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Information

  1. INFUSION SYSTEMS
    1. Plastic bag:
      1. Contains no vacuum—needs no air to replace fluid as it flows from container.
      2. Medication can be added with syringe through a resealable latex port.
        1. During infusion, administration set should be completely clamped before medications are added.
        2. Prevents undiluted, and perhaps toxic, dose from entering administration set.
    2. Closed system:
      1. Requires partial vacuum—however, only filtered air enters container.
      2. Medication may be added during infusion through air vent in administration set.
    3. Administration sets:
      1. Standard sets—deliver 10 to 15 drops (gtt)/mL.
      2. Pediatric or minidrop sets—deliver 60 drops (gtt)/mL.
      3. Controlled-volume sets—permit accurate infusion of measured volumes of fluids.
        1. Particularly valuable when piggybacked into primary infusion.
        2. Solutions containing drugs can then be administered intermittently.
      4. Y-type administration sets—allow for simultaneous or alternate infusion of two fluids.
        1. May contain filter and pressure unit for blood transfusions.
        2. Air embolism significant hazard with this type of administration set.
      5. Positive-pressure sets—designed for rapid infusion of replacement fluids.
        1. In emergency, built-in pressure chamber increases rate of blood administration.
        2. Pump chamber must be filled at all times to avoid air embolism.
        3. Application of positive pressure to infusion fluids is responsibility of physician.
      6. Infusion pumps—used to deliver small volumes of fluid or doses of high-potency drugs.
        1. Used primarily in neonatal, pediatric, and adult intensive care units.
        2. Have increased the safety of parenteral therapy and reduced nursing time.
    4. Long-term delivery systems—centrally placed venous access catheters and ports for the administration of drugs (e.g., chemotherapy), blood and blood products, antibiotics, analgesics, antiemetics, and total parenteral nutrition (TPN). Types: Hickman/Broviac, Groshong, venous access port (VAP).
      1. Inserted under strict aseptic conditions using local or general anesthesia.
      2. Major concern: prevention of infection.
  2. FLUID ADMINISTRATION
    1. Factors influencing rate:
      1. Client's size.
      2. Client's physical condition.
      3. Age of client.
      4. Type of fluid.
      5. Client's tolerance to fluid.
      6. Client's position.
    2. Flow rates for parenteral infusions can be computed using the following formula:
      gtt/mL of given set/60 min/hr × total volume/hr = gtt/min
      Example: if 1,000 mL is to be infused in an 8-hr period (125 mL/hr) and the administration set delivers 15 gtt/mL, the rate is 31.2 gtt/min:
      15/60 × 125 = 1/4 × 125 = 31.2 gtt/min
    3. Generally the type of fluid administration set determines its rate of flow.
      1. Fluid administration sets—approximately 15 gtt/min.
      2. Blood administration sets—approximately 10 gtt/min.
      3. Pediatric administration sets—approximately 60 gtt/min.
      4. Always check information on the administration set box to determine the number of gtt/mL before calculating; varies with manufacturer.
    4. Factors influencing flow rates:
      1. Gravity—a change in the height of the infusion bottle will increase or decrease the rate of flow; for example, raising the bottle higher will increase the rate of flow, and vice versa.
      2. Blood clot in needle—stopping the infusion for any reason or an increase in venous pressure may result in partial or total obstruction of needle by clot due to:
        1. Delay in changing infusion bottle.
        2. Blood pressure cuff on, or restraints on or above infusion needle.
        3. Client lying on arm in which infusion is being made.
      3. Change in needle position—against or away from vein wall.
      4. Venous spasm—due to cold blood or irritating solution.
      5. Plugged vent—causes infusion to stop.
  3. FLUID AND ELECTROLYTE THERAPY
    1. Types of therapy:
      1. Maintenance therapy—provides water, electrolytes, glucose, vitamins, and in some instances protein to meet daily requirements.
      2. Restoration of deficits—in addition to maintenance therapy, fluid and electrolytes are added to replace previous losses.
      3. Replacement therapy—infusions to replace current losses in fluid and electrolytes.
    2. Types of intravenous fluids (Table 8.1. Commonly Used Intravenous Fluids):
      1. Isotonic solutions—fluids that approximate the osmolarity (280 to 300 mOsm/L) of normal blood plasma.
        1. Sodium chloride (0.9%)—normal saline.
          1. Indications:
            1. Extracellular fluid replacement when Cl– loss is equal to or greater than Na+ loss.
            2. Treatment of metabolic alkalosis.
            3. Na+ depletion.
            4. Initiating and terminating blood transfusions.
          2. Possible side effects:
            1. Hypernatremia.
            2. Acidosis.
            3. Hypokalemia.
            4. Circulatory overload.
        2. Five percent dextrose in water (D5W).
          1. Provides calories for energy, sparing body protein and preventing ketosis resulting from fat breakdown.
            1. 3.75 calories are provided per gram of glucose.
            2. United States Pharmacopeia (USP) standards require use of monohydrated glucose, so only 91% is actually glucose.
            3. D5W yields 170.6 calories; D5W means 5 grams glucose/100 mL water.
              50 × 3.75 = 187.5 calories/L
              0.91 × 187.5 = 170.6 calories/L
          2. Indications:
            1. Dehydration.
            2. Hypernatremia.
            3. Drug administration.
          3. Possible side effects:
            1. Hypokalemia.
            2. Osmotic diuresis—dehydration.
            3. Transient hyperinsulinism.
            4. Water intoxication.
        3. Five percent dextrose in normal saline (D5NS).
          1. Prevents ketone formation and loss of potassium and intracellular water.
          2. Indications:
            1. Hypovolemic shock—temporary measure.
            2. Burns.
            3. Acute adrenocortical insufficiency.
        4. Same side effects as normal saline.
        5. Isotonic multiple-electrolyte fluids—used for replacement therapy; ionic composition approximates blood plasma.
          1. Types—Plasmanate, Polysol, and lactated Ringer's.
          2. Indicated in: vomiting, diarrhea, excessive diuresis, and burns.
          3. Possible side effect—circulatory overload.
          4. Lactated Ringer's is contraindicated in severe metabolic acidosis and/or alkalosis and liver disease.
          5. Same side effects as normal saline.
      2. Hypertonic solutions—fluids with an osmolarity much higher than 310 mOsm (+50 mOsm); increase osmotic pressure of blood plasma, thereby drawing fluid from the cells.
        1. Ten percent dextrose in normal saline (D10NS).
          1. Administered in large vein to dilute and prevent venous trauma.
          2. Used for: nutrition and to replenish Na+ and Cl–.
          3. Possible side effects:
            1. Hypernatremia (excessNa+).
            2. Acidosis (excess Cl–).
            3. Circulatory overload.
        2. Sodium chloride solutions, 3% and 5%.
          1. Slow administration essential to prevent overload (100 mL/hr).
          2. Indicated in water intoxication and severe sodium depletion.
      3. Hypotonic solutions—fluids whose osmolarity is significantly less than that of blood plasma (–50 mOsm); these fluids lower plasma osmotic pressures, causing fluid to enter cells.
        1. 0.45% sodium chloride—used for replacement when requirement for Na+ use is questionable.
        2. 2.5% dextrose (D) in 0.45% saline, also 5% D in 0.2% NaCl—common rehydrating solution.
          1. Indications:
            1. Fluid replacement when some Na+ replacement is also necessary.
            2. Encourage diuresis in clients who are dehydrated.
            3. Evaluate kidney status before instituting electrolyte infusions.
          2. Possible side effects:
            1. Hypernatremia.
            2. Circulatory overload.
            3. Use with caution in clients who are edematous with cardiac, renal, or hepatic disease.
            4. After adequate renal function is established, appropriate electrolytes should be given to avoid hypokalemia.
      4. Alkalizing agents—fluids used in the treatment of metabolic acidosis:
        1. Ringer's:
          1. Administration—rate usually not more than 300 mL/hr.
          2. Side effects—observe carefully for signs of alkalosis.
        2. Sodium bicarbonate:
          1. Indications:
            1. Replace excessive loss of bicarbonate ion.
            2. Emergency treatment of life-threatening acidosis.
          2. Administration:
            1. Depends on client's weight, condition, and carbon dioxide level.
            2. Usual dose is 500 mL of a 1.5% solution (89 mEq).
          3. Side effects:
            1. Alkalosis.
            2. Hypocalcemic tetany.
            3. Rapid infusion may induce cellular acidity and death.
      5. Acidifying solutions—fluids used in treatment of metabolic alkalosis.
        1. Types:
          1. Normal saline (see B.1.Isotonic solutions, Physiological Integrity).
          2. Ammonium chloride.
        2. Administration—dosage depends on client's condition and serum laboratory values.
        3. Side effects:
          1. Hepatic encephalopathy in presence of decreased liver function because ammonia is metabolized by liver.
          2. Toxic effects: irregular respirations, twitching, and bradycardia.
          3. Contraindicated with renal failure.
      6. Blood and blood products (Table 8.2. Transfusion with Blood or Blood Products).
        1. Indications:
          1. Maintenance of blood volume.
          2. Supply red blood cells to maintain oxygen-carrying capacity.
          3. Supply clotting factors to maintain coagulation properties.
          4. Exchange transfusion.
  4. INTRAVENOUS CANCER CHEMOTHERAPY
    1. Usual sites: forearm, dorsum of hand, wrist, antecubital fossa.
    2. Procedure:
      1. Normal saline infusion usually started first, to verify vein patency, position of needle. Chemotherapy "piggybacked" into IV line that is running.
      2. Rate: usually 1 mL/min. Running slowly decreases nausea, vomiting, and the degree of vein damage.
      3. Check vein patency every 3 to 5 minutes.
      4. If more than one drug is to be infused, normal saline should be infused between drugs.
      5. Never infuse against resistance.
      6. Stop treatment if client reports pain at needle site. Extravasation (infiltration of toxic drugs into tissue surrounding vessel) may be present
      7. If extravasation present, begin protocol appropriate to drug administered (e.g., flushing of line with saline, applying ice or heat, local injection of site with antidote drugs, topical application of steroid creams).
      8. Once treatment is completed, remove needle, apply Band-Aid, exert pressure to prevent hematoma formation.
  5. COMPLICATIONS OF IV THERAPY (Table 8.3. Complications of IV Therapy).
  6. TOTAL PARENTERAL NUTRITION (TPN): nutrition through a central venous line to clients who are in a catabolic state; are malnourished and cannot tolerate food by mouth or enteral nutrition; are in negative nitrogen balance; or have conditions that interfere with protein ingestion, digestion, and absorption (e.g., Crohn's disease, major burns, and side effects of radiation therapy of abdomen). Least desirable route for nutrition.
    1. Types of solutions:
      1. Hydrolyzed proteins (Hyprotein, Amigen).
      2. Synthetic amino acids (Freamine).
      3. Usual components:
        1. 3% to 8% amino acid.
        2. 10% to 25% glucose.
        3. Multivitamins.
        4. Electrolytes.
      4. Supplements that can be added:
        1. Fructose.
        2. Alcohol.
        3. Minerals: iron, copper, calcium.
        4. Trace elements: iodine, zinc, magnesium.
        5. Vitamins: A, B, C.
        6. Androgen hormone therapy.
        7. Insulin.
        8. Heparin.
        9. Fats (lipid or fat emulsions) with prolonged use. Lipid emulsions are contraindicated if client has allergy to eggs or is on ↑ lipid-containing medications such as propofol (Diprivan).
    2. Administration:
      1. Dosage varies with clinical condition; 1 to 2 L over 24 hours at a constant IV drip rate. If TPN is discontinued, the rate must be tapered over 4 to 8 hours to avoid fluid, electrolyte abnormalities.
      2. Solution prepared under laminar flow hood (usually in pharmacy); solution must be refrigerated; when refrigerated, expires in 24 hours; once removed from refrigerator, expires in 12 hours.
      3. Incompatible with most medications; check with pharmacy. Give in a dedicated TPN line. Do not inject IV push medications into TPN line.
      4. Route: Must be given via central line catheter—double- or triple-lumen catheter or infusion port of pulmonary artery (PA) catheter inserted by physician into internal jugular or subclavian vein. More commonly given via peripherally inserted central catheter (PICC line), inserted by specially trained IV nurses into brachial or cephalic veins. Placement must be confirmed by x-ray before beginning infusion. Catheter tip in superior vena cava or right atrium.
      5. Management of PICC line:
        1. Always wash hands before handling.
        2. Do not take BP in PICC arm.
        3. No needle sticks near or above PICC. If possible draw blood from opposite arm.
        4. Avoid excessive shoulder use; if sent home with PICC, cautious use of backpacks, playing basketball, shoveling, weight lifting.
        5. Cover PICC arm before bathing/showering.
        6. If dressing becomes wet, soiled, or loose, change as soon as possible.
        7. If catheter breaks, secure with tape and call care provider.
        8. If sudden chest pain, shortness of breath (SOB), or gurgling sensation heard near ear with catheter breakage, clamp or pinch catheter, have client lie on left side with head down. Call physician.
      6. Side effects:
        1. Hyperosmolar coma.
        2. Hyperglycemia greater than 130 mg/dL.
        3. Septicemia.
        4. Thrombosis/sclerosis of vein.
        5. Air embolus.
        6. Pneumothorax.
    3. Analysis/nursing diagnosis:
      1. Fluid volume excess, potential, related to inability to tolerate amount and consistency of solution.
      2. Fluid volume deficit related to state of malnutrition.
      3. Risk for injury related to possible complications.
      4. Altered nutrition, more or less than body requirements, related to ability to tolerate parenteral nutrition.
    4. Nursing care plan/implementation:
      1. Goal: prevent infection.
        1. Dressing change:
          1. Strict aseptic technique.
          2. Nurse and client wear mask during dressing change.
          3. Cleanse skin with solution as ordered:
            1. Acetone to defat the skin, destroy the bacterial wall.
            2. Iodine 1% solution as antiseptic agent.
          4. Dressing changed q48–72h; transparent polyurethane dressings may be changed weekly.
          5. Mark with nurse's initials, date and time of change.
          6. Air-occlusive dressing.
        2. Attach final filter on tubing setup, to prevent air embolism.
        3. Solution: change q24h to prevent infection.
        4. Culture wound and catheter tip if signs of infection appear.
        5. Monitor temperature q4h.
        6. Use lumen line for feeding only (not for CVP or medications).
      2. Goal: prevent fluid and electrolyte imbalance.
        1. Daily weights.
        2. I&O.
        3. Blood glucose q6h for 24 hours using glucometer; may need insulin coverage. If normal range, change to daily.
        4. Monitor Chem 20 electrolytes biweekly initially.
        5. Infusion pump to maintain constant infusion rate.
      3. Goal: prevent complications.
        1. Warm TPN solution to room temperature to prevent chills.
        2. Monitor for signs of complications (Table 8.4. Complications Associated with Total Parenteral Nutrition).
          1. Infiltration.
          2. Thrombophlebitis.
          3. Fever.
          4. Hyperglycemia.
          5. Fluid and electrolyte imbalance.
        3. Have client perform Valsalva maneuver or apply a plastic-coated clamp when changing tubing to prevent air embolism.
        4. Tape tubings together to prevent accidental separation.
    5. Evaluation/outcome criteria:
      1. No signs of infection.
      2. Blood sugar less than 130 mg/dL.
      3. Electrolytes within normal limits.
      4. Wounds begin to heal.
      5. Weight: no further loss, begins to gain.