Chapter 13 Intravenous Infusion and Blood Transfusion

SECTION ONE Intravenous Infusion Definition:IV infusion is a method that a large volume of solution is infused into vein to correct fluid and electrolyte disturbance． solution; passage (infusion set); vein

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

Intravenous Infusion Fluids are medications--IV infusion requires a physician’s order the type and amount of fluid administered will be based on types of patient’s need the patient’s age general health status the results of laboratory tests

Types of solutions There are many methods of classification． according to their osmolality in relation to normal blood plasma according to their purpose Hypotonic fluids Isotonic fluids Hypertonic fluids Nutrient solutions Electrolyte solutions Volume Expanders

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

Isotonic fluids have the same effective osmolality as plasma to expand the intravascular space to correct hypovolemia as in shock examples are lactated Ringer’s, 0.9 % ( normal ) saline(0.9%NaCl), 5 % dextrose in normal saline(5%GNS). 1.4%NaHCO3 excessive infusion can cause circulatory overload and pulmonary edema

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

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

Electrolytes solutions contain varied amounts of cations and anions examples are normal saline，Ringer’s solution, and lactated Ringer’s solution commonly be used to restore vascular vo1ume，particularly after trauma or surgery also be used to replace fluid and electrolytes for patients with continuing losses，for example，gastric suction or wound drainage

Volume expanders be used to increase the blood volume following severe loss of blood or loss of plasma examples are dextran，plasma，and human serum albumin

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

Crystalloid Solution have small molecular weights and stay in blood vessel for a short time maintain the balance of fluids in intracellular and extra- cellular correct the fluids and electrolytes disturbance commonly used crystalloid solutions are： Dextrose in Water Solutions Isotonic Electrolytes Solutions Alkaline solutions Hypertonic Solutions

Dextrose in Water Solutions Be used for fluids and calories replacement，decreasing the consumption of albumen，and preventing the production of ketone． glucose is decomposed quickly in body, usually doesn’t cause hypertonic and diuretic effects． Clinically there are usually 5％GS and 10％GS (25%GS; 50%GS rarely used)

Isotonic Electrolytes Solutions be used in electrolytes replacement． Loss of body fluids usually is accompanied with disturbance of electrolytes．So, the balance of fluids and electrolytes must be maintained during fluids replacement． examples are o.9％ NaCl，Ringer’s isotonic solution and 5% GNS．

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

Hypertonic Solutions be used for diuretic and dehydration purposes increase osmolality of blood plasm pulling fluids into plasma reduce the edema of tissues can decrease intracerebral pressure and improve the function of central nervous system． Clinically，mannitol 20%，sorbitol 25％ and dextrose 25％-50％ in water solutions are often used．

Colloidal Solution have large molecular weight，can stay in blood for a long time can maintain plasma colloid osmotic pressure effectively， expand the blood volume， improve microcirculation， elevate the blood pressure． examples are ：dextran plasma substitutes blood products

Dextran It is water-soluble polysaccharide of high molecular polymer． moderate molecular dextran : elevate plasma colloid osmotic pressure，expand blood volume small molecular dextran : reduce the viscosity of blood，decrease the accumulation of erythrocytes，improve microcirculation and tissue perfusion volume，and prevent the formation of thrombosis

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

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

Parenteral Nutrition Solutions be intravenously given to the patients who are unable to get nutrition via gastrointestinal tract or have inadequate intake of nutrients provide calories，proteins，vitamins and minerals，and maintain the balance of nitrogen main compositions : amino acids，fatty acids，vitamins，minerals，high concentration of glucose ，and water commonly used solutions : multiple amino acids solutions , fat emulsions

sequence principle of solution transfusion First crystalloid solutions then colloidal solutions First sodium chloride solutions then dextrose in water solutions first fast then slow, rather shortage than overload rather acid than alkaline Potassium solutions properly

Sites of Venipuncture Peripheral Superficial Vein veins in dorsal hands : the first choice for adult patients median cubital，basilic，cephalic veins :drawing blood bolus injections of medication PICC The saphena veins in legs and veins in dorsal feet are not the first choice because of the danger of thrombosis caused by the vein valve． Veins in dorsal foot are commonly used for children，but are avoided in adults because of the danger of thrombophlebitis． Veins in the Scalp :for infants Subclavian，External Jugular:for central venous access

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

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

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

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

Procedures and Key Points 1.Check and right the bed number，the patient’s name，medication name， concentration， dosage， date and usage the quality of solution(the cap of bottle, the expiration date , deposition，cloudiness， foreign matter, any cranny on the bottle’s body) 2. Complete the medication label and stick it to the solution container

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

7.Select the venipuncture site(pad , tourniquet ) 8.Sterilize the venipuncture site．Prepare adhesive tape. 9.Check again. 10. venipuncture The wizened The obese The elderly The dropsical (edema)

11.fixation 12. Regulate the flow rate 13. Check again. 14. Disposure after operation (equipment,patient) 15. Change bottles 16. Disposure after infusion

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

Cautions 4. Prevent air embolism by ejecting air thoroughly in infusion set, changing fluid bottles and withdrawing the venipuncture needle in time. 5. Assess for compatibility of medications. Ensure the needle have been inserted into vein before administration irritative or special medications. 6. Master the flow rate strictly. 7. Assess during infusion carefully in order to find the problems and settle the problems on time. Document the result after assessment.

Education 1. Tell the patient don’t regulate the flow rate optionally. 2. Introduce the signs and symptoms of complications with IV reactions, ask patient call nurse in time when he find the signs of IV reaction. 3. Instruct the patient to report any blood in the tube，a stoppage in the flow，or increased discomfort． 4. Intensify mental nursing to patient who need long-term IV infusion.

Evaluation Assess the status of the skin and dressing of IV site by observing whether there is heat，pain，redness，or swelling Whether the IV flows smoothly and whether the flow rate is consistent with what is ordered Check the information to ensure the right medication administered Signs and symptoms of complications with intravenous infusion Patient’s knowledge about medication and infusion Ability to perform self-care activities.

Regulating the Infusion Flow Rate Calculate the Flow Rate Common Infusion Control Device

Calculate the Flow Rate Total time of infusion (h) = Total infusion vo1ume (m1)×drop factor (drops/m1) Drops per minute×60 Drops per minute= Total time of infusion (min)

Calculate the Flow Rate Slow flow rate is suitable for the elderly，infants and patients with diseases in heart, 1ungs，or kidney． When hypertonic solutions，solutions containing potassium，or solutions containing medications for raising blood pressure are infused，the flow rate also should be slow． When a patient with normal heart and lung function has severe dehydration，the flow rate should be rapid．

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

The Usage of Infusion Pump

Assessing during infusion The responsibilities of nurses in assessment are： keeping the system sterile； changing solution，tube，and dressings on time； assisting the patient with self-care activities so as not to disrupt the system; instruct the patient to report any blood in the tube，a stoppage in the flow，or increased discomfort．

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

Slow Flow Rate or No Infusion Infiltration occlusion of the IV Needle or Catheter hyperkinesia of Vein Too Low Hydrostatic Pressure

Infiltration Cause:the needle dislodge from the vein and fluid exude in the subcutaneous space Signs: insertion site becomes swollen，clammy, and painful Alternative nursing actions: :discontinue IV and establish a new line at a new site

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

hyperkinesia of Vein Causes: extremity is exposed in cold environment for a long time the temperature of the fluid is too low Alternative nursing action: warm the extremity

Too Low Hydrostatic Pressure Raise the solution container increase hydrostatic pressure increase the flow rate

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

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

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

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

Fever Causes: allergic reactions to a medication or IV fluid impureness of the solution incomplete sterilization of the equipment no strict application of aseptic techniques during starting an IV Symptoms and signs: feel cold，trembling and with increased body temperature to 38℃ to 40℃ or higher． Systematic reactions may be present，such as nausea， vomiting，headache，and tachycardia．

Fever Preventions inspect the quality of solutions，the package of intravenous set and date of sterilization carefully Interventions reduce the flow rate or stop infusion and notice the physician immediately Give physical cold therapy to patient with T> 39℃ Administer the antiallergic medication according to physician’s order if necessary. Keep the residual solution，medication，and equipment for the laboratory test．

Phlebitis，Thrombosis，and Thrombophlebitis Causes: irritation to the lining of blood vessels chemical irritation to tissues by IV solutions or medications mechanical irritation to tissues by the needle or catheter localized allergic reaction to the indwelling catheter or needle local infection by undemanding sterile performance during initiating infusion

Phlebitis，Thrombosis，and Thrombophlebitis Symptoms and Signs feel pain in local site，with increased skin temperature swelling over the vein redness traveling along the path of the vein in some cases systemic reactions may be present，such as fever，chill

Phlebitis，Thrombosis，and Thrombophlebitis Preventions To follow sterile principles strictly，and protect the 1ocal site from contamination． Irritating medication should be diluted thoroughly and infused slowly． The needle should be secured firmly to prevent the needle sliding out of the vein．

Phlebitis，Thrombosis，and Thrombophlebitis Interventions Discontinue infusion and start IV at another vein． Apply warm compresses with 50％ magnesium sulphate． Use physical therapy of ultrashort wave on local site． If there is infection，use antibiotics according to physician’s order．

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

Circulatory overload reaction --acute pulmonary edema Symptoms and Signs: chest pressed，shortness of breath，cough, frothy or pinkish sputum，facial paleness，diaphoresis，neck vein distention，rales in the lungs，rapid heart rate，arrhythmia，rapid weight gain，pitting edema，and tachycardia

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

Circulatory overload reaction --acute pulmonary edema Interventions slow the rate of infusion or stop the infusion immediately，notify the physician assume a Folower’s position with the feet dangling at the bedside if the patient’s condition is allowed apply oxygen administration with greater flow rate, put 20％ to 30％ ethanol solution into humidified bottle administer the sedative，vasodilators，antiasthma，digitalis，and diuretics to the patient according to the physician’s order apply tourniquet to limbs of the patient in alternation in order to reduce the venous return if necessary

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

Air Embolism Symptoms and Signs feel discomfort in chest or pain under the sternum，with the presence of decreased blood pressure，cyanopathy，tachycardia，increased venous pressure， and unconsciousness Clear and continuous bubble sound can be auscultated．

Air Embolism Preventions inspect the quality of infusion set connect every part tightly ejecting air in tubing thoroughly check the tubing below the chamber to make sure no air after changing the bottle of solution appoint a nurse to watch the patient with press infusion have patient place head below heart level or perform Valsalva maneuver while changing tubing on central venous lines

Air Embolism Interventions help the patient to turn on left side with head down administer oxygen therapy with high flow rate for the patient monitor vital signs and notify the physician

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

Infection or Inflammation at the Insertion Site Causes Microorganisms gain access to the tissue and circulatory system through the tip of needle or cannula device inserted during venipuncture Microorganisms enter later by migration along the interface between the catheter and tissue Symptoms and Signs the local tissue may have redness，edema，heat，pain，and perhaps exudation．The patient may have systemic reactions，such as fever

Infection or Inflammation at the Insertion Site Preventions Using aseptic technique for all IV-related care; keeping dressing dry; changing dressing on time Interventions remove IV to another site if necessary apply cool compress to site as ordered by the physician elevate limb，and observe for signs of sepsis

INTRAVENOUS INDWELLING NEEDLE INFUSION Purposes Preparation Procedures Cautions

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

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

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

Procedures 1. Check and right 2. Complete the medication label 3. Add medications into solution 4. Insert the infusion set 5. Prepare the equipment and take them to the bedside．Check again 6. Discharge air

Procedures 7. Wear gloves, prepare IV indwelling needle Check the quality of the IV indwelling needle take out the indwelling needle sterile the heparin cap insert spike of infusion set into the heparin cap discharge again Close the clamp protect the indwelling needle

Procedures 8. Select the venipuncture site (1) Place a pad under the extremity (2) Apply a tourniquet firmly 10 to 15cm above the venipuncture site． 9. Sterilize the venipuncture site．(>10cm) 10.Check again.

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

Procedures 12. Fixation 13. Regulate the flow rate 14. Check again. release fist, tourniquet，and clamp Open the sterile adhesive tape bag, take out the crystal adhesive tape, and secure the injection site hermetically. Loop the tubing near the site of entry，fix with adhesive tape, and write down the date of installation on the tape． 13. Regulate the flow rate 14. Check again.

Procedures 15. Disposure after operation 16. Change bottles 17. Disposure after infusion After infusion，close the roller clamp，withdraw the needle from the heparin cap, sterile the heparin cap and seal the catheter with 0.9%NS in positive pressure Close the Luer Lock of primed IV catheter set to peripheral cannula Help the patient to have a comfortable position． Record the volume of fluid infused and the time of the discontinuation Dispose of the equipment in proper manner Wash hands. Document relevant data

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

EXTERNAL JUGULAR VENOUS CATHETER INFUSION Purposes Preparation Procedures Cautions

Purposes 1. Measurement of central venous pressure (CVP)； 2. Apply a venous access when no peripheral veins are available； 3. Administration of vasoactive medications which cannot be given peripherally； 4. Administration of hypertonic solutions including total parenteral nutrition.

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

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

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

Procedures Steps 1 to 6 are the same as described in Peripheral Intravenous Infusion 7. Select the position 8. Select insertion site and sterile the skin 9. Open the sterile venipuncture package, wear sterile gloves, and drap the area 10. Infiltrate the skin and deeper tissues with local anaesthetic 11. Insert the catheter and cover with a sterile dressing 12. Connect with infusion set

Procedures 13. Regulate the flow rate 14. Check again. 15. Disposure after operation 16. Change bottles 17. Disposure after infusion Seal the catheter with a small volume of dilute heparin ( 100 U/ml ) into the lumen. Clamp catheter lumen using online slide clamp. Stuff the needle hub hole with a sterile injection cap. Catheter insertion site protection and stabilization are accomplished by regular antimicrobial cleaning and sterile dressing changes every day.

Procedures 18. Infusion again 19. Withdraw the catheter Remove the sterile injection cap, sterile the needle hub hole, connect with infusion set, unclamp lumen, then initiate IV infusion. 19. Withdraw the catheter The lumen of the catheter connect with a syringe, withdraw the catheter while pump the syringe, press the insertion site for several minutes. Sterile the local skin with 75% ethanol solution, and cover it with sterile dressing.

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

Cautions 4. Seal the catheter with positive pressure after infusion to prevent occlusion of the catheter. Clot appears in the catheter should be sucked use a syringe to avoid to be pushed into blood circulation. 5. To stabilize and protect catheter site to prevent contamination or dislodgement. Observe the injection site carefully in order to find the complications and settle them on time.

SUBCLAVIAN VENOUS CATHETER INFUSION (self-study)

INFUSION PARTICLE CONTAMINATION (self-study)

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