INTRAVENOUS FULID THERAPY

INTRODUCTION
Intravenous Therapy or IV therapy is the act of infusion or administration of fluids, medications and nutrients directly through a venous access o Purpose: To restore and maintain fluid and electrolyte balance To provide a route for medication administration To transfuse blood or blood components To deliver parenteral nutrition o Indication Diagnostic Contrast enhanced imaging Therapeutic Fluid Resuscitation Medication Administration Blood Product Transfusion Parenteral Nutrition Benefits of IV therapy o Advantage Medication route when oral intake is contraindicated Permits manipulation of amount of medication introduced with right time Faster administration of drug thus, deemed fast absorption and fast action o Disadvantages Drug-IV fluid interaction Complications such as hematoma, phlebitis, extravasation, embolism and the such Limits Patients activities Nurses Responsibility during Intravenous Fluid Therapy o Select appropriate delivery system o Continuous patient assessment o Monitor for complications o Maintain peripheral access and central venous access o Must differentiate the common fluids o Vigilant Health Education o Proper documentation History of IV therapy o William Harvey Discovered Blood circulation o Sir Christopher Wren Discovered the hypodermic needle o Jean-Baptise Denis Animal to human transfusion o James Blundell Man to Man Transfusion Blood Loss and Hypoxia o Ignaz Semmelweis Hand washing Technique o Claude Bernard Total Parenteral Nutrition to dog o Karl Landsteiner Blood Typing o Ada Plummer

First to hold the title IV nurse Trends in IV Therapy o 81-85% of patients in a hospital requires IV access o More nursing time is dedicated only through IV Therapy o IV Therapy is required in a multi-disciplinary setting Anatomy and Physiology o Integumentary System Layers of the Skin Epidermis The outer layer of the skin o Stratum Basale o Stratum Spinosum o Stratum Granulosum o Stratum Licidum o Stratum Corneum Dermis o Mechanoceptors Skin tactile perception o Thermoceptors Process temperature perception o Nociceptors Process pain o Chemoceptors Process osmotic changes in blood and arterial pressure Hypodermis o Vascular System Arteries Blood from the Heart Body Veins Blood from the capillaries Heart Layers of Blood Vessel Tunica Adventitia Outer Layer ; mostly connective tissue and contains the nerves Tunica MediaThickest layer; rich in vascular smooth muscle Tunica IntimaThinnest layer Peripheral Blood Vessels with IV gauges Digital Vein( Gauge 24) MetacarpalVein ( Gauge 20,22) Cephalic Vein ( Gauge 18,20,22) Basilic Vein ( Gauge 18,20,22

INTRAVENOUS FLUIDS
Hypotonic Solutions o Hydrates Cell o Given in Cellular Dehydration o Cells Burst (<250 mOsm/L ) o Hypotonic fluids are used to treat patients with conditions causing intracellular dehydration, such as diabetic ketoacidosis, and hyperosmolar hyperglycemic state, when fluid needs to be shifted into the cell. o Administering hypotonic saline solutions also helps the kidneys excrete excess fluids and electrolytes. o Examples Tap Water 0.45% NaCl 0.33% NaCl o Nursing Considerations Be aware of how the fluid shift will affect various body systems. The lower concentration of solute within the vascular bed will shift the fluid into the cells and also into the interstitial spaces. Never give hypotonic solutions to patients who are at risk for increased ICP because of a potential fluid shift to the brain tissue, which can cause or exacerbate cerebral edema. Dont use hypotonic solutions in patients with liver disease, trauma, or burns due to the potential for depletion of intravascular fluid volume. Isotonic Solutions o Stays put o Given in Intravenous Dehydration o Cells neither shrink nor burst o Examples Dextrose 5% in Water (D5W) Isotonic outside the body but after dextrose metabolism it will be hypotonic Plain Lactated Ringers (PLR) or Hartmanns 0.9 NSS (PNSS) o Nursing Considerations For patients being treated with hypovolemia and infused with an Isotonic solution rapid hypervolemia can occur Document baseline VS, edema status, lung sound and heart sounds Educate patients and their families about signs and symptoms of volume overload and dehydration, and instruct patients to notify their nurse if they have trouble breathing or notice any swelling Hypertonic o Expands Volume o Given in Intravenous Dehydration with interstitial and intracellular fluid overload o Cells Shrinks (>300 mOsm/L) o Examples D5LR D5 0.45 NaCl 3% NaCl D10W Albumin D5NM D5NR D5IMB o Nursing Considerations

Maintain vigilance when administering hypertonic saline solutions because of their potential for causing intravascular fluid volume overload and pulmonary edema. Monitor serum electrolytes and assess for signs and symptoms of hypervolemia. Because hypertonic solutions can cause irritation, damage, and thrombosis of the blood vessel, some of these solutions shouldn't be administered peripherally.

Types of Parenteral solutions o Crystalloids Solutes that when places in a solution mix with and dissolve into a solution and cannot be distinguish from the resultant solution o Dextrose With Carbohydrate content Percentage solution expressed with the number of grams of solute per 100gg of solvent E.g D5W- infusion contains 5g of dextrose in 100mL of water All dextrose solution are acidic ( pH 3.5-5.0) and may cause thrombophlebitis o Sodium Chloride 0.25/0/45/0.9(PNSS)/3/5 Treatment of shock, hyponatremia, resuscitation in trauma situation and fluid challenges Used in blood transfusion(PNSS) Use cautiously in patients with CHF, edema or hyponatremia o Ringers Solution Treatment of any type of dehydration Restoration of fluid balance before and after surgery Replacement of fluid resulting from dehydration, GI losses, and fistula drainages o Lactated Ringers Solution or Hartmanns Solution Prescribed solution, with an electrolyte concentration closely resembling that of the ECF compartment Used to replace fluid loss resulting in burns and diarrhea Given to metabolic acidosis o Colloids Type of solution that contains macromolecules and electrolytes Colloids expand intravascular volume by drawing fluid from the interstitial spaces into the intravascular compartment through their higher oncotic pressure. Types of Colloid Solutions Non-Synthetic o Albumin- It contains plasma protein fractions obtained from human plasma and works to rapidly expand the plasma volume. It's used for volume expansion, moderate protein replacement, and achievement of hemodynamic stability in shock states. Availability 5% and 25% 5% is osmotically and oncotically equivalent to plasma 25% is equivalent to 500mL of plasma or 2 units of whole blood These are subjected to an extended heating thus, it does not transfer viral diseases Uses: Maintenance of Blood Volume Emergency treatment of: o Shock caused by acute blood loss o Hypovolemic shock caused by plasma rather than blood loss Synthetic o Dextran are polysaccharides that behave as colloids Are available as Low Molecular Weight Dextran (LMWD) Dextran 40

Are Available as High Molecular Weight Dextran (HMWD) Dextran 70 and Dextran 75 Volume Expansion for patients with hypovolemic shock or with risk of hypovolemia Interfers with blood typing or cross-matching Hetastarch (Hydroxyethyl Glucose) Synthetic from starch Availabilty: 6% or 10% diluted in isotonic NaCl in a 500mL container Hespan These starches are not derived from donor plasma thus making it more cost effective and low risk Doesnt interfere with blood typing or cross-matching

PHARMACOLOGICAL ASPECTS OF IV THERAPY

Pharmacologic aspects of IV Therapy o An IV medication may be ordered when: A patient needs a therapeutic effects Medication ordered that cant be absorbed by the GI tract Patient may receive NPO order and drugs that may irritate the GI tract A controlled administration rate is required Advantages o Directness to the circulatory system o Beneficially for medications that can irritate the gastric mucosa o Route of Instant drug action o Route for delivering high drug care o Provides for instant drug infusion termination if sensitivity or adverse reactions occurs o Better control over the rate of administration Disadvantages o Solution and Drug incompatibility o Physical Extravasation, phlebitis, extravasation o Chemical Can cause less potency of drugs o Therapeutic Antibiotics with 1 hour difference o Poor Vascular access Hypovolemia Vasoconstriction o Adverse Reaction Faster reaction time 10 Rights of Medication Administration o Right Drug o Right Patient o Right Dose o Right Route o Right Time & Frequency o Right Documentation o Right History and Assessment (Complete patient drug/relevant history) o Drug approach and Right to Refuse o Right Drug-Drug Interaction and Evaluation (drug-food incompatibilities/interaction) o Right Education and Information (Teach patient about the drug he is taking) Types of Infusion method o Direct Injection (Vein or existing line) o Intermittent Infusion o Continuous Infusion Infusion Pump o Intra-peritoneal drug administration o Intra-osseous drug administration o Intra-ventricular Drug Administration o Intra-arterial Drug Administration Patient Controlled Analgesia o Pain management strategy that allows a patient to self- administer IV narcotic medications by pressing a button that is attached to a computer group o Candidates Patient who are anticipating pain that is severe yet intermittent (e.g Kidney stones) Patient who have constant pain that worsen with activity Pediatrics patients who are older than age 7 years old, who are capable of being taught to manage PCA machine

Patients who are capable of manipulating the button Complications Anaphylaxis, Nausea, Vomiting, Constipation Orthostatic hypotension Respiratory Depression

INFECTION CONTROL IN IV THERAPY

Principles of Infection Control o Aseptic technique is utilized o The Nurse must be knowledgeable of the chain of infection o Breaking the chain of infection is through the mode of transmission, can be prevented by hand washing o IV catheter and IV tubing must be replaced after 3 days Risk Factors o Type of catheter used o Number of lumen of the catheter used o Total Parenteral Nutrition o Duration of the catheter o Site of the catheter where it is inserted o Management of catheter after insertion Common Pathogens o Candida Albicans o Staphylococcus Aureus o Enterobacter cloacae o Staphylococcus epidermis o Pseudomonas aeruginosa o E. fecalis Chain of Infection

Breaking the chain of Infection o Reservoir Standard precautions, Drug asepsis and Proper hygiene o Portal of Entry Hand washing, PPE, Proper waste disposal, and standard precaution o Mode of Transmission Hand washing, Standard precaution, Safe food handling, PPE, and Transmission based precaution o Portal of Entry Aseptic technique and surgical asepsis Principles of Preventing Infection o Consider every patients as infectious o Safe work practices should be applied o Isolate patients which is deemed necessary

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Preventing insertion through the subclavian, basilica, cephalic vein, and use of TPN catheter for other infusion purposes Use of Infusion pumps Use of needless system Use of sharp containers Monitoring and assessment of IV access Use of appropriate dressing, tegaderm to provide visualization of IV access

PRINCIPLE OF PERIPHERAL IV THERAPY

IV assessment o Length of IV Therapy o Patients age o Patients Diagnosis o Allergies o Type of Therapy o Laboratory Values Bleeding time o IV Therapy History Use of Previous site o Physical Assessment Check for the signs of skin infection o Mental Status o Transcultural Barriers Blood Transfusion- Jehovahs Witness Physical Principle of flow o Viscosity o Length o Internal Diameter IV Therapy Risks o Needle stick injury o Infectious organism exposure Catheter o Success in venipuncture is equated to the choice of catheter o Use the smallest gauge possible that can satisfy the indication of IV Therapy o The tip of catheter should be inspected for integrity prior to venipuncture o Only 2 attempts of venipuncture are recommended o Types of Catheter Over-the-needle Used for adults Used for long term IV Therapy for the active or agitated patient Advantage: o More comfortable for the patient o Radiopaque thread for easy location o Safety needles prevent accidental needle strides o Activity restricting device is rarely required Disadvantage o Difficult to Insert o Extra care is required to ensure the needle and catheter are inserted into the vein Butterfly or winged set Used for pediatric clients Used for short-term therapy and for cooperative adult patient, and it used for patients with fragile and sclerotic vein Advantage: o Easiest to insert o Ideal for non-irritating IV push o Available with a catheter that can be left I place Disadvantage: o Can Easily cause infiltration Needle Selection o G 16(gray), G14(red) Trauma Patients o G 18(green), G20(pink) Infusion of hypertonic solutions; Blood Transfusion

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G 22(yellow) Patients with fragile vein G 24(blue), G26(violet) Pediatric

IV Cannula

Principles for Vein selection o Vein should feel round, firm, elastic and engorged; not hard, bumpy or flat o Be aware that blood flow in the lower forearm and hand is 45 mL/minute o Be aware that sclerotic vein is common on narcotic addicts o Start with the distal veins of the upper extremities first, with subsequent venipuncture proximal to the previous sites o Palpate the vein prior venipuncture o Use veins appropriate for the prescribed infusate Hypertonic or Irritating infusates can cause discomfort when infused into small vein, where there is reduced hemodilution and the intima of the vein can be damaged o Use the smallest cannula appropriate for the infusate o Dont use veins of the lower extremities for active clients o Avoid Areas of flexion, unless the joint is immobilized o Avoid veins in the antecubital fossa It is difficult to directly immobilize the area, and damage to the antecubital veins restricts use of distal veins in the extremity that feed into these vessels o Dont use veins on the same side of mastectomy o Dont use veins of area that is partially amputated o Dont use veins on areas that has sustained 3rd degrees burn o Avoid Veins below areas of phlebitis, vein thrombosis Vein Dilation Methods o Tourniquet Placed 6-8 in above venipuncture site o Gravity Position extremity below the level of the bed o Fist Clenching Opening and closing of the fist o Tapping

Thumb and second finger, flick the veins Warm compress For maximum of 10 minutes o Multiple Tourniquet technique Use of 2-3 tourniquets o Blood pressure cuff Pump to 30mmHg; excellent choice for vein dilation o Transillumination Use of penlight or venoscope to illuminate the veins o Ultrasonography Used for short-term therapy when all dilation techniques failed Venipuncture Site Preparation o Do not shave the site of insertion, instead use clippers o Depilatories(Creams that act as shave) are not recommended o Cleanse area with one of the following, working from the center outward 2 % Chlorhexidine gluconate Providone-Iodine 70% isoprphyl alcohol Trincture of iodine, 2% o Local anesthetics Transdermal Analgesics Eutectic Mixture of Local Anesthetics (EMLA) o Wear gloves and use clean technique o Prepare the affected are by washing with mild soap and water o Apply small amount of the cream o Apply dressing after 30-60 minutes Bactriostatic Normal Solution Provides anesthetic action with reduced risk because of infusion of the preservative benzyl alcohol Instillation is either intradermal or subcutaneous forming a wheal just below or to the side of the vein IV Insertion o Verify the written prescription for IVT, check prepared IVF and other equipments necessary o Explain procedure to reassure the patient and significant others o Observe the 10 Rights of Medication administration o Perform hand hygiene o Apply Tourniquet 6-8 in above injection site o Check for radial pulse below tourniquet o Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow to dry for 30 seconds to dry (no touch technique) o Use the appropriate IV cannula and pierce the skin with the correct technique o Upon visualization of flashback, continue inserting the catheter into the vein o Position the IV catheter parallel to the skin. Hold the stylet stationary and slowly advance the catheter until the hub is 1mm to the puncture site o Slip a sterile gauze under the hub. Release the tourniquet, remove the stylet while applying digital pressure over the catheter with one finger about 1-2 inch from the tip of the inserted catheter o Connect the infusion tubing of the prepared IV fluid antiseptically to the IV catheter Note: When steel-winged needle is used Connect the IV tubing to the steel winged needle connector and prime the needle with IV fluid Using the steel winged Needle pierce the skin, with the needle bevel up, positions on a 5-10 degree angle Parallel to the skin , enter the vein o Open clamp and regulate the flow rate and then reassure the patient o Anchor needle firmly in place with the use of: o

Transparent tape/dressing Tape o Secure the catheter Methods: Chevron method U method H method o Label with writing the following Date and Time Type of IV catheter o Tape a small loop of IV tubing for additional infusion according to prescribed duration o Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration o Label on IV tape near the IV site to indicate the Date of insertion, type and gauge o Observe patient for any unusual effects o Document the procedure and endorse Maintaining peripheral IV Therapy o Changing the dressing Should be inspected and palpated regularly; tegaderm is advised o Changing the IV solution o Changing the administration set o Changing the IV site

PARENTERAL NUTRITION
Is a means of providing protein, carbohydrates, fats, vitamins, and minerals to those who are unable to assimilate nutrients provided via the gastrointestinal tract. Parenteral nutrition is safe and effective when delivered according to strict protocols by nutritional support team or other trained person. A Parenteral Nutrition solution also known as hyperalimentation or I.V. hyperalimentation o May contain two or more of the following elements: Carbohydrates - source of energy in your diet. The main energy source in the TPN is dextrose (sugar), which is a carbohydrate. Proteins - Amino acids are the source of protein in TPN. They are vital for growth, the building of new tissue and the repair of injured tissue. Protein is needed for your body to make healthy bones, muscle, skin, nails and hair. Lipids - source of energy in your diet that provides you with essential fatty acids. Fat acts to support and protect some of your organs and insulates your body against heat loss. Electrolytes - important for bone, nerve, organ and muscle function. The electrolytes in your TPN solution are calcium, phosphorus, magnesium, sodium, potassium, chloride and acetate. Vitamins and Minerals - TPN contains the suggested daily amounts of vitamins A, B, C, D, E and K. You will also receive trace minerals, which, like vitamins, are needed by the body. These minerals include zinc, copper and selenium. Trace elements Water - Water is a vital part of TPN. Your solution will be adjusted to meet your specific needs so you do not become dehydrated. Parenteral solutions can provide all necessary nutrients when a patient is unable to absorb nutrients through the GI tract. It enables the cells to function despite the patients inability to take in or metabolize foods. Like all invasive procedures, parenteral nutrition incurs certain risks, including: o Catheter infection o Hyperglycemia o Hypokalemia Complications of parenteral nutrition can be minimized with careful monitoring of the catheter site, infusion rate, and laboratory tests results. Another disadvantage of parenteral nutrition is the need for central venous access, which is used because the high dextrose concentration of parenteral nutrition solutions can cause vein sclerosis. Types of Parenteral Nutrition o Total Parenteral Nutrition-It is given when a patient requires an extended period of intensive nutritional support. TPN solutions contain high concentrations of proteins and dextrose. Various components like electrolytes, minerals, trace elements, and insulin are added based on the needs of the patient. Total parenteral nutrition provides the calories a patient requires and keeps the body from using protein for energy. It is usually administered through a central venous catheter. TPN is given using an infusion pump TPN is usually initiated at slow rate of 25 to 50cc per hour and advanced at 12 to 24 hour intervals as metabolic status allows, till the required volume and calories are reached. Indications for Total Parenteral Nutrition Long term therapy (2weeks or more)

Supply large quantities of nutrients and calories (2,000 to 3,000 calories/day or more) Debiliating illness lasting longer than 2 weeks. Inability to sustain adequate weight with oral or enteral feedings. Deficient or absent oral intake for longer than 7 days, as in cases of multiple trauma, severe burns, or anorexia nervosa. Loss of at least 10% of pre illness weight. Serum albumin level below 3.5g/dl. Chronic vomiting or diarrhea. GI disorders that prevent or severely reduce absorption, such as bowel obstruction, Chrons disease, ulcerative colitis, short-bowel syndrome, cancer malabsorption syndrome, and bowel fistulas. Poor tolerance of long-term enteral feedings. Inflammatory GI Disorders, such as wound infection, fistulas, or abscesses. o Peripheral Parenteral Nutrition Normally prescribed for patients who can tolerate some oral feedings but cannot ingest adequate amounts of food to meet their nutritional needs. It is usually administered through a peripheral intravenous catheter. Two types of solutions are commonly used in a number of combinations for PPN: lipid emulsions amino acid-dextrose solutions Indication for Peripheral Parenteral Nutrition Patients who dont need to gain weight, yet need nutritional support, may receive PPN for as long as 3 weeks. Short term therapy (3 weeks or less) is used to maintain nutritional state in patients who can tolerate relatively high fluid volume, who usually resume bowel function and oral feedings in a few days, and who arent candidates for CV catheters. Its used to help a patient meet minimal calorie and protein requirements approximately 1,300 to 1,800 calories/day. Methods of Administration o Central Venous Infusion If a patient needs long-term parenteral nutrition, he usually requires total parenteral nutrition (TPN). TPN with a final dextrose concentration of 10% or higher must be delivered through a CV line, usually placed in the subclavian vein, with the tip of the catheter in the superior vena cava. o Peripheral Infusion Peripheral parenteral nutrition (PPN) also called partial parenteral nutrition is the delivery of nutrients through a short catheter inserted into a peripheral vein. Generally, PPN provides fewer nonprotein calories than TPN because lower dextrose concentrations are used. A much larger volume of fluid must be infused for PPN to deliver the same number of calories as TPN. Therefore, most patients who require parenteral nutrition therapy receive TPN, and PPN is reserved for short-term therapy (1-3 weeks). Administering Parenteral Nutrition o Continuously With continuous delivery, the patient receives the infusion over a 24-hour period. The infusion begins at a slow rate and increases to the optimal rate as ordered. This type of delivery may prevent complications such as hyperglycemia cause by a high dextrose load.

Cyclically A patient undergoing cyclic therapy receives the entire 24-hour volume of parenteral nutrition solution over a shorter period, perhaps 8,10,12,14, or 16 hours. This type of therapy may be used to wean the patient from TPN. Nursing Responsibilities for Clients undergoing Parenteral Nutrition o Verify doctors orders. o Explain the procedure. Make sure that the patient understands what to expect before, during and after the therapy. o Obtain consent. o Select the patients largest available vein as the insertion site. Using a large vein enables the blood to adequately dilute the PPN solution, which can help avoid irritation. When using a short term catheter, rotate the site every 48 to 72 hours, or according to the hospitals policy and procedures. o PPN should be at room temperature. o Infusion pumps should always be used. o Check the written order against the written label on the bag. Make sure that the solution is for peripheral infusion and that the volumes, concentrations, and additives are included in the solution. -Also check the infusion rate. o Proper labelling is important. Label the container with the expiration date, time at which the solution was hung, glucose concentration, and total volume of solution. o Begin the PPN infusion as ordered. Watch for swelling at the peripheral insertion site. Swelling may indicate infiltration or extravasations of the PPN solution, which can cause tissue damage. o Maintain the infusion rate and care for the tubing, dressing, infusion rate and I.V. devices o Maintain flow rates as prescribed, even if the flow falls behind the schedule. o Monitor the patient for signs and symptoms of sepsis: Glycosuria chills malaise leukocytosis altered level of consciousness elevated glucose level elevated temperature o Dont allow TPN solutions to hang for more than 24 hours. o Change the tubing and filter every 24 hours, using strict aseptic technique. Make sure that all tubing junctions are secure. o Perform IV site care and dressing changes according to your facilitys policy and protocol. o Check the infusion pumps volume meter and time tape to monitor for irregular flow rate. Gravity should never be used to administer TPN. o Record the patients vital signs when you initiate therapy in every 4 to 8 hours thereafter (or more often, if necessary). Be alert for increased body temperature- one of the earliest signs of catheterrelated sepsis. o Monitor your patients glucose levels. o Accurately record the patients daily fluid intake and output, specifying the volume and type of each fluid. This record is the diagnostic that you can use to assure prompt, precise replacement of fluid and electrolyte deficits. o Assess the patients physical status daily. Weigh him at the same time each morning (avoid voiding), in similar clothing, using the same scale. Suspect fluid imbalance if the patient gains more than 1lb. per day. o Monitor the results of routine laboratory tests, such as serum electrolyte, blood urea nitrogen, and glucose levels, and report abnormal findings to the doctor so appropriate changes in the TPN solution can be made. o Provide emotional support. Keep in mind that patients commonly associate eating with positive feelings and become disturbed when its eliminated. o Provide frequent mouth care for the patient. o Document all assessment findings and nursing interventions. Discontinuing Therapy

One major difference exists between the procedures for discontinuing TPN and PPN therapy. A patient receiving TPN should be weaned from therapy and should receive some other form of nutritional therapy such as enteral feedings. When to wean and when not to wean When the patient is receiving PPN, therapy can be discontinued without weaning because the dextrose concentration is lower than the TPN. When discontinuing TPN therapy, you should wean the patient over 24 hours to prevent rebound hypoglycemia. Handling Parenteral Nutrition Hazards o Patients receiving parenteral nutrition therapy face many of the same complications as patients undergoing any type of peripheral I.V. o Complications of any parenteral nutrition therapy may result from problems that are: Catheter Related Clotting o Suspect a clotted catheter if the infusion flow rate is interrupted. o You may also notice a greater pressure is needed to maintain the infusion at the desired infusion rate. Dislodgement o When catheter comes out of the vein, catheter dislodgement may be obvious. o You may note that the dressing is wet. o The patient may report feeling cold or his gown is wet. o When the catheter is located peripherally, the area around the insertion site may be red or swollen from subcutaneous extravasations of the PPN solution. o With a centrally inserted catheter, there may be swelling and redness around the insertion site. o The most significant complications include bleeding from the insertion site or an air embolism. Cracked or Broken tubing o If the catheter or vascular access device is damaged, infusate may leak from a cracked area or the insertion site. o If the infusion tubing is damaged, the I.V. insertion site remains dry. o Both situations require immediate attention because of the risks of bleeding, contaminations or air emboli. Pneumothorax o Air in the pleural cavity usually results from trauma to the pleura during insertion of a CV access device. o The patient may have dyspnea and chest pain; he may also develop a cough. Auscultation reveals diminished breath sound, and the patient may be sweating and appear cyanotic. o Assessment may also reveal unilateral chest movement. o Pneumothorax should be confirmed by X-ray for the best treatment results. Sepsis o Sepsis can be fatal. o You can prevent it by providing meticulous, consistent catheter care. o If the patient is developing catheter-related sepsis, hell develop an unexplained fever, chills and a red, indurated area around the catheter site. o The patient may also have unexplained hyperglycemia, commonly an early warning sign of sepsis. Metabolic

o o

Hyperglycemia / Hypoglycemia o The patient may develop hyperglycemia if the formulas glucose concentration is excessive, the infusion rate is too rapid, or his glucose tolerance is compromised by diabetes, stress, or sepsis. Signs and symptoms of hyperglycemia include fatigue, restlessness, and weakness. o The patient may become anxious, confused and in some cases, delirious or even comatose. o Hell be dehydrated and have polyuria and elevated blood and urine glucose level. o Conversely, the patient may develop hypoglycemia if parenteral nutrition is interrupted suddenly or if he receives excessive insulin. o Signs and symptoms may include sweating, shaking, confusion, and irritability. Metabolic Acidosis (Hyperosmolar Hyperglycemia Nonketotic Syndrome) o An acute complication of hyperglycemia crisis, HHNS is caused by hyperosmolar diuresis resulting from untreated hyperglycemia. o A patient with HNSS has a high serum osmolarity, is dehydrated, and has extremely high glucose levels-as high as 4,800 mg/dl. o If untreated, he can develop glycosuria and electrolyte disturbances and even become comatose. o Suspect HNSS if your patient becomes confused or lethargic or experiences seizures. Refeeding Syndrome o Describes a systemic response that occurs when nutrients and fluids are administered too suddenly to a patient who has been severely malnourished for a long time. o The rapid introduction of electrolytes, vitamins, and macronutrients causes rapid and severe disruption in fluid and electrolyte balance, resulting in heart failure, generalized edema and acute renal failure. o This may be treated by administering diuretic agents and by adjusting the rate and composition of the Parenteral Nutrition solution. Mechanical o Air Embolism Suspect an air embolism if the patient develops apprehension, chest pain, tachycardia, hypotension, cyanosis, seizures, loss of consciousness, or cardiac arrest. Auscultation may also reveal the classic sign of an air embolism: a churning heart murmur. o Venous Thrombosis Suspect thrombosis when you see swelling at the catheter insertion site or swelling of the hand, arm, neck, or face on the same side as the catheter. Other signs and symptoms include pain at the insertion site and along he vein, malaise, fever, and tachycardia. o Too rapid an infusion If TPN is infused too rapidly, the patient may feel nauseated, have a headache, and become lethargic. ; Heart failure is also a risk because of fluid overload. o Extravasation

If you observe swelling of the tissue around the insertion site, it may indicate extravasation. The patient may also complain of pain at the insertion site. Phlebitis Pain, tenderness, redness, and warmth at the insertion site and along the vein path may indicate phlebitis.

Patient/Family Education o Assess patient and familys level of understanding. o Inform the patient and family everything about all that they need to know regarding parenteral nutrition in a manner that they comprehend. o Secure inform consent about the procedure if the patients needs to have a central line for total parenteral nutrition. o Inform patient regarding the proper regulation of the parenteral nutrition. o Inform the patient to report any unusual feelings such as chest pain, tachycardia, pain at the insertion site and the likes that may indicate air embolism. o Inform the patient regarding the importance of blood sugar monitoring while on parenteral nutrition. o Inform the patient signs and symptoms of hyper and hypoglycemia and report it if ever experienced. Documentation o All pertinent Vital Signs of the client should always be recorded before, during and after the therapy. o Started parenteral nutrition should be reflected on the Infusion Sheet. o Clients Blood Sugar should also be documented. o Total volume of parenteral nutrition infused should be documented at the Intake and Output Sheet.

BLOOD TRANSFUSION THERAPY

Blood o Having a volume of 8% of the total body weight (varies by age and body composition) CATEGORY mL / kg Blood Volume Adult Male 70 mL / kg 90 kg = 6300 mL Adult Female 70 mL / kg 60 kg = 4300 mL Child 80 mL / kg 30 kg = 2400 mL Neonate 85 90 mL 3 kg = 255 / kg 270 mL o Composition of Blood Temperature 38C (100.4F) pH 7.35 - 7.45 Specific Gravity 1.048 1.066 Body weight 7% 5 times the viscosity of water Volume: Male 5 6 Liters Female 4 5 Liters Portions of the Blood Composed of: o 55% plasma o 45% cellular components (formed elements of the blood) o Plasma: Liquid part of the blood It is consists of serum and fibrinogen It also contains plasma proteins such as: Albumin Serum globulins Fibrinogen,prothrombin, plasminogen o Cellular Components: RBC = responsible for oxygen transport WBC = play a major role in defence against microorganisms Platelets = function in homeostasis Cross Matching Blood Collection Methods o 3 Types of Blood Donor Sources for Routine Blood Collection:

Unrelated Donor (Allogeneic) Directed Donor Autologous Donor (Self) Understanding Transfusion Therapy o Eligible for blood donation Eligible Donors Must: Be at least age 17 Weigh at least 110 lb (50 kg) Be free from skin disease Not have donated in the past 56 days Have a hemoglobin level of at least 12.5 g/dl (women) or 13.5 g/dl (men) o Ineligible Donors Who have Human Immunodeficiency Virus or Acquired Immunodeficiency Syndrome Who have taken illegal drugs I.V. Who have had sex with prostitutes in the past 12 months Who have had sex with anyone above categories Who have had hepatitis With certain types of cancer (other than minor skin cancer) With hemophilia Who have received clotting factor concentrations Nurses Responsibility: Monitoring And Documenting o Transfusion the Nurses Responsibility Nurses must be knowledgeable about blood products, their safe administration, and how to monitor patients during and after transfusion therapy. The safety of your patient also depends on your adherence to the rules governing transfusion. Assure that informed consent has been obtained before starting a transfusion. Appropriate information to include in patient education includes the benefits, risks and alternatives to transfusion. Letting your patient know that transfusion is generally a safe and simple procedure is important and can help reassure a frightened patient, too. At the same time, patients should be told that reactions to blood components can occur. Document all patient education regarding transfusion therapy, and the responses of patients and family members after teaching. When assessing your patient before a transfusion, you should obtain important medical history information, review pertinent lab values, and perform a physical assessment. Find out whether your patient has ever been transfused and if so, if he or she experienced any adverse reactions. Review the laboratory studies that prompted the transfusion order to double-check why the physician has ordered the transfusion. Reviewing the physician order, including any special processing requested, provides an opportunity to be sure the blood component was properly ordered and dispensed. A baseline physical assessment should include vital signs and assessment for skin rashes, shortness of breath, wheezing, pain, chills, itching or nausea. In patients with cardiopulmonary disease, listen to the lungs to establish a baseline for the presence of any rales (crackles). When you receive the delivery from the blood bank, you should receive both the product and the transfusion record that corresponds to it. Once you have them, inspect for the following: o Labels Look for the expiration date, ABO/Rh label, unit number, component label, and any special processes (i.e. irradiation or leukocyte depletion) o Integrity of Unit

Press lightly on the unit and invert it to assure that all bag segments and seams are free of leaks and port covers are in place Appearance Look for uniformity of color between bag segments and the main part of the bag: RBCs should not be appreciably darker than the bag segments and the remaining plasma should not be murky, purple/blue, brown, or reddish Platelets should be clear to yellow/straw to light strawberry color, without obvious aggregates Thawed FFP should be clear with the color varying from yellow straw to light green to orange. If there are any abnormalities in appearance, they should be reported and the unit returned to the blood bank for replacement.

Before Transfusion: o Prior to starting the transfusion, perform the following verification process to ensure the correct blood is being given to the correct patient. Remember, most transfusion reactions occur because of errors in patient or component identification. o Recheck the physicians order to verify you have received the component ordered and any special processing that was ordered was completed. Note if the patient should be receiving autologous blood or directed donations. If such units are available, they should be administered first. o Three qualified individuals should verify the patient and unit identification: Compare the patient name and hospital/ID number on the patient identification band with the patient name and hospital/ID number on the transfusion report. Compare the unit number listed on the transfusion report with the unit number on the bag. Compare the patients blood type recorded on the transfusion report with the unit type recorded on the transfusion report to ensure they are compatible. If the patient is able, have him or her state his/her full name and compare it to the name on the transfusion report. (Do not state the patients name in a question which can be answered "yes" or "no".) The three people verifying the patient/unit identification should sign the transfusion report. o Document the date and time the transfusion is started. o Keep the Unit Record (or some piece of identification linking the patient and unit) attached to the unit until the transfusion is complete. o Once unit and patient identification are confirmed, assess the patency of the patients vascular access, and spike and prime the transfusion as described. o Obtain the patients temperature, pulse, respiration, and blood pressure and record. Recheck vital signs 15 minutes after starting the transfusion and as appropriate based on the patients condition, until the transfusion is complete. Record a final set of vital signs at the completion of the transfusion. During Transfusion: o Administer the blood or component at the recommended rate, based on the patients condition. Stay with the patient for the first few minutes of the transfusion (for about the first 25 ml.), and review signs and symptoms of what the patient should report to you. o If the patient experiences any symptoms of a reaction to the transfusion discontinue it immediately and call for assistance. After Transfusion: o Finally, document the transfusion in the patients chart. The Chart Record portion of the Transfusion Report should be placed in the patient chart as a permanent record. o Continue to monitor your patient for any signs and symptoms of reaction for at least one hour after the transfusion. Obtain any ordered post-transfusion laboratory studies. Comparing Cellular Products o Whole Blood

Complete (Pure) blood Volume: 500 ml Indications: To restore blood volume in hemorrhaging, trauma, or burn patients the rule of thumb is that each unit of whole blood infused should increase the hemoglobin by 1mg/dL and hemotocrit by 3 percent Nursing Considerations: Cross matching is ABO identical: Use a straight line or Y type I.V. set; can infuse rapidly in emergencies, but adjust the rate to the patients condition and the transfusion order, and dont infuse over more than 4 hours. Whole blood is used frequently in emergency treatment, but is seldom administered in nonemergent situations because its components can be extracted and administered separately. Avoid giving whole blood when the patient cant tolerate the circulating volume.

Packed Red Blood Cells Same red blood cells (RBC) mass a whole blood with 80% of the plasma removed Volume: 250 ml Indications: To restore or maintain oxygen carrying capacity To correct anemia and surgical blood loss To increase RBC mass Nursing Considerations: Cross matching: o Group A receives A or O o Group B receives B or O o Group AB receives AB, A, B, O o Group O receives O o Rh type must match Use a straight line or Y type I.V. set; can infuse rapidly in emergencies, but adjust the rate to the patients condition and the transfusion order, and dont infuse over more than 4 hours. RBCs have the same oxygen carrying capacity as whole blood, minimizing the hazard of volume overload. Using packed RBCs avoids the potassium and ammonia buildup that sometimes occurs in the plasma of stored blood. o Note: Packed RBCs shouldnt be used for anemic conditions correctable by nutrition or drug therapy. White Blood Cells (Leukocytes) Whole blood with all the red blood cells and 80% of the plasma removed Volume: Usually 150 ml Indications: To treat a patient with life threatening granulocytopenia (granulocyte count usually less than 500 / ml) who isnt responding to antibiotics (especially if he has positive blood cultures or a persistent fever greater than 101 F (38.3 C) Nursing Considerations: Cross matching: o Group A receives A or O o Group B receives B or O o Group AB receives AB, A, B, O o Group O receives O o Rh type must match Use a straight line I.V. set with a standard in line blood filter. Dosage is 1 unit daily for 5 days or until the infection clears.

Note: WBC infusion may induce fever and chills. To prevent this reaction, premedicate the patient with antihistamines, acetaminophen, steroids, or meperidine hydrochloride. Administer an antipyretic if fever occurs but dont discontinue the transfusion. The flow rate may be reduced for the patients comfort. Because reactions are common, administer slowly over 2 to 4 hours. Check the patients vital signs and assess him every 15 minutes thr oughout the transfusion. Give the transfusion in conjunction with antibiotics to treat infection. Agitate the container to prevent WBCs from settling, thus preventing delivery of a bolus dose of WBCs.

Platelets Platelet sediment from red blood cells or plasma Volume: 35 to 50 ml / U; 1 unit of platelets = 7 X 10 7 platelets Indications: To treat thrombocytopenia caused by decreased platelet production, increased platelet destruction, or massive transfusion of stored blood To treat acute leukemia and marrow aplasia To restore platelet count in a preoperative patient with a count of 100,000 / ml or less Nursing Considerations: Cross matching: ABO compatibility isnt necessary but is preferable with repeated platelet transfusions; Rh type match is preferred. Use a blood component drip administration set Infuse 100 ml over 15 minutes. Administer at 150 to 200 ml / hour, or as rapidly as the patient can tolerate; dont exceed 4 hours. Platelet transfusions arent usually indicated for conditions of accelerated platelet destruction, such as idiopathic thrombocytopenic purpura or drug induced thrombocytopenia. Patients with a history of platelet reaction require premedication with antipyretics and antihistamines. Avoid administering platelets when the patient has a fever. A blood platelet count may be ordered 1 hour after platelet transfusion to determine platelet transfusion increments. o Fresh Frozen Plasma Uncoagulated plasma separated from red blood cells; rich in coagulation factors V, VIII, IX Volume: 200 to 250 ml Indications: To expand plasma volume To treat postsurgical hemorrhage or shock To correct an undetermined coagulation factor deficiency To replace a specific factor when that factor alone isnt available To correct factor deficiencies resulting from hepatic disease Nursing Considerations: Cross matching: ABO compatibility isnt necessary but is preferable with repeated plasma transfusions; Rh type match is preferred. Use a straight line I.V. set and administer fresh frozen plasma (FFP) as rapidly as tolerated. Large volume transfusions of FFP may require correction for hypocalcemia. Citric acid in FFP binds calcium. Types of Acute Transfusion Reactions: o Acute Hemolytic Reaction occurs when a patient is transfused with the wrong blood type. Clinical manifestations tend to occur very quickly, within 5-15 minutes after the transfusion commences. These include the following: chills

fever low back pain tachypnea tachycardia hypotension pain and flushing at the infusion rate Febrile Nonhemolytic (FNH) Reaction occur when the recipients plasma cells form antibodies to Human Leukocyte Antigens(donor antigen that can cause recipient alloimmunization) found on transfused leukocytes or platelets. The likelihood that these reactions will occur increases with lengthier transfusion times and with repeated BT. Therefore, guidelines for transfusing whole blood or PRBCs specify that each unit infuse within 4 hours to decrease likelihood that FNH reactions may occur. Patients with a prior history of an FNH reaction or who are at increased risk of FNH reaction because they have had a multiple transfusions may be candidates for prophylactic transfusions or leukocyte-reduced PRBCs. Antipyretic such as Acetaminophen is administered immediately prior to commencement of the transfusion. Clinical Manifestations: o Chills o Fever o Headache o Myalgias o Nausea o Chest Pain Transfusion-Related Acute Lung Injury (TRALI) The pathophysiologic mechanism responsible for TRALI is similar to that found in FNH reactions in that the recipients immune system forms antibodies to allogeneically donated leukocytes. The response in TRALI tends to cause acute respiratory failure followed by a type of acute respiratory distress syndrome. These patients tend to respond well to early recognition, aggressive management of acute respiratory failure, and IV administration of corticosteroids. Allergic Reactions most allergic reactions to allogeneically transfused blood are mild and occur as a result of immunoglobulin E (IgE)- regulated sensitivity to the donated bloods plasma proteins. This type of reaction typically is delayed and occurs either toward the end of the transfusion or within a couple of hours after the transfusion is completed. Clinical manifestations include: flushing, urticaria, itching, particularly of the palms of the hands and soles of the feet. Patients with known prior histories of urticarial allergic reactions to BT may benefit from administration of Diphenhydramine (Benadryl) immediately prior to commencement of subsequent transfusions to mitigate allergic reactions infrequently, allergic reactions to allogeinically transfused blood can be IgE-mediated and thus exhibit as an anaphylactic type of reaction. This type of reaction typically occurs early during the first few minutes of the transfusion, and the patient rapidly deteriorates into anaphylactic shock unless rapid interventions are taken. Clinical Manifestations include the same signs and symptoms that are consistent with an allergic reaction plus the following: wheezing with respiratory distress, followed by the stridor and laryngospasm, nausea, abdominal pains, severe cramping tachycardia hypotension with narrowed pulse pressure Circulatory Overload patients with history of heart failure or those at risk of heart failure may not be able to handle rapid IV infusion of blood components and may exhibit clinical manifestations of acute heart failure or circulatory overload.

Clinical Manifestations: Angina dyspnea tachypnea tachycardia hypotension coughing crackles hemoptysis oliguria administer blood components slowly split packs of PRBCs so that the patients heart failure do not receive entire units of blood products within 4-hour time limits Administer prophylactic IV loop diuretics as ordered-diminish myocardial workload and the likelihood of circulatory overload o Bacteremia and Sepsis Contamination of the transfused blood component with pathogens, most commonly bacteria, can cause blood-borne bacterial infections (i.e. bacteremia) and systemic infection (i.e. sepsis) This can be prevented through administering the blood components within the specified time limits, by maintaining the sterililty of the IV administration setup with Luer-lock connections and by changing IV blood component unit. Clinical Manifestations: Fever and chills to manifestations that are consistent with septic shock What To Do When Transfusion Reaction Occurs o Ensure that the intended recipient is getting the intended unit at the time of transfusion. o Should any of these symptoms occur, discontinue the unit immediately, hang normal saline (on a new tubing) to maintain vascular access, and call for assistance. o Closely monitor the patients vital signs and symptoms. o Notify the physician and obtain further orders to address the patients symptoms. o Recheck the patients identifying information against the transfusion record and blood bag. o All bags, tubings, filters, and paperwork should be retained and forwarded per hospital policy. Documenting Blood Transfusions o Date and time the transfusion was started and completed o Name of the health care professional who verified the information of the patient and the blood o Catheter type and gauge o Total amount of the transfusion o Patients vital signs before and after the transfusion o Infusion device used o Flow rate and if blood warming was used o Vital signs obtain prior to, during, and after the transfusion o Name of the component, unit number o Evidence of possible transfusion reaction. o Document interventions done and to whom you notified. o Patients outcome.