howard griffiths, shs hazards of iv therapy n aim: to raise awareness of hazards n learning...
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Howard Griffiths, SHS
Hazards of IV therapyHazards of IV therapy
Aim:To raise awareness of hazards
Learning outcomes: Recall the role of the nurse in IV therapy
List the main risk factors of IV therapy
List complications to the patient of IV therapy
Howard Griffiths, SHS
Underpinning knowledge
Basic anatomy and physiology of the cardiovascular system
Principles of asepsis Pharmaceutical knowledge of
different fluids Drip factors and different giving
sets, their purpose Technical knowledge of
different pumps that may be used
Howard Griffiths, SHS
Role of the nurse Identifying and verifying prescription Checking for contamination and faults The 5 R,s of drug administration Controlling the prescribed flow rate Monitoring and reporting patient’s
condition Ensuring that IV device remains patent Inspecting the insertion site, reporting any
abnormalities Maintaining records
Howard Griffiths, SHS
Nursing interventions Good hand washing and universal
precautions Drug administration calculation Vital signs measurement during
therapy (BP, pulse, respiration, temperature)
Degree of consciousness of the patient Observe urinary output and maintain
fluid balance chart Report blood results of urea and
electrolytes to doctor Observe for local signs of infection at
the cannula site
Howard Griffiths, SHS
Methods of administration
– Intermittent fluids – Continuous fluids– Parenteral nutrition– IV bolus medication– IV intermittent injection of
medication
Howard Griffiths, SHS
Managing Risks
Infection control
Drug interactions
Correct use of syringe and infusion equipment
Correct checking procedures for drug administration
Howard Griffiths, SHS
Therapeutic use of Intravenous fluids
To maintain hydration To correct fluid and
electrolyte balance To administer bolus IV
systemic medication, such as prescribed antibiotics
To maintain haemodynamic stability during surgery, and or maintain stability during pathological crisis, e.g shock
Howard Griffiths, SHS
Factors to consider when administrating drugs
Does it require reconstitution storage stability expiry date drug action and side-effects what is it incompatible with physiological considerations, serum levels? is protective clothing required?
Howard Griffiths, SHS
Drug interactions
inadequate mixing of drugs fluid may have an affect on the stability of the
drug
drug degradation through light (frusemide, nitroprusside, vitamin A and K)
inadequate mixing of drug additives specific gravity of the added drug may be different
from fluid used, resulting in layering
Howard Griffiths, SHS
Patient related factors in drug administration
The 5 R’s allergies body mass vital signs informed consent clinical status do they understand the side-effects is the device patent?
Howard Griffiths, SHS
IV administration sets Use aseptic technique when handling Latex bungs and injection ports, clean
with 70% alcohol, and allow to dry before administrating drugs
Clear fluids/ stored plasma/ drug infusion should have:– standard administration sets (5-15
micron filter, 20 drops per ml).– Burette or buretol (15 micron filter, 60
drops/ml)
Howard Griffiths, SHS
Transfusions– blood administration sets (15 drops/ml) should
be used for blood and fresh frozen plasma (FFP)
– Albumin Solution, Hetastarch and Haemacell can be given through clear fluid sets, as they contain no cells
– Platelets and Cryoprecipitate is administered through a platelet set (15 drops/ ml)
Howard Griffiths, SHS
Factors affecting flow rates Fluid composition, viscosity and concentration of fluid Height of fluid container will alter the hydrostatic pressure of
fluid Change in the position of the client’s access site Administration sets
– distortion of tubing may render the clamp ineffective
– diameter of the lumen
– inclusion of in line devices such as filters Vascular access
– condition and size of vein
– cannula gauge
– occlusion
– pressure
Howard Griffiths, SHS
Infusion devices
Medical Device Agency has identified one of the most serious of medication errors involve the use of infusion pumps
One of the main areas where human error occurs is in drug calculation
The MDA has categorised infusion devices in terms of risk:
Howard Griffiths, SHS
– Neonatal risk infusionrequires high accuracy and consistency of flow, used in neonatal intensive care and paediatric services
– High-risk infusion similar to above but not as accurate over the short term (within 1 hour). More suitable for older children
and adults.
– Low-risk infusion infusion of simple electrolytes, antibiotics and total parenteral nutrition. Devices will not need to have accurate or consistent output, only rudimentary alarm and safety systems
– Ambulatory infusioninfusion devices worn to allow normal activities
during infusion, often battery powered
Howard Griffiths, SHS
Infusion device checklist
Uncontrolled flow– occur from gravity drips, volumetric and syringe
pumps
Selecting the right infusion pump for transfer– is it necessary to take all infusion devices, does
the pump meet the risk classification?, is the operator trained to use it
Changing the infusion during transit– avoid, calculate infusion requirements and
prepare so that the infusion will last the journey
Security and safety– ensure that all devices are fixed or clamped
secured
Howard Griffiths, SHS
Flushing and maintaining patency
Ensures that the whole drug is given
Ensures that the device remains patent
0.9% NaCl is effective in maintaining patency in peripheral devices
Flushing should be undertaken after each dose or at least every 24 hours
Howard Griffiths, SHS
Issues of infection control Transparent film dressings over catheter or cannula site
Change local dressings according to local protocols
Keep change of IV infusion bags, giving sets, disconnection or interruption to a minimum
Hand washing and asepsis should be maintained before manipulating the IV system
With minimal breaks in IV circuit, change administration sets every 72 hours.
With frequent breaks in IV circuit, change administration set every 24-48 hours. For blood products change after infusion.
Howard Griffiths, SHS
Fluid and blood product administration
DO NOT ADD DRUGS TO:– blood products– mannitol– sodium bicarbonate– parenteral nutrition
Ensure individual drugs and solutions are given by the optimal route
Howard Griffiths, SHS
Chemistry of body fluids
Electrolytes– it is common to measure
electrolytes in ECF, chiefly the plasma.
– The term ‘plasma’ and ‘serum’ are used interchangeably
– Na+ is the main cation in ECF and controls the volume of fluid in ECF
– K+ is the main concentration of ICF.
Howard Griffiths, SHS
Intravenous fluids
Correcting and maintaining fluid and electrolyte balance– isotonic fluids are prescribed fluids that
do not alter the osmotic movement of water across cell membranes.
0.9% Sodium chloride is used to sustain extra cellular fluid volume by compensating for volume lost be – dehydration– urinary excretion of sodium– fluid drains following surgery
Howard Griffiths, SHS
Hypertonic fluids are fluids that expand intravascular volume by moving endothelial and intracellar water into the intravascular space
These fluids contain a high concentration of particles when compared to plasma, has potential therefore to cause fluid overload.
These fluids also has the potential to irritate peripheral veins, administration should be slow
Howard Griffiths, SHS
Hypotonic saline (0.45%) is used to replenish electrolytes. Complications can include over hydration, sodium overload and potassium defecit.
Hypotonic fluids drive fluid from the plasma into the interstitial space, and therefore are used to re-hydrate the cells
Howard Griffiths, SHS
Potassium electrolyte infusion is used for patients with severe hypokaelaemia.
Conditions leading to hypokalaemia are- – vomiting, diarrhoea, use of potent diuretics,
malnutrition, some forms of renal diseases and metabolic acidosis
Careful infusion is required in order to avoid cardiac arrhythmias and death.
Howard Griffiths, SHS
Peripheral site complications
Phlebitis– caused by mechanical rubbing of cannula, or
chemical irritation from fluid, or through contamination through poor hand washing by the nurse
Occlusion– caused by incorrect flushing, empty bags, kinking
of line, precipitation, poor cannula site
Infiltration– a none blistering drug leaks into the surrounding
tissue
Extravasation– blistering drug that leaks into surrounding tissue
Howard Griffiths, SHS
Potential systemic complications of IV therapy
Circulatory overload Systemic infection Air embolism Allergic reaction
Howard Griffiths, SHS
Types of central venous access
Peripherally inserted catheters (PICCs)- for patients requiring several weeks of IV access
Short term tunnelled catheters- days to several weeks of IV access
tunnelled cuffed catheters- for long term intermittent continuous or daily IV access
Implanted venous access- for long term, intermittent, continuous or daily IV access
Howard Griffiths, SHS
Immediate Complications of central venous catheters
venous air embolism tamponade catheter embolus/rupture arterial puncture dysrhythmias pneumothorax
Howard Griffiths, SHS
Delayed complications of central venous catheters
Infection of tunnel infection within catheter occlusion drug precipitation thrombosis air embolism anaphylaxis broken hub, broken clamp, split
catheter catheter pulled or fallen out
Howard Griffiths, SHS
Safety issues in Critical Care Labelling of sets
– Functions of different sets must be clearly labelled– above will help prevent mal-administration of drugs
and avoid haemodynamic monitoring sets
Identify both proximal and distal end of a giving set Use uninterrupted tubing, free of junctions and access
ports Only use high pressure tubing for haemodynamic
measurements If stopcocks have to be used on administration sets,
clean with 70% alcohol beforehand
Howard Griffiths, SHS
Blood products Whole blood transfusion Packed RBC Platelets- Fresh frozen plasma Cryoprecipitated antihemophilic
factor Granulocytes Serum albumin and plasma
protein fraction (PPF)
Howard Griffiths, SHS
Therapeutic use of blood products
Whole blood transfusion – for massive blood loss in neonates
Packed RBC– for inadequate oxygen carrying capacity
Platelets– for treatment of thrombocytopenia, acute lukaemia,
and marrow aplasia, and to restore platelet count preoperatively inpatients with a count of <100,000/mm3 or less
Howard Griffiths, SHS
Fresh frozen plasma– for expansion of plasma volume, treat post-op
haemorrhage or shock and correct coagulation factor deficiencies
Cryoprecipitated antihaemophilic factor– for haemophilia A, von Wilerbrand’s
disease, hypofibrinogenemia Granulocytes
– for severe gram negative infection or severe neutropenia unresponsive to routine forms of therapy in immunosuppressed patient. Also
indicated in severe granulocyte dysfunction. Serum albumin and plasma protein
fraction – in hypovolaemia and hypoproteinemia (burns)
Howard Griffiths, SHS
Nursing interventions required for blood transfusions
All blood products should be correctly prescribed
Follow the local employer’s protocol on how to collect blood products from the blood bank
Blood should not be taken from the refrigerator no more than 30 minutes before transfusion, to reduce chances of bacterial growth (Pritchard and David 1990)
Always check with another registered nurse
Howard Griffiths, SHS
Check with the patient the details against the patient’s ID wristband and the component and prescription sheet at the bedside.
A range of details on the blood bag, patient’s identity bracelet and blood form should match:– Patient’s name– Hospital number– Date of birth– Blood group– Correct blood component– Blood unit number– Expiry date of the blood
Howard Griffiths, SHS
– The bag should be gently squeezed for leaks, and gently rocked to mix the contents
Check with the patient’s prescription ( any allergies)
A standard 19 gauge IV cannula through a blood giving set, which has filter to prevent small clots entering the blood stream.
Use correct hand washing technique and universal precautions
Howard Griffiths, SHS
Maintain baseline observation (BP, pulse, respiration and temperature), initially every 15 minutes.
Continue observations every 15 minutes for 1 hour, thereafter, where no complication remains, every 1 hour
Baseline observations should be repeated before commencing each new unit and 15 minutes after the new unit has commenced (Glover and Powell 1995)
Check cannula for signs of infection
Howard Griffiths, SHS
Observe urinary output and maintain fluid balance chart
Observe patient’s behaviour during transfusion
Observe the appearance of the patient during transfusion
Do not leave a unit of blood transfusing more than 5 hours
Howard Griffiths, SHS
Potential complications of blood transfusions
Infection
Febrile reaction
Allergic reaction
Transfusion hypothermia
Fluid overload
Howard Griffiths, SHS
Adverse reaction
Increase in temperature Hypotension Tachycardia Headaches Rashes Swelling around cannula site Pain in abdomen or chest Patient feeling agitated or unduly apprehensive
STOP TRANSFUSION, CONTACT DOCTOR AND FILL DOCUMENTATION
Howard Griffiths, SHS
Reporting adverse incident recheck the blood against the patient’s notes check the patient’s urine for blood
blood needs to be cross matched again
all equipment (blood bag, giving set and urine ) should be sent to the lab for testing
keep the iv line open with 0.9% normal saline complete the employer’s adverse clinical incident
form, and document in care plan
Howard Griffiths, SHS
Conclusion IV therapy must be prescribed by a medical
practitioner
Cannulation and insertion of catheters, together with administrating IV medication is regarded as extended Professional Scope of Practice.
Always check that equipment, the fluids and the flow rate with another R.N.
Howard Griffiths, SHS
The bedside check is the final opportunity to
prevent a mis-transfusion
Each hospital will have a formal policy which must be followed for blood tranfusion
Every patient should have an uniquely identified wristband
Each R.N must ensure responsibility regarding their competency .
Howard Griffiths, SHS
REFERENCES
Jane Mallet and Lisa Dougherty (2000) Manual of Clinical Nursing Procedures (5th edition); Blackwell Science, London
Fox, Nick (2000) Managing risks posed by intravenous therapy; Nursing Times Vol.96 (30), pp37-39
R.C.N. Guidance for Nurses Giving Intravenous Therapy
Serious Hazards of Transfusion (SHOT) Annual Report 1999-2000: htpp://www.shot.demon.co.uk/
Quinn, C. (2000)Infusion devices: risks, functions and management; Nursing Standard Vol. 14 (26):35-41