NU 311 Clinical Nursing Skills Final Exam

Infusion Nursing Society (INS) standards for reducing infection related to IV Therapy

• Assess the VAD catheter-skin junction site and surrounding area for redness, tenderness, swelling, and drainage by visual inspection and palpation through the intact dressing. Assess short-peripheral catheters minimally at least every 4 hours or more if clinically indicated and daily for outpatient or home care patients. CVADs should be assessed at least daily.

• Change the dressing immediately to assess, clean, and disinfect the site in the event of drainage, tenderness, other signs of infection or if dressing becomes loose or dislodged.

• Perform hand hygiene before placing and providing any VAD-associated interventions.

• Perform dressing changes at a frequency based on the type of catheter and dressing. Short-peripheral catheter dressings are changed if the dressing becomes damp, loosened, and/or visibly soiled; if there is blood or drainage under the dressing; and at least every 5-7 days. Change CVAD dressings at least every 5-7 days for TSM dressings and at least every 2 days for gauze dressings that cover a catheter site or are under a TSM.

• Use approved antiseptic agents before venipuncture and when performing skin antisepsis. The preferred skin antiseptic is >0.5% chlorhexidine gluconate (CHG) in alcohol solution. Tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may be used if CHG solution is contraindicated.

• Allow skin antiseptic to dry fully before dressing placement; alcoholic chlorhexidine solutions, for at least 30 seconds; iodophors, for at least 1.5-2 minutes.

• Use catheter stabilization device that allows visual inspection of access site.

• Use vigorous mechanical scrubbing methods when disinfecting needleless connectors before each access using 70% isopropyl alcohol, iodophors, or >0.5% chlorhexidine alcoholic solution. Disinfect before each access when multiple accesses are required.

• Change needleless connectors using aseptic no-touch technique no more frequently than 96-hour intervals.

• Use passive disinfection caps (e.g., isopropyl alcohol).

• Change administration sets based on solution administered and frequency of the infusion and immediately on suspected contamination or when integrity has been compromised.

CVAD, Central vascular access device; INS, Infusion Nurses Society; TSM, transparent semipermeable membrane; VAD, vascular access device.

The Needle Safety and Prevention Act of 2001

-Mandates that health care agencies use safe needle devices and manufactured needleless systems to reduce needlestick injury. Systems with catheter ports or Y-connector sites are designed to contain a needle housed in a protective covering. Needleless infusion lines allow a direct connection with the IV line via a recessed connection port, a blunt-ended cannula, or shielded-needle device, eliminating the risk for exposure to an IV needle.

Recommendations for the Prevention of Needlestick Injuries

• Avoid using needles when effective needleless systems or sharps with engineered sharps injury protection (SESIP) safety devices are available.

• Do not recap any needle after medication administration.

• Plan safe handling and disposal of needles before beginning a procedure.

• Immediately dispose of needles, needleless systems, and SESIP into puncture-proof and leak-proof sharps disposal containers.

• Maintain a sharps injury log that reports the following: type and brand of device involved in the incident; location of the incident (e.g., department or work area); description of the incident; and privacy of the employees who have had sharps injuries.

• Attend education offerings on bloodborne pathogens and follow recommendations for infection prevention, including receiving the hepatitis B vaccine.

• Participate in the selection and evaluation of SESIP devices with safety features within your agency whenever possible.

Isotonic solutions

•Dextrose 5% in water

-Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments so it acts like a hypotonic solution

•0.9% sodium chloride† (NS)

•Lactated Ringer's‡

-Has multiple electrolytes

Hypotonic solutions

•0.45% sodium chloride (half NS)

•0.33% sodium chloride (one-third NS)

Hypertonic solutions

•Dextrose 10% in water

•Dextrose 50% in water

•3%-5% sodium chloride

•Dextrose 5% in 0.9% sodium chloride

•Dextrose 5% in 0.45% NaCl sodium chloride

•Dextrose 5% in Lactated Ringer's

Prepare IV tubing and solution for continuous infusion.

a. Check IV solution using six rights of medication administration and review label for name and concentration of solution, type and concentration of any additives, volume, beyond-use and expiration dates, and sterility state. If using bar code, scan code on patient's wristband and then on IV fluid container. Be sure that prescribed additives such as potassium and vitamins have been added. Check solution for color and clarity. Check bag for leaks.

b. Open IV infusion set, maintaining sterility. NOTE: EIDs sometimes have a dedicated administration set; follow manufacturer's instructions.

c. Place roller clamp about 2 to 5 cm (1 to 2 inches) below drip chamber and move roller clamp to "off" position.

d. Remove protective sheath over IV tubing port on plastic IV solution bag or top of IV solution bottle while maintaining sterility.

e. Remove protective cover from IV tubing spike while maintaining sterility of spike. Insert spike into port of IV bag using a twisting motion. If solution container is glass bottle, clean rubber stopper on glass-bottled solution with antiseptic swab and insert spike into rubber stopper of IV bottle. Bottles require vented tubing.

f. Compress drip chamber and release, allowing it to fill one-third to one-half full

g. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end of IV tubing (some tubing can be primed without removing protective cover) and slowly open roller clamp to allow fluid to flow from drip chamber to distal end of IV tubing. If tubing has a Y connector, invert Y connector when fluid reaches it to displace air. Return roller clamp to "off" position after priming tubing (filled with IV fluid). Replace protective cover on distal end of tubing. Label IV tubing with date according to agency policy and procedure.

h. Be certain that IV tubing is clear of air and air bubbles. To remove small air bubbles, firmly tap tubing where they are located. Check entire length of tubing to ensure that all air bubbles are removed.

i. If using optional long extension tubing (not short tubing in Step 7), remove protective cover and attach it to distal end of IV tubing, maintaining sterility. Then prime long extension tubing. Insert tubing into EID with power off.

Starting and IV Implementation

1. Swabs injection cap and primes saline lock leaving syringe attached. Loosens protector cap (maintain sterility). Removes over needle catheter (ONC) and transparent dressing from wrappers.

2. Applies tourniquet 4 - 6 inches above selected site (check radial pulse) and assesses vein for appropriateness. If need additional prep time may release tourniquet temporarily.

3. Applies clean gloves

4. Moves saline lock nearby, on over-the-bed table, maintaining in sterile package.

5. Cleanses site with Chlorhexidine - using friction horizontal, vertical, and circular. Cleanse for at least 30 seconds and allow site to completely dry. Do not touch site!

6. Performs venipuncture: Anchors vein 1.5-2 inches below insertion site by gently stretching the skin against the direction of insertion site. Be sure not to touch the cleansed site or allow the ONC to touch the anchoring thumb; advises patient to remain still and that there will be a quick stick; inserts ONC with bevel up at 10-30 ° angle in the direction parallel to the vein.

7. Observes for blood return. Lowers needle and advances 1/4 inch.

8. Continues to hold skin and advances catheter all the way to hub without advancing the stylet/needle. Stabilizes catheter with one hand and releases tourniquet with the other hand. (Push and pop)

9. Apply gentle/firm pressure 1 1⁄4 inch above insertion site and removes stylet/needle of ONC. Disposes of stylet in sharps container if close or temporarily places on bedside table away from patient.

10. Removes cap and maintains sterility; quickly connects end of saline lock to catheter. Secures temporarily with tape.

11. Reassesses for blood return with gentle aspiration and flushes the vein with remaining saline, observing site for swelling. Removes flush syringe and places in sharps container.

12. Applies a sterile transparent dressing up to the hub of the catheter (leave connection below the extension set and hub uncovered) without touching under the dressing.

13.. Secures IV and IV tubing (Does not place tape under or over the transparent dressing). Allow saline lock tubing to assume a natural position prior to taping.

14. Disposes of equipment safely. Properly removes and disposes of gloves.

15. Writes date, time, gauge, and initials on tape/label before applying to edge of dressing.

16. Repositions patient for comfort and safety (lowers bed/raises siderail). Instructs patient how to prevent dislodging IV and s/s of IV related complications. (See book/video)

17. Performs hand hygiene.

18. Documentation: states date, time, describes location, # attempts, catheter gauge and length, patient tolerance, presence of saline lock or flow rate and method of infusion if

fluids are prescribed.

Principles for Vein selection

-Veins on dorsal and ventral surfaces of arms (e.g., metacarpal, cephalic, basilic, or median) are preferred in adults.

image

- Use most distal site in nondominant arm if possible.

Patients with VAD placement in their dominant hand have decreased ability to perform self-care.

- With your fingertip, palpate vein at intended insertion site by pressing downward. Note resilient, soft, bouncy feeling while releasing pressure

- Select well-dilated vein

Methods to improve vascular distention

-Increased volume of blood in vein at venipuncture site makes vein more visible.

(1) Position extremity lower than heart, have patient open and close fist slowly, and lightly stroke vein downward.

(2) Apply dry heat to extremity for several minutes.

Avoid vein selection

(1) Areas with pain on palpation, compromised areas, sites distal to compromised areas (e.g., open wounds, bruising, infection, infiltration, or extravasation)

(2) Upper extremity on side of breast surgery with axillary node dissection or lymphedema or after radiation, arteriovenous (AV) fistulas/grafts; or affected extremity from cerebrovascular accident (CVA)

(3) Site distal to previous venipuncture site, sclerosed or hardened veins, previous infiltrations or extravasations, areas of venous valves, or phlebitic vessels.

(4) Fragile dorsal hand veins in older adults. Veins of lower extremities should not be used for routine IV therapy in adults because of risk of tissue damage and thrombophlebitis

(5) Areas of flexion such as wrist or antecubital area

(6) Ventral surface of wrist (10-12.5 cm [4-5 inches])

(7) Choose site that will not interfere with patient's activities of daily living (ADLs), use of assist devices, or planned procedures.

Regulating Intravenous Flow Rates

1. Regulate gravity infusion

2. Regulate EID

3. Attach label to IV solution container with date and time container changed (check agency policy).

4. Teach patient purpose of EID if infusion therapy is delivered by EID, purpose of alarms, to avoid raising hand or arm that affects flow rate, and to avoid touching control clamp.

5. Remove and dispose of any used supplies; perform hand hygiene.

Regulate gravity infusion

a. Ensure that IV container is at least 76.2 cm (30 inches) above IV site for adults and increase height for more viscous fluids

b. Slowly open roller clamp on tubing until you can see drops in drip chamber. Hold a watch with second hand at same level as drip chamber and count drip rate for 1 minute. Adjust roller clamp to increase or decrease rate of infusion.

c. Monitor drip rate at least hourly.

Regulate EID (infusion pump or smart pump)

-Follow manufacturer guidelines for setup. Be sure you are using infusion tubing compatible with it.

a. Close roller clamp on primed IV infusion tubing.

b. Insert infusion tubing into chamber of control mechanism (see manufacturer directions). Roller clamp on IV tubing goes between it and patient.

c. Secure part of IV tubing through "air in line" alarm system. Close door and turn on power button, select required drops per minute or volume per hour, close door to control chamber, and press start button . If infusing medication, access the library of medications and set appropriate rate and dose limits. If smart pump alarms immediately and shuts down, your settings were outside unit parameters.

d. Open infusion tubing drip regulator completely while it is in use.

e. Monitor infusion rate and IV site for complications according to agency policy. Use watch to verify rate of infusion, even when using one.

f. Assess IV system from container to VAD insertion site when alarm signals.

Changing Intravenous Solutions

1. Change solution when fluid remains only in neck of container (about 50 mL) or when new type of solution has been ordered.

2. Perform hand hygiene.

3. Prepare new solution for changing. If using plastic bag, hang on IV pole and remove protective cover from IV tubing port. If using glass bottle, remove metal cap and metal and rubber disks.

4. Close roller clamp on existing solution to stop flow rate. Remove IV tubing from EID (if used). Then remove old IV solution container from IV pole. Hold container with tubing port pointing upward.

5. Quickly remove spike from old solution container and, without touching tip, insert spike into new container.

6. Hang new container of solution on IV pole.

7. Check for air in IV tubing. If air bubbles have formed, remove them by closing roller clamp, stretching tubing downward, and tapping tubing with finger (bubbles rise in fluid to drip chamber).

8. Make sure that drip chamber is one-third to one-half full. If drip chamber is too full, level can be decreased by removing bag from IV pole, pinching off IV tubing below drip chamber, inverting container, squeezing drip chamber, releasing and turning solution container upright, and releasing pinch on tubing.

9. Regulate flow to ordered rate by opening and adjusting roller clamp on IV tubing or by opening roller clamp and programming and turning on EID.

10. Place time label on side of container and label with time hung, time of completion, and appropriate intervals. If using plastic bags, mark only on label and not container.

11. Instruct patient on purpose of new IV solution, additives, flow rate, potential side effects, how to avoiding occluding tubing, and what to report.

Changing Infusion Tubing

1. Perform hand hygiene. Open new infusion set and connect add-on pieces (e.g., filters, extension tubing) using aseptic technique. Keep protective coverings over infusion spike and distal adapter. Place roller clamp about 2-2.5 cm (1-2 inches) below drip chamber and move roller clamp to "off" position. Secure all connections.

2. Apply clean gloves. If patient's IV cannula hub is not visible, remove IV dressing (see Skill 29.5). Do not remove tape securing cannula to skin.

3. Prepare IV tubing with new IV container.

4. Prepare IV tubing with existing continuous IV infusion bag.

a. Move roller clamp on new IV tubing to "off" position.

b. Slow rate of infusion through old tubing to keep vein open (KVO) rate using EID or roller clamp.

c. Compress and fill drip chamber of old tubing.

d. Invert container and remove old tubing. Keep spike sterile and upright.

e. Insert spike of new infusion tubing into solution container. Hang solution bag on IV pole, compress drip chamber on new tubing, and release, allowing it to fill one-third to one-half full.

f. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end of tubing and slowly open roller clamp to allow solution to flow from drip chamber to distal end of IV tubing. If tubing has Y connector, invert Y connector when solution reaches it to displace air. Return roller clamp to "off" position after priming tubing (filled with IV solution). Replace protective cover on end of IV tubing. Place end of adapter near patient's IV site.

g. Stop EID or turn roller clamp on old tubing to "off" position.

Prevents fluid spillage.

5. Prepare tubing with extension set or saline lock.

a. If short extension tubing is needed, use sterile technique to connect new injection cap to new extension set or IV tubing.

b. Scrub injection cap with antiseptic swab for at least 15 seconds and allow to dry completely. Attach syringe with 3 to 5 mL of NS flush solution and inject through injection cap into extension set.

6. Reestablish infusion.

a. Gently disconnect old tubing from extension tubing (or from IV catheter hub) and quickly insert Luer-Lok end of new tubing or saline lock into extension tubing connection (or IV catheter hub) (see illustrations for example of connecting tubing to short extension set).

b. For continuous infusion, open roller clamp on new tubing and regulate drip rate using roller clamp or insert tubing into EID, program to desired rate, and push on.

c. Attach piece of tape or preprinted label with date and time of IV tubing change onto tubing below drip chamber.

d. Form loop of tubing and secure it to patient's arm with strip of tape.

7. Remove and discard old IV tubing. If necessary, apply new dressing. Remove and dispose of gloves. Perform hand hygiene.

8. Teach patient how to move and turn properly with IV tubing.

Primary and Secondary Continuous Infusions

• Change no more frequently than every 96 hours for solutions other than lipid, blood, or blood products.

• In addition to routine changes, change the administration set whenever the short-peripheral IV site is changed or a new CVAD is placed.

• If the second set is removed from the first set, the second set is now an intermittent set and should be changed every 24 hours.

Primary Intermittent Infusions

• Should be changed every 24 hours because of increased risk of infection with repeatedly disconnecting and reconnecting administration set.

• Aseptically attach a new, sterile covering device to the Luer end of the administration set after each use. Avoid attaching the exposed end of the administration set to port on the same set (e.g., looping).

Use of Add-on Devices

• Should be minimized because each is a potential source of contamination and disconnection.

• Use of administration sets with devices as part of the set is preferred.

• Aseptically change with insertion of new VAD or with each administration set replacement.

• Change if the integrity of the product is compromised or suspected of being compromised.

Changing a Short-Peripheral Intravenous Dressing

2. Remove existing dressing: TSM or Gauze

3. Assess VAD insertion site for signs and symptoms of IV-related complications. If complication exists, determine if VAD requires removal. Remove catheter if ordered by health care provider

4. If catheter is to remain in place, assess integrity of engineered stabilization device. Continue to stabilize catheter and remove as recommended by manufacturer directions for use. Inspect for signs of adhesive-related skin injury from adhesive-based engineered stabilization devices.

NOTE: Some stabilization devices are designed to remain in place for length of time VAD is in as long as adequate stabilization is evident.

5. While stabilizing IV line, perform skin antisepsis to insertion site with CHG solution using friction in back-and-forth motion for 30 seconds and allow to dry completely. If using alcohol or povidone-iodine, clean in concentric circle, moving from insertion site outward with the swab. Allow antiseptic solution to dry completely.

6. Optional: Apply skin protectant to area where you will apply tape, dressing, or engineered stabilization device. Allow to dry.

7. While stabilizing catheter, apply sterile dressing over site (procedures differ; follow agency policy).

a. TSM dressing

b. Sterile gauze dressing

8. Option. Secure with new engineered catheter stabilization device

9. Remove and discard gloves and used equipment. Perform hand hygiene.

10. Optional: Apply site protection device (e.g., I.V. House Ultra Protective Dressing®).

11. Anchor extension tubing or IV tubing alongside dressing on arm and secure with tape directly over tubing. When using TSM dressing, avoid placing tape over dressing.

12. Label dressing per agency policy. Information on label includes date and time of IV insertion, VAD gauge size and length, and your initials.

13. Perform hand hygiene.

Removing TSM (tegaderm) dressing

Stabilize catheter with nondominant hand. Remove dressing by pulling up one corner and gently pulling straight out and parallel to skin. Repeat on all sides until dressing has been removed.

Removing gauze dressing

Stabilize catheter hub while loosening tape and removing old dressing one layer at a time by pulling toward insertion site. Be cautious if tubing becomes tangled between two layers of dressing.

Infiltration

-pain, swelling, coolness to touch, or presence of blanching (white, shiny appearance at or above IV site) or redness

• Stop infusion and remove IV catheter at first sign

• Elevate affected extremity.

• Avoid applying pressure, which can force solution into contact with more tissue, causing tissue damage.

• Use standard scale for assessing and documenting it

Catheter occlusion

-can occur from bent catheter, positional catheter (catheter resting against catheter wall), kink or knot in infusion tubing, clot formation, or precipitate formation from administration of incompatible medications or solutions

• Determine cause and consider catheter removal.

• Positional catheters can be repositioned to improve IV flow.

• Remove occluded IV catheter. Blocked catheters should not be flushed because an embolus can result from dislodging a clot

Phlebitis

-(i.e., vein inflammation): pain, redness, warmth, swelling, induration, or presence of palpable cord along course of vein. Rate of infusion may be altered.

• Notify health care provider.

• Determine cause (i.e., chemical, mechanical, bacterial) and consider removal or replacement of VAD.

• Chemical: Apply heat, elevate limb, consider slowing infusion rate, and determine if catheter removal is necessary

• Mechanical: Apply heat, elevate limb, monitor for 24-48 hours, consider catheter removal if signs and symptoms persist

• Bacterial: Remove IV catheter

• Document phlebitis using a standardized scale, including nursing interventions per agency policy and procedure

Catheter-related infection

-can present as redness, swelling around or above IV site, pain, purulent drainage at insertion site, and body temperature elevations

• Notify health care provider. Obtain order to culture drainage

• Remove IV catheter and culture purulent drainage from around IV site

Hematoma

-is bleeding under skin caused by trauma to vessel wall. It can occur during short-peripheral IV insertion if needle punctures either adjacent vessels or posterior vein wall or can be seen with multiple venipuncture attempts

• Remove IV catheter immediately and apply pressure and dry, sterile.

• Monitor for additional bleeding.

• Elevate extremity and monitor for circulatory, neurological, or motor dysfunction

Nerve injuries

-during short-peripheral IV insertion can occur. Be alert for patient complaints of paresthesias, including shocklike pain, tingling or pins and needles, burning, or numbness on insertion.

• Notify health care provider of any signs and symptoms injury

• Immediately stop VAD insertion and remove device if patient complains of symptoms of paresthesias

• Continue to monitor neurovascular status

Sudden infusion of large volume of solution occurs

-patient develops dyspnea, crackles in lung, dependent edema (edema in legs), and increased urine output, indicating FVE.

• Slow infusion rate: KVO rates must have specific rate ordered by health care provider.

• Notify health care provider immediately.

• Place patient in high-Fowler's position.

• Anticipate new IV orders.

• Anticipate administration of oxygen per order.

• Administer diuretics if ordered.

IV solution runs slower than ordered

• Check for positional change that affects rate, height of IV container, kinking of tubing, or obstruction.

• Check VAD site for complications.

• Consult health care provider for new order to provide necessary fluid volume.

IV patency is lost subsequent to IV solution container running empty.

• Discontinue present IV infusion and restart new short-peripheral catheter in new site.

IV catheter is removed or dislodged accidentally.

• Restart new short-peripheral IV line in other extremity or above previous insertion site if continued therapy is necessary.

0 on phlebitis scale

-No symptoms

-IV site appears healthy

1 on phlebitis scale

-Erythema at access site with or without pain

-One of the following signs is evident:

Slight pain near IV site or slight redness near IV site

2 on phlebitis scale

-Pain at access site with erythema and/or edema

-Two of the following signs are evident:

• Pain at IV site

• Erythema

• Swelling

3 on phlebitis scale

-Pain at access site with erythema and/or edema

-Streak formation

-Palpable venous cord

-All of the following signs are evident:

• Pain along the path of cannula

• Induration

4 on phlebitis scale

-Pain at access site with erythema and/or edema

-Streak formation

-Palpable venous cord >2.5 cm (1 inch) in length

-Purulent drainage

-All of the following signs are evident and extensive:

• Pain along the path of cannula

• Erythema

• Induration

• Palpable venous cord

5 on phlebitis scale

-All of the following signs are evident and extensive:

• Pain along the path of cannula

• Erythema

• Induration

• Palpable venous cord

• Pyrexia

Insertion of a Short-Peripheral Intravenous Device Pre-assessments

1. Review accuracy of health care provider's order: date and time, IV solution, route of administration, volume, rate, duration, and signature of ordering health care practitioner. Follow rights of medication administration.

a. Check approved online database, drug reference book, or pharmacist about IV solution composition, purpose, potential incompatibilities, adverse reactions, and side effects.

3.Check patient's knowledge of procedure, reason for prescribed therapy, and arm placement preference.

4. Check for clinical factors/conditions that will respond to or be affected by administration of IV solutions.

a. Body weight

b. Clinical markers of vascular volume

c. Clinical markers of interstitial volume

d. Thirst

e. Behavior and level of consciousness

4. Determine if patient is to undergo any planned surgeries or procedures.

5. Check available laboratory data (e.g., hematocrit, serum electrolytes, arterial blood gases, and kidney functions [blood urea nitrogen, urine specific gravity, and urine osmolality]).

6. Check patient's history of allergies, especially to iodine, adhesive, or latex.

Clinical markers of vascular volume

(1) Urine output (decreased, dark yellow)

(2) Vital signs: blood pressure, respirations, pulse, temperature

(3) Distended neck veins (Normally veins are full when person is supine and flat when person is upright.)

(4) Auscultation of lungs

(5) Capillary refill

Clinical markers of interstitial volume

(1) Skin turgor (Pinch skin over sternum or inside of forearm.)

(2) Dependent edema (pitting or nonpitting)

(3) Oral mucous membrane between cheek and gum

Behavior and level of consciousness

(1) Restlessness and mild confusion

(2) Decreased level of consciousness (lethargy, confusion, coma)

Insertion of a Short-Peripheral Intravenous Device Post-evaluations

1. Observe patient every 1 to 2 hours or at established intervals per agency policy and procedure for function, intactness, and patency of IV system and for correct infusion rate and accurate type/amount of IV solution infused by observing level in IV container.

2. Look at patient to determine response to therapy (e.g., laboratory values, input and output [I&O]), weights, vital signs, postprocedure assessments).

3. Look at patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications by inspecting and gently palpating skin around and above IV site over the dressing.

4. Use Teach-Back: "I want to make sure that I explained the problems that can happen with your IV. Tell me the signs or symptoms that you should tell me or the other nurses about." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.

Regulating Intravenous Flow Rates Pre-assessments

1. Review accuracy and completeness of health care provider order in patient's medical record for patient name and correct solution: type, volume, additives, infusion rate, and duration of IV therapy. Follow six rights of drug administration

3. Apply clean gloves; inspect and gently palpate skin around and above IV site over dressing. Ask patient how IV site feels. Assess VAD for patency and signs and symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or leaking under dressing). Dispose of gloves; perform hand hygiene.

4. Check IV system for patency from IV container to insertion site.

5. Identify patient risk for fluid and electrolyte imbalance given type of IV solution (e.g., neonate, history of cardiac or renal disease).

6. Check patient's knowledge of how positioning of IV site affects flow rate.

Regulating Intravenous Flow Rates Post-evaluations

1. Observe patient every 1 to 2 hours (see agency policy), noting volume of IV fluid infused and rate of infusion.

2. Look at patient's response to therapy (e.g., laboratory values, input and output [I&O], weights, vital signs, postprocedure assessments).

3. Look at patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications.

4. Use Teach-Back: "I want to be sure that I explained the importance of your IV fluids running on time at the rate ordered. Tell me what you think may cause the pump to alarm and what you would do." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.

Changing Intravenous Solutions Pre-assessments

1. Review accuracy and completeness of health care provider's order in patient's medical record for patient name and correct solution: type, volume, additives, rate, and duration of IV therapy. Follow rights of drug administration

2. Note date and time when IV tubing and solution were last changed.

3. Determine patient understanding of need for continued IV therapy.

4. Perform hand hygiene and apply clean gloves; inspect and gently palpate skin around and above IV site over dressing. Assess VAD for patency and signs and symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or leaking under dressing).

5. Check infusion system from solution container down to VAD insertion site for integrity, including but not limited to discoloration, cloudiness, leakage, expiration date. Determine compatibility of all IV solutions and additives by consulting approved online database, drug reference, or pharmacist. Discard gloves and perform hand hygiene.

6. Check pertinent laboratory data such as potassium level.

Changing Intravenous Solutions Post-evaluations

1. Observe patient every 1 to 2 hours or at established intervals per agency policy and procedure for function, intactness, and patency of IV system; correct infusion rate; and type/amount of IV solution infused.

2. Evaluate patient to determine response to therapy (e.g., laboratory values, input and output [I&O], weights, vital signs, postprocedure assessments).

3. Monitor patient for signs of fluid volume excess (FVE), fluid volume deficit (FVD), or signs and symptoms of electrolyte imbalances.

4. Evaluate patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications.

5. Use Teach-Back: "We talked about the importance of your IV solutions running continuously. I want to be sure I explained this clearly. Tell me in your own words what you should do if you notice that the IV is not dripping." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.

Changing Infusion Tubing Pre-assessments

1. Note date and time when IV tubing was last changed

2. Perform hand hygiene. Assess IV tubing for puncture, contamination, or occlusion that requires immediate change.

3. Determine patient understanding of need for continued IV therapy.

Changing Infusion Tubing Post-evaluations

1. Observe patient every 1 to 2 hours or at established intervals per agency policy and procedure for function, intactness, and patency of IV system and leaking at connection sites.

2. Evaluate patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications.

3. Use Teach-Back: "Let's go over what we talked about earlier regarding the problems that can occur with your IV line. Tell me how you can prevent the tubing from being pinched off and which signs and symptoms you would report to me or another nurse." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.

Changing a Short-Peripheral Intravenous Dressing Pre-assessments

1. Determine when dressing was last changed. Dressing should be labeled to include date and time applied, size and type of vascular access device (VAD) insertion date.

2. Perform hand hygiene and apply clean gloves. Observe present dressing for moisture and intactness. Determine if moisture is from site leakage or external source.

3. Inspect and gently palpate skin around and above IV site over dressing. Assess VAD for patency and signs and symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or leaking under dressing). Remove and discard gloves.

4. Assess patient's understanding of need for continued IV infusion.

Changing a Short-Peripheral Intravenous Dressing Post-evaluations

1. Evaluate function, patency of IV system, and flow rate after changing dressing.

2. Evaluate patient at established intervals per agency policy and procedure for signs and symptoms of IV line-related complications.

3. Use Teach-Back: "I want to be sure that I explained reasons for why we change the IV dressing. Tell me in your own words the problems that you would report that would require us to change the dressing." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.

Insertion of a Short-Peripheral Intravenous Device Pediatric Considerations

• Perform venipuncture in a neutral space to allow the child's room to be a safe place.

• In addition to the usual venipuncture sites, the four scalp veins are used in infants and toddlers and, if not walking, the dorsum of the foot.

• Needle selection is based on age: 26- to 24-gauge for neonates, 24- to 22-gauge for children.

• Use local anesthetics and distraction strategies to minimize distress associated with venipuncture.

• Apply latex-free tubing or use a blood pressure cuff inflated to just below diastolic blood pressure.

• Allow older children to select IV site to increase cooperation so they believe that they have some control over their treatment.

• To maintain safety in positioning, have extra help when starting an IV line on a child. Use therapeutic hugging, usually in a sitting position, to provide close contact. NAP can help with positioning.

• Choose age-appropriate activities compatible with the maintenance of the IV infusion to maintain normal growth and development.

Insertion of a Short-Peripheral Intravenous Device Geriatric Considerations

• Veins of the older population are very fragile; they have less subcutaneous support tissue, and their skin is thinning. Avoid sites that are easily moved or bumped. Use a commercial protective device to protect the site and reduce manipulation

• In older patients the use of a 22- or 24-gauge catheter is appropriate for most therapies. Smaller-gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of the IV solutions or medications

• If possible, avoid the back of the older adult's hand or the dominant arm for venipuncture because use of these sites interferes with their independence.

• As older adults lose subcutaneous tissue, the veins lose stability and roll away from the needle. To stabilize the vein, pull the skin taut and toward you with your nondominant hand and anchor the vein with your thumb.

Regulating Intravenous Flow Rates Pediatric Considerations

• Do not use containers exceeding 150 mL in children younger than 2 years of age, exceeding 250 mL in children younger than 5 years of age, or exceeding 500 mL in children younger than 10 years of age. Always use tamper-resistant volume-controlled EIDs to ensure accurate fluid delivery

Regulating Intravenous Flow Rates Geriatric Considerations

• Use an EID and microdrip tubing to administer IV solutions. Monitor vital signs, electrolyte levels, blood urea nitrogen (BUN), creatinine, urine output, and body weight

Changing a Short-Peripheral Intravenous Dressing Pediatric Considerations

• Patients are not always able to understand explanations fully. Presence of parent or security toy during procedure helps to decrease fear and increase cooperation. Perform procedure on patient's toy or doll first.

• Help is necessary to keep patient still and protect IV catheter from dislodgement.

• Use commercially available IV site protectors to cover and protect the IV site in young active children.

• Use CHG with care in premature infants and those under 2 months of age due to the risks of skin irritation and chemical burns

• Dried povidone-iodine should be removed with sodium chloride or sterile water for neonates with compromised skin integrity

Changing a Short-Peripheral Intravenous Dressing Geriatric Consideration

• Some older adults have fragile skin; therefore prevent skin tears by minimizing the use of tape or an engineered stabilization device directly on the skin and applying skin protectant before applying tape.

• Infiltration may go unnoticed because of the decreased elasticity of skin and loose skinfolds. Because of decreased tactile sensation, a large amount of fluid may infiltrate before pain occurs.

IV Start Documentation

-states date, time, describes location, # attempts, catheter gauge and length, patient tolerance, presence of saline lock or flow rate and method of infusion if

fluids are prescribed

• Record in nurses' notes in electronic health record (EHR) or chart the number of attempts (successful and unsuccessful) and sites of insertion; precise description of insertion site (e.g., cephalic vein on dorsal surface of right lower arm, 2.5 cm [1 inch] above wrist); flow rate; method of infusion (gravity or EID); size and type, length, and brand of catheter; and time infusion started and patient's response to insertion. Use an infusion therapy flow sheet when available.

• If using an EID, document type and rate of infusion and device identification number.

• Record patient's status, IV fluid, amount infused, integrity and patency of system according to agency policy.

• Record patient's and family caregiver's level of understanding following instruction in nurses' notes in EHR or chart.

• Report to oncoming nursing staff: type of fluid, flow rate, status of VAD, amount of fluid remaining in present solution, expected time to hang subsequent IV container, and patient condition.

• Report to health care provider any signs and symptoms of IV-related complications.

• Record signs and symptoms of IV-related complications, including interventions and patient response to treatments.

IV Discontinuation Documentation

-states date, time, describes location, # attempts, catheter gauge and length, patient tolerance, presence of saline lock or flow rate and method of infusion if

fluids are prescribed

-intactness of catheter tip

Why use a Central Line over a Peripheral Line

-To prevent infusion-related complications, solutions and medications with an osmolarity greater than 900 mOsm/L are infused through a CVAD. Short-peripheral catheters should not be used for vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900 mOsm/L. In addition, solutions or medications with low or high pH have the potential to cause infusion-related complications such as phlebitis when administered with a short-peripheral or midline catheter

confirm position of central catheter tip

-A chest x-ray verifies appropriate placement. Although chest x-ray is still the gold standard for determining placement, the use of transesophageal echocardiography, fluoroscopy, and C-arm can detect a catheter tip more readily and accurately compared with chest x-ray

Central Line Complications

-Catheter damage, breakage

-Occlusion: thrombus, fibrin sheath, fibrin tail, precipitation, malposition

-Infection and sepsis: catheter skin junction, tunnel, thrombus, port pocket, CLABSI

-Dislodgement

-Catheter migration (e.g., length of catheter moved from original position), pinch-off syndrome (e.g., compression of catheter between clavicle and first rib), port separation or catheter fracture (e.g., internal fracture or separation of catheter)

-Skin erosion (e.g., mechanical loss of skin tissue), hematomas (e.g., local collection of blood), cuff extrusion (e.g., tissue at edges of insertion site separate), scar tissue formation over port

-Infiltration, extravasation

-Pneumothorax, hemothorax, air emboli, hydrothorax

-Incorrect placement

Catheter damage, breakage

-Central Line/CVAD Complication

-Every shift observe for pinholes, leaks, tears.

-Assess for drainage from site after flushing.

Occlusion

-Central Line/CVAD Complication

-thrombus, fibrin sheath, fibrin tail, precipitation, malposition

-Assess insertion site and sutures.

-Assess for blood return.

-Assess for ability to infuse fluid.

-Assess equipment.

-If port is in place, reassess and verify noncoring needle placement.

-Assess with syringe directly on catheter.

-Assess for discomfort or pain in shoulder, neck, ear, or arm at insertion site.

-Assess for neck or shoulder edema.

Infection and sepsis

-Central Line/CVAD Complication

-catheter skin junction, tunnel, thrombus, port pocket, CLABSI

-Assess catheter skin junction for redness, drainage, edema, or tenderness.

-Assess for signs of systemic infection.

-Monitor laboratory findings.

Dislodgement

-Central Line/CVAD Complication

-Assess length of catheter daily.

-Inform patient of possible catheter dislodgement.

-Identify edema at catheter skin junction or drainage.

-Palpate catheter skin junction and tunnel for coiling (catheter can feel cordlike underneath the skin).

-Assess for distended neck veins.

Catheter migration

-Central Line/CVAD Complication

-(e.g., length of catheter moved from original position), pinch-off syndrome (e.g., compression of catheter between clavicle and first rib), port separation or catheter fracture (e.g., internal fracture or separation of catheter)

-Assess for patient complaints of gurgling sounds.

-Assess for change in patency of catheter by evaluating change in flow rate, local irritation, swelling, occlusion, tenderness, pain, inability to aspirate fluid and/or blood.

-Pain at site when flushed or symptoms of embolus.

-Obtain x-ray film examination.

-Assess edema of arm and hand on side of insertion.

-Assess for distended neck veins.

-Assess for inability to infuse solutions.

-Assess length of catheter daily.

Skin erosion

-Central Line/CVAD Complication

-(e.g., mechanical loss of skin tissue), hematomas (e.g., local collection of blood), cuff extrusion (e.g., tissue at edges of insertion site separate), scar tissue formation over port

-Assess for loss of viable tissue over septum site.

-Assess for separation of exit site edges.

-Assess for drainage at catheter skin junction.

-Assess for redness.

-Assess for edema, contusions.

-Note if tunneled catheter is exposed (Dacron cuff is visible.)

Infiltration, extravasation

-Central Line/CVAD Complication

-Assess for erythema.

-Assess for edema.

-Assess for spongy feeling.

-Assess for swelling around IV site and at termination of catheter tip.

-Assess for labored breathing.

-Assess for aspiration of fluid and/or blood.

-Assess for complaints of pain with infusion of solutions or medications (e.g., burning).

-Assess for no free-flow IV drip.

Pneumothorax, hemothorax, air emboli, hydrothorax

-Central Line/CVAD Complication

-Assess for subcutaneous emphysema by inspecting and palpating skin around insertion site and along arm.

-Inspection may reveal edema where air is located, and air may travel if skin is loose.

-Palpation reveals a crackling sensation such as popping plastic bubble wrap.

-Assess for chest pain.

-Assess for dyspnea, apnea, hypoxia, tachycardia, hypotension, nausea, confusion.

Incorrect placement

-Central Line/CVAD Complication

-Assess for cardiac dysrhythmias.

-Assess for hypotension.

-Assess for neck distention.

-Assess for narrow pulse pressure.

-Assess for inadequate blood withdrawal.

-Assess for retrograde flow of blood (flow of blood back into tubing usually caused by decreased pressure gradient between venous system and access device unit [e.g., IV infusion, heparin lock]).

Nontunneled Percutaneous

-CVAD

-Short-term device

• Length of dwell: Days to several weeks

• Insertion sites: Subclavian, external/internal jugular, and femoral veins

• Insertion technique: Not surgically placed; can be done at bedside; direct puncture into intended vein without passing through subcutaneous tissue

• Held in place with sutures or engineered securement device

Peripherally Inserted Central Catheters (PICCs)

-CVAD

-Short-term device

-Use engineered stabilization device (if not sutured) when cleaning

• Length of dwell: As long as they function properly with no evidence of intravenous (IV)-related complications

• Insertion sites: Antecubital fossa or upper arm (basilic or cephalic vein) and advanced until catheter tip reaches superior vena cava (SVC)

• Insertion technique: Not surgically placed; can be done at bedside, in home setting, or in radiology setting

• Held in place with sutures or engineered securement device

External Tunneled (Hickman, Broviac, Groshong)

-CVAD

-Long-term device

-placed under skin

• Length of dwell: Considered permanent

• Insertion sites: Chest region through subclavian or jugular vein

• Insertion technique: Surgery required; tunneling of proximal end subcutaneously from insertion site and bringing it out through skin at an exit site

• Held in place by a Dacron cuff coated in antimicrobial solution; in approximately 2-3 weeks scar tissue forms around cuff, fixing catheter in place

Implanted Venous Ports

-CVAD

-Long-term device

• Length of dwell: Considered permanent

• Insertion sites: Chest, abdomen, or inner aspect of forearm

• Insertion techniques: Requires surgery; catheter placed via subclavian or jugular vein and attached to reservoir located within a surgically created subcutaneous pocket

• Sutured in place within surgically created pocket and accessed using a noncoring needle through the skin

CVAD Insertion site care and dressing change

a. Position patient in comfortable position with head slightly elevated. Have arm extended.

b. Prepare dressing materials.

-TSM dressing: change at least every 5-7 days

-Gauze dressing: change at least every 2 days

-Gauze under TSM: change at least every 2 days

c. Perform hand hygiene and apply mask. Instruct patient to turn head away from site during dressing change or provide mask for patient.

d. Apply clean gloves. Remove old TSM dressing by stabilizing catheter with nondominant hand. Remove dressing by pulling up one corner and gently pulling straight out and parallel to skin. Repeat on all sides until dressing has been removed.

e. Remove catheter stabilization device if used and requires changing. Must use alcohol to remove adhesive stabilization devices.

f. Inspect catheter, insertion site, and surrounding skin. Measure external CVAD length and compare to measurement from insertion if dislodgement is suspected. For PICC and midlines, measure upper-arm circumference 10 cm above antecubital fossa if clinically indicated and compare to baseline.

g. Remove and discard clean gloves; perform hand hygiene. Open CVAD dressing kit using sterile technique and apply sterile gloves. Area to be cleaned should be same size as dressing.

h. Clean site:

(1) Perform skin antisepsis with CHG solution using friction in back-and-forth motion for 30 seconds and allow to dry completely.

(2) Povidone-iodine and alcohol may be used in some settings or if patient is sensitive to CHG (see agency policy). If using alcohol or povidone-iodine, clean in concentric circle, moving from insertion site outward with swab. Allow to dry completely.

i. Apply skin protectant to area and allow to dry completely so skin is not tacky. Skin protectant must be used if adhesive stabilization device will be used.

j. Option: Use CHG-impregnated dressing for short-term CVADs.

k. Apply sterile TSM dressing or gauze dressing over insertion site

l. Apply new catheter stabilization device according to manufacturer directions for use if catheter is not sutured in place

m. Apply label to dressing with date, time, and your initials.

n. Dispose of soiled supplies and used equipment. Remove gloves and perform hand hygiene.

Discontinuing a non-tunneled CVAD

- A nurse can perform this procedure

Blood Transfusion Preadministration protocol

a. Obtain blood component from blood bank following agency protocol

b. Check blood bag for any signs of contamination (i.e., clumping/clots, gas bubbles, purplish color) and presence of leaks.

c. Verbally compare and correctly verify patient, blood product, and type with another person considered qualified by your agency (e.g., RN or LPN) before initiating transfusion.

d. Review purpose of transfusion and ask patient to report any changes that he or she may feel during the transfusion.

e. Have patient void or apply clean gloves and empty urine drainage collection container.

Before initiating transfusion check the following

(1) Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Compare identifiers with information on patient's medication administration record (MAR) or medical record.

(2) Transfusion record number and patient's identification number match.

(3) Patient's name is correct on all documents. Check patient identification number and date of birth on identification band and patient record.

(4) Check unit number on blood bag with blood bank form to ensure that they are the same. Check expiration date and time.

(5) Blood type matches on transfusion record and blood bag. Verify that component received from blood bank is same component that health care provider ordered (e.g., packed red cells, platelets)

(6) Check that patient's blood type and Rh type are compatible with donor blood type and Rh type (e.g., Patient A+: Donor A+ or 0+).

(7) Check expiration date and time on unit of blood.

(8) Just before initiating transfusion, check patient identification information with blood unit label information (see illustration). Do not administer blood to patient without identification bracelet or blood identification bracelet (see agency policy).

(9) Both individuals verify patient and unit identification record process as directed by agency policy.

Blood Transfusion Administration

a. Perform hand hygiene. Apply clean gloves. Reinspect blood product for signs of leakage or unusual appearance.

b. Open Y-tubing blood administration set for single unit. Use multiset if multiple units are to be transfused.

c. Set all clamp(s) to "off" position.

d. Use aseptic technique and spike bag of 0.9% sodium chloride (NS) IV bag with one of Y-tubing spikes. Hang bag on IV pole and prime tubing. Open upper clamp on normal saline side of tubing and squeeze drip chamber until fluid covers filter and one third to one half of drip chamber.

e. Maintain clamp on blood product side of Y-tubing in "off" position. Open common tubing clamp to finish priming tubing to distal end of tubing connector. Close tubing clamp when tubing is filled with saline. All three tubing clamps should be closed. Maintain protective sterile cap on tubing connector.

f. Prepare blood component for administration. Gently invert bag two or three times, turning back and forth. Remove protective covering from access port. Spike blood component unit with other Y-connection. Close normal saline clamp above filter, open clamp above filter to blood unit, and prime tubing with blood. Blood will flow into drip chamber. Tap filter chamber to ensure that residual air is removed.

g. Maintaining asepsis, attach primed tubing to patient's VAD by first cleansing the catheter hub with an antiseptic swab. Then quickly connect NS-primed blood administration tubing directly to patient's VAD.

h. Open common tubing clamp and regulate blood infusion to allow only 2 mL/min to infuse in initial 15 minutes. Remain with patient during first 15 minutes of transfusion. Initial flow rate during this time should be 1-2 mL/min or 10-20 gtt/min (using macrodrip of 10 gtt/mL).

i. Monitor patient's vital signs within 5 to 15 minutes of initiating transfusion and at completion of transfusion or according to agency policy.

j. If there is no transfusion reaction, regulate rate of transfusion according to health care provider's orders based on drop factor for blood administration tubing.

k. After blood has infused, clear IV line with 0.9% sodium chloride (NS) and discard blood bag according to agency policy. When consecutive units are ordered, line patency with 0.9% sodium chloride (NS) at keep vein open (KVO) rate as ordered by health care provider and retrieve subsequent unit for administration.

l. Appropriately dispose of all supplies. Remove gloves and perform hand hygiene.

Over what period of time should a unit of blood be infused?

Do not let a unit of blood hang for more than 4 hours because of danger of bacterial growth. When a longer transfusion time is indicated clinically, the unit may be divided by the blood bank, and the part not being transfused can be properly refrigerated. Administration sets should be changed at the completion of each unit or every 4 hours to reduce bacterial contamination. Blood should only be stored in a refrigerator specific for blood or blood products to maintain appropriate temperature controls.

How much time do you have to hang the blood after the unit is received from the blood bank?

Blood transfusion should be initiated within 30 minutes from time of release from blood bank. If this cannot be completed because of factors such as an elevated temperature, immediately return the blood to the blood bank and retrieve it when you can administer it. It is important that the blood bag not be spiked until you ensure that no factors exist preventing transfusion.

frequency of monitoring while patients receive blood

-Monitor patient's vital signs every 15 minutes or per agency policy if you susupect a transfusion reaction

-before, during, and after transfusion

Adverse Transfusion Reactions

-Febrile, nonhemolytic

-Acute hemolytic transfusion reaction

-Delayed hemolytic transfusion reaction (extravascular)

-Allergic reaction (mild-to-moderate)

-Allergic reaction (severe)

-Graft-versus-host disease

-Circulatory overload

-Infectious disease transmission

-Iron overload

Febrile, nonhemolytic

-Mechanism: Most common type of transfusion reaction; caused by WBC antigen-antibody reaction

-Onset: May begin early in transfusion or as long as several hours after completion

-S&S: Temperature increase of 1°C (2°F) or more above baseline, chills, rigors, general malaise

-Prevention: Premedicate as ordered with antipyretics if prior history of reaction.

Use leukocyte-reduced blood products -Nursing Intervention: Stop transfusion. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Institute transfusion reaction protocol. Administer antipyretics as ordered to treat fever. Document clinical symptoms, when transfusion was stopped, notification of health care provider and blood bank, nursing interventions and response to interventions, and patient teaching.

Acute hemolytic transfusion reaction

-Mechanism: Caused by ABO, Rh incompatibility; donor red cells incompatible with recipient's plasma that can be potentially fatal with as little as 10-15 mL of incompatible blood; usually caused by administration of blood with wrong ABO blood group as a result of misidentification or improper labeling

-Onset: Within minutes of transfusion initiation

-S&S: Fever with or without chills, tachycardia, hypotension, lumbar/flank pain, hemoglobinemia, hemoglobinuria, dyspnea, shock, oliguria or anuria, abnormal bleeding -Prevention: Proper patient identification; proper labeling of blood sample; meticulous verification of ABO/Rh compatibility between donor and recipient before administration

-Nursing Intervention: Stop transfusion. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Monitor vital signs at least every 15 min. Administer ordered therapy to correct arterial blood pressure and coagulopathy. Insert Foley catheter. Monitor intake and output hourly. Assess for shock. Dialysis may be required. Obtain blood and urine samples and send to laboratory with unused part of unit of blood. Document reaction according to agency policy.

Delayed hemolytic transfusion reaction (extravascular)

-Mechanism: ABO, Rh incompatibility. Caused by donor plasma incompatible with recipient's red cells, usually the result of improperly identified blood sample, blood unit, or patient

-Onset: Several hours after transfusion

-S&S: Unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, jaundice

-Prevention: Proper patient identification; proper labeling of blood sample

-Nursing Intervention: Stop transfusion if in progress. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank immediately. Monitor laboratory values for anemia. (Recognition is important because subsequent transfusions may cause an acute hemolytic reaction.) Most delayed hemolytic reactions require no treatment.

Allergic reaction (mild-to-moderate)

-Mechanism: Thought to be caused by sensitivity reaction to foreign plasma protein in transfused product

-Onset: Within minutes of transfusion initiation

-S&S: Local erythema; hives; and urticaria, itching, or pruritus

-Prevention: May administer antihistamines before transfusion if prescribed

-Nursing Intervention: Stop transfusion. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Administer antihistamines as ordered. Monitor and document vital signs every 15 min. Transfusion may be restarted if fever, dyspnea, and wheezing are not present.

Allergic reaction (severe)

-Mechanism: Caused by recipient allergy to a donor antigen (usually IgA).

Agglutination of RBCs obstructing capillaries and blocking blood flow, causing symptoms to all major organ systems

-Onset: Within minutes of transfusion initiation

-S&S: Coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, possible cardiac arrest

-Prevention: Transfusion of saline-washed or leukocyte-depleted RBCs

-Nursing Intervention: Stop transfusion. This is a life-threatening reaction.

Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Administer antihistamines, corticosteroids, epinephrine, and antipyretics as ordered. Monitor and document vital signs until stable. Initiate cardiopulmonary resuscitation if necessary.

Graft-versus-host disease

-Mechanism: Donor lymphocytes destroyed by recipient's immune system In immunocompromised patients the donor lymphocytes are identified as foreign; however, patient's immune system is not capable of destroying, and in turn patient's lymphocytes are destroyed.

-Onset: 8 to 10 days after transfusion

-S&S: Skin rash, diarrhea, fever, jaundice caused by liver dysfunction, bone marrow suppression

-Prevention: Administration of irradiated blood and leukocyte-depleted RBC products as prescribed

-Nursing Intervention: Administer methotrexate and corticosteroids as ordered for treatment of symptoms.

Circulatory overload

-Mechanism: Occurs with transfusion of excessive volume or excessively rapid rate; can lead to pulmonary edema

-Onset: Anytime during or within 1-2 h after transfusion

-S&S: Dyspnea, cough, crackles at lung bases, tachypnea, headache, hypertension, tachycardia, increased central venous pressure, distended neck veins

-Prevention: Administration of blood or component at prescribed rate, usually no greater than 2-4 mL/kg/h; particular attention paid to rate and volume in older adults, young children, and patients with cardiac and renal disorders Administration of PRBCs instead of whole blood Minimizing amount of saline infused with transfusion -Nursing Intervention: Slow or stop transfusion as ordered. Elevate patient's head. Notify health care provider. Administer oxygen and diuretics as ordered.

Monitor and document vital signs, including a cardiac and respiratory assessment.

Infectious disease transmission

-Mechanism: Microorganism contamination of infused product

-Onset: During transfusion to 2 h after transfusion. Complete transfusion within 4 h -S&S: High fever, chills, abdominal cramping, vomiting, diarrhea, profound hypotension, flushed skin, back pain

-Prevention: Proper care of blood or blood product from time of procurement through end of administration

-Nursing Intervention: Stop transfusion. Change administration set and maintain patent IV access. Notify health care provider and blood bank. Monitor and document vital signs. Obtain samples for blood culture and Gram stain from recipient. Administer IV fluids, broad-spectrum antimicrobials, vasopressors, and steroids as ordered.

Iron overload

-Mechanism: Iron from donated blood binds to protein and is not eliminated

-Onset: May occur with multiple transfusions or chronic transfusion therapy

-S&S: Cardiac dysfunction, SOB, arrhythmias, HF, increased serum transferrin, increased liver enzymes, jaundice

-Prevention: Chelation, phlebotomy, monitoring of serum iron levels

-Nursing Intervention: Monitor patient for heart failure, cardiac disorder, liver disorder, serum transferrin.

If you suspect transfusion reaction

a. Immediately stop transfusion.

b. Remove blood component and tubing containing blood product. Replace them with new bag of 0.9% sodium chloride (normal saline [NS]) and tubing. Connect tubing directly to hub of vascular access device (VAD).

-Exception: If patient symptoms suggest mild allergic reaction, stop transfusion, administer antihistamine, and restart or discontinue transfusion per health care provider's order.

c. Maintain patent VAD using 0.9% sodium chloride (NS) at rate prescribed by health care provider.

d. Obtain vital signs. Remain with patient for continuous monitoring and assessment. Do not leave patient alone.

e. Notify health care provider.

f. Notify blood bank.

g. Obtain blood samples (if needed) from extremity opposite extremity receiving transfusion. Check agency policy regarding number and type of tubes to be used.

h. Return remainder of blood component and attached blood tubing to blood bank according to agency policy.

i. Monitor patient's vital signs every 15 minutes or per agency policy.

j. Administer prescribed medications according to type and severity of transfusion reaction.

(1) Epinephrine

(2) Antihistamine

(3) Antibiotics

(4) Antipyretics/analgesics

(5) Diuretics/morphine

(6) Corticosteroids

(7) Intravenous (IV) fluids

k. In event of cardiac arrest, initiate cardiopulmonary resuscitation

l. Obtain first voided urine sample and send to laboratory. You may need to insert Foley catheter to obtain urine.

Can be delegated to NAP

• Frequency of vital sign monitoring needed.

• What to observe such as complaints of shortness of breath, hives, and/or chills and reporting this information to the nurse.

• Obtaining blood components from the blood bank (check agency policy).

Can't be delegated to NAP

-The skill of initiating transfusion therapy

-After the transfusion has been started and the patient is stable, monitoring a patient by __________ does not relieve a registered nurse (RN) of the responsibility to continue to assess the patient during the transfusion.

licensed practical nurse (LPN)

-The skill of initiating transfusion therapy by a _______________________ varies by State Practice Acts.

-The skill of monitoring for adverse blood transfusion reactions by a _______________________ varies by state Nurse Practice acts.

Indications for Parenteral Nutrition

Nonfunctional GI Tract

• Small bowel resection

• Small bowel surgery or GI bleed

• Paralytic ileus

• Intestinal obstruction

• Trauma to abdomen, head, or neck

• Severe malabsorption

• Intolerant of slow rates of enteral tube feeding

• Chemotherapy, radiation therapy, bone marrow transplantation

• Severely catabolic patients when GI tract is not functioning for more than 7 days

Nonfunctional GI Tract

• Enterocutaneous fistula

• Inflammatory bowel disease

• Severe diarrhea

• Moderate-to-severe pancreatitis

Preoperatively

• Preoperative bowel rest

• Severe malnutrition before surgery

Complications of Parenteral Nutrition

-Pneumothorax

-Air embolism

-Localized infection (exit site or tunnel)

-Catheter-related sepsis or bacteremia

-Hyperglycemia

-Hypoglycemia

Pneumothorax

-Cause: Tip of catheter enters pleural space during insertion, causing lung to collapse -Symptoms: Sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, tachycardia

-Immediate Action: Per health care provider's order, the proper professional (CRNP, PA-C, or MD) may remove the central catheter. Administer oxygen via nasal cannula. Insert chest tube to remove air under water-seal drainage or dry one-way valve system.

-Prevention: Medical personnel should be properly trained to insert central catheters.

Researchers suggest use of ultrasound when placing CVCs. Catheter should be secured properly to prevent migration, movement.