iv therapy complete
TRANSCRIPT
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GEORGE MICHAEL P. LIM, RN, MN-NAS
Corporate Chief For Nursing
Director, TRAINING AND STAFF DEVELOPMENT
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INDICATIONS/PURPOSES:
Establish or maintain a fluid or electrolyte balance
Administer continuous or intermittent medication
Administer bolus medication
Administer fluid to keep vein openAdminister blood or blood components
Administer intravenous anesthetics
Maintain or correct a patients nutritional state
Administer diagnostic reagents
Monitor hemodynamic functions
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Drop factor
1. Macrodrop gtt; 15gtt/ml
2. Microdrop mgtt; 60 mgtt/ml
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FLUID & ELECTROLYTES
Fluid compartments:1. Cells
2. Blood vessels
3. Tissues space
Types of Fluid:
1. Intracellular Fluid 2/3 or 70% of the body fluid2. Extracellular Fluid 1/3 or 30% of the body fluid
1/4 intravascular
3/4 interstitial fluid
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functions of water:
1. Transporting nutrients to cells and wastes from cells
2. Transporting hormones, enzymes, blood platelets, andred and white blood cells
3. Facilitating cellular metabolism and proper cellularchemical functioning
4. Acting as a solvent for electrolytes and nonelectrolytes
5. Helping maintain normal body temperature
6. Facilitating digestion and promoting elimination
7. Acting as a tissue lubricant
(-) Effect of water loss: every 2% to 5% water loss --> 30%decrease in work performance.
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Electrolytes
Active chemicals that carry positive (cations)and negative (anions) electrical charges
Major cations: Major anions: Sodium
Potassium
Calcium
Magnesium
Hydrogen ions
Electrolyte concentrations differ in the fluid
compartments
Chloride
Bicarbonate
Phosphate
Sulfate
Proteinate ions
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Electrolytes (cont.)
Major cation in ECF
Sodium
Major cation in ICF
Potassium
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Physiological functions in
the body:1. Promote neuromuscular irritability
2. Maintain body fluid osmolarity3. Regulate acid-base balance
4. Distribute body fluids between the
fluid compartments
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Regulation of Fluid
Movement of fluid through capillary walls dependson:
Hydrostatic pressure
Pressure exerted on the walls of blood vessels Osmotic pressure
Pressure exerted by the protein in the plasma
The direction of fluid movement depends on thedifferences of hydrostatic and osmotic pressure
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Regulation of Fluid (cont.)
Osmosis
Diffusion
Filtration
Active transport
http://osmosis.ppt/http://diffusion.ppt/http://filtration.ppt/http://active%20transport.ppt/http://active%20transport.ppt/http://filtration.ppt/http://diffusion.ppt/http://osmosis.ppt/ -
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INTRAVENOUS SOLUTIONS
Isotonic Solutions:
Type:
- Normal Saline 0.9% NaCl
- D5W: acts as a hypotonic solution in the body
- Ringers Solution
- Lactated Ringers Solution
Nursing Responsibilities:- Expands the intravascular compartment.
- Monitor for fluid overload.
- avoid D5W if at risk with increase ICP
http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/ -
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Hypotonic Solution:
Type:
- 0.33% NaCl
- 0.45% NaCl
- 2.5% Dextrose
Nursing Responsibilities:
- these solutions shift fluid from the intravascularcompartment into the cells
- contraindicated for clients with increased ICPbecause of shift into the brain cells
- also contraindicated for clients who are at riskfor 3rd-space fluid shifts
http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/ -
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Hypertonic Solutions:
Types:
- D5 0.45%NaCl - 3.0% NaCl
- D5NSS - Sodium Bicarbonate 5%
- D5LR
Nursing Responsibilities:
- expands the intravascular compartment
- contraindicated for clients with kidney andheart problem
- contraindicated for clients who are dehydratedbecause it draws fluid from the intravascular
compartment
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Electrolyte Solutions:
contain varying amounts of cations and anions
includes:
- 0.9% NaCl
- Ringers Solution: with Na, Cl, Ca, & K
- Lactated Ringers Solution: same as above withlactate. Lactate is salt of lactic acid that is metabolized inthe liver to form HCO3
saline solutions are frequently used as initialhydrating solutions
multiple electrolyte solutions approximate the ionicprofile of plasma and are used to prevent dehydration orto restore or correct fluid and electrolyte imbalances
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Nutrient Solutions:
contain some form of carbohydrate
(dextrose and glucose) and water
water is supplied for fluidrequirements while carbohydrate is forcalories and energy
useful in preventing dehydration and
ketosis but do not provide sufficientcalories for wound healing, weight gain ornormal growth in children
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Alkalinizing Solutions:
administered to counteract metabolicacidosis.
example: Lactated Ringers Solution
Acidifying Solutions:
administered to counteract metabolicalkalosis.
example: 0.45% NaCl and 0.9 % Nacl
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Blood Volume Expander:
used to increase the volumeof blood following severe loss of
blood or loss of plasma
examples: dextran, human
serum albumin
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PERIPHERAL VENIPUNCTURE SITES
- site chosen varies with clients age, the length of
time the infusion to run, the type of solution used.ARM:
- cephalic vein - accessory cephalic vein
- basilic vein - median cubital vein- median antebrachial vein - radial vein
HAND:
- basilic vein - dorsal venous network- cephalic vein - dorsal metacarpal veins
FOOT:
- great saphenous vein - dorsal plexus
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Venipuncture sites
The site chosen for venipuncture
varies with:
Age
Length of time of infusion is to
run The type of solution used
Condition of the veins
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Venipuncture sites
The metacarpal, basilic and cephalic veins arecommonly used for intermittent andcontinuous infusions
Although the basilic and median cubital veinsin the anticubital space are convenient sitesfor the venipuncture, they are usually used for
blood draws, bolus injections of medicationsand insertion sites for a PICC
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GUIDELINES FOR VEIN SELECTION
- use distal veins of the arm first
- use the clients non-dominant arm wheneverpossible
- use veins in the feet and legs only when arm
veins are inaccessible, since they are more proneto thrombus formation and subsequent emboli
- select a vein that:
a. is easily palpated and feels soft and fullb. is naturally splinted by bone
c. is large enough to allow adequate
circulation around the catheter
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- avoid using the following veins:
a. those areas that are highly visible
since they tend to roll away from the needle
b. those damaged by previous use,phlebitis, infiltration or sclerosis
c. those continually distended withblood or that have been knotted or tortous
d. veins of surgically compromised orinjured extremity because of possibleimpaired circulation and discomfort for theclient
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INTRAVENOUS EQUIPMENT
- infusion set tubing, specify if for adult, child
or for blood transfusion- sterile parenteral solution - clean gloves
- IV pole - tourniquet
- antiseptic swab - IV catheter
- adhesive or non-allergenic tape
- antiseptic ointment such as Betadine
- gauze squares or other appropriate dressings
- arm splint if required
- towel or pad
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INFUSION
SET &
EQUIPMENT
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VOLUMETRIC SET
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HEPARIN LOCK
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STARTING INTRAVENOUS INFUSION
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STARTING INTRAVENOUS INFUSION
1. Check the doctors order. Verify the type of solution, the
amount to be administered and the rate of the infusion.
2. Take the initial assessment of the client. (Vital signs,skin turgor, bleeding tendencies, disease or injuries of
the extremity, status of the veins)
3. Explain the procedure to the client.
4. Provide any scheduled care before establishing the
infusion to minimize movement of the affected limb
during the procedure.
5. Prepare the equipment. Check the clarity, expirationdate and sterility of the IV solution as well as the tubing
and the venipuncture set or IC catheter.
6. Do handwashing.
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7. Open and prepare the infusion set aseptically.
a. Remove the tubing from the container and
straighten it out.
b. Slide the tubing clap along the tubing until itis just below the drip chamber.
c. Close the clamp/regulator.
d. Leave the ends of the tubing with plastic capuntil the infusion is started.
8. Open the seal of the IV solution and disinfectthe port with cotton balls with alcohol.
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9. Spike the solution container aseptically.
a. Remove the plastic cap of the spike and insertit to the solution.
b. Follow agency protocols regarding insertion. Itis recommended though, that twisting motionbe not applied while inserting the tubing to
the bottle.
10. Hang the solution container on the IV pole.Adjust the pole so that the container issuspended about 1 meter above the clientshead.
11. Partially fill the drip chamber with solution.Squeeze the drip chamber gently until it is half
full.
12. Prime the tubing.
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12. Prime the tubing.
a. Remove the protective and hold the tubing over acontainer. Maintain sterility of the end of the
tubing and the cap.b. Release the clamp and let the fluid run through the
tubing until all the bubbles are removed. This isdone to prevent air from entering the client.
c. Re-clamp the tubing and replace the tubing capwhile maintaining sterility.
13. Apply appropriate labels to the solution container.Include the clients name, solution, drugs
incorporated, date, time infusion started and IVFregulation.
14. Apply a timing label on the solution container.
15. Wash hands again if necessary.
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16. Select and prepare the venipuncture site.Starting at the distal end of the vein, select a siteby palpating accessible veins.
17. Dilate the vein:
a. Place the arm in a dependent position or lowerthan the clients heart. Gravity slows venous
return and distends the vein.
b. Apply tourniquet firmly to about 4-6 inchesabove the venipuncture site. It should be tight
enough to obstruct venous flow but not so tightto occlude the arterial flow.
c. Check by palpating the radial pulse.
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18.Put on clean gloves, and clean thevenipuncture site with the povidone-iodine or
alcohol. Use circular motion going from thecenter towards the outside of the venipuncturesite. Permit the solution to dry into skin beforeinsertion.
19.Insert the IV catheter and initiate the infusion.
20.Tape the catheter. Commonly used is the Umethod but methods may vary according to
manufacture.
21.Dress and label the venipucture site andtubing according to agency policy.
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22. Ensure appropriate infusion flow.
23. Label the IV tubing.
24. Document relevant data including
assessments.
REGULATING INTRAVENOUS FLOW RATES
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REGULATING INTRAVENOUS FLOW RATES
nurse should first determine the drop factor of theinfusion set used. It is printed on the packaging of the
infusion set.
to calculate the flow rates, nurse must know thevolume of the fluid to be infused and the specific timefor the infusion
millimeters per hour: volume to be infused
total time of the infusion
drops per minute: total infusion X drop factor
# of hours to infuse X 60 minutes
electronic infusion devices (EID) devices thatregulate the infusion depending on the presets selected
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FACTORS INFLUENCING
FLOW RATESposition for the forearm
position and patency of the tubing
height of the infusion bottle
possible infiltration or fluid leakage
relationship of the size of the IVcatheter to the size of the vein
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MONITORING AN INTRAVENOUS INFUSION
observe the rate of flow every hour
inspect the patency of the IV tubing and needle
observe the tubing for pinches or kinds of obstructionto flow
open the drip regulator and observe for a rapid flow(rapid flow would indicate patency)
regulate the infusion after checking patency
lower the IVF bottle below the insertion site to note
blood backflow
inspect the insertion site for fluid infiltration, dislodgedneedle, phlebitis or bleeding
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teach the client ways to maintain the infusionsystem:
- call for assistance if:
a.The solution is not dripping
b.The venipuncture site is swollen
c.There is a sudden change in the flow rate
d.The solution container is nearly empty
e.There is blood in the IV tubing
- avoid sudden twisting or turning of the arm wherethe insertion site is
- avoid stretching or placing tension on the tubing
- document all relevant information
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TROUBLESHOOTING IV PROBLEMS
PROBLEM ACTION1. IV off Schedule Figure rate to finish over remaining time ( if >3cc/hr, consult
physician
2. Incorrect
Solution
Slow rate to a minimum while initiating change to correct
solution assess patient. Notify Physician
3. Flow stopped To reestablish Flow:
Look for obstruction of tubing and correct if present
Open regulator completely, move to new position, and regulate
again if flow begins
Reposition arm
Place bottle lower than needle to see if blood flows back, which
would indicate tubing is patent
Gently raise needle hub. If this starts to flow, support hub with
cotton ball or gauze.
Pinch off tubing close to arm above soft rubber section of tube
then squeeze firmly
Obtain sterile needle & syringe. Insert into injection port closestto needle. Pinch off tubin s rin e and as irate. Then o en flow.
PROBLEM ACTION
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4. Tubing Kinked Straighten tubing and check flow rate again
5. Bubbles in tubing For a few small bubbles high in tubing:
Turn off flow - Stretch tubing downward
Flick tubing with fingers - Start flow rate & regulate
For large amount of air high in tubing:
Turn off flow
Insert sterile open needle into injection port to close air
Open flow slowly - Start flow & regulate
For air low in tubing, below last port:
Turn off flow - Obtain sterile needle & syringe Insert into last port closest to patient
Pinch tubing distal to the port & close it off
Aspirate air into syringe
Start flow rapidly to flush out blood
Regulate flow
6. Drip Chamber full of
fluid
For flexible drip chamber:
Pinch off tubing - Invert container
Squeeze fluid back into container - Hang up bottle
Release tubing
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CHANGING AN IV SOLUTION
1. Verify the doctors order for the IV solutionto follow.
2. Explain the procedure to the client andassess IV site for complications. Check the
date of the IV insertion. Ideally, insertionsite should be changed every 72 hours.
3. Wash hands before and after the procedure.
4. Prepare the necessary materials. Check thesterility of the IV solution.
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5. Place the necessary labels on the IVsolution.
6. Open and disinfect the rubber port of theIV solution to follow.
7. Close the clamp or kink the tubing justbelow the drip chamber, then remove theexisting bottle, and then spike thesolution to follow aseptically.
8. Open the clamp or un-kink the tubing andregulate the new solution as prescribe.
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COMPLICATIONS OF IV THERAPY
COMPLICATION MANIFESTATION NURSING
INTERVENTIONSINFILTRATION - blanching of the
skin
- edema
- swelling- pain at site
- cool to touch
- decrease infusion
- apply, tourniquetabove the infusionsite, if infusioncontinues to drip, it
is infiltrated
- discontinue IV,reinsert in a newsite
- apply warmcompress toincrease fluidabsorption
- apply steriledressing
- elevate arm
PHLEBITIS d di ti IV
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PHLEBITIS - redness
- heat
- swelling IV site- possible pain
- red line along thecourse of vein
- discontinue IV
- reinsert newsite
- apply warmcompress
THROMBO
PHLEBITIS
- pain
- swelling
- redness, warmth
around IV site orpath of the vein
- fever]
- leukocytosis
- d/c IV;reinsert IV onthe other
extremity- apply warmcompress
- elevate arm
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HEMATOMA - ecchymosis
- STAT IV siteswelling
- leakage of
blood at the IVsite
- d/c IV, reinsertin oppositeextremity
- apply pressure
with steriledressing
- apply ice bag for24 hours thenwarm compress
CLOTTING decrease IV d/c IV
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CLOTTING - decrease IVflow rate
- backflow of
blood into IVtubing
- d/c IV
-dont irrigate or milkthe tubing
-dont increase therate or hang it higher
-dont aspirate theclot from the cannula
- urokinase may beused
PYROGENIC
REACTION
- fever, chills
- gen. malaise- N/V
- head & backache
- d/c IV STAT
- monitor V/S- notify the physician
- retain IV equipmentfor culture study
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AIREMBOLISM
- dyspnea
- cyanosis
- hypotension- tachycardia
- loss ofconsciousness
- d/c IV STAT
- turn client tothe left sidewith head down
- ad. O2
- notify the
physicianCIRCULATORY
OVERLOAD
- SOB; increase BP
- restlessness
- coughing
- frothy sputum
- crackles
- engorge neck veins
- slow IVF rate
- monitor V/S
- notify thephysician
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DISCONTINUING IV INFUSIONS
Infusions are discontinued for one of the 3
reasons:
a. the clients oral fluid intake and hydrationstatus are satisfactory, so that no further IV
solutions are orderedb. there is a problem with the infusion that
cannot be fixed
c. the medications administered byintravenous route are no longer required
STEPS IN DISCONTINUING IV INFUSION
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STEPS IN DISCONTINUING IV INFUSION
1. Verify doctors order to discontinue Iv infusion or IV
medications.2. Assess and inform the patient of the order.
3. Prepare the necessary materials:
a. IV trayb. Sterile cotton balls with alcohol. Supply with
pick-up forceps
c. Sterile-dressing depends on hospital policy
d. Antiseptic solution
e. Plaster
f. Kidney basin
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10. Inspect IV catheter for completeness.
a. Check the IV catheter if it is intact.
b. Report broken catheter to the nurse in chargeor the physician immediately.
c. If the broken piece can be palpated, apply a
tourniquet above the insertion site.
11. Discard all waste materials including the IVcannula depending on hospital protocols.
12. Document the discontinuance, status of theinsertion site, and integrity of IV catheter.
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ALTERNATE VENOUS ACCESS
DEVICES1. Implantable Venous Access Devices
- used in the management of client with
chronic illness who require long term IVtherapy
- this device provides repeated access to the
central venous system while avoiding traumaand complications of multiple venipunctures
2 Central Venous Catheter
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2. Central Venous Catheter
- a catheter inserted into a large vein locatedcentrally into the body like in the vena cava orin the right atrium
- tubing is radio-opaque so that it will show upon x-ray for continuation of its placement
Insertion sites include:
a. subclavian: infraclavicular approach
supraclavicular approach
b. internal jugular vein
c. peripheral vein
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TYPES OF CENTRAL VENOUS ACCESSDEVICES
1. Peripheral Inserted Central Catheter (PICC)
- venipuncture is performed above or below
the anticubital fossa into the basilic, cephalic,or axillary veins of the dominant arm
- tip of the catheter is in the superior venacava or brachiocephalic veins
- may stay in place for up to 6 months
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2. Midline Catheter (MLC)
- increases in size 2 hours after insertion andbecomes softer
- venipuncture is 2-3 finger breaths above theantecubital fossa into thecephalic, basilic, or
median cubital vein
- tip of the cathete is between the antecubitalfossa and the head of the clavicle
- may stay in place of 1-8 weeks
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Complications:
- thrombosis - bleeding
- phlebitis - vascular perforation
- air embolism - infection
Nursing Care:
- change dressing 2-3 times a week, and whenwet or non-occlusive
- flush line after each infusion or every 12 hourswith 5-10 ml of normal saline followed by 1 mlHeparun (100/ml)
- anchor catheter securely
3 Percutaneous Central Catheters
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3. Percutaneous Central Catheters
- inserted through the subclavian vein
- triple lumen central catheter
a. distal lumen - G. 16: use to infuse/drawblood samples
b. middle lumen - G. 18: used for TPN infusionsc. Proximal Port - G. 18: used to infuse or draw
blood and administer medications
- extreme right atrial catheters Hickman/Broviac &
Groshong
- subcutaneous port Huber needle used to accessport through skin
Insertion:
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- place supine in head-low position: dilates thevessels and prevents air embolism
- patient turns head away from site duringprocedure
- while catheter is being inserted, patient
performs Valsalva maneuver
- antibiotic ointment and transparent dressingapplied using sterile technique
- verify position of tip of catheter by x-ray
- each lumen is secured with Leur-lock cap, andlabeled to indicate location (proximal, middle,distal)
Nursing Care:
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Nursing Care:
- site or catheter changes every 4 weeks
- each lumen flushed initially then twice a day withdiluted heparin to ensure patency
- flushed also after each infusion, specimen withdrawalor when disconnected
- never use force to flush catheter if resistance met,notify physician
- dressing changes every 2-3 times a week and PRN place in low fowlers position
- nurse and patient should wear mask
- alcohol and iodine swabs are used to clean site
change IV tubing every 2 4 hours