iggy ch 13 concepts of infusion therapy Flashcards

Question

Joint commission patient safety goals regarding blood products

Answer 1

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.

Answer 2

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.

Answer 3

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

Answer 4

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

Answer 5

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.

Answer 6

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.

Answer 7

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

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

* 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.

Answer 12

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.

Answer 13

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.

Answer 14

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.

Answer 15

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)

Answer 16

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

Answer 17

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.

Answer 18

* 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

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

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.

Answer 26

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.

Answer 27

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

Answer 28

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.

Answer 29

-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

Answer 30

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.

Answer 31

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.

Answer 32

purpose, duration, and insertion site availability.

Answer 33

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

Answer 34

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.

Answer 35

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

Answer 36

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.

Answer 37

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.

Answer 38

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.

Answer 39

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.

Answer 40

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.

Answer 41

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.

Answer 42

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.

Answer 43

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.

Answer 44

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)

Answer 45

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

Answer 46

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.

Answer 47

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

Answer 48

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.

Answer 49

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.

Answer 50

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.

Answer 51

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

Answer 52

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.

Answer 53

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.

Answer 54

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

Answer 55

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

Answer 56

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

Answer 57

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.

Answer 58

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

Answer 59

most often used for patients receiving chemotherapy. are immune comprimised-highly suseptible to infection

Answer 60

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.

Answer 61

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.

Answer 62

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.

Answer 63

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

Answer 64

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.

Answer 65

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.

Answer 66

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.

Answer 67

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

Answer 68

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

Answer 69

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.

Answer 70

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.

Answer 71

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

Answer 72

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.

Answer 73

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.

Answer 74

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.

Answer 75

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.

Answer 76

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.

Answer 77

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.

Answer 78

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.

Answer 79

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.

Answer 80

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.

Answer 81

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

Answer 82

Syringe pumps | ambulatory pumps

Answer 83

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.

Answer 84

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.

Answer 85

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.

Answer 86

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.

Answer 87

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

Answer 88

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.

Answer 89

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.

Answer 90

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.

Answer 91

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.

Answer 92

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!

Answer 93

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.

Answer 94

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.

Answer 95

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.

Answer 96

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.

Answer 97

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.

Answer 98

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.

Answer 99

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.

Answer 100

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.

Answer 101

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.

Answer 102

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

Answer 103

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.

Answer 104

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.

Answer 105

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.

Answer 106

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.

Answer 107

, 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.

Answer 108

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.

Answer 109

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.

Answer 110

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.

Answer 111

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.

Answer 112

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.

Answer 113

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.

Answer 114

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

Answer 115

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.

Answer 116

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.

Answer 117

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.

Answer 118

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.

Answer 119

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.

Answer 120

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.

Answer 121

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.

Answer 122

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

Answer 123

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.

Answer 124

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.

Answer 125

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.

Answer 126

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.

Answer 127

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.

Answer 128

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.

Answer 129

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.

Answer 130

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.

Answer 131

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.

Answer 132

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.

Answer 133

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

Answer 134

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

Answer 135

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.

Answer 136

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.

Answer 137

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.

Answer 138

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.

Answer 139

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.

Answer 140

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.

Answer 141

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.

Answer 142

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.

Answer 143

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.

Answer 144

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.

Answer 145

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.

Answer 146

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

Answer 147

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.

Answer 148

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

Answer 149

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.

Answer 150

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.

Answer 151

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

Answer 152

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

Answer 153

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.

Answer 154

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

Answer 155

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.

Answer 156

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

Answer 157

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.

Answer 158

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.

Answer 159

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.

Answer 160

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.

Answer 161

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.

Answer 162

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.

Answer 163

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.

Answer 164

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.

Answer 165

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.

Answer 166

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.

Answer 167

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.

Answer 168

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.

Answer 169

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.

Answer 170

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

Answer 171

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.

Answer 172

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.

Answer 173

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.

Answer 174

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.

Answer 175

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.

Answer 176

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!