iggy ch 13 concepts of infusion therapy

Question 1

infusion therapy

Answer 1

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 is the most common route for infusion therapy.

Question 2

Common reasons for infusion therapy

Answer 2

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

Question 3

Some benefits of infusion therapy

Answer 3

Advances in medicine and technology have made it possible for people with chronic diseases such as diabetes mellitus, chronic kidney disease, and malabsorption syndromes to live long and productive lives.

These patients often depend on long-term infusion therapy of some kind.

They often have very poor vascular integrity; therefore accessing their peripheral veins takes a high level of skill.

Question 4

Infusion nurses may perform any or all of these activities:

Answer 4

• 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.

Question 5

Training/nurses who perform infusion therapy

Answer 5

The registered nurse (RN) generalist is taught to insert peripheral IV lines; most institutions have a process for demonstrating competency for this skill.

Depending on the state’s nurse practice act, licensed practical/vocational nurses (LPNs/LVNs) and technicians may be trained and verified competent to perform the skill of peripheral IV insertion and assist with infusions.

The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks

Question 6

standards

Answer 6

The Infusion Nurses Society (INS) publishes guidelines and standards of practice for policy and procedure development in all health care settings.

These standards establish the criteria for all nurses delivering infusion therapy.

The Infusion Nurses Certification Corporation (INCC) offers a written certification examination.

Nurses who successfully complete this examination have mastered an advanced body of knowledge in this specialty and may use the initials CRNI, which stand for certified registered nurse infusion.

Question 7

Types of Infusion Therapy Fluids

Answer 7

Many types of parenteral fluids are used for infusion therapy. These fluids are IV solutions, including parenteral nutrition, blood and blood components, biologics, and pharmacological therapy.

Question 8

Intravenous Solutions classification:
classified by 2 things.. and
Normal serum osmolarity for adults

Answer 8

Each solution is classified by its tonicity (concentration) and pH.

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.

Question 9

isotonic

Answer 9

Parenteral solutions within that normal range are isotonic

Question 10

hypertonic

Answer 10

fluids greater than 300 mOsm/L are hypertonic

Question 11

hypotonic

Answer 11

fluids less than 270 mOsm/L are hypotonic

Question 12

isotonic infusate

Answer 12

solution that is infused into the body (within normal range)

Question 13

what happens when an isotonic infusate is used

Answer 13

When an isotonic infusate (solution that is infused into the body) is used, water does not move into or out of the body’s cells. Therefore patients, especially older adults, receiving isotonic solutions are at risk for fluid overload

Question 14

what happens when a hypertonic solution is used

Answer 14

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. Electrolytes and other particles also move across cell membranes across a concentration gradient (from higher concentration to lower concentration). Parenteral nutrition solutions are hypertonic

Question 15

what happens when a hypotonic infusate is used

Answer 15

Instead of moving water out of cells, hypotonic infusates move water into cells to expand them.

Question 16

risks when patients are receiving either hypertonic or hypotonic fluids

Answer 16

Patients receiving either hypertonic or hypotonic fluids are at risk for phlebitis and infiltration.

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.

Question 17

pH of IV solutions

Answer 17

The pH of IV solutions is a measure of acidity or alkalinity and usually ranges from 3.5 to 6.2.

Question 18

problems that can occur with extremes of osmolarity and pH

Answer 18

Extremes of both osmolarity and pH can cause vein damage, leading to phlebitis and thrombosis (blood clot in the vein).

Question 19

which fluids are best infused in the central circulation

Answer 19

Thus fluids and medications with a pH value less than 5.0 and more than 9.0 and with an osmolarity more than 600 mOsm/L are best infused in the central circulation where greater blood flow provides adequate hemodilution .

For example, total parenteral nutrition (TPN) solutions have an osmolarity greater than 1400 mOsm/L. TPN should not be infused in peripheral circulation because it can damage blood cells and the endothelial lining of the veins and decrease perfusion.

Question 20

drugs with irritants that have pH less than 5 and what can this cause

Answer 20

amiodarone (Cordarone), vancomycin (Vancocin), and ciprofloxacin (Cipro IV) are venous irritants that have a pH less than 5.0. Phlebitis occurs when patients require long-term infusion of these drugs in peripheral circulation.

Question 21

Vesicants

Answer 21

Drugs with vasoconstrictive action (e.g., dopamine or chemotherapeutic agents [e.g., vinblastine]) are vesicants (chemicals that damage body tissue on direct contact) that can cause extravasation.

Question 22

Extravasation

Answer 22

. Extravasation results in severe TISSUE INTEGRITY impairment as manifested by blistering, tissue sloughing, or necrosis from infiltration into the surrounding tissues.

Question 23

Nursing action regarding IV and potential problems

Answer 23

Monitor the IV insertion site carefully for early manifestations of infiltration, including swelling, coolness, or redness. If any of these symptoms are present, discontinue the drug immediately and notify the infusion therapy team, if available. If an infusion specialist is not available, notify the primary health care provider and remove the IV catheter.

Question 24

Blood transfusion and other blood components

Answer 24

Blood transfusion is given by using packed red blood cells, created by removing a large part of the plasma from whole blood. Other available blood components include platelets, fresh frozen plasma, albumin, and several specific clotting factors. Each component has detailed requirements for blood-type compatibility and infusion techniques

Question 25

Joint commission patient safety goals regarding blood products

Answer 25

For patient safety, The Joint Commission’s (TJC) 2015 National Patient Safety Goals (NPSGs) require agencies to ensure that blood components are properly ordered, handled and dispensed, and administered, and that patients are appropriately monitored. Positive patient identification using two patient identifiers and requiring two qualified health care professionals is essential before any blood or blood component is administered. Automated bar coding can be used for positive patient identification in ambulatory care, acute care, and critical access hospitals, and office-based surgery-accredited programs.

Question 26

International society of blood transfusion universal bar-coding system, and the 4 components

Answer 26

Most organizations use the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right patient (Fig. 13-1). The ISBT system includes four components that must be present on the blood label both in bar code and in eye-readable format. These four components are (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.

Question 27

adverse drug events

Answer 27

IV drugs provide a rapid therapeutic effect but can lead to immediate serious reactions, called adverse drug events (ADEs).Hundreds of drugs are available for infusion by a variety of techniques

Question 28

Nurses action-ADE’s

Answer 28

As with all drug administration, nurses must be:
knowledgeable about drug indications, proper dosage, contraindications, and precautions.

IV administration also requires knowledge of:
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.

Regardless of familiarity with the drug, never assume that IV administration is the same as giving that drug by other routes. New information is continuously being published, and new drugs are rapidly being introduced.

Medication safety is extremely important in all health care settings today

Question 29

Joint commission NPSG’s-and what is an example of high alert drugs

Answer 29

The Joint Commission’s 2014 NPSGs include as a major goal improving the safety of high-alert drugs. Examples of this type of drug are concentrated electrolyte solutions (e.g., potassium chloride), which require restricted access, prominent warnings about the concentration, and storage in a secured location.

Question 30

Preventing errors

Answer 30

Procedures must be established to prevent errors resulting from look-alike, sound-alike drugs such as Celebrex IV (celecoxib) and Cerebyx (fosphenytoin).

Other strategies to reduce errors include:
limiting available concentrations of drugs and dispensing all drugs, including catheter flush solutions, in single-dose containers.
Smart pumps with drug libraries (see Infusion Systems section), in combination with computer provider (physician, nurse practitioner, physician assistant) order entry (CPOE) and bar-code medication administration (BCMA) systems, use recent technology to help reduce adverse drug events (ADEs).

Electronic medication administration records (MARs) and multiple checks by pharmacists, as required by The Joint Commission’s NPSGs, also help reduce errors.

Question 31

prescriptions for infusion therapy-

Answer 31

A prescription for infusion therapy written by an authorized primary health care provider (physician, nurse practitioner, or physician assistant) is necessary before IV therapy begins. To be complete, the 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

Question 32

A drug prescription should include:

Answer 32

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)

Some continuously infused drugs such as those for pain management are prescribed as milligrams per hour. The type and volume of dilution for infusion medications may be included in the prescription or calculated by the infusion pharmacist.

Question 33

nursing action-safety for iv prescription

Answer 33

Determine that the IV prescription is appropriate for the patient and clarify any questions with the primary health care provider before administration. Be sure to check for the accuracy and completeness of the treatment prescription. An example of an incomplete one is “5% dextrose in water to keep the vein open” (TKO or KVO). This statement does not specify the rate of infusion and is not considered complete.

Question 34

infusion catheter, also known as a vascular access device (VAD),

Answer 34

is a plastic tube placed in a blood vessel to deliver fluids and medications.

This catheter should not be confused with the ventricular assist device, also called a VAD.

In this chapter VAD refers to vascular access devices. The specific type and purpose of the therapy determine whether the infusion can be given safely through peripheral veins or if the large central veins of the chest are needed.

Question 35

type of catheter used for peripheral and central IV therapy. Seven major types are described:

Answer 35

• Short peripheral catheters
• Midline catheters
• Peripherally inserted central catheters (PICCs)
• Nontunneled percutaneous central venous catheters (CVCs)
• Tunneled catheters
• Implanted ports
• Hemodialysis catheters

Assess the patient’s needs for vascular access and choose the device that has the best chance of infusing the prescribed therapy for the required length of time. Depending on the patient and type of VAD to be inserted, a topical anesthetic agent or intradermal lidocaine HCl 1% may be helpful to decrease patient discomfort. Obtain a primary health care provider’s prescription and check for patient allergies before administering any anesthetic.

Question 36

peripheral IV therapy

Answer 36

Short infusion catheters are the most commonly used vascular access devices (VADs) for peripheral IV therapy. They are usually placed in the veins of the arm. Another catheter used for peripheral IV therapy is a midline catheter.

Question 37

short peripheral catheters

Answer 37

Short peripheral catheters are composed of a plastic cannula built around a sharp stylet extending slightly beyond the cannula (Fig. 13-2). The stylet (sharp) allows for the venipuncture, and the cannula is advanced into the vein. Once the cannula is advanced into the vein, the stylet is withdrawn.

Question 38

insertion and placement methods for short peripheral catheters

Answer 38

Short peripheral catheters are most often inserted into superficial veins of the forearm using sterile technique. In emergent situations these catheters can also be used in the external jugular vein of the neck.

Avoid the use of veins in the lower extremities of adults, if possible, because of an increased risk for deep vein thrombosis and infiltration.

length range from 3/4 inch to 1 1/4inch, with gauge sizes from 26 gauge (the smallest) to 14 gauge (large bore). Choose the smallest-gauge catheter capable of delivering the prescribed therapy with consideration of all the contributing factors, including expected duration, vascular characteristics, and comorbidities

Current design improves the fluid flow through the catheter while using a smaller gauge and thereby decreases the possibility of vein irritation from a large catheter. For example, a thin-walled 24-gauge Insyte catheter has about the same flow-rate ability as a 22-gauge non–thin-walled Angiocath. Larger gauge sizes allow for faster flow rates but also cause phlebitis more often.

Question 39

Choosing the Gauge Size for Peripheral Catheters

Answer 39

Choosing the Gauge Size for Peripheral Catheters

CATHETER GAUGE INDICATIONS APPROXIMATE FLOW RATES

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
24 mL/min (1440 mL/hr)

22 gauge Adequate for most therapies; blood can infuse without damage 38 mL/min (2280 mL/hr)

20 gauge (1-1 1/4-inch length)
Adequate for all therapies
Most providers of anesthesia prefer not to use a smaller size than this for surgery cases
65 mL/min (3900 mL/hr)

18 gauge
Preferred size for surgery
Vein needs to be large enough to accommodate the catheter
110 mL/min (6600 mL/hr)

14-16 gauge
For trauma and surgical patients requiring rapid fluid resuscitation
Needs to be in a vein that can accommodate it
Over 200 mL/min (12,000 mL/hr)

Question 40

length of use and rotation of short peripheral catheters

Answer 40

current recommendations for dwell (stay-in) time of short peripheral catheters do not include a specific time frame. The recommendations from both the CDC and the INS are that the catheter should be removed and/or rotated to a different site based on clinical indications (e.g., signs of phlebitis [warmth, tenderness, erythema or palpable venous cord], infection, or malfunction) (INS, 2016). This process requires conscientious and frequent assessment of the site. INS (2016) recommends assessment at least every 4 hours—every 1 to 2 hours for vulnerable patients and every 4 hours for continuous infusions for outpatient and home care patients; otherwise site assessment should be done once a day. If the patient’s therapy is expected to be longer than 6 days, a midline catheter or PICC should be chosen

Question 41

selecting a site

Answer 41

When selecting the site for insertion of a peripheral catheter, consider the patient’s age, history, and diagnosis; the type and duration of the prescribed therapy; and, whenever possible, the patient’s preference.

Question 42

Best Practice for Patient Safety & Quality Care image

Placement of Short Peripheral Venous Catheters

Answer 42

• 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

Question 43

Vascular visualization technology

Answer 43

Vascular visualization technology (e.g., near infrared and ultrasound devices) are now available as tools to assist in IV line placement. Several different types of portable vein transilluminators are available such as VeinViewer, Veinlite LED, and AccuVein AV 300.

Although they may have different mechanisms of action (some use infrared light and some use laser), these devices penetrate only up to about 10 mm and are limited to finding superficial veins.

Question 44

Ultrasound-guided peripheral IV insertion

Answer 44

Ultrasound-guided peripheral IV insertion can allow insertion into deeper veins.
very valuable in assisting with cannulation of peripheral veins that the nurse cannot access with sight and touch.

risks the nurse must be aware of when using ultrasound guidance.
should be used only by nurses who have been trained and whose competencies are maintained.

Arteries and nerves lie parallel to deep veins, and training is needed to learn to identify these structures and avoid damaging them.

In addition, when deeper veins are accessed, infiltration may go undetected until a significant amount of fluid has collected in the tissues. This complication can be particularly devastating if the solution is an irritant or vesicant.

Question 45

Saline lock/intermittent IV lock

Answer 45

For patients who need IV access but are at risk for fluid overload or do not need extra IV fluids, the peripheral vascular access device (VAD) can be converted into an intermittent IV lock, also called a saline lock.

This device allows administration of specific drugs given IV push (e.g., furosemide [Lasix, Furoside]) or on an intermittent basis using a medication administration set. IV antibiotics are frequently given this way. In some cases the saline lock is placed in case there is a need for emergency drug administration via IV push. The intermittent device is flushed with saline before and after drug administration to ensure patency and prevent occlusion with a blood clot.

Question 46

The most appropriate veins for peripheral catheter placement

Answer 46

the dorsal venous network (i.e., basilic, cephalic, and median veins and their branches).

However, cannulation of veins on the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition and for active patients receiving infusion therapy in an ambulatory care clinic or home care. 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.

Question 47

Considerations when choosing site

Answer 47

Mastectomy, axillary lymph node dissection, lymphedema, paralysis of the upper extremity, and the presence of dialysis grafts or fistulas alter the normal pattern of blood flow through the arm. Using veins in the extremity affected by these conditions requires a primary health care provider’s request and order. Short peripheral catheters are not recommended for obtaining routine blood samples.

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. The cephalic vein begins above the thumb and extends up the entire length of the arm. This vein is usually large and prominent, appearing as a prime site for catheter insertion. Damage to the nerve from any injury can result in permanent loss of function or complex regional pain syndrome, type 2 (CRPS) (Kim et al., 2014). Reports of tingling, feeling “pins and needles” in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.

Question 48

Winged needles (“butterfly needles”)

Answer 48

Winged needles (“butterfly needles”) are easy to insert but are associated with a high frequency of infiltration. They are most commonly used for injecting single-dose drugs or drawing blood samples. Like a short peripheral catheter, winged needles should also have an engineered safety mechanism to house the needle when removed.

Question 49

Catheter-related bloodstream infection (CRBSI)

Answer 49

Aseptic skin preparation and technique before IV insertion are crucial. Catheter-related bloodstream infection (CRBSI) can occur from a peripheral IV site. To help prevent these infections, CDC recommendations include:

• 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.

Question 50

Midline catheters and their insertion sites

Answer 50

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.
The median antecubital vein is used most often if insertion is done without the aid of ultrasound guidance. With ultrasound guidance deeper veins can be accessed, and the insertion site can be farther above the antecubital fossa. The basilic vein is preferred over the cephalic vein because of its larger diameter and straighter path.
It also allows greater hemodilution of the fluids and medications being infused.
The catheter tip is located in the upper arm, with the tip residing no further into the venous network than the axillary vein .
Due to extended dwell time strict sterile technique is used for insertion and dressing changes.
Additional education and skill assessment are required for the nurse to be qualified to insert midline catheters.

Question 51

Benefits of midline catheters

Answer 51

found to reduce the number of repeated IV cannulations, which reduces patient discomfort, increases patient satisfaction, and contributes to organizational efficiency

Question 52

when to use midline catheters

Answer 52

when skin integrity or limited peripheral veins make it difficult to maintain a short peripheral catheter. Indications for these catheters include fluids for hydration and drug therapy that are given longer than 6 days and up to 4 weeks such as antibiotics, heparin, steroids, and bronchodilators. There are currently no recommendations for the optimal dwell time.

Question 53

fluids and medications infused thru a midline catheter

Answer 53

-considered to dwell in the peripheral circulation; the recommendations for infusates (fluids or drugs) are the same as for short peripheral IV lines.

Fluids and medications infused should have a pH between 5 and 9 and a final osmolarity of less than 600 mOsm/L (outside these parameters-increase risk for phlebitis and thrombosis

Question 54

when to use or not use midline catheter

Answer 54

should not be used for infusion of Vesicant medications–drugs that cause severe tissue damage if they escape into the subcutaneous tissue (extravasation)-is a concern that larger amounts of drug may extravasate before problem is detected

parenteral nutrition formulas-and those with low concentrations of dextrose and solutions with osmolarity above 600 mOsm/L not to be infused thru midline catheter.
Dont draw blood from these routinely.

Midline catheters should not be placed in extremities affected by mastectomy with lymphedema, paralysis, or dialysis grafts and fistulas. When using a double-lumen midline catheter, do not administer incompatible drugs simultaneously through both lumens because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein. Currently new midlines with power-injectable technology are available for use with computed tomography.

Question 55

Central intravenous therapy

Answer 55

In 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). Blood flow in the SVC is about 2 L/min compared with about 200 mL/min in the axillary vein.
Most central vascular access devices require confirmation of tip location at the CAJ by chest x-ray before solutions are infused. However, newer technologies use either a magnet tip locator or identification of the CAJ by electrocardiogram rather than by x-ray. Both the Sherlock 3CG by Bard and the VasoNova/Teleflex systems have received Food and Drug Administration (FDA) approval as alternatives to chest x-ray or fluoroscopy to verify PICC tip location.

Question 56

what determines the type of central vascular access device to use

Answer 56

purpose, duration, and insertion site availability.

Question 57

improvements in catheter materials

Answer 57

Several recent improvements in catheter materials allow antimicrobial and heparin coatings to reduce infection risk and improve the longevity of the catheter.

Question 58

power injection

Answer 58

Not all central-line catheters are approved for power injection used in radiologic tests. The catheter can rupture if it is not designed to handle the injection pressure necessary for some tests such as pulmonary CT angiography or CT angiography of the aorta (5 mL/sec and 300 per square inch [psi]). Even with power-injectable designed catheters, dislodgment may occur . Be sure to confirm if the PICC is power injectable or not.

Question 59

Peripherally Inserted Central Catheters

Answer 59

A 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. Nurses who insert these CVADs require special training and competency confirmation.

In adults the PICC length ranges from 18 to 29 inches (45 to 74 cm), with the tip residing in the superior vena cava (SVC) ideally at the caval-atrial junction

Question 60

mid-clavicular catheter,

Answer 60

Placement of the catheter tip in veins distal to the SVC is avoided. This inappropriate tip location, often called a mid-clavicular catheter, is associated with much higher rates of thrombosis than when the tip is located in the SVC at the CAJ. Mid-clavicular tip locations are used only when anatomic or pathophysiologic changes prohibit placing the catheter into the SVC.

Question 61

inserting PICCs

Answer 61

PICCs should be inserted early in the course of therapy before veins of the extremity have been damaged from multiple venipunctures and infusions. Insertion methods using guidewires and ultrasound systems greatly improve insertion success.

The basilic vein is the preferred site for insertion; the cephalic vein can be used if necessary. Two brachial veins are not recommended because they are more difficult to access; they are deeper in the arm and run close to the brachial artery.

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.

Question 62

types of PICCs available

Answer 62

available in single-, dual-, or triple-lumen configurations and with both the Groshong valve and the pressure-activated safety valve (PASV). PICCs are also available as “Power PICCs” and can be used for contrast injection at a maximum of 5 mL/sec and a maximum pressure of 300 psi. They can also be connected to transducers and used to monitor central venous pressure.

Question 63

complications of PICCs &

definition of CLABSI

Answer 63

most common complications from PICCs include phlebitis, thrombophlebitis, deep vein thrombosis (DVT), and CRBSIs

When infections occur from a central line, they are also referred to as central line-associated bloodstream infection, or CLABSI. Thrombophlebitis and DVT can be very serious, threaten the integrity of the vein, and decrease perfusion. The smallest possible French size should be used to decrease the rate of upper-extremity DVT, a potentially life-threatening event.

Accidental arterial puncture or excessive bleeding can occur on insertion and is controlled by direct pressure. Infiltration and extravasation are rare. Insertion complications such as pneumothorax associated with other CVCs do not occur with PICCs.

Question 64

factors affecting infection probability

Answer 64

CRBSI has been noted to be less common in PICCs than in other central venous catheters (CVCs) because of the insertion site in the upper extremity. The cooler, drier skin of the upper arm has fewer types and numbers of microorganisms, leading to lower rates of infection.

Question 65

types of infusion therapy used with PICCs

Answer 65

PICCs can accommodate infusion of all types of therapy because the tip resides in the SVC where the rapid blood flow quickly dilutes the fluids being infused.

there are no limitations on the pH or osmolality of fluids that can be infused through a PICC.

patients requiring lengthy courses of antibiotics, chemotherapy agents, parenteral nutrition formulas, and vasopressor agents can benefit from this type of catheter.

PICCs have been reported to dwell successfully for months or even years; however, the optimal dwell time is not known.

Question 66

PICCs and blood samples or transfusion

Answer 66

PICCs can be used for blood sampling; however, lumen sizes of 4 Fr or larger are recommended. Using lumens with small diameters may not yield a sample capable of producing the needed test results. In addition, frequent entry into any central line should be minimized and treated with strict aseptic technique to prevent CRBSI. Transfusion of blood through a PICC usually requires the use of an infusion pump. Packed red blood cells are cold and viscous. The length of the catheter adds resistance and may prevent the blood from infusing within the 4-hour limit.

Question 67

Patient teaching with PICCs

Answer 67

Teach patients with a PICC to perform usual ADLs; however, they should avoid excessive physical activity. Muscle contractions in the arm from physical activity such as heavy lifting can lead to catheter dislodgment and possible lumen occlusion. PICCs may be contraindicated in paraplegic patients who rely on their arms for mobility and in patients using crutches that provide support in the axilla.

Question 68

insertion of PICCs

Answer 68

commonly performed in patients hospital room, an ambulatory care treatment facility, or imaging dept. same precautions must be taken as with any other central line insertion using Catheter related bloodstream infection prevention bundle. (CRBSI)

Question 69

catheter-related bloodstream infection (CRBSI) prevention bundle

Answer 69

Major components of this prevention bundle include:

• 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

use of a checklist for sterility during the procedure, a line cart with all equipment, and a stop sign on the door of the room to stop unnecessary traffic through the room during the procedure. The checklist should be completed by another professional health care member who can stop the inserter when any breaks in technique are observed

Question 70

nursing safety priority action alert

Answer 70

The INS recommendation for flushing PICC lines not actively used is 5 mL of heparin (10 units/mL) in a 10-mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline is flushed after drawing blood. 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.

Question 71

Nontunneled Percutaneous Central Venous Catheters

Answer 71

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. Occasionally the patient’s condition may require insertion of the CVC in a femoral vein, but the rate of infection is very high. If the femoral site must be used, it is removed as soon as possible.

The tip resides in the superior vena cava (SVC) and is confirmed by a chest x-ray

Question 72

variations in non percutaneous CVC’s

Answer 72

CVCs are usually 7 to 10 inches (18 to 25 cm) long and have one to as many as five lumens (Fig. 13-7). These catheters are also available with antimicrobial coatings such as chlorhexidine and silver sulfadiazine.

Question 73

when to use nontunneled percutaneous CVC’s

Answer 73

Nontunneled percutaneous CVCs are most commonly used for emergent or trauma situations, critical care, and surgery. There is no recommendation for optimal dwell time. However, these catheters are commonly used for short-term situations and are not the catheter of choice for home care or ambulatory clinic settings.

Question 74

insertion of non tunneled percutaneous CVC’s

Answer 74

Insertion requires the patient to be placed in the Trendelenburg position, usually with a rolled towel between the shoulder blades. This position may be difficult or contraindicated for patients with respiratory conditions, spinal curvatures, and increased intracranial pressure, especially for older adults. Trauma, surgery, or radiation in the neck or chest prohibits the use of these devices as well. Insertion with ultrasound guidance has been demonstrated to improve the safety of insertion in the internal jugular site

The presence of a tracheotomy increases the risk for cross-contamination of the insertion site. The warmer, moister skin of the neck and upper chest has more types and higher numbers of microorganisms, resulting in more CRBSIs with this type of catheter.

Question 75

Tunneled Central Venous Catheters

Answer 75

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.
This separation is intended to prevent the organisms on the skin from reaching the bloodstream

Question 76

insertion of tunneled CVC’s

Answer 76

these catheters are usually inserted by physicians in the radiology suite rather than placed surgically. The catheter has a cuff made of a rough material that is positioned inside the subcutaneous tunnel. These cuffs commonly contain antibiotics, which also reduce the risk for infection. The tissue granulates into the cuff, providing a mechanical barrier to microorganisms and anchoring the catheter in place.
The design of tunneled CVCs requires surgical techniques for insertion and removal. Single, dual, and triple lumens are available. These catheters were originally named for the physicians who designed them, including Broviac, Hickman, and Leonard catheters.

Question 77

when are tunneled CVC’s used

Answer 77

Tunneled catheters are 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. For example, paraplegic patients needing 6 to 8 weeks of antibiotics are not good candidates for a PICC because of the excessive use of the upper extremities for mobility. Some oncology patients may prefer a tunneled catheter instead of an implanted port because they cannot tolerate the needlesticks required for accessing those devices.

Question 78

Implanted Ports

Answer 78

Implanted ports are very different from other central vascular access devices (CVADs). This type of device is chosen for patients who are expected to require IV therapy for more than a year

Question 79

how implanted ports are done

Answer 79

inserted by a physician in the radiology department or a surgeon in the operating suite

consist of a portal body, a dense septum over a reservoir, and a catheter.

can be single or double lumen and come in various sizes.

A subcutaneous pocket is surgically created to house the port body

catheter is inserted into the vein and attached to the portal body.

septum is made of self-sealing silicone and is located in the center of the port body over the reservoir; catheter extends from the side of the port body.

incision is closed, and no part of the catheter is visible externally; therefore this device has the least impact on body image

Question 80

more about implanted ports

Answer 80

Some are power injectable and can be used for obtaining contrast-enhanced computed tomography (CECT).

devices can withstand 5 mL/sec at up to 300 psi pressure.

The BARD PowerPort can be identified by palpation of three bumps on the top of the septum and a triangular-shaped port.

careful not to press firmly on the bumps because it can be painful to the patient.

use a power-injection–rated noncoring needle with this type of port when it is used for this purpose.

These needles come with labeling identifying that they are power-injection rated

Question 81

where they are implanted

Answer 81

Venous ports may be placed on the upper chest or the upper extremity. venous catheter may enter either the subclavian or internal jugular vein.

Although an implanted port is most commonly used in the venous system, the catheter may be placed in arteries, the epidural space, or the peritoneal cavity, with the port pocket located over a bony prominence.

Question 82

accessibility and number of punctures tolerated

Answer 82

Implanted ports are accessed by using a noncoring needle specially designed with a deflected tip.

This design slices through the dense septum without coring out a small piece of it, thus preserving the integrity of the septum.

Port bodies placed in the chest have a larger septum and usually tolerate about 2000 punctures.

Port bodies placed in the upper extremity are smaller and are rated to tolerate about 750 punctures.

port access should be done by formally trained HC professionals only-using mask and aseptic technique

Question 83

who are implanted ports used for

Answer 83

most often used for patients receiving chemotherapy.

are immune comprimised-highly suseptible to infection

Question 84

how to access

Answer 84

Before puncture, palpate the port to locate the septum. Carefully palpate to feel the shape and depth of the port body to ensure puncture of the septum, not the attached catheter. Some have attached extension sets and wings to stabilize the needle.
One important feature is an engineered safety mechanism to contain the needle when it is removed from the septum. Because the dense septum holds tightly to the needle, there can be a rebound when it is pulled from the septum, which can result in needlestick injury to the nurse.

Question 85

flushing and maintenance

Answer 85

implanted ports need to be flushed after each use and at least once a month between courses of therapy.
This procedure is done to prevent clot formation in the internal chamber of the port and is often referred to as “locking” or “de-accessing.” The INS recommendation for locking or de-accessing a port is the use of a 10-mL syringe with either heparin 10 units per milliliter or preservative-free 0.9% normal saline (INS, 2016). When the port is not accessed, there is no external catheter requiring a dressing. Puncture of the skin over the port is required to gain access to the port body, causing pain for some patients. Topical anesthetic creams can be used to make the access procedure more tolerable.

Question 86

Nursing Safety Priority

Drug Alert

Answer 86

Before giving a drug through an implanted port, always check for blood return. INS (2016) defines blood return “as the color and consistency of whole blood upon aspiration” (p.S147). If there is no blood return, withhold the drug until patency and adequate noncoring needle placement of the port are established. Serious extravasations of vesicant drugs can occur because a fibrin sheath (flap or tail) may occur at the tip of the catheter, clot it, and cause retrograde subcutaneous leakage.

Question 87

Hemodialysis Catheters

Answer 87

Hemodialysis catheters have very large lumens to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells. They may be tunneled for long-term needs or nontunneled for short-term needs. A hemodialysis catheter is critical to the management of renal failure and must function well

Question 88

Common problems

Answer 88

CRBSIs and vein thrombosis are common problems; therefore this catheter should not be used for administration of other fluids or drugs except in an emergency.

Question 89

concentration of heparin used to lock hemodialysis catheters

Answer 89

The concentration of heparin used to lock hemodialysis catheters ranges from 1000 to 10,000 units/mL. Researchers have demonstrated that using 1000 units/mL reduces the incidence of postinsertion bleeding but may be associated with an increased need for recombinant tissue plasminogen activator (tPA) to maintain patency. A flush of 1000 units heparin/mL or a solution of 4% sodium citrate in the amount of the dwell volume of each lumen has been recommended. Heparin is most often used because sodium citrate has not been as commercially available in the preparation needed. To prevent systemic anticoagulation and subsequent bleeding, be sure to aspirate the heparin from the lumens before use.

Question 90

Infusion containers

Answer 90

Infusion containers are made of glass or plastic.

Glass bottles were the original fluid container to be mass produced. They are easily sterilized, and it is easy to read the amount of fluid remaining in the bottle.
glass is inert and thus cannot interact with some drugs such as plastic can.

glass bottles are heavy and cannot be used easily in many situations such as patient transport during emergencies.

These containers require an air vent for fluids to flow freely from them. The most common method is to use an administration set with a special filtered vent. Some bottles may have a straw tube open to the room air through the rubber stopper in the bottle and extending to above the level of the fluid. Bottles with a venting straw do not have a barrier to prevent contaminants in the air from entering the fluid.

Question 91

Plastic containers

Answer 91

Plastic containers are considered closed systems because they do not rely on outside air to allow the fluid to infuse. Instead atmospheric pressure pushes against the flexible sides of the container, allowing the fluid to flow by gravity. For this reason plastic containers do not require vented administration sets. These containers are lightweight, resistant to breaking, easier to store, and easy to use in emergency conditions. Therefore they are used more frequently than glass containers.

were commonly made of polyvinyl chloride (PVC). To increase flexibility and strength, PVC required the addition of a plasticizer such as di-2-ethylhexyl-phthalate or DEHP.

Concern has been growing in the past few years over the exposure of patients to this chemical because it can leach from the plastic fluid container or tubing and infuse into the patient with the IV fluid or medication. The FDA has determined that there is little to no risk posed to most patients by exposure to the amount of DEHP released from IV bags with infusion of crystalloids or drugs. However, there is concern about the buildup of chemical exposure from many sources over a lifetime and specifically the potential effects of DEHP on the development of the male reproductive system. Therefore many hospitals are using PVC-free and DEHP-free IV bags, especially for high-risk groups.

removing DEHP cons-bags less pliable more prone to rupture

Question 92

Compatibility of plastic containers and other concerns

Answer 92

are not compatible with insulin, nitroglycerin, lorazepam (Ativan), fat emulsions, and lipid-based drugs. Nitroglycerin and insulin adhere to the walls of the PVC container, making it impossible to know exactly how much medication the patient is receiving.
concern with plastic bags is the accuracy of reading the amount of fluid remaining in the container and the residual volume in some sets. As much as 20% of a medication in an attached 100-mL bag may not be infused, which in a 24-hour period may result in a patient missing a whole dose of medication

Question 93

Nursing Safety Priority

Action Alert

Answer 93

Regardless of the type of fluid container being used, check it for cracks or pinholes before use. Always observe the fluid for turbidity (cloudiness) or any unusual color that could indicate contamination.

Question 94

Administration Sets

Answer 94

The administration set is the connection between the catheter and the fluid container. The type and purpose of the infusion determine the type of administration set needed. Some sets are generic, meaning that they are appropriate for most infusions. Other sets are used for specific types of infusions such as blood transfusion. Still others are dedicated, meaning that they must be used with a specific manufacturer’s infusion controlling device. Information that describes their proper use is provided on the packaging of administration sets.

Question 95

Secondary Administration Sets

Answer 95

A primary continuous administration set is used to infuse the primary IV fluid by either a gravity infusion or an electronic infusion pump. A short secondary administration set, also known as a piggyback set, is attached to the primary set at a Y–injection site and is used to deliver intermittent medications

Primary and secondary continuous infusion administration sets used to infuse fluids other than parenteral nutrition and lipids can be used for up to 96 hours unless the closed system has been compromised

Question 96

Intermittent Administration Sets

Answer 96

When no primary continuous fluid is being infused, use an intermittent administration set to infuse multiple doses of medications through a catheter that has been capped with a needleless connection device. Remove the medication bag from the previous dose and attach the new one. Remove the sterile cap covering the distal end of the set and attach the set to the catheter. Because both ends of the set are being manipulated with each dose, the INS standards of practice state that this set should be changed every 24 hours. When the administration set is used for infusion of parenteral nutrition or lipid solution, change it every 24 hours. Change blood tubing within 4 hours.

Administration sets are sterile in the fluid pathway and under the sterile caps on each end of the set. The set is not packaged as a completely sterile product and cannot be added to a sterile field. Careful attention is required to maintain the sterility of the spike and the connection end of the tubing to prevent introduction of microorganisms into the catheter and bloodstream.

Question 97

Add-on Devices

Answer 97

Several other types of add-on devices include short extension sets, injection caps, and filters. Extension sets may be packaged as a sterile product for adding to a sterile field; however, always check the product label for this information.

Administration sets have two ways to connect to the catheter hub: a slip lock or a Luer-Lok. The slip lock is a male end that slips into the female catheter hub. A Luer-Lok connection has the same male end with a threaded collar that requires twisting onto the corresponding threads of the catheter hub. All connections, including extension sets, should have a Luer-Lok design to ensure that the set remains firmly connected.

When using a central venous catheter, a Luer-Lok connection is critical to reduce the risk for air embolism. Tape is not considered an adequate mechanism for securing set connections.

Question 98

Luer-lok devices

Answer 98

Luer-Lok devices may be purposefully or accidentally disconnected. Patients or visitors may disconnect the system to allow the patient to get out of bed or the chair, or the device may become accidentally disconnected when the patient turns or moves. In either case be sure to reconnect the device by following the proper sequence to reassemble the IV system components. Fatalities have resulted when nurses have accidently reconnected IV tubing to a tracheostomy or other inappropriate port.

Question 99

Filters

Answer 99

Filters may be part of the administration set or separate add-on pieces. Their purpose is to remove particulate matter, microorganisms, and air from the infusion system. Filter sizes depend on the pore size, with common sizes being 1.2 microns used to filter lipid-containing parenteral nutrition and 0.2 microns intended to remove all particles and bacteria. Filters should be placed as close to the catheter hub as possible.

Question 100

Filtering particulate matter in IV fluid

Answer 100

Particulate matter in the IV fluid, a primary reason to use filters, comprises undissolved, unintended substances and may include rubber pieces, glass particles, cotton fibers, drug particles, paper, and metal fibers. These particles become trapped in the small circulation of the lungs. A red blood cell is about 5 microns in diameter and is the largest size that can pass through the pulmonary capillary bed; IV fluids may contain particles larger than 5 microns. For patients receiving infusion therapy for long periods, a significant number of particles could block the blood flow through the pulmonary circulation. Microcirculation in the spleen, kidneys, and liver could also be affected. Particulate matter has also been implicated in the development of phlebitis in peripheral veins.

Question 101

COncerns with using filters

Answer 101

Other concerns with using filters include the possibility for their rupture, their use with certain drugs that bind to the filter surface, using the incorrect size of filter for drugs with large molecules, and choosing a filter that will not tolerate the pressure exerted by infusion pumps. Rupture is most commonly associated with the exertion of high pressure exceeding the limit tolerated by the specific filter. Some drugs cannot be filtered because they are retained inside the filter because of their chemical nature or molecule size. For these reasons medication filtration during the process of admixing is commonly used today as an alternative to final filtration at the bedside. Drugs of a very small quantity should be administered below the filter.

Filters used on blood administration sets have much larger pore size and are not interchangeable with filters used for fluids and medications. A standard blood filter ranges from 170 to 260 microns and removes microclots and other debris caused by blood collection and storage. Microaggregate filters have a pore size of 20, 40, or 80 microns and are used to remove degenerating platelets, white blood cells, and fibrin strands. Leukocyte-removal filters are used to remove white blood cells that cause febrile and allergic blood transfusion reactions.

Question 102

Needleless Connection Devices

Answer 102

the Occupational Safety and Health Administration (OSHA) published guidelines entitled Occupational Exposure to Bloodborne Pathogens, Final Rule. This document requires health care organizations to initiate engineering controls “that isolate or remove the bloodborne pathogen hazard from the workplace.

Many products are designed to minimize health care workers’ exposure to contaminated needles

Luer-Lok–activated devices are the most common design for needleless systems today.

Although these devices have reduced the incidence of accidental needlesticks for health care professionals, it is imperative that the connector be disinfected with alcohol or chlorhexidine/alcohol before and after each use with a vigorous scrub for 5 to 60 seconds .

This method is known as “scrub the hub.” Blood and bacteria can be trapped in the crevices, and meticulous disinfecting is required with each use.

Question 103

Designs

Answer 103

Various designs are available for connectors that provide positive or negative displacement of fluid when the needleless syringe is removed. Needleless positive-pressure valve (PPV) connectors were developed to prevent backflow of blood into the IV catheter, thereby decreasing chances of thrombus formation and CRBSI.

Several newer connectors are silver-impregnated to reduce bacterial growth (Fig. 13-12). Be sure to check which type of connector valve is used in your facility because the flushing technique differs depending on type.

Question 104

Conclusive studies are needed to determine the best design for needleless systems. Until then, implement these interventions to reduce infection risk:

Answer 104

Clean all needleless system connections vigorously with antimicrobial for 60 seconds (usually 70% alcohol or alcohol and 2% chlorhexidine swabs) before connecting infusion sets or syringes, paying special attention to the small ridges in the Luer-Lok device. Newer caps that are impregnated with alcohol or chlorhexidine may be used to keep the port aseptic; however, these will increase costs, and research is needed to demonstrate the benefit.

• Do not tape connections between tubing sets.
• Use evidence-based hand hygiene guidelines from the CDC and OSHA.

Question 105

Rate-Controlling Infusion Devices

Answer 105

Electronic infusion devices (IV pumps) are used universally in acute care institutions. also used in long-term care settings and at home.

Remember that the use of pumps does not decrease your responsibility to carefully monitor the patient’s infusion site and the infusion rate.

In inpatient settings IV pumps are pole mounted. As their name implies, these electronic devices with battery backup pump drugs or fluids under pressure. They accurately measure the volume of fluid being infused by using one of three mechanisms:

• A syringe-type mechanism that fills and empties
• A wavelike, peristaltic action that pushes fluid along the tubing
• A series of microchambers that fill and empty

Question 106

these devices require dedicated cassette tubing designed to match the pump.

Answer 106

Syringe pumps

ambulatory pumps

Question 107

syringe pumps

Answer 107

Syringe pumps use an electronic or battery-powered piston to push the plunger continuously at a selected milliliter-per-hour rate.

The use of syringe pumps is limited to small-volume continuous or intermittent infusions and depends on the syringe size.

Antibiotics and patient-controlled analgesia are frequently delivered with syringe pumps. Patients requiring fluid restrictions can also benefit from using a syringe pump because smaller yet accurate volumes can be used to dilute medications.

Question 108

Ambulatory pumps

Answer 108

Ambulatory pumps are generally used for home care patients and allow them to return to their usual activities while receiving infusion therapy. These pumps have a wide range of sizes, with some requiring a backpack, but they usually weigh less than 6 lb. They are typically used to accurately deliver continuous infusions such as parenteral nutrition, pain medication, and many programmable drug schedules. Frequent battery recharging or replacement is usually necessary.

Question 109

Programming Electronic infusion devices

Answer 109

Electronic infusion devices can be programmed in many different ways and require a thorough knowledge of the specific brand being used. Infusion rate and the volume to be infused are usually entered in single milliliter increments, but some can be programmed as fractions of a milliliter. Some pumps allow the rate to be programmed to taper or ramp up and down at the beginning and ending of the infusion. Secondary syringe infusion, secondary infusion rate, remote site programming, adjustable infusion pressure, and integration into the nurse call system also are possible.

Question 110

electronic infusion device alarms

Answer 110

have a variety of alarms such as air-in-line, upstream and downstream occlusion, infusion complete, and low-battery or power warnings. All devices must have some mechanism to prevent free flow of the infusing fluid or medication. When the cassette or tubing is removed from the pump, this mechanism automatically stops fluid flow until it is properly replaced in the pump. This safety measure prevents accidental rapid infusion of large amounts of fluid or medication, which could lead to serious clinical problems.

Question 111

smart pumps

Answer 111

In the past few years, smart pumps (infusion pumps with dosage calculation software) have been promoted to reduce adverse drug events (ADEs). Incorrect programming of pumps without this feature is one of the most common types of drug errors, especially in hospitals. Multiple libraries of drug information are stored in the pump manufacturer’s medical management system. This software allows the facility to preprogram dosing limits, especially for high-alert drugs. Examples of smart pumps are the B. Braun Outlook 400ES and the Baxter Sigma Spectrum infusion system.

The newest development in smart pumps is a wireless network connection. Drug libraries can be updated via a wireless connection, thus eliminating the necessity of manually updating each pump. In addition to preventing drug errors, smart-pump systems record potential errors that would have occurred without these safety mechanisms

Question 112

dose track technology

Answer 112

Dose-track technology is intended to transmit the infusion data to the institution’s pharmacy so the correct patient receives the correct medication. Dose-guard technology alerts the nurse if institution-defined dose limits are exceeded. These newer technologies provide safeguards for patients to keep them safe.

Question 113

potential issues with smart pumps

Answer 113

the “smarter” the pump, the more extensive the programming steps, and the more alarms to which the nurse must respond. In addition, technology and wireless connections can fail. The challenge for nurses is to maintain the skill of manual dose calculation and rate control, acknowledge and validate all alarms, and guard against becoming desensitized to alarms.

Question 114

Mechanically regulated devices

Answer 114

Mechanically regulated devices can be used to deliver intermittent medications such as antibiotics or continuous pain medications in community-based health or home care settings. In acute care settings devices called “infusers” may be found in surgical services. They are powered by positive pressure from the collapsing balloon or roller returning to its coiled position.

The systems include elastomeric balloons, spring-coiled syringes and containers, and a multi-chambered fluid container placed in a mechanical roller (Accufuser or ON-Q PainBuster) (Fig. 13-13). These small portable devices do not require power sources such as batteries or electricity. They deliver a preset infusion rate, and fluid volume is determined by the size of the fluid container; however, most hold only 50 to 100 mL.

Question 115

Nursing Care for Patients Receiving Intravenous Therapy

Educating the patient

Answer 115

In 2010 The Joint Commission added the requirement that all patients who have central lines placed in the hospital must have education on prevention of catheter-related bloodstream infection (CRBSI). Before catheter insertion, educate the patient and family about:

• The type of catheter to be used
• Hand hygiene and aseptic technique for care of the catheter
• The therapy required
• Alternatives to the catheter and therapy
• Activity limitations
• Any signs or symptoms of complications that should be reported to a health care professional

Provide written information before placement of a long-term catheter and continue to assess the patient’s knowledge level and provide more information or answers as needed.

Conversation and pictures are helpful for patients who are literacy challenged (have a low reading level ability.) Patients who do not speak or read English will need a translator.

Question 116

performing a nursing assessment

Answer 116

documentation of tip location at the CAJ by electrocardiogram technology, fluoroscopy, or chest x-ray.

initial verbal and subsequent written report should contain specific information about the catheter tip location in relation to anatomic structures.

nurse’s knowledge of accurate tip location is required before beginning infusion through the catheter.

Repeating the x-ray during catheter use may be necessary if the patient reports unusual pain or sensation.

Nursing assessment for all infusion should be systematic

Begin with the insertion site and work upward, following the tubing.

Know the type of catheter
find out the length of catheter, the insertion site, and tip location to perform a complete assessment.

Assess the insertion site by looking for redness, swelling, hardness, or drainage.

assess the skin underneath the dressing especially for signs of medical adhesive–related skin injury

palpate area over dressing

for midline catheter or PICC assess entire extremity and upper chest for signs of thrombosis or phlebitis

for tunnelled catheter-assess exit ssite, length of tunnel and point wjere cath enters vein. for well healed one may not be possible to detect vein entrance site.

implanted ports assess incision and surgically created subq pocket

assess integrity of dressing -clean-dry-adherent to skin on all sides

check all connectionson administration set ensure security-make sure they are not taped

check rate of infusion for all fluids
assess amount of fluid that has infused from container, adjust to prescribed rate

. Check all labels on containers for the patient’s name and fluid or medication. Be sure that the correct solution is being infused!

Question 117

Nursing Safety Priority

Action Alert

Answer 117

Remind unlicensed assistive personnel (UAP) to avoid taking blood pressures in an extremity with any type of catheter in place. If a short peripheral catheter is being used for continuous infusion, the compression while taking the blood pressure can increase venous pressure, causing fluid to overflow from the puncture site and infiltration. When a midline catheter or PICC is being used, compression from the blood pressure cuff could increase vein irritation and lead to phlebitis.

Draw blood samples in the extremity opposite from all catheters. Blood should not be drawn from a venipuncture site proximal to (above) an infusing peripheral catheter because the infusing fluid could alter the results of the test to be performed. Venipuncture at or near the insertion site of a midline catheter or PICC could damage the catheter, add to areas of venous inflammation, and decrease perfusion.

Question 118

Securing and Dressing the Catheter

Answer 118

Tape, sutures, and specially designed securement devices can be used for securing catheter

For a short peripheral catheter, tape strips are most common; however, the tape should be clean. Tape strips from a peripheral IV start kit are preferred. Strips of tape should not be taken from rolls of tape moved between patient’s rooms, from other procedures, or from uniform pockets. Precutting tape and placing it on the patient’s bedrails, your uniform or scrubs, or other object should also be avoided to prevent transmission of microorganisms.

Newer securement devices are designed for all catheter types .

StatLock IV stabilization device prevent peripheral and central catheters from becoming dislodged .
they prevent complications such as phlebitis and infiltration. To prevent skin tears, remove the adhesive on a StatLock with 70% alcohol.

Question 119

What Is the Best Method for Securing a Patient’s Central Venous Access Device?

Answer 119

Central venous catheters require stabilization to ensure an extended lifeline. Dislodgment is one of the major complications associated with failure of the access device.

The researchers concluded that patients with central venous access devices are a heterogenous group and there is not one securement device that fits everyone. Individualized assessment is required to select the appropriate securement. Future studies are needed to determine the most effective securement that is cost-effective for all populations.

This research validated the effectiveness of IV catheter securement and stabilization devices for all patients receiving central infusion therapy. Clinicians need to recognize the priority of using an appropriate securement and dressing for the patient. Institutions need to recognize the long-term savings of using a securement and dressing to prevent catheter failure for improved patient outcomes.

Question 120

securment of PICCs and nontunneled percutaneous central catheters

Answer 120

may be sutured in place; however, this creates additional breaks in the skin that could become infected. If these sutures are loose or broken, notify the primary health care provider to replace them. IV catheter sutures are being replaced with securement devices and Dermabond glue in some facilities, which can decrease infection and avoid the need to remove sutures after infusion therapy is discontinued.

Question 121

securment of tunneled catheters

Answer 121

Tunneled catheters usually have sutures placed near the skin exit site, which are removed after the tunnel has healed. The incision over an implanted port pocket will have sutures until it has healed. After it is healed and when it is not accessed, no dressing is required. When an implanted port is accessed, the sterile occlusive dressing should cover the entire needle and site.

Question 122

short peripheral cath

Answer 122

Sterile dressings used over the insertion site protect the skin and puncture site. For a short peripheral catheter, the transparent membrane dressings do not require routine changes. Short peripheral lines do not usually dwell longer than a few days; and, as long as the dressing is dry, clean, and intact, it does not have to be changed. Any VAD dressing should be changed when it is loose or soiled.

Question 123

securment ofcentral lines and midline catheters

Answer 123

tape and sterile gauze or a transparent membrane dressing may be used. Change tape and gauze dressings every 48 hours; change transparent membrane dressings such as Tegaderm, every 5 to 7 days. The initial dressing on a midline catheter or PICC is usually tape and gauze, changed within 24 hours after insertion because some bleeding is likely. Transparent membrane dressings can be used for subsequent dressing. For patients who develop erythema (redness) from Tegaderm, the IV3000 dressing from Smith and Nephew may be used. Document when you change the sterile dressing and your IV site assessments in the appropriate electronic health record according to agency policy.

Question 124

Nursing Safety Priority

Action Alert

Answer 124

Site protection may be needed for short peripheral catheters or for port access needles. Plastic shields can be placed over the site to prevent accidental bumping or pressure from clothing. Make sure that you can easily assess the site frequently. Never place a restraint or opaque dressing over a peripheral IV site, especially when infusing an irritant or vesicant.

Question 125

Changing dressing

Answer 125

remove by pulling laterally from side to side.
can also be removed by holding the external catheter and pulling it off toward the insertion site. Never pull off by pulling away from the insertion site, this could dislodge the catheter!

dont remove dressing from a midline catheter or any central venous catheter, note the external catheter length compare with the original length at insertion.
If length has changed, the catheter tip location has also changed and may not be in a vein appropriate for infusion.
Follow agency policy or notify the primary health care provider about the length change.
chest x-ray may be needed, and careful assessment of the type of therapy and remaining length of therapy will likely be required.

Protect external catheter, dressing, and all attached tubing from water because it is a source of contamination. Remind unlicensed assistive personnel (UAP) to cover extremity where the IV line is located when giving the patient a bath.
A plastic bag or wrap can be taped over the extremity to keep the dressing and site dry.

Question 126

Changing Administration Sets and Needleless Connectors

Answer 126

Plan change of administration sets and fluid containers to occur at the same time, if possible, to minimize the number of times the system is opened.

For short peripheral catheters, the administration set and catheter should also be changed at the same time to avoid excessive manipulation of the catheter. Document these changes per agency policy.

Needleless connector devices can be changed when the administration set is changed. If being used for intermittent infusions, the device should be changed at least once per week. Fluid leakage from the device indicates that the integrity has been compromised, and it should be changed immediately.

Precautions to prevent air emboli are required when changing the set or connectors attached to any catheter; however, central venous catheters require special attention. Most catheters have a pinch clamp that can be closed during this procedure. Techniques used to increase the intrathoracic pressure and prevent air embolism during IV set change include:

• Placing the patient in a flat or Trendelenburg position to ensure that the catheter exit site is at or below the level of the heart
• Asking the patient to perform a Valsalva maneuver by holding his or her breath and bearing down
• Timing the IV set change to the expiratory cycle when the patient is spontaneously breathing
• Timing the IV set change to the inspiratory cycle when the patient is receiving positive-pressure mechanical ventilation

Question 127

Controlling Infusion Pressure

Answer 127

Fluid flow through the infusion system requires that the pressure on the external side be greater than the pressure at the catheter tip.

fluids can be slowed or obstructed by many reasons- inside the catheter lumen, resistance is created by the catheter length and diameter or by deposits of fibrin, thrombus, or drug precipitate. Near the catheter tip, resistance to flow comes from the catheter tip impinging on the vein wall, thrombus, or venous spasm.

All catheter manufacturers have warnings about the use of excessive pressure. Gravity and infusion pumps do not exert pressure too high for the catheter to handle; however, excessive pressure from syringes can lead to catheter damage.
For this reason use 10-mL syringes for central venous catheters.
Although these larger syringes generate less pressure, it is still possible to reach excessive pressure levels if great force is applied against a syringe attached to a catheter that is partially occluded.

Question 128

Flushing the Catheter

Answer 128

Catheter flushing prevents contact between incompatible drugs and maintains patency of the lumens. Normal saline alone or normal saline followed by heparinized saline may be used. When using valved catheters and certain positive fluid-displacement needleless devices, normal saline alone is acceptable because these devices have mechanisms that prevent the backflow of blood into the catheter lumen.

Question 129

flushing for short peripheral catheters

flushing for all others

Answer 129

usually 3 mL normal saline is adequate to flush the catheter.
. For all other catheters 5 to 10 mL of preservative-free normal saline is needed.

Bacteriostatic normal saline is limited to no more than 30 mL in a 24-hour period in adults. By using 10 mL before and after each dose of medication, it is easy to exceed this limitation. Check your agency’s policy and procedure about specific flushing amounts.

Flush catheters immediately after each use. Delay in disconnecting the intermittent administration set and flushing the catheter could cause lumen occlusion from blood that backflows into the lumen when the infusion pressure is lower than venous pressure.

All fluids used to flush catheters should be obtained from single-dose containers or prefilled syringes. Vials used for multiple doses contribute to medication errors and increase the risk for contamination.

Question 130

Obtaining Blood Samples From Central Venous Catheters

Answer 130

Short peripheral catheters should not be used routinely for obtaining blood samples. could lead to vein irritation that requires removal of the catheter.

Central venous catheters and midlines can be used for obtaining blood samples after a careful assessment of the risks versus the benefits. If your patient has no peripheral venipuncture sites or is fearful of needles, using the central venous catheter may be appropriate.

The risks associated with obtaining blood samples from a central venous catheter are numerous. procedure requires additional hub manipulation, which is a major cause of CRBSI.

Consider the laboratory tests needed and the types of fluids that have recently been infused.
For example, heparin interferes with coagulation studies, and electrolytes in the fluid may alter the results of serum electrolytes.

Drawing blood from catheters for blood culture should not be done within an hour of completion of antimicrobial infusions.

Question 131

blood sampling from central venous catheter

Answer 131

, vigorous cleaning of the connections with 70% alcohol is necessary. Use methods that do not require exposed needles.

Vacuum tubes attached via a “vacutainer” to the catheter hub eliminate the need to transfer the blood from a syringe into the tubes.

For small-diameter catheters, the vacuum in the tube may cause the catheter to temporarily collapse, preventing the backflow of blood into the tube. In this situation small syringes should be used,they create less pressure on aspiration, the opposite of what small syringes do on injection.
Transfer of the blood from the syringe to the vacuum tube requires the use of a “vacutainer needle holder.” This device keeps the needle housed in a plastic case and covered, preventing needlestick injuries. After blood draw from any catheter, a flush of 10 to 20 mL sterile normal saline is necessary to ensure a patent line. Be sure to clear the line and cap of blood to prevent a breeding ground for infection.

Question 132

Removing the Vascular Access Device–short peripheral catheters

Answer 132

lift opposite sides of the transparent dressing and pull laterally to remove the dressing from the site while stabilizing the catheter. Slowly withdraw the catheter from the skin and immediately cover the puncture site with dry gauze. Hold pressure on the site until hemostasis is achieved. Assess the catheter tip to make sure that it is intact and completely removed. Document the time of catheter removal and the appearance of the IV site.

Question 133

Removal of midline catheters and PICCs

Answer 133

must be performed with the same slow, gentle techniques used to insert the catheter. Veins can develop venospasms when rapid or forceful techniques are used. After explaining to the patient that this procedure will not be painful, remove the dressing and withdraw the catheter in short segments by pulling from the insertion site. If you feel resistance, always stop and never apply force to the catheter. Extreme traction or force could cause the catheter to break and embolize (travel) to the heart or pulmonary circulation.

Simple distraction techniques and deep breathing may be sufficient to relax the patient and remove the catheter. If these fail, replace the dressing and apply heat; allow time for the vein wall to relax. Keeping the extremity warm and dry and asking the patient to drink warm liquids could facilitate removal. Use of medications to relax the vein wall may be required if the catheter cannot be removed after several hours. Imaging studies may also be needed to determine whether the cause is a thrombosis instead of venospasm.

Question 134

removing non tunneled percutaneous cantral catheters

Answer 134

removed by clipping any sutures and withdrawing the catheter in short segments. Venospasm does not commonly occur when removing these catheters because the vein diameter is large.

To prevent venous air embolism when removing any central venous catheter (including PICCs), position the patient in a flat supine or Trendelenburg position according to agency policy. To ensure that the intrathoracic pressure is higher than atmospheric pressure, have the patient hold his or her breath or perform a Valsalva maneuver during removal. If the patient is mechanically ventilated, time the removal to the delivery of an inhalation by the ventilator. Be sure to keep the catheter clamped during this procedure. When a central venous catheter is removed, a tract between the skin and vein may create a conduit that could allow air to be pulled into the vein.

After removal, measure the catheter length and compare it with the length documented on insertion. If the entire catheter length was not removed, contact the primary health care provider immediately! Removal of tunneled catheters and implanted ports is usually performed by nurse practitioners or physicians.

Question 135

Documenting Intravenous Therapy

Answer 135

Intravenous therapy is risk prone. Nurses can protect themselves from malpractice claims with conscientious assessment, intervention, and documentation. Be sure that you document after insertion of a vascular access device (VAD) and throughout the course of the therapy. When inserting a venous catheter, remember to document the:

• Date and time of the VAD insertion
• Name of the nurse (you) who inserted the VAD
• Vein that was used for insertion
• Type of VAD used
• Number of insertion attempts and locations of attempts before successful insertion
• Response of the patient to the VAD insertion process
• Type of dressing applied
• Type of securement device, if used
• Special barrier precautions used, if any
• Patient and family education provided related to IV therapy

During the course of the patient’s infusion therapy, be sure to continue documenting in the electronic health record your assessments and any interventions needed as a result of complications. Follow your agency’s policies and procedures for additional requirements.

Question 136

Complications of Intravenous Therapy

Answer 136

can be minor and limited or life threatening. Serious life-altering or life-threatening complications are dramatically increasing in frequency and severity and present a tremendous financial burden to the U.S. health care system. Catheter-related bloodstream infection (CRBSI) is one of the most serious problems, often resulting in patient death. They are more common in patients with central VADs but can also occur with peripheral catheters.

Question 137

Catheter-Related Bloodstream Infection

Answer 137

The Institute for Healthcare Improvement identified CRBSI as one of several preventable hospital-acquired infections (HAIs). As part of their previous 100,000 Lives Campaign, a number of evidence-based interventions were combined into the CRBSI prevention bundle. As a nurse your accountability is to ensure that these interventions are followed:

The Catheter-Related Bloodstream Infection (CRBSI) Prevention Bundle

• Use a checklist during insertion to make sure that everything is done correctly. Tell anyone who violates the correct steps to stop the procedure immediately.
• Hand hygiene before inserting a central line must be thorough (i.e., no quick scrub). Anyone who touches the central line must also perform thorough hand hygiene.
• Maximal barrier precautions during line insertion require that the patient be draped from head to toe with a sterile barrier.
• The primary health care provider who inserts the VAD wears sterile gloves, gown, and mask. Anyone in the room during the procedure must also wear a mask.
• Traffic in and out of the room must be minimized. Many institutions use a “stop” sign on the door of the room to prevent people from coming in and going out during the procedure and a special “central line cart” to ensure that they have everything they need in the room.
• Chlorhexidine is used for skin disinfection because it has best outcomes for preventing infection.
• Use preferred sites. PICC in the upper arm and subclavian veins are the first choice. The next preference is the internal jugular vein, and the least preferred is the femoral vein.
• Post-placement care requires meticulous dressing changes and care of all parts of the IV system such as keeping ports and stopcocks clean; hanging bags using sterile technique; vigorously scrubbing catheter hub with alcohol when used.
• Review daily the need for the patient’s VAD. The incidence of CRBSI increases each day the device is in place. As soon as it is determined that the patient no longer needs the IV line, it should be removed.

Question 138

Local Complications of Intravenous Therapy

Answer 138

Local complications of IV therapy occur at or near the catheter. A priority for care for patients with IV therapy is to prevent, assess, and detect these complications. In some cases nurses also manage these problems.

on following pages

Question 139

Infiltration

Answer 139

Leakage of a nonvesicant IV solution or medication into the extravascular tissue

Cause:
Peripheral catheter has punctured opposite vein wall

Obstruction of blood flow causing backflow through original entrance site

Inflammatory process causing fluid leakage at the capillary level

Fibrin sheath fully encasing a central venous catheter, leading to retrograde flow and leakage from venipuncture site

Damaged septum of implanted port

Dislodged port access needle

Signs and symptoms:
IV rate slows

Increasing edema around site

Patient report of skin tightness; blanching or coolness of skin; burning, tenderness, or general discomfort at the insertion site; fluid leaking from puncture site; absence of a blood return (though this may not be reliable with a short peripheral catheter)

Interventions:
Stop infusion and remove short peripheral catheter immediately after identification of problem.

Apply sterile dressing if weeping from tissue occurs.

Elevate extremity.

Warm or cold compresses may be used according to the solution infiltrated and organizational policy. Warm compresses increase circulation to the area and speed healing. Cool compresses may be used to relieve discomfort and reduce swelling.

Insert a new catheter in the opposite extremity.

For all central venous catheters, obtain a study to determine the cause of the problem.

For implanted port, remove and insert a new port access needle.

Rate the infiltration using the INS Infiltration Scale and document (Table 13-7).

Prevention:
Catheter stabilization—use smallest catheter appropriate; avoid area of flexion or use armboard.

Avoid placing restraints at IV site.

Make successive venipunctures proximal to the previous site.

Monitor site frequently; educate patient about activities and signs and symptoms.

Central venous catheters—obtain a brisk blood return before using the catheter for infusion.

Frequently assess proper positioning of port access needle. Stabilize it well and protect from clothing.

Question 140

Extravasation

Answer 140

vesicant IV solution or medication into the extravascular tissue

Can occur with both peripheral and central catheters

Cause:
Same as for infiltration

Signs and symptoms:
Same as for infiltration

Blistering and tissue sloughing may not appear for a few days and resolves over 1-4 wks with infiltration of some chemotherapeutic agents such as anthracycline and alkylating agents

Interventions:
Stop infusion and disconnect administration set.

Aspirate drug from short peripheral catheter or port access needle.

Leave short peripheral catheter or port access needle in place to deliver antidote, if indicated by established policy.

If possible, aspirate residual drug from the exit site of a central venous catheter.

Administer antidote according to established policy.

Apply cold compresses for all drugs EXCEPT vinca alkaloids and epipodophyllotoxins.

Photograph site.

Monitor at 24 hrs, 1 wk, 2 wks, and as needed.

Surgical interventions may be required.

Provide written instructions to patient and family.

Prevention:
Same as for infiltration.

Know the vesicant potential before giving any IV medication.

Prevention is key.

Question 141

Phlebitis

Answer 141

Inflammation of the vein

Post-infusion phlebitis presents within 48-96 hrs after the catheter has been removed

cause:
cause from insertion technique, catheter size, and lack of catheter securement

Chemical cause from extremes of pH and/or osmolarity of the fluid or medication

Bacterial cause from a break in aseptic technique, poor securement, and extended dwell time

Signs and symptoms:
Patient may report pain at the IV site; nurse may observe that vein appears red and inflamed along the length; vein may become hard and cordlike

Interventions:
Remove short peripheral catheter at the first sign of phlebitis; use warm compresses to relieve pain.

Monitor frequently.

Document using Phlebitis Scale.

Insert a new catheter using the opposite extremity.

Mechanical phlebitis occurring in the first week after PICC insertion may be treated without catheter removal. Apply continuous heat; rest and elevate the extremity. Significant improvement is seen in 24 hrs, and complete resolution is seen within 72 hrs. Remove catheter if treatment is unsuccessful.

Prevention:
Choose the smallest-gauge catheter for the required therapy.

Avoid sites of joint flexion or stabilize with an armboard.

Avoid infusing fluids or medications with a pH below 5.0 or above 9.0 through a peripheral vein.

Avoid infusing fluids or medications with a final osmolarity above 500 mOsm/L through a peripheral vein.

Rotate sites every 72-96 hrs according to established policy.

Adequately secure the catheter.

Use aseptic technique.

For PICCs, teach patient to avoid excessive physical activity with the extremity.

Question 142

Thrombosis

Answer 142

Blood clot inside the vein

Cause:
Anything that damages the endothelial lining of the intima can initiate clot formation

Traumatic venipuncture

Multiple venipuncture attempts

Use of catheters too large for the chosen vein

Hypercoagulable state and venous stasis

Signs and symptoms:
Slowed or stopped infusion rate

Swollen extremity

Tenderness and redness

Engorged peripheral veins of the ipsilateral chest and extremity

Interventions:
Stop infusion and remove short peripheral catheter immediately.

Apply cold compresses to decrease blood flow and stabilize the clot.

Elevate extremity.

Surgical intervention may be required.

For central venous catheters, notify the physician and obtain requests for a diagnostic study. Low-dose thrombolytic agents can be used to lyse the clot.

prevention:
Use evidence-based venipuncture technique.

Make only two attempts to perform venipuncture.

Choose the smallest-gauge catheter in the largest vein possible.

Secure catheter adequately.

Use armboards if short peripheral catheters are placed in areas of joint flexion.

Ensure adequate hydration to avoid changes in blood composition and flexion of the extremity.

Prophylactic low-dose warfarin (Coumadin, Warfilone image) may be prescribed for patients with a central venous catheter.

Question 143

Thrombophlebitis

Answer 143

Presence of a blood clot and vein inflammation

Cause:
Same as for phlebitis and thrombosis

signs and symptoms:
Same as for phlebitis and thrombosis

interventions:
Same as for phlebitis and thrombosis.

Apply cold compresses initially, followed by warm.

Prevention:
Same as for phlebitis and thrombosis.

Question 144

Ecchymosis and Hematoma

Answer 144

Ecchymosis results from infiltration of blood into the surrounding tissue

Hematoma results from uncontrolled bleeding

Cause:
Unskilled or multiple IV insertion attempts

Patients with coagulopathy or fragile veins (e.g., older adults and patients on steroids)

Accidental laceration of a large vein or artery

Signs and symptoms:
Swelling

Bruising

Pain or tenderness

interventions:
When removing device, apply light pressure; excessive pressure could cause other fragile veins in the area to rupture.

For hematoma, apply direct pressure until bleeding has stopped. Elevate extremity, apply ice for first 24 hours and then warm compress for comfort.

Prevention:
Avoid veins that cannot be easily seen or palpated.

Use extra caution in patients with coagulopathies.

Use evidence-based venipuncture technique.

Question 145

Site Infection

Answer 145

Invasion of microorganisms at the insertion site in the absence of simultaneous bloodstream infection

Infection localized at the insertion site, the port pocket, or subcutaneous tunnel

Cause:
Break in aseptic technique during insertion or the handling of sterile equipment

Lack of proper hand hygiene and skin antisepsis

signs and symptoms:
Site appears red, swollen, and warm; patient may report tenderness at the site; may observe purulent or malodorous exudates

interventions:
Clean exit site with alcohol, expressing drainage if present.

For short peripheral catheter, midline catheter, or PICC, remove using sterile technique and avoid contact between skin and catheter.

Send catheter tip for culture, if requested.

Clean site with alcohol and cover with dry, sterile dressing; physician to evaluate for septic phlebitis and need for antimicrobial therapy or surgical intervention.

prevention:
Use strict aseptic technique when inserting, maintaining, or removing catheters.

Practice evidence-based hand hygiene.

Ensure that dressing remains clean, dry, and adherent to skin at all times.

Question 146

Venous Spasm

Answer 146

Sudden contraction of the vein

Cause:
Normal response to irritation or injury of the vein wall

signs and symptoms:
Cramping or pain at or above the insertion site

Numbness in the area

Slowing of the infusion rate

Inability to withdraw midline catheter or PICC

interventions:
Temporarily slow infusion rate.

Apply warm compress.

Do not immediately remove short peripheral catheter.

If occurring during midline catheter or PICC removal, do not apply tension or attempt forceful removal.

Reapply a dressing, apply heat, encourage patient to drink warm liquids, and keep extremity covered and dry. 12-24 hrs may be required before catheter can be removed.

prevention:
Allow time for vein diameter to return to normal after tourniquet removal and before advancing catheter.

Infuse fluids at room temperature if possible.

For a midline catheter or PICC, gently withdraw the catheter in short segments

Question 147

Nerve damage

Answer 147

Inadvertent piercing or complete transection of a nerve

cause:
Venipuncture near known nerve locations

Unanticipated nerve locations

signs and symptoms:
Reports of tingling or feeling “pins and needles” at or below the insertion site

Numbness at or near the insertion site

intervention:
Immediately stop the insertion procedure if the patient reports extreme pain.

Remove the catheter if reports of discomfort do not improve when the catheter is secured.

prevention:
Avoid using the cephalic vein near the wrist.

Avoid using veins on the palm side of the wrist.

Adequately secure the catheter, but avoid tape that is too tight.

Support areas of joint flexion with an armboard.

Question 148

Systemic complications of IV therapy

Answer 148

Systemic complications of IV therapy involve the entire vascular system or multiple systems. For central venous catheters (CVCs), complications can occur during the insertion procedure or during the dwell time. Tables 13-6 and 13-7 are the INS criteria for grading phlebitis and infiltrations. Document all assessments and complications in the patient’s electronic health record. Notify the infusion therapy team and/or primary health care provider per agency policy when complications occur.

Question 149

Circulatory Overload

Answer 149

Disruption of fluid homeostasis with excess fluid in the circulatory system

cause:
Infusion of fluids at a rate greater than the patient’s system can accommodate

signs and symptoms:
Patient may report shortness of breath and cough; patient’s blood pressure is elevated, and there is puffiness around the eyes and edema in dependent areas; patient’s neck veins may be engorged, and nurse may hear moist breath sounds.

interventions:
Slow the IV rate and notify physician; raise patient to an upright position; monitor vital signs and administer oxygen as prescribed; administer diuretics as prescribed.

prevention:
Monitor intake and output carefully and notify physician as soon as an imbalance is noticed between the patient’s intake and output.

Question 150

Speed Shock

Answer 150

Systemic reaction to the rapid infusion of a substance unfamiliar to the patient’s circulatory system

Cause:
Rapid infusion of drugs or bolus infusion, which causes the drug to reach toxic levels quickly

signs and symptoms:
Patient may report light-headedness or dizziness and chest tightness; nurse may note that patient has a flushed face and an irregular pulse; without intervention, patient may lose consciousness and go into shock and cardiac arrest.

interventions:
Immediately discontinue the drug infusion and hang isotonic solution to keep the vein open; monitor vital signs carefully and notify physician for further treatments.

prevention:
Be aware of the appropriate infusion rate of medications and adhere to them; use of infusion control devices helps to prevent speed shock.

Question 151

Catheter Embolism

Answer 151

A shaving or piece of catheter breaks off and floats freely in the vessel

Cause:
Anything that damages the catheter—during insertion, dressing change, excessive force with flushing, or medication administration

signs and symptoms:
Depending on where the catheter embolizes, this could be life threatening.

Cardiopulmonary arrest could occur.

interventions:
Emergently notify the physician. Remove the catheter and apply a tourniquet high on the limb of the catheter site; inspect catheter to determine how much may have embolized; an x-ray is taken to determine the presence of any catheter piece; surgical intervention may be necessary.

prevention:
When inserting over-the-needle catheters, never reinsert the needle into the catheter; avoid pulling a through-the-needle catheter back through the needle during insertion.

Avoid scissors near the catheter with dressing changes.

Question 152

Complications During the Dwell of Central Venous Catheters

Catheter Migration

Answer 152

Movement of a properly placed catheter tip to another vein

No change in the external catheter length

causes:
Changes in intrathoracic pressure caused by coughing, vomiting, sneezing, heavy lifting, and congestive heart failure

signs and symptoms:
For migration to the jugular vein—reports of hearing a running stream or gurgling sound on the side of catheter insertion

For migration to the azygos vein—back pain between the shoulder blades

Neurologic complications if medications are infused

interventions:
Stop all infusions and flush catheter.

Notify physician.

Obtain a chest x-ray, if required, to assess tip location.

Spontaneous repositioning back to the SVC is possible.

Repositioning by radiology may be required.

prevention:
Place catheter tip properly in the lower third of the SVC near the junction with the right atrium.

Instruct patient to perform usual ADLs but to avoid excessive physical activity.

Question 153

Catheter Dislodgment

Answer 153

Movement of catheter into or out of the insertion site

Cause:
Inadequate catheter securement

Excessive physical activity with a PICC

signs and symptoms:
External catheter length has changed, also changing the internal tip location

No other signs or symptoms may be noticed immediately

intervention:
Stop all infusions and flush catheter.

NEVER re-advance the catheter into the insertion site.

Determine the amount of external catheter length and compare with the length documented on insertion.

Notify the physician or nurse inserting the catheter for further assessment.

prevention:
Use proper catheter securement device.

Instruct patient to perform normal ADLs but to avoid excessive physical activity.

Question 154

Catheter Rupture

Answer 154

Catheter is broken, damaged, or separated from hub or port body

cause:
Forcefully flushing a catheter with any size syringe against resistance

Using scissors to remove a dressing

Catheter compression of a subclavian-inserted catheter between the clavicle and first rib (also known as pinch-off syndrome)

signs and symptoms:
Fluid leaking from insertion site

Pain or swelling during infusion

Reflux of blood into the catheter extension

Inability to aspirate blood from catheter

interventions:
Repair the damaged segment; depends on the availability of a repair kit designed for the specific brand of catheter being used; repair may be considered a temporary measure instead of a permanent treatment.

Remove catheter.

prevention
NEVER use excessive force when flushing a catheter, regardless of syringe size.

On injection, small syringes generate more pressure than larger syringes. Use of a 10-mL syringe is generally recommended for flushing procedures.

Insert catheter through jugular or upper-extremity sites instead of subclavian site.

Question 155

Lumen Occlusion

Answer 155

Catheter lumen is partially or totally blocked

cause:
Drug or mineral precipitate (calcium, diazepam, and phenytoin are common)

Lipid sludge from long-term infusion of fat emulsion

Blood clots and fibrin sheath caused by blood reflux into lumen

Allowing administration sets to remain connected for extended periods after medication has infused

signs and symptoms:
Infusion stops or pump alarm sounds

Inability or difficulty administering fluids

Inability or difficulty drawing blood

Increased resistance to flushing of the catheter

intervention:
Assess history of catheter use. A suddenly developing problem may indicate contact between incompatible medications. A problem that develops over an extended period may indicate a gradual clot formation.

For drug precipitate, determine the pH of the precipitated drug. Use hydrochloric acid for acidic drug. Use sodium bicarbonate for alkaline drugs.

For blood clot use thrombolytic enzymes such as alteplase.

prevention:
Always flush with normal saline between, before, and after each medication given through the catheter.

Use positive-pressure flushing techniques when a negative fluid-displacement needleless connector is being used.

Use a positive fluid-displacement needleless connector.

Flush catheters immediately when medication infusion is complete.

Question 156

Catheter-Related Bloodstream Infection (CRBSI)

Answer 156

Pathogenic organisms invade the patient’s circulation

The CDC has specific criteria to classify these infections

cause:
Lack of sterile field during insertion

Inadequate skin antiseptic agents and application techniques

Manipulation of the catheter hub leading to intraluminal contamination

Inadequate hand hygiene

Long dwell time

signs and symptoms:
Early symptoms include fever, chills, headache, and general malaise

interventions:
Change the entire infusion system from solution to IV device; notify physician, obtain cultures, and administer antibiotics as prescribed.

If the infusate is the suspected cause, send a specimen to the laboratory for evaluation.

prevention:
Maintain sterile technique.

Use the recommended CRBSI prevention bundle.

Question 157

Phlebitis Scale From INS Standards of Practice

Answer 157

0 No symptoms
1 Erythema with or without pain
2 Pain at access site with erythema and/or edema
3
Pain at access site with erythema and/or edema

Streak formation

Palpable cord

4
Pain at access site with erythema and/or edema

Streak formation

Palpable venous cord more than 1 inch long

Purulent drainage

Question 158

Infiltration Scale From INS Standards of Practice

Answer 158

0 No symptoms
1
Skin blanched

Edema <1 inch in any direction

Cool to touch

With or without pain

2
Skin blanched

Edema 1-6 inches in any direction

Cool to touch

With or without pain

3
Skin blanched, translucent

Gross edema >6 inches in any direction

Cool to touch

Mild-to-moderate pain

Possible numbness

4
Skin blanched, translucent

Skin tight, leaking

Skin discolored, bruised, swollen

Gross edema >6 inches in any direction

Deep pitting tissue edema

Circulatory impairment

Moderate-to-severe pain

Infiltration of any amount of blood product, irritant, or vesicant

Question 159

Intravenous Therapy and Care of the Older Adult:

Skin Care

Answer 159

Aging skin:
thinner, less subq fat, decreased ability for thermal regulation
fewer nerve endings-less ability to feel pain

Older patients may not perceive acute pain from traumatic venipuncture requiring excessive probing or multiple attempts

this action increases the risk for fluid leakage and subsequent infiltration or extravasation injury. Inserting and removing a catheter and dressing could tear the skin layers.

skin antisepsis important-decreased immunity with aging

lipids normally found in skin as protective agent-alcohol dissolves lipids-skin can become very dried

Current recommendations call for using friction when cleaning the skin to penetrate the layers of the epidermis. excessive friction may damage fragile skin and cause impaired TISSUE INTEGRITY. Chlorhexidine is preferred agent, and the product currently available contains alcohol.

Check for allergies to iodine before using iodine or iodophors. Iodophors such as povidone-iodine require contact with the skin for a minimum of 2 minutes to be effective. All antiseptic solutions must be thoroughly dry before applying the dressing or tape.

Skin should never be shaved before venipuncture, excessive amounts of hair should be clipped. Shaving causes micro-abrasions that can lead to infection. The skin of an older adult may be more delicate- more easily nicked while shaving.

Skin and TISSUE INTEGRITY can easily be compromised by the application of tape or dressings. Use of skin protectant solutions - protective barrier between the skin and dressing, improves the adherence of dressing to the skin. Removal of tape and dressings may require adhesive remover solutions, or an alcohol pad may accomplish the same purpose.

Securement devices such as the StatLock require the use of a skin protectant (e.g., Skin-Prep) before applying the device. The protectant prevents skin tearing when the device is removed.

Question 160

Vein and Catheter Selection

Answer 160

highest importance in older adults.

Choose insertion sites carefully after considering the patient’s skin integrity, vein condition, and functional ability.

The general principle of starting with the most distal sites usually indicates use of hand veins. However, avoid fragile skin and small, tortuous veins on the back of the hand (dorsum); select the initial IV site higher on the arm.

Venous distention use flat tourniquet; the veins may require longer to adequately distend.
Allowing a tourniquet to remain in place for extended periods causes an overfilling of the vein and can result in a hematoma when the vein is punctured.

On extremely fragile skin tourniquet application can lead to ecchymotic areas or skin tears.

Protect the skin by placing a washcloth or the patient’s gown between the skin and tourniquet. A tourniquet may not be required in veins that are already distended; however, carefully palpate these veins to determine their condition.
Avoid hard, cordlike veins.
Blood pressure cuffs can also be used for venous distention. Inflate the cuff and release until the pressure is slightly less than diastolic pressure. Other methods to distend veins include:

• Tapping lightly, but avoiding forceful slapping
• Asking the patient to open and close the fist so the muscles can force blood into the veins, making sure that the hand is relaxed when the venipuncture is attempted
• Placing the extremity lower than the heart
• Applying warm compresses or a heating pad (be careful not to make it too hot) to the entire extremity for 10 to 20 minutes and removing just before making the venipuncture

venipuncture technique requires adequate skin and vein stabilization during the puncture and complete catheter advancement. Veins of an older adult are more likely to roll away from the needle. Low angles of 10 to 15 degrees between the skin and catheter will improve your success with venipuncture.

As soon as the catheter enters the vein, it may be necessary to release the tourniquet. Release of venous pressure from the puncture can lead to ecchymosis. Allowing the tourniquet to remain in place during the complete catheter advancement could increase this problem.

Question 161

Nursing Safety Priority

Action Alert

Answer 161

Catheter securement may mean that administration sets are placed out of easy reach of a confused patient. Use flexible netting over the extremity to help prevent the patient from pulling at the dressing or tubing, while allowing easy access to the site. A device such as the I.V. House UltraDressing shown in Fig. 13-16 can also protect the site. Do not use rolled bandages to cover the extremity because they prevent insertion site assessment. Complications may progress to an advanced state before they are noticed.

Question 162

choosing infusion set in older adults

Answer 162

Choosing a midline catheter or PICC may be best in older patients with poor skin turgor; limited venous sites; or veins that are fragile, tortuous, or hard.
These catheters are placed in the upper extremity where venous distention techniques can be used.
Inserting nontunneled percutaneous central catheters in older adults can be challenging.
Venous distention for insertion requires the Trendelenburg position and a well-hydrated patient. Fluid volume deficit prevents adequate distention of the subclavian or jugular veins.
Patients with conditions such as chronic obstructive pulmonary disease and kyphosis cannot tolerate the Trendelenburg position.

Tunneled catheters and implanted ports may be appropriate after considering the surgical techniques required to insert these catheters.

Question 163

Cardiac and Renal Changes older adults

Answer 163

Because of changes in cardiac and renal status in older adults, the accuracy of infusion volume and flow rate measurements is very important in the older adult.

primary health care provider’s prescription for infusion therapy should be assessed for appropriateness for the patient’s condition.

Older adults prone to fluid overload and resulting heart failure. Electronic controlling devices can ensure the necessary accuracy.

When fluid restrictions are required, medications could be diluted in small quantities and delivered using a syringe pump or a manual IV push.

Consult with a pharmacist to determine the smallest amount of diluent required.
This alternative may allow the patient to have more fluid to drink.

Serum sodium levels should be considered when normal saline is routinely used for dilution in patients with hypertension or cardiac problems.

patients with chronic illness often need repeat and frequent IV therapies

Many of these patients are vein depleted and need vein preservation. Subcutaneous and intraosseous routes have demonstrated effectiveness in emergency resuscitation.

procedures may also be beneficial for routine infusion of isotonic, nonirritant, nonvesicant solutions in patients with chronic illness and vein depletion

Specific therapies requiring infusion into arteries and peritoneal, epidural, and intrathecal space are also available.

These therapies are most commonly used to administer chemotherapy, lytic therapy, or pain medication.

Question 164

Subcutaneous infusion therapy

Answer 164

Subcutaneous infusion therapy has been used for a variety of drug infusions. Most commonly it is used for administration of pain medications and insulin therapy. It is beneficial for palliative care patients who cannot tolerate oral medications, when IM injections are too painful, or when vascular access is not available or is too difficult to obtain.

Question 165

Hypodermoclysis or “clysis”

Answer 165

Hypodermoclysis or “clysis” involves the slow infusion of isotonic fluids into the patient’s subcutaneous tissue.

The growth of geriatric and palliative health care has increased use of this infusion therapy for selected patients and the emergent biologics.

can be used for short-term fluid volume replacement.

The patient must have sufficient sites of intact skin without infection, inflammation, bruising, scarring, or edema.

The most common sites are the front and sides of the thighs and hips, the upper abdomen, and the area under the clavicle.

the upper extremities should not be used because fluid is absorbed more readily from sites with larger stores of adipose tissue. Hypodermoclysis is not appropriate for emergency resuscitations and should not be used if the fluid replacement needs.

Question 166

Hyaluronidase

Answer 166

Hyaluronidase may be prescribed by the primary health care provider and is mixed with each liter of infusion fluid. This substance is an enzyme that improves the absorption of the infusion from the subcutaneous tissue.

Question 167

equipment used for subq IV therapy

Answer 167

A small-gauge (25 to 27) winged infusion or “butterfly” needle, a small-gauge short peripheral catheter, or an infusion set specially designed for subcutaneous infusion can be chosen. The subcutaneous infusion sets have a small needle extending at a right angle from a flat disk that helps stabilize the needle.

Question 168

considerations when choosing an infusion site for subq IV therapy

preparation and implementation

Answer 168

consider the patient’s level of activity. The area under the clavicle or the abdomen prevents difficulty with ambulation.

Clip excess hair in the area and clean the chosen site with the antiseptic solution, preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol to prevent infection
Prime the infusion tubing and the attached subcutaneous infusion set or winged needle. Gently pinch an area of about 2 inches (5 cm) and insert the needle using sterile technique. After securing the needle, cover the site with a transparent dressing.

Question 169

flow rates for subq

Answer 169

Flow rates for hydration fluids begin at 30 mL/hr. After 1 hour the rate can be increased if the patient has experienced no discomfort. The maximum rate is usually 2 mL/min or 120 mL/hr.

Question 170

assessment for subq, signs to watch for and rotation of sites

Answer 170

Assess the site every 4 hours while in a hospital setting and at least twice daily while at home. Redness, warmth, leakage, bruising, swelling, and reports of pain indicate tissue irritation and possible impaired tissue integrity. If these symptoms occur, remove the infusion needle. Rotate the site at least once a week. More frequent rotation may be needed, depending on TISSUE INTEGRITY

Question 171

Complications for subq IV therapy

Answer 171

Other complications include pooling of the fluid at the insertion site and an uneven fluid drip rate. Both of these problems may be resolved by restarting the infusion in another location. An infusion pump may also be used. Small ambulatory infusion pumps can be used to allow for greater mobility.

Question 172

Intraosseous (IO) Infusion Therapy

Answer 172

Intraosseous (IO) therapy allows access to the rich vascular network in the red marrow of bones.

Question 173

who uses IO therapy

Answer 173

Although IO has previously been regarded as a pediatric procedure, it is now considered acceptable for use in adults. Victims of trauma, burns, cardiac arrest, diabetic ketoacidosis, and other life-threatening conditions benefit from this therapy because often clinicians cannot access these patients’ vascular systems for traditional IV therapy

IO catheters may be established in the prehospital setting when IV access cannot be readily obtained in an emergency.

Question 174

what is administered using IO therapy, length of use, when to use

Answer 174

Absorption rates of large-volume parenteral (LVP) infusions and drugs administered via the IO route are similar to those achieved with peripheral or central venous administration.

The IO route should be used only during the immediate period of resuscitation and should not be used longer than 24 hours.

After establishing access, efforts should continue to obtain IV access as well.

Question 175

contraindications for IO therapy

Answer 175

absolute contraindication is fracture in the bone to be used as a site.

Conditions such as severe osteoporosis, osteogenesis imperfecta, or other conditions that increase the risk for fracture with insertion of the IO needle and skin infection over the site may also be contraindications for some patients.

Repeated attempts to access the same site should be avoided

Question 176

equipment used IO therapy and sites used

Answer 176

Any needle could be used to provide therapy and access the medullary space (marrow). However, 15- or 16-gauge needles specifically designed for IO therapy are preferred. New technology using a battery-powered drill has improved the ease of IO insertion.

A number of sites can be used, including the proximal tibia (tibial tuberosity), distal femur, medial malleolus (inner ankle), proximal humerus, and iliac crest. The proximal tibia is the most common site accessed for IO therapy

Question 177

procedure

Answer 177

If IV access cannot be obtained within the first few minutes of resuscitation procedures, IO therapy may be attempted. The leg is restrained, and the site is cleaned with an antiseptic agent such as chlorhexidine. After successful insertion the needle must be secured to prevent movement out of the bone. The same doses of fluids and medications can be infused by IO therapy as IV. An infusion pump may be used for rapid flow rates.

Question 178

reducing pain during procedure

Answer 178

During the procedure most patients rate the pain as a 2 or 3 on a scale of 0 to 10. Lidocaine 1% is used to anesthetize the skin, the subcutaneous tissue, and the periosteum to promote comfort. Pain is also reported during the initial infusion. This may be reduced by injecting 0.5 mg/kg of preservative-free lidocaine through the IO port before initiating the infusion

Question 179

complications of IO therapy

Answer 179

Improper needle placement with infiltration into the surrounding tissue is the most common complication of IO therapy. An accumulation of fluid under the skin at either the insertion site or on the other side of the limb indicates that the needle either is not far enough in to penetrate the bone marrow or is too far into the limb and has protruded through the other side of the shaft. Needle obstruction occurs when the puncture has been accomplished but flushing has been delayed. This delay may cause the needle to become clotted with bone marrow.

Osteomyelitis is an unusual but serious complication of IO therapy. You can help prevent this with meticulous aseptic technique, hand hygiene, and removal of the catheter as soon as it is no longer needed.

Question 180

Compartment syndrome

Answer 180

Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased perfusion (peripheral blood flow to the area). The decreased circulation to the area leads to hypoxia and pain in the area. Although the complication is rare in IO therapy, the nurse should monitor the site carefully and alert the primary health care provider promptly if the patient exhibits any signs of decreased circulation to the limb such as coolness, swelling, mottling, or discoloration. Without improvement in perfusion to the limb, the patient could ultimately require amputation of the limb

Question 181

Intra-Arterial Infusion Therapy

Answer 181

Catheters are placed into arteries to obtain repeated arterial blood samples, to monitor various hemodynamic pressures continuously, and to infuse chemotherapy agents or fibrinolytics (intra-arterial infusion therapy). Catheters placed in the radial, brachial, or femoral arteries are used for obtaining blood samples and arterial pressure monitoring. Arterial waveforms and pressures are converted to digital values displayed on attached monitors.

The pulmonary artery is used to monitor pressures in the heart and lungs. This artery is cannulated via the large central venous system and through the right side of the heart.

Question 182

setup of IA therapy

Answer 182

Between the catheter and the monitor is a special administration set capable of handling high infusion pressure, a pressurized fluid container, a continuous flush attachment, a three-way stopcock, and a transducer. The transducer is positioned at the level of the patient’s atrium and secured to an IV pole to enable correct arterial pressure measurements.

Question 183

benefits of IA therapy

Answer 183

Chemotherapy agents administered arterially allow infusion of a high concentration of drug directly to the tumor site before it is diluted in blood or metabolized by the liver or kidneys. Drug infusion through the same blood supply feeding the tumor optimizes cell destruction at the tumor site while minimizing systemic side effects.

Question 184

sites used for IA therapy, length of use

Answer 184

The most common arterial sites include the hepatic and celiac arteries for liver tumors, although the carotid artery for tumors of the head, neck, or brain and pelvic arteries for cervical tumors have been used.

Arterial catheter insertion can be performed through the skin via a surgical procedure or by an interventional radiologist.

Implanted ports are commonly used for extended therapies. For short-term therapy, an external catheter may be used for 3 to 7 days, although the risks for complications increase during dwell time.

Question 185

Considerations for IA therapy

Answer 185

Carefully secure all junctions on the administration sets with Luer-Lok devices. Life-threatening hemorrhage can occur if an accidental disconnection occurs! When an infusion pump is used, be sure that it has a pressure high enough to overcome arterial pressure. Closely monitor the arterial insertion site and affected extremity. Assess the extremity for warmth, sensation, capillary refill, and pulse.

When the carotid artery is involved, perform neurologic assessments. When a femoral catheter is used, apply antiembolic stockings or other measures to prevent deep vein thrombosis.

Question 186

complications for arterial catheters, IA therapy

Answer 186

Complications from arterial catheters are similar to those from venous catheters, including infection, bleeding from the insertion site, hemorrhage from a catheter disconnection, catheter migration, infiltration, and catheter lumen or arterial occlusion. Specialized training is required to manage patients with arterial catheters.

Question 187

Intraperitoneal Infusion Therapy

Catheters used

Answer 187

Intraperitoneal (IP) infusion therapy is the administration of chemotherapy agents into the peritoneal cavity. IP therapy is used to treat intra-abdominal malignancies such as ovarian and GI tumors that have moved into the peritoneum after surgery.

Catheters used for IP therapy may be an implanted port for long-term treatment or an external catheter for temporary use. These catheters, including those attached to an implanted port, have large internal lumens with multiple side-holes along the catheter length to allow for delivery of large quantities of fluid.

Question 188

Administration of IP therapy includes three phases:

Answer 188

the instillation phase; the dwell phase, usually 1 to 4 hours; and the drain phase. Because this treatment involves the delivery of biohazardous agents, additional competency is required to handle the infusion properly.

Question 189

conditions for treatment

Answer 189

The patient should be in the semi-Fowler’s position for the infusion. He or she may experience nausea and vomiting caused by increasing pressure on the internal organs from the infusing fluid. Pressure on the diaphragm may cause respiratory distress. Reducing the flow rate and treatment with antiemetic drugs may be needed. Severe pain may indicate that the catheter has migrated, and an abdominal x-ray is needed to determine its location.

Question 190

During the dwell and drainage phases,

Answer 190

the patient may need assistance in frequently moving from side to side to distribute the fluid evenly around the abdominal cavity. After the fluid has drained, the catheter is flushed with normal saline, although heparinized saline may be used in implanted ports. Catheter lumen occlusion is caused by the formation of fibrous sheaths or fibrin clots or plugs inside the catheter or around the tip.

Question 191

Complications for IP therapy

Answer 191

Exit site infection, indicated by redness, tenderness, and warmth of the tissue around the catheter, can occur. Microbial peritonitis and inflammation of the peritoneal membranes from the invasion of microorganisms are other complications. If peritonitis occurs, the patient may experience a fever and report abdominal pain. Abdominal rigidity and rebound tenderness may be present. This condition is preventable by using strict aseptic technique in the handling of all equipment and infusion supplies. Management includes antimicrobial therapy administered either IV or intraperitoneally.

Question 192

Intraspinal Infusion Therapy

Answer 192

The spinal column is covered by three layers: the dura mater, or outermost covering; the arachnoid, or middle layer; and the pia mater, which is closest to the spinal cord.

Two spaces used for infusion are the epidural space between the dura mater and vertebrae and the subarachnoid space.

The epidural space consists of fat, connective tissue, and blood vessels that protect the spinal cord.

Medications infused into the epidural space must diffuse through the dura mater, and there is the possibility that some drug will be absorbed systemically.

Intrathecal medications are infused into the subarachnoid space and directly into the cerebral spinal fluid, allowing reduced doses (Prager et al., 2014). Care of patients with these therapies requires competency training and validation.

Question 193

indications for use

Answer 193

Postoperative and chronic pain is the primary indication for epidural infusion (see Chapter 4). Opioids administered epidurally slowly diffuse across the dura mater to the dorsal horn of the spinal cord. They lock onto receptors and block pain impulses from ascending to the brain. The patient receives pain relief from the level of the injection caudally (toward the toes).

Local anesthetics administered epidurally work on the sensory nerve roots in the epidural space to block pain impulses.

The primary health care provider administers the first dose of medication; then, depending on state law, the type of medication, and facility policies, nurses trained in epidural therapy may administer subsequent doses.

Question 194

Intrathecal infusion of chemotherapy

Answer 194

Intrathecal infusion of chemotherapy has been used for treating central nervous system (CNS) cancers. The belief was that lower total body doses delivered directly to the tumor would help prevent side effects. Intrathecal infusion has also been used to manage chronic pain and treat spasticity of neurologic diseases such as cerebral palsy, multiple sclerosis, reflex sympathetic dystrophy, and traumatic and anoxic acquired brain injuries

Question 195

catheters/equipment used

temporary catheter and epidural catheter

Answer 195

temporary catheter used for epidural therapy can be a percutaneous catheter that is secured at the site and extends up the back toward the shoulder. These catheters are used for postoperative pain management and usually dwell for only several hours or a few days. Infection and subsequent meningitis and catheter migration are the possible complications.

Epidural catheters used for longer periods include a tunneled catheter and implanted port. Tunneled catheters are tunneled toward the abdomen and have a subcutaneous cuff to act as a barrier to infection. The external catheter exits the skin on the abdomen so it can be reached easily for use by the patient or caregiver. An epidural implanted port is the same design as an IV implanted port and is accessed with the same noncoring needle. The catheter extends from the lumbar puncture site to the port pocket and is located over a bony prominence on the abdomen through a subcutaneous tunnel. Surgically implanted pumps can also be used to deliver epidural and intrathecal infusion.

Question 196

intraspinal catheter

Answer 196

Using sterile technique, an intraspinal catheter usually is inserted in the lumbar region. The external part of a temporary epidural catheter is laid along the back toward the head and usually extends over the shoulder. The entire catheter length is taped for added security. Dressings are usually not routinely changed because they are used only for short periods. If bleeding or fluid leakage requires dressing removal, use extreme care to prevent dislodging the catheter.

Question 197

tunneled catheter

implanted port

Answer 197

For a tunneled catheter or implanted port, the entire subcutaneous tunnel and port pocket should be assessed frequently. Measurement of an external catheter segment could help identify catheter migration.

Question 198

in-line filter

Answer 198

An in-line filter is used on all intraspinal infusions to block the infusion of particulate matter. Medications commonly contain preservatives such as alcohol, phenols, or sulfites; however, these are toxic to the CNS. All medications used for intraspinal infusion must be free of preservatives. Alcohol and products containing alcohol should not be applied to the insertion site because the solution could track along the catheter and cause nerve damage. Povidone-iodine solutions are preferred for skin antisepsis before insertion and during catheter dwell, including tunneled catheter exit sites and implanted port pockets.

Question 199

complications from epidural and intrathecal infusion

Answer 199

Complications from epidural and intrathecal infusion can be caused by the type of medication being infused or can be related to the catheter. It is important to know the specific location of the intraspinal catheter because the doses of medications are quite different. When used for pain management, doses are usually 10 times greater for epidural than for intrathecal infusion. Assess the patient for response to the drugs being given, level of alertness, respiratory status, and itching.

Question 200

Catheter-related complications

Answer 200

Catheter-related complications include infection, bleeding, leakage of cerebrospinal fluid (CSF), occlusion of the catheter lumen, and catheter migration.

It is important to be aware of coagulopathy and timing of anticoagulant therapy when epidural catheters are inserted.

An epidural hematoma can cause neurologic damage if not corrected promptly.

Infection in the patient receiving either epidural or intrathecal therapy could be the result of a lack of asepsis when handling the medication or during the administration.

Evidence of local infection such as redness or swelling at the catheter exit site may be present.
The patient may also exhibit neurologic and systemic signs of infection (e.g., meningitis) such as headache, stiff neck, or temperature higher than 101° F (38.3° C). Report any neurologic change to the primary health care provider immediately!