Chapter 13 Intravenous Infusion and Blood Transfusion

SECTION ONEIntravenous InfusionDefinition:IV infusion is a method that a large volume of solution is infused into vein to correct fluid and electrolyte disturbance solution; passage (infusion set); vein

Intravenous InfusionIV infusion is a serious and complex responsibility that requires the nurse: proficiency in performance familiarity with the anatomy involved mindful use of principles of asepsis expertise in prevention, management of complications that may occur with treatment

Intravenous InfusionFluids are medications--IV infusion requires a physicians orderthe type and amount of fluid administered will be based on types of patients need the patients age general health status the results of laboratory tests

Types of solutions There are many methods of classificationaccording to their osmolality in relation to normal blood plasma

according to their purpose Hypotonic fluidsIsotonic fluidsHypertonic fluidsNutrient solutionsElectrolyte solutionsVolume Expanders

Hypotonic fluidshave lower osmolality than plasma to correct dehydration as they move from blood vessels into the cellsexamples are 0.45 % NaCl, 0.2 % NaCl, or 5%GS excessive infusion can cause water intoxication

Isotonic fluidshave the same effective osmolality as plasma to expand the intravascular space to correct hypovolemia as in shock examples are lactated Ringers, 0.9 % ( normal ) saline(0.9%NaCl), 5 % dextrose in normal saline(5%GNS). 1.4%NaHCO3excessive infusion can cause circulatory overload and pulmonary edema

Hypertonic fluidshave greater osmolality than plasmato pull fluid from cells and the interstitial space into the intravascular space to relieve edemaexamples are >5 % dextrose solutions, colloidal products such as dextran, 3 % saline ( rarely used ). excessive infusion can cause cellular dehydration and circulatory overload or diuresis.

Nutrient solutionscontain some form of glucose and water for calories and fluids replacementexamples are 5 or 10dextrose in water Hypertonic ( >10 percent dextrose ) parenteral nutrition solutions are irritating to peripheral veins and so must be infused into central veins.

Electrolytes solutionscontain varied amounts of cations and anionsexamples are normal salineRingers solution, and lactated Ringers solutioncommonly be used to restore vascular vo1umeparticularly after trauma or surgery also be used to replace fluid and electrolytes for patients with continuing lossesfor examplegastric suction or wound drainage

Volume expandersbe used to increase the blood volume following severe loss of blood or loss of plasmaexamples are dextranplasmaand human serum albumin

Clinical routineIn clinic, prepare fluids fall into the following three categories:Crystalloid Solution Colloidal Solution Parenteral Nutrition Solutions

Crystalloid Solutionhave small molecular weights and stay in blood vessel for a short timemaintain the balance of fluids in intracellular and extra- cellularcorrect the fluids and electrolytes disturbancecommonly used crystalloid solutions areDextrose in Water SolutionsIsotonic Electrolytes Solutions Alkaline solutions Hypertonic Solutions

Dextrose in Water SolutionsBe used for fluids and calories replacementdecreasing the consumption of albumenand preventing the production of ketoneglucose is decomposed quickly in body, usually doesnt cause hypertonic and diuretic effectsClinically there are usually 5GS and 10GS (25%GS; 50%GS rarely used)

Isotonic Electrolytes Solutions be used in electrolytes replacementLoss of body fluids usually is accompanied with disturbance of electrolytesSo, the balance of fluids and electrolytes must be maintained during fluids replacementexamples are o.9 NaClRingers isotonic solution and 5% GNS

Alkaline solutions NaHC03 in Water Solutions Be used in correcting acidosis, and regulating of acid-base balance NaHC03 Na+ and HCO3- HCO3- + H+ H2CO3 C02 +H2 OCommonly used solutions are 5 NaHC03 and 1.4 NaHC03 Solutions.Sodium Lactate in Water SolutionsThe concentrations of the solution usually used in clinic are 11.2 and 1.84%.

Hypertonic Solutions be used for diuretic and dehydration purposesincrease osmolality of blood plasm pulling fluids into plasma reduce the edema of tissuescan decrease intracerebral pressure and improve the function of central nervous systemClinicallymannitol 20%sorbitol 25 and dextrose 25-50 in water solutions are often used

Colloidal Solution have large molecular weightcan stay in blood for a long timecan maintain plasma colloid osmotic pressure effectivelyexpand the blood volumeimprove microcirculationelevate the blood pressureexamples are dextran plasma substitutes blood products

Dextran It is water-soluble polysaccharide of high molecular polymer moderate molecular dextran : elevate plasma colloid osmotic pressureexpand blood volumesmall molecular dextran : reduce the viscosity of blooddecrease the accumulation of erythrocytesimprove microcirculation and tissue perfusion volumeand prevent the formation of thrombosis

Plasma Substitutes can expand vascular volume and cardiac output greatly can be used with whole blood in acute massive hemorrhageexamples are 706 (hydroxyethylamylum)povidone and oxypolygelation

Blood Products can elevate colloid osmotic pressureexpand vascular volume provide protein and antibody help with tissue repair and enhance immunity of body

Parenteral Nutrition Solutions be intravenously given to the patients who are unable to get nutrition via gastrointestinal tract or have inadequate intake of nutrients provide caloriesproteinsvitamins and mineralsand maintain the balance of nitrogenmain compositions : amino acidsfatty acidsvitaminsmineralshigh concentration of glucose and watercommonly used solutions : multiple amino acids solutions , fat emulsions

sequence principle of solution transfusionFirst crystalloid solutions then colloidal solutionsFirst sodium chloride solutions then dextrose in water solutions first fast then slow, rather shortage than overloadrather acid than alkalinePotassium solutions properly

Sites of Venipuncture Peripheral Superficial Veinveins in dorsal hands : the first choice for adult patients median cubitalbasiliccephalic veins :drawing blood bolus injections of medication PICCThe saphena veins in legs and veins in dorsal feet are not the first choice because of the danger of thrombosis caused by the vein valveVeins in dorsal foot are commonly used for childrenbut are avoided in adults because of the danger of thrombophlebitisVeins in the Scalp :for infantsSubclavianExternal Jugular:for central venous access

peripheral intravenous infusion Purposes Preparation nurse patient environment equipment Procedures and Key Points Evaluation VCD

PurposesTo correct or prevent fluid and electrolyte disturbances resulted from illnesses, altered fluid intake, or prolonged episodes of vomiting or diarrhea.To increase the blood volume, maintain blood pressure following severe loss of blood, severe burns, or shock.To supply medication to cure diseases for rapid effectiveness.To supply nutrient substances to promote wound healing, weight gain and positive nitrogen balance for patients with chronic consuming illness, inability to intake, digest or absorb a diet.To establish a lifeline for rapidly needed medications.

PreparationNurse 1. Review the physicians order in patients record. 2. Evaluate patients age and medical status. Evaluate patients renal status and other pertinent lab data (e.g., electrolyte, serum glucose ). 3. Wash hands and wear mask. patient 1. Verify patients identity. 2. Explain the procedure and purposeAsk the patient to void 3. Position the patient for comfort and optimal visibility for skill performance.

PreparationEnvironment:cleanness, commodiousness and brightness equipment: Medical tray Antiseptic solution Sterile swab Tourniquet infusion Pad Adhesive tape File and vial opener IV solution and medication Bottle bag Infusion set kidney-shaped tray

Procedures and Key Points 1.Check and rightthe bed numberthe patients namemedication name concentration dosage date and usage the quality of solution(the cap of bottle, the expiration date , depositioncloudiness foreign matter, any cranny on the bottles body)2. Complete the medication label and stick it to the solution container

3. Add medications into solution 4.Insert the infusion set 5. Prepare the equipment and take them to the bedside Check again 6. Discharge air

7.Select the venipuncture site(pad , tourniquet )8.Sterilize the venipuncture sitePrepare adhesive tape. 9.Check again.

10. venipuncture

The wizenedThe obeseThe elderlyThe dropsical (edema)

11.fixation12. Regulate the flow rate 13. Check again. 14. Disposure after operation (equipment,patient)15. Change bottles 16. Disposure after infusion (equipment,patient)

Cautions 1. Follow the principles of asepsis and check system strictly to prevent infection and mistakes.2. Arrange the sequence of IV fluids rationally according to the patients need. Assign medications according to the therapeutic principles and the half life of medications.3. Protect and use veins reasonably (usually from small veins) to patients who need long-term IV infusion.

Cautions4. Prevent air embolism by ejecting air thoroughly in infusion set, changing fluid bottles and withdrawing the venipuncture needle in time.5. Assess for compatibility of medications. Ensure the needle have been inserted into vein before administration irritative or special medications.6. Master the flow rate strictly.7. Assess during infusion carefully in order to find the problems and settle the problems on time. Document the result after assessment.

Education 1. Tell the patient dont regulate the flow rate optionally.2. Introduce the signs and symptoms of complications with IV reactions, ask patient call nurse in time when he find the signs of IV reaction.3. Instruct the patient to report any blood in the tubea stoppage in the flowor increased discomfort4. Intensify mental nursing to patient who need long-term IV infusion.

Evaluation Assess the status of the skin and dressing of IV site by observing whether there is heatpainrednessor swellingWhether the IV flows smoothly and whether the flow rate is consistent with what is orderedCheck the information to ensure the right medication administeredSigns and symptoms of complications with intravenous infusionPatients knowledge about medication and infusionAbility to perform self-care activities.

Regulating the Infusion Flow RateCalculate the Flow RateCommon Infusion Control Device

Calculate the Flow Rate

Total time of infusion (h) = Total infusion vo1ume (m1)drop factor (drops/m1)

Drops per minute60Drops per minute= Total infusion vo1ume (m1)drop factor (drops/m1)

Total time of infusion (min)

Calculate the Flow RateSlow flow rate is suitable for the elderlyinfants and patients with diseases in heart, 1ungsor kidneyWhen hypertonic solutionssolutions containing potassiumor solutions containing medications for raising blood pressure are infusedthe flow rate also should be slowWhen a patient with normal heart and lung function has severe dehydrationthe flow rate should be rapid

Common Infusion Control Device Clamp:be easy to operate; not precise Infusion Pump:exert positive pressure on the tubing or on the fluid to ensure measured amount of fluid is infused uniformly in a given timehas a drop sensor, and an alarm that will sound if drops are not detected at the appropriate rate VCD

The Usage of Infusion Pump

Assessing during infusion The responsibilities of nurses in assessment arekeeping the system sterilechanging solutiontubeand dressings on timeassisting the patient with self-care activities so as not to disrupt the system;instruct the patient to report any blood in the tubea stoppage in the flowor increased discomfort

Common Problems during Infusion and Methods to Treat Slow Flow Rate or No Infusion Too Large Volume of Solution in Chamber Too Small Volume of Solution in Chamber The Surface of Liquid Fall down Automatically assess the site and the infusion rate at least once an hour

Slow Flow Rate or No InfusionInfiltrationocclusion of the IV Needle or Catheterhyperkinesia of VeinToo Low Hydrostatic Pressure

InfiltrationCause:the needle dislodge from the vein and fluid exude in the subcutaneous space

Signs: insertion site becomes swollenclammy, and painfulAlternative nursing actions: :discontinue IV and establish a new line at a new site

occlusion of the IV Needlecauses:there are clots at the tip of the needlethe needle tip is against the vein wall (flexed joint-wrist , elbow )narrowing the tubing may exist too-tight IV dressing a kink in the tubingmeasures:assess : lowering the IV container below the level of the IV insertion site, opening the roller clamp thoroughly, and observing for a blood returnAlternative nursing actions: inspect the area around the insertion site loose the IV dressing check the tubing change the position of the needle handle or extremity

hyperkinesia of VeinCauses:extremity is exposed in cold environment for a long timethe temperature of the fluid is too lowAlternative nursing action: warm the extremity

Too Low Hydrostatic Pressure Raise the solution container

increase hydrostatic pressure increase the flow rate

Too Large Volume of Solution in ChamberCauses:compress the drip chamber too many times or too hard when discharging air from tubingAlternative nursing actions: (3 methods)

Too Small Volume of Solution in Chamber Causes:compressing chamber with less force or fewer times too late when changing the IV solution during continuous infusionAlternative nursing actions:

The Surface of Liquid Fall down Automatically Causes: the tubing and chamber is not airtight Alternative nursing actions: check the whole infusion set system to see if there is untight connection of every part or cranny in infusion setif necessarythe tube system should be changed

Complications of Intravenous Therapy and Intervention Fever PhlebitisThrombosisand Thrombophlebitis Circulatory overload reaction Air Embolism Infiltration Local Allergic Reactions Infection or Inflammation at the Insertion Site

FeverCauses: allergic reactions to a medication or IV fluid impureness of the solution incomplete sterilization of the equipment no strict application of aseptic techniques during starting an IVSymptoms and signs: feel coldtrembling and with increased body temperature to 38 to 40 or higher Systematic reactions may be presentsuch as nausea vomitingheadacheand tachycardia

FeverPreventions inspect the quality of solutionsthe package of intravenous set and date of sterilization carefullyInterventionsreduce the flow rate or stop infusion and notice the physician immediatelyGive physical cold therapy to patient with T> 39 Administer the antiallergic medication according to physicians order if necessary.Keep the residual solutionmedicationand equipment for the laboratory test

PhlebitisThrombosisand Thrombophlebitis Causes: irritation to the lining of blood vessels chemical irritation to tissues by IV solutions or medicationsmechanical irritation to tissues by the needle or catheter localized allergic reaction to the indwelling catheter or needle local infection by undemanding sterile performance during initiating infusion

PhlebitisThrombosisand ThrombophlebitisSymptoms and Signs feel pain in local sitewith increased skin temperatureswelling over the veinredness traveling along the path of the vein in some casessystemic reactions may be presentsuch as feverchill

PhlebitisThrombosisand ThrombophlebitisPreventions To follow sterile principles strictlyand protect the 1ocal site from contaminationIrritating medication should be diluted thoroughly and infused slowlyThe needle should be secured firmly to prevent the needle sliding out of the vein

PhlebitisThrombosisand Thrombophlebitis InterventionsDiscontinue infusion and start IV at another veinApply warm compresses with 50 magnesium sulphateUse physical therapy of ultrashort wave on local siteIf there is infectionuse antibiotics according to physicians order

Circulatory overload reaction--acute pulmonary edema Causes: receive a too large volume and a too rapid administration of IV solutions a sudden increase of circulating blood volume and too heavy cardiac load

Circulatory overload reaction--acute pulmonary edemaSymptoms and Signs: chest pressedshortness of breathcough, frothy or pinkish sputumfacial palenessdiaphoresisneck vein distentionrales in the lungsrapid heart ratearrhythmiarapid weight gainpitting edemaand tachycardia

Circulatory overload reaction--acute pulmonary edemaPreventionsmaintain the appropriate flow rate during the infusion, especially for the patient with heart failurethe elderly and children Avoid rapid flow rate at night because of nocturnal decrease in renal function

Circulatory overload reaction--acute pulmonary edemaInterventionsslow the rate of infusion or stop the infusion immediatelynotify the physician assume a Folowers position with the feet dangling at the bedside if the patients condition is allowedapply oxygen administration with greater flow rate, put 20 to 30 ethanol solution into humidified bottleadminister the sedativevasodilatorsantiasthmadigitalisand diuretics to the patient according to the physicians order apply tourniquet to limbs of the patient in alternation in order to reduce the venous return if necessary

Air Embolism Causes did not eject air in infusion system thoroughly; infusion set is not air tight did not eject air in the tubing below the chamber on time after changing the solution containerdo not alter the bottle or withdraw the needle on time when the patient receives pressure infusion or pressure blood infusion

Air EmbolismSymptoms and Signs feel discomfort in chest or pain under the sternumwith the presence of decreased blood pressurecyanopathytachycardiaincreased venous pressure and unconsciousnessClear and continuous bubble sound can be auscultated

Air EmbolismPreventions inspect the quality of infusion setconnect every part tightlyejecting air in tubing thoroughlycheck the tubing below the chamber to make sure no air after changing the bottle of solutionappoint a nurse to watch the patient with press infusionhave patient place head below heart level or perform Valsalva maneuver while changing tubing on central venous lines

Air EmbolismInterventionshelp the patient to turn on left side with head down administer oxygen therapy with high flow rate for the patientmonitor vital signs and notify the physician

Local Allergic Reactions Causes Individuals may demonstrate sensitivity to antiseptic solutionsor tape used to secure the catheterIndwelling catheters and needles may also cause allergic reaction Preventions and Interventions assess allergic history of the patient very carefullychange some supplies which can cause allergic reactions administer antianaphylaxis medication based on the physician's order if necessary

Infection or Inflammation at the Insertion Site CausesMicroorganisms gain access to the tissue and circulatory system through the tip of needle or cannula device inserted during venipuncture Microorganisms enter later by migration along the interface between the catheter and tissue Symptoms and Signs the local tissue may have rednessedemaheatpainand perhaps exudationThe patient may have systemic reactionssuch as fever

Infection or Inflammation at the Insertion SitePreventions Using aseptic technique for all IV-related care; keeping dressing dry; changing dressing on time Interventionsremove IV to another site if necessaryapply cool compress to site as ordered by the physicianelevate limband observe for signs of sepsis

INTRAVENOUS INDWELLING NEEDLE INFUSION Purposes Preparation Procedures Cautions

PurposesApply to the patients that have difficult to puncture and need long-term IV infusion. Provide an easy access for intermittent infusions or IV administration.Protect patients veins from damnification of repeated venipuncture.

Preparation Nurse Review the physicians order in patients record.Evaluate patients age and medical status. Evaluate patients renal status and other pertinent lab data (e.g., electrolyte, serum glucose ).Wash hands and wear mask. patient Verify patients identity.Explain the procedure and purposeAsk the patient to void Position patient for comfort and optimal visibility for skill performance.

PreparationEnvironment:cleaning, commodious, bright Equipment: Medical tray Antiseptic solution Sterile swab Tourniquet Pad Crystal adhesive tape File and opener IV solution and medication Medical card Infusion set Bottle bag Kidney-shaped tray Sterile gloves Intravenous indwelling needle

Procedures1. Check and right2. Complete the medication label 3. Add medications into solution 4. Insert the infusion set 5. Prepare the equipment and take them to the bedsideCheck again 6. Discharge air

Procedures7. Wear gloves, prepare IV indwelling needle Check the quality of the IV indwelling needle

take out the indwelling needle sterile the heparin cap

insert spike of infusion set into the heparin cap

discharge again Close the clamp protect the indwelling needle

Procedures8. Select the venipuncture site(1) Place a pad under the extremity (2) Apply a tourniquet firmly 10 to 15cm above the venipuncture site 9. Sterilize the venipuncture site(>10cm)10.Check again.

Procedures 11.Intravenous injection(1) Use the left hand to pull the skin taut against the vein, hold the needle with right hand, insert the needle and catheter through the skin and into the vein(2) Once blood appears in the lumen of the catheter, reduce the angle of the needle until it is almost parallel to the skinadvance the needle 0.2cm, then withdraw the needle 0.5cm, advance the catheter and needle until the whole catheter is in veinHold the catheter shaft steady, withdraw the needle.

Procedures12. Fixationrelease fist, tourniquetand clampOpen the sterile adhesive tape bag, take out the crystal adhesive tape, and secure the injection site hermetically. Loop the tubing near the site of entryfix with adhesive tape, and write down the date of installation on the tape13. Regulate the flow rate 14. Check again.

Procedures15. Disposure after operation 16. Change bottles 17. Disposure after infusion After infusionclose the roller clampwithdraw the needle from the heparin cap,sterile the heparin cap and seal the catheter with 0.9%NS in positive pressureClose the Luer Lock of primed IV catheter set to peripheral cannulaHelp the patient to have a comfortable positionRecord the volume of fluid infused and the time of the discontinuationDispose of the equipment in proper mannerWash hands. Document relevant data

Cautions 1. Follow the principles of asepsis and check system strictly to prevent infection and mistakes.2. Keep the injection site cleaning. Observe the injection site carefully in order to find the complications and settle them on time. 3. Seal the catheter with positive pressure after infusion to prevent occlusion of the catheter or thrombophlebitis.4. The catheters indwelling time is commonly about 3 to 5 days5. Instruct the patient to take self-care. Avoid to energize and press excessive. Avoid the catheter to be pulled out when change clothes.

EXTERNAL JUGULAR VENOUS CATHETER INFUSIONPurposes Preparation Procedures Cautions

Purposes1. Measurement of central venous pressure (CVP)2. Apply a venous access when no peripheral veins are available3. Administration of vasoactive medications which cannot be given peripherally4. Administration of hypertonic solutions including total parenteral nutrition.

Preparation Nurse:Review the physicians order in patients record.Evaluate patients age and medical status. Evaluate patients renal status and other pertinent lab data (e.g., electrolyte, serum glucose ). Evaluate patients mental status and cooperation status.Evaluate the venipuncture site.Wash hands and wear mask.

Preparationpatient: Verify patients identity.Explain the procedure and purpose to reduce the patients anxiety and tension.Position patient for optimal visibility for skill performance. Environment:must be cleaning, commodious and bright

PreparationEquipment: Medical tray Antiseptic solution Sterile swab Crystal adhesive tape File and opener IV solution and medication Medical card Infusion set Bottle bag Kidney-shaped tray local anaesthetic Sterile venipuncture package Sterile gloves

Procedures Steps 1 to 6 are the same as described in Peripheral Intravenous Infusion7. Select the position8. Select insertion site and sterile the skin9. Open the sterile venipuncture package, wear sterile gloves, and drap the area10. Infiltrate the skin and deeper tissues with local anaesthetic11. Insert the catheter and cover with a sterile dressing12. Connect with infusion set

Procedures13. Regulate the flow rate 14. Check again.15. Disposure after operation16. Change bottles17. Disposure after infusionSeal the catheter with a small volume of dilute heparin ( 100 U/ml ) into the lumen. Clamp catheter lumen using online slide clamp. Stuff the needle hub hole with a sterile injection cap. Catheter insertion site protection and stabilization are accomplished by regular antimicrobial cleaning and sterile dressing changes every day.

Procedures18. Infusion againRemove the sterile injection cap, sterile the needle hub hole, connect with infusion set, unclamp lumen, then initiate IV infusion. 19. Withdraw the catheterThe lumen of the catheter connect with a syringe, withdraw the catheter while pump the syringe, press the insertion site for several minutes. Sterile the local skin with 75% ethanol solution, and cover it with sterile dressing.

Cautions 1. Follow the principles of asepsis and check system strictly to prevent infection and mistakes.2. Select the insertion site carefully.3. Intensify evaluation during infusion. Flush the catheter with dilute heparin ( 100 U/ml ) if return blood appears in the catheter to prevent occlusion.

Cautions4. Seal the catheter with positive pressure after infusion to prevent occlusion of the catheter. Clot appears in the catheter should be sucked use a syringe to avoid to be pushed into blood circulation.5. To stabilize and protect catheter site to prevent contamination or dislodgement. Observe the injection site carefully in order to find the complications and settle them on time.

SUBCLAVIAN VENOUS CATHETER INFUSION(self-study)

INFUSION PARTICLE CONTAMINATION (self-study)

END!