Chapter 6: I.V. Therapy

GENERAL CONSIDERATIONS

GOALS

The goals of I.V. therapy are to:

• Maintain or replace body stores of water, electrolytes, vitamins, proteins, fats, and calories in the patient who cannot maintain an adequate intake by mouth.
• Restore acid-base balance.
• Restore the volume of blood components.
• Administer safe and effective infusions of medications by using the appropriate vascular access.
• Monitor central venous pressure (CVP).
• Provide nutrition while resting the GI tract.

PHYSIOLOGIC ASSIMILATION OF INFUSION SOLUTIONS

Principles

• Tissue cells (such as epithelial cells and neurons) are surrounded by a semipermeable membrane.
• Osmotic pressure is the “pulling” pressure demonstrated when water moves through the semipermeable membrane of tissue cells from an area of weaker concentration to stronger concentration of solute (for example, sodium ions and blood glucose). The end result is dilution and equilibration between the intracellular and extracellular compartments.
• Extracellular compartment fluids primarily include plasma and interstitial fluid.

Types of Fluids

Isotonic

A solution that exerts the same osmotic pressure as that found in plasma.

• 0.9% sodium chloride solution (normal saline)
• Lactated Ringer's solution
• Blood components
  • Albumin 5%
  • Plasma
• Dextrose 5 % in water (D₅W)

Hypotonic

A solution that exerts less osmotic pressure than that of blood plasma. Administration of this fluid generally causes dilution of plasma solute concentration and forces water movement into cells to reestablish intracellular and extracellular equilibrium; cells will then expand or swell.

• 0.45% sodium chloride solution (half-normal saline)
• 0.33% sodium chloride solution (one-third normal saline)

Hypertonic

A solution that exerts a higher osmotic pressure than that of blood plasma. Administration of this fluid increases the solute concentration of plasma, drawing water out of the cells and into the extracellular compartment to restore osmotic equilibrium; cells will then shrink.

• D₅W in normal saline solution
• D₅W in half-normal saline solution (only slightly hypertonic because dextrose is rapidly metabolized and renders only temporary osmotic pressure)
• Dextrose 10% in water
• Dextrose 20% in water
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• 3% or 5% sodium chloride solution
• Hyperalimentation solutions
• D₅W in lactated Ringer's solution
• Albumin 25%

Composition of Fluids

See Table 6-1.

TABLE 6-1 Composition of Selected I.V. Solutions

SOLUTION TONICITY Na+ (mEq/l) K+ (mEq/l) Cl- (mEq/l) Ca++ (mEq/l) pH mOsm/L CALORIES 5% DW Isotonic — — — — 5.0 253 170 10% DW Hypertonic — — — — 4.6 561 340 0.9% NS Isotonic 154 — 154 — 5.7 308 — 0.45% NS Hypotonic 77 — 77 — 5.3 154 — 5% D and 0.9% NS Hypertonic 154 — 154 — 4.2 561 170 5% D and 0.45% NS* Slightly hypertonic 77 — 77 — 4.2 407 170 5% D and 0.2% NS Isotonic 34 — 34 — 4.2 290 170 Lactated Ringer's solution†Isotonic 148 4 156 4.5 6.7 309 9 5% DW and lactated Ringer's solution Slightly hypertonic 130 4 109 3.0 5.1 527 170 Normosol-R Isotonic 140 5 96 — 6.4 295 — Sodium lactate 1/6 molar Slightly hypertonic 167 — — — 6.9 333 55 6% Dextran 75 and 0.9% NS Isotonic 154 — 154 — 4.3 309 — DW: dextrose in water; NS: normal saline * 5% dextrose metabolizes rapidly in the blood and, in reality, produces minimal osmotic effects. †Lactate converts to bicarbonate in the liver.

• Saline solutions—water and electrolytes (Na⁺, Cl^-)
• Dextrose solutions—water or saline and calories
• Lactated Ringer's solution—water and electrolytes (Na⁺, K⁺, Cl^-, Ca⁺⁺, lactate)
• Balanced isotonic solution—varies; water, some calories, electrolytes (Na⁺, K⁺, Mg⁺⁺, Cl^-, HCO₃^-, gluconate)
• Whole blood and blood components
• Plasma expanders—albumin, mannitol, dextran, plasma protein fraction 5% (Plasmanate), hetastarch (Hespan); exert increased oncotic pressure, pulling fluid from interstitium into the circulation and temporarily increasing blood volume
• Parenteral hyperalimentation—fluid, electrolytes, amino acids, and calories

Uses and Precautions With Common Types of Infusions

See Table 6-2, page 86, for signs and symptoms of water excess or deficit, and Table 6-3, page 86, for signs and symptoms of isotonic fluid excess or deficit.

TABLE 6-2 Signs and Symptoms of Water Excess or Deficit

SITE HYPONATREMIA (WATER EXCESS) HYPERNATREMIA (WATER DEFICIT) Central nervous system Muscle twitching Hyperactive tendon reflexes Convulsions Increased intracranial pressure, coma Restlessness Weakness Delirium Coma Cardiovascular Increased blood pressure and pulse (if severe) Tachycardia Hypotension (if severe) Tissues Increased salivation, tears Watery diarrhea Fingerprinting of skin Decreased saliva and tears Dry, sticky mucous membranes Red, swollen tongue Flushed skin Renal Oliguria Oliguria Other None Fever

TABLE 6-3 Signs and Symptoms of Isotonic Fluid Excess or Deficit

SITE EXCESS DEFICIT Central nervous system Confusion (If severe) Fatigue, apathy Anorexia Stupor, coma Cardiovascular Elevated venous pressure Distended neck veins Increased cardiac output Heart gallops Pulmonary edema Orthostatic hypotension Flat neck veins Fast, thready pulse Hypotension Cool, clammy skin GI Anorexia, nausea and vomiting Edema of stomach, colon, and mesentery Anorexia Thirst Silent ileus Tissues Pitting edema Moist pulmonary crackles Soft, small tongue with longitudinal wrinkling Sunken eyes Decreased skin turgor Metabolism None Mild increase in temperature

• D₅W
  • Used to replace water (hypotonic fluid) losses, supply some caloric intake, or administer as carrying solution for numerous medications.
  • Cautious use in patients with water intoxication (hyponatremia, syndrome of inappropriate antidiuretic hormone release). Should not be used as concurrent solution infusion with blood or blood components.
• Normal saline solution
  • Used to replace saline (isotonic fluid) losses, administer with blood components, or treat patients in hemodynamic shock.
  • Cautious use in patients with isotonic volume excess (heart failure, renal failure).
• Lactated Ringer's solution
  • Used to replace isotonic fluid losses, replenish specific electrolyte losses, and moderate metabolic acidosis.

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TYPES OF I.V. ADMINISTRATION

I.V. “PUSH”

I.V. “push” (or I.V. bolus) refers to the administration of a medication from a syringe directly into an ongoing I.V. infusion. It may also be given directly into a vein by way of an intermittent access device (saline or heparin lock).

Indications

• For emergency administration of cardiopulmonary resuscitative procedures, allowing rapid concentration of a medication in the patient's bloodstream
• When quicker response to the medication is required (eg, furosemide [Lasix] or digoxin [Lanoxin])
• To administer “loading” doses of a drug that will be continued by way of infusion (eg, heparin)
• To reduce patient discomfort by limiting the need for intramuscular injections
• To avoid incompatibility problems that may occur when several medications are mixed in one bottle
• To deliver drugs to patients unable to take them orally (eg, coma) or I.M. (eg, coagulation disorder)
• Cost-effective method—no need for extra tubing or syringe pump

Precautions and Recommendations

• Before administration of the medication:
  • Determine that the medication matches the order.
  • Dilute the drug as indicated by pharmacy references. Many medications are irritating to veins and require sufficient dilution.
  • Determine the correct (safest) rate of administration. Consult the pharmacy or pharmaceutical text. Most medications are given slowly (rarely over less than 1 minute); sometimes as long as 30 minutes is required. Too rapid administration may result in serious adverse effects.
  • If I.V. push is to be given with an ongoing I.V. infusion or to follow another I.V. push medication, check pharmacy for possible incompatibility. It is always wise to flush the I.V. tubing or cannula with saline before and after administration of a drug.
  • Assess the patient's condition and ability to tolerate the drug.
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  • Assess patency of the I.V. line by the presence of blood return.
    • Lower running I.V. bottle.
    • Withdraw with syringe before injecting medication.
    • Pinch I.V. tubing gently.
  • Ascertain the dwell time of the catheter. For infusion of vesicants (some chemotherapy agents), a catheter placement of 24 hours or less is advisable.
• Watch the patient's reaction to the drug.
  • Be alert for major adverse effects, such as anaphylaxis, respiratory distress, tachycardia, bradycardia, or seizures. Notify the health care provider and institute emergency procedures as necessary.
  • Assess for minor adverse effects, such as nausea, flushing, skin rash, or confusion. Stop medication and consult the health care provider.
• Vesicants are always given through the side port of a running I.V. infusion.
• Be familiar with hospital policies and guidelines regarding how, where, and by whom I.V. push medications can be given.

NURSING ALERT

Unusual dosages or unfamiliar drugs should always be confirmed with the health care provider and pharmacist before administration. The nurse is ultimately accountable for the drug that she administers.

CONTINUOUS OR INTERMITTENT INFUSION USING INFUSION CONTROL DEVICES

Continuous or intermittent I.V. infusions may be given through traditionally hung bags of solution and tubing, with or without flow rate regulators. I.V., intra-arterial, and intrathecal (spinal) infusion may be accomplished through the use of special external or implantable pumps. See Procedure Guidelines 6-1, pages 88 to 90.

General Considerations

• Advantages
  • Ability to infuse large and small volumes of fluid with accuracy.
  • An alarm warns of problems, such as air in line, high pressure required to infuse or, ultimately, occlusion.
  • Reduces nursing time in constantly readjusting flow rates.
• Disadvantages
  • Usually requires special tubing.
  • There may be added cost to therapy.
  • Infusion pumps will continue to infuse despite the presence of infiltration.
• Nursing responsibilities
  • Remember that a mechanical infusion regulator is only as effective as the nurse operating it.
  • Continue to check the patient regularly for complications, such as infiltration or infection.
  • Follow the manufacturer's instruction carefully when inserting the tubing.
  • Double-check the flow rate.
  • Be sure to flush all air out of the tubing before connecting it to the patient's I.V. catheter.
  • Explain the purpose of the device and the alarm system. Added machines in the room can evoke greater anxiety in the patient and family.

Types

• Electronic flow rate regulators
  • These devices deliver a prescribed fluid volume per hour.
  • Often, pressure gradients may be adjusted so that high pressures are not used to deliver peripheral therapies.
  • Use of an electronic flow-rate regulator is indicated for continuous infusions of:
    • Chemotherapy.
    • Infant and pediatric therapies.
    • Hyperalimentation.
    • Fluid and electrolytes on patients at risk for fluid overload.
    • Most medications.
• Battery-powered ambulatory infusion pumps
  • Example: CADD PRISMâ„¢ pump (Pharmacia Deltec, Inc.)
  • These pumps deliver continuous or intermittent medications by way of I.V., subcutaneous, or spinal routes.
  • If used for pain control, patient may deliver a “bolus” injection if relief is not obtained from continuous, prescribed dose.
• Freon-controlled spring pump (implanted)
  • Example: Infusaidâ„¢ (Neuromed)
  • Placed subcutaneously, usually in the left lower quadrant of the abdomen
  • Will deliver continuous pain medication or chemotherapy by way of an artery, vein, or the spinal canal
• Computer-programmable pump (implanted)
  • Example: SynchroMed pumpâ„¢ (Medtronics)
  • Same actions as above

INTERMITTENT INFUSIONS

Intermittent I.V. infusions may be given through an intermittent access device (saline lock), “piggybacked” to a continuous I.V. infusion, or for long-term therapy through a venous access device. See Procedure Guidelines 6-2, 6-3 and 6-4, pages 91 to 94.

Intermittent Access Device (Saline Lock)

• This intermittent infusion reservoir permits the administration of periodic I.V. medications and solution without continuous fluid administration.
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• Many facilities do not use heparin solutions to keep short peripheral catheters open. A saline flush (2 mL) is administered and a clamp is tightened or the needle is withdrawn while injecting to create positive pressure and keep the vein open.

PROCEDURE GUIDELINES 6-1

Venipuncture Using Needle or Catheter

EQUIPMENT

• Tourniquet (non-latex preferred)
• Disposable gloves
• Antiseptic swab (alcohol, iodine, povidone-iodine, chlorhexidine)

If continuous infusion:

• I.V. solution
• I.V. tubing

If intermittent access device:

• Extension set or PRN adapter
• Heparin or normal saline solution (1 to 2 mL) in sterile syringe
• Tape
• Transparent I.V. dressing or other dressing supplies
• Covered armboard (if necessary)
• Desired cannula:
• Catheter (Teflon, Silastic polyurethane, or polyvinyl chloride) in chosen bore size (gauges 14–25)
• Winged (“butterfly”) needle

Note: Thorough hand washing is required before handling sterile supplies and initiating venipuncture.

PROCEDURE

Nursing Action Rationale Preparatory phase 1. Explain the procedure to the patient. Ascertain whether the patient is left- or right-handed. 1. Helps alleviate anxiety about the procedure. Start the infusion in the opposite arm if possible. 2. Clear all I.V. and winged needle tubing of air (clear air with fluid from infusion tubing by attaching a needle, or by irrigating the needle with saline in a sterile syringe). 2. To prevent infusion of air and potential air embolus. 3. Put on gloves. 3. Complies with CDC requirements to minimize passing of blood-borne pathogens between the patient and nurse. 4. Select a site for insertion. (See the discussion on site selection, page 96.) 5. Apply a tourniquet 2 to 6 inches (5 to 15 cm) above the desired insertion site and ascertain satisfactory distention of the vein. Distal pulses should remain palpable. 5. The vein must be visible or palpable before venipuncture is attempted. The tourniquet should not be applied too tightly so it does not interfere with arterial blood flow. 6. Have the patient open and close his fist several times. 6. To increase blood supply in the area. Further techniques to aid in vein distention are discussed on page 97. A tourniquet may not be necessary on greatly distended veins. 7. Remove the tourniquet. 7. To prevent trauma to the arm from extended application of the tourniquet. It can be reapplied later. 8. Clean the site: 8. To reduce the number of skin microorganisms and minimize risk of infection. Alcohol may be used alone if the patient is allergic to iodine; otherwise, it should be used as part of a two-step process. a. Clip hair if the site is too obscured. b. Clean the skin with an alcohol swab in a circular motion outward from the site for at least 30 seconds. c. Prepare the skin with a povidone-iodine swab for 1 minute, working from the center of the proposed site to the periphery until a circle of 2 to 4 inches (5 to 10 cm) has been disinfected. c. If a 1% to 2% iodine solution is used, it should be used before alcohol for 30 to 60 seconds and allowed to dry. Chlorhexidine is an alternative agent that can be used alone; follow the manufacturer's instructions. d. Allow the area to air dry. 9. Reapply a tourniquet. 9. To facilitate catheter insertion. Performance phase: Catheter insertion 1. Remove the needle guard. 2. Hold the patient's arm so your thumb is positioned approximately 2 inches (5 cm) from the site. Exert traction on the skin in the direction of your hand. 2. To stabilize the vein and facilitate successful cannulation. 3. Insert the needle, bevel up, through the skin at an angle. Use a slow, continuous motion. 3. Bevel up position allows for the smallest and sharpest point of the needle to enter the vein first. 4. If the vessel rolls, it may be necessary to penetrate the skin first at a 20-degree angle and then apply a second thrust parallel to the skin. 4. Satisfactory penetration is evidenced by a sudden decrease in resistance and by the appearance of blood coming back into catheter. 5. When the vein is entered, lower the catheter to skin level. 5. This will prevent puncturing the vessel wall. 6. When inserting, always hold the catheter by the clear plastic flashback chamber and not by the colored hub. 7. Advance the catheter approximately ¼ to ½ inch (0.5 to 1.5 cm) into the vein. 7. To ensure entry into the vein. 8. Pull back on needle to separate needle from catheter about ¼ inch and advance the catheter into the vein. 8. Pulling back on the needle prevents inadvertent puncture of the vein and provides stability of catheter for insertion. 9. If resistance is met while attempting to thread the catheter, stop, release the tourniquet, and carefully remove both the needle and the catheter. Attempt another venipuncture with a new catheter. 9. The catheter may have become dislodged or encountered a turn or valve in the vein. It is better to start again than to cause further damage to the vessel. NURSING ALERT Never reinsert a stylet back into a catheter once it has been removed. You may puncture or sever the catheter. a. Alternately, if the catheter does not freely advance, attach I.V. tubing or a heparin lock and flush, attempting to float the catheter into the vein. a. Flow of flush solution may advance catheter. 10. Apply pressure on the vein beyond the catheter tip with your little finger (see illustration); release the tourniquet and slowly remove the needle while holding the catheter hub in place. 10. This will reduce blood leakage while removing the needle and connecting tubing to the infusion set. Finger palpation of dorsal venous arch. 11. If an I.V., attach the cleared administration set to the hub of the catheter and adjust the infusion flow at the prescribed rate. 12. If an intermittent access device, attach lock cap and extension set, taking care to maintain sterility of the set. Flush with 0.5 mL heparin or normal saline solution. 13. Apply transparent dressing to the site or use dressing according to institutional protocol (see illustration). 13. Transparent dressing secures the I.V. catheter and prevents infection. 14. Loop tubing and tape to dressing or arm. 14. Prevents tension on the I.V. catheter itself. Transparent I.V. dressign. (Courtesy of 3M Health Care.) 15. Label the strip of tape with an arrow indicating the path of the catheter, size of catheter, date, time of insertion, and your initials. Affix the tape to the dressing. Prepare a similar label with each dressing change. 15. Labeling the dressing is dictated by hospital policy. Such a practice provides information useful in determining the next dressing change and the capability of the needle to accommodate various types of infusion. NURSING ALERT Standard dwell time for a short peripheral catheter is 3 days. However, exceptions may be made due to the patient's venous access, type of solution, and catheter material. A facility that does not maintain a phlebitis rate of 5% or less should use a 48-hour site rotation interval according to the Infusion Nurses Society (INS) I.V. Standards of Practice, 2000. If the catheter is not rotated according to facility policy, document the reason.

PROCEDURE GUIDELINES 6-2

Intermittent Access Device (Saline Lock)

A saline lock is an intermittent infusion reservoir that permits administration of periodic I.V. medications and solution without continuous fluid administration and aspiration of blood samples for laboratory analysis.

EQUIPMENT

• Antiseptic swabs (usually alcohol)
• Syringe with normal saline solution
• Preflushed extension set with 2 mL sterile normal saline solution if converting I.V. line to existing cannula in vein
• Tape
• Unsterile gloves
• Optional: Syringe containing 1 to 2 mL flush solution of heparin 10 units/mL

PROCEDURE

Nursing Action Rationale Preparatory phase 1. Wash hands. 2. Explain the procedure to the patient. 2. To minimize patient anxiety. 3. Put on gloves. Performance phase 1. Clean the port of the saline lock with alcohol. Insert a normal saline syringe needle into the port and aspirate slightly. 1. Use either a protected needle or a blunt-end syringe to access the port. This equipment avoids accidental needle sticks. If a small gauge catheter does not show a positive blood return, monitor the site carefully. 2. Inject normal saline solution slowly to flush the reservoir of saline or heparin solution and blood. 2. Not all institutions use heparin to maintain peripheral locks. 3. Check with the patient to ensure he has no pain on flushing. 3. May indicate a clot or infiltration. 4. Check for swelling at the needle site when flushing. 4. May indicate a clot or infiltration. 5. Insert medication tubing, administer the drug, and infuse at the prescribed rate. 6. After drug or solution administration, insert the saline syringe and flush the reservoir slowly. Remove the syringe while still pushing the plunger of the syringe to ensure positive pressure. 6. To prevent blood clotting in the I.V. cannula. Central venous catheters require more than 2.5 mL of solution to be effective. (INS suggests 2 times the volume of the catheter and any add-on devices) 7. Optional: If using a heparin lock, insert heparin solution into the reservoir after saline. Follow-up phase 1. Maintain patency of saline lock by flushing it every 8 to 12 hours, regardless of use. 1. If resistance is met, the device should not be flushed. Attempt to remove the occlusion via aspiration. If unable to restore patency, remove the I.V. device. 2. I.V. administration set for intermittent therapy should be changed according to institutional policy. The tubing should only be used for the same medication. 2. It is recommended that the tubing be changed every 24 hours because the tubing is not maintained as a closed system and therefore poses a risk for infection.

PROCEDURE GUIDELINES 6-3

Setting Up an Automatic Intravenous “Piggyback”

EQUIPMENT

• Sterile infusion set (primary)
• Sterile infusion set (secondary)
• Optional: Syringe containing 1 to 2 mL heparin for a solution of 10 units/mL

PROCEDURE

Follow the procedure of the manufacturer of the “piggyback” infusion set being used. In general, most procedures are similar to the following:

Nursing Action Rationale Preparatory phase 1. Wash hands thoroughly. 1. Minimizes the possibility of infection. 2. Set up the primary infusion set; this may have a check-valve (see A in illustration). 2. The primary set should be functioning effectively before the secondary (piggyback) set can be attached. 3. Lower the primary flask on the I.V. pole; usually, an extension hook accompanies the set. 3. This will permit the check-valve to function. (A) “Piggyback” I.V. On the left is the primary infusion flask. Note the use of an extension hook (hanging from the I.V. pole) to suspend the primary flask. The backcheck valve is seen more clearly in B and C. The 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 the fluid source from the secondary flask (where pressure is greater because the flask source is higher) is forcing the movable disc upward, thereby closing off fluid from the primary source. (D) When the last of the fluid from the secondary source reaches the level of the fluid in the primary set drip chamber (as indicated by a broken line), hydrostatic pressure between both sets will equalize. This releases the check-valve; flow will shift from the secondary to the primary source. (Adapted from Abbott Laboratories) Performance phase 1. Use an alcohol swab to carefully clean the injection site. 1. Usually, this is a Y-connection on the primary site. 2. Attach secondary tubing to primary tubing—preferably with a needle-free adapter—at entry port. 3. Lower secondary solution, open clamp, and allow infusate from primary solution to prime secondary tubing. Close clamp. 3. This clears the secondary tubing of air and prevents any loss of medication from the secondary line. 4. Hang secondary solution higher than primary solution. Open roller clamp (see D in illustration). 5. Program pump or controller for rate of infusion for secondary medication. 5. To ensure medication administration over the appropriate time period. Follow-up phase 1. Change I.V. administration tubing according to your institution's guidelines. 2. If possible, do not detach the secondary tubing from the primary tubing after the infusion regimen has started. 2. If using more than one secondary medication, the same tubing may be used. Back-flush the tubing into old secondary bag or bottle. Dispose of bag or bottle. Hang new secondary medication to same tubing.

PROCEDURE GUIDELINES 6-4

Accessing an Implanted Port

Implanted ports are becoming increasingly popular for patients with diseases such as cancer, sickle cell anemia, or cystic fibrosis to administer medications and continuous or intermittent I.V. fluids.

EQUIPMENT

• Two 10-mL syringes filled with normal saline solution
• Noncoring Huber needle
• Heparin flush solution 100 units/mL
• Alcohol prep pads
• Three povidone-iodine swab sticks
• Sterile gloves

PROCEDURE

Nursing Action Rationale Preparatory phase 1. Wash hands thoroughly. 2. Explain the procedure to the patient. 2. To minimize anxiety and facilitate learning. Performance phase 1. Palpate the port—feel the septum. 1. To ensure placement and patency. 2. Select the appropriate Huber needle—gauge and length. 3. Flush Huber needle and extension with normal saline solution, leaving one of the 10-mL syringes attached, being careful not to touch the needle with unsterile gloves or fingers. 3. Priming of the needle is essential to prevent infusion of air and ensure patency. 4. Put on sterile gloves and clean site with alcohol and three povidone-iodine swabs. Allow to dry. 4. To prevent the introduction of organisms into the central line. 5. Hold the Huber needle with one hand and stabilize the port with the other hand—again locating septum. 6. With a firm, steady motion, insert the needle into the port. 7. Aspirate. If unable to aspirate, flush the port with saline solution and try to aspirate blood again. 7. By aspirating first, you withdraw saline solution that has been in the port. 8. After aspirating blood, flush with 10 mL normal saline solution. 8. The presence of blood confirms correct needle placement in the port. 9. If still no blood return, repeat port access or report findings to the health care provider. 9. May order a radiologic study or urokinase declotting procedure. 10. When placement of the needle is confirmed, attach the I.V. or “heparin lock” the port. Follow-up phase 1. Maintain patency by flushing according to your institution's guidelines. Change the needle every 7 days. 2. Instruct the patient to have the port flushed monthly and notify the health care provider of any problems.

“Piggyback” I.V. Administration

• Means of administering medication by way of the fluid pathway of an established primary infusion line.
• Drugs may be given on an intermittent basis through a primary infusion.
• When a check valve is present on the primary tubing, it:
  • Permits the primary infusion to flow after the medication has been administered.
  • Prevents air from entering the system.
  • Prevents secondary fluid from “running dry.”
  • Permits less mixing of primary fluid with secondary solution.
• Use of an infusion pump or controller will permit rate changes between primary and secondary infusates.

Central Venous Access Devices

Indications

• Long-term therapy—weeks, months, or years
• Chemotherapy, medication, or blood product infusion; blood specimen collection
• I.V. fluids in the home
• Limited peripheral venous access due to extensive previous I.V. therapy, surgery, or previous tissue damage

Types

See Figure 6-1.

FIGURE 6-1 Common sites for long-term venous access devices. (Courtesy of American Cancer Society.)

• Central catheter—nontunneled; commonly called percutaneous
  • Has one to four lumens
  • Dwell time usually less than 1 month
  • May be inserted in femoral, jugular, or subclavian veins
• Central catheter—tunneled
  • A tunneled catheter is inserted into a central vein (usually the subclavian, then the superior vena cava) and subcutaneously tunneled to an exit site approximately 4 inches (10 cm) from the insertion site.
  • A Dacron cuff is located approximately ¾ to 1 inch (2 to 3 cm) from the exit site, providing a barrier against microorganisms.
  • Examples of the tunneled catheters in current use are Hickmanâ„¢, Broviacâ„¢, and Groshongâ„¢.
• Central implanted device
  • A subcutaneous pocket is formed and a reservoir is placed; a catheter is attached to the reservoir and tunneled subcutaneously and inserted into a central vein
    

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    (usually the catheter tip is in the superior vena cava). This device cannot be seen exteriorly.
  • Examples of implanted devices in current use include the Port-A-Cathâ„¢, Medi-Portâ„¢, Infuse-A-Portâ„¢, and Groshong Portâ„¢.
• Peripheral central—nontunneled
  • Peripherally inserted central catheter (PICC); used in patients in acute, long-term, and home care settings.
    • Inserted in basilic, median cubital, or cephalic veins.
    • May be inserted by nurses with special training or interventional radiologists.
    • PICC tip placement must be located in superior vena cava (verified by X-ray). Tip placement in subclavian or innominate vein contraindicated for hyperosmolar solutions (hyperalimentation).
    • PICC insertion site and hub should be covered by a transparent dressing.
    • Extension tubing must be clamped when no solution is being infused. Tape it securely to the patient's arm.
    • Positive pressure flushing will keep PICC from clotting. (See Table 6-4, page 96.)
    • PICCs placed in the median cubital vein tend to follow the cephalic vein to central placement. Observe carefully for pain and tenderness because the cephalic vein is smaller than the basilic.
  • PAS Portâ„¢
    • Inserted in basilic vein.
    • Connected to a subcutaneously implanted port in the forearm.
    • Delivers fluid centrally into superior vena cava.
• Midline catheters
  • These catheters are inserted into the basilic, cephalic, or median cubital vein and extend 3 to 8 inches (7.5 to 20 cm) up the arm with the distal tip resting in the upper arm just distal to the axillary arch.
  • They are inserted by specially trained nurses.
  • Dwell time—for intermediate therapy of 2 to 6 weeks.
  • They are considered deep peripheral and not appropriate for hyperosmolar solutions such as hyperalimentation and some antibiotics, such as erythromycin (Ilotycin) and nafcillin (Unipen).

NURSING ALERT

An X-ray to determine placement of central catheter is necessary for all devices that deliver fluid into the subclavian vein or superior vena cava.

NURSING ALERT

If central catheters are placed too deeply and extend into the right atrium, an irregular heartbeat may result. Monitor heart rhythm and notify the health care provider immediately.

TABLE 6-4 I.V. Catheter Maintenance Guidelines

CATHETER DRESSING CHANGE FLUSH (MAINTENANCE) FLUSH (AFTER BLOOD DRAW) Short peripheral 3 days after site changed If used as a lock, 2 mL normal saline solution every shift or heparin flush solution;10 units/mL N/A Midline Every 3 to 5 days 3 mL;10 units/mL heparin flush solution 5 mL normal saline solution 3 mL 1;100 units/mL heparin flush solution Peripherally inserted central catheter 24 hours postinsertion, then weekly 2 to 3 mL 100 units/mL heparin flush solution every day 10 mL normal saline solution 3 mL 100 units/mL heparin flush solution Groshong (tunneled) Every 1 to 2 days postinsertion for 1 week postoperative, then every 3 days until the site is fully healed, then every week; when the site has healed, no dressing is needed (secure the catheter to the patient's chest with tape) 10 mL normal saline solution weekly 10 to 20 mL normal saline solution Hickman/Broviac Same as Groshong 3 mL 100 units/mL heparin flush solution every day if accessed every 8 hours or more frequently, no need for heparin between infusions 10 mL normal saline solution 3 mL 100 units/mL heparin flush solution Implanted ports (including PAS Port) Needle and dressing change every week when accessed If accessed and locked: 5 mL normal saline solution and 5 mL 100 units/mL heparin flush solution after each infusion Terminal flush: 5 to 7 mL 100 units/mL heparin flush solution and every 4 weeks thereafter 10 mL normal saline solution 5 mL 100 units/mL heparin flush solution Percutaneous catheters (triple/double lumen) Every 2 to 3 days 3 mL normal saline solution 2 mL 10 units/mL heparin flush solution twice per day or after each infusion 3 mL normal saline solution 3 mL 10 units/mL heparin flush solution Quinton/Perm-A catheter (blue lumen, use only with order) Every 2 to 3 days 2 mL 1,000 units/mL heparin flush solution every 2 to 3 days (always withdraw heparin first when using catheter) 10 mL normal saline solution 2 mL 1,000 units/mL heparin flush solution

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NURSING ROLE IN I.V. THERAPY

INITIATING AN I.V.

Nurses must be familiar with the procedure as well as the equipment involved in initiating an I.V. to provide effective therapy and prevent complications. See Standards of Care Guidelines.

Selecting a Vein

• First verify the order for I.V. therapy unless it is an emergency situation.
• Explain the procedure to the patient.
• Select a vein suitable for venipuncture.
  • Back of hand—metacarpal vein. (See Figure 6-2A, page 98.) Avoid digital veins, if possible.

    FIGURE 6-2 (A) Superficial veins, dorsal aspect of the hand. (B) Superficial veins, forearm.

    • The advantage of this site is that it permits arm movement.
    • If a vein problem develops later at this site, another vein higher up the arm may be used.
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  • Forearm—basilic or cephalic vein. (See Figure 6-2B, page 98.)
  • Inner aspect of elbow, antecubital fossa—median basilic and median cephalic for relatively short-term infusion. However, use of these veins prevents bending of arm.
  • Lower extremities.
    • Foot—venous plexus of dorsum, dorsal venous arch, medial marginal vein
    • Ankle—great saphenous vein
• Central veins are used:
  • When medications and infusions are hypertonic or highly irritating, requiring rapid, high-volume dilution to prevent systemic reactions and local venous damage (eg, chemotherapy and hyperalimentation).
  • When peripheral blood flow is diminished (eg, shock) or when peripheral vessels are not accessible (eg, obese patients).
  • When CVP monitoring is desired.
  • When moderate or long-term fluid therapy is expected.

NURSING ALERT

The median basilic and cephalic veins are not recommended for chemotherapy administration due to the potential for extravasation and poor healing resulting in impaired joint movement. In addition, these veins may be needed for intermediate or long-term indwelling catheters.

NURSING ALERT

Use lower extremities as a last resort. A patient with diabetes or peripheral vascular disease is not a suitable candidate. Obtain an order from the health care provider for the I.V. site and monitor lower extremity closely for signs of phlebitis and thrombosis.

Methods of Distending a Vein

• Apply manual compression above the site where the cannula is to be inserted.
• Have the patient periodically clench fist if the arm is used.
• Massage the area in the direction of venous flow.
• Apply a tourniquet (made of soft non-latex tubing) at least 2 to 6 inches (5 to 15 cm) above the planned insertion site, fastening it with a slip knot or hemostat.
• An alternative is to apply a blood pressure cuff (keep pressure just below systolic pressure).
• Lightly tap the vein site; this is to be done gently so the vein is not injured.
• Allow the extremity to be dependent (below heart level) for a few minutes.
• Apply heat to a possible needle site by using a moist, warm towel.

STANDARDS OF CARE GUIDELINES

I.V. Therapy

To prevent adverse effects of I.V. therapy, perform the following assessments and procedures:

• Before starting I.V. therapy, consider duration of therapy, type of infusion, condition of veins, and medical condition of the patient to assist in choosing I.V. site and type of catheter.
• Ensure that you are competent in initiating the type of I.V. therapy decided on and familiar with institutional policy and procedure before initiating therapy.
• After initiation of I.V. therapy, monitor the patient frequently for:
  • Signs of infiltration or sluggish flow
  • Signs of phlebitis or infection
  • Correct solution, medication, volume, and rate
  • Dwell time of catheter and need to be replaced
  • Condition of catheter dressing and frequency of change
  • Fluid and electrolyte balance
  • Signs of fluid overload or dehydration
  • Patient satisfaction with mode of therapy.

This information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches.

Selecting Needle or Catheter

• Use the smallest gauge catheter suitable for the type and location of the infusion.
• If a blood transfusion is to be given, use a larger-bore catheter, preferably 20G.
• For very small veins and an infusion rate below 75 mL/ hour, a 24G catheter may be appropriate.
• Consider local anesthesia.
  • If large-bore needle (greater than 18G) is being inserted in an unusually sensitive patient, 0.1 mL 1% lidocaine (without epinephrine) may be ordered and infiltrated intradermally around the site to provide local anesthesia. Topical cream may also be applied 1 hour before vein cannulation.
  • Local anesthesia is best avoided because it may cause collapse of desired veins, allergic reactions, and increased cost of the procedure.
• For a short-term infusion of 1 hour or less, a steel needle may be used.
• For longer-term therapy, choose a flexible catheter.

NURSING ALERT

Needle sticks are a constant risk in I.V. therapy. Catheter companies manufacture many protective devices such as retractable stylets in I.V. catheters. Institutions are strongly encouraged to stock and use these safety devices to protect employees (see Figure 6-3, page 99).

FIGURE 6-3 The activation button is pressed after the catheter is in the vein so that the needle will retract into the safety barrel while the needle is still in the catheter. (Courtesy of Becton Dickinson.)

Cleaning the Infusion Site

• If skin is dirty, clean the infusion site thoroughly with a surgical soap and rinse.
• Clean the I.V. site with an effective topical antiseptic according to facility protocol; INS approves the following agents, singly or in combination:
  • Alcohol swabs, used one at a time, in a circular movement from the site outward for a minimum of 30 seconds; allow to dry before I.V. insertion. (Commonly
    

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    used first in a 2-step process with povidone-iodine, but 3 swabs may be used singly if the patient is allergic to iodine).
  • Povidone-iodine, used for 1 minute and allowed to dry completely before I.V. insertion. (If 1% to 2% iodine used, alcohol should be used second because iodine is very irritating).
  • 2% tincture of chlorhexidine, used as a single agent antiseptic and allowed to dry is also an appropriate agent, but is expensive.

DRUG ALERT

Iodine solutions may cause allergic reactions in some patients. The patient should be assessed for iodine allergies before I.V. insertion. Iodine products should dry to facilitate their antimicrobial properties.

DRUG ALERT

Chlorhexidine or a combination of alcohol and povidone-iodine should be used for patients who are immunocompromised and at high risk for infection.

Initiating the Venipuncture

Follow steps in Procedure Guidelines 6-1, pages 88 to 90.

Infusion Tubing

• Drip chambers
  • A “microdrip” system delivers 60 drops/mL and is used when small volumes are being delivered (eg, less than 50 mL/hour); this reduces the risk of clotting the I.V. line due to slow infusion rates.
  • The “macrodrip” system delivers 10, 15, or 20 drops/mL and is used to deliver solution in large quantities or at fast rates.
• Vents
  • Vented tubing should be used with standard glass bottles; this permits air to enter the vacuum in the bottle and displace solution as it flows out.
  • Nonvented tubing should be used for I.V. bags and glass bottles that have a built-in air vent.
• Filters
  • Filters help minimize the risk of contamination from certain microorganisms and particulate matter.
  • Filters should be changed every 24 to 48 hours because bacteria may become trapped in the filter and release endotoxins, a small pyrogen capable of passing through the filter.
  • Filters are found “in line” on conventional I.V., blood, and hyperalimentation tubing. Check your institution's equipment and protocols to see if an additional filter is warranted. (An additional filter is needed for mannitol infusions.)
• Special tubing
  • Most mechanical infusion pumps and controllers require specialized tubing to fit their particular pumping chamber. Need for such a device should be determined before initiating infusion therapy.
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  • If added tubing length is required (especially for children and restless patients), extension tubing is available; this should be added at the time of I.V. setup.
  • Secondary tubing is used for administration of intermittent “piggyback” medications that are connected to the port closest to the drip chamber.
  • Special coated tubing, designed to prevent leaching of polyvinyl chloride, is used for delivering medications, such as nitroglycerin (Tridil), paclitaxel (Taxol), and cyclosporine (Sandimmune).
• Tubing change
  • Check your institutional protocol for time of tubing change. Standard is 48 to 72 hours.
  • Label new tubing with the date, the time it was hung, and your initials.
• Dressing changes and flushing of I.V.—vary depending on type of I.V. (see Table 6-4, page 96).

Adjusting Rate of Flow

The health care provider prescribes the flow rate. The nurse is responsible for regulating and maintaining the proper rate.

Patient Determining Factors

• Surface area of the patient—depending on the size of the patient, more fluid may be required and tolerated.
• Condition—a patient in hypovolemic shock requires greater amounts of fluids, whereas the patient with heart or renal failure should receive fluids judiciously.
• Age—fluids should be administered slowly in the very young and elderly.
• Tolerance to solutions—fluids containing medications causing potential allergic reactions or intense vascular irritation (eg, potassium chloride) should be well diluted or given slowly.
• Prescribed fluid composition—efficacy of some drugs is based on speed of infusion (eg, antibiotics); rate for other solutions is titrated to the patient's response to them (eg, dopamine [Intropin], nitroprusside [Nipride], heparin).

Factors Affecting Rate of Flow

• Gauge of I.V. catheter
• Pressure gradient—the difference between two levels in a fluid system
• Friction—the interaction between fluid molecules and surfaces of inner wall of tubing
• Diameter and length of tubing
• Height of column of fluid
• Characteristics of fluid
  • Viscosity
  • Temperature—refrigerated fluids may cause diminished flow and vessel spasm; bring fluid to room temperature before infusion
• Vein trauma, clots, plugging of vents, venous spasm, and vasoconstriction
• Flow-control clamp derangement
  • Some clamps may slip and loosen, resulting in a rapid, or “runaway,” infusion. Many tubings now have safety clamps to prevent this rapid infusion.
  • Plastic tubing may distort, causing “creep” or “cold flow”—the inside diameter of tubing will continue to change long after clamp is tightened or relaxed.
  • Marked stretching of tubing may cause distortions of tubing and render clamp ineffective (may occur when patient turns over and pulls on a short tubing).
• If there is any question about the rate of fluid administration, check with the health care provider.

GERONTOLOGIC ALERT

Be aware that veins are more likely to roll within the loose tissue beneath the skin, collapse, and become irritated in elderly people. Also, fluid overload may be more pronounced, making I.V. therapy more difficult and potentially dangerous.

Calculation of Flow Rate

• Most infusion rates are given at a certain volume per hour.
• Delivery of the prescribed volume is determined by calculating necessary drops per minute to deliver the volume.
• Drops per milliliter will vary with commercial parenteral sets (eg, 10, 15, 20, or 60 drops/mL). Check the directions.
• Calculate the infusion rate using the following formula:
  
  Example: Infuse 150 mL of D₅W in 1 hour (set indicates 10 drops/mL)
  
• The nurse hanging a new I.V. solution should write the date, time, and his or her initials on the container label.

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NURSING ALERT

To avoid leaks, never write directly on the I.V. bag. Write on the label or tape using a regular pen. Do not use magic markers because they are absorbed into the plastic bag and possibly into the solution.

COMPLICATIONS OF I.V. THERAPY

Infiltration

Cause

• Dislodgment of the I.V. cannula from the vein results in infusion of fluid into the surrounding tissues.

Clinical Manifestations

• Swelling, blanching, and coolness of surrounding skin and tissues
• Discomfort, depending on nature of solution
• Fluid flowing more slowly or ceasing
• Absence of blood backflow in I.V. catheter and tubing

Preventive Measures

• Make sure that the I.V. and distal tubing are secured sufficiently with tape to prevent movement.
• Splint the patient's arm or hand as necessary.
• Check the I.V. site frequently for complications.

Nursing Interventions

• Stop infusion immediately and remove the I.V. needle or catheter.
• Restart the I.V. in the other arm.
• If infiltration is moderate to severe, apply warm, moist compresses and elevate the limb.
• If a vasoconstrictor agent (eg, norepinephrine bitartrate [Levophed], dopamine [Intropin]) or a vesicant [various chemotherapy agents]) has infiltrated, initiate emergency local treatment as directed. Serious tissue injury, necrosis, and sloughing may result if actions are not taken.
• Document interventions and assessments.

Thrombophlebitis

Causes

• Injury to vein during venipuncture, large-bore needle or catheter use, or prolonged needle or catheter use.
• Irritation to vein due to rapid infusions or irritating solutions (eg, hypertonic glucose solutions, cytotoxic agents, strong acids or alkalis, potassium, and others). Smaller veins are more susceptible.
• Clot formation at the end of the needle or catheter due to slow infusion rates.
• More commonly seen with synthetic catheters than steel needles.

Clinical Manifestations

• Tenderness at first, then pain along the vein
• Swelling, warmth, and redness at infusion site; the vein may appear as a red streak above the insertion site

Preventive Measures

• Anchor the needle or catheter securely at the insertion site.
• Change the insertion site at least every 72 hours. If the facility phlebitis rate goes above 5%, insertion sites should be changed every 48 hours (Infusion Nurses Society [INS] Infusion Nursing Standards of Practice, 2000).
• Use large veins for irritating fluid because of higher blood flow, which rapidly dilutes the irritant.
• Sufficiently dilute irritating agents before infusion.

Nursing Interventions

• Apply cold compresses immediately to relieve pain and inflammation.
• Follow with moist, warm compresses to stimulate circulation and promote absorption.
• Document interventions and assessments.

Bacteremia

Causes

• Underlying phlebitis increases risk 18-fold.
• Contaminated equipment or infused solutions (see Figure 6-4).

  FIGURE 6-4 Potential mechanisms for contamination of I.V. infusion systems.

• Prolonged placement of an I.V. device (catheter or needle, tubing, solution container).
• Nonsterile I.V. insertion or dressing change.
• Cross-contamination by the patient with other infected areas of the body.
• A critically ill or immunosuppressed patient is at greatest risk of bacteremia.

Clinical Manifestations

• Elevated temperature, chills
• Nausea, vomiting
• Elevated white blood cell (WBC) count
• Malaise, increased pulse
• Backache, headache
• May progress to septic shock with profound hypotension
• Possible signs of local infection at I.V. insertion site (eg, redness, pain, foul drainage)

Preventive Measures

• Follow the same measures as outlined for thrombophlebitis.
• Use strict sterile technique when inserting the I.V. or changing I.V. dressing.
• Solutions should never hang longer than 24 hours.
• Change the insertion site at least every 48 to 72 hours.
• Change continuous I.V. administration sets every 48 to 72 hours and intermittent I.V. administration sets every 24 hours.
• Change the I.V. dressing every 48 to 72 hours.
• Maintain integrity of the infusion system.

Nursing Interventions

• Discontinue infusion and I.V. cannula.
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• I.V. device should be removed and the tip cut off with sterile scissors, placed in a dry sterile container, and immediately sent to the laboratory for analysis.
• Check vital signs; reassure the patient.
• Obtain WBC count, as directed, and assess for other sites of infection (urine, sputum, wound).
• Start appropriate antibiotic therapy immediately after receiving orders.
• Document interventions and assessments.

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Circulatory Overload

Cause

• Delivery of excessive amounts of I.V. fluid (especially a risk for elderly patients, infants, or patients with cardiac or renal insufficiency).

Clinical Manifestations

• Increased blood pressure and pulse
• Increased CVP, venous distention (engorged jugular veins)
• Headache, anxiety
• Shortness of breath, tachypnea, coughing
• Pulmonary crackles
• Chest pain (if history of coronary artery disease)

Preventive Measures

• Know whether patient has existing heart or kidney condition. Be particularly vigilant in the high-risk patient.
• Closely monitor the infusion flow rate. Keep accurate intake and output records.
• Splint the arm or hand if the I.V. flow rate fluctuates too widely with movement.

Nursing Interventions

• Slow infusion to a “keep-open” rate and notify the health care provider.
• Monitor closely for worsening condition.
• Raise the patient's head to facilitate breathing.
• Document interventions and assessments.

Air Embolism

Causes

• A greater risk exists in central venous lines, when air enters catheter during tubing changes (air sucked in during inspiration due to negative intrathoracic pressure)
• Air in tubing delivered by I.V. push or infused by infusion pump

Clinical Manifestations

• Drop in blood pressure, elevated heart rate
• Cyanosis, tachypnea
• Rise in CVP
• Changes in mental status, loss of consciousness

Preventive Measures

• Clear all air from tubing before infusion to patient.
• Change solution containers before they run dry.
• Ensure that all connections are secure. Always use luer-lock connections on central lines.
• Use precipitate and air-eliminating filters unless contraindicated.
• Change I.V. tubing during expiration.

Nursing Interventions

• Immediately turn the patient on his left side and lower the head of the bed; in this position, air will rise to right atrium.
• Notify the health care provider immediately.
• Administer oxygen as needed.
• Reassure the patient.
• Document interventions and assessments.

Mechanical Failure (Sluggish I.V. Flow)

Causes

• Needle lying against the side of the vein, cutting off fluid flow
• Clot at the end of the catheter or needle
• Infiltration of I.V. cannula
• Kinking of the tubing or catheter

Clinical Manifestations

• Sluggish I.V. flow
• Alarm of flow regulator sounding
• May be signs of local irritation—swelling, coolness of skin

Preventive Measures

• Check the I.V. often for patency and kinking.
• Secure the I.V. well with tape and an armboard, if necessary.

Nursing Interventions

• Remove tape and check for kinking of tubing or catheter.
• Pull back the cannula because it may be lying against wall of vein, vein valve, or vein bifurcation.
• Elevate or lower needle to prevent occlusion of bevel.
• Move patient's arm to new position.
• Lower solution container below level of patient's heart and observe for blood backflow.
• If an electronic flow-rate regulator is in use, check its integrity.
• If none of the preceding steps produces the desired flow, remove needle or catheter and restart infusion.

Hemorrhage

Causes

• Loose connection of tubing or injection port
• Inadvertent removal of peripheral or central catheter
• Anticoagulant therapy

Clinical Manifestations

• Oozing or trickling of blood from I.V. site or catheter
• Hematoma

Preventive Measures

• Cap all central lines with luer-lock as-needed adapters and connect luer-lock tubing to the cap—not directly to the line.
• Tape all catheters securely—use transparent dressing when possible for peripheral and central catheters. Tape the remaining catheter lumens and tubing in a loop so tension is not directly on the catheter.
• Keep pressure on sites where catheters have been removed—a minimum of 10 minutes for a patient taking anticoagulants.

Venous Thrombosis

The vein in which the peripheral or central catheter lies becomes partially or fully occluded by a thrombus.

Causes

• Infusion of irritating solutions
• Infection along catheter may preclude this syndrome
• Fibrin sheath formation with eventual clot formation around the catheter (This clot will eventually occlude the vein.)

Clinical Manifestations

• Slowing of I.V. infusion or inability to draw blood from the central line
• Swelling and pain in the area of catheter or in the extremity proximal to the I.V. line

Preventive Measures

• Ensure proper dilution of irritating substances.
• Ensure superior vena cava catheter tip placement for irritating solutions.

Nursing Interventions

• Stop fluids immediately and notify health care provider.
• Reassure patient and institute appropriate therapy:
  • Anticoagulants
  • Heat
  • Elevation of affected extremity
  • Antibiotics