chapter 13 concepts of infusion therapy Flashcards
Infusion therapy
is the delivery of medications in solution and fluids by parenteral (piercing of skin or mucous membranes) route through a wide variety of catheter types and locations using multiple procedures.
Intravenous (IV) therapy
delivers solutions directly into the veins of the vascular system.
reasons for using infusion therapy are to:
- Maintain FLUID BALANCE or correct fluid imbalance
- Maintain ELECTROLYTE or acid-base BALANCE or correct electrolyte or acid-base imbalance
- Administer medications
- Replace blood or blood products
Infusion nurses may perform any or all of these activities:
- Develop evidence-based policies and procedures.
- Insert and maintain various types of peripheral, midline, and central venous catheters and subcutaneous and intraosseous accesses.
- Monitor patient outcomes of infusion therapy.
- Educate staff, patients, and families regarding infusion therapy.
- Consult on product selection and purchasing decisions.
- Provide therapies such as blood withdrawal, therapeutic phlebotomy, hypodermoclysis, intraosseous infusions, and administration of medications.
RN and peripheral IV lines
taught to insert LPNs can sometimes insert as well
The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks
CRNI
which stand for certified registered nurse infusion.
Tonicity
is typically categorized by comparison with normal blood plasma as osmolarity (mOsm/L)
normal serum osmolarity for adults
is between 270 and 300 mOsm/L.
isotonic
Parenteral solutions within that normal range
hypertonic
fluids greater than 300 mOsm/L
hypotonic.
fluids less than 270 mOsm/L
infusate
solution that is infused into the body
When an isotonic infusate is used:
water does not move into or out of the body’s cells
Hypertonic solutions are used to:
correct altered FLUID AND ELECTROLYTE BALANCE and acid-base imbalances by moving water out of the body’s cells and into the bloodstream
parenteral nutrition”
administered or occurring elsewhere in the body than the mouth and alimentary canal
hypotonic infusates move water:
into cells to expand them
Phlebitis
is the inflammation of a vein caused by mechanical, chemical, or bacterial irritation
Infiltration
occurs when IV solution leaks into the tissues around the vein.
swelling, coolness, or redness
discontinue IV and notify infusion therapy team and PCP
thrombosis
(blood clot in the vein)
Extremes of both osmolarity and pH can cause:
vein damage, leading to phlebitis and thrombosis
total parenteral nutrition (TPN) solutions have an osmolarity:
greater than 1400 mOsm/L
pH of IV solutions
3.5 to 6.2
vesicants
(chemicals that damage body tissue on direct contact
Drugs with vasoconstrictive action
chemotherapeutic agents
Extravasation
results in severe TISSUE INTEGRITY impairment as manifested by blistering, tissue sloughing, or necrosis from infiltration into the surrounding tissues
available blood components include
platelets, fresh frozen plasma, albumin, and several specific clotting factors.
Blood transfusion is given by
using packed red blood cells, created by removing a large part of the plasma from whole blood.
International Society of Blood Transfusion (ISBT) universal bar-coding system
to ensure the right blood for the right patient
(1) a unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor.
adverse drug events (ADEs).
immediate serious reactions
things you need to know to give IV meds:
indications, proper dosage, contraindications, and precautions. appropriate dilution, rate of infusion, pH and osmolarity, compatibility with other IV medications, appropriate infusion site (peripheral versus central circulation), potential for vesicant/irritant effects, and specific aspects of patient monitoring because of its immediate effect.
same drug IV vs other route:
Regardless of familiarity with the drug, never assume that IV administration is the same as giving that drug by other routes
high-alert IV drugs:
restricted access, prominent warnings about the concentration, and storage in a secured location.
prescription for infusion fluids should include:
- Specific type of fluid
- Rate of administration written in milliliters per hour (mL/hr) or the total amount of fluid and the total number of hours for infusion (e.g., 125 mL/hr or 1000 mL/8 hrs)
- Drugs and the specific dose to be added to the solution such as electrolytes or vitamins
A drug prescription should include:
- Drug name, preferably by generic name
- Specific dose and route
- Frequency of administration
- Time of administration
- Length of time for infusion
- Purpose (required in some health care agencies, especially nursing homes)
vascular access device (VAD)
is a plastic tube placed in a blood vessel to deliver fluids and medications.
catheter used for peripheral and central IV therapy
- Short peripheral catheters
- Midline catheters
- Peripherally inserted central catheters (PICCs)
- Nontunneled percutaneous central venous catheters (CVCs)
- Tunneled catheters
- Implanted ports
- Hemodialysis catheters
peripheral IV therapy
IV therapy in which a vascular access device (VAD) is placed in a peripheral vein, usually in the arm.
Short infusion catheters
most commonly used vascular access devices (VADs) for peripheral IV therapy.
Short peripheral catheters
are composed of a plastic cannula built around a sharp stylet extending slightly beyond the cannula
stylet
(sharp) of the short peripheral cath
hollow-bore, blood-filled needle
what veins to avoid in older people:
Avoid the use of veins in the lower extremities of adults, if possible, because of an increased risk for deep vein thrombosis and infiltration.
veins on the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition
how to pick cath size
Choose the smallest-gauge catheter capable of delivering the prescribed therapy
24-26 gauge
Smallest, shortest (image-inch length)
Not ideal for viscous infusions
Expect blood transfusion to take longer
Preferred for infants and small children
22 gauge
Adequate for most therapies; blood can infuse without damage
20 gauge (1-image-inch length)
Adequate for all therapies
Most providers of anesthesia prefer not to use a smaller size than this for surgery cases
18 gauge
Preferred size for surgery
Vein needs to be large enough to accommodate the catheter
14-16 gauge
For trauma and surgical patients requiring rapid fluid resuscitation
Needs to be in a vein that can accommodate it
when to change/remove/rotate IV
based on clinical indications (e.g., signs of phlebitis [warmth, tenderness, erythema or palpable venous cord], infection, or malfunction)
If the patient’s therapy is expected to be longer than 6 days:
midline catheter or PICC should be chosen
how often to asses IV site
assessment at least every 4 hours—every 1 to 2 hours for vulnerable patients and every 4 hours for continuous infusions for outpatient
otherwise site assessment should be done once a day
Placement of Short Peripheral Venous Catheters
- Verify that the prescription for infusion therapy is complete and appropriate for infusion through a short peripheral catheter.
- For adults choose a site for placement in the upper extremity. DO NOT USE THE WRIST.
- Choose the patient’s nondominant arm when possible.
- Choose a distal site and make all subsequent venipunctures proximal to previous sites.
- Do not use the arm on the side of a mastectomy, lymph node dissection, arteriovenous shunt or fistula, or paralysis.
- Avoid choosing a site in an area of joint flexion.
- Avoid choosing a site in a vein that feels hard or cordlike.
- Avoid choosing a site close to areas of cellulitis, dermatitis, or complications from previous catheter sites.
- Choose a vein of appropriate length and width to fit the size of the catheter required for infusion.
- Limit unsuccessful attempts to two per clinician and no more than four total
Ultrasound-guided peripheral IV insertion
can allow insertion into deeper veins
vein transilluminators
devices penetrate only up to about 10 mm and are limited to finding superficial veins.
why is a saline lock is placed
in case there is a need for emergency drug administration via IV push
The most appropriate veins for peripheral catheter placement
include the dorsal venous network
when not to use veins on hand:
older adults
active patients
veins on dorsal surface of hands:
Use of veins on the dorsal surface of the hands should be reserved as a last resort for short-term infusion of nonvesicant and nonirritant solutions in young patients.
why you wouldnt put an IV on one side of a patient:
Mastectomy, axillary lymph node dissection, lymphedema, paralysis of the upper extremity, and the presence of dialysis grafts or fistulas
Avoid veins on the palmar side of the wrist because?
the median nerve is located close to veins in this area, making the venipuncture more painful and difficult to stabilize
Reports of tingling, feeling “pins and needles” in the extremity, or numbness during the venipuncture procedure:
stop the IV insertion procedure immediately, remove the catheter, and choose a new site.
Winged needles (“butterfly needles”)
easy to insert but are associated with a high frequency of infiltration.
catheter-related bloodstream infection (CR-BSI)
Health care–acquired bloodstream infection caused by the presence of any type of intravenous catheter.
to avoid CR-BSI:
- Perform evidence-based hand hygiene before palpating the insertion site.
- Clip hair—do not shave.
- Ensure that skin is clean. If visibly soiled, cleanse with soap and water.
- Wear clean gloves for peripheral IV insertion; do not touch the access site after application of antiseptics.
- Prepare clean skin with a skin antiseptic (chlorhexidine 2% with 70% alcohol, 70% isopropyl alcohol, or povidone-iodine) with a back-and-forth motion for 30 seconds and allow the solution to dry before peripheral venous catheter insertion.
- Do not retouch the proposed insertion site. If retouching occurs, prepare the skin antiseptic again and allow to dry.
Midline catheters
can be anywhere from 3 to 8 inches long, 3 to 5 Fr, and double or single lumen. They are inserted through the veins of the upper arm.
median antecubital vein most common
considered to dwell in the peripheral circulation
Indications for midline cath
include fluids for hydration and drug therapy that are given longer than 6 days and up to 4 weeks
vesicant medications
—drugs that cause severe tissue damage if they escape into the subcutaneous tissue
pH and osmolarity of drugs in midline cath
pH between 5 and 9 and a final osmolarity of less than 600 mOsm/L
central IV therapy
the vascular access device (VAD) is placed in the central circulation
specifically within the superior vena cava (SVC) near its junction with the right atrium, also called the caval-atrial junction (CAJ)
xray to confirm placement
antimicrobial and heparin coatings to reduce infection risk and improve the longevity of the catheter.
peripherally inserted central catheter (PICC)
is a long catheter inserted through a vein of the antecubital fossa (inner aspect of the bend of the arm) or the middle of the upper arm.
tip residing in the superior vena cava (SVC) ideally at the caval-atrial junction (CAJ)
basilic vein is the preferred site for insertion; the cephalic vein can be used if necessary.
Mid-clavicular tip locations
inappropriate tip location
are used only when anatomic or pathophysiologic changes prohibit placing the catheter into the SVC.
when placing a PICC and after it is placed:
Sterile technique is used for insertion to reduce the risk for CRBSI. Before the catheter can be used for infusion, a chest x-ray indicating that the tip resides in the lower SVC is required when the catheter is not placed under fluoroscopy or with the use of the electrocardiogram tip-locator technique.
common complications from PICCs include
phlebitis, thrombophlebitis, deep vein thrombosis (DVT), and CRBSIs
central line-associated bloodstream infection, or CLABSI.
infections occur from a central line
pH and osmolality of PICC
no limitations on the pH or osmolality of fluids that can be infused through a PICC.
Patients with PICCs should avoid:
should avoid excessive physical activity
can lead to catheter dislodgment
catheter-related bloodstream infection (CRBSI) prevention bundle.
- Hand hygiene
- Measuring upper arm circumference as a baseline before insertion (INS, 2016)
- Maximal barrier precautions on insertion
- Chlorhexidine skin antisepsis
- Optimal catheter site selection and post-placement care with avoidance of the femoral vein for central venous access in adult patients
- Daily review of line necessity with prompt removal of unnecessary lines
flushing a PICC
Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.
Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline is flushed after drawing blood.
Nontunneled percutaneous central venous catheters (CVCs)
are inserted by a physician, physician assistant, or nurse practitioner through the subclavian vein in the upper chest or the internal jugular veins in the neck using sterile technique.
Tunneled central venous catheters
are VADs that have part of the catheter lying in a subcutaneous tunnel, separating the points where the catheter enters the vein from where it exits the skin.
separation is intended to prevent the organisms on the skin from reaching the bloodstream
when to use Tunneled central venous catheters
used primarily when the need for infusion therapy is frequent and long term. Patients needing parenteral nutrition for months, years, or the remainder of their lives commonly choose a tunneled catheter. Tunneled catheters are also chosen when several weeks or months of infusion therapy are needed and a PICC is not a good choice.
Implanted ports
type of device is chosen for patients who are expected to require IV therapy for more than a year
