses (Medical Device Agency 1995): neonatal devices which provide low flow rates in very accurate doses high-risk infusions such as for intravenous drugs, which require pumps to deliver at a set, consistent flow rate with a high degree of accuracy low-risk infusions for routine fluid administration, e.g. through gravity-controlled administration sets where regular delivery is important, but a high level of accuracy is not essential 154 Maintaining fluid balance patient-controlled analgesia pumps that provides a consistent level of pain relief, with additional bolus doses in response to patient demands pre-filled devices that are self-regulating and suitable for care in the community. Selection of appropriate pump As technology changes rapidly it is impossible to review all methods here but there are some key considerations to be aware of when caring for a patient with an IV pump. It is important to know why the patient needs an IV pump so that you can select the correct one. Make sure to check the following issues: What is the pump needed for? Is it for drug dose accuracy? Is it for fast or slow fluid rate? Is it because the patient is vulnerable and needs close monitoring? Particular risk factors to be considered are extremes of age (such as the very young or very old), immuno-compromised patients, or cardiac or renal problems. Preparing to use a pump If you are unfamiliar with the pumps being used in your location, ask for appropriate training before using one. Be sure you know: how to set or change the rate how to commence a new infusion which administration set is required for each different type in your area how to insert the specialist administration set and prime it how to respond to the alarm, and reset it how to connect the power supply, or switch to battery power. All infusion devices will have a power supply, which is usually backed up by batteries. When not in use most pumps should be kept plugged in to recharge how to clean and store it between patients. Only qualified staff should adjust the rate of flow of an infusion pump as they are held accountable for fluid or drug administration. 155 Key Nursing Skills ALERT! Alarms may be muted while dealing with problems, but should never be disabled while the infusion is running, as serious faults may go undetected. If there is a reason to believe the alarm is false, check the entire system including the cannula site. User error may be at fault rather than the machine (Pickstone 1999), so ensure the correct equipment is used, and that the patient’s vein is patent. If a thorough check does not reveal the problem, change the pump and seek advice from senior staff. Gravity infusion sets These have a flow rate controller integral to the administration set, and there is minimal pressure used to infuse the fluid. To be effective, the IV bag should be raised to at least 1 metre above the patient (Pickstone 1999). Be aware that if the patient is mobilizing and push- ing an IV stand around, this distance may not be maintained consis- tently so will affect the IV flow. This is not the most accurate method of fluid delivery and so is used for low-risk infusions. It is important to remember the following when using a flow rate controller: Calculate the number of drops per minute accurately and monitor it regularly throughout the infusion. Explain to the patient that only staff should adjust the rate, and that tampering with the speed may not finish the infusion quicker, but may cause additional problems if fluid is infused too quickly. Monitor the amount of fluid that has been infused by observing the level of fluid in the IV bag. If the infusion stops or slows, the tubing should never be twisted to try to restart the flow. This can cause a high-pressure flow in the vein resulting in spasm, collapse and loss of IV site (Hecker 1988). Ask a qualified nurse to flush the cannula with saline to check the patency instead. Volumetric pumps These are used for highly accurate administration of fluids or drugs and 156 Maintaining fluid balance use pressure to infuse. Volumes from 1 to 999 ml/hour are delivered depending on the predetermined settings. As well as being able to deliver fluid at a given rate, advancing technology offers additional features, which include: running an infusion at ‘keep vein open’ (KVO) to provide a very slow rate monitoring and recording a patient’s fluid history detecting problems such as air in the administration set or an occlusion in the vein which may trigger the alarm. It is important to remember the following when using a volumetric pump: Use the correct infusion set for the type of machine; otherwise, the infusion can free-flow (Morling 1998). Ensure the infusion set is inserted in the machine as outlined in the manufacturer’s instructions. No force should be required to insert or remove it. Move the tubing in the controller every few hours to prevent compression or tubing damage. Syringe pumps and drivers These are used to deliver small amounts of fluid or drugs accurately. Syringe pumps may take 5–60 ml syringes and deliver 0.5–200 ml/hour. Syringe drivers take smaller amounts, up to 35 ml syringes, and del- iver in mm/hour rather than ml/hour (Woollon 1997); they therefore need careful calculations to ensure the correct dose is given. Both these devices are usually used in the delivery of complex drug regimes and should be set by a qualified nurse. It is important to remember the following when caring for a patient with these devices: Syringe drivers usually run on batteries, so check the battery indi- cator regularly to monitor it. The cannula site may be intravenous or subcutaneous and should be monitored for any adverse reactions. Is it delivering at the correct speed? When receiving a handover 157  Key Nursing Skills from the previous shift check the position of the syringe then, and check it an hour later to ensure it is running as programmed. Continue to observe its progress regularly throughout the shift to ensure that faults can be detected speedily and the patient’s drug regime is maintained. TIP! There may be a delay between starting the pump and when the drug is actually delivered to the patient. This delay can be avoided by ensuring the syringe is fitted tightly into the pump; ensuring that the ‘prime’ or ‘purge’ facility has prepared the tubing and syringe so that it is ready to deliver; or by using a smaller syringe if appropriate (Amoore et al. 2001). Evaluation Mr Elliot’s infusion runs according to prescribed schedule. Intervention: changing an IV solution Collect prescribed fluid and check with another nurse against the prescription sheet: Right patient, Right fluid (drug), Right time, Right route, and Right dose. Wash hands. Open the outer wrapper of the prescribed fluid and check the con- tainer for cracks, leaks or breakage in sterility; production date and expiry date; and clear fluid – any discolouration, particles or cloudiness will indicate contamination. Invert the bag several times gently, but do not shake to ensure the solution is well mixed. This is particularly important if potas- sium or other drugs have been added to prevent layers forming (Metheny 1990). Take it to the patient and identify him by name, confirming iden- tity with hospital number on wrist band and prescription sheet. Place new bag on level surface. Turn infusion off by closing the clamp. If an electronic pump is being used stop it. Take down the old bag from the IV stand and remove it from the administration set, holding the spike carefully so that it does not touch anything. Open the new bag by removing the cap from the port. 158  Maintaining fluid balance Insert the administration set spike into the port. Hang up the bag and ensure fluid is flowing. Set the rate or recommence the pump. Dispose of bag and wash hands. Document on the prescription sheet and fluid balance chart. Intervention: changing the administration set Equipment IV administration set. Gloves. Alcohol rub. Sterile gauze. IV dressing or tape. Protective waterproof pad. Procedure Wash hands. Gather equipment on a clean tray. Go to the patient and confirm his identity. Explain the procedure to gain his consent and cooperation. Turn off current infusion. Remove the tape that is securing the administration set to the limb and place a waterproof sheet under the patient’s arm to pro- tect the bed linen and provide a clean working area. Place the gauze next to the cannula/administration set connection to soak up any fluid leaks. Open the new administration set and close the clamp on it. Disconnect the old set from the bag, and position it above the patient’s heart level. TIP! Ifprevent long enough, the old set can be looped over the IV pole to it from being contaminated or being at a low level. Connect the new set into the bag, squeeze the chamber to half full and run through with fluid, excluding air bubbles (see ‘Commencing intravenous therapy’, page 144), and hang up the bag. Clip the end of the administration set into the roller clamp. 159 Key Nursing Skills Clean hands with alcohol rub and put on gloves. Holding the new tubing in your non-dominant hand for easy access, press a finger of your non-dominant hand over the cannulated vein to prevent bleeding (Figure 7.7) and carefully dis- connect the old administration set, taking care not to dislodge the cannula. Figure 7.7 Applying pressure to vein above cannula. WARNING! The connection may be difficult to twist open. You may see small artery forceps being used to hold the cannula hub to enable disconnection, but this may damage the cannula hub, so use this method with caution. Remove the protective cap from the new tubing and connect tubing to the cannula. Release pressure from finger on cannula. Recommence fluid flow to check for patency, supporting the can- nula so that it does not slip out. If in any doubt, get a qualified nurse to flush the cannula with 0.9% saline flush. Retape/redress the cannula hub and IV administration set to secure it (Figures 7.4 and 7.5 on pages 148 and 149), wiping around the cannula site with the sterile gauze to remove any leak- age during reconnection. 160  Maintaining fluid balance Set rate of IV flow. Label the tubing with date, time of change and your initials. Document the change in the nursing notes and fluid balance chart. NURSING PROBLEM 7.4 Problem: Mr Elliot has an intravenous infusion in situ, and requires daily maintenance of cannula site and infusion to prevent com- plications of IVT. Goal: Mr Elliot will not develop any complications of IVT. Intervention: care of IV infusion and site Wash hands. To prevent complications of IV therapy any manip- ulation of the cannula site or infusion equipment should be under- taken using aseptic principles. Check infusion site: (a) before and after commencing a new infusion fluid; (b) when assisting Mr Elliot to wash or dress; (c) before and during IV drug administration; (d) when checking flow rate. Observe for: (a) swelling and colour of limb or around cannula entry site: this may indicate infiltration or extravasation; (b) evi- dence and extent of inflammation, redness or pain: this may sug- gest phlebitis, infection or nerve injury; (c) leakage from cannula site, slowing or stopping of infusion flow: this may indicate a blocked cannula, possibly from venospasm or infiltration, and may occur especially at night (Campbell 1997); (d) secure dressing or taping of the cannula: if loose, this allows the cannula to move and irritate the vein and may lead to phlebitis; (e) correct rate of fluid delivery: too much may lead to fluid overload, or if it con- tains a drug may lead to speedshock. If any of these are present, stop the infusion and report to senior staff. If the cannula is loose, provided there are no local signs of inflammation or infection it may be secured and redressed following aseptic principles. (See ‘Commencing intravenous therapy’, page 150.) 161  Key Nursing Skills If an infusion has been discontinued, but the cannula not removed immediately, ensure it is removed within 48–72 hours of insertion to prevent complications developing. Document your findings and actions. Ensure you have informed a senior nurse or medical staff of any abnormalities. TIP! When helping a patient with an IV infusion to dress, thread the infusion set through the sleeve and then put the affected arm in first. To undress, take the arm with the administration set out last and thread the set through the sleeve. This allows the patient more freedom of movement. IVIs should never be disconnected for dressing as it increases the infection risks. Summary of IV complications Local complications Infiltration Also known as tissuing. Fluid no longer enters the vein, because either the cannula has slipped out of the vein or the vein has collapsed, causing a blockage and backflow of fluid into the interstitial spaces (Hecker 1988). Signs/symptoms: Swelling, cool blanched skin, leakage from can- nula, infusion slow or stopped, loose cannula. Interventions: Discontinue IV, elevate arm on pillows or a sling, monitor limb for circulation, motor and sensation. Advise patient that the swelling will recede slowly. Extravasation This is when vesicant (toxic) drugs, e.g. 10% or 20% dextrose, or cyto- toxic drugs have infiltrated the tissues rather than isotonic fluid, and cause tissue damage (Lamb 1996). Signs/symptoms: As above, but swelling may be rapid and re- lated to an IV drug injection. There may be some discolouration of the skin. 162 Maintaining fluid balance Interventions: As above, but follow local protocol to provide anti- dote or hydrocortisone injection. Extravasation can result in tis- sue necrosis if not corrected quickly. Phlebitis The inner lining of the vein is irritated by: a chemical such as a drug, or acidic infusion such as potassium chloride a physical irritation from the type of cannula used the poor placement of a cannula mechanical irritation from poor fixation. Once inflamed the vein may then become infected. Signs/symptoms: Swelling, inflammation, red, tense and hard vein (induration), possibly purulent discharge at cannula exit site. Interventions: Discontinue IV, send the cannula for Microscopy Culture and Sensitivity. Use smallest possible cannula to reduce local irritation. Prevention includes careful aseptic site prepara- tion and sterile dressing. Change cannula, dressing and adminis- tration set every 48–72 hours. Monitor temperature and pulse every 4 hours for early detection. Thrombophlebitis This is when a thrombus (blood clot) forms inside the inflamed vein. Signs/symptoms: Severe discomfort, inflammation visibly track- ing up vein, pyrexia, tachycardia, enlarged lymph glands, raised white cell count. Interventions: As above, discontinue IV. May need resiting for IV antibiotics. Assess wound for appropriate dressing. Nerve injury This may result from the swelling caused by infiltration or extravasa- tion, poor location of cannula, too many attempts at cannulation, or bandaging or splinting too tightly or in an abnormal position (Masoorli 1995; Dougherty 1996). 163 Key Nursing Skills Signs/symptoms: Pain in hand or arm before and after discontin- uation of IV, numbness, tingling. Interventions: Early detection of infiltration/extravasation and appropriate treatment. If patient complains of pain or discomfort in hand during infusion, report it to a senior member of staff and document it. Check for swelling or inflammation. Discontinue IV. If IVT is continued it should be recommenced on the other limb. Systemic complications Bacteraemia Micro-organisms in the blood. May go undetected until septicaemia develops. Septicaemia Presence of pathogenic bacterial toxins in the blood. Signs/symptoms: General malaise, pyrexia, rigors, nausea, vomit- ing and hypotension (Lamb 1996). May have evidence of inflam- mation at cannula site and along the vein, but may be no visible inflammation. Interventions: Notify the doctor. Take vital signs. Prevention requires maintenance of scrupulous aseptic technique whenever manipulating the IV equipment. Always wash hands before and after touching the system. Keep the number of extensions and three-way taps to the minimum. Change whole system every 48–72 hours. Monitor cannula site for signs of infection. Blood cultures taken and the cannula tip should be sent for microscopy, sensitivity and culture. IV antibiotics and additional therapeutic interventions will be required. Emboli Air, particle, catheter or thrombus; occurs when a foreign body enters the circulation and travels until it occludes a small vessel: Air embolism may result from poor connections or air bubbles in the IV system. Particulate embolism may result from poorly dissolved drug com- ponents, or contamination of fluid. 164 Maintaining fluid balance A catheter emboli may occur either during cannulation if the needle is inadvertently reinserted through the cannula, severing it, or if scissors are used to remove tape, and cut the cannula by accident. A thrombus may form inside a vein or on the end of a cannula, and be dislodged when the cannula is flushed. Signs/symptoms: Breathlessness, chest pain, weak pulse, loss of consciousness. Air noted in administration set. If the cannula is severed the end may be visible. Interventions: Stop IV. Call for assistance. Take vital signs. Turn patient onto left-hand side to encourage air to rise into the right atrium. If cannula end is visible attempt to retrieve it. Circulatory overload This can occur when too much fluid has been infused and the patient is not able to disperse it naturally. It may happen due to a fault in an IV pump or administration set, or positional cannula, or due to over- transfusion. Signs/symptoms: Discomfort, neck vein enlargement, respiratory distress, cough with white or pink frothy sputum. Interventions: Stop IV. Inform the doctor. Sit patient up and administer oxygen if prescribed. Ensure patients at risk (see ‘Fluid delivery by IV pump’, page 154) have fluids administered by pump and check flow rate regularly. Diuretics may be given to increase the rate of fluid excretion. Drug incompatibility Patients who are receiving IV drugs may be prescribed drugs that are incompatible with each other, which if administered through the same or connecting IV administration sets may result in a chemical reaction causing particles to form in the infusion. Signs/symptoms: Blocked cannula, poor infusion flow, evidence of particles in infusion fluid, patient discomfort. Interventions: Stop infusion, change administration set. Prevent by checking drug compatibility before administration. Inform medical staff. 165 Key Nursing Skills Speedshock Caused by the rapid infusion of an IV drug resulting in a toxic blood concentration. Signs/symptoms: Flushed face, headache, dizziness, chest tight- ness, tachycardia and hypotension. Interventions: Stop infusion. Provide symptomatic relief, e.g. sitting up, oxygen therapy. Take vital signs. May need to be given an antidote. Inform medical staff. Prevent by administering through a pump, burette or by syringe driver. Anaphylactic/allergic reaction This is a result of allergen or drug reaction and can be very sudden and life-threatening. Signs/symptoms: Itching, rash, watering eyes, sneezing, broncho- spasm, facial flushing, and swelling, anxiety, rapid swelling at IV site, sudden collapse, cardiac arrest. Interventions: Discontinue infusion immediately. Call for urgent assistance. Take vital signs. Maintain airway. Administer epine- phrine according to local policy. Prevent by taking a thorough his- tory of allergy, and monitor patient closely when giving potential allergens. Removal of cannulas Cannulas should be removed as soon as possible after therapy has been discontinued (Spencer 1996), otherwise patients could be exposed to unnecessary infection risks. Intervention: removal of IV cannula Equipment Sterile gauze. Hypoallergenic tape. Gloves. Small sharps disposal box. 166 Maintaining fluid balance Procedure Wash hands. Collect equipment on a clean tray. Explain the procedure to Mr Elliot and gain his cooperation. Provide privacy. If infusion is still in progress, turn off. Record amount of fluid administered. Put on gloves. Open gauze swabs. Loosen dressing and remove from the skin. An elderly patient’s skin may be fragile and tear easily (Whitson 1996), so ease off gently. Observe site for signs of inflammation or infection. With your non-dominant hand, put pressure over the end of the cannula in the vein. Fold a piece of gauze in half and hold in your non-dominant hand. With your dominant hand, withdraw cannula. As soon as it has been removed place the folded gauze on the entry site and apply pressure for 2–3 minutes until bleeding stops. Apply a fresh piece of gauze and secure with hypoallergenic tape. If infection or localized tissue damage is present, apply appropriate dressing. Dispose of equipment, placing cannula in sharps container. Ensure Mr Elliot is comfortable and has all he needs. Record removal in the nursing notes, documenting your observa- tions of the condition of the site. Observe the site closely over the next 24 hours to ensure that post-infusion phlebitis does not occur (Millam 1988). If there are no signs of inflammation or infec- tion the dressing can be removed after 8–12 hours, and the site exposed. Evaluation Mr Elliot’s infusion site heals with no complications or discomfort. Blood transfusion The aim of a blood transfusion is to increase the oxygen delivery to the tissues in a short time (Togshill 1997). It is the most effective method of replacing acute blood loss, but whole blood is rarely used as various 167 Key Nursing Skills blood components are extracted and used for a variety of purposes. Blood can be considered as living tissue and as such there are several risks associated with transfusion. Incorrect transfusions have frequently been found to result from errors involving incorrect identity of the patient or of the blood, and there are several stages in the process when these errors can occur (SHOT 1999). To promote safe practice for the care of patients receiving a blood transfusion, national guidelines have been published by the British Committee for Standards in Haematology Blood Transfusion Task Force (BCSH 1999). The prescribing of blood and blood components is the sole responsibility of medical staff unless local guidelines have determined otherwise (BCSH 1999). Blood products for transfusion Whole blood Contents: Red and white blood cells and plasma. Uses: Replacement of red cells and plasma proteins as in massive blood loss. Red cells Contents: Concentrated red cells, reduced plasma component, in additive solution such as saline, adenine, glucose and mannitol (SAG-M). Uses: To restore oxygen-carrying capacity in chronic or haemolytic anaemia, or replace blood loss. Platelets Contents: Concentrated platelets in plasma, with red cells removed. Uses: To treat clotting abnormalities as a result of large transfusions or thrombocytopenia (too few platelets resulting in haemorrhage). Fresh frozen plasma Contents: Plasma and plasma components frozen within eight hours of collection. Uses: Bleeding disorders where clotting factors are absent. 168  Maintaining fluid balance Patient history Mr Ammon has been involved in a road traffic accident (RTA) having been knocked off his motor cycle. He has a suspected fractured pelvis, left fractured femur and a right compound fracture of tibia and fibula, and possible internal injuries. It is estimated that he will need at least four units of blood to compensate for the blood loss from the accident and the surgical operation. NURSING PROBLEM 7.5 Problem: Mr Ammon requires a blood transfusion and is at risk of adverse reactions. Goal: Prevention and early detection of adverse reactions to blood transfusion. Preventing adverse reactions to blood transfusions To minimize risk factors there are some key points where specific safety measures should be adopted: blood sample collection for cross-matching collection, storage and transport checking before administration care during administration. Blood sample collection for cross-matching To minimize hazards that may result in the wrong blood type being administered to a patient the BCSH (1999) guidelines recommend: The patient’s identity should be confirmed verbally if possible. If the patient is unconscious additional confirmation using gender and hospital number should be included. Identity is confirmed with the identity band giving full name, date of birth, gender and hospital number. 169 Key Nursing Skills The request form must include surname, first name, gender, date of birth, hospital number. Blood samples should be labelled directly after collection and while beside the patient so that details can be checked immedi- ately. Addressograph labels should not be used on sample tubes. Any factors, such as previous transfusions and current medication that may contribute to potential complications should be identi- fied during preliminary nursing and medical assessments for trans- fusion (Bradbury and Cruickshank 2000). Collection, storage and transport Collection of blood for transfusion should only occur when: the prescription has been written the patient has a patent IV access ready for transfusion the patient’s consent has been obtained and any concerns that he may have regarding the integrity of the transfusion have been allayed. Patients may express particular concerns regarding their religious views or the transmission of blood-borne viruses such as HIV, new variant CJD, or hepatitis B or C. Reassurance may be given that all donated blood in the UK is screened for these infective diseases, and that the UK has implemented a process called ‘leucocyte depletion’ to reduce potential infection and reaction risks (Gray and Murphy 1999). Leucocyte deple- tion involves the leucocytes being removed from the blood before trans- fusion to reduce potential reactions and transmission of infection. Anxieties relating to religious or ethical concerns may be of con- cern to Mr Ammon so a clear explanation of the benefits and risks of transfusion should be offered to enable him to make an informed deci- sion about his treatment (Atterbury and Wilkinson 2000). Once blood has been removed from the storage fridge transfusion should commence within 30 minutes. If transfusion does not com- mence within 30 minutes, blood should not be stored in a non-blood fridge, but the blood bank should be contacted to confirm whether it is safe to commence transfusion, or if the unit should be returned to the haematology department. Blood should be used within 4 hours of leav- ing cold storage (Togshill 1997), since micro-organisms may multiply and the quality of the red cells deteriorate. 170 Maintaining fluid balance To collect a unit from storage (Atterbury and Wilkinson 2000): Take the compatibility report (cross-match form) or prescription sheet with the details to the blood bank. Check that the blood label on the unit agrees with the patient details: full name, hospital number, date of birth, required blood component, for example red cells or whole blood, and number of units issued. Confirm blood group on unit with patient details and compatibility report. Select units in order (depending on number required for trans- fusion), and close door firmly. Sign with the date, time and name in the blood bank register. Transport to clinical area in bag or tray if provided. Care should be taken not to damage the pack in transit. The pack should be delivered directly to the qualified practi- tioner responsible for administration. Checking before administration Equipment required to commence a blood transfusion Prescription sheet. Compatibility form. Fluid balance chart. Disinfected tray containing the following: – IV cannula; usual size for blood transfusion is 21 gauge (green) or above (19 or 20 gauge). – Alcohol wipes or chlorhexidine cleanser. – Blood administration set. – IV pole/stand. – Sterile dressing and tape or semi-permeable transparent IV dressing. – Gloves. IV access IV access should be obtained before blood is collected from storage. (See ‘Commencing an infusion’, page 144.) 171 Key Nursing Skills This is the final opportunity to detect any errors of incompatibil- ity. Unfortunately failure to follow stringent procedures has resulted in fatalities (Gray and Murphy 1999). The qualified nurse is as account- able for safety during transfusion as during drug administration. As an unqualified practitioner, you may find yourself checking blood with a qualified practitioner, and should remain accountable for your actions. Be vigilant at all stages, even if Trust policy considers the qualified practitioner as ultimately responsible as if administering a drug single- handedly. Blood unit numbers can be long and mistakes can easily be made. Final checks All checks should be done at the patient bedside (Gray and Murphy 1999): Confirm Mr Ammon’s identity, verbally and from his wrist band. Check first name and surname, date of birth, gender and hospital number. Check identity details on blood compatibility form and confirm against identity wrist band. Confirm compatibility between blood unit number, type and blood compatibility form with the label on the blood pack (Figure 7.8). Figure 7.8 Blood unit details. 172 173 Maintaining fluid balance Confirm patient identity and blood request with the prescription form and medical notes. Check the blood bag for expiry date, possible leaks around seams or entry points. Look for any abnormal presentation of contents such as air bubbles, discolouration or clotting (Bradbury and Cruickshank 2000). Check the prescription sheet for any medication required prior to or during the infusion. If all checks tally proceed to transfusion. ALERT! The blood group ABO and Rhesus factor on the blood unit and compatibility form should be identical. In cases of emergency transfusion, O Rhesus negative may be used as it is the universal donor (Table 7.1). If there is any doubt or discrepancy between the group on the blood unit and the blood group of the patient, contact the blood bank immediately and do not commence the infusion. No drugs should be added to the blood or administration set as they could contaminate or react with the blood. If intravenous drugs are required ensure that the patient has two patent IV access sites, or a Y type cannula may be used, depending on local policy. Approximately 85 per cent of people in the UK are Rhesus D positive. Those who are Rh D negative have no Rhesus antigen, but a Rh D antibody can be produced after exposure to Rh D positive blood (Glover and Powell 1996). This will have consequences for the recipient so check that the Rh D is compatible. Table 7.1 Blood group compatibility Blood group Compatible groups Percentage in UK O O 47 (O Rh –ve = universal donor) A A and O 42 B B and O 8 AB AB, A, B, and O 3 (AB Rh +ve = universal recipient) 173 Key Nursing Skills Care during administration Close monitoring of the patient during blood administration will detect any adverse reactions. Intervention: safe blood transfusion Take baseline vital signs of temperature, pulse and respiratory rate (TPR), and BP and commence an observation record solely for the period of transfusion. Ensure a blood administration set with an integral filter is ready for use. An IV administration set may be primed with 0.9% saline solution before transfusion, but Atterbury and Wilkinson (2000) suggest that this may prevent complete filling with blood and some filters and administration sets should not be primed in this way. Alternatively, the IV cannula can have patency confirmed with a 0.9% saline flush and the blood administration set primed then with blood. The drip and filter chambers should be filled half full before the tubing clamp is opened and the tubing filled, to exclude as much air as possible so that blood is not wasted. (To prepare an infusion see ‘Commencing an IV’, page 144.) ALERT! Only 0.9% saline solutions should come into contact with blood or blood products. If dextrose is given it will cause haemolysis (breakdown of red blood cells). Set the rate of flow as calculated. A severe reaction may commence within the first 10–15 minutes of infusion as it takes very little incompatible blood to cause a reaction (Bradbury and Cruickshank 2000). The patient should be in a position for close observation during transfusion. Some Trusts require a nurse to remain present during the first 10–15 minutes. Research evidence has not yet identified the ideal fre- quency to monitor vital signs but Gray and Murphy (1999) and Bradbury and Cruickshank (2000) suggest that TPR and BP should be recorded: 174  Maintaining fluid balance – before the transfusion begins – 15 minutes after commencement of each unit – temperature and pulse may be recorded more regularly during transfusion, e.g. every 15 minutes of the first hour and hourly thereafter – on completion of the transfusion – 4-hourly for 24 hours after completion to identify any post- transfusion reaction. TIP! Unconscious patients should have hourly observations throughout a transfusion as they are unable to communicate any discomfort. Observe urine output closely for any signs of haematuria (blood). Mr Ammon should be advised to report any feelings of breath- lessness, loin pain, abdominal discomfort, shivering, or feeling unwell. He should be observed for pyrexia, tachycardia, rashes, flushing or blood in his urine. If any of these occur stop the trans- fusion and seek medical advice. Documentation of vital signs and blood pack details should be completed and maintained throughout the treatment. Should any adverse reactions occur (see section below) inform senior nurse and medical staff. Document your response and interventions in the nursing record. A permanent record of the following should be kept in the med- ical notes (Gray and Murphy 1999): – type of transfusion of blood or blood products – compatibility form – nursing observation record – indications for and response to the transfusion – occurrence and management of adverse reactions. A fluid balance record should be maintained, recording the amount of each unit, the patient’s overall fluid balance and if blood was detected in the urine during transfusion. On completion the blood bag is sealed with the attached bung, placed in an outer bag, and discarded or returned to the haematol- ogy department, depending on the local policy. A new administra- tion set should be used for any subsequent fluids, or the cannula may be removed. 175 Key Nursing Skills Evaluation Mr Ammon receives a blood transfusion without adverse reactions. Common adverse reactions Pyrexia Mild: Up to 38°C. Actions: Stop or slow transfusion; inform medical staff; administer paracetamol and observe response to medication. Severe: Temperature above 38°C, rigors/shivering. Actions: Stop infusion; inform medical staff; maintain IV access with 0.9% saline via new administration set; administer antipyretics as prescribed. Allergic reaction Mild: Urticarial rash (hives), pyrexia. Severe: Facial oedema, bronchospasm. Actions: Stop infusion; administer antihistamines. In case of a severe reaction respond as for an emergency. Infections Symptoms: Pyrexia, rigors, hypotension, phlebitis at IV site. Actions: Stop infusion. Inform medical staff. Save unit of blood and return to blood bank for analysis. Haemolytic reaction Symptoms: Destruction of donor red cells by recipient causing: pain at IV site; facial flushing; back or loin pain; falling BP and raised temperature and pulse; decreased urine output; blood in urine; breathlessness; collapse. This can be severe and is life- threatening. Actions: Stop transfusion immediately; take vital signs; maintain IV access with 0.9% saline solution. Inform medical staff urgently. 176  Maintaining fluid balance Circulatory overload Symptoms: Breathlessness; cough; distress. Actions: Stop or slow infusion; diuretic therapy; monitor urine output. TIP! Emergency drugs such as IM epinephrine and IV piriton should be readily available when blood transfusions are in progress in case of allergic reaction. Further reading Amoore J, Dewar D, Ingram P, Lowe D (2001) Syringe pumps and start up time: ensur- ing safe practice. Nursing Standard 15(17): 43–45. Bradbury M, Cruickshank JL (2000) Blood transfusion: crucial steps in maintaining safe practice. British Journal of Nursing 9(3): 134–38. Morling S (1998) Infusion devices: risks and user responsibilities. British Journal of Nursing 7(1): 13–19. Woollon S (1997) Selection of intravenous and infusion pumps. Professional Nurse Supplement 12(8): S14–S15. Workman B (1999) Peripheral intravenous therapy management. Nursing Standard 14(4): 53–60. 177