Test 1- WALDEN

IV THERAPY:
1. PURPOSE- To access the venous circulation in order to dra !lood "or la!orator# screens and dia$nostic tests or to ad%inister "luids& electrol#tes& %edications& !lood& !lood 'roducts &and nutritional su''le%ents. Indicated "or situations hen oral or other 'arenteral routes are not a''ro'riate.

(ontinuous IV ad%inistration Inter%ittent IV is used 'ri%aril# "or IV %edication ad%inistration )olus increase in %edication i%%ediatel# IV %edications !#'ass the en*#%atic 'rocess o" the liver +ursin$ Res'onsi!ilities ,no in$ IV sets and their "unctions (alculatin$ IV dri' rates -i.in$ and dilutin$ %edications in IV "luids ,no in$ the %edications& 'ur'oses& and side e""ects +ursin$ Res'onsi!ilities continued Assess%ent o" the client& site& in"iltration& rates& adverse reactions& thera'eutic actions IV route is the "astest onset o" %edication ad%inistration& ho ever& once in/ected& the %edication can not !e retrieved IV route could 'rovide a direct route "or conta%ination ith 'atho$ens (losel# %onitor the client "or adverse reactions IV (onsiderations Is "luid loss severe or li"e-threatenin$0 1hat is %issin$0 1hat is current health status0 (o- %or!idities: cardiac& renal& liver& 'ul%onar#& I 2 O

3ail# ei$ht 4 "luids calculated on chan$es in current ei$ht 5T o 6ilo$ra%s o" ei$ht $ain is e7uivalent to 8 liters o" "luid $ain 9 'ounds : 8.9 liters "luid Restorin$ "luids !# IV 1h#: "luid; !lood loss& 'recautionar# <ar$e IV ideal !ut=. 3i""icult to "ind a vein Small bore initially- large (18-20GA) once fluids reestablished IV 'u%' to re$ulate in"usion and decrease ris6 o" too ra'id an in"usion -onitor sites& solution& and outco%es "re7uentl# Restorin$ "luid ris6s Renal& cardiac& 'ul%onar# overload Over"lo diuresis ithout cellular re'lace%ent H#'ernatre%ia ith diuresis 3ilution o" electrol#tes

I+TRAVE+OUS THERAPY 1. >oal: Correct or pre ent fluid ! electrolyte disturbances Allo s "or direct access to the vascular s#ste%& 'er%ittin$ the in"usion o" continuous "luids over a 'eriod o" ti%e -ust !e continuousl# re$ulated !ecause o" continuous chan$es in the client?s "luid 2 electrol#te !alance. 8. T#'es o" IV catheters: Peri'heral Venous (atheters (entral venous catheters @central linesA Peri'herall# inserted central venous catheters @PI(( linesA (entral he%odial#sis catheters A. Peri'heral (atheters: -(o%%on t#'e- o er the needle catheter Color coded "ip should be radiopa#ue

-<ess co%%on- through the needle catheter !utter"l# Potter 'a$e BBC- BBD Read re$ardin$ "lo rate& sites& lar$e $tt Elo "actor and %icro dri' "actor "or slo IV in"usions as PE3s. EI3 @Electronic in"usion deviceA >ather su''lies Assess 'atient "or sa"e site (o%%on sites in adult veins in hands and ar%s See 2 ,no "i$ure 19 4 9 '$BBC PP )asic. a''roach Sites to avoid Areas o" in"la%%ation In"iltration Thro%!osis -astecto%# sides IV $ra"ts sites Avoid adult "oot Use %ost distal hen 'ossi!le& allo in$ 'ro.i%al sites "or su!se7uent veni'uncture Elderl# Perr# Potter )asic BBD !o. 19 4 F Use o" tourni7uet Site to avoid >au$e to use Insertion an$le Elo rate "or IV %edication S6in !arrier reco%%endation

Use o" nettin$ to secure Avoid restraints 'recaution -ental status assess%ent EI3 >au$e and Eluid Rate 8B $au$e @#ello A : 19-89%l;%in 88 $au$e @!lueA : 8C-FC %l;%in 8G $au$e @'in6A : 9G-C9 %l;%in @%aintenance rateA 1H $au$e @$reenA : H9-1G9 %l;%in @ hen lar$e !olus ra'id in"usion neededA >eriatrics 88 4 8B $au$e Tourni7uet %a# not !e necessar# Position hand de'endent +o sla''in$ see !o. 19- F 'a$e BBD Techni7ues. Re%e%!er $eriatric care. (entral venous catheters Icentral linesJ -ultilu%en or sin$le lu%en non-tunneled <u%ens @I'i$tailJA di""erent len$th and color @1&F&BA -3 or +P to insert Sutured to s6in <on$er ter% catheters as co%'ared to 'eri'heral +on-tunneled catheter Sterile dressin$ chan$es !# R+ ; <P+ 7 F-D da#s or PR+

-aintenance @"lushin$ K shi"tA- R+ (entral lines cont. Uses $lood sampling C%& monitoring Continuous' intermittent drug infusions (iagnostic testing Simultaneous infusion of se eral medications %iscous or high- olume fluids ' blood "&) (total parenteral nutrition) PI(( IV access @alternate accessA Peri'herall# inserted central catheters @ar%A <on$er catheter& ter%inates at su!clavian vein <on$er ter% than 'eri'heral IV caths @Dda#s to F %onthsA -ust !e s'eciall# trained R+ Sterile techni7ue Eunction and %aintenance is sa%e TP+ PI(( PI(( The PI(( a""ords a $reater he%odilution hich decreases the ris6 o" 'hle!itis and in"iltration so sta#s in lon$er. PI(( -a# !e used to in"use h#'er 4 os%olor "luids as TP+& )lood& che%ical irritants and vesicants. (entral he%odial#sis catheters

Su!clavian& /u$ular& or "e%oral catheter Te%'orar# vascular access T o 'orts - !lue and red Used "or acute he%odial#sis -3 to insert Sutured to s6in S'ecial trainin$ to access Accounta!ilit# and In"usion Thera'# The R+ is accounta!le "or 6no in$ *hat is ordered *hy it is intended +mpact on the patient Any possible side effects ,o- to administer the infusion ,o- to maintain the infusion ,o- to discontinue properly ,o- to document appropriately R+ Res'onsi!ilities IThe R+ re%ains accounta!le and res'onsi!le "or all dele$ated tas6s and %ust have a clear 6no led$e o" the nursin$ sco'e o" 'ractice relative to assess%ent& 'lannin$& i%'le%entation& and evaluation o" in"usion thera'#& as ell as le$al res'onsi!ilities associated ith dele$ation o" nursin$ care activities.J @I+S& 8GGGA R+?s Res'onsi!ilities 3ele$ate certain nursin$ tas6s to licensed and unlicensed 'ersonnel Still res'onsi!le "or tas6s dele$ated -ust evaluate others co%'etenc#& instruct the%& and veri"# 'ro'er trainin$

Res'onsi!ilities %a# var# a%on$ states and e%'lo#ers (o%'ati!ilit# +urse is res'onsi!le to veri"# co%'ati!ilit# o" "luids ith %edication ad%inistered via IV Or i" a -edication is in the IV "luid and a dru$ is $iven inter%ittentl# +urse %ust %a6e certain "luids and dru$s are co%'ati!le. IV Thera'# R+ vs. <P+ I=..res'onsi!ilities include ad%inisterin$ %edications and treat%ents 'rescri!ed !# a licensed or other ise le$all# authori*ed 'h#sician.J I=..res'onsi!ilities include ad%inisterin$ %edications and treat%ents& under the direction o" a licensed re$istered nurse or a licensed or other ise le$all# authori*ed 'h#sician.J +o IV %edications +urse res'onsi!le to O!serve clinet Re'ort an# reactions Ta6e %easures necessar# to avoid co%'lications Assess IV site on adult ever# 8 hours Pediatric and Hi$h alert %edication %ore o"tenA (hec6 'oint A client has a continuousl# runnin$ 'eri'heral in"usion. The 'h#sician orders a 'i$$#!ac6 anti!iotic in"usion B ti%es a da#. In order to ad%inister the anti!iotic& the nurse should do hich o" the "ollo in$: (hoices: 1 start a ne IV access "or the 'i$$#!ac6 anti!iotic so no co%'ati!ilit# issues occur 8. start a ne IV site to 'revent "luid volu%e overload F. Increase the IV "luid rate to dilute the anti!iotic in"usin$ 'i$$#!ac6

B. (hec6 to see i" the anti!iotic is co%'ati!le ith the soluitions in"usin$.

(O+SI3ER A>E+(Y IV THERAPY PO<I(Y R)(s in isotonic solution IV THERAPY Revie Addin$ %edications to !a$- la!elin$ S'i6in$ !a$& "illin$ dri' cha%!er Pri%in$ @!leedin$A line Accessin$ 'orts on line Runnin$ 'i$$#!ac6 @secondar#A ith 'ri%ar# line Eluid co%'ati!ilit# (onnectin$ tu!in$ and 'ri%in$ lines O'en trans"usion set Insert IV tu!in$ s'i6e into o'enin$ o" !a$ o" "luids Re%e%!er to 6ee' ends sterileLL (o%'ress dri' cha%!er to 1;F "ull Pri%e !# o'enin$ roller cla%'- all air !u!!le should !e re%oved- then close roller cla%' Ta' to re%ove s%all air !u!!les All lines %ust !e 'ri%ed includin$ PR+ loo's Elushin$ a saline lov6 Use a''ro.i%atel# 1 M ti%es the a%ount o" "luid that the tu!in$ ill hold in order to "lush the tu!in$. USE sterile @ase'tic A techni7ue to 'revent co%'lications as in"ection. Inter%ittent IV Thera'#

IV Thera'# that is ordered "re7uentl# "or short 'eriods o" ti%e. EN: .ocephin 1gm +%&$ / 12 hours 0 1 doses2 (emerol 23mg +%& / 4-1 hours &.) pain2 IV 'ush @IVPA or IV 'i$$#!ac6 @IVP)& secondar#A Re7uires tu!in$ and site chan$e 7 BH-D8 hours Ere7uent site %onitorin$ Eluid in"used recorded on chart 7 shi"t IVP @IV 'ush %edicationsA (hec6 order Pre'are %edications and chec6 co%'ati!ilit# ith "luids Assess site Select 'ort 'ro.i%al to 'atient (lean 'ort ith alcohol s a! Elush ith 1G%l o" +S !e"ore %edication Insert;attach %edication s#rin$e Occlude IV tu!in$ a!ove 'ort @'inchA Pull !ac6 $entl# to as'irate !lood return @%a# not $etA In/ect %edication in desi$nated ti%e "ra%e @loo6 u' in dru$ !oo6A Release tu!in$ i" "luids runnin$ - i" saline loc6& "lush ith 1G%l o" +S and loc6 S%all volu%e needs to han$ hi$her IV PUSH 3ra u' correct dose into a 1G%< s#rin$e. Veri"# dose ith second nurse Then add additional saline to s#rin$e to e7ual 1G %<

Pause. <ets thin6 1 %<; over 1 %inute <et?s see that is O %<; in 19 seconds So ever# 19 second interval 'ush O o" a %<. This a# e are %ore controlled and %ore 'recise ith a 'ush over one %inute. Ho lon$ ill it ta6e to $ive 8 %< over one %inute0 1 %< over t o %inutes. O,: Tell %e ho ould #ou divide this to deliver the 'ush in a controlled slo 'rocess0000

(ontinuous IV Thera'# IV thera'# that continues over a lon$ 'eriod o" ti%e. EN: 391;8 +S P D9%l;hr Re7uires "re7uent site %onitorin$ Eluid in"used docu%entation @7 H hoursA IV Tu!in$ chan$e 7 D8 hours Site chan$e 7 BH-D8 hours 5 Tu!in$ and site chan$e %a# var# de'endin$ on a$enc# 'olic#. ,VO or T,O I,VOJ or IT,OJ : "lo at rate to ,ee' Vein O'en or To ,ee' O'en O"ten ill see this order: +% )S 5 6%7 rate +% .8 "67 rate 1hat do #ou do0 There is no esta!lished %ini%al "lo "or ,VO;T,O 99999Clarify :(;s order99999

:ay be any-here from <0-100ml'hr but this must be specified by :(2 )olus Introducin$ a concentrated dose directl# into s#ste%ic circulation 7uic6l# Into tu!in$ 'ort or saline loc6 Rate o" ad%inistration @!olusA varies "ro% dru$ to dru$ -a# !e "luids or %edications Rate "or "luids should !e included in -3?s order IV solutions 1G1 T o !asic cate$ories: Eirst cate$or#: (r#stalloids: contain ater& de.trose& and or electrol#tes Used to treat "luid and electrol#te i%!alances IV solutions Second !asic cate$ories: (olloids: re"erred to as: 'las%a e.'anders or volu%e e.'anders Increased os%otic 'ressure in co%'arison ith cr#stalloids (olloids re%ain in vascular s'ace lon$er and are used "or volu%e e.'ansion Volu%e e.'anders Include: (olloids& de.tran& and hetastarch. (olloids are 'rotein solutions as al!u%in& 'las%a& and Plas%anate @ 're'ared !# 'har%aceutical co%'an#A. Volu%e E.'anders Al!u%in is the %ost a!undant 'las%a 'rotein in hu%ans USES: Al!u%in 9Q ra'id volu%e e.'ansion and %o!ili*e interstitial ede%a

89Q H#'o'roteine%ia Volu%e E.'ansion Others are 3e.tran& s#nthetic colloid %ade o" $lucose-o!ili*es interstitial ede%a Hetastarch @Hes'anA -ade "ro% corn. -o!ili*es interstitial ede%a Volu%e e.'anders Plas%a 'las%anate @Plas%a 'rotein "raction (ontains hu%an 'las%a 'roteins in +or%al Saline @+SA. Increases seru% colloid os%otic 'ressure T#'es o" intravenous solutions Isotonic )ormal Saline ()S) ! .ingers 8actate(.8) (e0trose in -ater ((3*) H#'otonic 0243= )ormal Saline 02<<= Saline 223= (e0trose H#'ertonic "otal &arenteral )utrition ("&)) (e0trose in )ormal Saline ((3)S) (e0trose in 243 )ormal Saline ((3 > )S) Isotonic ISa%e as !loodJ Isotonic Solutions

<iver converts lactate to !icar!onate- atch 'H& liver "unction Has sa%e os%olalit# as !od# "luids H#drates all cells ithout a""ectin$ %ove%ent o" "luid- +O SHIET E.'and IV co%'art%ent 1atch "or overload Used %ost co%%onl# "or E(E volu%e re'lace%ent Isotonic solutions E.'and onl# E(E @IV(A no net loss or $ain. <;R contains +a ,(l (l (a and <actate Sa%e concentration as !lood. Uses +a(l used to re'lace !oth "luid and sodiu% losses or Vascular re'lace%ent in h#'ovole%ic shoc6. HYPOTO+I( SO<UTIO+S OUT OE VAS(U<AR (O-PART-E+T H#drates cells (an cause sudden shi"t Cardio ascular collapse +ncreased +C& +ot "or treat%ent o" head in/ur#& trau%a& neurosur$er#& !urns H#'otonic H#'otonic "luid 'ushes "luid into cell . (ontains %ore ater than electrol#tes So& are there concerns ith HYPOTO+I( Solutions0

Push "luid into cells : 1h# %i$ht e see %ental status chan$e0 1h# is 39 1 isotonic in the !a$ A+3 HYPOTO+I( in the vein >lucose enters the vascular co%'art%ent Is then ra'idl# %eta!oli*ed !# the <IVER thus <eaves ater in vascular co%'art%ent. HYPERTO+I( SO<UTIO+S PU<<S I+TO VEI+ ERO- (E<< 3eh#drates cells and interstitial co%'art%ents 1atch "or venous overload +ot "or 'atients ith 6idne# "ailure& heart disease H#'ertonic soulutions E.'and E(E @IV(A @3ra s "luid into veinA Used to treat: H#'ovole%ia @lo volu%eA H#'o natre%ia @lo sodiu%A

3 9G 1 Ver# h#'ertonic. Push slo l# <et?s recall Assess%ent Ho do e atch "or EVO @Eluid volu%e overloadA0 );P

<un$ sounds Seru% Sodiu% <evel Ede%a RV3 1hat else00 Other h#'ertonic solutions 3 1G 1 or $reater (entral lines should !e used. To avoid shrin6a$e o" R)(s. IV SA<I+E solutions +S @G.S Q +a (<A Saline FQ +a(l 9Q +a(l (ontains sodiu% and chloride in ater Uses: Al6alosis Eluid loss Sodiu% de'letion 3e.trose @de.trose in aterA 391 31G 1

Uses: Re'lace calories as car!oh#drates Prevent deh#dration

-aintain ater !alance Pro%ote sodiu% diuresis 3e.trose in Saline 39+S 391;8 +S 31G +S Pro%otes diuresis (orrect %oderate "luid loss Prevent al6alosis Provides calories and sodiu% chloride Electrol#tes <actated Rin$ers Rin$ers <actate (ontains +a& (l& ,& (a& and lactate Re'laces "luid lost in vo%itin$& or >I suction& Treat deh#dration Restore nor%al "luid !alance IV Additives Vita%ins 2 ,(< are "re7uentl# added to IV Solutions Veri"# ade7uate urine out'ut !e"ore ad%inisterin$ ,(< ,5Under no circu%stances can 'otassiu% chloride @,(<A !e $iven IV 'ush. A direct IV in"usion o" ,(< is "atal. So -s Verho"" i" ,(< is an electrol#te in the !od# 1h# veri"# ,(< doses0 1h# are there no ,(< 'ush0

1h# is an EI3 used "or concentrated !olus ad%inistered. 1hat is a concentrated !olus. TP+ +utritional ade7uate h#'ertonic solution consistin$ o" $lucose and other nutrients and electrol#tes $iven throu$h an ind ellin$ 'eri'heral or central line Used as intervention in severe cases o" %alnutrition. TP+ 000000 1h# should e %onitor >lucose ever# C hours0 1h# should e not allo the solution container o" TP+ run out0 1h# should e closel# %onitor T P R and );P0 1)(0 In"usion site0 1h# is ase'sis so vital0 TO START A+ IV== 3e%onstration in la! E7ui'%ent and Su''lies IV catheter @8B>A& 88>A& 8G>A& 1H>A& 1C>AA IV start 6it @dra'e& cleanin$ and antise'tic 're's& dressin$s& ta'e& la!el& tourni7uet& trans'arent dressin$A ><OVES Tu!in$ i" "luids ordered& "luids ordered In/ection ca' @PR+ ada'terA or IV loo' @'i$tailA Shar's container Elush Volu%e re$ulator Pur'ose and Selection o" IV su''lies IV (atheter Si?e Con entional or safety

Eluids vs. PR+ loc6 @saline or he'arinA Tu!in$ and e.tension -edication; )lood ad%inistration Pu%'s& dial-a-"lo & volu%e control device @$ravit#A (hildren Aller$# to iodine& late.& or ta'e Ar% !oard Trans'arent dressin$; ta'e Practice correctl# Assess%ent "or initiatin$ IV thera'# Asse%!le correct su''lies Revie -3?s order 9 ri$hts Assess "or clinical "actors; conditions Assess 'revious e.'erience; e.'ectations (onsider "uture treat%ents Aller$ies; la! data @!etadine ta'eA Plannin$ "or initiatin$ IV thera'# @$oalsA E 2 E )alance and VS ill return to nor%al IV line ill !e 'atent Site ill !e !eni$n (lient ill understand 'ur'ose IV site selection A$e and status o" 'atient Pur'ose o" the in"usion

3uration o" thera'# (ondition o" 'atient?s veins <ocation o" 'revious site@sA -ost co%%on in lo er ar% and hand. I" 'ossi!le use the non-do%inant hand;ar% Hand and ar% IV site location -ost distal in nondo%iniant ar% (li' hair 4 do not shave Avoid !ruises& scars <ar$e vein (onsider activit# -edical histor# (hildren& adults Other o'tions as a!ove I%'le%entation o" IV thera'# (o%"orta!le 'osition& chan$e $o n 1ash hands O'en sterile 'ac6a$es usin$ sterile ase'tic techni7ue Pre'are IV solution& o'en in"usion set& s'i6e !a$& and 'ri%e line& ca'& or 'i$tail Place roller cla%' in Io""J 'osition Identi"# accessi!le vein and a''l# tourni7uet @B-C I a!ove 'ro'osed siteA A''l# $loves Pre' site and allo to dr# -ethods to distend veins Place hand de'endent

Use distal vein to 'ro.i%al 1ar% co%'ress (hec6 arterial 'ulse to ensure ade7uate !lood "lo to "ill veins 1hen 're' i'e accordin$ to 'olic#: (&'& say distal to pro0imal) (hloro-'re' 3o not !lot4 this re%oves anti%icro!ial 'ro'erties SO ho do e 6no ho "ast to re$ulate the "lo rate00 (ount dro's 19 seconds . B : $tts ; %inute Re$ulate "lo rate Ad/ust rate as 'rescri!ed !# health care 'rovider "oo slo- @ ein clots 'occlude line or client goes into circulatory 'C% collapse "oo fast @ Aluid olume e0cess (A%B) (alculate rates on 'a'er. (O+T. S. Per"or% veni'uncture at 8G-FG de$ree an$le.

<oo6 "or !lood return I"lashJ in the cha%!er. <o er the needle and advance OJ Sta!ili*e cath and release tourni7uet& a''l# "ir% 'ressure ith inde. "in$er 1 OJ a!ove insertion site. Re%ove needle- do not reca' (onnect tu!in$ or PR+ ada'tor and "lush Secure IV catheter 3iscard su''lies <a!el IV site- initials& date& ti%e& si*e o" catheter Patient teachin$

3ocu%ent 'rocedure Patient Teachin$ 1hen to call the nurse .ednessC painC bloodC dressing loose Alo- stopsC blood in tubing +% pump alarm A%!ulate ith IV 'ole& %ove%ent As6 "or assistance hen needed. 3ocu%entation T o" atte%'ts @I" several %a# chart I%ulti'le atte%'tsJA T#'e o" "luid and "lo rate Insertion site @<ocationA Si*e @>AA o" catheter 1hen in"usion !e$un Re%e%!er i" it is not docu%ented- IT 3I3 +OT HAPPE+ 3O(U-E+TATIO+ ENA-P<E 88>A IV catheter 8 atte%'ts < rist 39 M +S at 1GG;hr )lood dra n I19GG 88>A IV to < rist . 8 atte%'ts& !lood dra n and sent to la!& 39 M +S P1GG %l;hr 'er 'u%'. Site clear& no redness or ede%a. -------------------------------------------------+ +urse R+ 5TIP5 An#ti%e #ou do an#thin$ ith a 'atient?s IV @han$ "luids& $ive %edicationsA& al a#s chec6 the IV site. I" the IV is not "unctional& then #ou are doin$ nothin$ "or the 'atient. OR #ou %a# !e

da%a$in$ tissueLLLLL IV -ana$e%ent O!serve site ever# 1-8 hours& docu%ent K BH and PR+ 8ooD at amount infused Count drip rateC pump function ChecD patency ChecD insertion site O!serve client ever# hour and PR+ to deter%ine res'onse to thera'# +!7 *eights %S IV -ana$e%ent cont. (han$e site K BH-D8 hours or PR+ :ust mo e pro0imal to pre ious site2nge +% tubing / E2 hours or &.) 3ressin$ chan$es K BH-D8 hours or PR+ *etC soiledC loosenedC remo ed Elush ith 1G %l +S !e"ore and a"ter %eds (hec6 sites "re7uentl#. +OR-A< SA<I+E (o%'lications o" IV thera'# Phle!itis In"iltration He%ato%a Pul%onar# e%!olus Air e%!olus

(irculator# overload Phle!itis @thro%!o'hle!itisA

3e"inition: In"la%%ation o" a vein& o"ten acco%'anied !# "or%ation o" a clot S 2 SN: Indicated !# 'ain& increased s6in te%'& er#the%a alon$ 'ath o" vein @cord alon$ veinA (lots %a# occur TN: Sto' in"usion and discontinue IV Ble ate e0tremityC -arm moist compresses .estart ne- +% if +% therapy is needed .otate sites / 48-E2, (auses: 3ru$ irritation& trau%a to vein& in"ection& stasis& i%%o!ili*ation& IV catheter in 'lace too lon$ In"iltration 3e"inition: 'rocess in hich a "luid 'asses throu$h the tissues S 2 SN: Indicated !# s ellin$ and 'ossi!le 'ittin$ ede%a& 'allor& coolness& 'ain at insertion site& 'ossi!le decrease or a!sent "lo rate TN: Sto' in"usion and discontinue IV. .estart +% in ne- location if +% therapy indicated *arm compresses and ele ation of e0tremity (auses: IV catheter not in vein& in surroundin$ tissue E.travasatinon RE>ITI+E around IV SITE 3O not elevate ar%s 3O not a''l# cold or ar% co%'ress +oti"# health care 'rovider and "ollo instructions. 1hat is di""erence in I+EI<TRATIO+ A+3 ENTRAVASATIO+00 He%ato%a

3e"inition: collection o" !lood in tissue or s6in due to trau%a& a6a: !ruise S 2 SN: discoloration& 'ain& locali*ed ede%a to site Usuall# sel" li%itin$ TN: Initiall# %oderate 'ressure %a# reduce a%ount o" !ruisin$ (auses: trau%a or inco%'lete he%ostasis a"ter sur$er#

)leedin$ (an occur around veni'uncture site and under s6in (o%%on in clients on he'arin& ASA A''l# 'ressure dressin$ to site and docu%ent E<EVATE U ar% site a!ove heart and a''l# 'ressure. Pul%onar# e%!olis% Occlusion o" the 'ortion o" the 'ul%onar# !lood vessels !# a clot that is carried "ro% the 'oint o" ori$in. @so%e here elseA -a# !e lethal S 2 SN: a''ear late& tach#'nea& d#s'nea& an.iet#& "ret"ulness& and (P. Possi!l# h#'o.e%ia& dia'horesis& s#nco'e& crac6les& "ever& %ur%urs +EVER EOR(E Elush or Irri$ate IV <I+E Pul%onar# e%!olis% Sources: dee' cal"& tu%ors& air& "at& heart arrh#%ias& !one %arro & 'ost-o' %a/or o'erations& 'rolon$ed sittin$ )lood "lo is o!structed in the lun$ hich leads to decreased 'ro"usion o" the lun$ and decreased cardiac out'ut TN: O8& anticoa$ulant thera'# THIS IS A+ E-ER>E+(YLLL Venous Air E%!olis% @VAEA

3e"inition: entr# o" air into venous circulation (auses: Secondar# to trau%a& IV tu!in$ not 'ri%ed <ar$e a%ts o" air in vascular s#ste%- leads to cardiac arrest S 2 S: sudden d#s'nea& tach#cardia& heart %ur%ur& h#'otension& decreased <O(& (P& circulator# shoc6& sudden death TN: 'lace in < lateral Trendelen!ur$ 'osition& 1GGQ O8. THIS TOO IS A+ E-ER>E+(YLLL (irculator# Overload (irculator# overload occurs hen "luid is ad%inistered %ore ra'idl# than the circulator# s#ste% can ad/ust. 3RO1+I+> I+ O1+ E<UI3S IS A+ E-ER>E+(YL S;S: cou$h& d#s'nea& HT+& 'ul%onar# ede%a& RV3& HA& crac6les (auses: Eluid overload& renal or liver "ailure Interventions: slo IV to ,VO rate& elevate HO)& O8& VS& noti"# -3& diuretics (lients at increased ris6: Blderly +nfants ! Children &resence of (isease (CardiacC .enalC etc2) Outco%es o" IV thera'# -aintain or restore "luid !alance -aintain or re'lace electrol#tes Provide a source o" calories; nutrients Ad%inister dru$s )lood Trans"usions 1h#0- t. o" ane%ia due to acute !lood loss or chronic conditions Ris6: he%ol#tic trans"usion reactions and 'ossi!ilit# o" contractin$ in"ectious diseases @He' )& HIV& (-V& E)V& 1est +ile virusA -3 %ust consider 'otential ris6s and alternative interventions

1ritten order: !lood co%'onent& volu%e& rate o" in"usion 1hen a client is to receive !lood& the nurse is lar$el# res'onsi!le "or its sa"e ad%inistration. A)O and Rh TYPE A)O- t#'e o" anti$en co%'onents that R)(?s have. T#'e A : A anti$en T#'e ) : ) anti$en T#'e A) : !oth T#'e O : none Rh- anti$enic su!stance 'resent in R)(?s I" have : RhV I" do not have : RhAutolo$ous trans"usion (ollect !lood "ro% client 'rior to e.'ected sur$ical 'rocedure& rein"use client ith !lood in sur$er Salva$e !lood in sur$er# and ad%inister. Autolo$ous- donate o n !lood. )lood (o%'onents 1hole )lood PR)( Platelets @P<T?sA Eresh Ero*en Plas%a @EEPA (r#o'reci'itate >ranuloc#te (oncentrations Plas%a (lottin$ Eactors

Other volu%e e.'anders 1hole )lood Used in e.san$uinations@)leedin$A 'atient (ontains all !lood 'roducts Usuall# contains BGG %l VUSE3 hen !oth volu%e and cells are needed 1hole )lood R)(& 'las%a& 'las%a 'roteins ith CF %l o" anticoa$ulant. 9GG %l;unit A)O identical and Rh "actor %ust %atch Rarel# indicated Outco%es: 'revention; resolution o" h#'ovole%ic shoc6 and ane%ia Ris6: volu%e overload PR)(?s Red !lood cells ith anticoa$ulant-'reservative @no clottin$ "actorsA Unit si*e- 89G to BGG%l;unit A)O co%'ati!le& Rh "actor %atch >iven "re7uentl# !lood loss- sur$er#& trau%a HGQ 'las%a has !een re%oved. Outco%es: resolution o" ane%ia PR)(s >iven "or acute and chronic ane%ia & )lood loss 3esired over hole !lood in cardiovascular 2 renal co%'ro%ised& and elderl# clients !ecause PR)(s contain less "luid volu%e.

Platelets @P<TA Platelets: Pla# a role in !lood coa$ulation& he%ostasis& and !lood thro%!us "or%ation. A)O and Rh "actor co%'ati!ilit# reco%%ended @contain "e R)(A S'ecial "ilters "or 'latelets Outco%es: 'revention;resolution o" !leedin$ due to thro%!oc#to'enia or P<T d#s"unction Platelets Usuall# $iven in 'ools o" C 4 1G units USES: lo 'latelet counts& coa$ulo'athiesW 1 unit %a# increase 'latelet count !# CGGG units Eresh Ero*en Plas%a @EEPA Plas%a: li7uid 'art o" !lood. -ediu% "or trans'ortin$ su!stances. (olorless hen "ree o" cells. (ontains 'las%a $lo!ulin& anti!odies& clottin$ "actors. A)O co%'ati!ilit#& Rh "actor no %atch Still has disease trans%ission ris6 Outco%es: decreased coa$ulation ti%es Eresh "ro*en Plas%a Used to re'lace clotin" "actors a"ter %ulti'le trans"usions @ X C units o" PR)(sAW (ou%adin into.ication Re'laces clottin$ "actors& Kuestion A 'atient 'resents to ER a"ter !ein$ involved in a -VA& );P is DG;9G& HR 1FH& R. BB& the 'atient has an o'ened chest ound and has lost a lot o" !lood. Pt?s H$! is C.G. The -.3. orders t o units o" !lood STAT. 1hich intervention ould !e a''ro'riate at this ti%e0 A.A t#'e and cross %atch "or !lood ).A $ive t o units o" t#'e O !lood stat (.A dra !lood& !and 't ith a''ro'riate !lood !and an send to la!& 3.Start h#'otonic "luids and continue to %onitor 't.

(r#o'reci'itate Antihe%o'hilliac "actor VIII and "actor NIII 9-1G%l;unit (ontains no R)( and a s%all volu%e o" 'las%a A)O co%'ati!ilit# not needed Outco%es: correction o" "actor VIII& v1E& NIII and "i!rino$en de"icienc#& cessation o" !leedin$ (r#o'reci'itate (o%'onents : clottin$ "actors USES: he%o'hilia& "i!rino$en de"icienc#& 3I(. Plas%a 3erivatives Al!u%in- al!u%in& $lo!ulin and other 'roteins Anti!odies destro#ed durin$ 'rocessin$- co%'ati!ilit# not a "actor Ra'id in"usion %a# cause h#'otension& !ut 89Q al!u%in can cause a si$ni"icantl# increased !lood 'ressure !ecause o" its a!ilit# to dra "luid into the intravascular s'ace (annot trans%it he'atitis or HIV in"ection due to the 'asteuri*ation 'rocess used to 're'are Outco%es: %aintain; ac7uire ade7uate !lood 'ressure and volu%e su''ort (lottin$ Eactors <ar$e 'ools o" 'las%a Eactors VIII and "actor IN A)O and Rh co%'ati!ilit# not i%'ortant- R)(?s destro#ed durin$ 'rocessin$ Outco%es: he%ostasis due to increased "actor activit#. Other volu%e e.'anders 3e.tran and Hetastarch are s#ntheticall# 're'ared %olecules. In"re7uentl# used due to cost

Outco%e: 'ro%ote circulator# volu%e and tissue 'er"usion !# ra'idl# e.'andin$ 'las%a volu%e +ot a su!stitute "or !lood or its co%'onents Volu%e e.'anders Re%ain in vascular s'ace and increase os%otic 'ressure Plas%a e.'ander include de.tran& hetastarch and 'las%a al!u%in Al!u%in A<!u%in Al!u%in is availa!le in 9 Q and 89 Q 9 Q al!u%in e.'ands vascular s'ace %< "or %< 89 Q dra s additional "luid "ro% interstitiu%. STEPS EOR TRA+SEUSIO+ I+EOR-E3 (O+SE+T : VERIEY SI>+E3 O!tain venous access Validate Vital si$ns Re7uest !lood release (on"ir% !lood acce'ta!ilit# In"use !lood -onitor durin$ the trans"usion 1atch "or trans"usion reaction Vials %ust !e la!eled and a la!el on 't ar% to %atch. I+EOR-E3 (O+SE+T An in"or%ed consent -UST !e o!tained and docu%ented 'rior to !lood ad%inistration E.'lanation to the client or "a%il# %e%!er o" %edical indications "or ho%olo$ous @ho%olo$ous vs. autolo$ousA trans"usion and its !ene"its& ris6s& and alternatives Assess client histor# "or an# 'revious trans"usions and client?s res'onse

VE+OUS A((ESS +eed lar$e !ore IV @8G $au$e or lar$erA -a# use a 88 >A "or adults ith s%all veins or children- not !est o'tion (an use a VA3 @central lineA& !ut a lar$e volu%e o" re"ri$erated !lood in"used ra'idl# into the ventricle can cause cardiac d#srh#th%ias 1ar%in$ the !lood can reduce the ris6 o" this co%'lication (aution Ra'id in"usion ith cold !lood can cause d#srrh#th%ia IE +E(ESSARY TO use s%all $ua$e %a# need to as6 la! to s'lit unit into t o !a$s. S%aller needle can !e used "or 'latelets& al!u%in and clottin$ "actors. )lood Release )e"ore $oin$ to !lood !an6& several thin$s %ust !e done: 'ri%e !lood tu!in$ ith +S onl# and start +S at ,VO& ta6e VS& 're%edicate i" ordered& I!andin$J the 'atient )lood %ust !e 'ic6ed u' "ro% the !lood !an6 !# an R+ The na%e and identi"ication nu%!er o" the reci'ient %ust !e 'rovided and a 'er%anent record o" this in"o %aintained in !lood !an6 )lood !an6 is re"rid$erator There is a !oo6 ith lot nu%!ers and 'atient identi"ication data. Record FG %inute indo )lood %ust !e started ithin thirt# %inutes o" o!tainin$ unit "ro% la! USE )<OO3 TRA+SEUSIO+ TU)E ith %icro a$$re$ate "ilter 391 and <R can cause he%ol#sis USE +OR-A< SA<I+E. <e is DF1. (O+EIR- )<OO3 (O-PATA)I<ITY -ost crucial 'hase )lood is "irst veri"ied in the !lood !an6 and R+ !# chec6in$ A)O and Rh co%'ati!ilit#. This is done !# chec6in$ the !a$ a$ainst the %edical record and "or%s issued !# !lood !an6

Second chec6 is done at !edside !# 8 R+sW co%'are na%e& nu%!er& A)O& Rh co%'at.& !lood !and (hec6 date Ins'ect !a$ "or lea6s& clots& e.cessive air The orst reactions to !lood are usuall# due to %isidenti"ication o" !lood or client TU)I+> -ust use !lood tu!in$ ith "ilter. E%'t# to "ull REA(TIO+S SGQ o" he%ol#tic trans"usion reactions are "ro% i%'ro'er 'atient to 'roduct identi"ication <E1IS POTTER Sa#s this is the -AI+ REASO+ EOR TRA+SEUSIO+ REA(TIO+X )lood trans"usion IEs Usuall# in"use !lood PR)(s over 8 4 B hours @B hours i" at ris6 "or EVEA IE !lood not co%'lete in B hours return unit to la!. IE 'atient cannot tolerate volu%e& s'eci"# ti%e "ra%e and have la! s'lit !lood unit into t o !a$s in la!. I"& Ra'id in"usion& !llod %a# chill 'atient& consider !lood ar%er. Reli$ion and !lood: Ri$ht to re"use. I+EUSE )<OO3 )lood tu!in$ should !e alread# han$in$W usuall# a Y-t#'e that contains a 1DG-%% "ilter desi$ned to tra' "i!rin clots& and other de!ris that accu%ulates durin$ !lood stora$e -ust ad%inister ithin FG %inutes a"ter receivin$ "ro% !lood !an6 (han$e tu!in$ ever# B-C hours or 'er 'olic#& %a# trans"use 8 units ith sa%e tu!in$ )lood should !e in"used 'er 'u%'

+o other %edications to !e $iven in sa%e tu!in$- EVER @<e is '$ DF1A )lood ar%ers %a# !e used "or ra'id in"usions to 'revent h#'other%ia -O+ITOR 3URI+> THE TRA+SEUSIO+ Eirst 1G-19 %in are the %ost critical Sta# ith the 'atient durin$ "irst 19 %in or %ore Initial "lo rate 8G-FG $tts; %in @ 9G %<A I" A)O inco%'ati!ilit# e.ists or a severe aller$ic reaction& ana'h#la.is& occurs& it is usuall# ;in "irst 9G %lW start trans"usion slo l# and closel# %onitor 'tW then increase rate to 'rescri!ed rate. Instruct client to re'ort an#thin$ unusual- nausea& chills& !urnin$ sensations& HA Volu%e 89G 4 FGG %< o" PR)(s over 8 4 B hours i" over 8 hours then 189 %< hour& i" over B then CF %< HR I" 9G %< o" !lood to in"use in "irst 19 %inutes hou %an %< ; %inute should in"use00 8 %< . 19 %inutes : FG %< in 19 %inutes F %< . 19 : B9 %< in 19. -O+ITORI+> (O+T Ta6e and record VS !e"ore trans"usion !e$ins then ever# 9 %in "or "irst 19 %in& then ever# hour until 1 hour a"ter trans"usion Rate varies: 'latelets& 'las%a& 2 cr#o'reci'itate can !e in"used ra'idl# To avoid se'tice%ia& in"usion should not e.ceed B hours @in"use over 8 hours $enerall#A 3etailed docu%entation TRA+EUSIO+ REA(TIO+S Overvie Acute or dela#ed s#ste%ic reaction to inco%'ati!le !lood Aller$ic- sensitivit# to "orei$n 'las%a Ee!rile-Sensiti*ation to donor cells @1)(& P<T& PPA He%ol#tic- In"usion o" A)O inco%'ati!le cells

Ana'h#lactic- In"usion o" I$A 'roteins to I$A de"icient 'atient Other reactions In"ections "ro% !lood trans"usion include reaction to %alaria& he'atitis& HIV See <e is DF8 4 D88 Pa$e BD9 Kuestion 1hile receivin$ a unit o" 'ac6ed red !lood cells& the 'atient develo's chills and a te%'erature o" 1G8.8. The nurse should A.A +oti"ies the 'h#sician and the !lood !an6 ).A Sto's the trans"usion and re%oves the IV catheter. (.A Adds a leu6oc#te reduction "ilter to the !lood ad%inistration set. 3.AReco$ni*e this as a %ild aller$ic trans"usion reaction and slo s the trans"usion. Reaction is sus'ected STOP TRA+SEUSIO+ ,ee' vein o'en ith nor%al saline O!tain vital si$ns +oti"# -3 and <a! In"iltration Phle!itis PREVE+T 1st
)e"ore

o!tainin$ !lood& !e certain 'atent vein.

Start ne IV site and re%e%!er !lood $oes in under B hour 'eriod& consider: IIs the needle $au$e lar$e enou$h0J 1hat i"00

1hat i" the rate o" in"usion slo s ithout si$ns o" in"iltration00 Su$$est "lush line ith sterile nor%al saline. 1hat i"0 Si$ns and s#%'to%s o" EVE as short o" !reath or crac6les occurs000 Sto' or slo the in"usion Elevate the HO) Vital si$ns +oti"# -3 Antici'ate 3iuretic; -or'hine sul"ate O.#$en Aller$ic Trans"usion Reaction see Techni7ues SCH. Ere7uenc# 1Q S 2 S.: Urticaria& "lushin$& itchin$& @no "everA -$t: antihista%ines& trans"usion %a# continue Prevention: treat 'ro'h#lacticall# ith antihista%ines 2 aceta%ino'hine e'ine'hrine& corticosteroids "or severe reaction Ee!rile Trans"usion Reaction Ere7uenc#: G.9-1Q S 2 SN: "ever and;or 'ul%onar# s#%'to%s& sudden chills and "ever& HA& "lushin$& an.iet#& %uscle 'ain -$t: I" "ever and;or 'ul%onar# s#%'to%s- 3O +OT resu%e in"usion& treat shoc6& $ive anti'#retics Prevention: (onsider leu6oc#te 'roducts hich have !een "iltered& ashed or "ro*en.A Acute He%ol#tic Trans"usion Reaction Ere7uenc#: 1:89&GGG S 2 SN: chills& "ever& Y)P& "lushin$& tach#cardia& tach#'nea& h#'otension& vascular colla'se&

ARE& shoc6& cardiac arrest& 3EATH -$t: Send !lood and UA sa%'les to la! "or testin$& %aintain )P& Eole# to %easure out'ut& 'ossi!le dial#sis Prevention: 55(hec6 and dou!le chec6& then chec6 a$ain.55 @-ISS <a!eled s'eci%ensA So -rs Verho""& h# do so%e 'eo'le react to !lood trans"usions0 Anti!odies in the reci'ients !lood react to donor?s anti$ens on R)(s. (auses cells to a$$lutinate hich o!structs ca'illaries and !loc6s !lood "lo . He%o$lo!in is "iltered !# ,idne# and is "ound in u;a. H$! %a# o!struct renal tu!ules leads to acute renal "ailure X 3I(X 3eath. Kuestion Si$ns and s#%'to%s o" a he%ol#tic trans"usion reaction include all o" the "ollo in$: choose all that a''l#W A.A chills& "ever& "lushin$ ).A lo !ac6 'ain (.A tach#cardial& tach#'hea& h#'otension& vascular collas'e 3.A acute renal "ailure& shoc6& cardiac arrest& death E. +one o" these are a he%ol#tic reaction (ritical Thin6in$ Ten %inutes a"ter a trans"usion o" PR)(?s !e$in in"usin$ #our "or%erl# a"e!rile 8C #ear old client has a te%'erature o" 1G1.C and "eels ti$htness in the chest. 1hat is the "irst thin$ #ou should0 1h# is "irst voided urine collected to send to the la!0 Eirst voided urine is collected and sent to la! to chec6 "or he%o$lo!inuria ith he%ol#tic reactions. Assess "or da%a$e to 6idne#. )lood trans"usion reaction intervention continue (onsider need "or antihista%ine Vaso'ressors& "luids& steroids& (PR u;a s'eci%en

1hat i"0000 I" reaction is sus'ected& should nurse turn saline on and allo saline to "lo throu$h tu!in$0 1h# han$ saline ith !lood trans"usion and not de.trose0 Ans er: 3e.trose cause coa$ulatio o" donor !lood. Ana'h#lactic Trans"usion Reaction Ere7uenc#: 1:19G&GGG S 2 SN: an.iet#& urticaria& hee*in$& d#s'nea 'ro$ressin$ to c#anosis& shoc6& cardiac arrest -$t: Sto' trans"usion& (PR i" needed& have E'ine'hrine read# "or in/ection Prevention: >iven !lood "ro% I$A de"icient donors or 'las%a ash 3O +OT restart trans"usion 3ela#ed trans"usion reactions 3ela#ed he%ol#tic He'atitis ) and ( HIV Iron Overload 1est +ile Virus -a# occur ee6s to %onths a"ter the trans"usion. )lood (ollection )lood s'eci%en collection -ost co%%onl# used dia$nostic aids in the care and evaluation o" clients Yield valua!le in"or%ation a!out nutritional& he%atolo$ical& %eta!olic& i%%une and !ioche%ical status Screen "or earl# si$ns o" disease& 'lot current treat%ent course& and %onitor res'onse to thera'# -a# !e 'er"or%ed !# R+& or other trained 'ersonnel

T#'es o" !lood collection Veni'uncture- insertin$ a hollo !ore needle into the lu%en o" a lar$e vein to o!tain a s'eci%en. Vaccutainer tu!e- allo s the dra in$ o" %ulti'le !lood sa%'les (a'illar# 'uncture- least trau%atic& uses sterile lancet to 'uncture a vascular area a "in$er& toe& or heel T#'es cont. Arterial !lood $as- dia$nosis o" res'irator# disorder. Arterial 'uncture @radial or !rachialA )lood cultures- aid in detectin$ !acteria in the !lood. T o cultures "ro% t o di""erent sites. )e"ore anti!iotic thera'# is started A)>s Usuall# "ro% radial arter# Allen test 3o not let air enter s#rin$e Su!%er$e s#rin$e in cu' o" ice i%%ediatel# !e"ore trans'ort to la! A''l# 'ressure . 9 %inute to site lon$er i" on anticoa$ulant Pea6 and Trou$h <a! value dra n "or s'eci"ic dru$s that %easure thera'eutic levels at the dru$s I'ea6J ti%e and Itrou$hJ ti%e. Usuall# done ith certain anti!iotics EN: Vanco%#cin )lood collection su''lies Alcohol or antise'tic s a! (lean $loves Sterile $au*e 'ad @8 . 8A Tourni7uet Adhesive !anda$e or ta'e

)lood tu!es I3 la!els "or tu!es <a! re7uisition Plastic !a$ 8G-89 >A !utter"l# Sterile s#rin$e Vaccutainer tu!e Sterile dou!le ended needle 8G-89>A Anaero!ic and aero!ic culture !ottles Su''lies de'end on hat !lood tests are ordered (onsider- !e"ore #ou stic6 Antici'ate client?s an.iet# Assess "or an# 'ossi!le ris6s Is the 'atient a!le to coo'erate0 (ontraindicated sites0 So%e s'eci%ens re7uire s'ecial collection re7uire%ents- 6no "acilit# 'olic# 1hich tu!e do I use0 Pur'le - !lood cell counts @()(A Solid red - dru$ levels in !lood S'ec6led red - che%istr#; electrol#te levels )lue - clottin$ ti%es >reen - cardiac s'eci"ic ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ 555THIS VARIES ERO- EA(I<ITY TO EA(I<ITY- (HE(, A>+(Y PO<I(Y555 )lood dra 'rocedure

>ather su''lies 1ash hands Provide 'rivac#& 'osition 'atient A''l# tourni7uet @1 %in %a.A A''l# $loves 3eter%ine !est site- strai$ht& 'ro%inent vein (leanse site and allo to dr# Pull s6in taut& hold needle at 19-FG de$ree an$le ith !evel u' Procedure cont. Slo l# insert into vein- "eel the I'o'J 1ithdra !lood hile 6ee'in$ needle sta!ili*ed Release tourni7uet hen !lood collected A''l# sterile 'ressure dressin$ 3is'ose o" su''lies 'ro'erl# The )lood dra and the IV line I" ne IV& dra !lood "ro% hu! !e"ore "lushin$ I" it is an old IV line- TOO )A3 1hen dra in$ !lood "or la!& avoid the ar% ith the IV 4 it %a# alter la! results I" have to use sa%e ar%& turn o"" "luids "or 1G %inutes and use site distal to IV i" 'ossi!le Handlin$ )lood S'eci%ens Rotate !lood tu!es $entl# a"ter dra <a!el s'eci%en ith initials& date& and ti%e Place in !ioha*ard s'eci%en !a$ Trans'ort to la! ith $loves on in ti%el# %anner 5555A$enc# 'olicies ill var#55555

3is'osal o" %aterials +eedles- shar's I" not saturated ith !lood %a# $o into re$ular $ar!a$e. I" saturated ith !lood %ust $o into !ioha*ard rece'tacle. IV "luid !a$s can $o into the $ar!a$e hen drained& tu!in$ %ust $o in !ioha*ard container )lood collection de%onstrated in la! Vaccutainer )utter"l# Ero% IV site S%all orld Positive "luid dis'lace%ent. (<AVE