Intravenous (I.V.) therapyIntravenous (I.V.) therapyis the insertion of is the insertion of

needle or catheter/cannula needle or catheter/cannula into the vein, based on the into the vein, based on the physician’s written physician’s written prescription. The needle or prescription. The needle or catheter/cannula is attached to catheter/cannula is attached to sterile tubing and a fluid sterile tubing and a fluid container to provide container to provide medication and fluidsmedication and fluids..

Indication of I.V. TherapyIndication of I.V. Therapy

• 1. To maintain hydration and/or correct 1. To maintain hydration and/or correct dehydration in patients unable to tolerate dehydration in patients unable to tolerate sufficient volumes of oral fluids and sufficient volumes of oral fluids and medication.medication.

• Parenteral NutritionParenteral Nutrition

• Administration of drugs, i.e. Administration of drugs, i.e. ChemotherapyChemotherapy

• Transfusion of blood or blood Transfusion of blood or blood components.components.

Contraindication of Peripheral IV Contraindication of Peripheral IV TherapyTherapyAdministration of irritant fluids or drugs through Administration of irritant fluids or drugs through peripheral access(i.e. highly concentrated, high peripheral access(i.e. highly concentrated, high osmolarity solutions like… Nacl. Hypertonic Kcl, etc.osmolarity solutions like… Nacl. Hypertonic Kcl, etc.

Key Points prior to initiation of I.V. Key Points prior to initiation of I.V. therapytherapy Physician’s prescribed treatment.The initiation of Physician’s prescribed treatment.The initiation of intravenous therapy is upon the written prescription intravenous therapy is upon the written prescription of a licensed physician which is checked for the of a licensed physician which is checked for the following:following: -- Type and amount of solution -- Type and amount of solution-- The flow rate-- The flow rate-- The type,dose and frequency of medications to -- The type,dose and frequency of medications to be incorporated/pushed.be incorporated/pushed.-- Others affecting the procedures (x--- Others affecting the procedures (x-rays,treatments to the other extrmities,etc)rays,treatments to the other extrmities,etc)

• 10 GOLDEN RULES FOR DRUGS SAFELY.10 GOLDEN RULES FOR DRUGS SAFELY.– Administer the right drugAdminister the right drug– Administer the right drug to right personAdminister the right drug to right person– Administer the right doseAdminister the right dose– Administer the right drug by the right routeAdminister the right drug by the right route– Administer the right drug at the right timeAdminister the right drug at the right time– Document each drug you administerDocument each drug you administer– Teach your patient about the drugs he is receivingTeach your patient about the drugs he is receiving– Take a complete patient drug history. (There is a risk Take a complete patient drug history. (There is a risk

of adverse drug reactions when a number of drugs of adverse drug reactions when a number of drugs are taken or when patient is taking alcoholic drinks)are taken or when patient is taking alcoholic drinks)

– Find out if the patient has any drug allergies.Find out if the patient has any drug allergies.– Be aware of potential drug- drug – or drug-food Be aware of potential drug- drug – or drug-food

interactions.interactions.

SELECTION OF VENIPUNCTURE SITESELECTION OF VENIPUNCTURE SITEThe patient’s condition and age, the The patient’s condition and age, the size and vein condition, type and size and vein condition, type and duration of therapy and functional duration of therapy and functional utilization of the hand shall be utilization of the hand shall be assessed to ensure ideal and safe assessed to ensure ideal and safe IV access.IV access.

SELECTION OF PERIPHERAL IV SITESELECTION OF PERIPHERAL IV SITE

• Veins in the hand, forearm, antecubital Veins in the hand, forearm, antecubital fossa, scalp and feetfossa, scalp and feet

• Assess the veins of both arms closely Assess the veins of both arms closely before selecting a sitebefore selecting a site

• Start IV infusion distallyStart IV infusion distally

• Determine the clients dominant sideDetermine the clients dominant side

• Bending the elbow on the arm with IV may Bending the elbow on the arm with IV may obstruct the flow causing thrombophlebitis obstruct the flow causing thrombophlebitis and infiltrationand infiltration

• Use an armboard/splint as needed in the Use an armboard/splint as needed in the area of flexionarea of flexion

INFECTION CONTROLINFECTION CONTROLInfection at the venipuncture site is Infection at the venipuncture site is usually caused by a break in aseptic usually caused by a break in aseptic technique during the procedure. The technique during the procedure. The following measures reduce patient’s following measures reduce patient’s risk:risk:

– Wash hands before starting an IV or before Wash hands before starting an IV or before handling any of the IV equipment.handling any of the IV equipment.

– Use an approved antiseptic( as per hospital’s Use an approved antiseptic( as per hospital’s protocol) to clean the patient’s skin.protocol) to clean the patient’s skin.

– Cut/clip the hairs of the venipuncture site if Cut/clip the hairs of the venipuncture site if necessary. Do not shavenecessary. Do not shave

– Do not re-use a catheter or needle.Do not re-use a catheter or needle.

ADMINISTRATION OF IV SOLUTIONADMINISTRATION OF IV SOLUTION

• Check the IV solution for the type amount, Check the IV solution for the type amount, percent of solution and rate of flow percent of solution and rate of flow

• Assess the health status and medical Assess the health status and medical disordersdisorders

• Wash hands thoroughly and use sterile Wash hands thoroughly and use sterile techniquetechnique

• Prime the tubing to remove air from the Prime the tubing to remove air from the systemsystem

ADMINISTRATION OF IV SOLUTIONADMINISTRATION OF IV SOLUTION

• Change the IV site every 48 – 72 hrsChange the IV site every 48 – 72 hrs

• Change the IV dressing every 72 hrs Change the IV dressing every 72 hrs especially when wet and contaminatedespecially when wet and contaminated

• Change the IV tubing every 24 to 72 hrsChange the IV tubing every 24 to 72 hrs

• Label the tubing, dressing and solution Label the tubing, dressing and solution bags indicating the date and time when bags indicating the date and time when changedchanged

• Before adding med or solutions, swab Before adding med or solutions, swab access ports with 70% alcoholaccess ports with 70% alcohol

COMPLICATIONSCOMPLICATIONS

• InfectionInfection – – redness, swelling and drainage redness, swelling and drainage at site; chills, fever, malaise, headacheat site; chills, fever, malaise, headache

• Tissue damage Tissue damage – – skin color change, skin color change, sloughing of skin, discomfort at sitesloughing of skin, discomfort at site

• PhlebitisPhlebitis – – heat, redness, tenderness, not heat, redness, tenderness, not hard and swollenhard and swollen

• ThrombophlebitisThrombophlebitis – heat, redness, – heat, redness, tenderness, hard and cordlike veintenderness, hard and cordlike vein

• InfiltrationInfiltration – – Edema, pain, and coolness at Edema, pain, and coolness at the sitethe site

•Catheter embolism Catheter embolism – decrease BP, – decrease BP, pain along vein, weak, rapid pulse, pain along vein, weak, rapid pulse, cyanosis of nail beds, loss of cyanosis of nail beds, loss of consciousnessconsciousness

•Circulatory overload Circulatory overload – increased BP, – increased BP, distended jugular veins, rapid distended jugular veins, rapid breathing, dyspnea, moist cough breathing, dyspnea, moist cough and cracklesand crackles

•Electrolyte Electrolyte overloadoverload – signs depend – signs depend on the specific electrolyte on the specific electrolyte imbalanceimbalance

•HematomaHematoma – ecchymosis, – ecchymosis, immediate swelling and leakage of immediate swelling and leakage of blood at the site, and hard painful blood at the site, and hard painful lumps at the sitelumps at the site

•Air embolism Air embolism – tachycardia, – tachycardia, dyspnea, hypotension, cyanosis, dyspnea, hypotension, cyanosis, decreased level of consciousnessdecreased level of consciousness

( 5ml and above)( 5ml and above)

IV CONTAINERSIV CONTAINERS

•Glass or plasticGlass or plastic

•Do not write the plastic IV Do not write the plastic IV bag with marker penbag with marker pen

IV TUBINGIV TUBING

•Contains the spike end, drop Contains the spike end, drop chamber, roller clamp, Y – site and chamber, roller clamp, Y – site and adapter endadapter end

•Use of vented or non – vented tubingUse of vented or non – vented tubing

•Shorter secondary tubing – use for Shorter secondary tubing – use for piggyback solutions, connecting piggyback solutions, connecting them to the injection sitethem to the injection site

DRIP CHAMBERDRIP CHAMBER

• Microdrip Microdrip – Are used if fluid will be infused at 50cc/ hrAre used if fluid will be infused at 50cc/ hr– Used if solution contains potent medication Used if solution contains potent medication

that needs to be titratedthat needs to be titrated– Delivers 60drops/ mlDelivers 60drops/ ml

• Macrodrip Macrodrip – Use if solution is thick or need to infuse Use if solution is thick or need to infuse

rapidlyrapidly– Delivers 10 – 20drops/ mlDelivers 10 – 20drops/ ml

FILTERSFILTERS

• Filters provide protection by preventing particles Filters provide protection by preventing particles from entering the client’s veinsfrom entering the client’s veins

• Filters are used in IV lines to trap small particles Filters are used in IV lines to trap small particles such as undissolved antibiotics or salt or such as undissolved antibiotics or salt or medications that have precipitated in solutionmedications that have precipitated in solution

• Assess the agency policy regarding the use of Assess the agency policy regarding the use of filtersfilters

• A 0.22-um filter is used for most solutions, a 1.2-A 0.22-um filter is used for most solutions, a 1.2-um for solutions containing lipids or albumin, um for solutions containing lipids or albumin, and a special filter for blood componentsand a special filter for blood components

IV GAUGESIV GAUGES

• Gauge 14 – 25Gauge 14 – 25• The smaller the gauge the larger the The smaller the gauge the larger the

outside diameteroutside diameter• G14 -19 – for rapid fluid administration G14 -19 – for rapid fluid administration

(blood products or anesthetics)(blood products or anesthetics)• G20 - 21 – for peripheral fat infusionG20 - 21 – for peripheral fat infusion• G22 - 24 – STD IV fluid and clear liquid G22 - 24 – STD IV fluid and clear liquid

medicationmedication• G24 - 25 – for very small veinsG24 - 25 – for very small veins

Procedure in setting up/ Procedure in setting up/ changing/Discontinuing I.V. changing/Discontinuing I.V. InfusionInfusion

• A. Setting upA. Setting up– Verify doctor’s order and make a label.Verify doctor’s order and make a label.– Observe (10) R’s when preparing & Observe (10) R’s when preparing &

administering IVFadministering IVF– Explain procedureExplain procedure– Assess patient’s vein, choose appropriate Assess patient’s vein, choose appropriate

vein, location, size and condition.vein, location, size and condition.– Wash hands and maintain asepsis throughout Wash hands and maintain asepsis throughout

preparation and during therapy.preparation and during therapy.– Prepare necessary materialsPrepare necessary materials

• IV tray with IV solutionsIV tray with IV solutions

• Administration setAdministration set

• IV cannulaIV cannula

Cont.Cont.• Alcohol swabs or cotton balls soaked with alcoholAlcohol swabs or cotton balls soaked with alcohol• Plaster (micropore)Plaster (micropore)• TourniqueTournique• SplintSplint

• Gloves (optional)Gloves (optional) – Check the sterility and integrity of the IV Check the sterility and integrity of the IV

solutions, IV set and other devices.solutions, IV set and other devices.– Place IV label on the bottle, patients name, Place IV label on the bottle, patients name,

room #, solutions, drug incorporation, time room #, solutions, drug incorporation, time started, time consumed, flow rate, # of started, time consumed, flow rate, # of hours and signature.hours and signature.

– Open the seal aseptically of the solutions Open the seal aseptically of the solutions and disinfect rubber port with cotton balls and disinfect rubber port with cotton balls with alcohol.with alcohol.

– Open administration set aseptically and Open administration set aseptically and close the IV clampclose the IV clamp

– Spike the infusate asepticallySpike the infusate aseptically– Fill drip chamber to at least haft and Fill drip chamber to at least haft and

prime the tube asepticallyprime the tube aseptically– Remove air bubbles if any and put back Remove air bubbles if any and put back

the cover to the distal end of the IV the cover to the distal end of the IV tubing (get ready for insertion)tubing (get ready for insertion)

IV INSERTIONIV INSERTION

1.Verify written order for IV therapy,check prepared IVF 1.Verify written order for IV therapy,check prepared IVF and other things needed(procedure setting up)and other things needed(procedure setting up)

2.Explain procedures and observe the 10 R’S2.Explain procedures and observe the 10 R’S

3.Wash hands before and after procedure.3.Wash hands before and after procedure.

4.Choose site for IV.4.Choose site for IV.

5.Apply tourniquet 5 to 12cm(2-6 inches)above the 5.Apply tourniquet 5 to 12cm(2-6 inches)above the injection site,depending on condition of the client.injection site,depending on condition of the client.

6.Prepare site with effective topical antiseptic according 6.Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry.(No touch circular motion and allow 30 seconds to dry.(No touch technique)technique)

7.Using appropriate IV cannula,pierce skin with needle 7.Using appropriate IV cannula,pierce skin with needle positioned on a 15-30 degree andle;upon flashback positioned on a 15-30 degree andle;upon flashback visualization decrease the angle,advance the visualization decrease the angle,advance the catheter and stylet into the vein.catheter and stylet into the vein.

8.Position the IV catheter parallel to the skin.Hold stylet 8.Position the IV catheter parallel to the skin.Hold stylet stationary and slowly advance the catheter off,of the stationary and slowly advance the catheter off,of the stylet,until the hub nearly meets the puncture site.stylet,until the hub nearly meets the puncture site.

9.Release the tourniquet,remove the stylet while 9.Release the tourniquet,remove the stylet while applying digital pressure over the catheter with one applying digital pressure over the catheter with one finger about ½ inch from the tip of inserted catheter.finger about ½ inch from the tip of inserted catheter.

10. Open the clamp and regulate the flow rate.10. Open the clamp and regulate the flow rate.

11.Anchor needle firmly in place with the use of;11.Anchor needle firmly in place with the use of;

a.) transparent tape/dressing directly on the a.) transparent tape/dressing directly on the puncturepuncture

site.site.

b.) tape ( using any appropriate anchoring style)b.) tape ( using any appropriate anchoring style)

12. Tape a small lope of IV tubings for additional 12. Tape a small lope of IV tubings for additional anchoring;apply splint (if needle)anchoring;apply splint (if needle)

13. Regulate flow of infusion according to duration.13. Regulate flow of infusion according to duration.

14. Label on IV tape near the IV site to indicate the 14. Label on IV tape near the IV site to indicate the date of insertion.date of insertion.

15. Label with plaster on the IV tubings to indicate 15. Label with plaster on the IV tubings to indicate the date when to change the IV tubings.the date when to change the IV tubings.

16. Observe and reassure the patient.16. Observe and reassure the patient.

17. Document in the patient’s chart and endorse to 17. Document in the patient’s chart and endorse to incoming shift.incoming shift.

18. Observe/report any untoward effect.18. Observe/report any untoward effect.

19. Discard sharps and waste according to hospital 19. Discard sharps and waste according to hospital policypolicy

Changing the IV InfusionChanging the IV Infusion

• Verify doctor’s order, countercheck IV Verify doctor’s order, countercheck IV label, IV card, type, amount, additives (if label, IV card, type, amount, additives (if any), duration.any), duration.

• Observe (10) R’sObserve (10) R’s• Explain procedure to the patient assess IV Explain procedure to the patient assess IV

site for redness, swelling, pain, etc.site for redness, swelling, pain, etc.• Check date of IV insertion, re-site if 48-78 Check date of IV insertion, re-site if 48-78

hours has lapsed.hours has lapsed.• Check date of changing IV tubing, change Check date of changing IV tubing, change

if due for changing ( with in 72 hours).if due for changing ( with in 72 hours).

Cont.Cont.

• Wash hand before and after the procedure.Wash hand before and after the procedure.

• Prepare necessary materials (IV sols, IV Prepare necessary materials (IV sols, IV label, disinfectant, IV tray)label, disinfectant, IV tray)

• Check sterility and integrity of IV solutionsCheck sterility and integrity of IV solutions

• Place label on IV bottlePlace label on IV bottle

• Open and disinfect the rubber port of IVOpen and disinfect the rubber port of IV

• Close the IV clamp or kink the tubing and Close the IV clamp or kink the tubing and spike the container aseptically.spike the container aseptically.

• Regulate the flow rate based on duration of Regulate the flow rate based on duration of infusion. Remove air bubbles.infusion. Remove air bubbles.

• Reassure patient and significant others.Reassure patient and significant others.

• Discard all waste materials according to Discard all waste materials according to MMDA ordinance #16MMDA ordinance #16

• Document accordingly and endorse to Document accordingly and endorse to incoming shift. incoming shift.

Discontinuing an IV infusionDiscontinuing an IV infusion

• Verify doctor’s order to discontinue the IVVerify doctor’s order to discontinue the IV• Observe (10) R’sObserve (10) R’s• Assess and inform the patient.Assess and inform the patient.• Prepare the necessary materialsPrepare the necessary materials• Wash handWash hand• Close IV clamp of the tubing.Close IV clamp of the tubing.• Moisten adhesive tapes and remove Moisten adhesive tapes and remove

plaster gently.plaster gently.• Remove IV catheter then immediately Remove IV catheter then immediately

apply pressure over the venipuncture site.apply pressure over the venipuncture site.

• Inspect IV catheter for completenessInspect IV catheter for completeness

• Place dressing or tape over the Place dressing or tape over the venipuncture sitevenipuncture site

• Discard all waste materials according Discard all waste materials according to MMDA ordinance # 16to MMDA ordinance # 16

• Reassure patientReassure patient

• Document and endorse accordingly.Document and endorse accordingly.

DOCUMENTATION OF IV DOCUMENTATION OF IV THERAPYTHERAPY

• Proper documentation provides:Proper documentation provides:

• an accurate description of care that an accurate description of care that can serve as legal protectioncan serve as legal protection

• a mechanism for recording and a mechanism for recording and retrieving informationretrieving information

INFORMATION WRITTEN ON INFORMATION WRITTEN ON IV TAPEIV TAPE

•size, type and length of cannula/ size, type and length of cannula/ needleneedle

•name of person who inserted the name of person who inserted the IV catheterIV catheter

•date and time of insertiondate and time of insertion

Label the IV solution Label the IV solution specifyingspecifying

•type of IV fluidtype of IV fluid

•medication additives and flow medication additives and flow raterate

•use of any electronic infusion use of any electronic infusion devicedevice

•duration of therapy and the duration of therapy and the nurse’s name and signaturenurse’s name and signature

Procedural Problems Associated Procedural Problems Associated with IV therapywith IV therapy

• Fluctuating flow rateFluctuating flow rate

• Runaway IVRunaway IV

• Sluggish IVSluggish IV

• Tubing disconnectionTubing disconnection

• Blood back-up in tubingBlood back-up in tubing

• IV line obstruction/kinking of IVIV line obstruction/kinking of IV

• Clogged filterClogged filter

• Break in aseptic techniqueBreak in aseptic technique

• Leaks due to inappropriate deviceLeaks due to inappropriate device

ComputationComputation

• Common FormulaCommon FormulaGtts/minGtts/min = Vol. in cc X drop factor = Vol. in cc X drop factor

# of hours X 60 min.# of hours X 60 min.

CC/hour = CC/hour = Vol. in ccVol. in cc # of hours# of hours

# of hours = # of hours = Vol. in cc X drop factorVol. in cc X drop factor

Gtts/min X 60Gtts/min X 60

Calculation of oral drugsCalculation of oral drugs

• FormulaFormula– D D x Q orx Q or Desired dose Desired dose x Quantityx Quantity

SS StockStock

Example:Example:

Ampicillin 500mg PO BID, the stock dose Ampicillin 500mg PO BID, the stock dose is 250mg. is 250mg.

500mg 500mg x 1 capsule = 2 capsulesx 1 capsule = 2 capsules

250mg250mg

Calculation of IVF flow rateCalculation of IVF flow rate

• FormulaFormula– gtts/min = gtts/min = Total vol. in cc X drop factorTotal vol. in cc X drop factor

# Of HOURS X 60# Of HOURS X 60

ExampleExampleOrder 1,000ml of D5w to run for 8hrs. The Order 1,000ml of D5w to run for 8hrs. The

drop factor is 15 gtts/min. What is the drop factor is 15 gtts/min. What is the regulation?regulation?

1,000 x 151,000 x 15 = 15,000= 15,000 = = 31.25gtts/min.31.25gtts/min.

8hrs. X 608hrs. X 60

Is there such a thing like Fluid

types???

! Of Course mr.Presiden

t…Actually there are 3 fluid types

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FLUID TYPESFLUID TYPES

33 TYPES OF TYPES OF SOLUTIONSOLUTION

1.1.Isotonic Isotonic SolutionSolution

2.2.Hypotonic Hypotonic SolutionSolution

3.3.Hypertonic Hypertonic solutionsolution MR.FLORENCE V QUINTANA MR.FLORENCE V QUINTANA

RNRN

Isotonic SolutionIsotonic Solution• Have equal solute Have equal solute

concentrationconcentration

• In adjacent In adjacent compartment compartment result in result in NO NET NO NET FLUID SHIFTFLUID SHIFT

• EXAMPLE :EXAMPLE :– Normal saline Normal saline

solution (PNSS,PLR)solution (PNSS,PLR)– Na in solution = Na Na in solution = Na

in Bloodin BloodMR.FLORENCE V QUINTANA MR.FLORENCE V QUINTANA

RNRN

ICF

ECF

Hypotonic SolutionHypotonic Solution

• ICF Has lower solute ICF Has lower solute concentration than concentration than other solutionsother solutions

• In adjacent In adjacent compartments result in compartments result in fluid shifting from the fluid shifting from the compartment of lower compartment of lower concentration to higher concentration to higher concentrationconcentration– Fluid From ECF Fluid From ECF ICF ICF

thus cell will burst or thus cell will burst or swellswell

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HYPERTONIC SOLUTIONHYPERTONIC SOLUTION

• Have higher solute Have higher solute concentrations than other concentrations than other solutionssolutions

• Adjacent compartments Adjacent compartments result in fluid shifting from result in fluid shifting from compartment with the compartment with the lower concentration to the lower concentration to the higher concentration.higher concentration.– Fluid From ICF Fluid From ICF ECF = cell ECF = cell

will shrinkwill shrink

• EXAMPLE : D5 NSSEXAMPLE : D5 NSS

D5LR,D5NM,D5NR,D5IMBD5LR,D5NM,D5NR,D5IMB

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FLUIDS and ELECTROLYTES

IV FLUID REPLACEMENT THERAPY

Types of Solutions • ( CRYSTALLOIDS)

Isotonic 0.9% sodium chloride (NSS) Lactated Ringer’s sol’n (PLR)

Hypotonic 5% dextrose and water (D5W) 0.45% sodium chloride 0.33% sodium chloride

Hypertonic D5 NaCl Protein sol’ns

Colloids Salt poor albumin, Dextran 40

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• D10W - 10% Dextrose in water D10W - 10% Dextrose in water hypertonic (505 hypertonic (505 mOsm/L)mOsm/L)

• D10W - 20% Dextrose in waterD10W - 20% Dextrose in water hypertonic (1011 hypertonic (1011 mOsm/L) mOsm/L)

• D50W - 50% Dextrose in waterD50W - 50% Dextrose in water hypertonic (1700 hypertonic (1700 mOsm/L)mOsm/L)

• D5NS - 5% Dextrose & 0.9NaCl D5NS - 5% Dextrose & 0.9NaCl hypertonic (559 hypertonic (559 mOsm/L) mOsm/L)

• D10NS - 10% Dextrose & 0.9NaClD10NS - 10% Dextrose & 0.9NaCl hypertonic hypertonic (812 mOsm/L) (812 mOsm/L)

• D5LR - 5% Dextrose in Lactated Ringers D5LR - 5% Dextrose in Lactated Ringers hypertonic (524 mOsm/L hypertonic (524 mOsm/L

TONICITY OF IV FLUIDSTONICITY OF IV FLUIDS

• 0.45% SALINE (1/2 NS) Hypotonic0.45% SALINE (1/2 NS) Hypotonic• 0.9% NS Isotonic0.9% NS Isotonic• 5% dextrose in water D5W Isotonic5% dextrose in water D5W Isotonic• D5 ¼ NS IsotonicD5 ¼ NS Isotonic• Lactated Ringer’s solution IsotonicLactated Ringer’s solution Isotonic• D5LR D5LR HypertonicHypertonic• D5 ½ NS HypertonicD5 ½ NS Hypertonic• D5 NSS HypertonicD5 NSS Hypertonic• D10W HypertonicD10W Hypertonic

Types of Blood ComponentTypes of Blood Component• Packed RBCPacked RBC

– Replaces erythrocyte and resolution of Replaces erythrocyte and resolution of anemiaanemia, , usually a unit of packed RBC’s are supplied in usually a unit of packed RBC’s are supplied in 250 ml unit bag250 ml unit bag

– Each unit increases the hemoglobin by 1 g/dl Each unit increases the hemoglobin by 1 g/dl and hct by 2-3% which will change in 4-6 hours and hct by 2-3% which will change in 4-6 hours after completion of blood transfusionafter completion of blood transfusion

• Whole BloodWhole Blood– Rarely used, used to resolve Rarely used, used to resolve Hypovolemic Hypovolemic

shockshock from Hemorrhage from Hemorrhage– Each unit normally contain 500mlEach unit normally contain 500ml

• PlateletsPlatelets– Used to treat Used to treat Thrombocytopenia and Thrombocytopenia and

Platelet dysfunctionPlatelet dysfunction– Cross-matching is not required but may Cross-matching is not required but may

done, bags contains 50-70 ml per unit to done, bags contains 50-70 ml per unit to 200-400 ml per unit200-400 ml per unit

– Administered immediately on receipt Administered immediately on receipt from blood bank and may be given from blood bank and may be given rapidly over 15 to 30 minutesrapidly over 15 to 30 minutes

• Fresh Frozen PlasmaFresh Frozen Plasma– Provides Provides Clotting factors or Volume Clotting factors or Volume

expansion; NO PLATELETSexpansion; NO PLATELETS– Infused within 6 hours, Rh and ABO Infused within 6 hours, Rh and ABO

compatibility test required compatibility test required – About 200-250 ml per unitAbout 200-250 ml per unit– PT and PTT is a done post transfusion for PT and PTT is a done post transfusion for

resolution of resolution of Coagulation defects or Coagulation defects or HypovolemiaHypovolemia

• AlbuminAlbumin– Prepared in plasma and can stored for 5 Prepared in plasma and can stored for 5

yearyear– Treat Treat Hypovolemic shock or Hypovolemic shock or

HypoalbunemiaHypoalbunemia

• CryoprecipitateCryoprecipitate– Are prepared from Fresh Frozen Plasma Are prepared from Fresh Frozen Plasma

and can be stored for 1 yearand can be stored for 1 year– Used to replace clotting factors, especially Used to replace clotting factors, especially

Factor VIII and FibrinogenFactor VIII and Fibrinogen

COMPATIBILITYCOMPATIBILITY• Clients blood sample are drawn and Clients blood sample are drawn and

labelled at the bedside when drawn, the labelled at the bedside when drawn, the client is asked to state his or her name, client is asked to state his or her name, which compared with the name of the which compared with the name of the client’s identification band or braceletclient’s identification band or bracelet..

• The recipient’s The recipient’s ABO and Rh typeABO and Rh type are are identifiedidentified

• An Antibody screen is done to determine An Antibody screen is done to determine the presence of antibodies other than anti-the presence of antibodies other than anti-A and Anti-BA and Anti-B

• Cross-matching is done in which Cross-matching is done in which donor RBC are combined with donor RBC are combined with recipient’s serum and Coomb’s recipient’s serum and Coomb’s serum; Crossmatching is compatible serum; Crossmatching is compatible if NO RBC Coagulation occursif NO RBC Coagulation occurs

• The Universal RBC donor is The Universal RBC donor is O O negativenegative, The Universal recipient is , The Universal recipient is AB positiveAB positive

Infusion Controllers and Infusion Controllers and PumpsPumps

• Infusion controllers and PumpsInfusion controllers and Pumps– Used to administer blood products if Used to administer blood products if

they are designed to function with they are designed to function with opaque soln’opaque soln’

• Special manual Pressure CuffSpecial manual Pressure Cuff– May be used to increase the flow rate May be used to increase the flow rate

but should not exceed 300 mmHgbut should not exceed 300 mmHg

BLOOD WARMERSBLOOD WARMERS

• To prevent HYPOTHERMIA and To prevent HYPOTHERMIA and adverse reactions when several units adverse reactions when several units of blood being administeredof blood being administered

• Do not warm blood products in the Do not warm blood products in the microwave or in hot watermicrowave or in hot water

Precautions and Nursing Precautions and Nursing Interventions and Interventions and ResponsibilitiesResponsibilities

General PrecautionsGeneral Precautions

• Avoid large vol. of refrigerated blood Avoid large vol. of refrigerated blood infused rapidly which can cause cardiac infused rapidly which can cause cardiac dysrhythmiasdysrhythmias

• No other soln’ other than NSS should be No other soln’ other than NSS should be added to blood componentsadded to blood components

• Medications are NEVER added to blood Medications are NEVER added to blood components or piggy backed into a blood components or piggy backed into a blood transfusiontransfusion

• Infusions (1 Unit) shout NOT exceed 4 Infusions (1 Unit) shout NOT exceed 4 hours to avoid Septicemiahours to avoid Septicemia

• Blood administration set should be Blood administration set should be changed every 4-6 hourschanged every 4-6 hours

• Always check the blood bag for the Always check the blood bag for the expiration dateexpiration date

• Inspect the blood bag for leaks, abnormal Inspect the blood bag for leaks, abnormal color clots and bubblescolor clots and bubbles

• Blood must be administered as soon as Blood must be administered as soon as possible (within 20-30 mins.) from possible (within 20-30 mins.) from receiving from the blood bankreceiving from the blood bank

• Never refrigerate blood, if blood is Never refrigerate blood, if blood is administered within 20-30 mins. administered within 20-30 mins. Return it Return it to the blood bankto the blood bank

• Blood is infused as quickly as the Blood is infused as quickly as the clients condition allowsclients condition allows

• Components containing few RBC and Components containing few RBC and Platelets may be infused rapidly but Platelets may be infused rapidly but caution must be taken to avoid caution must be taken to avoid circulatory overloadcirculatory overload

• The nurse should measure the vital The nurse should measure the vital signs and assess the lung sounds signs and assess the lung sounds before the transfusion and again after before the transfusion and again after the 1the 1stst 15 mins and every hour until 1 15 mins and every hour until 1 hour after the transfusion is completedhour after the transfusion is completed

Blood Bank PrecautionBlood Bank Precaution• Blood will be released from the Blood Bank Blood will be released from the Blood Bank

only by recognized personnelonly by recognized personnel• The The Name and the identification numberName and the identification number of of

the intended recipient must be provided to the intended recipient must be provided to the blood bank and a documented the blood bank and a documented permanent record of this information must permanent record of this information must be maintainedbe maintained

• Blood should be transported from the Blood should be transported from the blood bank to blood bank to only one client at a timeonly one client at a time to to prevent blood delivery to the wrong prevent blood delivery to the wrong patientpatient

Client Identity and Client Identity and CompatibilityCompatibility• The most critical phase of the transfusion The most critical phase of the transfusion

is is Confirming product compatibility and Confirming product compatibility and verifying clients identityverifying clients identity

• Two registered nurses are needed to Two registered nurses are needed to check the physician’s order, the clients check the physician’s order, the clients identity, and the client’s identification identity, and the client’s identification band or bracelet and number, verifying band or bracelet and number, verifying that the name and number are identical to that the name and number are identical to those on the blood component bagthose on the blood component bag

• At the bedside, the nurse ask the client to state At the bedside, the nurse ask the client to state his or her name, the nurse compares he name his or her name, the nurse compares he name with the name on the identification band or with the name on the identification band or braceletbracelet

• The nurse checks the blood bag tag, label, The nurse checks the blood bag tag, label, blood requisition form to ensure that ABO and blood requisition form to ensure that ABO and Rh type are compatibleRh type are compatible

• If the nurse notes any unconsistencies when If the nurse notes any unconsistencies when verifying client identity and compatibility, the verifying client identity and compatibility, the nurse notifies the blood bank immediatelynurse notifies the blood bank immediately

Client AssessmentClient Assessment

• Assess for any cultural or religious Assess for any cultural or religious beliefs regarding blood transfusion beliefs regarding blood transfusion (Jehovah’s witness)(Jehovah’s witness)

• Ensure that an Informed consent is Ensure that an Informed consent is signedsigned

• Determine any previous reaction to Determine any previous reaction to blood transfusionblood transfusion

• Check the clients VS, assess renal, Check the clients VS, assess renal, circulatory and respiratory status and circulatory and respiratory status and the client’s ability to tolerate the client’s ability to tolerate intravenously administered fluidsintravenously administered fluids

• If the client’s temperature is If the client’s temperature is elevated, notify the physician before elevated, notify the physician before beginning the transfusion, a fever beginning the transfusion, a fever may be a cause for delaying the may be a cause for delaying the transfusion in addition to masking a transfusion in addition to masking a possible symptoms of an acute possible symptoms of an acute transfusion reactiontransfusion reaction

Administration of the Administration of the TransfusionTransfusion

• Maintain standard, transmission based, Maintain standard, transmission based, and other precautions as necessaryand other precautions as necessary

• Insert an IV line and infused normal saline; Insert an IV line and infused normal saline; maintain the infusion at KVOmaintain the infusion at KVO

• An 18 or 19 gauge IV needle will be An 18 or 19 gauge IV needle will be needed to achieved maximum flow rate of needed to achieved maximum flow rate of blood products and prevent damage to blood products and prevent damage to RBC; if a smaller gauge needle must be RBC; if a smaller gauge needle must be used, RBC must be diluted with normal used, RBC must be diluted with normal salinesaline

• Always check the bag for the volume of Always check the bag for the volume of the blood componentthe blood component

• Blood products should be infused through Blood products should be infused through administration set designed specifically for administration set designed specifically for blood; use a Y tubing or straight tubing blood; use a Y tubing or straight tubing blood administration set that contains a blood administration set that contains a filte designed to trap fibrin clots and other filte designed to trap fibrin clots and other debris that accumulate during blood debris that accumulate during blood storagestorage

• Premedicate the client with Premedicate the client with Acetaminophen or Diphenylhydramine as Acetaminophen or Diphenylhydramine as prescribed if the client has a history of prescribed if the client has a history of adverse reactions 30 minutes before the adverse reactions 30 minutes before the transfusion is started if orallly or transfusion is started if orallly or immediately before transfusion if IV immediately before transfusion if IV administeredadministered

• Instruct the client to report anything Instruct the client to report anything unusual immediatelyunusual immediately

• Determine the rate of infusion by Determine the rate of infusion by physician orderphysician order

• Begin the transfusion slowly under close Begin the transfusion slowly under close supervision; if NO reaction is noted within supervision; if NO reaction is noted within the 1the 1stst 15 mins. The flow can be increased 15 mins. The flow can be increased to the prescribed rateto the prescribed rate

• During the transfusion, monitor the client During the transfusion, monitor the client for signs and symptoms of transfusion for signs and symptoms of transfusion reaction, the 1reaction, the 1stst 15 mins of the transfusion 15 mins of the transfusion are the most critical, and the nurse must are the most critical, and the nurse must stay with the clientstay with the client

• If a major compatibility exist or a If a major compatibility exist or a severe allergic reaction occurs, the severe allergic reaction occurs, the reaction is usually evident within the reaction is usually evident within the 11stst 50 ml of the transfusion 50 ml of the transfusion

• Document the clients tolerance to Document the clients tolerance to the administration of the blood the administration of the blood productsproducts

• Monitor appropriate laboratory Monitor appropriate laboratory values and document the values and document the effectiveness of treatment related to effectiveness of treatment related to the specific type of blood productsthe specific type of blood products

Reactions to the TransfusionReactions to the Transfusion• If a transfusion reaction occurs, stop the If a transfusion reaction occurs, stop the

transfusion, the change in IV tubing down transfusion, the change in IV tubing down to the IV site, keep the IV line open with to the IV site, keep the IV line open with normal saline, notify the physician and normal saline, notify the physician and blood bank and return blood bag and blood bank and return blood bag and tubing in the blood banktubing in the blood bank

• Do not leave the client alone and monitor Do not leave the client alone and monitor the client for nay life life threatening the client for nay life life threatening symptomssymptoms

• Obtain appropriate: laboratory samples, Obtain appropriate: laboratory samples, such as blood and urine samples (free such as blood and urine samples (free hemoglobin indicates the RBC cell are hemoglobin indicates the RBC cell are hemolyzed)hemolyzed)

COMPLICATIONS OF COMPLICATIONS OF BLOOD TRANSFUSIONBLOOD TRANSFUSION

TRANSFUSION REACTIONTRANSFUSION REACTION• SignsSigns: chills and diaphoresis, muscle : chills and diaphoresis, muscle

aches, back pain, or chest pain, rashes, aches, back pain, or chest pain, rashes, hives, itching swelling, rapid thready hives, itching swelling, rapid thready pulse, dyspnea, cough, wheezing or rales, pulse, dyspnea, cough, wheezing or rales, pallor, cyanosis, apprehension, tingling pallor, cyanosis, apprehension, tingling and numbness, headache, nauses, and numbness, headache, nauses, vomiting, abdominal cramping and vomiting, abdominal cramping and diarrheadiarrhea

• Unsconscious clientUnsconscious client: weak pulse, fever, : weak pulse, fever, tachycardia or bradycardia, hypotension, tachycardia or bradycardia, hypotension, visible hemoglobinuria, oliguria or anuriavisible hemoglobinuria, oliguria or anuria

• Delayed Transfusion reactionDelayed Transfusion reaction: occurring : occurring days to years after a transfusiondays to years after a transfusion

• Nursing Interventions:Nursing Interventions:– Stop the transfusionStop the transfusion– Keep the intravenous line open with 0.9% Keep the intravenous line open with 0.9%

normal salinenormal saline– Notify the physician and the blood bankNotify the physician and the blood bank– Remain with the client, observing signs and Remain with the client, observing signs and

symptoms and monitoring vital signs as often symptoms and monitoring vital signs as often as every 5 minutesas every 5 minutes

– Prepare to administer Emergency medications Prepare to administer Emergency medications such as antihistamines, vasopressors, fluids, such as antihistamines, vasopressors, fluids, corticosteroids as prescribedcorticosteroids as prescribed

– Obtain urine specimen for laboratory studiesObtain urine specimen for laboratory studies– Return blood bag, tubing attached labels, Return blood bag, tubing attached labels,

transfusion record to the blood banktransfusion record to the blood bank

CIRCULATORY OVERLOADCIRCULATORY OVERLOAD• Signs: Cough, dyspnea, chest pain, and Signs: Cough, dyspnea, chest pain, and

rales, headache, hypertension and rales, headache, hypertension and tachycardia and a bounding pulse, tachycardia and a bounding pulse, distended neck veinsdistended neck veins

• Nursing Interventions:Nursing Interventions:– Slow the rate of InfusionSlow the rate of Infusion– Place the client in an Upright position, with the Place the client in an Upright position, with the

feet in a dependent positionfeet in a dependent position– Notify the physicianNotify the physician– Administer O2 diuretics, morphine, SO4 as Administer O2 diuretics, morphine, SO4 as

prescribedprescribed– Monitor for dysrythmiasMonitor for dysrythmias– Phlebotomy also may be a method of Phlebotomy also may be a method of

prescribed treatment in a severe caseprescribed treatment in a severe case

SEPTICEMIASEPTICEMIA

• Signs: Rapid onset of chills and a high Signs: Rapid onset of chills and a high feverfever

• Nursing Interventions:Nursing Interventions:– Notify the physicianNotify the physician– Obtain blood cultures and cultures in the Obtain blood cultures and cultures in the

blood bagblood bag– Administer O2, IV fluids, antibiotics, Administer O2, IV fluids, antibiotics,

vasopressors and corticosteroids as vasopressors and corticosteroids as orderedordered

IRON OVERLOADIRON OVERLOAD• Signs: Vomiting, diarrhea, Signs: Vomiting, diarrhea,

hypotension, altered hematological hypotension, altered hematological valuesvalues

• Nursing Interventions:Nursing Interventions:– Deferoxamine (Desferal) administered IV Deferoxamine (Desferal) administered IV

or SubQ, removes accumulated iron via or SubQ, removes accumulated iron via the kidneysthe kidneys

– Urine turns red as iron is excreted aa Urine turns red as iron is excreted aa administration of deferoxamine; administration of deferoxamine; treatment is discontinued when serum treatment is discontinued when serum iron level return to normaliron level return to normal

DISEASE TRANSMISSIONDISEASE TRANSMISSION

• Signs: A disease commonly transmitted is Signs: A disease commonly transmitted is Hepatitis CHepatitis C which is manifested by anorexia, which is manifested by anorexia, nausea, vomiting, dark urine, and jaundice; the nausea, vomiting, dark urine, and jaundice; the symptoms usually occur within 4-6 weeks after symptoms usually occur within 4-6 weeks after the transfusionthe transfusion

• Other infectious agents transmitted include Other infectious agents transmitted include Hepatitis B virus, HIV, HHV6, Epstein-Barr Virus, Hepatitis B virus, HIV, HHV6, Epstein-Barr Virus, Human T-cell Leukemia, Cytomegalovirus and Human T-cell Leukemia, Cytomegalovirus and MalariaMalaria

• Nursing Intervention:Nursing Intervention:– Donor screeningDonor screening– Antibody testing of donors for HIVAntibody testing of donors for HIV

Hypocalcemia and Citrate Hypocalcemia and Citrate IntoxicationIntoxication

• Description: Citrate is transfused, blood Description: Citrate is transfused, blood binds with Calcium and is exercisedbinds with Calcium and is exercised

• Nursing InterventionNursing Intervention– Assess serum Calcium before and after the Assess serum Calcium before and after the

transfusiontransfusion– Monitor for signs of HypocalcemiaMonitor for signs of Hypocalcemia– Slow the transfusionSlow the transfusion– Notify physician if signs og Hypocalcemia Notify physician if signs og Hypocalcemia

occursoccurs

HYPERKALEMIAHYPERKALEMIA

• Description: Stored blood liberates K+ Description: Stored blood liberates K+ through Hemodialysisthrough Hemodialysis

• Nursing Intervention:Nursing Intervention:– The older blood the greater risk of The older blood the greater risk of

hyperkalemia; therefore patient at risk such hyperkalemia; therefore patient at risk such as those with renal insufficiency or renal as those with renal insufficiency or renal failure, should receive fresh bloodfailure, should receive fresh blood

– Assess the date on the blood and the serum Assess the date on the blood and the serum potassium level before and after the potassium level before and after the transfusion and notify the physicians if signs transfusion and notify the physicians if signs of Hyperkalemia occurof Hyperkalemia occur