Fluids, Electrolytes, & IV Therapies Body Fluids Intracellular Fluid (ICF): - Account for 2/3 of body fluid - Fluid within the cell Extracellular Fluid (ECF): - Accounts for 1/3 of total body water - Intravascular (plasma): Fluid within blood vessel - Interstitial: fluid between cells, tissues, organs, and blood vessels - Transcellular: cerebrospinal, pericardial, synovial, intraocular, and pleural fluid Fluids are in constant motion. Carry nutrients, electrolytes, and oxygen to cells. Carry waste products away from cells. Fluid Balance Adaptive responses keep composition and volume of fluid and electrolytes within normal limits to maintain homeostasis. Fluid Intake - Ingestion of liquids, food, byproduct of metabolism. - Regulated primarily by the thirst mechanism. Fluid Output - Sensible losses: urination, defecation, and wounds - Insensible losses: evaporation through the skin and as water vapor. Evaporation from lungs during respirations Maintaining Fluid Balance Fluid or Electrolyte Imbalance Fluid Imbalances Volume Deficit: - GI losses (N/V/D) - Overuse of diuretics - Inadequate fluid intake - Burns - Surgery - Medication induced (diuretics) Volume Excess: - Heart failure – pump failure, unable to pump things to kidneys. - Renal failure – kidneys cannot remove fluids. - Excess fluid intake - Medication induced (corticosteroids, estrogens) Signs & Symptoms: Volume Deficit (Hypovolemia): - Restlessness - Lethargy - Thirst - Dry mucous membranes - Decreased skin turgor - Weight loss Volume Excess (Hypervolemia): - Edema - JVD - Dyspnea/crackles - Weight gain - Increased BP Management: - Correct the underlying cause - Daily weight measurement - Strict I&O - Assess mental status - Medication Therapy (electrolyte replacement, antidiarrheals, antiemetics, or adjust diuretic therapy) Electrolyte Imbalances Electrolyte Imbalances: Sodium (Na) Sodium (Na) - Normal Range: 135 – 145 mEq/L - Function: - Water distribution (volume/concentration) - Muscle contraction - Nerve impulses - Most dominant electrolyte in the ECF - Plays major role of distribution of water throughout the body - volume and concentration. Muscle contraction. Transmission of nerve impulses. Regulates acid-base balance. Regulated by thirst. - “Where sodium goes, water follows.” HyPOnatremia: - Decreased sodium (<135 mEq/L) - Causes: - Sodium Loss (hypovolemia) - Vomiting or NG suction - Diarrhea - Diuretics - Adrenal insufficiency – decreased aldosterone causes sodium and water excretion. - Burns - Excess Water Gain (Hypervolemia) - Renal failure - Heart failure - Cirrhosis - Excess IV fluids - SIADH - - “When sodium is down, you’re about to drown.” Clinical Manifestations: - Critical: <120 mEq/L - Primarily neurological: headache, altered LOC, anxiety, seizures, confusion, lethargy. - Orthostatic hypertension - Sodium loss (hypovolemia): - Dry mucous membranes - Cold, clammy skin - Poor skin turgor - Nausea, abdominal cramping - Hypotension - Excess Water Gain (hypervolemia) - Edema - Weight gain - Crackles on auscultation – pulmonary edema - Medical & Nursing Management - Treat the underlying cause. - Avoid rapid correction or overcorrection. - Frequently monitor serum lab values. - Careful administration of sodium (PO, IV) - Lactated Ringers solution or 0.9% normal saline given IV - In severe cases, may use 3% sodium chloride. - Seizure precautions - Thorough neuro assessments - Daily weights HyPERnatremia: increased sodium - Increased sodium (>145 mEq/L) - Causes: - Inadequate water intake - Excess water loss - Polyuria - Diuretic therapy - Excess sodium intake - Decreased excretion - Diabetes insipidus - Cushing Syndrome - “When sodium is high, you’re very dry.” - HypErnatremia: dEhydration - Clinical Manifestations: - Primarily neurological: restlessness, agitation, lethargy coma - Intense thirst - Dry swollen tongue - Flushed, dry skin. - Oliguria - Increased deep tendon reflexes. - Peripheral and pulmonary edema - Potassium (K) Medical & Nursing Management - Goal: gradually lower the sodium level to prevent cerebral edema - Treat the underlying cause. - Monitor urine output and sodium levels. - Administer fluids cautiously. - Hypotonic electrolyte solution - Isotonic non-saline solution D5W - Restrict sodium intake. - Diuretics - Seizure precautions - Thorough neuro assessments Potassium (K) - Normal Range: 3.5 – 5 mEq/L - Function: - Manage heart and muscle function. - Maintain fluid balance and blood pressure. - Regulated by kidneys. - Most dominant electrolyte in the ICF - “Kalemias do the SAME AS the prefix except for HEART RATE and URINE OUTPUT.” HyPOkalemia: - Decreased potassium (<3.5 mEq/L) - Causes: - Increased Output: - Excessive fluid loss: - Diarrhea - Vomiting - NG suction - Diuretics - Cushing’s - Decreased Intake: - NPO - Anorexia - Alcoholism - Fasting diets - Redistribution - Metabolic alkalosis - Excess insulin - Life threatening! Decreased neuro excitability - Clinical Manifestations: - Neurovascular - Altered mental status - Irritability - Anxiety - Lethargy - Coma - Cardiovascular - Weak, thready pulse - Arrhythmias - EKG changes - - Flat or inverted T waves - ST depression - Prominent U wave - Respiratory - Shallow breathing - Intestinal - Decreased peristalsis - Hypoactive bowel sounds - Nausea/vomiting/constipation - Abdominal distention - Musculoskeletal - Weakness - Decreased deep tendon reflexes. Nursing & Interprofessional Management - Correct the underlying cause, monitor serum levels. - Oral or IV replacement of K+ - Diet high in potassium - Fruit & veggies - Milk - Meat, fish - Processed foods - Chocolate - Monitor ECG - Monitor kidney function/urine output. Potassium Replacement Therapy - Always verify most recent serum potassium level before administering. - Monitor renal function before giving. - Can be given oral or IV - NEVER give Potassium replacement (KCl) IV push or as a bolus will cause cardiac arrest and death. - Most commonly given 10mEq/100mL via IV pump over 1hr. - Higher concentrations may be given depending on level of unit. - Central line and telemetry monitoring required for some concentrations. - Irritating to the tissues in higher doses HyPERkalemia: - Increased potassium (>5 mEq/L) - Causes: - Impaired Renal Excretion: - Renal failure - Oliguria - Excessive Intake: - Salt substitutes - Potassium supplements - Cell Injuries: - Trauma - Burns - Tumor lysis - Severe injections - Adrenal Insufficiency: - Ex: Addison’s Disease - - - Medications: - ACE Inhibitors - K+ replacement - K sparing diuretics - NSAIDs (overuse) - ARBs Increased neuro excitability Clinical Manifestations: - Neuromuscular - Fatigue - Irritability - Skeletal muscle weakness/paralysis - Loss of muscle tone - Flaccid paralysis - Cardiovascular - Bradycardia - Hypotension - EKG changes - Tall peaked T waves - Prolonged PR interval - Widened QRS - ST depression - Ventricular arrhythmias/cardiac arrest - Intestinal - Increased motility - Diarrjea - Hyperactive bowel sounds - “Kalemias do the SAME AS the prefix except for HEART RATE and URINE OUTPUT.” Medical & Nursing Management - Restrict dietary potassium & potassium containing medications. - Resins that bind to potassium: Kayexalate by mouth or enema, Lokelma PO - Emergency therapy: - IV Calcium Gluconate - IV Sodium Bicarb - IV Regular Insulin & IV Dextrose - IV Furosemide - May need hemodialysis. - Continuous ECG monitoring - Monitor patients at risk. - Educate patients on dietary modifications. - Obtain blood samples correctly. (Don’t leave torniquet on too long.) - Verify abnormal results. Hyperkalemia Normal: Calcium (Ca) - - - Normal Range: 8.5 – 10.5 mg/dL Function: - Stabilize neuron excitability - Control 3 B’s - Bones - Blood (clotting factors) - Beats (heart beats) Regulated by parathyroid hormone (PTH) (increases bone reabsorption which moves calcium out of bones and into extracellular space) and Calcitonin (high serum calcium stimulates release of calcitonin which has opposite effect of PTH) Inverse relationship with Phosphorous “Calcemias do the OPPOSITE the prefix.” Keep in mind: measuring serum calcium – half is ionized (free form) and other half is bound to proteins – mostly albumin. Not enough protein – not enough calcium. HyPOcalcemia: - Decreased calcium (<8.5 mg/dL) - Causes: - Insufficient dietary intake of Ca+ & vitamin D - Alcoholism & Malnutrition - Hypoparathyroidism - Thyroidectomy - Malabsorption - Severe diarrhea, laxative abuse, increased phosphorous. - Renal failure – kidneys can’t make active Vitamin D, without enough Vit D don’t absorb enough calcium. - Massive blood transfusion – citrate used in packed RBC’s as an anticoagulant binds to calcium - Increased neuromuscular excitability - Clinical Manifestations: - Neuromuscular - Seizures - Peripheral numbness/tingling - Muscle twitching - Painful cramps - - Chvosteks (tap face below & in front of ear to trigger nerve – get twitching on one side) Trousseau’s sign (inflate BP cuff above systolic for a few minutes) - Cardiovascular - Bradycardia - Decreased contractility of cardiac muscle. - EKG changes - QT interval (if severe, V-tach) - Slow clotting factorsbleeding - Intestinal - Hyperactive bowel sounds - Painful abdominal cramping - Skeletal - Loss of: - Bone density - - Height - Curvature of the spine Medical & Nursing Management: - Acute symptomatic hypocalcemia is life threatening. - IV administration of Ca+ dilute with D5W and give slowly. If given too fast, cause cardiac arrest. - Calcium gluconate - Calcium chloride - Oral Calcium (watch phosphorus levels) - Encourage dietary intake (milk, cheese, broccoli) - Seizure precautions - Airway monitoring – laryngeal strider can occur. - Monitor for ECG changes. - Monitor medication list. - Calcium supplements - Laxative and antacids that contain phosphorus. - Assess patients with recent thyroid or neck surgery closely. HyPERcalcemia - Increased calcium (>10.5 mg/dL) - Causes: - Hyperparathyroidism - Malignant cancer cells - Excess calcium or vitamin D intake - Osteoporosis - Prolonged immobilization - Thiazide diuretics – stimulate PTH - Decreased neuromuscular excitability. - Clinical Manifestations: - Neuromuscular - Fatigue - Confusion - Impaired memory - Decreased deep tendon reflexes - Muscle weakness - Bone pain - Cardiovascular - ↓ HR – extra calcium slow electrical conduction - Hypertension – calcium effects blood vessels causing constriction - EKG changes - Prolonged PR segment - Shortened QT interval - Intestinal - Nausea/Vomiting - Constipation - Abdominal distention - Anorexia - “Bones (bone pain), stones (kidney), groans (pain), and psychic moans (anxiety, psychiatric symptoms).” - Medical & Nursing Management: - Treat underlying cause - Increased fluids PO or IV - Lasix to promote urinary excretion - Biophosphonate: gold standard for cancer related hypercalcemia - IM CalcitoninCalcium excretion - Dialysis may be indicated - Increase patient mobility - Monitor ECG Magnesium (Mg) Magnesium (Mg) - Normal Range: 1.6 – 2.2 mEq/L - Function: - Neuromuscular function – irritability & contractility, normal neurologic function, neurotransmitter release, intracardiac conduction and myocardiac contraction. - Second most abundant intracellular cation-after potassium - Excreted by the kidneys - Most of our organs depend on magnesium to function HyPOmagnesemia: - Decreased Magnesium (< 1.6 mEq/L) - Causes: - Excessive alcohol - GI fluid loss: NG suction, vomiting/diarrhea, ulcerative colitis - Prolonged malnutrition - Increased urine output - Treatment of Diabetic Ketoacidosis - Diuresis - Shift of Magnesium from ECF into the ICF with insulin therapy - Clinical Manifestations: - Neuromuscular excitability - Secondary changes due to potassium and calcium metabolism. Consider if you have low potassium and you’re replacing it and it is not getting higher – check magnesium. - Neuromuscular - Seizures - Mood changes - Apathy, depression, insomnia, hallucinations, delusions, hyperirritability - Hyperactive deep tendon reflexes - Numbness, tingling, tremors, athetoid - Cardiovascular - EKG changes - Prolonged QT interval - Depressed ST segment - Inverted T wave - Torsade’s de pointes – life threatening ventricular tachy - Can see premature ventricular contractions and heart block. - “Magnesemias do the OPPOSITE the prefix” - Medical & Nursing Management - IV Magnesium Sulfate replacement - Must be given slow and via IV pump - Bolus may result in heart block or cardiac arrest - PO Magnesium Oxide - Increase dietary intake - Monitor ECG - Thorough Neuro assessments - Seizure precautions - Education regarding alcohol use & laxative abuse HyPERmagnesemia - Increased Magnesium (>2.2 mEq/L) - Rare due to kidneys ability to remove magnesium. - Causes: - Diabetic Ketoacidosis - Antacids with Mg - Renal failure - Adrenal insufficiency – diminished aldosterone – volume depletion and hemo concentration - - Neuromuscular relaxation Clinical Manifestations: - Neuromuscular - Depressed CNS & Respiratory muscle paralysis - Lethargy - Drowsiness - Hyporeflexia and decreased deep tendon reflexes. - Urinary retention - Cardiovascular - ECG changes - Prolonged PR interval - Widened QRS - Hypotension - Peripheral vasodilation - Facial flushing, warm skin Medical & Nursing Management: - Monitor and support cardiac & respiratory function - Assess DTR’s - Hemodialysis Remove excess Mg+ - IV calcium gluconate to oppose the effects of Mg+ on cardiac muscle - Increased fluid intake (PO or IV) - Dietary modifications - Limit: green vegetables, nuts, bananas, peanut butter, oranges, chocolate Phosphorous (𝑷𝑶𝟑− 𝟒 ) Phosphorous (𝑃𝑂43−) - Normal range: 2.5 – 4.5 mg/dL - Function: - Bone and teeth formation - Repair cell tissue - Essential for function of muscle, RB formation, ATP production - Regulated by PTH - Inverse relationship with calcium HyPOphosphatemia - Decreased phosphate (<2.5) - Causes: - Too much excreted - Hyperparathyroidism (raises calcium levels) - Chronic diarrhea - Not enough absorbed. - Alcoholism - Antacids - Malabsorption - Malnourished - Anorexia - Diabetic ketoacidosis - Respiratory alkalosis – CO2 outside of cell creates demand for phosphorous - Clinical Manifestations: due to impaired oxygen delivery - CNS depression: - Paresthesia's, muscle weakness, tremors, irritability - Respiratory failure - Rhabdomyolysis - Tissue anoxia - Hemolytic anemia - Bruising or bleeding related to platelet dysfunction. - Medical & Nursing Management: - Goal: Prevention - PO phosphorus replacement - IV replacement with sodium phosphate or potassium phosphate - Administer IV solutions slowly and be careful to avoid hypocalcemia. - Tissue sloughing and necrosis can occur with IV infiltration. - Monitor serum levels of Phos and Ca+ - Assess for early signs: confusion, change in LOC. - Encourage dietary intake. HyPERphosphatemia - Increased phosphate (> 4.5) - Causes: - Renal failure most common - Hypoparathyroidism - Increased intake, decreased output, or a shift from ICF to ECF - Tumor lysis syndrome & bone tumors - Rhabdomyolysis - Hyperthermia - Clinical Manifestations: - Causes few symptoms alone, most are related to the inverse relationship with Calcium. - Numbness & tingling - Hyperreflexia, muscle cramps - Tetany, seizures - Calcium-phosphate deposits in skin, soft tissue, cornea or blood vessels - Medical & Nursing Management: - Identify and treat underlying cause. Chloride (Cl) - - - Phosphate binding medications - Hemodialysis - Loop diuretics - Surgical removal of large calcium-phosphate deposits - Education on low phos diet - Monitor urine output. - Monitor serum Phos and Ca+ levels Normal Range: 97 – 107 mEq/L Function: - Blood volume - Blood pressure - pH of body fluids Follows sodium (Na) Competes with bicarb HyPOchloremia: - Decreased Chloride (<97 mEq/L) - Causes: - Rarely occurs without other electrolyte disturbances. - Will be seen with any disorder that causes hyponatremia. - Metabolic alkalosis - GI loss, antacids - GI tube drains, ileostomy, severe vomiting/diarrhea, fistulas - Clinical Manifestations: - Tetany, hyperactive deep tendon reflexes, weakness, muscle twitching and muscle cramps - Related to Na+: seizures and coma. - Related to K+: cardiac arrhythmias. - Medical & Nursing Management: - IV replacement with 0.9% sodium chloride or 0.45% sodium chloride - Discontinue use of loop, osmotic, or thiazide diuretics - Encourage foods with chloride: tomato juice, bananas, dates, eggs, cheese, milk, salty broth, canned veggies, and processed meats. - Ammonium chloride can be given to treat metabolic alkalosis. - Monitor I&O - Monitor ABGs and electrolytes. - Assess for LOC changes, DTRs, and vitals. HyPERchloremia: - Increased Chloride (>107 mEq/L) - Causes: - Related to ↑ Na, bicarbonate loss, and metabolic acidosis. - Increased intake by mouth or use of hypertonic IV solutions - Decreased chloride loss in hyperparathyroidism, hyperaldosteronism, and renal failure - Clinical Manifestations: - The same as seen in metabolic acidosis, hypervolemia, and hypernatremia. - Tachypnea, weakness, lethargy, deep rapid respirations (Kussmaul breathing), diminished cognitive ability, and hypertension. - If left untreated decreased cardiac output, arrhythmias, and coma. - Medical & Nursing Management: - Correct the underlying cause. - Provide hypotonic IV solutions or lactated ringers. - IV sodium bicarbonate - Diuretics - Restrict sodium, chloride, and fluids. - Monitor I&O - Monitor ABGs, electrolytes & vitals. - Assess respiratory, cardiac & neuro systems. BMP Memory Trick Intravenous Therapy Intravenous Fluid Use Types of IV Solutions ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Sodium: 135-145: “145, your mouth is DRY” Potassium: 3.5-5: You buy 3-5 bananas in a bunch Calcium: 9-11: call 9-1-1 Magnesium: 1.5-2.5: Magnifying glass will magnify by 1.5-2.5x Phosphorus: 2.5-4.5: “PHOR” = 4 letters; “US” = 2 letters (Remember the 0.5 for both) Chloride: 95-105: Chlorine pool. Best time to go in when its 95-105 degrees outside Glucose: 70-100: SUGAR = I can eat 70-100 M&M’s BUN: 10-20: Hamburger BUNS in a pack Creatinine: 0.6-1.2: Creatinine (waste product) will pass through (kidneys) if you’re between 0.6-1.2” Intravenous Fluid Use - Choice of fluid depends on its intended use. - Goals of therapy: - Provide water, electrolytes, and nutrients to meet daily needs. - Replace water and correct electrolytes. - Administer blood products and medications. Pure electrolyte free water is never given intravenously. Types of IV Solutions - Crystalloid Solutions – (ability of solutes to move water from one component to another) - Isotonic – expand extracellular volume - 0.9% NaCl (normal saline) - Lactated Ringer - 5% Dextrose in water (D5W) - Hypotonic – moves water into the cells - 0.45% NaCl (half-strength saline) - Hypertonic – good for patients with cerebral edema – moves from cells - 3% NaCl - 5% NaCl Isotonic Fluids - - 0.9% Sodium Chloride Lactated Ringers - D5W Hypotonic Fluids - - Expand the extracellular fluid. Replace fluid loss. Expanding volume. (trauma, burns, etc) Content determines indication. Caution with HF and Renal failure Examples: - 0.9% NaCL: used in hypovolemic states: shock, DKA, mild Na deficit, resuscitative effort. - Lactated Ringers: contains Na, K, Ca, Cl, lactate. Avoid in renal failure, liver failure, lactic acidosis. - 5% Dextrose in water (D5W): no electrolytes, contains dextrose. Avoid in head injury or fluid resuscitation. Watch for volume overload. Also called “normal saline” or just “0.9” Contains only sodium and chloride. Only solution given with blood products. Used to replace large sodium losses such as burns, vomiting & diarrhea. Use cautiously in patients with excess fluid volume Also called “LR” or Contains sodium, potassium, chloride, calcium, and lactate. Used in treatment of hypovolemia, burns, surgical patients, fluid lost as bile or diarrhea or acute blood loss, Avoid in patients with renal failure, liver failure or lactic acidosis – can’t convert lactate into bicarb. Renal patients can’t get rid of potassium. 5% Dextrose in Water Contains no electrolytes. 1L provides 170 cal/L, 50g Dextrose, and free water. Becomes hypotonic solution as it metabolizes. Used in treatment of fluid loss, hypernatremia, and dehydration. Contraindicated in head injury or fluid resuscitation Dilutes extracellular fluid, moving water into interstitial space and cells. o Osmolality lower than plasma o Replace cellular fluid, provide free water. Provide free water for excretion of body waste. (bowel and renal obstruction) Potential to cause cellular swelling, avoid in increased ICP. Example: o 0.45% NaCl with or without 5% dextrose: use in hypertonic dehydration, hypernatremia, gastric fluid loss. 0.45% Sodium Chloride Hypertonic Fluids - Other IV Solutions Nursing Management of IV Therapy IV Set Up - Also called “0.45” or “half strength” Provides only sodium, chloride, free water Can be mixed with 5% Dextrose (D5/.45) Used to treat hypernatremia, uncontrolled hyperglycemia, hypertonic dehydration, gastric fluid loss. Avoid in third-space fluid shifts or increased ICP Osmolality greater than plasma Used to increase extracellular volume and decrease cellular swelling. o Draws water out of cells and into ECF. Used in critical situations to treat hyponatremia and pts with cerebral edema and increased ICP. Irritating to veins → use central line & check agency policies Administer slowly. Frequent monitoring and assessment. Mental status assessment frequently. Weight gain. Vital signs and electrolytes. Can quickly cause volume overload, pulm edema. Examples: o 3% NaCl o 5% NaCl Total Parenteral Nutrition (TPN): o Consult with Dietary and Pharmacy to adjust nutrients. o Given when patient’s GI tract unable to tolerate food. o Central line required. o Change tubing with each new bag/every 24 hours o Filter must be used with tubing. - Colloid Solutions o “Volume expanders” or “plasma expanders” o Helps restore lost blood volume o Examples: Albumin Fresh frozen plasma (FFP) Blood products - Determine if ordered IV therapies are appropriate. - Choose and insert appropriate IV catheters. - Monitor for adverse reactions. - Assess for s/s fluid overload, hypovolemia, fluid and electrolyte imbalances, hypovolemia. - Collaborate with members of interdisciplinary team Primary Line: - Commonly used for maintenance IV fluids (MIV) or continuous fluids - Larger volume medications - Medications that run over a longer period of time - Medications that are not compatible with others - Change tubing every 96hrs Intravenous Push (IVP) Intravenous Access Intravenous Sites Venipuncture Devices Secondary Line: - Also called “piggy back”, “IVPB” - Commonly used for anti-biotics, medications unable to be given IV push due to volume - Attaches to a primary line - Must check compatibility of all components - Change tubing every 24hrs - Administered directly into venous system - Knowledge regarding: o Compatibility with all running fluids o Dilution may be necessary o Look up rate to push medication before giving - Selecting a site – things to consider o Type of fluid or medication o Duration of therapy o Patient’s condition o Availability/condition of veins o Medical history & current health status o Skill of the practitioner o Most common: basilic, median cubital, cephalic - - Over the needle cannula/catheter Sizes range from 14-26 gauge The larger the number, the smaller the catheter o 14-18 gauge trauma/surgical patients o 20-22 gauge most IV fluids Length ranges from 0.75in – 1.25in Styles vary, but function is the same Most commonly seen sizes in adults: Green, Pink, and Blue Other Peripherally Inserted Devices - Central Venous Access Devices - Midline Catheter o Does not enter central vein. o Use & care is similar to PICC line. o Indicated when IV therapy is > 6 days. o Starts above AC but catheter tip terminating before axilla. o Not power injectable. o Not for continuous vesicant therapy or TPN o Requires specialized training for insertion. Catheters placed in large blood vessels. Must be placed under ultrasound guidance or surgically. Placement confirmed by x-ray and order for use required. Indications: - Frequent blood sampling/lab draws. - Vesicant medications and most vasopressor medications - TPN, chemotherapy, dialysis, apheresis - Multiple IV access is needed. - Patients with limited peripheral access Central Venous Catheter Common Types: - Central Venous Catheters (CVC) - Peripherally Inserted Central Catheters (PICC) - Implanted Ports - Hemodialysis catheters - Optimal position is midproximal 1/3 of superior vena cava at junction of right atrium of the heart. - Placed in subclavian vein, internal jugular vein, or femoral vein. - Tunneled vs. Non-tunneled. - Single, double, or triple lumen Tunneled: - Used for long-term use (years) - Inserted surgically and threaded under the skin. - Examples: Hickman, Groshong, and PermCath Nontunneled: - Used for short-term IV therapy (<6 weeks) - Inserted by provider. - Used in acute-care, long-term care, and homecare settings. - Examples: Vas-Cath, Percutaneous subclavian Arrow, and Hohn catheters Nursing Considerations: - Review facility policy - Must have “OK to use” order in place. - Antimicrobial dressing should be used unless contraindicated. - Transparent dressing changed every 5-7 days or PRN. - Gauze dressing changed every 48 hours or PRN. - Blood collection follows central line policy. - RN’s may remove non-tunneled CVC lines with order . Peripherally Inserted Central Catheters (PICC) - Inserted by specialized nurses Inserted through a vein in the arm, tip ends in SVC Single, double, or triple lumen Best for patients requiring moderate to long-term IV therapy For complications contact provider for PICC team consult Power PICCs allow rapid injection of contrast media May be valved (no clamps) or non valved (clamps) Nursing Considerations: - Review facility policy - Must have “OK to use” order in place - Antimicrobial dressing should be used unless contraindicated - Transparent dressing changed every 5-7 days or PRN - Gauze dressing changed every 48 hours or PRN - Blood collection follows central line policy - RN’s may remove PICC lines Implanted Ports - Surgically implanted CVC connected to a reservoir/port Port is accessed using special non-coring needle Best for long-term therapy (chemo most common) Must be surgically removed, RN’s cannot remove Nursing Considerations: - Monitor for infiltration - Blood return should be present - Dressing policy same as CVC/PICC IV Therapy Complications Systemic: - Circulatory overload - Air embolism - Infection Circulatory Overload Local: - Infiltration - Extravasation - Phlebitis - Thrombophlebitis - Hematoma - Clotting blood - Circulatory overload - Air embolism – respiratory distress - Infection - Due to excessive IV fluid Air Embolism Assessment Findings: - Crackles - Edema - Weight gain Treatment: - Decrease fluid rate - High fowlers position Complications: - Heart failure - Pulmonary edema - Often associated with cannulation of CVCs Systemic Complications Assessment Findings: - Respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis) - Hypotension - Weak, rapid pulse - Change in LOC - Chest pain Treatment: - Clamp cannula - Apply O2 if indicated. - Place patient on left side in Trendelenburg position - Obtain vitals & respiratory assessment. - Notify provider. Infection Complications: - Shock - Death Prevention: - Luer-lock adapters on all devices - Prime tubing - Air detection via IV pump - Proper CVC & PICC removal techniques Ranges in severity from local to systemic involvement. Prevention: - Hand hygiene before handing equipment. - Examine all containers for contamination. - Strict aseptic technique - Disinfecting access ports: alcohol or curos cap - Remove IV at first sign of infection. - Changing tubing per policy & dating tubing upon initiation Local Complications Infiltration - Infiltration Extravasation Phlebitis Thrombophlebitis Hematoma Clotting Blood Unintentional administration of a non-vesicant in to surrounding tissue May happen when catheter becomes dislodged or goes through the vein wall Assessment Findings: - Edema at insertion site - Leaking of fluid - Discomfort/coolness - Decrease in flow rate Intervention: - Stop the infusion - Discontinue the IV - Apply sterile dressing - Start new IV access proximal to the infiltration - Warm or cold compress depending on solution Prevention: - Assessment every 2 hours - Appropriate size catheter Extravasation Infiltration Scale: - 0 - No symptoms - 1 - Skin blanched, edema less than 1 inch in any direction - 2 - Skin blanched, edema 1-6 inches in any direction - 3 - Skin blanched, translucent; gross edema greater than 6 inches in any direction; cool to touch; moderate pain; possible numbness - 4 - Skin blanched; translucent skin, tight; leaking; skin discolored, bruised, swollen; gross edema greater than 6 inches in any direction; deep pitting tissue edema; circulatory impairment; moderate-severe pain; infiltration of any amount of bio product, irritant, or vesicant Same as infiltration but with a vesicant or irritant solution. Examples of Medications: - Chemotherapy - Vancomycin Assessment Findings: - Blistering - Necrosis - Inflammation Intervention: - Stop the infusion & Check the patient - Notify the provider - Follow specific protocol for solution involved - Avoid use of that extremity if possible Prevention: - Careful assessment of IV site Q2 - Avoid points of flexion - Use smallest catheter - Always check IV compatibility Phlebitis Inflammation of the vein Categories: - Chemical - Mechanical - Bacterial Assessment Findings: - Reddened, warm area at insertion site or path of vein. - Pain or tenderness at insertion site or along vein - Swelling Intervention: - Stop the infusion. - Discontinue the IV - Choose a new site for cannulation. - Apply warm, moist compress. Prevention: - Use aseptic technique. - Appropriate size catheter - Consider the fluids to be infused. - Change tubing every 96 hours. - Assess IV site every 2 hours. Phlebitis Scale: - 0 -No symptoms - 1 - Erythema at access site with or without pain - 2 - Pain at access site with erythema and or edema - 3 - Pain at access site with erythema and streak formation, or palpable venous cord - 4 - Pain at access site with erythema, streak formation, palpable venous cord greater than one inch in length and purulent drainage Thrombophlebitis Presence of blood clot PLUS inflammation of the vein. Assessment Findings: - Localized pain, redness, warmth, & swelling at insertion site - Immobility of extremity - Sluggish flow rate - Fever, malaise & leukocytosis Intervention: - Stop the IV infusion - Apply cold compress first followed by warm - Flushing of line will depend on clinical situation Discontinue IV line Culture if indicated/ordered Prevention: - Avoiding trauma during IV insertion - Assess IV site every 2 hours - Checking for IV compatibility Hematoma - Blood leaking into surrounding tissue at IV insertion site Can occur during venipuncture or after removal of IV Assessment Findings: - Ecchymosis - Immediate swelling at insertion site - Blood leaking into insertion site Intervention: - Discontinue infusion and IV. - Apply pressure with sterile dressing. - Apply ice to insertion site. - Elevating the extremity - Start new IV in the other extremity if possible. Blood Clots Prevention: - Careful insertion of the IV - Caution with bleeding disorders, low platelet counts, & patients on anticoagulants - Apply pressure after IV removal insertion or blood draw. May form in the IV line. Assessment Findings: - Decreased flow rate - Blood backflow into the IV tubing Intervention: - Discontinue IV infusion. - Restart IV in another site with a NEW cannula and administration set - Do not irrigate or milk tubing. - Do not increase the infusion rate. Prevention: - Do not allow the IV solution bag to run dry. - Tape tubing to prevent kinking and maintain patency. - Maintain an adequate flow rate. - Flush the line after intermittent medication or solution administration. Blood Transfusions Blood Transfusion & Blood Components Initiating Blood Transfusion Obtaining Blood Products Pretransfusion Assessment Blood Transfusion Patient Monitoring During Transfusion Disposal of Blood Components - An order is required for all transfusions & related testing. Current type & cross match: good for 72hrs Provider must obtain consent prior to blood administration unless in an emergent situation. Order requisition form must accompany all tests. Use two identifiers before placing type & cross armband on patient. Blood Products: - RBCs - FFP - Platelets - Cryoprecipitate - Transfusion services/Blood Bank notifies the unit that blood components are ready. - Before sending for the blood component: - Verify informed consent. - Confirm order for transfusion. - Vital signs obtained. - Adequate IV access available - 20 gauge or larger preferred - Courier must be trained in proper handling and transport of blood products. - Blood release form complete and hand carried to the blood bank. - Staff member must have medical center ID badge to obtain blood components and able to verify information. - Only one component may be picked up at a time* (*multiples can be obtained in emergency situations.) - Courier must promptly deliver blood to receiving RN and complete the delivery section of cross match tag. - Blood must be infused within 4 hours of release from blood bank. - Baseline vital signs obtained 15min or less before starting transfusion. - Physically trace all tubing before initiating any IV infusion - Must have an order to transfuse any blood component is patient’s temperature is >101ºF. - Dual verification of blood component identification - Two RNs; an RN & LPN; RN & MD (must have license) - Any discrepancy blood must be returned to blood bank. - Infused through an uninterrupted IV line. - Only compatible with 0.9% Sodium Chloride - Use standard blood tubing with filter. - Educate the patient on transfusion reaction symptoms and to notify RN promptly. - RN to stay with patient for initial 10-15 minutes. - Discontinue transfusion after 4 hours from release time. - After infusion complete, flush IV line with 0.9% NaCl to clear. - RN to stay with patient for initial 10-15 minutes. - Vitals obtained 10-15mins after transfusion initiation. - Monitor for signs of circulatory overload & transfusion reactions. - Frequent assessment of IV site - Obtain VS after completion of transfusion. - Record intake volume amount after completion of transfusion - After complete transfusion – discard the tubing and empty bag in the biohazard trash. - Notify blood bank of part of a unit is not transfused. Transfusion Reaction If biohazard trash not available, the RN may deliver the bag and tubing to the blood bank. Range in severity from mild to life threatening Most commonly caused by ABO-incompatibility, leukocytes, platelets, and plasma proteins Will usually develop in the first 15mins of transfusion. Assessment findings: - Fever, flushing, sweating. - Itching - ABD, back, or chest pain - Tachycardia - Shortness of breath, tachypnea, bronchospasm - Rash, urticaria, pruritus - Headache - vomiting - Any unusual symptoms require investigation and are considered a reaction until proven otherwise. - 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Stop the transfusion immediately. Disconnect blood tubing. Do NOT discard the remaining blood component or tubing. Maintain open IV line by attaching a new 0.9% NaCl solution with new tubing. Notify the MD and Blood bank. Monitor VS until baseline. Complete the transfusion reaction battery order in IHIS. Perform clerical checks. Collect a blood sample (two lavender tubes) Deliver blood sample, completed form, the remaining blood component including IV tubing to blood back.
