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IV THERAPY for LPNs and RNs

Author: Alene Burke RN, MSN
22 Contact Hours

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DESCRIPTION:

This course includes information about the venous system; peripheral veins; common IV medical terminology and abbreviations; venipuncture; various means of intravenous to deliver IV therapy, including different catheter types and their use; special IV therapies; the adverse reactions and complications associated with IVs; different types of IV equipment and their uses; the appropriate and accurate administration of IV medications and solutions, including those delivered via a central line; caring for patients receiving IV therapy, blood and blood components, and parenteral nutrition; and the incorporation of infection control procedures into all aspects of venipuncture and intravenous therapy.

This course has been approved by the Florida State Board of Nursing and the Council of Licensed Midwifery. This course can be taken by Rns and LPNs. This course fulfills Florida State's 30-hour requirement for IV Therapy training for LPNs. It is designed to complement an 8-hour class including instruction and return demonstration.

OBJECTIVES:

1. Detail the anatomy and physiology of the skin, venous and arterial systems, and discuss the purposes of intravenous therapy.
    
2. Discuss osmosis and the effects of numerous intravenous fluids on the body.
    
3. Define a multitude of medical terms that are pertinent to intravenous therapy.
    
4. Accurately calculate IV flow rates, total infusion time, concentrations of medications in an intravenous solution, and intravenous rates based on body weight.
    
5. Describe the legal aspects of IV administration including competency and scope of practice.
    
6. Fully detail infection control practices during venipuncture and during the course intravenous therapy.
    
7. Relate the procedures for venipuncture and starting and managing peripheral, midline, and central venous catheter lines.
    
8. Describe the purpose of and care of the patient with a peripheral IV, a midline catheter, and a central line.
    
9. Recognize and intervene appropriately when a complication or adverse reaction to intravenous therapy arises.
    
10. Care for a patient receiving IV medications, chemotherapy, blood and blood products, and parenteral nutrition.

NTRODUCTION: THE PURPOSE OF INTRAVENOUS THERAPY

Intravenous therapy is a relatively common and multifaceted form of treatment in the healthcare environment. Intravenous therapy is used to:

• restore or maintain fluid stores in the body;
• administer medications;
• restore and maintain electrolyte and acid-base (PH) balance;
• provide the patient with vitamins, calories, protein and fats when the patient is not getting an adequate diet, or there is a medical need to give the gastrointestinal system a rest, as is the case after a patient has had major gastrointestinal surgery; and
• administer blood and blood products.

Additionally, one central intravenous line is used to measure and monitor central venous pressure (CVP).

Because of its frequency of use, registered nurses and practical nurses as permitted by law need more information to be thoroughly knowledgeable about a wide variety of venous devices, their uses, insertion procedures, care and maintenance including site rotations and dressing changes; procedures associated with the administration of fluids; medications and taking blood samples; calculation of dosage and solution rates; available infusion devices; and complications associated with the many intravenous therapy modalities that are available on the current market.

COMMON INTRAVENOUS TERMS AND ABBREVIATIONS

The glossary contains some common medical terms and abbreviations that are associated with intravenous therapy. It is suggested that you refer back to this glossary throughout this course if there is a term or abbreviation that you do not understand. Click on this link, and the glossary will be opened in a new window along side this one, so you can continue to read the course. You can also print out the glossary and be able to refer to it that way.

ASEPSIS: MEDICAL AND SURGICAL

The skin, or integumentary system, is the body's first line of defense against infection and the invasion of pathogens. It is also the first body system encountered during venipuncture. The skin serves as a barrier that protects the body and its internal tissues, organs, and systems from the environment that surrounds it.

When the skin surface is broken and not intact as a result of venipuncture, an injury, or a wound, it is no longer an effective barrier of defense. The body's internal tissues, organs, and systems are at risk for infection when there is an alteration or disruption of skin integrity. Venipuncture and intravenous therapy, therefore, must be performed and maintained using aseptic technique.

Aseptic technique, or asepsis, is necessary in order to prevent infections. It is an infection control technique that ensures either sterility or the cleanest possible completion of a procedure when sterile technique is not possible. There are two kinds of asepsis, medical and surgical asepsis.

Medical asepsis is the type of asepsis that eliminates the presence of bacterial pathogens. Surgical asepsis is the type of asepsis that eliminates all microorganisms, viruses, spores, and so on. Medical asepsis is sometimes referred to as clean technique; surgical asepsis is referred to as sterile technique. Venipucture is done using medical asepsis, rather than surgical or sterile asepsis because the skin that is punctured during venipuncture cannot be sterilized. It can only be disinfected with an antimicrobial agent such as 70% isopropyl alcohol.

Generally, medical asepsis is used in healthcare when surgical asepsis is not possible. Sterility is not possible when external structures, such as intact skin, are being cared for and when internal structures that are not sterile, such as the colon and a colostomy, are being cared for. Medical asepsis is, therefore, employed for this care. Surgical asepsis, on the other hand, is used for all other procedures and equipment. Intravenous tubings, catheters, and dressings are handled and used using surgical asepsis. Strict surgical asepsis must be used throughout the course of intravenous therapy in order to prevent the spread of infection throughout the body, as introduced through the skin and the intravenous therapy line, now open portals of entry into the body.

ANATOMY AND PHYSIOLOGY: THE SKIN, VENOUS SYSTEM, AND RELATED STRUCTURES

In addition to serving as the body's first line of defense, the skin also serves these other functions by:

• helping to control the temperature of the body;
• allowing the body to sense or feel certain sensations, such as heat, cold, and pain; and
• contributing to fluid and electrolyte balance.

Physiologically the skin consists of two layers, the epidermis and the dermis. The epidermis is the top layer of the skin. It is comprised of squamous cells. The epidermis is thinner than the dermis, and it has less sensory nerve fibers than the dermis. Therefore, it is less sensitive to pain and discomfort than the dermis.

The dermis, the second layer of the skin, lies directly under the epidermis or the outer layer of the skin. The dermis is thicker than the epidermis, and it consists of nerves, blood vessels, sweat glands, hair follicles, sebaceous glands, and collagen. Pain and discomfort during venipuncture is related to the sensory function of the nerves in the dermis. It is also more sensitive to heat and cold. Because of this highly sensitive sensory function, it is suggested the dermis be passed through rather rapidly during the course of venipuncture in order to decrease the patient's pain and discomfort.

Below the epidermis and the dermis lies fascia. Fascia covers the muscles of the body and the blood vessels.

THE CARDIOVASCULAR SYSTEM

The cardiovascular system, a combination of the cardiac and circulatory systems, is comprised of the heart and the circulatory labyrinth of arteries, arterioles, venules, veins, and capillaries. The heart, located in the center of the chest, is a muscular organ with four chambers, two on the top and two on the bottom. The upper chambers are called atria and the lower chambers are called the ventricles. Deoxygenated blood from the body moves from the right atrium, to the right ventricle and then to the lungs for reoxygenation. After reoxygenation, the blood enters the left atrium and finally passes through the left ventricle before it is ejected into the body's systemic circulation.

The primary functions of the heart and the cardiovascular system are to rid the body of carbon dioxide, a bodily waste product, and to supply the body with oxygen rich blood necessary to sustain life.

With every beat of the heart, all four chambers of the heart fill with blood. During the relaxation stage, referred to as diastole, oxygenated blood enters the left atrium of the heart from the lungs at the same time that deoxygenated blood enters the right atrium from the systemic circulation. After the atria are filled, the blood flows into the ventricles as a result of atrial systole or contraction. Once the blood has entered the ventricles, they contract to eject the blood to the lungs via the pulmonary artery and then to the systemic circulation through the aorta. This ventricular contraction is referred to as ventricular systole, or systole. Simply stated, diastole is a rest period during which the chambers of the heart fill, and systole is the period during which contraction occurs.

The arteries carry blood away from the heart, and the veins carry blood toward the heart. Arteries transport freshly oxygenated blood to arterioles and then to the capillaries where bodily tissue exchanges of carbon dioxide and oxygen occur. After capillary exchange, the blood, now saturated with carbon dioxide, flows into the venules and then into the veins, as the blood is transported into the heart for reoxygenation.

Coronary arteries provide oxygenated blood to the heart muscle itself. Anatomically, the arteries are relatively flexible and strong. They are lined with muscle tissue, while the veins are not. Another difference between the arteries and veins is the fact that veins are greater in diameter and accommodate much less pressure than the arteries do.

In summary, the vascular system vessels differ in terms of their function and their size. Arteries carry oxygen rich blood from the heart. The aorta, the largest artery in the body, branches off to all other arteries of the body. As they continue to branch, they become smaller and smaller until they become arterioles. Arterioles then branch off, become smaller and eventually lead to the capillaries. Capillaries provide the cells with oxygen and nutrients and they transport cellular wastes away for elimination.

Venules, the smallest of all the veins in the body, begin the passage of blood back to the heart after the capillaries have performed their physiological role. Venules and veins carry deoxygenated blood. As the venules get larger and larger, they lead into veins. Eventually, all the deoxygenated blood is transported to the superior vena cava, the largest vein in the body. The superior vena cava is directly connected to the right side of the heart at the right atria. After the blood reaches the right atria, it circulates through the right ventricle to the pulmonary artery and then to the lungs for reoxygenation. After this oxygenation, the blood flows through the pulmonary veins to the left atrium, the right ventricle, and the aorta and the arterial system of the body.

Veins, the focus of attention during venipuncture and intravenous therapy, consist of three layers. The three layers of the vein, moving from the outermost to the innermost are the:

• tunica adventitia;
• tunica media; and
• tunica intima.

The tunica adventitia is the outermost layer of the vein. It is comprised of connective tissue. The tunica media, the middle layer of the vein, consists of elastic and muscle tissue. This is the layer of the vein that contracts and dilates during the vasoconstriction and vasodilation, and the tunica intima is the innermost delicate and fragile endothelial lining of the vein. Semilunar valves that push the flow of the returning blood to the heart rather than to the extremities are found in the tunica intima layer of the vein.

Veins are classified as superficial or deep. Systemically, deep veins parallel and are in close proximity with a correlate artery. They lie deeper under the skin than superficial veins. For example, the femoral artery is in close proximity to the femoral vein, a deep vein.

Superficial veins lie close to the skin. The superficial veins that are found on the forearm and the hands are the most frequent sites for an intravenous line.

INTRAVENOUS FLUIDS AND ASSIMILATION

Intravenous fluid therapy consists of using one of three different kinds of intravenous solutions, each of which has a different osmotic, or pulling pressure, in the veins when it comes in contact with and combines with blood, the natural intravenous fluid. Each of these three intravenous solution types creates a different effect on the body and its water, electrolytes, and glucose. The three intravenous solutions types are:

• isotonic;
• hypertonic; and
• hypotonic.

TABLE 1: OSMOSIS AND SOLUTION TYPES

ISOTONIC HYPOTONIC HYPERTONIC Blood Half strength normal saline (0.45%) Albumin 25% Plasma One-third sodium chloride (0.33%) Hyperalimentation solutions Albumin 5% and 0.2% normal saline Dextrose 5% in normal saline Normal saline (0.9%) Dextrose 5% in half strength normal saline Lactated Ringer's Dextrose 5% in lactated Ringer's 5 % Dextrose in water (D 5 W) Dextrose 10% in water Normosol-R Dextrose 20% in water 6% Dextran 75 and 0.9% NS Saline 3% Saline 5% Sodium lactate 1/6 molar

Source: Compiled by the author.

In the body, osmosis is a very fundamental and basic bodily function. Osmotic pressure, is the pulling pressure between two solutions that are separated with a semipermeable barrier or membrane. Osmosis is the bodily process during which water passes from the side of a semipermeable membrane that has the lower solute concentration to the side that has the higher solute concentration.

An isotonic solution is one that has the same pH level as the blood and exerts the same osmotic pressure as plasma. A hypertonic solution is a solution that has a pH level greater than that of blood and one that exerts a greater pulling osmotic pressure than blood plasma. Lastly, a hypotonic solution is one that has a lower pH level than blood. Hypotonic solutions have less osmotic pressure than that of blood.

IV fluids are comprised of a number of electrolytes. Table 1 summarizes the different types of isotonic and hypertonic solutions.

Saline solutions, including normal saline (NS), contain the electrolytes sodium (Na+) and chloride (Cl-); dextrose solutions contain caloric dextrose in addition to either saline or water. Balanced isotonic solutions vary. They can contain gluconate, calories, and electrolytes such as sodium (Na+), chloride (Cl-), potassium (K+), magnesium (++), and HCO-3. Parenteral nutrition solutions consist of electrolytes, fluid, calories, and amino acids, and finally, plasma expanders are comprised of plasma protein fraction 5% (Plasmanate), albumin, dextran, mannitol, and hetastarch (Hespan). Plasma expanders increase circulating blood volume on a temporary basis because these hypertonic solutions pull fluid from the interstitial fluids into the circulation through osmosis.

Table 2 displays some commonly used intravenous fluids, their pH, and the number of calories found in them.

TABLE 2: INTRAVENOUS SOLUTIONS: CALORIES AND PH

INTRAVENOUS SOLUTION CALORIES PH 5% DW 170 5.0 10% DW 340 4.6 0.9% NS -- 5.7 0.45% NS -- 5.3 5% D and 0.9% NS 170 4.2 5% D and 0.45% NS 170 4.2 5% D and 0.2% NS 170 4.2 Lactated Ringer's 9 6.7 5% D and lactated Ringer's 170 5.1 Normosol-R -- 6.4 Sodium lactate 1/6 molar 55 6.9 6% Dextran 75 and 0.9% NS -- 4.3

Source: Compiled by the author.

Lactated Ringer's is used to:

• replace the body's electrolyte losses;
• replenish isotonic bodily fluid losses; and
• correct metabolic acidosis. Normal saline solutions are used to:
• replenish saline isotonic bodily fluid losses;
• treat shock concurrent with the administration of blood and blood products; and
• serve as a diluent for the administration of many medications in solution that are delivered with the intravenous route.

D5 %W, an isotonic solution like normal saline, is used to:

• replenish water and isotonic bodily fluid losses;
• provide the body with a minimum amount of necessary calories; and
• serve as a diluent for the administration of many medications in solution that are delivered with the intravenous route.

THE MATHEMATIC CALCULATION OF IV FLOW RATES USING DIMENSIONAL ANALYSIS

A number of calculations are necessary when administering IV fluids and intravenous medications. You will have to know how to accurately calculate:

• IV flow rates;
• total infusion time;
• concentrations of medications in an intravenous solution; and
• intravenous rates based on body weight.

For this course, these intravenous calculations are presented using a simple method of calculation called, dimensional analysis. You may prefer to use ratio and proportion or another rule-based method; the answers to all the practice questions and post test questions will be identical, regardless of the method used.

In dimensional analysis, you set up an equation that consists of a starting factor, one or more conversion factors, and the answer unit. For example, if you want to know how many nickels there are in $3.00, you have to consider the number of nickels in each dollar, which is the known conversion factor, and what you want to know, that is, the number of nickels in $3.00. To determine how many inches there are in 9 feet, you have to consider the number of inches in 1 foot, the known conversion factor, and what you are trying to find out, that is, the number of inches in 9 feet.

Below is an example of how to set up a dimensional analysis equation using a starting factor, a conversion factor, and the answer unit, or the measurement unit, and the number that you are trying to calculate.



When you set up the equation, each numerator label should cancel out the denominator label that follows it. The numerator is the number on top of a fraction and the denominator is the number on the bottom of a fraction. When you have feet as a numerator and feet in one of the denominators of the equation, the word feet can be crossed off, or canceled out in both the numerator and the denominator because they are identical. In the example above, the only remaining unit of measurement is inches because the feet labels were cancelled out. In this example, inches should match the unit of measurement used in the answer. As shown below, the unit of feet in the starting factor cancels out the foot unit in the conversion factor. The final answer is computed by simply multiplying 12 by 9.



In the equation below, the unit of dollars in the starting factor cancels out the dollar unit in the conversion factor, and the remaining unit of measurement, nickels, is identical to the measurement unit used in the answer. Multiplying 20 by 3 gives the answer, 60 nickels.



In more complex calculations, once all the units of measurement that can be canceled have been struck out, the remaining numerators are multiplied and this product, or answer, is then divided by the product of all the remaining denominators. If the numerators and denominators can be divided by a common number, or reduced, the multiplication of the numerators and denominators as well as the final division will be somewhat simpler and less mathematically challenging. You will be taught how to reduce in this course.

The conversion factors that are used to calculate dosages and IV flow rates can consist of either established mathematical conversion equivalents, such as 20 nickels in a dollar, or manufacturers' equivalents. Some examples of manufacturers' equivalents are 1 tablet = 250 mg, 5 gr per kg, and 20 gtt = 1 mL.

Many dosage calculations require knowledge of mathematical conversion equivalents to move from one measurement system to another. We use metric, apothecary, and household measurement systems in pharmacology.

It is suggested that you refer to a table of equivalents for the less frequently used mathematical conversion equivalents. See Table 3 and memorize the ones that you use most often. Some of the commonly used conversion equivalents follow.

TABLE 3: CALCULATION EQUIVALENTS: AN EASY REFERENCE

1 gr 60 milligrams (mg) 15 gr 1 g or 1000 mg 1000 mcg 1 mg 1 kg 2.2 pounds (lbs) 1 mL or 1 cc 15 minims (m) 4 mL or 4 cc 1 dram (dr) 5 mL or 5 cc 1 teaspoon (tsp or t) 30 mL or 30 cc 1 ounce (oz), 2 tablespoons (T), 6 t or 8 dr teaspoons, or 8 dr 500 mL or 500 cc 1 pint (pt) or 16 ounces (oz) 1000 mL or 1000 cc 1 liter (L), 1 quart (qt), or 32 ounces (oz)

Source: Joanne M. Daniels and Loretta M. Smith. Clinical Calculations:
A Unified Approach. 4th Edition. Delmar Publishers: Albany et al. 1994.

Calculating IV Flow Rates Using Dimensional Analysis

IV tubing is manufactured by a number of companies. Each tubing set has a drop factor that indicates whether it delivers 10, 15, 20, or 60 drops (gtt) per mL of solution. The 60 gtt per mL tubing, which is often referred to as microdrop tubing or pediatric tubing, delivers the smallest drops of all the sets. The 10 gtt/mL tubing delivers the largest drops of solution. Drops are rounded off to the nearest whole drop when calculations are performed.

The IV flow rate calculations immediately below are set up and performed using dimensional analysis.

Example 1

Doctor's order: 0.9% NaCl solution at 90 mL per hour

How many gtt per minute would you give if the tubing delivered 20 gtt/mL?

The starting factor is 1 min; the conversion factors are 1 hour [h] = 60 min, 90 mL/1 h, and 20 gtt/1 mL; and the answer unit is the number of gtt per min, or gtt.

Example 2

Doctor's order: 1,000 mL of 5% D 0.45 normal saline solution to infuse over 5 hours

How many gtt per minute would you give if the tubing delivered 10 gtt/mL?

The starting factor is 1 min; the conversion factors are 1 h = 60 min, 1,000 mL/5 h, and 10 gtt/1 mL; and the answer unit is the number of gtt.

Example 3

Doctor's order: 25 mL/h of 5% D 0.45 normal saline solution

How many gtt per minute would you give if the tubing delivers 60 gtt/mL?

The starting factor is 1 min; the conversion factors are 1 h = 60 min, 25 mL/1 h, and 60 gtt/1 mL; and the answer unit is the number of gtt.

Example 4

Doctor's order: 45 mL/h of 5% D 0.45 normal saline solution

How many gtt per minute would you give if the tubing delivers 60 gtt/mL?

The starting factor is 1 min; the conversion factors are 1 h = 60 min, 45 mL/1 h, and 60 gtt/1 mL; and the answer unit is the number of gtt.

Did you notice that the last two calculations, which use the microdrop, or 60 gtt/mL, IV tubing, yield the same number of gtt per minute as the number of mL per hour that was ordered?

Specifically, the first doctor's order was for 25 mL per hour. You would have to run the IV solution at 25 gtt per minute to deliver 25 mL per hour. The second doctor's order called for 45 mL per hour. You would have to run the IV solution at 45 gtt per minute in order to deliver 45 mL an hour.

Calculating Total Infusion Time

When you have adjusted an IV solution to run at a certain number of drops per minute, you will want to know when the solution is due to finish infusing so that you can anticipate the need to hang another bag of solution, if so ordered. You must, therefore, be able to calculate the total infusion time for the presently infusing bag.

Following is an example of how this type of calculation is accomplished using dimensional analysis.

Total volume of IV fluid: 1,000 mL

Infusion rate: 23 gtt/min

Drop factor: 10 gtt/mL

When will the liter of fluid run out?

The starting factor is 1,000 mL; the conversion factors are 10 gtt/1 mL and 23 gtt/1 min; and the answer unit is time, that is, the number of hours and/or minutes.

Calculating the Concentration of a Medication in an IV Solution

On some occasions, a physician may order an hourly dosage of a medication that has been diluted in an IV fluid. For example, the doctor may order an hourly dosage of 1,200 units of heparin that has 20,000 units of heparin diluted in 1,000 mL of normal saline solution. The nurse must then be able to calculate the flow rate of the fluid based not on the volume of the fluid ordered but on the dosage of the medication.

The starting factor is 1 h; the conversion factors are 1,200 U/1 h and 20,000 U/1,000 mL; and the answer unit is the number of mL.

Calculating IV Flow Rates Based on Body Weight

When a doctor's order specifies a volume of fluid or a dosage of a diluted medication over a period of time based on body weight, the calculation is similar to those described above with the addition of a conversion factor that allows for body weight.

For example, if you are caring for a patient that weighs 200 lb and the doctor orders 5 mcg [μg,] /kg/min of a medication intravenously infused via 500 mL of an IV fluid that contains 250 mg of the medication, you would perform the following computation to determine the number of mL per minute or hour that the patient will receive.

The starting factor is 200 lb; the conversion factors are 1 kg = 2.2 lb, 5 mcg/1 kg, 1 mg = 1,000 mcg, and 250 mg/500 mL. The answer unit is the number of mL to be administered per minute. If you want to determine how many mL to administer per hour, you would simply multiply the answer by 60.


The number of mL to be administered per hour = 0.9 X 60 = 54.

Practice IV Rates

1. Total volume of IV fluid at the beginning of your shift: 375 mL
   Infusion rate: 21 gtt/min
   Drop factor: 15 gtt/mL
   When will this fluid run out?
   (The starting factor is 375 mL; the conversion factors are 15 gtt/1 mL, 21 gtt/1 min, and 1 h = 60 min; and the answer unit is the number of hours and/or parts thereof.)
2. How many mL/h would you administer if the doctor orders 25 U/h of a medication that has been diluted in a solution with a total of 250 U in 1,000 mL?
   (The starting factor is 25 U, the conversion factor is 250 U/1,000 mL, and the answer unit is the number of mL/h.)
3. If your patient weighs 100 lb and the doctor orders 5 mcg/kg/min of a medication intravenously infused via 500 mL of an IV fluid that contains 250 mg of the medication, how many mL/min and mL/h would you administer?

Answers

1. 4 h 28 min
2. 100 mL
3. 0.45 mL/min and 27 mL/h

THE LEGAL ASPECTS OF VENIPUNCTURE AND INTRAVENOUS THERAPY

Nurses can be held liable for negligence, criminal negligence, professional malpractice, abuse, and neglect as a result of venipuncture as well as the care and maintenance of intravenous access lines.

Negligence. A nurse who fails to act (omission) or whose act (commission) falls below the accepted standard of care established by law may be held accountable for injuries and losses incurred by the patient as a result of such omission or act of commission.

Negligence is a departure from the conduct (breach of duty) that can, and should, be expected of a reasonably prudent person under similar circumstances. The provider can be held accountable for injuries and losses that result from such an omission or act of commission; that is, not doing the correct thing, not doing something in the correct way, doing the wrong thing, and/or doing something in the wrong way.

For example, a nurse who allows a nursing assistant to hang an intravenous solution that is not the correct intravenous solution and this act has caused harm or injury to the patient or resident, can be found negligent for assigning a task outside of the scope of practice for a nursing assistant.

Criminal negligence consists of those acts that represent an extreme departure from the standards of care. The nurse who has used reckless or conscious disregard for the dangers that this act, or these acts can cause, can be found to be criminally negligent. In some cases, the healthcare provider can be charged with involuntary manslaughter, a felony, when a person has died as a result of criminal negligence. In some rare and extremely unfortunate cases, a nurse has been charged and convicted of murder when he or she has willfully and knowingly injected unordered medications, such as an anticholinergic medication, into a person's intravenous line.

Professional malpractice is the failure of a nurse to render professional services while exercising the degree of skill and knowledge that is commonly applied in circumstances within their professional community by the average, prudent, reputable member of the profession; this failure results in injury, loss, or damage to the recipient of those services or to those entitled to rely on them.

In order to be found guilty of professional malpractice, the patient's or resident's attorney must establish (1) the duty or standard of care owed by the professional; (2) that breach of that standard of care by the professional has occurred; and (3) that the breach of the standard of care was the legal cause of the injury or harm alleged by the claimant. The duty owed by the professional is based on the professional relationship with the patient. A patient-healthcare professional relationship requires conduct on the part of the healthcare professional similar to conduct expected by a reasonably prudent person within the profession in the same or similar circumstances. The relationship may help define the duty. For instance, a nurse who witnesses a patient, not assigned to her or him, receiving the wrong blood during a transfusion has a legal duty to correct and report the incident, because of his or her employment relationship to the hospital and duty to render assistance to the patient. A breach of duty occurs when there is a failure by the professional to use the care a reasonably prudent professional would use under similar circumstances. As an example, it is a breach of duty to administer medication to a patient to which the patient has a documented allergy. The breach of the duty of care must be the legal cause of injury to the patient. If penicillin was negligently administered to a patient with a documented allergy to it, the penicillin must have caused some bad effect. A causal link between the act or misconduct and the resultant harm must be demonstrated to the extent that had the professional acted in a reasonable and prudent manner the injury or harm to the patient would not have occurred.

The recipient of health care or a representative on his behalf who claims that the harm, injury, or loss resulted from the professional malpractice of a healthcare provider has the burden of proof. Every element must be proven for the claimant to prevail. The greater weight of the evidence presented must prove that the alleged acts or conduct of the healthcare professional represented a breach of the prevailing professional standard of care for that healthcare professional and caused the injury or loss to the patient.

In reference to abuse and neglect, many states may have civil and criminal statutes to punish alleged perpetrators of abuse or neglect. Healthcare professionals accused of providing substandard health care to elders or children may find that the alleged acts qualify as abuse or neglect under state laws, and may subject them to criminal charges or additional causes of action. Civil or criminal allegations of abuse and neglect may often trigger concurrent licensure investigation of the incident.

CASE ILLUSTRATION: CRIMINAL NEGLIGENCE In Colorado, three nurses were charged with criminally negligent homicide. The nurses participated in a medication error that resulted in the death of a newborn. Penicillin was ordered for the newborn because the mother had a history of venereal disease. The newborn received a dose of Penicillin that was ten times larger than what had been ordered, and received the medication intravenously (IV) rather than intramuscularly (IM) as had been ordered. In addition it is noted in published reports of this incident, that the pharmacist prepared incorrect dosages. The dosage errors were not detected. A nurse practitioner in consultation with the newborn's primary care nurse changed the route of the medication from IM to IV without consulting the newborn's physician. The state prosecutor described the actions of the nurses as grossly negligent in that the nurses committed a flagrant deviation from the standard of care that resulted in a substantial and unjustified risk. The pharmacist was not prosecuted because it is reported that the incorrect dosages that were prepared would not have been fatal had they been administered IM as originally ordered.1

Institutional Liability for the Acts of Healthcare Professionals

Healthcare employers, and other employers, are liable for the acts of their employees through the legal theory of vicarious liability. Under common law, this is known as respondeat superior. This is Latin for the principle of "let the master answer." A healthcare professional employed by a healthcare institution owes a duty of care to the patients while acting within the scope of employment. Should the employee breach this duty of care to the patient, the institution, whether it be a hospital, nursing home, agency, physician's office, or another healthcare institution, will be held liable for the negligent acts. The theory of respondeat superior requires that at the time the negligent acts or omissions took place, the healthcare professional be an employee of the institution, be performing duties required by the employment, and the acts or omissions must have occurred on the institution's premises.²

When a medical malpractice suit is filed under this theory, the healthcare professional may or may not be a named defendant. This decision will depend on whether he or she was acting within the scope of employment. Some factors for determining whether a healthcare professional is acting within the scope of employment include: the time, place, and purpose of the act; the deviation from the standard of care; the relationship between the employer and employee; and whether the employer could reasonably expect the act to be done.³

Intravenous Therapy Standards of Care

The standard of care expected of the provider of health care is that level or degree of care or skill that a reasonably prudent person should exercise under the same or similar circumstances. Should the professional's conduct fall below the recognized standard of care, he or she may be held liable for injuries or damages resulting from the conduct. The standard of care is derived from various sources including the profession's state practice act, professional association standards, regulatory body standards, and the policies and procedures of the employing healthcare agency. Some examples of standards of care for intravenous therapy include those put forward by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the states' departments of health, the states' nurse practice acts, and professional organizations such as the Intravenous Nurses Society (INS) and the National Association of Vascular Access Networks (NAVAN).

Standards of care are closely related to current accepted practice; thus it is imperative that healthcare professionals remain up to date in their knowledge of their own specialty of practice. The first of the legal self-protection strategies involves a familiarity with and an adherence to the professional standards of care. Some state statutes may only broadly, but not specifically, define the prevailing standard of care for a given healthcare provider as that level of care, skill, and treatment, which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate, by reasonably prudent similar healthcare providers.⁴ The healthcare professional is required to maintain that level of expertise and competency that reflects the standard of practice in his or her community and throughout the practice community at large. In addition, if a healthcare professional practices outside the boundaries of the professional's practice act or certification and provides a diagnosis or treatment for a condition which is beyond his or her training and experience, the standard of care which is applicable may become that of the specialist who has been trained to diagnose and treat such a condition. It is essential that the healthcare professional know the boundaries of his or her practice as contained within the professional's applicable practice act and standards of care.

Competency and Competency Assessment

A special area of concern for healthcare professionals is competency in rendering patient care. Competency is also critical in the area of venipuncture and intravenous therapy. Education, with a course like this one, provides you with the knowledge and skills necessary to become competent in the area of intravenous therapy and venipuncture. It is, however, only the beginning. You must, according to external regulatory bodies such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and by common sense, be able to use this information and demonstrate competency in the clinical area. If, at any time, you do not feel competent in performing a task, including venipuncture and intravenous therapy, immediately contact your supervisor. Do not do anything unless you feel that you are competent to do so.

Competency is measured and documented prior to your beginning to incorporate venipuncture and intravenous therapy into your role and responsibility and also in an ongoing and continuous manner. Your competency and the competency of all other nurses performing venipuncture and/or maintaining and caring for intravenous lines and/or administering intravenous fluids with or without medications must be observed for their competency by a person who is able to perform this performance evaluation, usually a supervisor or a nursing instructor.

The word certify or certification is a misused and misunderstood term in health care, especially nursing. When a person is IV certified or he or she has an IV certification, it does not necessarily mean that the person is competent in venipuncture and intravenous therapy. IV therapy and venipuncture have two components of competency.

One component of IV and venipuncture competency is the knowledge or cognitive domain and the other component is the psychomotor or hands on skill domain. Most certifications and certification exams given by professional organizations and groups test and substantiate only cognitive competency in the area of IV therapy and venipuncture; they do not test and substantiate the psychomotor competency. Psychomotor competency can only be demonstrated and substantiated in the clinical area while actually performing venipuncture, and administering intravenous fluids.

Some hospitals and nursing homes also certify nurses in IV and intravenous therapy. This kind of certification more closely approximates competency assessment and validation. If done correctly, the hospital or nursing home provides education about IV therapy and venipuncture to nurses upon orientation and throughout the course of employment, as needed, and also with direct observation validates that the nurse has been able to demonstrate competency- psychomotor and cognitive-in the actual area of practice. This certification process, when done in this manner, is identical to the competency assessment discussed above. As you can see, this process is quite different than a certification in intravenous therapy that only tests a wide scope of knowledge-cognitive domain-and not clinical performance and return demonstration.

ADHERENCE TO ESTABLISHED POLICIES AND PROCEDURES IN THE FACILITY

The healthcare professional must also be familiar with the policies and procedures of the institution in which he or she practices. These policies and procedures are generally developed on the basis of the federal and state laws affecting health care as well as external regulatory bodies, such as JCAHO, and standards of care. Therefore, compliance with the rules and regulations of the facility helps to ensure that the healthcare professional has complied with all these regulations as well. The policies and procedures also should reflect the facility's interest in quality of care and the standards of practice within the community. They provide the healthcare professional with a useful set of guidelines. At trial, the facility's policies may also be used as evidence of the professional standard of care.

AVOIDING ERRORS OF IV FLUIDS AND MEDICATION ADMINSTRATION

Pharmacology is the study of medications and drugs and how they act on the body. Nurses administering medications are accountable for a thorough knowledge of all the medications that they administer. This nursing responsibility can only be fulfilled by staying current with the latest pharmacological advances and a continuous professional commitment to refer to credible and current resources whenever one is less than absolutely certain about a medication, an aspect of the medication, and the appropriate care of the patient as relates to IV therapy. This course will provide you with current and comprehensive information about IV medications and the care of the patient.

The nurse's knowledge about medications should minimally include competency in the following areas:

• classifications of medications;
• similarities among medications in the same classification;
• differences among medications in a particular classification;
• brand names and generic names;
• actions and mechanisms of action;
• pharmacodynamics;
• pharmacokinetics;
• uses and indications;
• contraindications and precautions;
• side effects and adverse reactions;
• interactions of medications with other drugs, foods, herbs, lifestyle, and diagnostic tests;
• recommended dosages and dosage modifications based on the characteristics of the patient and his or her condition;
• age-specific routes for the pediatric patient;
• nursing implications and considerations, including patient and family teaching;
• how to refer to published pharmacological resources;
• the components of a complete doctor's order for a medication including one administered intraveneously;
• the Seven Rights of Medication Administration;
• legal responsibilities associated with medication administration; and
• pharmacological safety.

CASE ILLUSTRATION: IV AND VENIPUNCTURE COMPETENCY A licensed practical (vocational) nurse has been asked to start an IV in an orthopedic unit by the charge nurse. This LPN is licensed in the State of Florida, a state that allows LPNs to start IVs after education and training. The LPN (LVN) refused to start the IV, stating that he felt incompetent to do so. At the time the nurse was hired, he was aware of the fact that licensed practical (vocational) nurses were expected to start IVs with venipuncture. The nurse was suspended for two days. He requested a grievance hearing regarding his suspension. The personnel director gave the nurse a copy of the Problem Review Procedure and offered to re-educate the nurse in venipuncture and IV therapy so he would feel competent should the need to start an IV arose again. The nurse refused the opportunity to be re-educated. The court found that the hospital presented the nurse with sufficient opportunity to become competent. In conclusion, the court held that the nurse's suspension and later termination were warranted.5

THE CLASSIFICATION OF MEDICATIONS

Medications are most often classified and categorized according to their function or use. For example, the nonsteroidal, anti-inflammatory medication classification group is primarily used to decrease inflammation. This classification includes a number of medications including aspirin, ibuprofen, and etodolac, among others. Within drug classifications, most of the medications are similar, however, they are not identical.

The classification of medications permits us to more readily identify the similarities and differences of many medications within and outside of a particular classification or category. One of the best and most efficient ways, therefore, to master pharmacology is to become familiar with classifications of medications and then to focus in on what makes medications within the same classification uniquely different.

Most pharmacology resource books index and categorize medications according to one or more of these classification systems. Nonetheless, there is considerable overlapping of information between systems. For example, a functional classification such as antiinfectives includes a number of subcategories, such as aminoglycosides, antifungals, antimalarials, antimycobacterials, antiparasitics, antivirals, carbapenems, cephalosporins, fluoroquinolones, macrolides, penicillins, sulfas, and tetracyclines, among others.

In summary, knowledge about major drug classifi- cations enables us to become more knowledgeable about a larger number of medications than would be possible by studying individual medications. However, be aware that our memories often fail us and printed information about medications is too voluminous for even the most intellectually gifted nurse to memorize. Therefore, it is critical that you are able to utilize reliable printed resources whenever you administer medications to your patients.

Some examples of medication classifications include:

• Beta blockers
• ACE inhibitors
• Cephalosporins
• Fluoroquinolones
• Penicillins
• Sulfa drugs
• Tetracyclines

Knowledge of how medications act on the body is also highly important. Such knowledge enables the nurse to critically think about and plan care related to how a medication can or cannot be therapeutic for the patient; how it is absorbed, distributed, metabolized, and excreted; if it can produce drug-drug, drug-food, drug-herb, drug-lifestyle, or drug-diagnostic test interactions; if the patient may be experiencing an adverse reaction or side effect; the correct dosage based not only on recommended dosage but also on the patient's age, health, or disease status and idiosyncrasies; how the patient is responding to the medication in terms of effectiveness; and what nursing considerations, cautions, and precautions must be addressed to safely and most effectively administer the medication, based on the unique and individual characteristics of the patient that is receiving it.

An illustration that reinforces the need for nurses to know about the actions of medications is the need to know about the actions of the loop diuretics. Furosemide (Lasix), bumetanide (Bumex), ethacrynic acid (Edecrin), and torsemide (Demadex) all belong to a classification of drugs known as loop diuretics. Nurses who administer loop diuretics to their patients must be knowledgeable about the mechanisms of action of this medication and the fact that it inhibits the reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle, thus placing the patient prone to electrolyte imbalances, such as hyponatremia, hypokalemia, and hypochloremia. This knowledge mandates that the nurse must monitor, assess, and act upon the patient's laboratory data relating to these electrolytes.

Nurses should also be knowledgeable about some of the most frequently occurring factors or variables that affect how medications act on the body. Some of these factors include the normal physiological changes associated with the aging process, the age-specific characteristics of neonates, infants, and children, the presence of some chronic diseases such as hepatic and renal disease, and the tenuous risks associated with giving medications to neonates, infants, and children. Most, if not all, of these variables impact nursing practice.

PHARMACODYNAMICS

Medications chemically and therapeutically perform a role. Pharmacodynamics provides information about the metabolism and excretion which, with many medications, is affected by renal or hepatic dysfunction.

PHARMACOKINETICS

The pharmacokinetics of a medication provide information about the drug's half-life, onset, peak, and duration. Pharmacokinetics have implications for nurses administering medications.

USES OF MEDICATIONS AND INDICATIONS FOR USE

All pharmacological agents have intended uses. Most intended uses result from the medication's direct action. Some uses, however, are related to the indirect action or side effects of a medication. For example, diphenhydramine (Benadryl) is an antihistamine that blocks histamine. It is primarily intended to be used for allergic reactions; however, because diphenhydramine produces drowsiness as one of its common side effects, it is also used for sedation and the promotion of sleep onset, particularly among the elderly. Both of these intended uses, that is, for sedation and as an antihistamine, are published in reliable pharmacology resource books, such as the PDR or a current nursing drug handbook. Some resource books use the term indications for intended uses.

Dosages of medications sometimes vary according to their intended use. For example, the adult dosage of timolol maleate for hypertension is 20 to 40 mg a day, and the recommended dosage of the same medication for the propylaxis of a myocardial infarction is 10 mg twice a day (bid).

CONTRAINDICATIONS AND PRECAUTIONS

Certain medications should be used with caution or not at all among some populations. For example, barbiturates should be used cautiously in patients with pulmonary disease, and they are contraindicated, or completely prohibited, for patients with severe pulmonary insufficiency. Many medications are contraindicated for pregnant women because these drugs can cause fetal harm as they cross the placental barrier. Additionally, many medications are also contraindicated during lactation because they can be passed to the baby through the mother's milk, as they also are for those allergic to a specific medication or an entire classification of a medication.

Some of the most frequent pharmacological precautions relate to the geriatric and pediatric populations as well as those with renal or hepatic disease, pregnancy, and lactation. Prior to the administration of a medication, nurses must be aware of its precautions and contraindications. If a medication order could possibly be contraindicated for a particular patient, the nurse should clarify the order with the physician prior to administration.

THE SIDE EFFECTS AND ADVERSE SIDE EFFECTS OF MEDICATIONS

Virtually all medications produce side effects. Some side effects are desirable, as is the case with sedation from diphenhydramine when sedation is desired. Other side effects can be troublesome but not life threatening, as is the case with the headaches that can result from trimethobenzamide (Tigan), an antiemetic and anticholinergic. Still, other side effects can be life threatening and extremely problematic. These side effects are often referred to as adverse drug reactions (ADRs). For example, nonsteroidal, antiin flammatory agents, such as fenoprofen calcium (Nalfon), are associated with the possibility of a severe, life-threatening hypotensive crisis. Medication can also produce what is referred to as a toxic effect. For example, tinnitus is a toxic side effect of, or a sign of, toxicity related to aspirin. Some pharmacological resource books refer to all side effects as adverse reactions.

As with all other aspects of the medication, nurses must be fully knowledgeable about the side effects, toxic effects, and adverse reactions of all medications they administer. They also have to monitor the patient for these undesirable effects in addition to monitoring for therapeutic effectiveness.

INTERACTIONS

Medications interact with and react to other medications, including over the counter and herbal preparations, foods, and lifestyles. Some medications also alter laboratory and other diagnostic findings. Interactions can create additive effects, antagonistic effects, and potentiated effects. For example, fluoxetine hydrochloride (Prozac) interacts with a number of medications including phenytoin, lithium, and tricyclic antidepressants. Drug-drug interactions can potentiate, or increase, the effect of one or both of the drugs, or it can serve to antagonize, or diminish, the effect of one or both of the interacting drugs. The same additive or diminishing effect can occur when certain medications interact with certain foods (drug-food interactions). For example, dietary intake of vegetables high in vitamin K can inhibit or diminish the effectiveness of coumadin. Patients, therefore, should be taught to avoid foods high in vitamin K. Examples of drug-lifestyle interactions include exposure to sunlight and the use of alcohol. For example, diclofenac potassium (Voltaren), a nonsteroidal antiin flammatory medication, places a patient at risk for photosensitivity when the patient is exposed to the sun. Certain medications are also capable of altering the results of some diagnostic tests. This interaction is referred to as a drug-diagnostic test interaction. Recently, some pharmacology resource books have added drug-herb interaction information, particularly important since more and more patients are using herbs for self-healing and wellness promotion.

In summary, the following interactions are associated with medications:

• drug-drug interactions;
• drug-food interactions;
• drug-test interactions;
• drug-lifestyle interactions; and
• drug-herb interactions.

Nurses who administer intravenous medications must also be knowledgeable about what intravenous medications are compatible and not compatible with others, important information that many pharmacology resource books do not include. The Springhouse Nurse's Drug Guide, however, does contain this critically important information. Before administering a diluted intravenous medication, the nurse is responsible for insuring that it is compatible with the fluid.

Additionally, when administering several intravenous medications using the same tubing, the nurse is responsible for insuring that these medications are also compatible with each other. Using written resources, such as the Physician's Desk Reference (PDR) or consulting with a pharmacist, will ensure that you are administering compatible medications and fluids.

DRUG DOSAGES

All medications have approved and published dosages or dosage ranges. Obviously, pediatric dosages are less than that for adults. Additionally, geriatric dosages also have to be frequently adjusted to accommodate for the natural physical changes associated with the aging process. In addition to being competent about what dosages are acceptable for different age groups, nurses should also be aware that these published recommended dosages are guidelines that should not be viewed as fail proof. Sometimes the approved therapeutic dose published in reliable resources may be dangerously close to or break through the threshold of toxicity for a patient, particularly a physically compromised or elderly one. If a doctor's order appears to exceed recommended dosages, the nurse should clarify the order prior to administration. Additionally, calculations and computation of dosages must be highly accurate and without error.

Pharmacology dosage and route considerations vary according to the characteristics of virtually all age groups except for the young and middle-aged adult. For the infant, toddler, preschool, and school-age children, dosage is very often determined according to the weight of the child in kilograms. By the time the child reaches adolescence most adult dosages are appropriate. As is the case with all medication administration, nurses must be knowledgeable about the medications they are administering and should question or clarify any medication orders that are unclear or possibly inappropriate.

NURSING IMPLICATIONS INCLUDING PATIENT AND FAMILY EDUCATION

Most if not all medications have implications for nursing practice. Some of these implications revolve around laboratory data, patient assessment/reassessment, the medication administration procedure, and the evaluation of the medication's outcome in terms of effectiveness, side effects, interactions, and patient/ family teaching. For example, prior to the administration of heparin, the nurse should check the PT/PTT, and prior to the administration of digoxin, the nurse should check the apical heart rate. When a patient is taking insulin for diabetes, the nurse must monitor the blood glucose levels to determine the insulin's effectiveness and also monitor the patient for hypoglycemia, a side effect of this medication.

In terms of patient and family education, it is the nurse's responsibility to provide complete information about all the medications that a patient is taking. The teaching plan should minimally include understandable information about the medication's:

• name;
• actions;
• uses and indications;
• contraindications and precautions;
• side effects and adverse drug reactions;
• possible interactions, including possible interactions with over-the-counter medications and herbs;
• dosage;
• route;
• age-specific information;
• warnings such as not driving a vehicle and not crushing the medication, and
• therapeutic effect and when to notify one's physician.

See Table 4, Table 5, and Table 6 below for some of the acceptable abbreviations of medications.

USING PRINTED PHARMACOLOGY RESOURCES

Based on the voluminous number of medications available and the complexities of all medications, the proficient use of written pharmacological resources is essential for the safe and competent administration of medications. This section of the course will review the use of these resources. For the post test, you can and should refer to either the PDR or a current nursing handbook, such as the one published by Springhouse Publishers or Mosby.

COMPONENTS OF A COMPLETE DOCTOR'S ORDER

It is necessary that the nurse confirm that the doctor's order is complete and appropriate before any medication orders are transcribed on to the medication administration record (MAR). Complete medication orders have all of the following elements:

• patient name;
• date and time of the order;
• name of the medication;
• dosage of the medication;
• route and form of administration;
• time and frequency of administration; and
• physician's signature.

If an order is illegible or questionable, it is necessary that the nurse communicate with the doctor and others, such as a pharmacist, whenever necessary. The nurse is responsible and accountable for all medications he or she administers.

TRANSCRIBING AND DOCUMENTING MEDICATION ORDERS AND MEDICATION ADMINISTRATION

Medications orders are transcribed on to a medication administration record, such as an MAR or Medex, unless a facility is using computerized order entry. Medications must be transcribed exactly as the order is written. If the order is incomplete or questionable, the nurse must clarify it with the physician prior to transcription. Medication administration records are also a vehicle on which medications administered, omitted, held, refused by the patient, and delayed for diagnostic testing or other procedures are documented. Most medication administration records also allow a space for preadministration data, such as an apical rate prior to the administration of digoxin. A complete and acceptable medication administration record must minimally contain:

• the patient's full name;
• room number;
• patient's age;
• physician;
• allergies;
• name of the ordered medications;
• medication dosage;
• route of administration;
• date of the order and dates of administration;
• time of administration;
• start and end dates;
• initials and full signature of administering nurses; and
• title (RN or LPN).

Legal Responsibilities

Nurses are legally and ethically accountable for accurate medication administration, observation, documentation, and record keeping. Medications must be documented immediately after administration. A controlled substance is documented on the narcotic record immediately upon removal from its secure location and then documented on the patient's medication administration record immediately after being given. If a controlled substance is wasted, either entirely or partially, it must be witnessed and signed on the narcotics record by two nurses. All medications, controlled substances, and noncontrolled medications must be securely maintained at all times, particularly when children and cognitively impaired elderly adults are present.

Additional responsibilities include the observation and assessment of the patient prior to administration, like taking and assessing the apical rate and rhythm of the patient prior to the administration of digoxin; the evaluation of the patient's response to a medication, such as the relief of pain after the administration of a prn analgesic; the questioning of questionable doctors' orders; and a thorough knowledge about all medications given.

Source: Joanne M. Daniels and Loretta M. Smith. Clinical Calculations: A Unified Approach. 4th Edition. Delmar Publishers: Albany et al. 1994

Source: Joanne M. Daniels and Loretta M. Smith. Clinical Calculations: A Unified Approach. 4th Edition. Delmar Publishers: Albany et al. 1994 Source: Joanne M. Daniels and Loretta M. Smith. Clinical Calculations: A Unified Approach. 4th Edition. Delmar Publishers: Albany et al. 1994

CLASSIFICATION OF MEDICATION ERRORS

There are three major events in the medication process:

• the "point-of-entry" written order prescribing the medication route and dosage;
• the dispensing of the medication; and
• the administration of the medication to the patient.

Several studies have focused on the errors unique to each stage of medication errors.

Point-of-Entry Errors

Point-of-entry errors (POEs) include errors involving prescribing, ordering, and transcription. Several reports have concluded that mistakes in prescribing or ordering medication are the most frequently encountered forms of error. Many factors, such as interruptions, distractions, or incomplete orders, have been identified as contributing to this problem. The relatively recent use of computers to prescribe medications has reduced many potential POE errors. A 1998 report showed a 50% reduction in POE errors with the use of computerized order entry.⁶

Bates et al. found that when a physician used a computer system for all in-house prescribing, there was a 19% reduction in order errors, an 84% decrease in transcription errors, a 23% decrease of dosage errors, and a 56% reduction in allergy errors.⁷ Other researchers have found that using computers for point-of-entry have reduced patient length of stay, hospital costs, and the frequency of allergic reactions to drugs. These systems have also achieved an improvement in the appropriateness of the dosage ordered. All of these benefits improve the safety of the consumer and decrease the magnitude as well as the frequency of adverse drug events.

Verbal orders pose another threat to point-of-entry accuracy. For many years verbal orders have been strongly discouraged by healthcare facilities and external regulatory bodies because they are highly prone to error. Existing policies within healthcare facilities that prohibit verbal orders should be enforced in order to improve safety and to decrease unnecessary, preventable errors.

Dispensing Errors

A 1995 study of a community pharmacy found a 24% error rate in dispensing; of those errors, 4% were considered "clinically significant." In a high-volume, hospital-based outpatient pharmacy, a 12.5% error rate was found; 1.6% of the errors was deemed potentially harmful.⁸

State boards of pharmacy are exploring several ways to reduce dispensing errors. These efforts are focusing on three primary problem areas. First, they are trying to determine the number of prescriptions per hour a pharmacist can safely manage without error. Although no state has defined a specific number of prescriptions a pharmacist is permitted to fill in a given amount of time, the Iowa State Board of Pharmacy in 1993 established a restriction of no more than 14.2 prescriptions per pharmacist per hour.⁹ This decision came as the result of complaints relating to dispensing errors, insufficient staffing, and the lack of adequate time for patient counseling.

Secondly, pharmacy boards are evaluating competencies and the minimum level of training for pharmacy technicians. Thirdly, the boards are developing criteria to limit the number of hours a pharmacist will be allowed to work daily and weekly.

The prevailing impression among researchers who study medication errors is that most errors are caught and prevented before the medication is dispensed. Although patients perceive doctors and nurses as being primarily responsible for medication therapy, pharmacists are also crucial to the prevention of harm due to medications. One study conducted in two pediatric hospitals found that pharmacists intervened to prevent, respectively, an average of three to five medication errors per 1,000 orders.¹⁰

A 20-month study at New York's Albany Medical Center Hospital showed that pharmacists prevented 1,048 antibiotic prescription errors. These potential errors represented 7.5% of all prescriptions written; 14% were potentially harmful, and 16% could have led to the death of the patient.¹¹

At the University of California, San Francisco, pharmacists recommended changes to 6% of antibiotic prescriptions over two years. This totaled 3,041 questioned prescriptions; 858 of these, which included 68 cases of kidney toxicity and 40 cases of potential hearing loss, were considered potentially harmful.¹²

Detecting a dispensing error before a medication leaves the pharmacy lessens the chance that the wrong medication will be given, but it does not guarantee an error-free system. For this reason, double-checking medications against the medication administration record (MAR) is a very effective practice.

If an error in medication administration occurs, the error must be documented on an incident report and in the patient's record. This documentation is necessary for legal reasons and to provide nursing with a tool to explore ways in which to prevent similar errors. Was the error an isolated incident or part of a pattern that must be reversed?

Although the literature varies, the most common administration errors include incorrect infusion rate, unprescribed or extra doses, administration of medication to the wrong patient, and the administration of the wrong drug.¹³ An incorrectly read order or an inaccurate calculation are frequent causes of dosage errors. Medication administration errors are most commonly attributed to nurses. The administration of the wrong drug is most often the result of a misread prescription, order, or drug label.

Be certain that all calculations are accurate. A 1995 research study determined that 18.5% of nurses do not possess the mathematical skills required to calculate dosages correctly.¹⁴

Unit dosing and automated bedside dispensing systems have successfully decreased the rate of medication and administration errors. One study indicates that the unit-dose system had a 15.9% error rate. The error rate for the automated system was 10.6%. Doses given at the wrong time were the most prevalent errors: 9.2% for the automated system and 5.4% for the unit-dose system.¹⁵

DRUGS INVOLVED IN ADVERSE DRUG EVENTS

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization dedicated to the prevention of medication errors. The ISMP publishes a biweekly newsletter that identifies errors that have been reported by other organizations and offers recommendations to prevent those errors from occurring. Among medication error-related deaths reported in journal articles, newsletters, and materials published by ISMP, there are a few drugs that are most frequently associated with serious medication errors. They include:

• cancer chemotherapy;
• parenteral narcotics;
• insulin;
• lidocaine for cardiac use;
• magnesium sulfate;
• neuromuscular blockers; and
• potassium chloride injection concentrate.

Drug Pairs with Look-Alike Names

The drug pairs in Table 7 are products with look-alike or sound-alike names (trade or generic). In many cases they are available in the same dosage form and have similar doses. Drug pairs that look alike can lead to POE, dispensing, and administration errors.

TABLE 7: DRUG PAIRS WITH LOOK-ALIKE NAMES

Norvasc (amlodipine) Navane (thiothixene) Prilosec (omeprazole) Prozac (fluoxetine) Lamictal (lamotrigine) Lamisil (terbinafine) Fosamax (alendronate) Flomax (tamsulosin) Gabitril (tiagabine) Zanaflex (tizanidine) Narcan (naloxone) Norcuron (vecuronium) Zomig (zolmitriptan) Imitrex (sumatriptan) Celebrex (celecoxib) Cerebyx (fosphenytoin) Celexa (citalopram)

Source: Adverse Drug Reactions and Reducing Medication Errors

THE PSYCHOLOGY OF ERRORS

Healthcare professionals are taught to "do no harm," and that perfect performance is an attainable goal. When faced with a deviation from perfection, an individual's foundation of self-esteem and self-worth is shaken. Several factors often seem to lead to medication errors. These negative factors include:

• stressful work circumstances;
• constant interruptions;
• poor packaging and labeling of pharmaceuticals; and
• lack of unit-dose packaging.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has emerged as a benchmark provider of standards for the analysis and prevention of medical injuries including adverse drug reactions (ADRs) and medication errors. Their standards mandate that all sentinel events involving near misses and actual harm be reported and analyzed in order to prevent future mishaps. The Harvard Medical Practice Study has explored the root causes of errors leading to adverse drug events. One of this study's leaders, Dr. James Reason, divides errors into two broad categories: slips, errors in automatic mechanisms and mistakes, errors in problem-solving mechanisms. See Table 8.

Slips

Slips are unintentional departures from an otherwise adequate plan of action. They occur when attention is diverted because of preoccupation or distraction. Stress, fatigue, anger, noise, distractions, temperature, and substance abuse are some types of distractions that may occur. Some forms of slips are listed below.

• A capture slip is an error in which a more frequently used pattern of behavior displaces a less familiar one. An example is when a patient who has always taken a certain medication is erroneously given it even though the order has been changed or discontinued.
• A description error occurs when the right action is taken on the wrong object. An example is when a medication intended for rectal administration is administered vaginally.
• An association-activation error results from a faulty mental association. The act of pouring medication into a cup results in the nurse drinking the medication herself. The association of pouring a drink resulted in the mental cue to drink.
• A loss-of-activation error is an error caused by a physical or mental interruption that results in memory loss. An example of this is picking up the telephone and forgetting whom you intended to call or a failure to give a medication to a patient because you were interrupted during the medication administration process by a patient fall.

Mistakes

Mistakes are errors made in solving a problem. They occur when inadequate means are used to address rule-based or knowledge problems. A rule-based mistake, for example, comes from misapplied expertise. The mistake occurs while trying to solve familiar problems with stored rules (i.e., if this occurs, then that will always follow). Knowledge-based mistakes arise when a person encounters a new problem and does not have the training or knowledge to solve it. Such mistakes include the following:

• Biased memory decision-making is biased toward our commonplace generalizations. Professionals who revert to generalizations formulated early in their careers, rather than researching new data for a patient's treatment, are making a biased decision.
• Overemphasis on the discrepant results when contradictory experience is exaggerated in importance. We become biased rather than able to make a logical decision. This type of mistake occurs when one chooses a drug based on personal experience, even though research shows that a very high percentage of patients do best on another form of medication.
• Confirmation bias is a tendency to look for evidence that supports an early hypothesis and ignores data that contradicts it. A professional may become so satisfied with the response of a patient to a medication that negative data regarding the medication may not seem important.
• Availability heuristic is a preference for using the first information that comes to mind. In these cases, the first medication that comes to mind is used even though further thought could have led to the conclusion that another medication is more appropriate for the patient.
• Overconfidence is a tendency to believe in a chosen course of action and refute evidence that doesn't reinforce our convictions. The professional may continue with a therapy course even though the patient's lab data indicates that a change is advised.
• Focusing of attention is the tendency, in an emergency, to focus on a single information source. The professional may be focused on reading the electrocardiogram and ignore the respiration rate, patient's color, or blood gases during a cardiac emergency.
• Reversion under stress is a tendency in stressful situations to revert to previous experience even if inappropriate, rather than to apply recently learned, less familiar skills. Using a defunct advanced cardiac life support (ACLS) algorithm, rather than the latest one, during a code is an example.

TABLE 8: PROXIMAL CAUSES OF ERRORS IN USE OF MEDICATIONS

PROXIMAL CAUSE

DESCRIPTION

EXAMPLES

Lack of knowledge about the medication.

Inadequate knowledge of indications for use, available forms, appropriate doses, routes, adverse side effects, toxicity, and compatibilities.

Physician: excessive doses of haloperidol in the elderly; overdoses of various drugs in patients in renal failure. Nurse: rapid infusion of vancomycin that resulted in hypotension; administration of phenytoin in an incompatible solution.

Lack of information about the patient

Nurse, physician, or pharmacist was unaware of an important aspect of the patient's condition.

Physician: ordering morphine for a patient with a paralytic ileus; prescribing potassium chloride for a patient in renal failure. Nurse: giving an antihypertensive medication to a patient with a low blood pressure measurement. Pharmacist: dispensing an antibiotic to a patient with a known allergy.

Rule violations

Failure to follow accepted and well-established procedures.

Physician: failure to write orders in an acceptable form (e.g., omitting route or frequency) Nurse: giving an infusion of red blood cells with a 5% dextrose injection instead of a 0.9% sodium chloride injection.

Slips and memory lapses

Errors in which the individual "knew better" and could not explain why the error occurred or just forgot.

Physician: an order for 1 g of lorazepam instead of 1mg; an order for acetaminophen per rectum following rectal surgery. Nurse: missed or late dose(s) due to memory lapses(s).

Transcription errors

Unexplained errors associated with the order transcription and verification process

Nurse: includes a variety of omissions, inadvertent cancellations or duplications and dose transcription errors, such as reversing the doses between two drugs or charting a drug that is to be administered every 8 hours (q8h) as every 6 hours (q6h); mostly slips.

Faulty drug identity checking

Pharmacists' and nurses' checking errors that resulted in patients getting (or nearly getting) the wrong medication.

Nurse: patient received phenylephrine instead of fentanyl by epidural catheter. Pharmacist: ceftriaxone dispensed instead of clindamycin; errors due to confusion of drugs with similar names or similar packaging.

Faulty interaction with other services

Problems in communicating with others (particularly physicians) and errors that occur when patients are in transition between services or units.

Nurse: hypoglycemia due to lack of awareness that patient had received insulin prior to transfer. Pharmacist: delay in filling order because of inability to verify with physician.

Faulty dose checking

Failure to ensure that the proper dose was dispensed or administered.

Nurse and pharmacist: overdoses because of errors in drawing up medications.

Infusion pump and parenteral delivery problems

Errors in setting pumps; accidental tubing disconnections; confusion between central and peripheral lines.

Nurse: overdose of heparin because of error in setting infusion pump; administration of parenteral nutrition fluid through peripheral line instead of central line.

Inadequate monitoring

Failure to adjust the dose of a medication appropriately either because necessary monitoring (blood levels, vital signs, laboratory values) was not carried out or the changes were ignored.

Physician: seizures due to prolonged subtherapeutic doses of phenytoin; heparin dose not decreased despite increasing partial thromboplastin time.

Drug stocking and delivery problems

Otherwise unexplained late or missing deliveries of medication to the patient care units.

Pharmacist: six- to 18-hour delays in receiving antibiotics for a patient with a serious infection.

Preparation errors

Pharmacists' and nurses' errors in calculation and mixing of drugs that resulted in incorrect doses.

Pharmacist or nurse: lorazepam drip solution prepared in too high a concentration; vasopressin dose excessive.

Lack of standardization

Administration errors by nurses that resulted from nonstandard concentrations, dosing schedules and infusion rates.

Nurse: ten times overdose of epidural fentanyl due to provision of vial with nonstandard concentration.

Source: Adverse Drug Reactions and Reducing Medication Errors

ERROR REPORTING

The process of documenting medication errors often results in the identification of the same recurring pattern of error. For this reason, even trivial errors should be recorded and reported. Reporting medication errors raises awareness among caregivers of potential problem areas. It increases their vigilance about potential sources of error and can produce preventive changes as simple as rearranging the order of floor stock on the shelves to restructuring the medication administration practices throughout an institution.

Past studies headed by Bates, Classen, Lesar, and Leape found that staff personnel have been reticent regarding the documentation of errors. Documenting errors, however, has resulted in identifying many problems with systems and procedures. A study performed at Bon Secours Hospital, Grosse Point, Michigan, identified three barriers to revealing a medication error:

• the stigma of being associated with an error;
• the work involved in reporting the error; and
• the possibility of being identified as a person who would report the errors of a co-worker.¹⁶

Publications from staff members of Brigham and Women's Hospital, Boston, Massachusetts, have concluded that a more effective system for error reporting would include:

• a clear, concise definition of various types of medication errors (Table 9);
• specific parameters for each type of error;
• a severity scale, ranging from "no harm done" to "death occurred";
• a simple form that is quick and easy to complete; and
• identification of where and when the medication error occurred.

There are four generally accepted methods of error reporting. They are the anonymous self-report (questionnaire), the incident report, the criticalincident technique, and disguised observation. Two additional methods are rarely used: urinalysis, to check for absence or presence of a drug in a patient's urine, and omission-error detection, based on returned medications to the pharmacy which uses a unit-dose system.

See Table 10 for websites devoted to medication error reporting.

Many medication errors occur because one or more of the basic rights of medication administration has been violated. In nursing school, most of us learned about the Five Rights of medication administration, but for additional safety we have added two additional rights-the right form and the right documentation to the original five rights. These additional two rights help to ensure that the correct form of a medication is given and that timely, accurate, and complete medication documentation is accomplished.

For the purpose of this discussion the Seven Rights of medication administration are the right:

• patient;
• medication;
• dosage (for intravenous therapy, this means the right flow rate);
• frequency or time;
• route;
• form; and
• documentation.

	TABLE 9: VARIOUS TYPES OF MEDICATION ERRORS
	MEDICATION ERROR				EXAMPLES
		Prescribing error				Incorrect drug selection (based on indications, contraindications, known allergies, existing drug therapy, and other factors), dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by a physician (or other legitimate prescriber); illegible prescriptions or medication orders
		Omission error				The failure to administer the ordered dose to the correct patient
		Wrong-time error				Administration of medication outside a predefined time interval from its scheduled administration time. This interval, usually a half hour or one hour before or after the scheduled time, should be established by each individual healthcare facility.
		Unauthorized-drug error				Administration of medication that is not authorized by a legitimate prescriber for the patient.
		Improper-dose error				Administration of a dose that is greater than or less than the amount ordered by the prescriber or the administration of duplicate doses to the patient. This can result from a calculation error.
		Wrong dosage-form error				Administration of a different dosage form from that ordered by the prescriber
		Wrong drug-preparation error				Drug product incorrectly formulated or manipulated before administration
		Wrong administration technique				Inappropriate administration procedure For example, a failure to use the Z-track technique for ferrous sulfate (iron)

Source: Adverse Drug Reactions and Reducing Medication Errors

TABLE 10: WEB SITES DEVOTED TO MEDICATION ERRORS AND ERROR REPORTING

Web Site Address

Organization

E-Mail Address

www.mederrors.com

Bridge Medical

info@bridgemedical.com

www.usp.org

Practitioners' Reporting Network

Webmaster@USP.org

www.ismp.org

The Institute for Safe Medication Practices

Ismpinfo@ismp.org

www.ama-assn.org

The National Patient Safety Foundation

Npsf@ama-assn.org

www.aphanet.org

The American Pharmaceutical Association

Webmaster@mail.aphanet.org

www.fda.gov/medwatch

MedWatch

-

Source: Adverse Drug Reactions and Reducing Medication Errors

PERIPHERAL IVS, MIDLINE CATHETERS, AND CENTRAL LINES

There are three basic categories of lines for intravenous therapy. They are:

• peripheral IVs;
• midline catheters; and
• central lines.

Peripheral IVs

A peripheral IV is the most common IV access. Intravenous therapy given with a peripheral IV is delivered with a short catheter that is three inches long or shorter and is made of Teflon® or other synthetic material, which is inserted into a peripheral vein, usually in the forearm area, and it is used for the delivery of many fluids and medications. Although possible, peripheral IVs are much less often inserted into the foot since this is not the site of choice, particularly since central lines are an available preferable alternative.

Peripheral Intravenous Therapy

Intravenous therapy can be delivered either through a peripheral vein or a central vein. Most intravenous therapy is delivered with a peripheral IV. A peripheral IV is inserted into a peripheral vein, usually into one of the large veins in the arms. A peripheral catheter is short and made of Teflon®, polyvinylchoride, or Silastic® polyurethane. Peripheral IVs are used for a wide variety of fluids and medications. They are not used, however, for:

• vesicant chemotherapy;
• parenteral nutrition with more than 10% dextrose or more than 5% protein;
• medications with a pH greater than 9 or less than 5;
• fluids and solutions with a pH greater than 9 or less than 5; or
• medications and solutions that have an osmolarity that is greater than 500 mOsm/L.

One type of peripheral IV was called a heplock because a heparin flush was used every eight hours to maintain patency if a continuous IV was not infusing through the catheter. However, nursing research has now shown that heparin is not necessary, and flushing every eight hours with normal saline instead will keep the heplock patent. The infusion of a flush solution has been found to be more important than the solution itself in flushing the device. Be very careful, however, if blood has clotted the tubing or catheter. Vigorous pushing or flushing could send a blood clot into the patient's circulatory system. Because heparin is no longer needed, these devices are now simply called medlocks. Medlocks should be changed and the site rotated every 48 to 96 hours to prevent irritation to the lining of the vein. If a patient requires one to four weeks of IV therapy and has poor veins, a medlock may not be the ideal solution. Instead, a longer lasting IV catheter, such as the midline catheter, may be a better choice.

See Table 11 for peripheral veins location and type of catheters used.

VENIPUNCTURE: INITIATING A PERIPHERAL IV

The venipuncture procedure consists of several major components. They are:

• prevenipuncture preparation and assessment;
• vein selection and patient preparation; and
• venipuncture.

Prevenipuncture Preparation and Assessment

Prior to the initiation of intravenous therapy, the patient and the patient's condition must be evaluated and assessed. Some of the components of this evaluation or assessment process include the:

• patient's general condition;
• patient's current health problem and disease history;
• patient's age;
• condition of the skin;
• limb mobility;
• fluid volume status;
• level of cognition and psychological status; and
• patient activity, personal preferences, and other patient specific conditions.

The Patient's General Condition

An assessment of the patient's general physical condition may yield some information about the duration of therapy and the kinds of therapy that the patient may need in the immediate or more distant future. For example, a cachexic, immediate postoperative patient who has suffered significant blood loss may need whole blood, other blood products, volume expanders, fluids, and electrolytes in the immediate and more distant future. This patient will need a larger catheter.

On the other hand, you can anticipate the need for a medlock or saline lock to keep a vein open if your assessment of a 53-year-old patient appearing to be in a relatively good state of health was just admitted to your patient care area from the emergency room with a diagnosis of rule-out myocardial infarction.

The Patient's Current Health Problem and Disease History

It is important to also evaluate the patient's current health problem and his or her disease history prior to the initiation of intravenous therapy. The patient's history of chronic diseases and disorders, such as chronic obstructive pulmonary disease (COPD) or diabetes often confounds and complicates a typically simple admission for an acute disorder, such as a urinary tract infection. Not only is the primary diagnosis considered when intravenous therapy is ordered, but comorbidities and underlying chronic diseases and disorders must also enter into the assessment process when deciding upon the site where the intravenous line will be initiated.

The Age of the Patient

The anatomy of the venous system, like many other physical attributes, has age-specific characteristics that must be addressed during the vein selection process. The elderly tend to have very fragile and delicate veins. A looser tourniquet should be used when preparing for venipuncture on an elderly patient. Infants, too, have age-specific venipuncture challenges. Neonates and infants do not have as many accessible veins as adults do. For this reason, the feet, hands, and antecubital area are usually the venipuncture sites of choice. Scalp veins can be used for infants less than 6 months of age.

The Condition of the Skin

The condition of the skin is assessed when selecting a site for venipuncture because the condition of the skin may indicate some alteration of circulation or venous pathology below the skin. It is, therefore, recommended that you avoid areas that are reddened, sore or painful to the touch, tender, blanched, ecchymotic, cool, swollen, or with evidence of a hematoma.

Mobility of the Limbs

A brief assessment of the patient's upper extremity mobility is also done before an intravenous line is inserted. For example, placing an intravenous line in the right antecubital space of a patient who has a severely contracted right elbow will lead to failure. Contractures may lead to a mechanical intravenous therapy failure, specifically sluggish flow.

Fluid Volume Status

The patient's fluid volume and hydration status should also be determined and evaluated prior to the initiation of intravenous therapy. Not only will this fluid and hydration status suggest what kinds of fluids the patient may need in the near or relatively distant future, it may also suggest which veins will be and will not be full enough to enter successfully during venipuncture. Venous dilation challenges are often encountered when patients are dehydrated or they have a decreased circulating volume.

The Patient's Level of Cognition and Psychological Status

A patient's level of cognition will also provide data about the venipuncture site of choice. As we continuously strive to have and maintain a restraint free environment, we must also carefully select intravenous therapy sites that will not be prone to accidental dislodgement by a confused patient. Intravenous sites in the direct line of the patient's sight are at risk for dislodgment. Sites that are not easily visualized by confused patients have a much better chance of success. We do not want to restrain patients in order to maintain the integrity of a necessary medical intervention, such as intravenous therapy, and we also do not want to subject our patients to unnecessary needle sticks and the associated discomfort. Choose a site that has the greatest chance of success, based on the patient and his or her challenging behavior.

Patient Activity and Personal Preference

Consider the patient's activities when choosing a venipuncture site. For example, if you are caring for a patient post cerebrovascular accident (CVA) who is going to physical therapy for right arm strengthening exercises using small weights, selecting the right arm antecubital space is not wise. The patient will be flexing this arm at the antecubital space while exercising this arm.

Additionally, whenever possible ask the patient which arm or hand is preferable to him or her. Most often the nondominant side will be chosen and used.

Other Patient Specific Conditions

The following conditions of the body on the right or left side are not suitable sites for venipuncture or intravenous therapy:

• mastectomy;
• hemodialysis shunt;
• graft;
• arteriovenous shunt or fistula;
• serious burns; or
• paralysis.

Additionally, the following areas must be avoided:

• those that have been previously infiltrated;
• areas below phlebitic sites;
• sclerosed areas;
• thrombosed areas; or
• edematous areas.

	TABLE 11: PERIPHERAL VEINS LOCATION AND TYPE OF CATHETERS USED
		VEINS		LOCATION		COMMENTS		CATHETER TYPE
		Digital		Lateral and dorsal segments of fingers		Very small veins Limits mobility Difficult to access		Use small flexible catheter
		Metacarpal		Dorsum of hand, proximal to knuckles				Use flexible catheter or steel needle
		Cephalic		Continuation of metacarpal vein of thumb Parallels the radial bone		Continues into antecubital fossa		Use flexible catheter
		Median antebrachial		Travels along ulnar side of inner forearm		Easily visualized; painful insertion		Use small, flexible catheter
		Basilic		Travels along ulnar path on underside of forearm				Use flexible catheter
		Cephalic		Travels up radial or lateral side of the lower and upper arm Easy to access				Use flexible catheter

Source: Compiled by the author.

Selecting a Vein

There are several veins in the body that are acceptable for intravenous therapy. The veins on the fingers (digital), found on the back of the hand (metacarpal veins), in the forearm (basilic and cephalic veins), the inner aspect of the elbow or antecubital fossa or space, (median basilic and median cephalic), the lower extremities of the foot (medial marginal, dorsal venous arch, and venous plexus of dorsum), and the feet (great saphenous vein) can be used depending on the patient factors listed and described above, the variables listed and discussed below, and a few other guidelines. For example, the tiny digitial veins should be avoided whenever possible; the veins in the antecubital fossa should be used only for short term intravenous therapy because they prohibit the person's use of the arm; the median basilic and median cephalic are not appropriate for the administration of chemotherapy because of the increased risk of extravasation; and, the veins of the lower extremities should be used only when an alternative site is not possible and with a physician's order. Close and frequent monitoring of the intravenous site is crucial if the less desirable lower extremities must be used. Phlebitis and thrombosis are high-risk complications of lower extremity intravenous therapy. See Figure 1.

The following variables must be also be considered when selecting a vein for intravenous therapy when several alternatives are available:

• vein condition;
• the anticipated duration of the therapy; the type of intravenous solution and/or medications that will be infused;
• catheter or cannula size needed; and
• venous distention.

Vein Condition

The condition of the veins is a highly important factor for consideration during the vein assessment process. Avoid the use of veins that have been used for a recent, prior infusion, particularly when the area surrounding or near the vein appears to be swollen, red, ecchymotic (bruised), or the patient tells you that the area is sore. If the patient is experiencing local soreness or the vein and/or the area surrounding it appears red, do not select it for use. Veins that are in poor condition will not accommodate successful venipuncture and proper intravenous fluid flow. Attempt to use the longest and straightest vein possible.

Anticipated Duration of Therapy

The choice of veins for venipuncture and intravenous therapy is far greater when the anticipated duration of therapy is short lived. The choice of veins becomes progressively more limited if the anticipated duration of therapy is long term. For example, there are more veins to select from when you are caring for a patient who is admitted for an outpatient surgical procedure. The choice is more difficult and limited for a patient with a chronic disease, such as cancer, which often necessitates long-term intravenous therapy.

The choice of vein should be driven by the need to preserve veins when the anticipated duration of the intravenous therapy is long term. Veins used for intravenous therapy are somewhat short lived in terms of their adequacy. Frequent venipuncture and multiple sites are often necessary with long-term intravenous therapy. In order to best ensure veins for future use, arms should be alternated, and the most distal vein possible should be used. For example, if a patient had an intravenous line in the right arm that must now be replaced, use a left hand or lower forearm vein for the next venipuncture. Alternate arms and work from the most distal to the proximal veins, whenever possible, in order to preserve veins for future use.

Figure 1. (A) Superficial veins, forearm; (B) Superficial veins, dorsel aspect of the hand. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001. 101.

Types of Intravenous Solutions and/or Medications to be Infused

Many medications, including chemotherapy and intravenous fluids such as hypertonic solutions, are highly irritating to the veins. Larger veins in the lowest possible forearm area, rather than smaller ones, should be used for irritating solutions and medications. Consult a pharmacology resource book, such as the Physician's Desk Reference (PDR), a nurses' pharmacology book, drug manufacturer's drug insert, or your pharmacist if you are unsure of whether or not a medication is chemically irritating to veins.

Catheter or Cannula Size Needed

Different size catheters are manufactured and used, according to the patient and the patient's needs. They are manufactured in gauges from 14 to 25. A 14-gauge catheter is the largest and a 25-gauge is the smallest.

Ideally, an intravenous catheter of the smallest gauge and shortest length possible should be used. If a small gauge catheter can be used for the ordered fluids and/or medication(s), a small vein can be chosen. However, if a larger gauge catheter is necessary, a larger vein will have to be chosen during the vein selection process. For example, a 20-gauge catheter is necessary when the patient has an ordered blood transfusion. A vein of large enough size must then be selected to accommodate this gauge catheter. A 24gauge catheter, on the other hand, can be used if small veins are accessible and usable and the infusion rate is 75 milliliters (mL) or less in one hour (h).

Venous Distention

Some veins dilate more than others. Dilation is necessary in order to introduce a catheter into the vein. An alternate vein may have to be considered if a vein does not dilate well after the placement of a tourniquet just above the site under consideration. Choose veins that are easily palpable and easily visualized. More information about venous distention and ways to dilate veins in preparation for venipuncture is described below. In summary, the selection of a vein is a complex process that necessitates a careful assessment of the patient and the patient's venous system. General maxims that should not be forgotten are:

• Begin inspecting suitable veins distally and then work proximally if necessary.
• Identify long, straight veins. They tend to be most successful.
• Choose easily palpable veins that are easily visualized. These veins are the most accessible.
• The ideal vein is full, straight, soft, unobstructed, distal, and easily palpated and visualized.

Please be advised that techniques of insertion and cateter advancement may vary depending upon the particular manufacturer. Always refer to manufacturer's instructions to verify recommended technique. See Table 12 for a summary of venipuncture interventions and rationales for the interventions. Some of the problems that can be encountered during the venipuncture process include:

• a lack of venous distention;
• rolling veins; and
• fragile veins.

Venipuncture and IV catheter insertion cannot be successful unless the vein is adequately distended to permit the entry and threading of the catheter. If the vein does not dilate enough with the tourniquet, remove the tourniquet and:

• apply heat or a warm compress to create vasodilation;
• lower the limb into a dependent position to facilitate a great volume of fluid in the vein;
• gently pat the vein;
• apply a small amount of pressure just above the intended site of insertion; or
• rub the vein gently in one continuous motion from the proximal to the distal.

Rolling veins are also a challenge during the venipuncture process. If the desired vein starts to move or roll out of position after you have pierced the skin, perform another gentle trust of the needle parallel to the skin while holding the area taunt. Fragile veins, on the other hand, may not respond well to a tourniquet. On some rare occasions, such as when a fragile vein is encountered, it is necessary to avoid the use of a tourniquet. Tourniquets are also not necessary when a vein is adequately dilated, visible, and palpable without it. If you feel that you cannot start the IV, or if you have been unsuccessful on two attempts, notify your supervisor. A physician or an IV nurse may be contacted to start difficult IVs.

An armboard is sometimes used after the intravenous catheter is in place and the dressing has been applied. Armboards are primarily used when the intravenous device is placed in an area of flexion, like the antecubital fossa. When used to prevent the disruption of intravenous flow when the person flexes the arm, the armboard is not considered a restraint device by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) or The Center for Medicare and Medicaid Services (CMS). Instead, the armboard used for this purpose is considered a medical treatment immobilization device and despite the fact that it limits voluntary movement, its use is a generally accepted practice for intravenous therapy and not related in any way to the person's behavior but instead to the treatment itself.

	TABLE 12: VENIPUNCTURE
		INTERVENTION		RATIONALE FOR INTERVENTION
		Check and verify the doctor's or licensed independent practitioner's order.		Venipuncture and IV therapy, with and without added medications, require an order. The kind of fluid, tubing, catheter, etc., used for the initiation of the IV is determined by the type of fluid, medication, and/or the purpose of the venipuncture ordered.
		Gather necessary supplies and equipment and place them in close proximity to the client. Minimally, you will need: disposable gloves; a tourniquet; antiseptic swabs (70% isopropyl and either povidine-iodine or a 1% to 2% iodine tincture of iodine); IV tubing; tape; a transparent, occlusive IV dressing or another sterile dressing; catheters of varying sizes from 14 to 25 gauge and/or a butterfly needle (metal); and for a continuous IV - IV tubing and the ordered intravenous solution. For a saline lock or Medlock-1 to 2 mL normal saline for injection in a sterile syringe.		Organization enables a timely and successful initiation of IV therapy after venipuncture.
		Examine any IV fluids for expiration date and clarity.		Report and discard all fluids that have exceeded their expiration date. Expired fluids should not be accessible for possible use. Report and discard all fluids that are cloudy or with particles. Cloudiness and particulate matter are indications that the fluid is not as it should be. Sometimes an entire lot, or batch, of fluid is bad so it is necessary to report this finding.
		Examine all medications for expiration date and an unusual appearance.		Report and discard all medications that have exceeded their expiration date. Expired medications should not be accessible for possible use. Report and discard all liquid IV medications that do not appear as they should.
		Prepare your supplies and equipment so they are ready for use.		Use sterile technique to prepare sterile supplies like the dressing, catheter,and tubing. IVs and venipuncture are sterile procedures. If the person is to have a continuous intravenous flow, clear the IV tubing by attaching it to the solution and letting the fluid fill the tubing to the tip. If a controller or pump is being used, turn it on and set the tubing up in it at the ordered rate. If a saline lock or medlock is being used, prepare the saline solution that will be used to flush the catheter.
		Identify the client.		Check the person's identification band and ask his or her name. Do not rely on room number and bed number for accuracy. Starting an IV on the wrong client is considered a medical error.
		Explain the procedure and the purpose of the procedure to the client.		Patients have a right to receive full information about any treatments. They also have the right to refuse. If the person is not competent, the procedure and the purpose of the IV should be explained to the family member, healthcare surrogate, health proxy, etc., as indicated. Explaining procedures and treatments to clients relieves anxiety and increases their cooperation.
		Place the client in the supine position, if at all possible.		The possibility of a vasovagal reaction can be decreased with the supine position.
		Wash your hands.		Handwashing is the single most important thing that you can do to prevent the spread of nosocomial infections. Handwashing must be done for at least 15 seconds, using ample friction and soap. Handwashing must be done before and after every direct patient contact. Handwashing must be done before donning gloves and immediately after the removal of gloves.
		Don gloves.		CDC, OSHA, all healthcare facilities and other bodies advocate the use of gloves during venipuncture and any other procedure when contact with blood or another bodily fluid is possible in order to prevent the spread of bloodborne pathogens such as HIV/AIDS and hepatitis.
		Select the vein.		Using the distal veins on the nondominant side saves more proximal veins for future use and it allows clients to use their dominant hand and arm more freely.
		Place the tourniquet 2 to 6 inches above the site that was selected.		The tourniquet will distend the vein. The tourniquet should be tight enough to distend the vein but not too tight as to cut off arterial circulation. Quickly check the radial pulse to ensure that the arterial circulation is not impaired. The selected vein must be palpable and visible before venipuncture is attempted. If the vein is not distended enough, additional measures may be necessary. For example, placing the limb in a dependent position may create satisfactory distention of the vein. Do not leave the tourniquet in place if venipuncture cannot be successfully completed in a minute or two. If additional time is needed, release the tourniquet and reapply it a few minutes later to continue the procedure.
		Ask a responsive client to clench and unclench her fist several times.		This fist clenching will bring a great blood flow to the area and a great degree of distention.
		Using an alcohol swab, cleanse the skin about 3 to 4 inches in diameter around the intended site. Wipe in a circular fashion starting at the inside of the circle and moving to the periphery of the 4-inch in diameter circle over the intended insertion site. (Some facilities use Povidine iodine followed by an alcohol prep with one swipe away from the insertion point. Additionally, povidine iodine is not used when the person is allergic to iodine.)		Alcohol cleanses the skin with medical asepsis. This cleansing prevents the introduction of microorganisms through the skin from the skin surface during venipuncture.
		Use a povidone-iodine swab to cleanse the skin about 3 to 4 inches in diameter around the intended site. Wipe in a circular fashion starting at the inside of the circle and moving to the periphery of the 4-inch diameter circle over the intended insertion site and allow it to air dry. Remove the needle guard.		Povidone-iodine cleanses the skin with medical asepsis. This cleansing prevents the introduction of microorganisms through the skin from the skin surface during the venipuncture.
		Grasp the arm (or leg) with your thumb and gently pull the skin taut distally to the intended insertion site.		This stabilizes the vein and also makes entry into the vein easier.
		With the bevel up, insert the needle at a 10- to 30-degree angle directly into or along side the vein from an angle of entry with a gentle, slow, and steady movement.		Holding the bevel up allows the sharpest and smallest part of the needle to enter the vein. Slow and steady movement ensures that you can see blood return and/or feel a decreased resistance before you inadvertently pass through the tunica intima (inside of the vein) and pass through the other side.
		Look for blood return and feel for decreased resistance in the vein as you enter, both indications that the vein has been successfully entered.		Blood return indicates that you have successfully entered the vein's tunica intima, the inside of the vein. A feeling of decreased resistance also indicates that you have entered the vein's hollow interior.
		Lower the angle of the catheter against the skin.		This lowering prevents piercing through the vein.
		Advance the catheter into the vein about ¼ inch.		This advancement ensures placement in the vein.
		Pull back on the needle so it separates from the catheter and advance the catheter another ¼ inch while applying a small amount of pressure just above the placed catheter tip and release the tourniquet.		Removing the needle prevents an accidental piercing of the vein while advancing the catheter into place. Applying light pressure at the catheter tip prevents excessive blood flashback as the needle is being removed and the IV tubing is being connected.
		Administer the IV fluid or perform the saline flush, as ordered.		Attach the cleared and primed IV tubing to the hub of the catheter if an IV infusion has been ordered. Attach the saline lock or a medlock cap and instill the saline flush if a saline lock or a medlock is ordered.
		Dress the catheter site using a transparent dressing, chevron, or a U pattern.		Commercially prepared transparent dressings are superior to taping and sterile 2 x 2 dressings. They allow ready visualization of the insertion site. To apply a transparent dressing, simply pull off the backing and place the clear transparent area over the insertion site and gently rub around the periphery of the dressing where the adhesive is. Dispose of all sharps in the proper container. Dispose of other hazardous waste in the proper manner. To do a Chevron dressing, take a 3-inch piece of adhesive tape that is ½ inch wide. Place the adhesive tape with the adhesive side up under the hub of the catheter and then in a crisscross manner bring both sides across the catheter site. Place sterile 2 x 2s over the site and tape them into place. Dispose of all sharps in the proper container. Dispose of other hazardous waste in the proper manner. To do a U dressing, take a 3-inch piece of adhesive tape that is ½ inch wide and with the adhesive side up, position the tape under the tubing and then above the wings while folding it down onto the wings of the cannula. Place sterile 2 x 2s over the site and tape them into place. Dispose of all sharps in the proper container. Dispose of other hazardous waste in the proper manner. After all dressings are complete, anchor a 3- or 4-inch of tubing on the dressing or arm for added security.

Source: Compiled by the author.

Flushing the Medlock (Saline Lock) After Venipuncture

Intravenous fluids infuse into veins when the positive pressure of the fluid is greater than the pressure exerted by the vein. When no positive pressure is exerted against the vein, the venous blood can back u into the catheter and close it off so that it is no longer patent and useable.

Medlocks, also referred to as saline locks, provide continuous venous access without the need for continuous infusions of fluid. They are most often needed when a person needs periodic medications but has no need for fluids and/or electrolytes. After the venipuncture procedure, the catheter is capped with an access injection cap and ready for use after it is flushed with saline in order to maintain its patency and usability.

To keep the medlock patent, a flush called a saline flush is done. Clean the hub cap with an alcohol swab and instill a small amount of injectable normal saline, as detailed in your facility's procedure.

Another flush called SAS (saline, administration, saline) is performed before and after the administration of a medication through the medlock. If no medications have infused in the medlock for the past eight hours, the medlock should be flushed with saline to ensure continuous patency.

Dating, Timing, and Initialing the Dressing and Other Documentation

After the dressing is applied, follow your healthcare facility's procedure for the dressing. Many facilities require that you sign your name, write the date and time that the IV was started, and the gauge of the catheter on the transparent dressing or on the tape covering the 2 x 2 of the Chevron or U dressing.

It is also necessary to document the location of the IV catheter, the date and time that the IV was started, the length and gauge of the catheter, and the type of dressing used in the progress note or the IV flow sheet, as dictated by the healthcare facility's procedure. Any patient teaching done and patient responseto the procedure should also be documented.

When the IV dressing is changed, according toyour facility's procedure, the nurse changing the dressing will sign, date, and time the dressing and also include the catheter gauge on the new transparent dressing or the tape of a Chevron or U dressing.

IV Infusions: Continuous and Intermittent

Intravenous infusions can be ordered as continuous or intermittent. Intermittent intravenous solutions can be delivered with a saline lock or a medlock or in conjunction with a continuous infusion using a piggyback IV infusion set.

Continuous intravenous therapy is most often delivered with an automatic, electronic IV controller or pump device with a backup battery to ensure safe delivery of intravenous fluids when the patient is not near a source of electricity; for example, when the person is being transported in an elevator to a diagnostic test in radiology or during utility failures. The manufacturer's instruction and troubleshooting tips for these electronic IV devices vary, so refer to the manufacturer's instructions for the specific device you are using. Generally speaking, however, these devices deliver the ordered number of ccs an hour when adjusted correctly. The IV tubing is threaded into the machine and then with the IV clamp wide open, the door on the IV controller is closed and the IV rate is set. Although these devices are highly reliable and dependable, they sometimes malfunction. It is, therefore, necessary that the nurse monitor the flow rate and the optimal performance of the electronic IV controller.

Intermittent IV therapy is delivered either in conjunction with a primary, continuous intravenous fluid with a piggyback fluid and secondary tubing or with a small amount of fluid holding the ordered intermittent medication directly into the saline lock or a medlock.

An intermittent IV piggyback is given using an infusion controller, or pump, or by using the procedure shown in Figure 2. Regardless of method used, the SAS flush must be done. The SAS flush consists of a saline flush into the hub after cleansing the hub with an alcohol swab, followed by the administration of the medication after cleansing the hub with an alcohol swab and then finally another cleansing of the hub with an alcohol swab followed by another saline flush.

S - saline flush

A - administration

S - saline flush

Changing and Discontinuing the Peripheral Intravenous Site

Facilities vary in terms of their policies on discontinuing and changing IV sites, however, the Centers for Disease Control (CDC) says that they can be changed at least every 96 hours and immediately when a complication is present. Check your facility's policy for their mandated change policy.

The procedure for discontinuing a peripheral venous catheter is:

1. Gather necessary supplies, that is, gloves, sterile gauze and tape.
2. Stop the infusion by closing off the clamp to the solution if in fact an infusion is running.
3. Wash your hands.
4. Put on gloves.
5. Remove the dressing.
6. Hold the sterile gauze against the insertion site.
7. Gently pull the catheter out parallel to the skin surface.
8. Look at the catheter to insure that it is still intact and unbroken.
9. Apply pressure to the site for about two minutes. Apply pressure for about 5 to 10 minutes if the person is taking anticoagulation medications.
10. Apply a sterile dressing to the old site.
11. Discard the catheter and old dressing in the proper manner for biohazardous waste
12. Document the removal, as per facility policy.

If the IV has been discontinued, the procedure is now done. If the IV site is due for a change, either as part of the normal routine or as a result of a complication, proceed to start another IV using the procedure described above.

EQUIPMENT Sterile infusion set (primary) Sterile infusion set (secondary) Alcohol prep pad Admixture PROCEDURE: Follow procedures of particular manufacturer's "piggyback" infusion set. In general, most procedures are similar to the following: NURSING ACTION 1. Wash hands thoroughly. 2. Set up primary infusion set; this may have a check-valve (see A in accompanying figure). 3. Lower the primary flask on the IV pole; usually, an extension hook accompanies the set. RATIONALE 1. Minimizes possibility of infection 2. The primary set should be functioning effectively before the secondary (piggyback) set can be attached. 3. This will permit the check-valve to function. (A) "Piggyback" IV. On left is the primary infusion flask. Note use of extension hook (hanging from IV pole) to suspend primary flask. Backcheck valve is seen more clearly in B and C. Secondary "piggyback" source is seen on the right. (B) Open check-valve. Fluid from primary source flows down on either side of movable disc. Fluid from secondary source is closed off with clamp (not visible). (C) Closed check-valve. Note that fluid source from secondary flask (where pressure is greater because flask source is higher) is forcing movable disc upward, thereby closing off fluid from primary source. (D) When last of fluid from secondary source reaches the level of the fluid in the primary set drip chamber (as indicated by broken line), hydrostatic pressure between both sets will equalize. This releases check-valve; flow will shift from secondary to primary source. (Adapted from Abbott Laboratories) 4. Use alcohol swab to carefully cleanse injection site. 5. Attach secondary tubing to primary tubing-preferably with a protected needle-at entry port. 6. Lower secondary bottle, open clamp, and allow infusate from primary bottle to prime secondary tubing. Close clamp. 7. Then hang secondary bottle higher than primary solution. Open roller clamp (see D in accompanying figure). 8. Program pump or controller for rate of infusion for secondary medication. 4. Usually this is a Y-connection on the primary site. 6. This clears secondary tubing of air and prevents any loss of medication from secondary line. 8. To ensure medication administration over appropriate time period.   FOLLOW-UP PHASE 1. Change IV administration tubing according to your institutional guidelines. 2. If possible, do not disattach secondary tubing from primary after infusion regimen started. 2. If using more than one secondary medication, the same tubing may be used. Back-flush tubing into old secondary bag or bottle. Dispose of bag or bottle. Hang new secondary medication to same tubing. Figure 2. Setting Up an Automatic Intravenous Piggyback Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 98.

Potential Complications: Peripheral, Midline, and Central Venous Catheters

A number of complications can occur with peripheral IVs, midline catheters, and central lines. When a complication occurs, it is sometimes necessary to contact the physician but in all cases, the complication, signs and symptoms, and corrective actions must be documented.

Some of the complications that can occur are described in Table 13.

Table 14 describes preventive measure for some complications that could occur.

TABLE 13: POTENTIAL COMPLICATIONS COMPLICATION SIGNS & SYMPTOMS INTERVENTIONS Infiltration: The infusion of a nonvesicant fluid into the extravascular tissue as a result of catheter dislodgement. Coolness, blanching, skin tautness, and swelling around the site. Pain or tenderness at the site. Slowed or stopped IV flow. No blood flashback in the tubing or catheter. See Table 15 Infiltration Scale. Discontinue the IV fluid and start another one. Elevate the extremity and apply warm or cold compresses depending on your facility's procedure. Extravasation: The infusion of a vesicant fluid, usually chemotherapy, into the extravascular tissue as a result of catheter dislodgement. Coolness, skin tautness, tissue necrosis, and swelling around the site. Pain or tenderness at the site. Slowed or stopped IV flow. No blood flashback in the tubing or catheter. Immediately stop the infusion. Begin your facility's extravasation procedure, usually consisting of aspiration of the remaining contents of the catheter, injection of an antidote into the IV tubing, after which it is immediately removed, and subcutaneous multiple antidote injections into surrounding tissue for several hours. Notify the physician. Phlebitis and thrombophlebitis: Vein inflammation that is caused by some mechanical, chemical irritant and injury or a clot. Redness, heat, soreness, and pain around the site. A red streak above the site. Slow or ceased IV flow See Table 15 Phlebitis Rating Scale. Discontinue the IV. Apply cold and/or warm compresses, according to your facility's procedure. Thrombosis: The vein becomes occluded with a clot or thrombus. (occurs most often with central lines). Slow or ceased IV flow Swelling and pain at site and proximal to the site. Inability to draw blood from the central line. Discontinue the IV and immediately notify the physician. Sometimes the following are ordered:     Heat;     Elevation of the affected extremity;     Anticoagulation therapy; or     Antibiotics. Catheter embolus: A floating piece of the IV catheter in the venous system. Pain and discomfort along the length of the vein. Hypotension Weak, thready, and rapid pulse Cyanosis and loss of consciousness Discontinue the IV, inspect the catheter for rough and broken areas. Do not discard the catheter. Apply a tourniquet above the site and take emergency medical measures for any hypotension, etc. Notify the physician. Sometimes an X-Ray is taken to visualize the presence of catheter fragments followed by surgical removal of particles. Air embolus: Air entering the venous system through an IV catheter (most common with central lines). Hypotension Rapid pulse and respiratory rate. Cyanosis Altered level of consciousness and level of cognition Decreased blood pressure. Discontinue the IV. Take emergency medical measures for any hypotension, etc. Place patient in the Trendelenberg position which allows air to enter the right atrium and be dispersed via the pulmonary artery. Administer oxygen. Notify the physician. Hematoma: The presence of blood leaking outside the vein into the extravascular tissue. Edema at the site. Ecchymotic discoloration of the surrounding area Discontinue the IV. Apply light pressure to the area for about 5 minutes after discontinuing the IV. Apply warm soaks as per your institution policy. Hemorrhage: Blood flow from the venous system to the external environment through the catheter. Presence of varying amounts of blood on the patient, bed linens, etc. Correct the underlying cause: Connect central line tubing to an adapter cap and not directly to the central line. Tape and secure all catheters and tubings. Infection and Bacteremia: Systemic or local infection caused when pathogenic organisms enter via the IV tubing and/or catheter. Edema, heat, redness, pain, and soreness around the site. Drainage from the site, sometimes foul. Possible fever, chills, severe hypotension, increased pulse rate, nausea, vomiting, malaise, headache, backache, elevated white blood cells, and life threatening septic shock. Discontinue the IV. Take emergency medical measures for any hypotension, etc. Notify the physician. Send drainage for culture Cleanse the area with povidone-iodine and cover it with a sterile dressing. Circulatory overload: Excessive intravenous fluids. Hypertension Increased pulse, respiration, and central venous pressure (CVP). Engorged neck veins; Coughing, abnormal breath sounds (pulmonary crackles), and shortness of breath Chest pain Anxiety Notify the physician. Keep the vein open with the slowest IV rate possible Monitor closely and take necessary emergency medical measures, as needed Elevate the head of the bed for orthopnea and shortness of breath Administer oxygen as needed Mechanical failures: Catheter or tubing kinks, infiltration, thrombophlebitis, and catheter tip lying against the wall of the vein. Sluggish IV flow rate. Swelling and coolness of the skin around the site Look for the cause of the problem: Are there any kinks in the tubing or catheter? Move the person's arm up and down; move the person's arm to a different position. Does the flow start when the hub is gently pulled back slightly from against the vein wall? Do you get blood return when the IV fluid container is lowered below the level of the person's heart? No flow indicates that it is occluded. If none of these measures are effective, discontinue the IV and start another one. Speed shock Headache, syncope, irregular pulse, shock, cardiac arrest. Stop infusion Notify MD KVO with D5w Initiate any necessary emergency procedures (CPR) Source: compiled by the author

TABLE 14: PREVENTING COMPLICATIONS COMPLICATION PREVENTIVE MEASURES Infiltration Secure the catheter and tubing well with tape. Use an armboard, if necessary, to prevent dislodgement of the catheter. Check the site and tubing often. Extravasation Make sure that the catheter is secured properly to decrease the chance of mechanical irritation. Change the peripheral IV site every 48 to 96 hours, as dictated by facility policy. Ensure that irritating medications are diluted properly, run at the proper slow rate, and are instilled into large enough veins to prevent chemical irritation. Phlebitis Make sure that the catheter is secured properly to decrease the chance of mechanical irritation. Change the peripheral IV site every 48 to 96 hours, as dictated by facility policy. Ensure that irritating medications are diluted properly, run at the proper slow rate, and are instilled into large enough veins to prevent chemical irritation. Thrombosis Ensure that irritating medications are diluted properly, run at the proper slow rate, and are instilled into preferably the superior vena cava to prevent chemical irritation. Catheter embolus Make sure that the needle is never rethreaded into the catheter once withdrawn. Air embolus Ensure that air is never permitted to enter into a central venous catheter or any tubing (peripheral, midline, and central venous). Hematoma Check the site often. Ensure that the catheter and tubing are securely anchored. Hemorrhage Connect central line tubing to an adapter cap and not directly to the central line. Tape and secure all catheters and tubings. Keep pressure on the site of a discontinued IV for at least 2 minutes and for at least 5 to 10 minutes if the patient is taking an anticoagulant. Infection and Bacteremia Change the IV site every 48 to 96 hours, according to the facility's policy to prevent phlebitis, a major risk factor that leads to infection. Use asepsis when starting and dressing the IV. Maintain the integrity of the IV system. It is a closed sterile system. (See Figure 3 for potential sources of contamination). Date all IV fluids and tubing. The maximum number of hours for IV supplies is as follows: IV tubing: 48 to 96 hours IV fluids: 24 hours IV dressings: 48 to 96 hours Circulatory overload Closely monitor IV flow rates, even when a mechanical pump or controller is being used, particularly for patients with renal or cardiac disease, the elderly, infants, and young children. These populations are at greatest risk for fluid, circulatory overload. If the IV flow rate fluctuates with positional changes of the arm, splint the arm with an armboard to ensure a consistently accurate flow rate or restart the IV at a better site. Mechanical failures Secure the catheter and tubing. Use an armboard when necessary. Check the IV frequently for kinks and patency. Immediately respond to IV controller and pump alarms. Source: compiled by the author

TABLE 15: PHLEBITIS AND INFILTRATION RATING SCALES PHLEBITIS RATING SCALE Grade Clinical Criteria Grade Clinical Criteria 0 No symptoms 0 No symptoms 1 Erythema at access site with or without pain 1 Skin blanched Edema <1 inch in any direction 2 Pain at access site with erythema and/or edema 2 Cool to touch With or without pain Skin blanched Edema 1-6 inches in any direction 3 Pain at access site with erythema and/or edema Streak formation Palpable venous cord 3 Cool to touch With or without pain Skin blanched, translucent Gross edema >6 inches in any direction 4 Pain at access site with erythema and/or edema Streak formation Palpable venous cord >1 inch in length Purulent drainage 4 Cool to touch Mild-moderate pain Possible numbness Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction Deep pitting tissue edema Circulatory impairment Moderate-severe pain Infiltration of any amount of blood product, irritant or vesicant Source: Compiled by the author.

MIDLINE CATHETERS: AN INTERMEDIATE NEED CATHETER

Midline catheters are shorter than central lines but longer in length than peripheral catheters. They are at least 3 inches in length. They are placed in larger veins than peripheral IVs, usually in one of the larger veins of the upper arm. When properly inserted, a midline catheter tip extends and lies below the axilla, near the head of the clavicle. The insertion site is no more than 1.5 inches below or above the antecubital fossa. Midline catheters start here because they are used in the large veins of the upper arm. Use of the large veins of the upper arm allows for greater dilution and less vein irritation than use of smaller veins. For this reason, midline catheters can be utilized for intermediate term therapy (2-4 weeks) that does not require a central venous access. They are particularly useful for people that have poor veins. See Figure 4.

Midline catheter solutions should be iso-osmotic or near iso-osmotic to decrease the risk of chemical injury to the tunica intima, which will compromise its optimal dwell time. They should not be used for:

• parenteral nutrition with 10% or more dextrose;
• parenteral nutrition with more than 5% protein;
• vesicant chemotherapy;
• medications or solutions with an osmolarity greater than 500 mOsm/L;
• medications with a pH of greater than 9 or less than 5; and
• fluids with a pH of greater than 9 or less than 5.

Midline catheters are inserted peripherally into the large veins of the arm and then advanced up towards the axilla, ending up in the larger vessels of the upper arm. When properly inserted, a midline catheter tip extends and lies below the axilla, near the head of the clavicle. The insertion site is no more than 1.5 inches below or above the antecubital fossa. The name midline catheter is derived from the fact that the end or tip of the catheter ends approximately midway between the antecubital space and the head of the clavicle. Midline catheters for neonates and young children may be inserted into the external jugular, axillary, sapphenous, temporal, or posterior auricular veins.

Midline catheters are made of a special material that becomes hydrated after placement in the vein. Two hours post insertion, the catheter increases two gauges in size and 2.5 cm in length. Within 90 minutes of contact with body fluids, the catheter becomes 50 times softer and much less irritating to the vein than older catheters had been. Because of this special material, the catheter can remain in place without being changed for up to five weeks, or until complications such as dislodgment or phlebitis occur.

A midline catheter can be:

• open ended; or
• valved.

The two types of midline catheters with valves are:

• PASV™; and
• Groshong®.

The PASV™ valved midline catheter houses the valve in the hub. This valve opens only when positive or negative pressure is exerted on it. It opens with positive fluid pressure and when aspiration, or negative pressure, is applied, thus allowing us to withdraw blood from it for laboratory analysis.

A Groshong® catheter has a closed terminal end and a slit on the body of the catheter which opens with positive and negative pressure to the adapter end, which is external to the body. The term Groshong® refers to a special valve on the tip of the catheter, developed in 1978 by surgical oncologist, Dr. Leroy Groshong. Unlike most catheters, the Groshong® catheter has a closed, rounded tip. This design allows a three-position valve to be placed on the side of the catheter near the tip. This special valve allows fluids to flow in or out, but the valve remains closed when it is not in use.

When fluid is introduced into the catheter lumen, the positive pressure pushes the valve open outward, admitting the fluid into the bloodstream. On the other hand, when negative pressure such as suction or aspiration with a syringe is applied, it causes the valve to open inward. This opening allows blood to flow through the catheter into the syringe. When no pressure at all is applied, the valve remains closed. Unlike many other catheters, Groshong® valve catheters do not need heparin to stay patent nor do they have to be clamped shut when not in use with a continuous IV infusion.

The potential complications of midline catheters are identical to those described above under peripheral catheters.

Midline Catheters: Insertion and Care

Midline catheters are inserted by physicians, other licensed independent practitioners like nurse practitioners, and specially trained registered nurses who have demonstrated competent insertion of midline catheters.

Midline catheters, like all other intravenous access devices and catheters, require sterile dressing maintenance with the frequency and procedure described in one's facility's policy and procedure. The dressing change procedure is usually the same as described above for peripheral catheters except that the site should be prepped three times with 70% isopropyl alcohol swab sticks in a circular pattern from the inside to the outside about 6 inches, followed by prepping three times with povidine iodine in the same 6inch circular pattern from the inside to the outside.

If the patient has an order for intermittent, rather than a continuous infusion, the midline catheter needs flushing. See your facility's policy for your flushing regimen. It is important to keep all sharp objects away from the catheter in order to avoid any accidental piercing and damage.

The procedure for discontinuing a midline catheter is:

Figure 4: This photo depicts a midline catheter (Arrow Midline Catheter Set MS-02041).

1. Wash your hands and put on gloves.
2. Stop the infusion if one is running.
3. Remove the tape and dressing and discard this biohazardous waste in the proper manner.
4. Place a sterile gauze square over the entry site; and then
5. Pull the catheter with a gentle continuous movement along the skin surface. If resistance is encountered, stop the removal, reapply a sterile dressing, and call the physician. Some facilities allow the nurse two attempts to remove the midline catheter before notifying the physician. If this is the established procedure in your facility, calm the patient with relaxation techniques, reapply a sterile dressing, apply a warm compress for 2 to 4 hours and then try again. If the second attempt is unsuccessful, call the physician.
6. Apply pressure to the site and then cover the site with a sterile dressing and tape. Date, time, and initial the dressing. This dressing should remain in place for at least 24 hours.
7. Inspect and measure the catheter to ensure that it has remained intact while in place. If any irregularities are noticed, do not discard it. Report your abnormal findings, as detailed in your facility's policy and procedure.
8. Document the discontinuation of the catheter and all abnormal findings.

Figure 3: Potential Mechanisms for Contamination of IV Infusion Systems. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 104.

CENTRAL LINES: A LONG-TERM NEED CATHETER

High-tech IV therapy has become a common component of care in hospital, clinic, and home health settings. High-tech IV therapy is so common that more than 175 million intravascular devices of various types are sold in the United States each year.¹⁷ With the shorter lengths of stay in the hospital and the advent of high technology home care, central access IV devices are now designed to allow multiple types of drugs and fluids to be administered to the patient at home. Adults and children increasingly are receiving at-home intravascular infusions of medications and fluids for a variety of conditions. Vascular access devices are used in the home setting to infuse chemotherapy, total parenteral nutrition (TPN), blood components, anti-infection agents, cardiac medications (inotropic agents), and investigational drugs.¹⁸ High-tech vascular access devices are designed to maximize treatment options, reduce the risks of infections to the patient, and deliver optimal patient outcomes while in the home or the hospital.¹⁹

A thorough knowledge of how to assess, care for, and maintain these devices is imperative for the nurse who wants to be proficient in IV therapy. Effective patient care involves both the routine management of these devices, as well as identifying potential complications.²⁰

Central line catheters include:

• open-ended tunneled lines;
• tunneled and valved lines;
• implanted vascular access devices or ports;
• nontunneled central venous catheter lines (CVCs); and
• peripherally inserted central catheters (PICCs).

Open-ended Tunneled Lines

Open-ended tunneled lines are surgically placed catheters that are flexible in composition and intended for long-term intravenous therapy. These catheters are placed in the lower third portion of the superior vena cava through the subclavian or internal jugular veins. They are surgically placed by a physician and tunneled and threaded under the skin. These catheters may have only a single lumen or multiple ones. Since this type of catheter is open ended, fibrin and clots may collect in the area. It is, therefore, necessary to flush the catheter with heparin. When this flushing is done, a 10cc or larger syringe must be used and no pressure should be exerted. When not in use, the catheter should be capped between intermittent therapies. All sharp objects should be kept away from the catheter to maintain its integrity. Additionally, central lines should always be connected with a Luer Lock device to prevent accidental disconnection.

Hickman®, Broviac®, and Leonard® external tunneled catheters are constructed of silicone with a special dacron felt cuff that fixes the catheter in its subcutaneous tunnel placement by encouraging tissue growth at the insertion site. These cuffs help prevent bacteria from traveling up the tunnel of the catheter invading the central circulatory system. The catheters are intended for long-term vascular access and for patients who lack suitable sites for peripheral vascular access. Silicone catheters have been found to produce fewer venous thromboses than polyethylene catheters.

These catheters differ slightly in lumen construction. The Hickman® and Leonard® are dual lumen catheters that are intended for multiple purposes and long-term vascular access. Their smaller lumens can be used to infuse TPN, while medications are simultaneously infused through the larger lumen. The Broviac® single lumen catheter can be used to administer TPN, but problems with clotting may arise when the small lumen is used for blood withdrawal for lab samples. The Hickman® catheter which now comes as a triple lumen with large lumens can be used for all IV functions. The greater the catheter lumen size, however, the greater the risk of thrombosis.

Ensure that the patient's catheter is clamped unless it is a Groshong® type. To protect your patient from air emboli and to keep the catheter patent, this catheter must always be clamped when an IV is not infusing. If you are not sure whether or not and/or how the catheter should be clamped, check the manufacturer's instructions.

When a clamp is needed, carefully examine the catheter clamps. They should be smooth-edged and nontraumatic to the catheter. Never use anything other than medical clamps on the catheter since they could damage the catheter. The catheter should always be clamped on the special protective clamping sleeve. If this is not visible, place a reinforcement piece of tape over the catheter and use this for the clamp site. Do not use instruments such as scissors or scalpels near the catheter. Additionally, the catheter must be capped off when not in use, such as when an intermittent intravenous fluid or medication is not currently infusing.

If the catheter is inadvertently punctured or it leaks or breaks, immediately clamp the catheter using a nonserrated clamp between the broken area and the exit site. The broken or damaged part of the catheter should then be wrapped with sterile gauze squares and taped securely. Notify the physician and document the incident and your followup care. Do not under any circumstances use the catheter until it is repaired or replaced.

If the patient's external catheter does not have a clamp or clamp sleeve, it probably means that your patient has had a Groshong® valve catheter inserted. Because of their special valve construction, Groshongs® do not need to be kept clamped, and they do not need to be heparinized for patency. Check the medical record to determine whether or not it is a Groshong® valve catheter if you are not certain.

Tunneled catheters are inserted under surgical conditions. With the percutaneous approach, the catheter is inserted into the axillary-subclavian vein with a peel-away introducer. Before insertion, the catheter is primed with a heparinized saline solution and then clamped. The catheter is placed through the skin and into a vein in the chest or neck. The tip of the catheter is threaded through the vein to a point just above the right atrium of the heart. A special tunneling device or long forceps are used to push the catheter down through the subcutaneous tissue and out the chest wall at the exit site. Several inches of the catheter remain outside of the body. It takes approximately two weeks for this catheter tract or tunnel to heal and become well established in the body.

The subcutaneous tunnel usually measures four to six inches in length. The Dacron® cuff on the catheter usually rests approximately midway between the point of exit from the skin and the point of entry into the vein. The surgeon must take care when placing the catheter. If the catheter is inserted into the subclavian vein medially near the articulation of the clavicle with the sternum and cartilage of the first rib, the catheter could be compressed or pinched. This will lead to damage or severing of the catheter within the body. Permanent catheters are usually inserted on the right side, because venous drainage to the superior vena cava is more direct. The preferred catheter tip location is in the superior vena cava, above its junction with the right atrium. Catheters extending too far into the atrium can impinge on the endocardium, causing cardiac arrhythmias.

If the catheter is leaking or it breaks:

• place a nonserrated clamp between the broken or leaking area and the exit site;
• put sterile gauze over the broken or leaking area; and
• tape it securely and notify the physician.

The sterile dressing procedure is the same as described above for the midline catheter. This type of central venous catheter has a Dacron® cuff which, over several weeks, promotes tissue growth, thus preventing an accidental dislodgment of the catheter and providing an extra barrier to ward off infection. Some physicians may order no dressing at all after tissue has proliferated into this special cuff.

Tunneled and Valved Lines

These catheters are very similar to the open-ended tunneled lines. They are intended for long-term, intravenous therapy, they are flexible, and surgically placed. They, too, are threaded into the lower third of the superior vena cava by way of the subclavian or internal jugular vein.

One valved catheter, the PASV™ has its valve housed in the catheter hub.²¹ This valve remains closed when the catheter is not in use and simply subject to normal central venous pressures. The valve, however, opens when positive fluid pressure is applied through the Luer Lock hub to permit the infusion of fluids through the catheter. The valve also opens with negative pressure, that is, aspiration, thus permitting blood to be drawn out with a syringe. This catheter also has a growth facilitating cuff make of polyester.

Implanted Ports

Implanted ports do not have any external exit. They are completely implanted surgically under the skin in the clavicular or antecubital area. On some occasions, these ports are implanted into the intraperitoneal, intrapleural, or epidural area. An implanted port is a small reservoir or portal (port) attached to a small catheter. In the center of the portal is a self-sealing silicone septum. Ports can be either open ended or valved. Open-ended ports require heparin flushes. Valved ports do not require heparin flushes. All ports require the use of a special noncoring needle (a Huber needle) for access site. This special needle has the bevel of the needle on the side, thus allowing a clean penetration of the septum without any coring or leakage as the septum closes when the needle is removed. See Figure 5.

Figure 5 This photo shows an implanted port (Horizon Medical Products, Inc.).

These infusion systems are placed into the subclavian vein or internal jugular. They terminate in the lower one-third of the superior vena cava. The chest tissue is then sutured closed over the port and the catheter so that the access device is totally hidden under the skin, similar to a pacemaker. Because the device is implanted, these ports are also referred to as implanted vascular access devices (IVADS).

If a patient does not desire an external catheter, the implanted port may be the best approach for him or her because the entire device is implanted under the skin. Some of the newest ports are now designed with a double port system thus allowing two medications or IV solutions to be infused simultaneously. If necessary, these ports can also be placed in the thigh area. If a patient or family member is able to and desires to care for a port themselves, then a peripherally placed implantable venous access device may be the device of choice.

One example of a peripheral port is the PASport®. The PASport® is smaller than a regular port so that it can be inserted into the anterior forearm slightly below the antecubital space. During surgery, the catheter is placed in a vein of the lower arm, and then the tip of the catheter is threaded up through the vein to a point just above the heart. The other end of the catheter is tunneled under the skin for a short distance. An incision is made and the port is placed under the skin. The catheter is then attached to the port and the incision is closed. The port and catheter are completely hidden under the patient's skin of the arm. This placement allows easy access by the patient and/or family member.

Procedure for Accessing the Implanted Port Using a Huber Needle

Accessing the port is a sterile procedure that entails the following steps:

1. Wash your hands and don nonsterile gloves.
2. Open a sterile field and drop the noncoring needle with an extension, a 10cc syringe and needle, and an injection cap on the sterile field using sterile technique.
3. Remove the nonsterile gloves.
4. Wash your hands.
5. Don sterile gloves and a facemask.
6. Prime your huber needle and extension with normal saline solution Withdraw 10cc of sterile saline for injection up into the 10cc syringe using your nondominant hand and place it on the sterile field.
7. Remove the gloves and put on another pair of sterile gloves.
8. Cleanse the site three times in a circular pattern of 6 inches in diameter from the inside to the outside of the circle using three 70% isopropyl alcohol swab sticks remembering to properly discard each individual swab after you have completely encircled the site.
9. Cleanse the site three times in a circular pattern of 6 inches in diameter from the inside to the outside of the circle using three povidoneiodine swabs swabs or chlorhexidine gluconate.
10. Allow the site a couple of minutes to air dry.
11. After palpating the port to find the center of the septum, insert the Huber needle into the septum center until you feel that it makes contact with the back of the port.
12. Check the patency of the port by aspirating a small amount of blood. If no blood return is noted at first, have the patient cough or raise the arm that has the implanted port's insertion site above his or her head.
13. If patent, instill the 10cc of normal saline.
14. Flush an open-ended port with heparin if it is not going to be immediately used for an infusion. Generally, an open-ended port is flushed with 5cc of heparin (100u/cc). Follow your own facility's policy.
15. Cover the site with a sterile transparent dressing.

An important factor to consider is the length of time that treatment will be needed. Some points to remember about external tunneled catheters when contrasted with implanted ports include the fact that external tunneled catheters:

• have a greater risk of infection;
• have a decreased risk of extravasation, that is, less fluid leaks out of the catheter due to vein perforation or misplacement of the needle;
• require more time to maintain and care for;
• create less discomfort and anxiety because the needle is inserted into a catheter, when medications or other fluids are given, rather than the patient's skin;
• are easier to access since the catheter is visible;
• require an adjustment to an obvious and visible alteration in body image; and
• limit some activities, such as swimming.

Alternatively, implanted ports:

• have a lower risk of infection;
• need less care and maintenance by the patient;
• require insertion of a needle through the skin wall to access the port;
• necessitate more skill to find and access the port since it is hidden under the skin;
• create minimal change in body image; and
• minimally limit physical activity. Individuals can swim and do all kinds of physical activity.

Choosing an access device is a major decision for the patient. Knowing these facts can help your patients make knowledgeable decisions about what choice best meets their individual needs and treatment plans.

Nontunneled Central Venous Catheter Lines (CVCs)

Nontunneled central venous catheter lines (CVCs) are placed with percutaneous venipuncture into the lower third of the superior vena cava and then sutured in place. Once inserted, the tip of the catheter will lie just above the right atrium in the distal portion of the superior vena cava. They have larger lumen diameters than the PICC or midline catheters and are intended for shorter-term intravenous therapy than other central lines. They can be open ended or valved and with single or multiple lumens. If an open-ended, nonvalved CVC is used, again, heparin flushes are necessary using a 10cc syringe.

The sterile dressing change is performed as follows:

1. Wash your hands.
2. Put on gloves.
3. Apply a face mask to the patient and yourself. Have the patient turn his or her head away from the catheter site.
4. Remove the old dressing and discard it in the appropriate manner.
5. Inspect the site for any signs of infection such as swelling, redness, and/or drainage. Also examine the sutures. If they are loose, notify the physician.
6. Discard the gloves and put on a pair of sterile gloves.
7. Using 70% isopropyl alcohol swab sticks, cleanse site, rotating in a four to six inch circular method from inside outward, as previously described in this course, at least three times.
8. Repeat the cleansing procedure above, using povidone-iodine swab sticks or chlorhexidine gluconate. Allow it to air dry.
9. Dress the site with a transparent dressing or sterile gauze.

Removing a nontunneled central venous catheter is a sterile procedure, done only by physicians, other licensed independent practitioners, such as a nurse practitioner and registered nurses who have received specialized training in this area. The procedure is as follows:

1. Wash your hands.
2. Have the person lie in a supine position with the catheter exit site near or just below the level of the heart.
3. Put on clean, nonsterile gloves.
4. Open the suture removal kit using sterile technique supplied by and used at your facility.
5. Remove the dressing and discard it in the proper manner.
6. Don sterile gloves.
7. Remove the sutures.
8. Instruct patient to bear down or cough, thus performing the Valsalva maneuver.
9. Withdraw the catheter and measure it.
10. Cover the site immediately with a petroleumbased dressing which prevents air from entering into the chest.
11. Instruct patient to breathe normally.
12. Hold pressure until bleeding has stopped.
13. The dressing should remain in place for at least 24 hours.

Peripherally inserted central catheters (PICCs)

Peripherally inserted central catheters (PICCs) are ideal for long-term intravenous therapy. They measure from 14 to 24 inches in length and are composed of a soft, flexible material, either silicone or a polymer. A PICC is inserted into one of the superficial veins of the peripheral vascular system and advanced upward toward the central venous system. The catheter ends in the lower third of the superior vena cava, near the area where the superior vena cava and the right atrium join, or at some other preselected site along the peripheral vascular system, such as a midclavicular placement in the subclavian or proximal axillary vein. The preferred site of placement, however, is the lower third of the superior vena cava. Rates of infection and thrombosis are least with this preferred placement site. When a PICC is inserted, its position is confirmed with an X-ray or another diagnostic method before it is used. To differentiate PICCs from external tunneled catheters, PICCs are sometimes referred to as nontunneled peripheral central catheters. See Figure 6.

Figure 6 This photo depicts a peripherally-inserted central catheter (PICC)

The first dressing change after insertion is critically important. The dressing is changed after 24 hours; then follow your hospital or agency policy for subsequent dressing changes.

Removal of a PICC line can be done by an RN or a CRNA as follows:

1. Gather sterile gloves, sterile 2 x 2 gauze, antiseptic ointment, transparent dressing, and measuring tape.
2. With nonsterile gloves, remove the dressing by pulling it from the forearm toward the upper arm. Inspect site for abnormal changes.
3. With sterile gloves, grasp the catheter as close to the site of insertion as possible, and gently pull the catheter out hand-over-hand every one to two inches.
4. Apply pressure with sterile gauze to stop or prevent bleeding.
5. Apply ointment to seal the site and prevent air from entering into the insertion site.
6. Cover with gauze and a transparent dressing.
7. Measure the catheter and compare measurements with the insertion length.

Managing the PICC Catheter

PICC lines vary in gauge size, from a large 14 gauge to a tiny 28 gauge used for newborns. PICC catheters are also available in a variety of lengths so that they can be used for both infants and full grown adults. The diameter of the catheter also varies. To infuse a highly viscous solution, or to use the catheter for blood sampling, the PICC catheter must have an internal diameter of 4.0 or larger. At least seven different PICC lines are currently available with single, double, and triple lumens or "tails." When PICCs were first introduced, they had only a single-lumen; thus, only one IV or medication at a time could be infused. The multi-lumen catheters of today allow for simultaneous infusion of different solutions or medications.

PICCs can be inserted by educated and competent nurses or doctors. One of the advantages of this catheter is that it can be inserted in the physician's office, patient's home, or at the hospital bedside. This insertion location is much less expensive than those devices that require an operating room or ambulatory surgery facility. Another advantage is that they are placed in a site that is easily accessible to the patient who prefers selfcare for medication/fluid administration.

PICC lines are indicated for long-term IV therapy in the home, hospital, or clinic setting. Indications include the lack of peripheral vascular access, infusion of hyperosmolar solutions or vesicant/irritant drugs, blood and blood products, and intermittent drug therapy. In the average adult, a catheter length of 20 to 22 inches is required to reach the superior vena cava. Correct catheter placement is usually confirmed by x-ray. TPN infusions require that the PICC line be inserted into or close to the superior vena cava. Research has shown that PICC lines are excellent for long-term vascular access needs and are cost-effective because the cost of insertion is less than the cost of insertion of a central venous catheter. PICC lines are safe for use in a wide variety of patients including pediatric patients, HIV and trauma patients, and others who are seriously compromised and critically ill.

Insertion and Post Insertion Care

PICC lines are inserted into one of the superficial veins of the peripheral vascular system, commonly in the antecubital area. After the vein is selected, a small incision is made. Then, using an introducer over the catheter, the catheter is initially advanced into the vein. Once the catheter is moving freely into the vein, the introducer is removed and the catheter is advanced forward. The catheter should terminate in the superior vena cava so that the infused fluids will directly empty into the high-flow chamber of the right atrium of the heart. Nurses are responsible for assessing and caring for the PICC after it is inserted.

Equipment needed is as follows:

• 5 cc syringe
• 4 ccs of normal saline in a 5 cc syringe
• Heparin IOOU/cc 1 cc in a 3 cc syringe
• Injection cap
• Extension set
• Paper measuring tape
• Transparent dressing (Large Tegaderm)
• 1 inch Dermicel tape
• 2 x 2 gauze
• Gloves
• Steristrips

After the PICC is inserted, use a 5 cc syringe to check for a blood return. Ensure that the catheter flushes easily, and that you are able to easily aspirate blood. Next, attach an injection cap to the extension tubing and prime the tubing with three to four ccs of normal saline. Now you can attach the primed IV tubing to the end of the PICC.

Clean the insertion site; however, care must be taken not to dislodge the PICC. Some PICCs come with a ring that is sutured, while others have a wing that will be taped down to secure the catheter. Because nurses are not allowed to suture in most states, winged catheters are most often used.

Adhere a steristrip across the wings of the catheter to stabilize the catheter while the site is cleansed. Use alcohol to gently cleanse the skin being careful not to pull on the catheter. Place a folded 2 x 2 gauze just above the insertion site to serve as a wick for drainage. A small amount of bleeding can be expected for the first 24 hours since an incision was made to introduce the catheter and its introducer into the vein.

Apply the transparent dressing over the site and down to the most distal edge of the catheter wing. Apply a second steristrip, adhesive side up, under the catheter hub and chevron the steristrip around the catheter hub and onto the transparent dressing. To prevent the catheter from clotting, heparize the PICC by administering 1 cc of Heparin 100U/cc into the catheter.

Check all catheter connections to make sure that they are secure and tight. If needed, apply tape to hold the cap firmly on the catheter. The catheter must always have a cap at the end, and the connection should be tight.

Assessments are important at this time in order to determine if any postprocedure complications are occuring. Measure the upper arm circumference for a baseline measurement. For standardization, it is best to measure at the level of the top of the axillia (armpit). Let the patient know that this will serve as a reference point for future measurements to determine if swelling or edema are present. Also, measure the length of catheter beyond the insertion site in order to detect any catheter dislodgment from the insertion site. Again, explain to the patient why you have done this measurement so that the patient can communicate the information to other healthcare providers assessing for catheter dislodgement.

Assess the site every eight hours for the following: redness, edema, pain, drainage, development of a palpable venous cord, and other possible post-op complications which may include:

• excessive or persistent bleeding for more than 24 hours.
• phlebitis due to catheter introduction. This usually occurs in the first 48 to 96 hours after insertion and is more frequent in women than men. It also occurs more often with left-sided insertions and large gauge catheters. The usual signs include erythema, swelling, induration, and a palpable, distended, hard venous cord. Treat phlebitis with warm compresses placed between the insertion site and the shoulder.
• cellulitis which is usually evidenced with redness and/or localized infection at the catheter exit site. The patient may complain of pain and tenderness. Cellulitis spreads in a diffuse circular pattern, and it usually responds well to oral antibiotics.
• pain during infusion that may be related to the IV solution. Apply warm compresses to the arm and ask the doctor if slowing the IV rate is permissible in order to decrease the site irritation.
• catheter migration which is most often accompanied by severe coughing or vomiting. Patients may complain of referred pain in the jaw, ear, or teeth. Check the catheter placement with a chest x-ray.

When not in use, flush the non-Groshong® type PICC every 12 hours with 2 to 3 cc of Heparin 100U/cc. If a medication is to be administered, use the SASH method of flushing. Flush the line with 2 to 3 cc of normal saline, and administer medication or infusion. Once completed, flush again with 2 to 3 cc of normal saline, followed by a Heparin flush using 2 to 3 cc of Heparin 100U/cc solution.

1. Change the initial dressing 24 hours postinsertion.
2. Check for drainage since only a minimal amount is expected. Redress the area using sterile techniques.
3. Remember that the dressing serves two important functions: it provides a sterile environment for the catheter and prevents the catheter from moving in and out. To prevent infection, the insertion site must be kept covered with the dressing.
4. The dressing should be changed on a weekly basis. Care must be taken when changing the dressing to prevent pulling on the catheter which can cause dislodgment or catheter malposition.
5. The PICC will need patency checked on a daily basis while the patient is in the hospital. If a blood return is not immediately noted, have your patient raise his or her arm, move, or change position or cough.
6. When aspirating, always use a syringe that is 10 cc or larger to avoid rupturing the catheter. Catheter rupture occurs when pressures over 25 pounds per square inch (psi) are exerted. The smaller the syringe diameter, the greater the pressure the syringe exerts.
7. To maintain the patency of the PICC, it should be flushed every 12 hours when a continuous IV is not in place.
8. Remember to pull the needle out as the last of the solution is being injected. This helps deter clot and fibrin sheath formation at the tip of the catheter.
9. To avoid aspirating any solution from the catheter while removing the needle from the injection cap, keep gentle pressure on the syringe plunger.

When therapy has ended, the PICC is removed from the patient's arm. Have the patient relax in a comfortable position, with the arm extended. Wearing gloves, remove the external dressing, change gloves, and clean the insertion site with an alcohol prep pad. Then grasp the PICC and gently pull out about one inch of the line. Release the PICC, and then grasp it again back at the insertion site. Gently remove the remainder of the line using short, regular strokes. After all of the line is removed, place a small dressing over the insertion site. Most institutions require that the nurse measure the PICC line and document the length that was removed, to ensure that all of the PICC line has been removed.²²

Patient Education

Teach your patient to flush the catheter once a day at home when medications or fluids are not being administered. Use the following steps as a teaching plan for your patient.²³

1. Collect the following items before beginning:
   1. a syringe with a needle with 1 cc of heparin flush (Heparin 100 units in one cc of saline);
   2. alcohol wipes; and
   3. a metal container (can be an old coffee can with a hole cut in the top of the plastic cover) to discard needles.
2. Wash hands with soap and water.
3. Clean the work area.
4. Obtain a syringe containing heparin flush solution, and place the syringe on the clean work area.
5. Clean the injection cap on the catheter by wiping with an alcohol wipe.
6. Remove the cap from the needle.
7. Hold the syringe with the needle upward, and expel all air by slowly pushing on the plunger. Do not let the exposed needle touch anything.
8. Puncture the injection cap of the catheter with the needle.
9. Flush the catheter by slowly injecting the heparin flush.
10. Carefully pull the needle out from the injection when the last of the solution is being injected.
11. Do not recap the needle.
12. Dispose of the syringe and all needles in a metal container.
13. Check all catheter connections to be sure that they are tight. If necessary, apply tape to hold the cap firmly on the catheter.

If the patient is self administering medication or an infusion, teach them the SASH method.

S - Saline

A - Administer

S - Saline

H - Heparin

Instruct your patient that if a medication or fluid is to be infused through the catheter, a flush of 2 cc of saline should first be given. After the medication is infused, the PICC should be flushed with saline again, followed by a heparin flush to heplock the PICC. If blood was withdrawn from the catheter or blood was administered, the PICC should be flushed with 5 cc of normal saline. If the PICC is a Groshong®, remember to instruct the patient to use saline instead of heparin.

After time, a small red bump will eventually develop at the insertion site. Assure your patient that this is a normal occurrence, and also instruct the patient about the following signs and symptoms that require calling the doctor or the home health nurse:

• excessive bleeding or drainage at the insertion site;
• extreme redness or swelling at the insertion site;
• pain during infusion of the IV solution;
• chest pain;
• catheter movement, either in or out (the catheter will look longer or shorter);
• leakage or breakage of the catheter (Fold the catheter above the break or leak and tape the folded, pinched catheter together until the doctor or nurse provides further guidance.)

MANAGING CATHETER OCCLUSIONS

When catheter obstruction occurs due to a thrombus or clot formation in the catheter, flushing, infusing, or aspirating may not be possible. Occasionally resistance will occur when you attempt to flush or infuse the catheter. This resistance could be due to blockage. Blocked catheters may need to be x-rayed to determine the cause of the blockage. However, there are a few simple steps that the nurse can take first. If you are unable to infuse fluids into the catheter, first check the catheter and make sure that it is unclamped and not kinked. Next, check all of the IV tubing for clamps, kinks, or crimps. Then try a patient position change. Instruct the patient to move his or her upper body and arm to rule out posture-related catheter kinking or blocking. Then ask the patient to lie down and sit up, turn side to side, lean forward, raise and lower arms, and shrug shoulders. Increase the patient's intrathoracic pressure by having him or her cough, take deep breaths, and bear down. This procedure is called the Valsalva maneuver. If this fails, try placing the patient in the Trendelenburg position.

If the IV still does not infuse, remove the injection cap and attach a syringe to the catheter. Try to aspirate blood with the syringe. If successful in getting a blood return, aspirate the line clear of all blood clots. Then flush with heparinized saline. If blood cannot be aspirated, then attempt to clear the occlusion by using a gentle alternating irrigation and aspiration with a 20 cc or larger syringe. This step will avoid the excessive pressures that smaller syringes can generate. The syringe should be filled with heparinized saline 100 units per cc. Remember, do not force the fluid. This could cause catheter rupture. If still unable to aspirate blood, the physician should be called. The physician may order installation of urokinase, a thrombolytic agent. Heparin will not work because it helps prevent clot formation but it does not dissolve clots like urokinase does. Urokinase will not work if catheter malposition or pinch-off is the problem. Catheter pinch-off occurs when there is compression of the catheter between the clavicle and the first rib. Catheter pinch-off can be used by having the patient lie supine with the arm and shoulder slightly raised. If this position promotes the IV to begin infusing, the problem is probably catheter pinch-off inside the body. Pinching will require that the physician readjust or remove the catheter.

If you are able to infuse fluids into the catheter, but unable to aspirate, a one-way effect or withdrawal occlusion may be present. The intermittent inability to withdraw blood occurs in 10 to 20% of catheters, because catheters that have been in place for a period of time often develop an extraluminal fibrin sheath that creates withdrawal occlusion. When an unpreventable fibrin sheath forms over the catheter tip, it may be possible to infuse and flush, but not to aspirate blood. Without urokinase to dissolve the sheath, it can eventually lead to vascular thrombosis.

To perform a urokinase insertion, obtain a physician's order. Usually, 1 ml of urokinase (5000 IU/ml) is needed, drawn up into a 3 cc syringe.

1. Use an empty 10 cc syringe to aspirate any residual fluid in the catheter before administering the urokinase.
2. Remove the syringe.
3. Insert the syringe containing urokinase.
4. Slowly instill the urokinase using a back-and-forth motion.
5. Remove the empty syringe.
6. Wait patiently 30 to 60 minutes and then reattempt catheter aspiration. If unsuccessful, wait another 30 minutes and try again.
7. Administer a second dose of urokinase, using the same procedure, if you cannot aspirate after an hour and a half.
8. If aspiration is unsuccessful after two insertions, notify the physician. The problem may be unrelated to an occlusion or fibrin sheath.
9. If blood is successfully aspirated, withdraw 5 cc of blood and discard the remaining urokinase and blood.
10. Attach a 10 cc syringe of normal saline and flush.
11. Heparize the catheter.

Some feel that the urokinase can be safely inserted up to three times in a four-hour period if the patient's platelet count is greater than 20,000; however this procedure should be done only once in a four-hour period if the platelet count is below 20,000.

Sometimes the problems occur as a result of an occlusion of the vessel where the catheter lies from a subclavian vein thrombosis. The clinical signs and symptoms of this thrombosis are often subtle and with an insidious onset. Clinical findings may include swelling of the arm on the same side of the body as the catheter, neck pain or swelling, jugular vein distention, prominent chest wall veins, nonspecific chest wall pain, shortness of breath, coughing, and occasionally cyanosis of the face and upper extremities. The patient may complain of pain with the infusion, and you may not be able to infuse or aspirate blood from the catheter. A diagnostic venogram may be ordered to establish the diagnosis. Thrombosis occurs most often with left-sided catheters. Treatment usually includes the administration of fibrinolytic agents, anticoagulants, and the elevation of the extremity. Fortunately, with treatment the catheter usually does not have to be removed; however, if the thrombosis is left untreated, the patient can develop pulmonary emboli, venous gangrene, or post thrombotic syndrome.

TROUBLESHOOTING CATHETER COMPLICATIONS

Other problems that can occur with external catheters include damage to the catheter, extravasation, catheter displacement, exit site infection, tunnel infection, systemic infection, septic thrombosis, or an air embolus.

Catheter Damage

If the catheter is damaged, you will notice fluid leaking from the catheter. If fluid is leaking from the catheter hub, it is an indication that the hub is cracked. Catheter rupture may be suspected if you hear a pop while flushing the catheter. A hole in the catheter may be caused by a needle puncture, scissors used near the catheter, hemostats used for clamping, or rupture from the too forceful irrigation of a clamped or obstructed catheter.

If a hole is present in the catheter, have the patient exhale and clamp the catheter proximal to the patient. Apply tape over the hole while awaiting the arrival of the repair kit. Do not use the catheter until it has been repaired. If the rupture is internal, the catheter will have to be removed. Repair kits are usually available from the manufacturer. If there are no kits available, use a peripheral IV catheter for a temporary repair, using the following procedure.

1. Clamp the catheter, leaving as much external catheter as possible.
2. Cut off the damaged portion and discard.
3. Insert the 14 or 16 gauge blunt-end peripheral IV catheter into the open lumen.
4. Tape it in place.
5. Place an injection cap onto the catheter and flush with saline.
6. Tie a silk suture around the end of the catheter.

Permanent repair kits from the manufacturer usually contain a sterile hub with attached tubing, a connector, and silastic glue. Follow the same procedure as above but insert the new hub, tubing, and glue. Tape a tongue depressor to both sides of the hub joint for 24 hours to stabilize it while the glue sets; however, the catheter can be flushed and used immediately after repair.

Extravasation

Extravasation of medication can occur if the catheter is misplaced out of the blood vessel, or the catheter is ruptured or damaged internally. Some clinical signs and symptoms include stinging or burning pain along the catheter site during an infusion, or swelling along the catheter site; palpation of fluid along the subcutaneous tract; redness and warmth at the site; and leaking at the catheter exit site. Stop the infusion and notify the physician. An x-ray may be ordered to determine catheter position. Warm compresses may be ordered to alleviate the discomfort. If catheter displacement occurs, the physician may be able to readjust the catheter under fluoroscopy.

Exit Site Infection

An exit site infection is related to bacterial contamination at the exit site. This may be related to inadequate site care, or the patient's immunocompromised status. The signs of an exit site infection include: erythema, swelling or tenderness at the site, a fever, and/or some purulent drainage at the exit site. If drainage is present, blood and exit site cultures may be ordered. Warm soaks may be used and an antibiotic may be administered. Additionally, an antibiotic ointment may be added to the site care/dressing change procedure to treat the infection. The catheter can still be used while the infection is being treated.

Tunnel Infection

With a tunnel infection, you will typically note erythema or a red streak along the route of the catheter. This may be accompanied by warmth and swelling along the catheter tract. Tenderness or an induration may also be noted 2 cm or more away from the exit site. The patient usually has a fever, and purulent drainage is sometimes present. Treatment will again involve antibiotics; however, if symptoms do not resolve after 48 hours of antibiotic therapy, the patient may require the catheter to be removed surgically.

Systemic Infections

Systemic infection or septic thrombosis usually presents with fever, chills, and hypotension. This type of infection can be due to a small clot or fibrin sheath that has colonized and seeded through the patient's bloodstream, the contamination of the IV fluid being infused, or the entry of bacteria through the skin. The physician will usually order cultures and lab tests to determine the source of the infection, and may not wish the catheter to be used until the infection is identified. IV antibiotics are usually administered. To prevent infection, meticulous handwashing/aseptic techniques are essential when caring for the catheter and changing the dressing.

Air Embolus

An air embolus may occur when there is an inadvertent opening of the closed catheter system without clamping the catheter, accidental disconnection of the tubing, damage to the catheter, or the introduction of air during catheter placement. The patient may experience a sudden onset of chest pain, shortness of breath, light-headedness, tachycardia, pleuritic pain, and anxiety. If these signs appear, immediately clamp the catheter, and have the patient lie on the left side in the Trendelenburg position. Call the doctor and administer oxygen as ordered.

An embolus is an unexpected and uncommon occurrence, so the doctor may order several diagnostic tests to determine the cause of the problem.

It usually takes at least 10 to 20 mL of air to produce clinical symptoms of air embolism. A rapid infusion of air can be fatal. The average lethal dose is 70 to 150 mL of air per second. However, a larger dose of air over a long period of time, such as from a leaking catheter, may be tolerated without producing any clinical symptoms. To prevent the possibility of air embolus, make sure all IV connections are secure.

NEWER IV AND IV SITE CARE PRODUCTS

The traditional method for IV site care has included prepping the skin with a povidone-iodine and alcohol solution applied in a circular manner. In July 2000, the FDA approved a new product and method for IV site care, Medi-Flex's ChloraPrep® One-Step. Several research studies since 1991 have demonstrated that chlorhexidine is more effective in preventing IV catheter-related bacteremia than povidone-iodine and alcohol-based skin disinfectants. ChloraPrep® uses a specially designed applicator to deliver a combination skin disinfectant, 2% chlorhexidene gluconate and 70% isopropyl alcohol, applied in a back-and-forth manner. The innovative applicator is designed with a special handle, angled like a pen, which allows easy application while keeping the clinician's hand away from the prep site. The wing design of the handle allows the clinician to gently squeeze the handle, which releases the solution that is stored in the handle, down to the sponge pad applicator. The chlorhexidine product should not be wiped off after application. It dries within 30 seconds of application and then provides six hours of residual antibacterial activity post-application. See Figure 7.

One concern with the product is flammability. The product must be kept away from fire and should not be used with electro-autery procedures. Another concern is the potential for anaphylactoid reaction. However, one researcher has stated that the risk of anaphylaxis is rare and much less than the risk with antibiotics or other drugs.

A chlorhexidine product for IV catheter site preparation is also being studied by Becton Dickinson.

Figure 7 This photograph depicts Medi-Flex's new product, ChloraPrep® One-Step for IV catheter site preparation. The product dries within 30 seconds of application and then provides six hours of residual antibacterial activity post-application. Source: Medi-Flex, Inc. www.medi-flex.com/new_site/3ml.shtml

SAFER NEEDLE DEVICES

A new federal measure went into effect on April 18, 2001 which will help protect healthcare workers from accidental needlestick injuries that can cause exposure to potentially lethal organisms carried in the blood. The American Nurses Association (ANA) worked with federal legislators to get the Needlestick Safety and Prevention Act passed. This Act, which amended the existing Bloodborne Pathogen Standard administered by OSHA, gives nurses workplace input by requiring facilities to seek nursing input when selecting and evaluating safer needle devices. The ANA also reports that the new law will help in recognizing unsafe devices, because it requires employers to maintain a sharps injury log, which must at least document the type and brand of device involved in the incident, the department or work area where the exposure occurred, and an explanation of how the incident occurred. After months of active lobbying, ANA leaders joined President Clinton on November 6, 2000, for the bill signing ceremony. For further information visit the ANA website at www.ana.org.

Since the healthcare industry and external regulatory bodies, such as OSHA, have become progressively more concerned about the occupational risk of bloodborne pathogen exposure during intravenous therapy, the drive has been on for the elimination of needlesticks and the safest possible intravenous therapy equipment.

During the initiation of intravenous therapy, the act of venipuncture itself poses a needlestick risk and exposure to the patient's venous blood. To prevent a needlestick during venipuncture, nurses should never re-cap venous access devices and they should be aware and anticipate other factors, such as the possibility of unexpected patient movement. Those performing venipuncture must also have readily accessible and appropriate containers for the disposal of used sharps, including those used to initiate intravenous therapy. Intact, clean gloves on both hands during the venipuncture procedure are also mandated in order to prevent unnecessary exposure to the patient's blood, as consistent with standard precautions and accepted standards of practice.

In the course of intravenous therapy, secondary lines are often needed to administer medications and other ordered solutions. In the past, these lines were connected to the primary intravenous line using a needle. Now, these needles are unnecessary and undesirable. Safer needleless devices are now available on the market. The characteristics of the safest and best devices, according to OSHA are ones that have:

• one-handed safety feature activation;
• an inability to function unless the safety feature is activated;
• expeditious and safe use despite the presence of the safety device, that is, one that is as easy and quick to use as one without a safety device;
• some signal or alert to indicate that the safety feature is indeed correctly in place and activated;
• little or no proneness to error or variations of performance of individuals;
• a consistently reliable safety activation feature that operates with zero defects;
• a mechanism that completely covers or blunts the sharp after use; and
• a device that requires little or no education and training in order to use it appropriately, safely, and effectively.

THE ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS

There are a wide variety of blood and blood products. These products include:

• whole blood;
• packed red blood cells;
• platelet concentrates;
• fresh and fresh frozen plasma;
• cryoprecipitate;
• fractionated plasma products;
• granulocyte concentrates; and
• modified blood products.

Whole blood consists of plasma, plasma proteins, red blood cells, and an anticoagulant that preserves the blood. The volume of one unit of whole blood is 500 mL. Whole blood is used to replace blood after a large loss, that is, for blood losses greater than 1000 mL. A small pore filter, 20 to 40 μm, is sometimes used as is a blood warmer to prevent cardiac arrhythmias and hypothermia complications that sometimes occur when a refrigerated blood product is administered rapidly. The most common complication associated with a whole blood transfusion is circulatory overload. The signs and symptoms of circulatory overload include:

• dypnea;
• coughing;
• rising venous pressure;
• distended neck veins; and
• crackles in the bases of the lungs.

Packed red blood cells consist of plasma and platelets. One unit of packed red blood cells has 50 to 400 mL of plasma and a minimum of 5.5 x 1011 platelets. They are administered to restore and/or maintain adequate oxygenation without the risks associated with a greater extension of blood volume, as is the case with the administration of whole blood. Typically, an adult patient may receive two units and a child would receive 5 to 15 mL for each kg of body weight. The rate of administration for adults is one unit over one and a half to two hours; the rate for children is 2 to 5 mL/kg in one hour. Packed red blood cells must be completely infused within four hours after the unit has left the blood bank and its proper refrigeration.

Patients, particularly those with aplastic anemia or leukemia, usually have packed red blood cells administered through a small pore filter. The most commonly occurring complications associated with transfusions of packed red blood cells are:

• hemolytic transfusion reactions;
• febrile transfusion reactions; and
• allergic transfusion reactions.

Platelet concentrates contain a high concentration of platelets suspended in plasma that is obtained from either a single donor apheresis or multiple donor whole blood which then undergoes centrifuging to take out the platelet laden plasma. Single donor platelets are most often used when the risk of transfusion transmitted diseases or alloimmunization are present.

Platelet transfusions are typically indicated to correct or prevent hemorrhaging when a patient has a platelet dysfunction or has thrombocytopenia. These transfusions are contraindicated when the source of the problem is heparin because a platelet transfusion could lead to arterial thrombosis. Also if the patient has thrombotic thrombocytopenic purpura, it may hasten autoimmune platelet destruction. The average dose is typically 1 unit of platelets for every 10 kg of body weight. Adults generally receive a unit of platelets in 20 minutes to one half hour. The most common complications associated with platelet concentrates are febrile and allergic transfusion reactions.

Fresh and fresh frozen plasma are comprised of essential clotting factors, plasma proteins, water, and carbohydrates. A unit of plasma is from 200 to 250 mL. Plasma can be stored as a liquid or frozen within 6 hours after collection for storage. Fresh and fresh frozen plasma are indicated for patients who have:

• a blood loss;
• a clotting disorder, such as one resulting from liver failure or another hepatic disorder;
• anticoagulation problems subsequent to warfarin (Coumadin) therapy;
• disseminated intravascular coagulation (DIC);
• had a massive blood replacement and dilutional coagulopathy occurs; and
• acquired or congenital clotting factor disorders.

The dosage of plasma depends on the person's clinical status, including the prothrombin time (PT) and partial thromboplastin time (PTT). A unit of plasma is usually infused in 15 to 30 minutes.

Cryoprecipitate consists of clotting factors suspended in plasma. Each unit of cryoprecipitate contains 250 units of fibrinogen, 80 to 120 units of Factor VIII, and 20% to 30% the amount of Factor XIII found in a unit of whole blood. Cryoprecipitate is indicated for disorders associated with a deficiency of factor VIII, such as von Willebrand's disease and hemophilia A and also for deficiencies of factor XIII and fibrinogen, as occurs with disseminated intravascular coagulation.

The usual adult dosage of cryoprecipitate is 10 units, with repeated transfusions every 8 to 12 hours until the deficiency is corrected. One unit of cryoprecipitate is usually infused within 3 to 15 minutes.

Fractionated plasma products currently on the market include colloid solutions such as albumin, plasma protein fraction, and albumin in combination with plasma protein fraction, immune serum globulins that contain large amounts of gamma globulin in an aqueous solution, intravenous immunoglobulins, and Factor VIII and Factor IX concentrates.

Colloid fractionated plasma products, such as albumin, plasma protein fraction (PPF), and albumin in combination with PPF, are used to replace volume during shock and massive hemorrhaging. These products are also used to treat hematological complications associated with newborn hemolytic disease, burns, and acute liver failure. Rapid administrations of PPF can lead to hypotension.

Immune serum globulins (ISGs) contain large amounts of gamma globulin. This preparation is given with a deep intramuscular injection, rather than via an infusion. A complication associated with immune serum globulins is pain at the injection site. ISG is not associated with a risk of HIV/AIDS, hepatitis B, or other bloodborne pathogens.

Intravenous immunoglobulins (IVIGs) contain a larger volume and a greater concentration of immunoglobulins than immune serum globulins (ISGs). These preparations are used for acquired and congenital immunodeficiency disorders, such as chronic lymphocytic leukemia and immune thrombocytopenic purpura, and the treatment of platelet alloimmunization, as well as some investigational uses in the treatment of rheumatoid arthritis, influenza, Guillain-Barre syndrome, and myasthenia gravis. IVIG, like immune serum globulins, do not carry HIV/AIDS; however, they have been reported to transmit non-A, non-B hepatitis. The dosage and rate of administration varies according to the manufacturer. The most common complication of IVIGs is anaphylaxis.

Factor VIII and IX concentrates are lyophilized concentrates. Factor VIII concentrates are used to treat hemophilia A and von Willebrand's disease in their most severe stages. Factor IX is primarily used to treat Christmas disease, a disorder associated with a deficiency of factor IX.

Granulocyte concentrations consist of granulocytes, lymphocytes, platelets, red blood cells, and plasma. These concentrations are indicated for the treatment of severe, life threatening fungal or bacterial infections that have not successfully been responsive to other therapy and the person has significant neutropenia. Granulocyte concentrates are administered at the rate of one unit per day for about five to ten days. Because the white blood cells have a shortlived life and the benefit of the concentrate is a function of white blood cell survival, the granulocytes should be infused immediately. The transfusion should be started in a slow manner and the total duration of the infusion should be from one to two hours. During the infusion, the infusion bag should be agitated to prevent the granulocytes from collecting at the bottom of the infusion bag. This blood product must be administered while constantly monitoring the patient for complications, such as anaphylaxis, febrile reactions, and allergic reactions. Emergency medical equipment should be readily accessible for the duration of the infusion.

If the patient is taking amphotericin B (Fungizone), it should not be given four hours before or after the administration of the granulocytes because it may lead to pulmonary insufficiency. Acetaminophen and an antihistamine are given prior to the administration to prevent side effects. At times, a steroid or meperidine may also be administered.

Modified blood products are blood preparations that undergo further processing, such as additional washing, filtration, irradiation, and freezing to reduce the risk of transfusion reactions. These preparations are particularly useful to immunocompromised patients.

Transfusion Reactions

Transfusion reactions can be delayed or acute. Acute blood transfusion reactions occur either during the blood or blood product infusion or up to several hours after the infusion is completed. Delayed blood transfusion reactions occur days or years after a transfusion has been received. Acute blood transfusion reactions include:

• circulatory overload;
• air embolism;
• febrile, septic, allergic, and hemolytic reactions;
• hyperkalemia;
• hypothermia; and
• hypcalcemia.

Delayed blood transfusion reactions include:

• infections, such as Epstein-Barr virus, malaria, AIDS/HIV, hepatitis B and C;
• hemosiderosis (iron overload); and
• hemolytic reactions.

Acute and delayed reactions to transfusion therapy, their causes, clinical manifestations, management, and prevention are shown on the Table 16 and Table 17.

TABLE 16: ACUTE REACTIONS TO BLOOD TRANSFUSIONS ACUTE REACTION CAUSE CLINICAL MANIFESTATIONS MANAGEMENT PREVENTION Allergic Sensitivity to plasma protein or donor antibody, which reacts with recipient antigen. 1. Flushing 2. Itching, rash 3. Urticaria, hives 4. Asthmatic wheezing 5. Laryngeal eddema 6. Anaphylaxis 1. Stop transfusion immediately. Keep vein open (KVO) with normal saline. Notify healthcare provider and blood bank. 2. Give antihistamine as directed (diphenhydramine). 3. Observe for anaphylaxis-prepare epinephrine if respiratory distress is severe. 4. If hives are the only clinical manifestation, the transfusion can sometimes continue at a slower rate. 5. Send blood samples and blood bags to blood bank. Collect urine samples for testing. Before transfusion, ask patient about past reactions. If patient has history of anaphylaxis, alert healthcare provider, have emergency drugs available, and remain at bedside for the first 30 min. Febrile, nonhemolytic Hypersensitivity to donor WBCs, platelets, or plasma proteins. 1. Sudden chills and fever 2. Headache 3. Flushing 4. Anxiety 1. Stop transfusion immediately and KVO with normal saline. Notify healthcare provider and blood bank. 2. Send blood samples and blood bags to blood bank. Collect urine samples for testing. 3. Check temperature ½ h after chill and as indicated thereafter. 4. Give antipyretics as prescribed- treat symptomatically. Given antipyretic (acetaminophen or aspirin) before transfusion as directed. Leukocyte-poor blood products may be recommended for future transfusions. Septic reactions Transfusion of blood or components contaminated with bacteria. 1. Rapid onset of chills 2. High fever 3. Vomiting, diarrhea 4. Marked hypotension 1. Stop transfusion immediately and KVO with normal saline. Notify healthcare provider and blood bank. 2. Obtain cultures of patient's blood and return blood bags with administration set to blood bank for culture. 3. Treat septicemia as directed-antibiotics, IV fluids, vasopressors, steroids. Do not permit blood to stand at room temperature longer than necessary. Warm temperatures promote bacterial growth. Inspect blood for gas bubbles, clotting, or abnormal color before transfusion. Complete infusions within 4 h. Change administration set after 4 h of use. Ciculatory overload Fluid administration at a rate or volume greater than the circulatory system can accommodate. Increased blood in pulmonary vessels and decreased lung compliance. 1. Rise in venous pressure 2. Distended neck veins 3. Dyspnea 4. Cough 5. Crackles at base of lungs. 1. Stop transfusion and KVO with normal saline. Notify healthcare provider. 2. Place patient upright with feet in dependent position. 3. Administer prescribed diuretics, oxygen, morphine, and aminophylline. Concentrated blood products should be given whenever positive. Transfuse at a rate within the circulatory reserve of the patient. Monitor central venous pressure of patient with heart disease. Hemolytic reaction Infusion of incompatible blood products: 1. Antibodies in recipient's plasma attach to transfused RBCs, hemolyzing the cells either in circulation or in the reticuloendothelial system. 2. Antibodies in donor plasma attach to recipient RBCs, causing hemolysis (may result from infusion of incompatible plasma- less severe than incompatible RBCs). 1. Chills; fever 2. Low back pain 3. Feeling of head fullness; flushing 4. Oppressive feeling 5. Tachycardia, tachypnea 6. Hypotension, vascular collapse 7. Hemoglobinuria, hemoglobinemia 8. Bleeding 9. Acute renal failure 1. Stop transfusion immediately-KVO with 0.9% saline. 2. Notify healthcare provider and blood bank. 3. Treat shock, if present. 4. Draw testing samples, collect urine sample. 5. Maintain blood pressure with IV colloid solutions. Give diuretics as prescribed to maintain urine flow, glomerular filtration, and renal blood flow. 6. Insert indwelling catheter to monitor hourly urine output. Patient may require dialysis if renal failure occurs. Meticulously verify patient identification- from sample collection to product infusion. Begin infusion slowly and observe closely for 30 min-consequences are in proportion to the amount of incompatible blood transfused. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 898-899.

TABLE 17: DELAYED REACTIONS TO TRANSFUSION THERAPY TRANSFUSIONS ACUTE REACTION CAUSE CLINICAL MANIFESTATIONS MANAGEMENT PREVENTION Delayed hemolytic reaction The destruction of transfused RBCs by antibody not detectable during crossmatch, but formed rapidly after transfusion. Rapid production may occur because of antigen exposure during previous transfusions or pregnancy. 1. Fever 2. Mild jaundice 3. Decreased hematocrit Generally, no acute treatment is required, but hemolysis may be severe enough to cause shock and renal failure. If this occurs, manage as outlined under acute hemolytic reactions. The crossmatch blood sample should be drawn within 3 d of blood transfusion. Antibody formation may occur within 90 d of transfusion and/or pregnancy. Iron overload (hemosiderosis) Deposition of iron in the heart, endocrine organs, liver, spleen, skin, and other major organs as a result of multiple, long-term transfusions (aplastic anemia, thalassemia). 1. Diabetes 2. Decreased thyroid function 3. Arrhythmias 4. CHF and other symptoms related to major organ failure 1. Treat symptomatically. 2. Deferoxamine (Desferal), which chelates and removes accumulated iron through the kidneys; administered IV, IM, or SC. . Graft-versus-host disease Engraftment of lymphocytes in the bone marrow of immunosuppressed patients, setting up an immune response of the graft against the host. 1. Erythematous skin rash 2. Liver function test abnormalities 3. Profuse, watery diarrhea 1. Immunosuppression with corticosteroids, cyclosporine A. 2. Symptomatic management of pruritus, pain 3. Fluid and electrolyte replacement for diarrhea Transfuse with irradiated blood products. Infectious disease 1. Hepatitis B Hepatitis B virus transmitted from blood donor to recipient via infected blood products. 1. Elevated liver enzymes (SGPT and SGOT) 2. Anorexia, malaise 3. Nausea and vomiting 4. Fever 5. Dark urine 6. Jaundice Usually resolves spontaneously within 4-6 wk. Can result in permanent liver damage. Treat symptomatically. Screen blood donors, temporarily rejecting those who may have had contact with the virus. Those with a history of hepatitis after age 11 are permanently deferred; pretest of blood products (EIA). 2. Hepatitis C (formerly non-A, non-B hepatitis) Hepatitis C virus transmitted from blood donor to recipient via infected blood products. Similar to serum B hepatitis, but symptoms are usually less severe. Chronic liver disease and cirrhosis may develop. Symptoms usually mild and require no treatment. Pretest all blood donors (ALT, anti-HBc antibody, anti-hepatits C antibody). 3. Epstein-Barr virus, cytomegalovirus, malaria Transmitted through infected blood products. 1. Fever 2. Fatigue 3. Hepatomegaly 4. Splenomegaly Rest and supportive management. Question prospective blood donors, regarding colds, flu, foreign travel. 4. Acquired immunodeficiency syndrome HIV virus transmitted from blood donor to recipient via infected blood products. 1. Night sweats 2. Unexplained weight loss 3. Lymphadenopathy 4. Pneumocystis pneumonia 5. Kaposi's sarcoma 6. Diarrhea AZT may delay onset of AIDS symptoms. Active disease is treated symptomatically. Test each donor for HIV antibody. Reject prospective highrisk donors: males who have had sex with another male since 1977; users of selfinjected IV drugs; male or female partners of prostitutes; hemophiliacs or their sexual partners; sexual partners of those with AIDS or high risk for AIDS; immigrants from Haiti or sub- Saharan Africa. 5. HTLV-1 associated myelopathy and tropical spastic paraparesis (HAM/TSP) Adult T-cell leukemia Human Tlymphotropic virus type 1 (HTLV-1) transmitted from blood donor to recipient via blood products. Signs of neuromuscular disease. Signs of T-cell leukemia HTLV-1-infected individuals have a low risk of developing disease (3-5%). Incubation period 10-20 y. Should disease occur, treat symptomatically. Screen all prospective blood donors for anti- HTLV-1 antibody. 6. Syphilis Spirochetemia caused by Treponema pallidum. (Incubation 4-18 wk.) 1. Presence of chancre 2. Regional lymphadenopathy 3. Generalized rash Penicillin therapy Test blood before transfusion (rapid plasma reagin-RPF). Organism will not remain viable in blood stored 24-48 h at 4ºC. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 900-901.

Guidelines for the Administration of Blood and Blood Products

The administration of whole blood and blood products require that the nurse:

• ensures that the patient is getting the correct blood product, the correct ABO type, and the correct Rh compatibility;
• establishes an appropriate IV line if not already available;
• selects and uses the correct administration set, filter, warmer, and so on;
• verifies the patient's identity by asking the person to state their full name, comparing the name on the ID wristband with the blood product bag, the transfusion form, and the medical record; always have a second licensed caregiver present at bedside to verify all findings.
• checks the expiration date on the blood or blood product,;
• takes the baseline vital signs prior to the transfusion and throughout the infusion;
• transfuses the product at the ordered rate;
• carefully observes the patient for any transfusion reactions;
• notifies the doctor if any untoward reactions occur; and
• completes the required documentation.

The procedure and rationale for the administration of blood and blood products is shown on Table 18.

TABLE 18: PROCEDURE GUIDELINES, ADMINISTERING BLOOD AND BLOOD COMPONENTS EQUIPMENT Tourniquet Iodine-containing skin antiseptic Needle or venous catheter Y-Type blood infusion set 170-μ filter Normal saline Blood product as described PROCEDURE NURSING ACTION Preparatory phase 1. Inform the patient of the procedure, blood product to be given, approximate length of time, and desired outcome of transfusion. 2. Obtain and record baseline vital signs. 3. Prepare infusion site. Select a large vein that allows patient some degree of mobility. Start the prescribed intravenous infusion. RATIONALE 1. Instruct the patient to report unusual symptoms immediately. 2. If the patient's clinical status permits, delay transfusion if baseline temperature is greater than 38.5ºC (101.7º). 3. Antecubital veins are not recommended for lengthy infusions. Prolonged restriction of arm movement is uncomfortable and inconvenient for the patient. In the event of an acute reaction, the intravenous catheter should be maintained with normal saline. DRUG ALERT: Crystalloid solutions other than 0.9% saline and all medications are incompatible with blood products. They may cause agglutination and/or hemolysis. 4. Obtain blood product from blood bank. Inspect for abnormal color, cloudiness, clots, and excess air. Read instructions on the product label regarding storage and infusion. Check expiration date. 5. Verify patient identification. a. Ask the patient to state his or her full name and compare with name on the wrist band. If the patient is unable to state his or her name, verify identity with an individual familiar with the patient. b. Compare the name and ID number on the wristband with the bag tag, transfusion form, and medical order. c. Confirm ABO and Rh compatibility by comparing the bag label, bag tag, medical record, and/or transfusion form. d. Check bag labels for expiration date and satisfactory serologic testing. 4. Platelets are normally cloudy. If the transfusion cannot begin immediately, return product to blood bank. Blood out of proper storage for more than 30 min (above 10ºC [150ºF]) cannot be reissued. Never store blood in unauthorized refrigerators, such as those on the nursing unit. 5. The majority of acute fatal transfusion reactions are caused by clerical errors. Patient and product verification is the single most important function of the nurse. It is strongly recommended that two qualified individuals perform this task. Do not proceed with the transfusion if there is any discrepancy. Contact the blood bank immediately. PERFORMANCE PHASE 1. Start infusion slowly (ie, 2 mL/min). Remain at bedside 15-30 min. If there are no signs of side effect, increase flow to the prescribed rate. 2. Observe the patient closely and check vital signs at least hourly until 1 h after transfusion. Report signs of side effect to healthcare provider immediately. 3. Record the following information on the patient's chart: a. Time and names of persons starting and ending the transfusion. b. Names of individuals verifying patient ID. c. Unique product identification number. d. Product and volume infused. e. Immediate response-for example, "no apparent reaction." 1. Institutional policy may vary regarding flow rates and patient monitoring. Signs of a severe transfusion reaction (ie, acute hemolytic, anaphylactic) are usually manifested during infusion of the initial 50-100 mL. 2. Acute reactions may occur at any time during the transfusion. 3. Facts relating to the transfusion should be charted exactly. c. It must be possible to trace each transfusion product to the original donor. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 893.

PARENTERAL NUTRITION

Parenteral nutrition involves the infusion of essential nutrients, including carbohydrates, amino acids, vitamins, lipids, minerals, and water through venous access devices. Parenteral is primarily given to patients who are in a hypermetabolic state as a result of burns, sepsis, or trauma and when a person cannot tolerate enteral nutrition for one of a variety of reasons including:

• severe diarrhea;
• severe and persistent vomiting;
• acute pancreatitis;
• a paralytic ileus;
• an intestinal obstruction;
• malabsorption;
• a fistula; or
• inflammatory bowel disease and other disorders of the gastrointestinal tract. Parenteral nutrition is administered as:
• total nutrient admixtures (TNA);
• peripheral parenteral nutrition (PPN);
• total parenteral nutrition (TPN); and
• fat emulsion lipids.

Total nutrient admixtures consist of a highly concentrated dextrose solution of carbohydrates, amino acids, a source of protein, lipids including triglycerides, glycerol, and egg phospholipids, water, minerals, and vitamins. They are administered through a central vein, most often the superior vena cava. Total nutrient admixture therapy is usually reserved for those patients who will require more than seven days of parenteral nutrition.

Peripheral parenteral nutrition is a form of parenteral nutrition that is administered through a peripheral vein. These solutions are comprised of a lower caloric and less concentrated glucose solution than TNA which contains vitamins, amino acids, minerals, and lipids. These solutions are used for patients that will require less than seven days of parenteral nutrition.

Total pareneteral nutrition, given through a central IV line, consists of glucose, vitamins, minerals, and amino acids. Lipids are sometimes added when needed. Fat emulsion lipids, on the other hand, can be administered with either a central or peripheral intravenous line. They are comprised of egg phospholipids, triglycerides, glycerol, and water.

Parenteral nutrition can be infused using a:

• venous access device such as a Broviac®, Hickman®, or Groshong® catheter;
• mutilumen venous access device that permits the simultaneous infusion of the parenteral nutrition and other solutions and/or blood;
• peripherally inserted central catheter (PICC);
• peripheral catheter into a large arm or leg vein, when necessary; and
• midline catheter.

A filter is needed during the administration of parenteral nutrition. A 1.2 micron filter is used for TNA and fat emulsion lipids. A 0.22 micron filter is needed when you are infusing TPN without any fat emulsion. To ensure proper flow and patient safety, a mechanical volume control infuser is used to infuse all forms of parenteral nutrition.

The complications of parenteral nutrition are described in Table 19 and Table 20.

TABLE 19: COMPLICATIONS OF ADMINISTRATION OF TOTAL NUTRIENTS ADMIXTURE (TNA) AND TREATMENT COMPLICATION CAUSES INTERVENTIONS Sepsis High glucose content of fluid Venous access device contamination Monitor temperature, WBC count, insertion site for signs and symptoms of infection. Maintain strict surgical asepsis when changing dressing and tubing. Consider decreasing glucose content of fluid.* Consider removal of venous access device with replacement in alternate site.* If blood cultures positive, consider institution of antibiotic therapy.* Electrolyte imbalance Iatrogenic Effect of underlying diseases, ie, fistule, diarrhea, vomiting Monitor electrolyte levels at least 2-3 days. Monitor signs and symptoms of electrolyte imbalance. Treat underlying cause.* Change concentration of electrolytes in TNA as necessary to address blood levels.* Hyperglycemia High glucose content of fluid Insufficient insulin secretion Monitor blood glucose frequently. Decrease glucose content of fulid if possible.* Administer exogenous insulin per additions to TNA, subcutaneously or through a separate intravenous drip.* Hypoglycemia Abrupt discontinuation of TNA administered through a central vessel. After discontinuation of centrally administered TNA, start D10W at the same rate.* Hypervolemia Iatrogenic Underlying disease, ie, CHF, renal failure Monitor intake and output, daily weights, CVP, breath sounds, peripheral edema. Consider administering more concentrated TNA solution.* Hyperosmolar diuresis High osmolarity of TNA Monitor intake and output, daily weights, CVP. Consider decreasing concentration or amount of fluid administered.* Hepatic dysfunction High concentration of carbohydrates and/or fats relative to protein in TNA Monitor liver function tests, triglyceride levels, presence of jaundice. Consider alteration in formula content.* Hypercapnea High carbohydrate content of fluid. Consider changing formula to increase the proportion of fat relative to carbohydrate. Lipid intolerance Low birth weight or premature infant History of liver disease History of elevated triglycerides Monitor for bleeding (check stools for occult blood, coagulation studies, platelet levels). Monitor O2 levels for impaired oxygenation. Monitor for fat overload syndrome: monitor triglyceride levels and liver function tests, hepatosplenomegaly, decreased coagulation, cyanosis, dyspnea. Monitor allergic reaction: nausea, vomiting, headache, chest pain, back pain, fever. Administer lipid-containing solutions slowly, initially, while observing for symptoms. Lipid particulate aggregation Unstable mixture of dextrose solution with lipid emulsion Observe for cracking or creaming of fluid, and avoid use of fluid with these characteristics. WBC: white blood cell; CHF: congestive heart failure; CVP: central venous pressure. * Obtain orders from healthcare providers. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 666-667.

TABLE 20: PROCEDURE GUIDELINES, ADMINISTRATION OF TOTAL NUTRIENT ADMIXTURE (TNA) (SIMILAR PROCEDURE FOR TOTAL PARENTERAL NUTRITION [TPN] AND OTHER COMPONENTS) EQUIPMENT Volume control infuser Bag of TNA Administration tubing with luer-lock connections 1 2-μm filter Hypoallergenic tape, 1 in Face mask (optional) Clean gloves Sterile dressing kit to include:     Alcohol swab sticks (3)     Povidone-iodine sticks (3)     Sterile gloves     Transparent dressing PROCEDURE NURSING ACTION RATIONALE To change bag and bottle: PREPARATORY PHASE 1. Remove TNA from refrigerator at least 1 h before hanging. 2. Inspect fluid for presence of cracking or creaming. 3. Wash hands. 1. Decreases incidence of hypothermia, pain, and venospasm. 2. Indicates fluid separation, do not use. If infusing TPN, solution should be clear without clouding. 3. Prevents bacterial contamination PROCEDURE NURSING ACTION RATIONALE PREPATORY PHASE 1. Using strict sterile technique, attach tubing (with filter) to TNA bag and purge of air. 2. Close all clamps on new tubing. Insert tubing into volume control infuser. 3. If venous access device (VAD) has a clamp at proximal end, clamp tubing. 4. If no clamp is available on central VAD, instruct patient to Valsalva maneuver (bear down and hold breath) while new tubing is connected. 5. Sterilely connect tubing to hub of VAD, making certain the connection is securely fastened using luer-lock connections. 6. Open all clamps and regulate flow through volume control infuser. 1. Prevent air embolus. 2. *Tubing should be changed on a regular basis (every 2-3 d). Filter will be different for TPN, because lipids are not included. 3. Prevents air embolus if VAD is inserted in a central vein. 4. Valsalva's maneuver creates positive pressure, preventing air from getting sucked into tubing. 5. Prevents disconnection of tubing. FOLLOW-UP PHASE   1. Monitor administration hourly, assessing for integrity of fluid and administration system and patient tolerance and complications. 2. Document tubing change and fluid administration, observations, presence of complications, and any treatment given.   PATIENT EDUCATION   1. Teach patient signs and symptoms of complications, including sepsis, phlebitis, extravasation, and to report any changes to nursing personnel. 2. If patient is to be discharged to home with TNA, begin instruction regarding proper storage, handling, and administration of TNA. Include family members as appropriate. 1. Patient can assist nursing personnel in monitoring therapy and in detecting complications. 2. Long-term therapy may be indicated in burns, emaciation due to cancer treatment, and other conditions. Home care nurses will reinforce your teaching. PROCEDURE NURSING ACTION RATIONALE To change central venous catheter dressing: PERFORMANCE PHASE 1. Don clean gloves and carefully remove old dressing. 2. Inspect insertion site for complications. 3. Clean insertion site with each alcohol swab beginning at insertion site and moving outward in a circular pattern. 4. Repeat using each povidone-iodine swab. 5. Allow to dry. 6. Remove adhesive backing of transparent dressing. Center dressing over site. 7. Loop and tape tubing to skin using 1-in tape. Do not tape over dressing. 2. Observe for edema, erythema, tenderness, and leakage of fluid. 3. Moves potential contaminants away from insertion site. 4. Removes bacteria from insertion site. 5. Drying allows adhesive dressing to adhere securely. 6. Application of transparent dressing provides a bacterial barrier while allowing full visualization of insertion site. 7. Prevent dislodgement of tubing. PREPARATORY PHASE 1. Obtain equipment. 2. Explain procedure to patient. 3. Place patient in a comfortable supine position and turn head away from site. 4. Wash hands. 5. Don mask (optional). 3. Turning patient's head away from site will decrease possible microbial contamination of site. 4. All precautions are taken to prevent bacterial contamination. FOLLOW-UP PHASE 1. Document dressing change and observation of insertion site. 2. Observe insertion site frequently for signs of complications. 2. Observe for edema, erythema, tenderness, and leakage of fluid. PATIENT EDUCATION 1. Teach patient signs and symptoms of infection, phlebitis, and fluid extravasation and to report any changes to nursing personnel. 2. If patient is to be discharged to home with TNA, begin instruction regarding sterile dressing change. Include family members as appropriate. 1. Patient may be first to notice complications. 2. Because risk of sepsis is so great, sterile technique is still required for home dressing changes. Source: The Lippincott Manual of Nursing Practice, 7th ed., Sandra M. Nettina. Lippincott, Philadelphia PA: 2001, 667-669.

SUMMARY

Intravenous therapy and venipuncture are frequently done in the healthcare setting. This course has provided you with the knowledge you need to become proficient in these areas, however, practice under the guidance and direction of your supervisor or nursing educator is needed to refine and validate your competency in the hands on or psychomotor aspects of IVs and IV therapy.

NOTES

1. S. Laughlin, "Criminal Charges for Clinical Errors, Advanced Practice Nurse Liability," Journal of Nursing Law 5, no, 2 (1998): 65-73.
2. T. D. Aiken and J. T. Catalano, Legal, Ethical, and Political Issues in Nursing, (Philadelphia, PA: F. A. Davis Company, 1996), 192.
3. Ibid.
4. Florida Statutes, section 766.102.
5. Francis vs. Memorial General, 726 P. 2d, 852 (1986).
6. I. Coleman, "Medication errors: picking up the pieces," Drug Topics 103 (1997): 83-92.
7. D. W. Bates, et al., "The costs of adverse drug events in hospitalized patients," JAMA 227 (1997): 307-311.
8. L. Leape, D. W. Bates, et al., "Systems analysis of adverse drug events," JAMA 274 no. 1 (1995): 35-43.
9. I. Coleman.
10. T. Piazza-Hepp and D. Kennedy, "Reporting of adverse events to MedWatch," Am J Health Syst Pharmi 52 (1995): 1436-1439.
11. L. Leape, D. W. Bates, et al.
12. J. Korin, " Cost implications of malpractice and adverse events," Hosp Formulary 28 (1993): 59-36.
13. D. Bates, D. Cullen, and N. Laird, "Incidence of adverse drug events and potential adverse drug events: implications for prevention," JAMA 274 (1995) 29-34.
14. Ibid.
15. M. Auriche, E. Loupi, "Does proof of casualty ever exist in pharmacovigilance?" Drug Safety 9 (1993): 230-235.
16. L. Leape, D. Bates, et. al.
17. J. N. Greene, "Infections related to vascular access devices." Cancer Control: Journal of the Moffitt Cancer Center 3, no.5 (1996): 456-464.
18. C. A. Bean, "High-tech homecare infusion therapies." Critical Care Nursing Clinics of North America 10, no. 3 (1998): 287-303.
19. E. A. McConnell, "Vasuclar access devices lines to live by." Nursing Management 30, no. 12 (1999): 49, 52.
20. E. A. Krzywda, "Central venous access - catheters, technology, and physiology." MedSurg Nursing 7, no. 3 (1998): 132-139.
21. S. Laughlin.
22. Mount Sinai Medical Center. "Nursing Policy and Procedures for PICC Care," 1999. Mount Sinai Medical Center, Miami Beach, FL.
23. D. Macklin. "Removing a PICC." AJN 100, no. 1 (2000): 52-54

BIBLIOGRAPHY

Aiken, T. D. and J. T. Catalano. Legal, Ethical, and Political Issues in Nursing. Philadelphia, PA: F. A., Davis Company, 1996.
Auriche, M. and E. Loupi. "Does proof of casualty exist in pharmacoviginlance?" Drug Safety 9, 1993.
Bates, D., D. Cullen, and N. Laird. "Incidence of drug events and potential adverse drug implication for prevention." JAMA 274, 1995.
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Contact Hours: 22
Price: $95.95
Course Title: IV THERAPY for LPNs and RNs
Course Number: 20-53217

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