overview iv therapy
TRANSCRIPT
Test 1- WALDEN
IV THERAPY: 1. PURPOSE- To access the venous circulation in order to draw blood for laboratory
screens and diagnostic tests or to administer fluids, electrolytes, medications, blood,
blood products ,and nutritional supplements.
Indicated for situations when oral or other parenteral routes are not
appropriate.
Continuous IV administration
Intermittent IV is used primarily for IV medication administration
Bolus increase in medication immediately
IV medications bypass the enzymatic process of the liver
Nursing Responsibilities
Knowing IV sets and their functions
Calculating IV drip rates
Mixing and diluting medications in IV fluids
Knowing the medications, purposes, and side effects
Nursing Responsibilities continued
Assessment of the client, site, infiltration, rates, adverse reactions, therapeutic actions
IV route is the fastest onset of medication administration, however, once injected, the
medication can not be retrieved
IV route could provide a direct route for contamination with pathogens
Closely monitor the client for adverse reactions
IV Considerations
Is fluid loss severe or life-threatening?
What is missing?
What is current health status? Co- morbidities: cardiac, renal, liver, pulmonary, I & O
Daily weight – fluids calculated on changes in current weight
*Two kilograms of weight gain is equivalent to 2 liters of fluid gain
5 pounds = 2.5 liters fluid
Restoring fluids by IV
Why: fluid/ blood loss, precautionary
Large IV ideal but…. Difficult to find a vein
Small bore initially- large (18-20GA) once fluids reestablished
IV pump to regulate infusion and decrease risk of too rapid an infusion
Monitor sites, solution, and outcomes frequently
Restoring fluid risks
Renal, cardiac, pulmonary overload
Overflow diuresis without cellular replacement
Hypernatremia with diuresis
Dilution of electrolytes
INTRAVENOUS THERAPY
1. Goal: Correct or prevent fluid & electrolyte disturbances Allows for direct access to the vascular system, permitting the infusion of continuous fluids over a period of time Must be continuously regulated because of continuous changes in the client’s fluid & electrolyte balance.
2. Types of IV catheters: Peripheral Venous Catheters Central venous catheters (central lines) Peripherally inserted central venous catheters (PICC lines) Central hemodialysis catheters
A. Peripheral Catheters: -Common type- over the needle catheter Color coded Tip should be radiopaque -Less common- through the needle catheterbutterfly
Potter page 446- 447
Read regarding flow rate, sites, large gtt
Flow factor and micro drip factor for slow IV infusions as PEDs.
EID (Electronic infusion device)
Gather supplies
Assess patient for safe site
Common sites in adult veins in hands and arms
See & Know figure 15 – 5 pg446 PP Basic.
approach
Sites to avoid
Areas of inflammation
Infiltration
Thrombosis
Mastectomy sides
IV grafts sites
Avoid adult foot
Use most distal when possible, allowing proximal sites for subsequent venipuncture
Elderly Perry Potter Basic 447 box 15 – 3
Use of tourniquet
Site to avoid
Gauge to use
Insertion angle
Flow rate for IV medication
Skin barrier recommendation
Use of netting to secure
Avoid restraints precaution
Mental status assessment
EID
Gauge and Fluid Rate
24 gauge (yellow) = 15-25ml/min
22 gauge (blue) = 26-36 ml/min
20 gauge (pink) = 50-65 ml/min (maintenance rate)
18 gauge (green) = 85-105 ml/min
(when large bolus rapid infusion needed)
Geriatrics
22 – 24 gauge
Tourniquet may not be necessary
Position hand dependent
No slapping see box 15- 3 page 447 Techniques.
Remember geriatric care.
Central venous catheters
“central lines”
Multilumen or single lumen non-tunneled
Lumens (“pigtail”) different length and color (1,3,4)
MD or NP to insert
Sutured to skin
Longer term catheters as compared to peripheral
Non-tunneled catheter
Sterile dressing changes by RN / LPN q 3-7 days or PRN
Maintenance (flushing Q shift)- RN
Central lines cont.
Uses
Blood sampling
CVP monitoring
Continuous/ intermittent drug infusions
Diagnostic testing
Simultaneous infusion of several medications
Viscous or high-volume fluids / blood
TPN (total parenteral nutrition)
PICC IV access (alternate access)
Peripherally inserted central catheters (arm)
Longer catheter, terminates at subclavian vein
Longer term than peripheral IV caths (7days to 3 months)
Must be specially trained RN
Sterile technique
Function and maintenance is same
TPN
PICC
PICC
The PICC affords a greater hemodilution which decreases the risk of phlebitis and infiltration
so stays in longer.
PICC
May be used to infuse hyper – osmolor fluids as TPN, Blood, chemical irritants and vesicants.
Central hemodialysis catheters
Subclavian, jugular, or femoral catheter
Temporary vascular access
Two ports - blue and red
Used for acute hemodialysis
MD to insert
Sutured to skin
Special training to access
Accountability and Infusion Therapy
The RN is accountable for knowing
What is ordered
Why it is intended
Impact on the patient
Any possible side effects
How to administer the infusion
How to maintain the infusion
How to discontinue properly
How to document appropriately
RN Responsibilities
“The RN remains accountable and responsible for all delegated tasks and must have a clear
knowledge of the nursing scope of practice relative to assessment, planning, implementation,
and evaluation of infusion therapy, as well as legal responsibilities associated with delegation
of nursing care activities.” (INS, 2000)
RN’s Responsibilities
Delegate certain nursing tasks to licensed and unlicensed personnel
Still responsible for tasks delegated
Must evaluate others competency, instruct them, and verify proper training
Responsibilities may vary among states and employers
Compatibility
Nurse is responsible to verify compatibility of fluids with medication administered via IV
Or if a Medication is in the IV fluid and a drug is given intermittently
Nurse must make certain fluids and drugs are compatible.
IV Therapy
RN vs. LPN
“…..responsibilities include administering medications and treatments prescribed by a
licensed or otherwise legally authorized physician.”
“…..responsibilities include administering medications and treatments, under the direction of
a licensed registered nurse or a licensed or otherwise legally authorized physician.”
No IV medications
Nurse responsible to
Observe clinet
Report any reactions
Take measures necessary to avoid complications
Assess IV site on adult every 2 hours
Pediatric and High alert medication more often)
Check point
A client has a continuously running peripheral infusion.
The physician orders a piggyback antibiotic infusion 4 times a day. In order to administer the
antibiotic, the nurse should do which of the following:
Choices:
1 start a new IV access for the piggyback antibiotic so no compatibility issues occur
2. start a new IV site to prevent fluid volume overload
3. Increase the IV fluid rate to dilute the antibiotic infusing piggyback
4. Check to see if the antibiotic is compatible with the soluitions infusing.
CONSIDER AGENCY IV THERAPY POLICY
RBCs in isotonic solution
IV THERAPY
Review
Adding medications to bag- labeling
Spiking bag, filling drip chamber
Priming (bleeding) line
Accessing ports on line
Running piggyback (secondary) with primary line
Fluid compatibility
Connecting tubing and priming lines
Open transfusion set
Insert IV tubing spike into opening of bag of fluids
Remember to keep ends sterile!!
Compress drip chamber to 1/3 full
Prime by opening roller clamp- all air bubble should be removed- then close roller clamp
Tap to remove small air bubbles
All lines must be primed including PRN loops
Flushing a saline lovk
Use approximately 1 ½ times the amount of fluid that the tubing will hold in order to flush the
tubing.
USE sterile (aseptic ) technique to prevent complications as infection.
Intermittent IV Therapy
IV Therapy that is ordered frequently for short periods of time.
EX:
Rocephin 1gm IVPB Q 12 hours x 6 doses.
Demerol 25mg IVP Q 4-6 hours PRN pain.
IV push (IVP) or IV piggyback (IVPB, secondary)
Requires tubing and site change q 48-72 hours
Frequent site monitoring
Fluid infused recorded on chart q shift
IVP (IV push medications)
Check order
Prepare medications and check compatibility with fluids
Assess site
Select port proximal to patient
Clean port with alcohol swab
Flush with 10ml of NS before medication
Insert/attach medication syringe
Occlude IV tubing above port (pinch)
Pull back gently to aspirate blood return (may not get)
Inject medication in designated time frame (look up in drug book)
Release tubing if fluids running - if saline lock, flush with 10ml of NS and lock
Small volume needs to hang higher
IV PUSH
Draw up correct dose into a 10mL syringe.
Verify dose with second nurse
Then add additional saline to syringe to equal 10 mL
Pause.
Lets think
1 mL/ over 1 minute
Let’s see that is ¼ mL/ in 15 seconds
So every 15 second interval push ¼ of a mL. This way we are more controlled and more
precise with a push over one minute.
How long will it take to give
2 mL over one minute?
1 mL over two minutes.
OK: Tell me how would you divide this to deliver the push in a controlled slow process????
Continuous IV Therapy
IV therapy that continues over a long period of time.
EX: D51/2 NS @ 75ml/hr
Requires frequent site monitoring
Fluid infused documentation (q 8 hours)
IV Tubing change q 72 hours
Site change q 48-72 hours
* Tubing and site change may vary depending on agency policy.
KVO or TKO
“KVO” or “TKO” = flow at rate to Keep Vein Open or To Keep Open
Often will see this order:
IV NS @ KVO rate
IV RL TKO rate
What do you do? There is no established minimal flow for KVO/TKO
*****Clarify MD’s order*****
May be anywhere from 30-100ml/hr but this must be specified by MD.
Bolus
Introducing a concentrated dose directly into systemic circulation quickly
Into tubing port or saline lock
Rate of administration (bolus) varies from drug to drug
May be fluids or medications
Rate for fluids should be included in MD’s order
IV solutions 101
Two basic categories:
First category:
Crystalloids: contain water, dextrose, and or electrolytes
Used to treat fluid and electrolyte imbalances
IV solutions
Second basic categories:
Colloids: referred to as:
plasma expanders or volume expanders
Increased osmotic pressure in comparison with crystalloids
Colloids remain in vascular space longer and are used for volume expansion
Volume expanders
Include: Colloids, dextran, and hetastarch.
Colloids are protein solutions as albumin, plasma, and Plasmanate ( prepared by
pharmaceutical company).
Volume Expanders
Albumin is the most abundant plasma protein in humans
USES: Albumin 5% rapid volume expansion and mobilize interstitial edema
25%
Hypoproteinemia
Volume Expansion
Others are Dextran, synthetic colloid made of glucose-
Mobilizes interstitial edema
Hetastarch (Hespan) Made from corn.
Mobilizes interstitial edema
Volume expanders
Plasma plasmanate (Plasma protein fraction
Contains human plasma proteins in Normal Saline (NS).
Increases serum colloid osmotic pressure
Types of intravenous solutions
Isotonic
Normal Saline (NS) & Ringers Lactate(RL)
Dextrose in water (D5W)
Hypotonic
0.45% Normal Saline
0.33% Saline
2.5% Dextrose
Hypertonic
Total Parenteral Nutrition (TPN)
Dextrose in Normal Saline (D5NS)
Dextrose in .45 Normal Saline (D5 ½ NS)
Isotonic “Same as blood”
Isotonic Solutions
Liver converts lactate to bicarbonate- watch pH, liver function
Has same osmolality as body fluids
Hydrates all cells without affecting movement of fluid- NO SHIFT
Expand IV compartment
Watch for overload
Used most commonly for ECF volume replacement
Isotonic solutions
Expand only ECF (IVC) no net loss or gain.
L/R contains Na KCl Cl Ca and Lactate
Same concentration as blood.
Uses
NaCl used to replace both fluid and sodium losses or
Vascular replacement in hypovolemic shock.
HYPOTONIC SOLUTIONS
OUT OF VASCULAR COMPARTMENT
Hydrates cells
Can cause sudden shift
Cardiovascular collapse
Increased ICP
Not for treatment of head injury, trauma, neurosurgery, burns
Hypotonic
Hypotonic fluid pushes fluid into cell
.
Contains more water than electrolytes
So, are there concerns with HYPOTONIC Solutions?
Push fluid into cells : Why might we see mental status change?
Why is D5 W isotonic in the bag
AND HYPOTONIC in the vein
Glucose enters the vascular compartment
Is then rapidly metabolized by the LIVER thus
Leaves water in vascular compartment.
HYPERTONIC SOLUTIONS
PULLS INTO VEIN FROM CELL
Dehydrates cells and interstitial compartments
Watch for venous overload
Not for patients with kidney failure, heart disease
Hypertonic soulutions
Expand ECF (IVC) (Draws fluid into vein)
Used to treat:
Hypovolemia
(low volume)
Hypo natremia
(low sodium)
D 50 W
Very hypertonic.
Push slowly
Let’s recall Assessment
How do we watch for FVO (Fluid volume overload)?
B/P
Lung sounds
Serum Sodium Level
Edema
JVD
What else??
Other hypertonic solutions
D 10 W or greater
Central lines should be used. To avoid shrinkage of RBCs.
IV SALINE solutions
NS (0.9 % Na CL)
Saline
3% NaCl
5% NaCl
Contains sodium and chloride in water
Uses:
Alkalosis
Fluid loss
Sodium depletion
Dextrose (dextrose in water)
D 5 W
D10 W
Uses:
Replace calories as carbohydrates
Prevent dehydration
Maintain water balance
Promote sodium diuresis
Dextrose in Saline
D5NS
D51/2 NS
D10 NS
Promotes diuresis
Correct moderate fluid loss
Prevent alkalosis
Provides calories and sodium chloride
Electrolytes
Lactated Ringers
Ringers Lactate
Contains Na, Cl, K, Ca, and lactate
Replaces fluid lost in vomiting, or GI suction,
Treat dehydration
Restore normal fluid balance
IV Additives
Vitamins & KCL are frequently added to IV Solutions
Verify adequate urine output before administering KCL
K*Under no circumstances can potassium chloride (KCL) be given IV push. A direct IV
infusion of KCL is fatal.
So Ms Verhoff if KCL is an electrolyte in the body
Why verify KCL doses?
Why are there no KCL push?
Why is an EID used for concentrated bolus administered.
What is a concentrated bolus.
TPN
Nutritional adequate hypertonic solution consisting of glucose and other nutrients and
electrolytes given through an indwelling peripheral or central line
Used as intervention in severe cases of malnutrition.
TPN ??????
Why should we monitor Glucose every 6 hours?
Why should we not allow the solution container of TPN run out?
Why should we closely monitor T P R and B/P? WBC? Infusion site? Why is asepsis so
vital?
TO START AN IV……
Demonstration in lab
Equipment and Supplies
IV catheter (24GA, 22GA, 20GA, 18GA, 16GA)
IV start kit (drape, cleaning and antiseptic preps, dressings, tape, label, tourniquet,
transparent dressing)
GLOVES
Tubing if fluids ordered, fluids ordered
Injection cap (PRN adapter) or IV loop (pigtail)
Sharps container
Flush
Volume regulator
Purpose and Selection of IV supplies
IV Catheter
Size
Conventional or safety
Fluids vs. PRN lock (saline or heparin)
Tubing and extension
Medication/ Blood administration
Pumps, dial-a-flow, volume control device (gravity)
Children
Allergy to iodine, latex, or tape
Arm board
Transparent dressing/ tape
Practice correctly
Assessment for initiating IV therapy
Assemble correct supplies
Review MD’s order
5 rights
Assess for clinical factors/ conditions
Assess previous experience/ expectations
Consider future treatments
Allergies/ lab data (betadine tape)
Planning for initiating IV therapy (goals)
F & E Balance and VS will return to normal
IV line will be patent
Site will be benign
Client will understand purpose
IV site selection
Age and status of patient
Purpose of the infusion
Duration of therapy
Condition of patient’s veins
Location of previous site(s)
Most common in lower arm and hand. If possible use the non-dominant hand/arm
Hand and arm
IV site location
Most distal in nondominiant arm
Clip hair – do not shave
Avoid bruises, scars
Large vein
Consider activity
Medical history
Children, adults
Other options as above
Implementation of IV therapy
Comfortable position, change gown
Wash hands
Open sterile packages using sterile aseptic technique
Prepare IV solution, open infusion set, spike bag, and prime line, cap, or pigtail
Place roller clamp in “off” position
Identify accessible vein and apply tourniquet (4-6 “ above proposed site)
Apply gloves
Prep site and allow to dry
Methods to distend veins
Place hand dependent
Use distal vein to proximal
Warm compress
Check arterial pulse to ensure adequate blood flow to fill veins
When prep wipe according to policy:
(P/P say distal to proximal)
Chloro-prep
Do not blot– this removes antimicrobial properties
SO how do we know how fast to regulate the flow rate??
Count drops 15 seconds x 4 = gtts / minute
Regulate flow rate
Adjust rate as prescribed by health care provider
Too slow = vein clots /occlude line or client goes into circulatory /CV collapse
Too fast = Fluid volume excess (FVE)
Calculate rates on paper.
CONT.
9. Perform venipuncture at 20-30 degree angle.
Look for blood return “flash” in the chamber. Lower the needle and advance ¼”
Stabilize cath and release tourniquet, apply firm pressure with index finger 1 ¼” above
insertion site.
Remove needle- do not recap
Connect tubing or PRN adaptor and flush
Secure IV catheter
Discard supplies
Label IV site- initials, date, time, size of catheter
Patient teaching
Document procedure
Patient Teaching
When to call the nurse
Redness, pain, blood, dressing loose
Flow stops, blood in tubing
IV pump alarm
Ambulate with IV pole, movement
Ask for assistance when needed.
Documentation
# of attempts (If several may chart “multiple attempts”)
Type of fluid and flow rate
Insertion site (Location)
Size (GA) of catheter
When infusion begun
Remember if it is not documented- IT DID NOT HAPPEN
DOCUMENTATION EXAMPLE
22GA IV catheter
2 attempts
L wrist
D5 ½ NS at 100/hr
Blood drawn
“1500 22GA IV to L wrist x 2 attempts, blood drawn and sent to lab, D5 ½ NS @100 ml/hr
per pump. Site clear, no redness or edema. -------------------------------------------------N Nurse
RN
*TIP*
Anytime you do anything with a patient’s IV (hang fluids, give medications), always check the
IV site. If the IV is not functional, then you are doing nothing for the patient. OR you may be
damaging tissue!!!!!
IV Management
Observe site every 1-2 hours, document Q 4H and PRN
Look at amount infused
Count drip rate, pump function
Check patency
Check insertion site
Observe client every hour and PRN to determine response to therapy
I&O
Weights
VS
IV Management cont.
Change site Q 48-72 hours or PRN
Must move proximal to previous site.nge IV tubing Q 72 hours or PRN
Dressing changes Q 48-72 hours or PRN
Wet, soiled, loosened, removed
Flush with 10 ml NS before and after meds
Check sites frequently.
NORMAL SALINE
Complications of IV therapy
Phlebitis
Infiltration
Hematoma
Pulmonary embolus
Air embolus
Circulatory overload
Phlebitis (thrombophlebitis)
Definition: Inflammation of a vein, often accompanied by formation of a clot
S & SX: Indicated by pain, increased skin temp, erythema along path of vein (cord along
vein)
Clots may occur
TX: Stop infusion and discontinue IV
Elevate extremity, warm moist compresses
Restart new IV if IV therapy is needed
Rotate sites Q 48-72H
Causes: Drug irritation, trauma to vein, infection, stasis, immobilization, IV catheter in place
too long
Infiltration
Definition: process in which a fluid passes through the tissues
S & SX: Indicated by swelling and possible pitting edema, pallor, coolness, pain at insertion
site, possible decrease or absent flow rate
TX: Stop infusion and discontinue IV.
Restart IV in new location if IV therapy indicated
Warm compresses and elevation of extremity
Causes: IV catheter not in vein, in surrounding tissue
Extravasatinon
REGITINE around IV SITE
DO not elevate arms
DO not apply cold or warm compress
Notify health care provider and follow instructions.
What is difference in INFILTRATION AND EXTRAVASATION??
Hematoma
Definition: collection of blood in tissue or skin due to trauma, aka: bruise
S & SX: discoloration, pain, localized edema to site
Usually self limiting
TX: Initially moderate pressure may reduce amount of bruising
Causes: trauma or incomplete hemostasis after surgery
Bleeding
Can occur around venipuncture site and under skin
Common in clients on heparin, ASA
Apply pressure dressing to site and document
ELEVATE ^ arm site above heart and apply pressure.
Pulmonary embolism
Occlusion of the portion of the pulmonary blood vessels by a clot that is carried from the
point of origin. (somewhere else)
May be lethal
S & SX: appear late, tachypnea, dyspnea, anxiety, fretfulness, and CP. Possibly hypoxemia,
diaphoresis, syncope, crackles, fever, murmurs
NEVER FORCE Flush or Irrigate IV LINE
Pulmonary embolism
Sources: deep calf, tumors, air, fat, heart arrhymias, bone marrow, post-op major operations,
prolonged sitting
Blood flow is obstructed in the lung which leads to decreased profusion of the lung and
decreased cardiac output
TX: O2, anticoagulant therapy
THIS IS AN EMERGENCY!!!
Venous Air Embolism (VAE)
Definition: entry of air into venous circulation
Causes: Secondary to trauma, IV tubing not primed
Large amts of air in vascular system- leads to cardiac arrest
S & S: sudden dyspnea, tachycardia, heart murmur, hypotension, decreased LOC, CP,
circulatory shock, sudden death
TX: place in L lateral Trendelenburg position, 100% O2. THIS TOO IS AN
EMERGENCY!!!
Circulatory Overload
Circulatory overload occurs when fluid is administered more rapidly than the circulatory
system can adjust. DROWNING IN OWN FLUIDS IS AN EMERGENCY!
S/S: cough, dyspnea, HTN, pulmonary edema, JVD, HA, crackles
Causes: Fluid overload, renal or liver failure
Interventions: slow IV to KVO rate, elevate HOB, O2, VS, notify MD, diuretics
Clients at increased risk:
Elderly
Infants & Children
Presence of Disease (Cardiac, Renal, etc.)
Outcomes of IV therapy
Maintain or restore fluid balance
Maintain or replace electrolytes
Provide a source of calories/ nutrients
Administer drugs
Blood Transfusions
Why?- tx of anemia due to acute blood loss or chronic conditions
Risk: hemolytic transfusion reactions and possibility of contracting infectious diseases (Hep B,
HIV, CMV, EBV, West Nile virus)
MD must consider potential risks and alternative interventions
Written order: blood component, volume, rate of infusion
When a client is to receive blood, the nurse is largely responsible for its safe administration.
ABO and Rh TYPE
ABO- type of antigen components that RBC’s have.
Type A = A antigen
Type B = B antigen
Type AB = both
Type O = none
Rh- antigenic substance present in RBC’s
If have = Rh+
If do not have = Rh-
Autologous transfusion
Collect blood from client prior to expected surgical procedure, reinfuse client with blood in
surger
Salvage blood in surgery and administer.
Autologous- donate own blood.
Blood Components
Whole Blood
PRBC
Platelets (PLT’s)
Fresh Frozen Plasma (FFP)
Cryoprecipitate
Granulocyte Concentrations
Plasma
Clotting Factors
Other volume expanders
Whole Blood
Used in exsanguinations(Bleeding) patient
Contains all blood products
Usually contains 400 ml +-
USED when both volume and cells are needed
Whole Blood
RBC, plasma, plasma proteins with 63 ml of anticoagulant.
500 ml/unit
ABO identical and Rh factor must match
Rarely indicated
Outcomes: prevention/ resolution of hypovolemic shock and anemia
Risk: volume overload
PRBC’s
Red blood cells with anticoagulant-preservative (no clotting factors)
Unit size- 250 to 400ml/unit
ABO compatible, Rh factor match
Given frequently blood loss- surgery, trauma
80% plasma has been removed.
Outcomes: resolution of anemia
PRBCs
Given for acute and chronic anemia ,
Blood loss
Desired over whole blood in cardiovascular & renal compromised, and elderly clients because
PRBCs contain less fluid volume.
Platelets (PLT)
Platelets= Play a role in blood coagulation, hemostasis, and blood thrombus formation.
ABO and Rh factor compatibility recommended (contain few RBC)
Special filters for platelets
Outcomes: prevention/resolution of bleeding due to thrombocytopenia or PLT dysfunction
Platelets
Usually given in pools of 6 – 10 units
USES: low platelet counts, coagulopathies; 1 unit may increase platelet count by 6000 units
Fresh Frozen Plasma (FFP)
Plasma= liquid part of blood. Medium for transporting substances. Colorless when free of
cells.
Contains plasma globulin, antibodies, clotting factors.
ABO compatibility, Rh factor no match
Still has disease transmission risk
Outcomes: decreased coagulation times
Fresh frozen Plasma
Used to replace clotinf factors after multiple transfusions ( > 6 units of PRBCs);
Coumadin intoxication
Replaces clotting factors,
Question
A patient presents to ER after being involved in a MVA, B/P is 70/50, HR 138, R. 44, the
patient has an opened chest wound and has lost a lot of blood. Pt’s Hgb is 6.0. The M.D.
orders two units of blood STAT. Which intervention would be appropriate at this time?
A.) type and cross match for blood
B.) give two units of type O blood stat
C.) draw blood, band pt with appropriate blood band an send to lab,
D.Start hypotonic fluids and continue to monitor pt.
Cryoprecipitate
Antihemophilliac factor VIII and factor XIII
5-10ml/unit
Contains no RBC and a small volume of plasma
ABO compatibility not needed
Outcomes: correction of factor VIII, vWF, XIII and fibrinogen deficiency, cessation of
bleeding
Cryoprecipitate
Components = clotting factors
USES: hemophilia, fibrinogen deficiency,
DIC.
Plasma Derivatives
Albumin- albumin, globulin and other proteins
Antibodies destroyed during processing- compatibility not a factor
Rapid infusion may cause hypotension, but 25% albumin can cause a significantly increased
blood pressure because of its ability to draw fluid into the intravascular space
Cannot transmit hepatitis or HIV infection due to the pasteurization process used to prepare
Outcomes: maintain/ acquire adequate blood pressure and volume support
Clotting Factors
Large pools of plasma
Factors VIII and factor IX
ABO and Rh compatibility not important- RBC’s destroyed during processing
Outcomes: hemostasis due to increased factor activity.
Other volume expanders
Dextran and Hetastarch are synthetically prepared molecules.
Infrequently used due to cost
Outcome: promote circulatory volume and tissue perfusion by rapidly expanding plasma
volume
Not a substitute for blood or its components
Volume expanders
Remain in vascular space and increase osmotic pressure
Plasma expander include dextran, hetastarch and plasma albumin
Albumin
ALbumin
Albumin is available in 5 % and 25 %
5 % albumin expands vascular space mL for mL
25 % draws additional fluid from interstitium.
STEPS FOR TRANSFUSION
INFORMED CONSENT : VERIFY SIGNED
Obtain venous access
Validate Vital signs
Request blood release
Confirm blood acceptability
Infuse blood
Monitor during the transfusion
Watch for transfusion reaction
Vials must be labeled and a label on pt arm to match.
INFORMED CONSENT
An informed consent MUST be obtained and documented prior to blood administration
Explanation to the client or family member of medical indications for homologous
(homologous vs. autologous) transfusion and its benefits, risks, and alternatives
Assess client history for any previous transfusions and client’s response
VENOUS ACCESS
Need large bore IV (20 gauge or larger)
May use a 22 GA for adults with small veins or children- not best option
Can use a VAD (central line), but a large volume of refrigerated blood infused rapidly into the
ventricle can cause cardiac dysrhythmias
Warming the blood can reduce the risk of this complication
Caution
Rapid infusion with cold blood can cause dysrrhythmia
IF NECESSARY TO use small guage may need to ask lab to split unit into two bags. Smaller
needle can be used for platelets, albumin and clotting factors.
Blood Release
Before going to blood bank, several things must be done: prime blood tubing with NS only
and start NS at KVO, take VS, premedicate if ordered, “banding” the patient
Blood must be picked up from the blood bank by an RN
The name and identification number of the recipient must be provided and a permanent
record of this info maintained in blood bank
Blood bank is refridgerator
There is a book with lot numbers and patient identification data.
Record
30 minute window
Blood must be started within thirty minutes of obtaining unit from lab
USE BLOOD TRANSFUSION TUBE with micro aggregate filter
D5W and LR can cause hemolysis USE NORMAL SALINE. Lewis 731.
CONFIRM BLOOD COMPATABILITY
Most crucial phase
Blood is first verified in the blood bank and RN by checking ABO and Rh compatibility. This
is done by checking the bag against the medical record and forms issued by blood bank
Second check is done at bedside by 2 RNs; compare name, number, ABO, Rh compat., blood
band
Check date
Inspect bag for leaks, clots, excessive air
The worst reactions to blood are usually due to misidentification of blood or client
TUBING
Must use blood tubing with filter.
Empty to full
REACTIONS
90% of hemolytic transfusion reactions are from improper patient to product identification
LEWIS
POTTER Says this is the MAIN REASON FOR TRANSFUSION REACTION>
Blood transfusion IFs
Usually infuse blood PRBCs over 2 – 4 hours (4 hours if at risk for FVE)
IF blood not complete in 4 hours return unit to lab.
IF patient cannot tolerate volume, specify time frame and have lab split blood unit into two
bags in lab.
If, Rapid infusion, bllod may chill patient, consider blood warmer.
Religion and blood:
Right to refuse.
INFUSE BLOOD
Blood tubing should be already hanging; usually a Y-type that contains a 170-mm filter
designed to trap fibrin clots, and other debris that accumulates during blood storage
Must administer within 30 minutes after receiving from blood bank
Change tubing every 4-6 hours or per policy, may transfuse 2 units with same tubing
Blood should be infused per pump
No other medications to be given in same tubing- EVER (Lewis pg 731)
Blood warmers may be used for rapid infusions to prevent hypothermia
MONITOR DURING THE TRANSFUSION
First 10-15 min are the most critical
Stay with the patient during first 15 min or more
Initial flow rate 20-30 gtts/ min ( 50 mL)
If ABO incompatibility exists or a severe allergic reaction, anaphylaxis, occurs, it is usually
w/in first 50 ml; start transfusion slowly and closely monitor pt; then increase rate to
prescribed rate.
Instruct client to report anything unusual- nausea, chills, burning sensations, HA
Volume
250 – 300 mL of PRBCs over 2 – 4 hours if over 2 hours then 125 mL hour, if over 4 then 63
mL HR
If 50 mL of blood to infuse in first 15 minutes houw man mL / minute should infuse??
2 mL x 15 minutes = 30 mL in 15 minutes 3 mL x 15 = 45 mL in 15.
MONITORING CONT
Take and record VS before transfusion begins then every 5 min for first 15 min, then every
hour until 1 hour after transfusion
Rate varies: platelets, plasma, & cryoprecipitate can be infused rapidly
To avoid septicemia, infusion should not exceed 4 hours (infuse over 2 hours generally)
Detailed documentation
TRANFUSION REACTIONS
Overview
Acute or delayed systemic reaction to incompatible blood
Allergic- sensitivity to foreign plasma
Febrile-Sensitization to donor cells (WBC, PLT, PP)
Hemolytic- Infusion of ABO incompatible cells
Anaphylactic- Infusion of IgA proteins to IgA deficient patient
Other reactions
Infections from blood transfusion include reaction to
malaria,
hepatitis,
HIV
See Lewis 732 – 722
Page 475
Question
While receiving a unit of packed red blood cells, the patient develops chills and a temperature
of 102.2. The nurse should
A.) Notifies the physician and the blood bank
B.) Stops the transfusion and removes the IV catheter.
C.) Adds a leukocyte reduction filter to the blood administration set.
D.)Recognize this as a mild allergic transfusion reaction and slows the transfusion.
Reaction is suspected
STOP TRANSFUSION
Keep vein open with normal saline
Obtain vital signs
Notify MD and Lab
Infiltration Phlebitis
PREVENT 1st
Before obtaining blood, be certain patent vein.
Start new IV site and remember blood goes in under 4 hour period, consider: “Is the needle
gauge large enough?”
What if??
What if the rate of infusion slows without signs of infiltration??
Suggest flush line with sterile normal saline.
What if?
Signs and symptoms of FVE as short of breath or crackles occurs???
Stop or slow the infusion
Elevate the HOB
Vital signs
Notify MD
Anticipate Diuretic/ Morphine sulfate
Oxygen
Allergic Transfusion Reaction see Techniques 968.
Frequency 1%
S & Sx: Urticaria, flushing, itching, (no fever)
Mgt: antihistamines, transfusion may continue
Prevention: treat prophylactically with antihistamines & acetaminophine
epinephrine, corticosteroids for severe reaction
Febrile Transfusion Reaction
Frequency: 0.5-1%
S & SX: fever and/or pulmonary symptoms, sudden chills and fever, HA, flushing, anxiety,
muscle pain
Mgt: If fever and/or pulmonary symptoms- DO NOT resume infusion, treat shock, give
antipyretics
Prevention: Consider leukocyte products which have been filtered, washed or frozen.)
Acute Hemolytic Transfusion Reaction
Frequency: 1:25,000
S & SX: chills, fever, <BP, flushing, tachycardia, tachypnea, hypotension, vascular collapse,
ARF, shock, cardiac arrest, DEATH
Mgt: Send blood and UA samples to lab for testing, maintain BP, Foley to measure output,
possible dialysis
Prevention: **Check and double check, then check again.** (MISS Labeled specimens)
So Mrs Verhoff, why do some people react to blood transfusions?
Antibodies in the recipients blood react to donor’s antigens on RBCs.
Causes cells to agglutinate which obstructs capillaries and blocks blood flow.
Hemoglobin is filtered by Kidney and is found in u/a. Hgb may obstruct renal tubules leads
to acute renal failure > DIC> Death.
Question
Signs and symptoms of a hemolytic transfusion reaction include all of the following: choose all
that apply;
A.) chills, fever, flushing
B.) low back pain
C.) tachycardial, tachyphea, hypotension, vascular collaspe
D.) acute renal failure, shock, cardiac arrest, death
E. None of these are a hemolytic reaction
Critical Thinking
Ten minutes after a transfusion of PRBC’s begin infusing your formerly afebrile 26 year old
client has a temperature of 101.6 and feels tightness in the chest. What is the first thing you
should?
Why is first voided urine collected to send to the lab?
First voided urine is collected and sent to lab to check for hemoglobinuria with hemolytic
reactions. Assess for damage to kidney.
Blood transfusion reaction intervention continue
Consider need for antihistamine
Vasopressors, fluids, steroids, CPR u/a specimen
What if????
If reaction is suspected, should nurse turn saline on and allow saline to flow through tubing?
Why hang saline with blood transfusion and not dextrose?
Answer: Dextrose cause coagulatio of donor blood.
Anaphylactic Transfusion Reaction
Frequency: 1:150,000
S & SX: anxiety, urticaria, wheezing, dyspnea
progressing to cyanosis, shock, cardiac arrest
Mgt: Stop transfusion, CPR if needed, have Epinephrine ready for injection
Prevention: Given blood from IgA deficient donors or plasma wash
DO NOT restart transfusion
Delayed transfusion reactions
Delayed hemolytic
Hepatitis B and C
HIV
Iron Overload
West Nile Virus
May occur weeks to months after the transfusion.
Blood Collection
Blood specimen collection
Most commonly used diagnostic aids in the care and evaluation of clients
Yield valuable information about nutritional, hematological, metabolic, immune and
biochemical status
Screen for early signs of disease, plot current treatment course, and monitor response to
therapy
May be performed by RN, or other trained personnel
Types of blood collection
Venipuncture- inserting a hollow bore needle into the lumen of a large vein to obtain a
specimen.
Vaccutainer tube- allows the drawing of multiple blood samples
Capillary puncture- least traumatic, uses sterile lancet to puncture a vascular area a finger,
toe, or heel
Types cont.
Arterial blood gas- diagnosis of respiratory disorder. Arterial puncture (radial or brachial)
Blood cultures- aid in detecting bacteria in the blood. Two cultures from two different sites.
Before antibiotic therapy is started
ABGs
Usually from radial artery
Allen test
Do not let air enter syringe
Submerge syringe in cup of ice immediately before transport to lab
Apply pressure x 5 minute to site longer if on anticoagulant
Peak and Trough
Lab value drawn for specific drugs that measure therapeutic levels at the drugs “peak” time
and “trough” time.
Usually done with certain antibiotics
EX: Vancomycin
Blood collection supplies
Alcohol or antiseptic swab
Clean gloves
Sterile gauze pad (2 x 2)
Tourniquet
Adhesive bandage or tape
Blood tubes
ID labels for tubes
Lab requisition
Plastic bag
20-25 GA butterfly
Sterile syringe
Vaccutainer tube
Sterile double ended needle 20-25GA
Anaerobic and aerobic culture bottles
Supplies depend on what blood tests are ordered
Consider- before you stick
Anticipate client’s anxiety
Assess for any possible risks
Is the patient able to cooperate?
Contraindicated sites?
Some specimens require special collection requirements- know facility policy
Which tube do I use?
Purple - blood cell counts (CBC)
Solid red - drug levels in blood
Speckled red - chemistry/ electrolyte levels
Blue - clotting times
Green - cardiac specific
____________________________________
***THIS VARIES FROM FACILITY TO FACILITY- CHECK AGNCY POLICY***
Blood draw procedure
Gather supplies
Wash hands
Provide privacy, position patient
Apply tourniquet (1 min max)
Apply gloves
Determine best site- straight, prominent vein
Cleanse site and allow to dry
Pull skin taut, hold needle at 15-30 degree angle with bevel up
Procedure cont.
Slowly insert into vein- feel the “pop”
Withdraw blood while keeping needle stabilized
Release tourniquet when blood collected
Apply sterile pressure dressing
Dispose of supplies properly
The Blood draw and the IV line
If new IV, draw blood from hub before flushing
If it is an old IV line- TOO BAD
When drawing blood for lab, avoid the arm with the IV – it may alter lab results
If have to use same arm, turn off fluids for 10 minutes and use site distal to IV if possible
Handling Blood Specimens
Rotate blood tubes gently after draw
Label specimen with initials, date, and time
Place in biohazard specimen bag
Transport to lab with gloves on in timely manner
****Agency policies will vary*****
Disposal of materials
Needles- sharps
If not saturated with blood may go into regular garbage. If saturated with blood must go into
biohazard receptacle.
IV fluid bags can go into the garbage when drained, tubing must go in biohazard container
Blood collection demonstrated in lab
Vaccutainer
Butterfly
From IV site
Small world
Positive fluid displacement. CLAVE