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Hazards of IV therapy Aim: To raise awareness of hazards

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1 Hazards 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

2 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

3 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

4 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

5 Methods of administration
Intermittent fluids Continuous fluids Parenteral nutrition IV bolus medication IV intermittent injection of medication Howard Griffiths, SHS

6 Managing Risks Infection control Drug interactions
Correct use of syringe and infusion equipment Correct checking procedures for drug administration Howard Griffiths, SHS

7 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

8 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

9 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

10 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

11 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

12 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

13 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

14 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

15 Neonatal risk infusion
Neonatal risk infusion requires 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 infusion infusion devices worn to allow normal activities during infusion, often battery powered Howard Griffiths, SHS

16 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

17 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

18 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 hours. For blood products change after infusion. Howard Griffiths, SHS

19 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

20 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

21 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

22 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

23 Hypotonic saline (0. 45%) is used to replenish electrolytes
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

24 Conditions leading to hypokalaemia are-
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

25 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

26 Potential systemic complications of IV therapy
Circulatory overload Systemic infection Air embolism Allergic reaction Howard Griffiths, SHS

27 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

28 Immediate Complications of central venous catheters
venous air embolism tamponade catheter embolus/rupture arterial puncture dysrhythmias pneumothorax Howard Griffiths, SHS

29 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

30 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

31 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

32 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

33 Cryoprecipitated antihaemophilic factor
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

34 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

35 Correct blood component Blood unit number Expiry date of the blood
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

36 Check with the patient’s prescription ( any allergies)
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

37 Check cannula for signs of infection
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

38 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

39 Potential complications of blood transfusions
Infection Febrile reaction Allergic reaction Transfusion hypothermia Fluid overload Howard Griffiths, SHS

40 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

41 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

42 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

43 Every patient should have an uniquely identified wristband
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

44 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 : htpp://www.shot.demon.co.uk/ Quinn, C. (2000)Infusion devices: risks, functions and management; Nursing Standard Vol. 14 (26):35-41 Howard Griffiths, SHS


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