Class 42- IV admin. Flashcards
Crystalloids vs colloids
Aqueous solution; contains larger insoluble molecules
Types of IV Access
- Peripheral
- Total Parenteral Nutrition
- Intermittent
- Central Venous Access
Isotonic crystalloids
•0.9% NaCl (normal saline), (NS)
• Lactated Ringers (balanced electrolyte solution- contains Na+, K+, Ca++, Cl-, and lactate)
• D5W 5% dextrose in water
Same osmolarity as serum and body fluids
•Diffuse throughout the extracellular space
•Do not usually enter cells
•Example of distribution:
3000mL normal saline (NS) in 24 hours
2250mL into interstitial space
750mL into intravascular space
does not enter cells due to sodium/potassium pump
Hypotonic crystalloids
•0.45% NaCl Half normal or Half strength saline
0.33% NaCl one third normal saline (1/3 NS)
Osmolarity lower than serum
- Do not give with low blood pressure, could worsen hypotension
- Should not be given to patients with brain injury, could cause cerebral edema
- Never give at fast rate
Hypertonic crystalloids
Osmolarity higher than serum
•D5NS - 5% dextrose in water and normal saline or
D5½NS – 5% dextrose in water and ½ normal saline
D5LR – 5% dextrose in Lactated Ringers
•Increases serum osmolarity so fluid moves from intracellular and interstitial into intravascular
•Greatly expand intravascular compartment so monitor for circulatory overload
- Irritating to vein, give slowly
- Used after surgery to pull fluid from interstitial compartment back into blood vessels, not uncommon
- May be beneficial in some brain injuries
- A higher percentage of NaCl may be used to treat some types of hyponatremia
- D5NS
- D5½NS
- D5LR
All these provide some calories and hydrate cells
Normal saline uses
Could be used to temporarily expand the vascular compartment in hypotension due to hypovolemia
Could be used to replace isotonic fluid loss: blood loss, gastrointestinal losses
Could cause Hypervolemia and hypernatremia
Lactated Ringers
Contains several electrolytes in roughly the same concentration as plasma
Useful in replacing isotonic fluid loss
Often used for burns
Contains potassium, don’t give if renal impairment
Contains lactate, don’t give if liver impaired
D5W
•D5W- contains H2O and dextrose
( Isotonic in the bag, hypotonic in the body )
1/2 NS
•½ Normal Saline (½ NS) - 0.45%sodium chloride
Hypotonic solutions lower the serum osmolarity so fluid shifts out of blood vessels and enters the interstitial space and cells
Hydrate cells but can deplete circulatory system
Colloids
- Contain protein or starch molecules that remain in vascular space
- Increase osmotic pressure and pull fluid into intravascular space
- Plasma Expanders (Albumin 5%, 25%)
- Albumin (protein)
- Dextran (starch)
- Plasma (formed part of the blood)Monitor for fluid overload
Cannula
a tube which can be inserted into a cavity
Central devices
•Central devices: Central Lines
nontunneled central venous catheter (subclavian or internal jugular), short term intervention ( less than 4 wks)
tunneled central venous catheter
implanted infusion port Portacath
PICC (peripherally inserted central venous catheter)
Assessment findings in increased vascular volume:
increased blood pressure
bounding pulse
distended neck veins
slow-emptying peripheral veins
weight gain
congestive heart failure-
jugular vein distension
dyspnea
increased respiratory rate
crackles in lungs
S3 gallop
lab work- will indicate dilution
decreased hematocrit
decreased serum electrolytes
decreased BUN
•Interventions:
decrease flow rate
assess patient
notify MD
Infiltration
infiltration- inadvertent administration of a nonvesicant solution into surrounding tissues
•Assessment findings: swelling blanching coolness leaking feeling of tightness pain
•Interventions:
discontinue IV cold compress for majority of solutions warm compress for vinca alkaloids Elevate the Extremity Notify MD if needed for antidotes
Phlebitis
•Irritation of the vein
•Causes: Long Term IV Sites – change by 72 hrs. best mechanical trauma chemical trauma precursor of infection
•Assessment findings:
tenderness/pain
redness at site, red streak along vein
warmth
swelling
•Prevention-Changing IV sites at least every 72 hours has shown to reduce phlebitis incidents
–Avoid placing IV at a site where joint movement will cause the IV catheter to “piston”, or rub against the inside of the vein
–Use large vein if infusing hypotonic or hypertonic solution , or irritating medications
•Interventions
discontinue IV
warm, wet compress
sterile dressing
Extravasation
vesicant- solution capable of causing tissue injury or destruction if it escapes into the surrounding tissue
extravasation- inadvertent administration of a vesicant solution into surrounding tissue
•Assessment findings:
local- tender, red, warm, swollen, drainage
systemic- fever
malaise
•Interventions:
stop infusion
notify MD
remove device, culture if ordered
meds if ordered
Infection prevention
- Replace adult’s peripheral catheter every 72 – 96 hr
- Child’s peripheral catheter stays until IV therapy complete or complication occurs
- Central venous catheter replaced when purulent drainage is observed or if patient is unstable and infection is suspected
- When possible, avoid opening system by coordinating tubing changes with bag changes
- Change solution bag every 24 Hr
- Replace administration sets every 72 hrexceptions:
blood tubing- 4hr
TPN- 24 hr
Air Embolism
- Caused by air entering vein
- More common with air dependent containers and central lines
•Assessment findings:
respiratory distress
weak pulse
decreased BP
•Interventions:
place patient in left side, head lower than heart to keep air in right atrium and out of pulmonary artery
notify MD
•Prevention:
purge air out of tubing before infusing
use unvented tubing instead of vented
use plastic bag instead of glass bottle
use infusion pump with air detecting capability
•Change bag before it is completely dry
use clamps when performing tubing changes ( when system is open)
Use of Luer locks to avoid line disconnection
Use of check valves to prevent entrainment of air after disconnection and use of air in line detector on pump
Tape loop of tubing at insertion site for strain relief
Place patient in Trendelenburg when inserting or changing catheter, Inspect all catheter hubs/connectors
Insertion Site Assessment
assess insertion site every hour
vesicants- assess every 30 minutes
follow protocol of nursing unit
CENTRAL VENOUS ACCESS DEVICES (CAVDs)
•“CENTRAL” Defined by the position of the tip of the catheter
•Tip In Superior Vena Cava (SVC),
3-4cm above the right atrium
•If Femoral Vein–Tip Inferior Vena Cava
CVADs
Central Venous Access Devices •Nontunneled central venous catheter •Tunneled central venous catheter •PICC: peripherally inserted central venous catheter •Implanted infusion port
NONTUNNELED CENTRAL VENOUS CATHETERS
•Short term- days to weeks
- Percutaneous insertion
- Subclavian Preferred
- Internal Jugular and Femoral
- Inserted at bedside or in surgery
- Inserted by physician
- Risks of insertion- pneumothorax, hemothorax, arterial puncture etc
- Port designations- follow institutions protocol
PICC
- Short term- days to weeks
- Percutaneous insertion
•Veins in antecubital fossa usually used
( basilic, cephalic, median cubital)
- Catheter tip should be in SVC
- Can be inserted at bedside
- Can be inserted by specially trained RN
- Advantage- eliminates risks associated with neck or chest insertion
In the extremity with a PICC, avoid:
- Measuring blood pressure
- Performing venipuncture
- Administering injections
Tunneled Catheters
•Long term, > 6months
•Tunneled Beneath the Skin
•Have a small cuff around which fibroblasts form and help secure the catheter in place.
This cuff is under the skin, not far from the insertion site.
*Inserted in surgery
•Broviac
- Hickman
- Hohn
- Groshong- describes tip which is closed but has a three way slit valve close to distal end, *eliminates the need for daily heparin flushes and catheter clamping before disconnection at the catheter hub
Implanted ports
- Long term, >6 months
- Port consists of a metal reservoir with septum and catheter. No external segment.
• Incision made, usually near clavicle. Pocket formed to house the port.
Catheter is inserted into superior vena cava.
To prevent infection
- Hand hygiene
- Maximal barrier precautions upon insertion
- Skin asepsis maintained per facility protocol.
- Optimal site selection- avoid femoral and jugular
- Daily review of line necessity, prompt removal
- If nontunneled Catheter inserted at beside, ensure that physician has on mask, cap, sterile gown, sterile gloves. Sterile drapes are used around the insertion site. Assistant should wear mask.
- Mask and sterile gloves during dressing changes
–Transparent dressing- change at least every 7 days ( in peds, risk of dislodging catheter may outweigh benefit)
- Gauze dressing- change at least every 48 hours
- Change either dressing when it becomes contaminated, damp, or nonadherent
Valsalva
Valsalva: forced exhalation against closed airway
Instruct patient to take a deep breath, hold it with mouth closed, and bear down for 10 sec, then exhale and breath normally
*Used if central line is open to air.
Contraindicated in increased intracranial pressure, recent eye surgery, MI, bradycardia, or resp distress
Flushing
•Flush according to institution policy
Flush with NS then heparin
Heparin flush solution 10units/ml (could see 100units/ml)
General rule: flush volume needs to be two times the internal fill volume of the catheter
Use protocol- 5ml NS then 2ml heparin flush solution
Flush with pulsatile push-pause technique
to remove residues and fibrin buildup.
Frequency:
Flush with NS- before meds, blood products, TPN (NS)
Flush with NS then heparin- whenever line is locked
after each blood draw (attempts)
following meds, blood products, or TPN and per agency’s frequency (every 12hr)
PSI Pounds per square inch. If too much pressure is used, can collapse the catheter or cause it to burst. Would not be a good situation.
Must use a 10ml or larger syringe. Do not have to use 10ml volume.
10ml syringe exerts 7 pounds per square inch (psi)
3ml syringe exerts >25psi
1ml syringe exerts >300psi
Catheter burst pressure is 25-40 psi
Paraenteral nutrition used
•Patient is malnourished
•Patient at risk for developing malnutrition
•Patient unable to meet nutritional need via
the enteral route
Partial para enteral nutrition
- Supplements oral intake. Not used for nutritionally depleted patients.
- Usually isotonic so may be given in a peripheral vein
- Lower dextrose concentration as compared to TPN
TPN
- Non-functional GI tract
- Comatose
•Inability to consume adequate diet (Cancer patient receiving chemotherapy)
•High metabolic demand ( increase in need for calories and protein)
–Trauma
–Infection (Sepsis)
–Burns
–Surgery
–Fever
TPN components
–Dextrose
–Amino acids Proteins
–Fat emulsion
These three provide calories
–Electrolytes –Trace elements –Minerals –H2O –Possibly insulin, heparin, and famotidine (Pepcid)
Preventions for complications with TPN
–Hyperglycemia- high blood glucose
Begin TPN at a slow rate (50ml/hr) and increase rate gradually
Use infusion pump
Check blood glucose every 6hr
•Line dedicated to TPN – not for other medications – unless added to TPN solution
• - Hyperglycemia – High blood glucose
–Hypoglycemia- low blood glucose
Discontinue TPN gradually over 24-48hr
If new TPN bag not available when needed, hang a D10 solution
–Fluid and electrolye imbalance
Use infusion pump
Monitor I&O and other fluid balance parameters
Monitor electrolytes
–Infection- sepsis
Refrigerate solution (remove from fridge 1hr prior to administration)
Solution and tubing change every 24hr
Aseptic technique- keep fluid path sterile
Use in-line filter
Use same catheter lumen for each TPN bag
VS every 4hr
•Monitor for “Cracking”
Occurs if calcium or phosphorous content is too high.
Appears as an oily or fatty layer on top of solution and should not be used.
•Monitor for effectiveness
•Pre-Albumin also known as
thyroxin-binding pre-albumin or transthyretin
- Has half-life of 2 days, so is a better than albumin as an indicator of recent changes in nutrition. (Albumin has a longer half-life)
- Transferrin , another useful test for malnutrition
- Monitor for effectiveness:
- Weight gain: Daily weight gain of up to 1KG/day
- A weight gain of more than 1Kg/day is probably from fluid volume.
