A.

Function of the Lungs

1. Respiration: overall process by which exchange takes place between the
atmosphere and the cells of the body. Normal adult respiratory rate: 12-20 breaths
per minute.
2. Ventilation: movement of air in and out of the airways, intermittently replenishing the
oxygen and removing the carbon dioxide from the lungs
3. Dead space: the 150 cc area where there is no air exchange; anatomically from the
nose and mouth to the alveoli. Therefore, 150 cc of the tidal volume is not used in
any air exchange.

B. Factors Affecting Airflow

1. Normally airways are open, moist, intact, and not inflamed. Cilia clear
foreign substances.
2. Objective of care is to keep the airways healthy by the nursing interventions:
a. Promote adequate fluid intake
b. Prevent exposure to infections
c. Decrease exposure to tobacco smoke
d. Decrease environmental pollutants
e. Avoid triggers which cause inflammation of airways, such as
allergens
3. If airways are affected, the diameter of the airways narrows causing an
increase in airway resistance.

C. General Causes of Airway Illnesses Are:

1. Infections which cause mucus and swelling
2. Allergens which cause swelling and bronchospasm
3. Foreign bodies which cause obstruction
4. Obstructive disorders: COPD, bronchiectasis
5. Restrictive disorders: kyphoscoliosis, abdominal distension, edema
6. Trauma: stab wound, surgery

Diagnostic Test

A. Chest X-ray: noninvasive procedure with no special preparation; lead shield

for women of childbearing age
B. Mantoux Test: positive result only indicates client was exposed to
Tuberculosis (TB); it is not diagnostic for active TB
1. Upper 1/3 inner surface forearm
2. Needle bevel up
3. 0.1 ml of purified protein derivative (PPD) subdermal
4. Read in 48-72 hours
5. Measure induration: if 10 mm or greater, it is a positive reading
 C. Sputum Examination: first morning specimen preferable, approximately 15
ml required; always obtain before initiating antibiotics

D. thoracentesis: aspiration of pleural fluid and/or air from the pleural space
1. Preparation
a. Consent and explanation
b. Position: sitting on side of bed with feet on chair, leaning over bedside
table
c. No more than 1,200 ml should be removed at one time
2. Post-procedure
a. Apply pressure to puncture site
b. Use Semi-Fowler's position or puncture site up
c. Monitor for shock, pneumothorax, respiratory arrest, subcutaneous
emphysema
d. Assess breath sounds

E. Bronchoscopy: examination of tracheobronchial tree using a bronchoscope

1. Preparation
a. Consent and explanation
b. NPO after midnight
c. ABG, oxygen administration

2. Post-procedure
a. Keep client NPO until return of gag reflex is confirmed
b. Monitor vital signs until stable
c. Assess for respiratory distress
d. Administer warm saline gargles after gag reflex returns
e. Use Semi-Fowler's position
f. Give water as first fluid
g. Inform client that it is possible to expectorate some blood
tinged mucus secretions, especially when a biopsy was
performed.

A. Chronic Airflow Limitation (CAL): also called Chronic Obstructive Pulmonary

Disease (COPD)
1. Definition: a group of chronic lung diseases including pulmonary
emphysema, chronic bronchitis, and bronchial asthma
2. Major diseases
a. Pulmonary emphysema ("pink puffer")
1. Definition: destruction of alveoli, narrowing of small airways
(bronchioles) and the trapping of air resulting in loss of lung
elasticity
 2. Etiology: cigarette smoking (#1 preventable cause of
respiratory problems), deficiency of alpha anti-trypsin
(enzyme that blocks the action of proteolytic enzymes that
are destructive to elastin and other substances in the alveolar
walls)
3. Manifestations
a. Shortness of breath
b. Difficult exhalation
c. Pursed-lip breathing
d. Wheezing, crackles
e. Shallow rapid respirations
f. Hypoxia
g. Productive cough
h. Respiratory acidosis
i. Barrel chest
j. Anorexia, weight loss
k. Finger clubbing

4. Nursing Interventions
a. Position sitting up, leaning forward
b. Provide pulmonary toilet
1. Bronchodilator medications via nebulization as ordered
2. Chest physiotherapy/pulmonary drainage (CPT/PD)
3. Assess if effective by checking the breath sounds and the pulse oximetry
on a routine basis.
c. Encourage frequent rest periods
d. Use intermittent positive pressure breathing (IPPB)
e. Administer oxygen at low flow (under most circumstances, limited to 1 liter, but
may go no higher than a maximum 3 liters or less): to prevent CO2 narcosis
f. Encourage fluids: 3000 cc per day if not contraindicated
g. Administer prophylactic antibiotics, as ordered
h. Provide appropriate nutrition: decrease carbohydrates in order to decrease
carbon dioxide. Increase calories and protein to meet increased energy
requirements. Lower intake of gas forming foods to decrease dyspnea and SOB.
i. Promote deep breathing exercises
j. Promote energy conservation exercises to enhance rest
k. Provide emotional support to decrease anxiety
l. Address sexual concerns
m. Provide teaching
1. Avoid crowds
2. Diaphragmatic breathing
3. Pursed-lip breathing
4. Report first sign of upper respiratory infection (URI)
5. Avoid allergens (examples: dust, odors, dander, etc.)
5. (blue bloater)
a. Definition: excessive mucus secretions within the airways and recurrent cough
b. Etiology: heavy cigarette smoking, pollution, infection

3. Manifestations
a. Cough (copious sputum)
b. Dyspnea on exertion, later at rest
c. Hypoxemia resulting in polycythemia: ruddy look to
skin, compensation
d. Crackles, rhonchi
e. Pulmonary hypertension leading to cor pulmonale and
signs of right heart failure such as peripheral
dependent edema

4. Nursing Interventions
a. Prevent exposure to irritants
b. Reduce irritants
c. Increase humidity: 70% is best
d. Relieve bronchospasm through deep breathing and
medications
e. Provide chest physiotherapy (CPT)
f. Provide postural drainage (PD)
g. Promote breathing techniques; same as COPD

c. Asthma
1. Definition: condition of abnormal bronchial hyperreactivity to
certain substances
2. Etiology
a. Extrinsic: antigen-antibody reaction triggered by food,
drugs, or inhaled particles
b. Intrinsic: pathophysiological conditions within the
respiratory tract, non-allergic form

3. Manifestations: acute attack

a. Severe, sudden dyspnea
b. Use of accessory muscles; for adults neck muscles; child will get
retractions
c. Sitting up
d. Diaphoresis
e. Anxiety, apprehension
f. Wheezing
g. Cyanosis: very late sign
h. Remember, an improvement in wheezes with no improvement in the
client's condition may actually indicate worsening of the condition
and tightening of airways to the point where air flow is diminishing
 i. Decrease in tidal volume is measured by a spirometer

4. Nursing Interventions
a. Remain with client
b. Use High-Fowler's position
c. Provide emotional support
d. Monitor respiratory status: ABGs, lung sounds, and pulse oximetry
e. Promote hydration with fluids
f. Administer epinephrine hydrochloride (Adrenalin) subcutaneously
and monitor its effectiveness
g. Administer aminophylline, theophylline and ethylenediamine
(Phyllocontin) IV

1. Monitor for side effects such as GI upsets (nausea and

vomiting) and seizures
2. Monitor theophylline level to assure therapeutic action and
eliminate toxic effects: therapeutic serum level is 10-20
mcg/ml

h. Provide bronchodilators via nebulization and metered dose inhalers

(MDI)
i. Monitor oxygen therapy
j. Administer corticosteroids: to decrease airway inflammation and
open airways

4. Status Asthmaticus: attack lasting more than 24 hours; medical emergency

h. Use High-Fowler's position

i. Monitor vital signs for signs of hypoxia
j. Monitor respiratory status
k. Administer aminophylline (Phyllocontin) IV as ordered
l. Administer bronchodilator therapy as ordered
m. Provide emotional support

B. Complications of CAL

1. Cor Pulmonale (form of heart failure)

a. Definition: right ventricular hypertrophy or failure secondary to disease of
the lungs, pulmonary vessels or chest wall
b. Etiology: causes increased pressure and pulmonary hypertension
1. Decrease in the size of the pulmonary vascular bed from destruction
of the pulmonary capillaries
2. Increased resistance of pulmonary capillary bed
 3. Shunting of unaerated blood across the collapsed alveoli

c. Manifestations: signs of heart failure; initially the right heart fails, then the
left heart fails because of decreased cardiac output
1. Right heart failure
a. Peripheral edema (dependent)
b. Jugular vein distension
2. Left heart failure
a. Dyspnea
b. Cyanosis
c. Cough
d. Substernal pain
e. Syncope on exertion
f. Paroxysmal nocturnal dyspnea (PND)and orthopnea

d. Nursing Interventions
1. Promote bed rest
2. Monitor oxygen therapy
3. Maintain low-sodium diet
4. Monitor for side effects of digitalis (Digoxin) and diuretics

2. Carbon dioxide narcosis/oxygen toxicity

a. Definition: near comatose state secondary to increased CO2 due to chronic
retention
b. Etiology: carbon dioxide retention and secondary to excessive oxygen
delivery
c. Manifestations: signs of hypoxia
1. Drowsy
2. Irritable
3. Hallucinations
4. Coma
5. Paralysis
6. Convulsions
7. Tachycardia
8. Arrythmias
9. Poor ventilation

d. Nursing Interventions
1. Avoid high concentrations of oxygen -keep below 3 L. per minute, no
more than 70% oxygen delivered. Make sure you know the
approximate concentration delivered by the oxygen delivery method
 you are using Cannula: 40%; mask: 60%; rebreather mask: 100%.
2. Monitor response to oxygen therapy; monitor blood gases. If
pCO2 level is above normal, it is not preferable to have the oxygen
at normal level because it will shut off the hypoxic drive which is
triggered by a low O2 level. This will cause client to go into
respiratory arrest.

3. Pneumothorax
a. Definition: collection of air or fluid in the pleural space. Can come from
outside chest wall or inside the lung.
b. Etiology
1. Trauma: gunshot, stabbing
2. Thoracic surgery: open thoracotomy
3. Positive pressure ventilation: causes segment of the lung to rip
open, expose pleural space.
4. Iatrogenic, adverse effects of
a. Thoracentesis
b. Central venous pressure line insertion
c. Unknown cause
c. Types
1. Spontaneous
2. Tension: due to build up of pressure. Results in a shift of the major
organs and vessels in the chest cavity.
3. Open: from trauma such as a gunshot or stab wound

d. Manifestations: depend on severity

1. Spontaneous
a. Sudden, sharp chest pain
b. Sudden shortness of breath with violent attempts to breathe
c. Hypotension
d. Tachycardia
e. Hyperresonance and decreased breath sounds over the affected
lung
f. Anxiety, diaphoresis, restlessness
2. Tension
a. Subcutaneous emphysema (crepitus), dyspnea
b. Cyanosis
c. Acute chest pain
d. Tympany on percussion
3. Mediastinal shift: contents of mediastinum pushed to unaffected side

a. Cyanosis
b. Tracheal deviation-away from injured side
 c. Cardiovascular compromise: may have signs and symptoms
depending on degree of deviation

e. Nursing Interventions
1. Remain with client and remain calm
2. Position in High-Fowler's
3. Assess vital signs and breath sounds
4. Provide oxygen therapy as ordered
5. Prepare for chest x-ray
6. Provide thoracentesis tray to reestablish negative pressure or relieve
pressure with tension pneumothorax
7. Monitor ABGs
8. Monitor for shock
9. Assist with insertion of chest tubes
a. At the bedside or in operating room by physician
b. Aseptic technique
c. Local anesthetic, stab wound
1. Upper for evacuation of air
2. Lower for evacuation of fluid
d. Occlusive dressing

Closed Chest Drainage

1. Purposes
a. Remove fluid and/or air from the pleural space
b. Reestablish normal negative pressure in the pleural space
c. Promote re-expansion of the lung
d. Prevent reflux of air/fluid into pleural space from the drainage apparatus
e. Used commonly after thoracic surgery or pneumothorax

2. General Principles: the nurse must ask the following when confronted with any
chest drainage system:
a. Where is the water seal? How can it be maintained?
b. What controls the suction in the system? Is it gravity or is it a negative
pressure? What is the setting?
c. Where does the drainage collect, and how can I maintain the patency of this
system? How can I measure the drainage?
3. Usage: the most commonly used today are disposable chest tube systems (Pleur-
evac,Thora-seal)
a. Replacing two and three-bottle systems, these are made of molded plastic
 to form three chambers.
1. Suction control chamber (closest to suction): when on should be
continuously bubbling. Amount is usually determined by a water
level in the suction control chamber.
2. Water seal chamber is middle seal; intermittent bubbling occurs if
there is air in the chest. In this area you will observe the rise and fall
of fluid in the system with respirations This is called tidaling.
3. Drainage collection (closest to chest tube)
b. Suction is controlled by the amount of water in the suction control chamber.
Make sure evaporation does not change the amount of suction by lowering
the water level.

4. Nursing Interventions
a. Check for bubbling and fluctuation
b. Assess respiratory status
c. Turn client; ask client to cough, deep breathe
d. Mark the amount of drainage at the beginning of each shift. Should see a
decrease in the amount over time.
e. Note character of drainage
f. Be sure tubing is without kinks, coiled on the bed
g. Keep bottles below level of heart
h. Maintain water seal
i. Maintain dry, sterile, occlusive dressing
j. Do not strip tubes, avoid milking
k. Obtain STAT Chest x-ray (CXR)
5. Removal of chest tubes: done by physician
a. Provide equipment: suture removal kit, sterile gauze, petroleum gauze,
adhesive tape
b. Use Semi-Fowler's or High-Fowler's position
c. Instruct client on that removal of tubes will be done during expiration or at
end of full inspiration
d. Apply air-occlusive dressing immediately
e. Obtain STAT Chest x-ray
f. Assess for complications: subcutaneous emphysema, respiratory distress.
Major complication is pneumothorax

D. Infectious Pulmonary Diseases

1. Tuberculosis
a. Reportable, communicable, infectious, inflammatory disease that can
occur in any part of the body
b. Etiology: mycobacterium tuberculosis (nonmo-tile, aerobic, killed by heat
and ultraviolet light); droplet nuclei spread by laughing, sneezing,
coughing. Can spread to other areas of the body and is called miliary TB.
Causes caseation in the lungs and Ghon tubercles which can stay with
the client for years, lay dormant then open again and reinfect the client.
c. Risk factors
1. Overcrowded, poor living conditions
 2. Poor nutritional status
3. Previous infection
4. Inadequate treatment of primary infection leads to multi-drug
resistant organisms
5. Close contact with infected person
6. Immune dysfunction or HIV
7. Long-term care facilities, prisons
8. Elderly
9. Substance abuse

d. Manifestations: same as other pulmonary inflammations and

infections
1. Productive cough
2. Night sweats, low-grade fever
3. Hemoptysis
4. Dyspnea
5. Malaise
6. Weight loss
7. Anorexia, vomiting, indigestion
8. Pallor

e. Diagnostic tests
1. Mantoux test
2. Sputum for acid-fast bacillus, x3
3. Chest x-ray
4. History and physical exam

f. Treatment
1. Chemotherapy (all are hepatotoxic)
a. Ethambutol (Myambutol): impairs RNA synthesis; side
effects: optic neuritis, skin rash
b. Rifampicin (Rifadin): impairs RNA synthesis; side
effects: red-orange color to urine and feces; negates
birth control pill; nausea, vomiting, thrombocytopenia
c. Isoniazid (INH): interferes with DNA synthesis used in
prophylactic treatment; side effects: peripheral
neuritis, hepatotoxicity, GI upset; must take vitamin
B6 (pyridoxine) (Beesix) in conjunction with this
therapy to prevent peripheral neuritis
d. Streptomycin; side effects: 8th nerve damage, use
with caution in renal disease. Should have hearing
tests done routinely.
1. Nursing Interventions
a. Teaching plan includes:
1. Preventive measures to avoid catching viral infections (infection control)
2. Drugs must be taken in combination to avoid bacterial resistance
3. Drugs should be taken either once each day or 2-3 times per week, but
always at the same time of day and on an empty stomach
4. Drugs must be taken for 6-12 months
5. Maintaining adequate nutritional status
6. Promoting yearly checkups
7. Make sure the client knows to have liver function tests.
b. Hospital care
1. Teaching: hand washing, cover nose and mouth when sneezing,
coughing
2. Wear special particulate respirator mask when in the client's room
3. Isolation room ventilated to outside (negative pressure room);
discontinued when client no longer considered infectious
4. Psychological support: reinforcement of the need to take medications.
Many clients choose to stop drug therapy.

POINTS TO REMEMBER:

5. Obtain sputum specimens before drug therapy is initiated

6. Multiple drug therapy is necessary to prevent the development of
resistant organisms
7. Give drugs in a single daily dose
8. Drug therapy must be continued for 6-12 months even though the x-ray,
sputum specimens, and manifestations are within normal limits
9. Client is generally considered noninfectious after 1-2 weeks of continuous
drug therapy
10. Avoid use of alcohol during drug therapy to reduce risk of hepatotoxicity

2. Pneumonia
a. Definition: inflammation of the lung parenchyma caused by infectious agents
b. Etiology: classified as community acquired or hospital acquired (nosocomial)
1. Community acquired
a. Streptococcus pneumoniae or pneumococcal
b. Haemophilus influenzae
c. Legionella pneumonia
d. Atypical pneumonia: most commonly seen in children; usual
organism is mycoplasma pneumoniae; differs from the others in
that minimal mucus is produced
2. Hospital acquired

1. Staphylococcus aureus
2. Klebsiella pneumoniae
3. Pseudomonas pneumoniae
 4. Fungi (various types, i.e., histoplasmosis)

c. Persons at risk
a. Elderly
b. Infants
c. Substance abusers
d. Cigarette smokers
e. Postoperative clients or those on prolonged bed rest
f. Clients with chronic illnesses such as COPD;CAL
g. Clients with AIDS - Pneumocystis carinii pneumonia (PCP)
h. Other immunosuppressed clients

d. Common manifestations
1. Sudden onset of chills, fever
2. Cough: dry and painful at first, later produces rusty colored sputum
3. Dyspnea
4. Flushed cheeks
5. Pallor, cyanosis
6. Pleuritic pain that increases with respiration
7. Tachypnea, tachycardia

e. Nursing Interventions
1. Administer drug therapy as ordered
a. Cough suppressants (be careful giving to children and clients
who have chest congestion; generally only given to them for
sleep), expectorants
b. Bronchodilators; teach use of metered dose inhaler
c. Antibiotics as ordered
d. Mild analgesic - to decrease pain and enable client to deep
breathe
2. Encourage ambulation as tolerated
3. Provide pulmonary toilet
4. Assess for sputum thickness, color
5. Administer oxygen to maintain oxygen saturations >95%
6. Provide small frequent meals, increase fluid intake
7. Maintain fluid and electrolyte balance
8. Isolate as indicated
9. Provide oral hygiene

POINTS TO REMEMBER:

10. Most pneumonias have a sudden onset

11. Penicillin remains the drug of choice for pneumococcal pneumonias
 (unless allergic to PCN)
12. Antibiotics must be given on time to maintain blood levels
13. Watch for side effects of penicillin therapy - especially allergies

E. Cancer of the Lungs (see also under oncology)

1. Definition: primary or secondary (metastatic from a primary site) malignant
tumor located in the lung or bronchi
2. Etiology: cigarette smoking, exposure to asbestos and other carcinogens
(coal dust, uranium, nickel)
3. Manifestations:
a. Asymptomatic in the early stages
b. Later stages:
1. Coughing
2. Wheezing
3. Dyspnea
4. Hemoptysis
5. Weight loss
6. Anorexia
7. Fever

c. Nursing Interventions
1. Support cessation of smoking
2. Postoperative care for lung excision
a. Pneumonectomy: removal of an entire lung (reasons: cancer,
abscess); postop: dorsal recumbent or Semi-Fowler's position on
affected side; range of motion to affected shoulder; no chest tube.
Make sure nursing interventions are instituted to prevent infection in
the other lung.
b. Lobectomy: removal of a lobe for TB or abscess; postop: chest tube
c. Segmentectomy: removal of a lobe(reason: infection in localized
area); postop: chest tube
d. Wedge resection: removal of a small portion of lung tissue (reason:
small localized area of disease near the surface of the lung); postop:
chest tube
3. Encourage turn, cough, deep breathe
4. Administer oxygen
5. Provide pain interventions so that client will be able to move and deep
breathe
6. Promote fluids to maintain thin respiratory tract secretions
7. Instruct client to splint chest incision when coughing
8. Teach client exercises for arm on affected side to prevent frozen shoulder
9. Place needed articles on side of surgery so client will move arm to get them
10. Assess wound for infection
Pulmonary Therapies

A. Chest Physiotherapy (CPT) (using cupped hands)

1. Definition: percussion and vibration over the thorax to loosen secretions in
the affected areas of the lung
2. Procedure
a. Keep a layer of material (gown or pajamas) between your hands and
the client's skin
b. Stop if pain occurs
c. Best time to do is in the morning upon rising, 1 hour before meals or
2-3 hours after meals
d. Client must be instructed to deep breath and cough during the
procedure
e. Should be followed with oral hygiene
3. Contraindications

1. When bronchospasm is increased by its use

2. History of pathological fractures, rib fractures, or osteoporosis
3. Obesity
4. New incisions in the chest area or upper abdominal area
5. Pain in the chest
B. Postural Drainage

1. Definition: use of gravity to drain secretions from segments of the lung; may
be combined with chest PT
2. Nursing Interventions
a. Proper positioning (lung segment to be drained is uppermost)
b. Stop if cyanosis or exhaustion increases
c. Provide mouth care after procedure; best time is in the morning upon
rising, 1 hour before meals or 2-3 hours after meals
d. Maintain position 5-20 minutes or as tolerated
3. Contraindications
a. Unstable vital signs
b. Increased intracranial pressure
B. Pulmonary Toilet
1. Cough
2. Breathe deeply
3. Chest PT
4. Turn and position

A. Body Fluids
1. Adults
a. Women: 50-55% body weight is water
b. Men: 60-70% body weight is water
c. Infant: 75-80% body weight is water
 d. Elderly: 47% body weight is water
2. Intracellular: 80% of total body water
3. Extracellular: 20% of total body water
a. Interstitial
b. Intravascular (plasma)
c. Other: cerebrospinal fluid, intraocular fluid, bone water, gastrointestinal
secretions

B. Electrolytes (normal values may vary slightly between institutions and laboratories)
1. Extracellular
a. Na+ 135-145 mEq/1
b. Ca++ 8-10mg/dl
c. Cl- 85-115 mEq/1
d. HCO3- 22-29 mEq/1
2. Intracellular
a. K+ 3.5-5.5 mEq/1
b. PO4 2.5-4.5 mg/dl
c. Mg+ 1.3-2.0 mEq/l
3. Electrolytes Functions
a. Promote neuromuscular excitability
b. Maintain fluid volume
c. Distribute water between fluid compartments
d. Regulate acid-base balance

C. Movement of Fluids and Electrolytes

1. Diffusion: molecules move from an area of higher concentration to an area
of lower concentration
2. Osmosis: water moves from an area of lower concentration of particles to
an area of higher concentration
3. Filtration: water and dissolved substances move from an area of greater
hydrostatic pressure to an area of lower hydrostatic pressure.
4. Types of solution
a. Isotonic 0.9% NaCl

1. Same osmolarity as plasma

2. Example: D5W: To replace fluid volume or increase ADH activity
b. Hypertonic 3.0% NaCl
c. Hypotonic 0.45% NaCl
2. Types of pressures

1. Osmotic
2. Hydrostatic

D. echanisms of Fluid Balance

1. Kidneys: regulate fluids and electrolytes, secrete renin
2. Lungs: regulate CO2 levels, water vapor
3. Skin: regulate fluid losses (sweat)
 4. Types of solution
a. ADH (antidiuretic hormone)
b. Aldosterone
c.

Assessment of Fluids

a. Daily Weight
b. Skin Turgor
c. Intake and Output
d. Fontanel
e. Orbits of Eyes
f. Urine Specific Gravity

1. Fluid volume deficit: water and electrolytes lost in same proportion (blood and urine
become concentrated)
a. Causes
1. Fever
2. Vomiting
3. Diarrhea or ostomy losses
4. Increased urine output
5. Increased respirations
6. Use of diuretics
7. Insufficient IV fluid replacement
8. Draining fistulas
9. Third spacing (burns, ascites)

b. Manifestations
1. Weight loss
2. Poor skin turgor
3. Urine: decrease in volume, dark, odorous, increased specific gravity
4. Increased respirations
5. Dry mucous membrane
6. Increased heart rate
7. Increased hematocrit (hemoconcentration)
8. Decreased central venous pressure (CVP)

c. Nursing Interventions
1. Weigh client daily
2. Monitor intake and output
3. Replace fluid-P.O. or IV (Lactated Ringers, 0.9% NS) per order
4. Measure urine specific gravity
 5. Correct underlying cause

2. Fluid volume excess

a. Causes
1. Excessive IV fluids
2. Decreased kidney function, congestive heart failure (CHF), cirrhosis
3. Excessive ingestion of table salt

b. Manifestations (same as CHF)

1. Cough, dyspnea, crackles, tachypnea
2. Increased blood pressure, pulse
3. Decreased hematocrit (hemodilution)
4. Headache
5. Weight gain (1 liter of water = 1 kg of weight gain)
6. Increased CVP
7. Flushed skin
8. Late Signs
a. Neck vein distention
b. Tachycardia
c. Pitting edema

c. Nursing Interventions
1. Administer diuretics - furosemide (Lasix) as per order
2. Restrict fluids, monitor intake and output
3. Weigh client daily
4. Provide skin care
5. Use Semi-Fowler's position
6. Maintain low-sodium diet

Regulation of Body pH

1. Normal value is 7.35-7.45

2. Mechanisms regulating pH
a. Chemical buffers: protein molecules, phosphate
b. Lungs: control carbon dioxide levels
c. Kidneys: bicarbonate

Perfusion Incentive

1. Increase in Heart Rate - Tachycardia

2. Increase in Respiration - Tachypnea
3. Decrease in Circulation in Lower extremities - Vasoconstriction
4. Decreased urine output - Oliguria
5. Increased Bone marrow production - Thick Blood

A. Acid-Base Imbalance
1. Metabolic acidosis
a. Definition: Base Bicarbonate Deficit - increase in hydrogen ion
concentration
b. Causes

1. Long-Term Diarrhea
2. Renal failure
3. Systemic infections
4. Diabetic acidosis
5. Starvation, malnutrition, ketogenic (high-fat) diet

c. Manifestations
1. Headache
2. Confusion, stupor
3. Loss of consciousness
4. pH below 7.35
5. HCO3-below 22
6. Tachypnea (increased respirations) or Kussmaul's
respirations

d. Nursing Interventions
1. Promote good air exchange
a. Semi-Fowler's Position
b. Incentive Spirometer
c. Coughing and Deep Breathing
2. Monitor K+ level
3. Give sodium bicarbonate, as ordered

2. Metabolic alkalosis
a. Definition: Base Bicarbonate Excess - decrease in hydrogen ion
concentration
b. Causes
1. Vomiting (excessive loss of chloride)
2. Gastric suction
3. Alkali ingestion (excessive bicarbonate)
 4. Long-term diuretic therapy

3. Respiratory acidosis
a. Definition: Excess Carbonic Acid - increase in hydrogen ion concentration
b. Causes
1. Acute: respiratory suppression or obstruction due to pulmonary edema,
over-sedation, pneumonia
2. Chronic: chronic airflow limitation (CAL) Or COPD

c. Manifestations
1. Acute
a. Confusion
b. Restlessness
c. Weakness
d. Headache
e. Coma
f. pH below 7.35
g. pCO2 above 45 mm Hg
2. Chronic (These symptoms are classic signs of COPD)
a. pCO2 above 45 mm Hg
b. Tachypnea
c. Dyspnea
d. Weight loss

d. Nursing Interventions
1. Administer sodium bicarbonate per order
2. Promote good respiratory exchange
3. Administer bronchodilators per order
4. Monitor arterial blood gases (ABGs)

4. Respiratory alkalosis
a. Definition: carbonic acid deficit; decrease in hydrogen ion
concentration
b. Causes
1. Hyperventilation - secondary to pain, anxiety, thyroid
toxicosis
2. Decreased O2 (pneumonia, pulmonary edema)
3. Elevated body temperature
4. Salicylate intoxication

c. Nursing Interventions
1. Have client breathe into paper bag
 2. Have client breathe into cupped hands
3. Provide oxygen, if hypoxic

d. Manifestations
1. Unconsciousness
2. Circumoral numbness
3. pCO2 below 35 mm Hg

B. Blood Gases
1. Arterial Blood Gases (ABG)s
a. Most accurate means of assessing respiratory function
b. Must be sterile, anaerobic
c. Drawn into heparinized syringe
d. Keep on ice and transport to lab immediately
e. Document amount of oxygen delivered
f. Document client's body temperature
g. Apply pressure to site for 5-10 minutes
2. Components

pH measure of acidity or alkalinity of blood

     N = 7.35-7.45
pCO2 partial pressure of carbon dioxide respiratory parameter influenced by lungs only
     N = 35-45, remember this by taking the seven away from pH
Hypoventilation results in hypercapnia (high CO2)
Hyperventilation results in hypocapnia (low CO2)
pO2 partial pressure of oxygen measure of amount of oxygen delivered to the lungs
     N = 80-100
HCO3- bicarbonate, metabolic parameter influenced only by metabolic factors
     N = 22-26

Respiratory & Metabolic Acidosis vs.

Alkalosis
R - Respiratory
O - Opposite
      High pH and Low in pCO2 = Alkalosis
      Low in pH and High in pCO2 = Acidosis
M - Metabolic
E - -Equal
      High in pH and High in HCO3 = Alkalosis
      Low in pH and Low in HCO3 = Acidosis
TABLE 1-2. ACIDOSIS/ALKALOSIS
  pH pCO2 HCO3-      
 Respiratory Acidosis  low high Normal or high        
Respiratory  high low Normal or low
Alkalosis
Metabolic  Acidosis low low low
Metabolic  Alkalosis high high high

RESPIRATORY RESPIRATORY ALKALOSIS

ACIDOSIS
pH                    7.32 pH            7.48
pCO2               48 pCO2       33                       
HCO3-             20 HCO3-     28
pO2                 90 pO2         90
METABOLIC METABOLIC ALKALOSIS
ACIDOSIS
pH                    7.32 pH            7.48                    
pCO2               30 pCO2       38                       
HCCV             20 HCO3-     28
pO2                 90 pO2         90                       

Starting an IV - Overview of the Skill

   
Overview: Performing venipuncture in order to establish venous access is a
priority for clients with fluid and electrolyte disturbances, clients who
are critically ill, clients who are NPO after surgery, or clients who for
other reasons are not able to take fluids or food by mouth. Venous
access can be used for infusions of IV fluids, emergency medications,
parenteral nutrition, blood products, and routine IV medications.
 
There are a variety of IV needles and catheters. They vary in gauge
from small bore to large bore. A 20 to 22-gauge flexible catheter is
used for adults while a 22 to 24-gauge catheter is used for pediatric
clients. If large volumes of fluid or blood products are anticipated to be
given, a larger bore (18 or 19-gauge) is recommended.
  
A commonly used angiocatheter has an over-the-needle catheter
(ONC) made of plastic, Teflon, or other materials. These flexible
catheters have a metal stylet that is used to pierce the skin and vein
and a plastic catheter that is threaded into the vein and attached to
the IV tubing after the stylet has been removed.
 
The other type of IV needle is a straight steel needle that is inserted
into the vein and secured after being attached to an IV tubing. With an
increased emphasis on safety, many health care facilities use a
safety-shielded intravenous catheter or retractable needle system
when placing a peripheral intravenous line. This consists of a
traditional metal stylet used for the skin puncture covered by the
plastic or Teflon angiocatheter. Once the intravenous line is
successfully placed, the health care provider initiating the IV pushes a
button and the stylet retracts completely into a protective casing,
thereby reducing the risk of needle-stick injury.
 
Needle sticks are common among health care workers, so strict care
in handling needles while starting an IV is imperative. Centers for
Disease Control and Prevention (CDC) guidelines must be followed in
order to decrease the risk of infection for the client such as changing
the IV solution every 24 hours, changing the IV site and catheter
every 48 to 72 hours, and changing the IV tubing every 48 hours.
Occupational Safety and Health Administration (OSHA) standards are
necessary to prevent exposure to blood-borne pathogens through the
use of gloves, puncture-resistant containers for sharps, and special
training for health care workers (see Figure 8-2-1).
   

   
Assessment: 1. Check the health care provider's order for the type of therapy
planned to determine the optimal needle size and type to use.
2. Review information regarding the insertion of the IV in order to
insert the catheter safely.
3. Know the agency's policy regarding who may start an IV as many
agencies require that nurses have special training before they
can perform this procedure.
4. Assess the client's veins to optimize planning of the IV site.
5. Check the client's fluid, electrolyte, and nutritional status to provide
baseline data for comparison with the client's response to IV
therapy.
6. Assess the client's understanding of the purpose of the procedure so
 that client teaching can be used to decrease anxiety.

   

   
Diagnosis:  Deficient Knowledge, related to the need for IV therapy
 Risk for Infection
 Excess Fluid Volume
 Deficient Fluid Volume
 Impaired Skin Integrity

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-2-2):
Needs:
 

 Appropriate safety needle or catheter for venipuncture

 Tourniquet
 Povidone-iodine swabs (3) or chlorhexidine alcohol (chloroprep)
 Alcohol swab sticks (3) (not needed if using chlorhexidine alcohol)
 Disposable gloves
 Arm board, if needed
 Towel or absorbent drape
 Povidone-iodine ointment (not used in all institutions)
 Gauze dressing
 Tape
 Scissors
 IV tubing and solution

   

   
Expected 1. The IV will be inserted into the vein without complications and will
Outcomes: remain patent.
2. Fluid and electrolyte balance will be restored to the client.
3. Nutrition will be restored or maintained.
4. The IV site will remain free of swelling and inflammation.

   

   
Client 1. Give the client oral and written instructions about the insertion of an
Education IV.
Needed: 2. Teach the client to report any signs of inflammation, clotting, leaking,
or breaking.
3. Teach the client how to bathe without getting the dressing wet.
4. Instruct the client how to prevent the IV from becoming dislodged.
5. Instruct the client how to properly position the arm to maintain IV flow
if the IV is positional.
6. Teach the client how to walk with an IV pole.
7. Suggest client wear clothes with wide sleeves.
8. Discuss with the client what activities he or she engages in to be
sure such activities are safe and will not cause damage to the IV

Starting an IV - Implementation—Action/Rationale

   
Implementation ACTION RATIONALE
Action/Rational 1. Check health care provider's 1. Ensures accurate insertion of
e order for an IV and identify catheter.
client.
2. Wash hands and put on mask 2. Reduces the transmission of
and gown if needed. microorganisms.
3. Organize all equipment at 3. Ensures smooth procedure
bedside. without accidents or
contamination.
4. Explain procedure and reason 4. Information decreases anxiety.
the catheter is being inserted.
5. Inspect potential veins to be 5. Promotes ease of placement of
used: catheter.

 Place a tourniquet  Distends vein to allow

around the upper arm
close to the axilla.
 Examine the veins as
they dilate.
 Palpate the vein to test
for firmness (see Figure
8-2-3).
 Release the tourniquet.
visual and tactile
examination.
 To evaluate the viability of
the vein.
 To determine the best site
for venipuncture and IV
placement.
 Prevents engorgement of
vein.

6. Select vein for venipuncture: 6.  If the vein is later

damaged, the proximal

 Use most distal part of
the vein first.
 Avoid bony
prominences.
 Avoid client's wrist or
hand.
 Avoid client's dominant
hand and arm.
 Avoid an extremity with
decreased sensation.
 Avoid an area of skin
affected by a rash or
infection.
part can be used.
 Increases client comfort.
 Bending of the wrist or
hand increases the risk of
infiltration or phlebitis.
 Allows freedom of
movement.
 Promotes earlier detection
of infiltration.
 Decreases risk of
infection.

7. Select safety shield or 7. Necessary to puncture vein.

angiocatheter that is
appropriate for ordered IV fluid.
Select the correct size of gauge
and length of catheter.
8. Prepare supplies:
 Place towel or drape on
table for supplies.
 Place supplies on towel.
 Open needle adapter
end of IV tubing set.
Angiocatheter gauge sizes vary
widely. Particular intravenous
therapies, such as transfusions,
require specific sizes of
intravenous access. Age and
quality or location of veins can
affect choice of size.
8. Provides a clean working surface
for an efficiently performed
procedure.

9. Shave hair on skin at site if 9. Ensures adherence of dressing

necessary.
10. Ask client to rest arm in a
dependent position, if possible.
11. Put on disposable gloves.
12. Prepare insertion site
(see Figure 8-2-4):
 Place absorbent drape
under the arm.
 Scrub the insertion site
and that removal is less painful.
Shaving should be avoided as it
causes small abrasions that
increase the risk of infection.
10. Allows better venous dilation and
visibility.
11. Reduces transmission of
microorganisms.
12.  Reduces transmission of
microorganisms.
 Alcohol removes fat on
the skin and vigorous in
circular motion with
povidone-iodine removes
 with 3 alcohol swabs
then 3 povidone-iodine
swabs.
 Follow institution
protocol. Some facilities
use chlorhexidine
alcohol instead of iodine.
 Allow the antiseptic
solution to air dry.
13. Apply tourniquet 5 to 6 inches 13. Tourniquet is needed to allow the
above the insertion site.
 Secure it tightly enough
to occlude venous flow,
not arterial flow.
 Check presence of distal
pulse.
14. Perform the venipuncture: 14.
 Anchor the vein by
placing thumb over vein
and stretching the skin
against the direction of
insertion 2 to 3 inches
distal to the site.
 Insert the stylet needle
at a 20 to 30° angle with
the bevel up (see Figure
8-2-5).
 Watch for a quick blood
return through the
flashback chamber of
the ONC.
 Verify needle placement
in a vein, not artery.
 Advance ONC 1/4 inch
into the vein while it is
parallel to the skin.
 Loosen stylet and
advance catheter into
vein until hub rests at
venipuncture site
(see Figure 8-2-6).
 Do not reinsert stylet.
bacteria. Using a separate
swab and starting in the
middle of the site working
outward prevents bacteria
from being reintroduced to
the site.
 Povidone-iodine or
chlorhexidine alcohol
must be dry to be
effective.
vein to engorge for easier
venipuncture.
 Decreased arterial flow
prevents venous filling.
 Ensures arterial flow is
present.
 Stabilizes the vein for
ease of venipuncture.
 Prevents puncture of
posterior wall of vein.
 Venous pressure from
tourniquet causes
backflow of blood into
catheter or tubing.
 Some veins are close to
an artery. Arterial blood is
bright red and pulses.
 Ensures the catheter is in
the vein.
 Ensures proper
placement of the catheter.
 Prevents the catheter
from being punctured by
the stylet.
 Prevents blood from
leaking out of vein until IV
tubing is connected.
 Re-establishes venous
blood flow.
  Hold thumb over vein
above catheter tip.
 Release the tourniquet.

15. Attach IV tubing to ONC. 15.  Maintains catheter

placement.
 Stabilize the catheter  Provides entry portal for
with one hand. IV fluids. Reduces risk of
 Remove the stylet from inadvertent needle-stick
injury.
ONC or if using a safety
 Reduces blood loss.
catheter push the button
 Prompt initiation of
on the protective casing
and stylet will fully infusion maintains
patency of IV.
retract into the casing.
 Quickly release pressure
over vein and quickly
connect needle adapter
of IV set to hub of ONC.
 Begin infusion at slow
rate to keep vein open
(see Figure 8-2-7).

16. Secure catheter in place: 16.  Ensures catheter's safe

 Place tape over the hub
of the catheter.
 Place transparent
dressing over the site
and secure.
 Secure tubing in loop
fashion with tape.
position.
 Controls bleeding and
prevents infection. Allows
visualization of site
through transparent
dressing.
 Prevents dislodgement of
IV if tubing is pulled.

17. Remove gloves and dispose 17. Reduces transmission of

with all used materials. microorganisms.
18. Place label with date and time 18. Provides information to schedule
of insertion and size and gauge next dressing change.
of catheter on the dressing.
Follow protocol for scheduled
dressing change.
19. Wash hands. 19. Reduces transmission of
microorganism

Starting an IV - Post-Skill

   
Evaluation:  The IV was inserted into the vein without complications and
remains patent.
 Fluid and electrolyte balance were restored to the client.
 Nutrition was restored or maintained.
 The IV site remains free of swelling and inflammation.

   

   
Documentation: Nurses' Notes
 

 Note date and time the IV was inserted.

 Document type and gauge of catheter.
 Record date of dressing placement.
 Describe client's reaction to the procedure.
 Document fluid to be infused or if a saline or heparin lock.

   

   
   
Variations

   
Geriatric Variations:  The veins of elderly clients may be more fragile. Be aware of
this when assessing IV sites for continued patency.
 Be careful to use only minimal pressure of the tourniquet
because of fragile skin and veins.
 Use a 5 to 15° angle when inserting the needle as the elderly
client's veins are more superficial.
 Elderly clients develop fluid imbalances more rapidly because of
a larger extracellular fluid volume.
 Some elderly clients may have cardiac or renal failure that
requires specialized IV therapy because of increases in vascular
volume or inability to eliminate extracellular fluid.
 Tourniquet should be left in place a minimal amount of time
because of more fragile veins in the elderly.

   

   
Pediatric  In neonates, veins of the scalp and feet can be used.
Variations:  Use the smallest gauge needle possible according to the IV
therapy needed.
 Special precautions are needed to maintain an intact IV in very
young clients.
  Allow older children to help in the selection of the IV site in order
to increase cooperation and decrease anxiety.
 Teenagers and young adults often have thicker, tougher skin
than a middle-aged client. The nurse should bear this in mind
when starting an IV on someone this age.

   

   
Home Care  A more secure dressing may be necessary if the client is active.
Variations:  Ensure that containers for proper disposal of equipment are in
place.
 Arrange for delivery of IV supplies.

   

   
Long-Term Care  Clients in the long-term care setting may have more contact with
Variations: nurses' aides than with nurses. The aides must be taught to
recognize and report IV infiltrations or other problems.
 Be sure to assess the IV site often and to change the IV site
every 3 days or according to the policies of the institution.

   
Starting an IV - Common Errors

   
Possible The catheter is noted to be pulled out 1 inch at the time of the dressing
Errors: change.
   

   
Prevention: Be sure to secure the catheter with tape. Advise the client to be careful of the
catheter during activity. If the catheter is pulled out, do not push catheter
back into vein. Check for patency of the catheter. If it is patent, it may
continue to be used when properly secured. If it is not patent, it will need to
be replaced.
   

   
Nursing Tips:  Methods to promote venous dilatation are:
o Stroking the extremity from distal to proximal below the
proposed venipuncture site
o Opening and closing the fist
o Light tapping with two or three fingers over the vein
o Applying a warm washcloth or other heat to the extremity
  Be sensitive to the client's dominant arm and need for some
movement.
 Use 18-gauge or larger needle if the infusion of blood products is
anticipated.
 Always insert the IV needle/catheter in the direction of venous return
(toward the heart) to avoid damaging the venous valve.


   

   
   
Critical Thinking Skill

   
Introduction: When an IV infiltrates, it damages the vein and tissue surrounding it. Some
clients require multiple venipunctures to maintain a patent IV. It is necessary
to preserve the veins that are remaining for future use.
   

   
Possible An elderly gentleman was admitted to the cardiac intensive care unit after
Scenario: complaining of chest pains. The nurse noted that the IV inserted in the
emergency room was placed in the large vein in the antecubital space. A
large-bore needle was used in case emergency medications were needed.
However, the site appeared to be slightly swollen after the client had been
moving his arm around during transport.
   

   
Possible The nurse assessed the IV site and determined that the IV was still patent.
Outcome: As the site was already punctured and a large-bore needle was used, the
nurse decided to place the client's arm on an arm board to prevent further
trauma and continued to use this site. Shortly afterward, the client's blood
pressure started to drop and his physician ordered dopamine to be started
immediately. The nurse started to hang the dopamine and reassess the IV
site and noted that the site was definitely swollen and infiltrated. This was the
client's only venous access site, and with his low blood pressure, obtaining a
new venous access site was difficult and time consuming. The nurse was
able, finally, to secure a new IV site and the dopamine infusion was started.
The client's blood pressure was stabilized but his life was unnecessarily
jeopardized by the lack of patent venous access.
   

   
Prevention: The nurse looked for another vein more distal on the opposite arm
after asking the client which was his dominant arm, and was
successful in starting a large-bore IV that was in a much more
comfortable site and preserved the proximal sites for later use if
needed. The nurse then removed the IV that would soon be infiltrated.
 
In emergency situations, it is not always possible to select a
comfortable site; however, planning for short-term IV therapy should be
done whenever possible.

Inserting a Butterfly Needle - Overview of the Skill

   
Overview: Performing a venipuncture in order to establish a venous access is a
priority for clients with fluid and electrolyte disturbances, clients who
are critically ill, clients who are NPO after surgery, or clients who for
other reasons are not able to take fluids or food by mouth. Venous
access can be used for infusions of IV fluids, emergency medications,
parenteral nutrition, blood products, and routine IV medications.
 
There are a variety of IV needles and catheters. They vary in gauge
from small bore to large bore. A 20 to 22-gauge flexible catheter is
used for adults while a 22 to 24-gauge catheter is used for pediatric
clients. If large volumes of fluid or blood products are expected to be
given, a larger bore (18 or 19-gauge) is recommended.
A butterfly needle is commonly used for short-term venous access or
for pediatric clients. It is called a butterfly because of the flexible wings
on either side of a short needle and 2 to 3-inch tubing that ends with a
hub. This design makes it easy for the nurse to guide the needle into
a vein to draw blood or to infuse medication or fluid. Unlike the flexible
catheters commonly used for IVs, the butter- fly needle uses a rigid,
sharp needle as the venous access port. Because the sharp tip
remains in the vein during the IV infusion, infiltration of the IV is more
common than with the flexible catheter. Butterfly needles are not
commonly used for long-term IV therapy, although they may still be
used in clients who have very small veins or in areas where a larger
catheter cannot be advanced into the vein. Butterfly needles may be
used when venous access is only required for short-term IV therapy.
When a butterfly needle has been used for IV access, the nurse must
check the IV site frequently for infiltration.
   
   
Assessment: 1. Assess the purpose of the IV. Butterfly needles are more often
used in short-term IV therapy.
2. Assess the client's veins. A butterfly needle may be necessary if
the client's veins are small or the vein is in a difficult position to
access.
3. Check the client's fluid, electrolyte, and nutritional status to provide
baseline data for comparison with the client's response to IV
therapy.
4. Assess the client's understanding of the purpose of the procedure so
that client teaching can be used to decrease anxiety.

   

   
Diagnosis:  Deficient Knowledge
 Excess Fluid Volume
 Deficient Fluid Volume
 Risk for Infection
 Impaired Skin Integrity
 Risk for Injury

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-3-1A and B):
Needs:
 

 Appropriate gauge butterfly needle for venipuncture

 Tourniquet
 Povidone-iodine swabs (3) or chlorhexidine alcohol
 Alcohol swab sticks (3) (not needed if use chlorhexidine alcohol)
 Disposable gloves
 Arm board, if necessary
 Towel or absorbent drape
 Povidone-iodine ointment
 Gauze dressing or transparent dressing
 Tape
 Scissors
 IV tubing and solution

   
   
Expected 1. The IV will be inserted into the vein without complications and will
Outcomes: remain patent.
2. The IV site will be without signs or symptoms of infiltration.
3. The IV will be started and will infuse with a minimum of trauma and
discomfort to the client.

   

   
Client 1. Teach the client to report any signs of inflammation or swelling.
Education 2. Teach the client how to bathe without getting the dressing wet.
Needed: 3. Instruct the client how to prevent the IV from becoming dislodged.
4. Provide written and oral instructions about the care of an IV.
5. Instruct the client how to properly position the arm to maintain IV flow
if the IV is positional.
6. Teach the client how to walk with an IV pole.
7. Discuss with the client what activities he or she engages in to be
sure such activities are safe and will not cause damage to the IV.

Inserting a Butterfly Needle - Implementation—Action/Rationale

   
Implementation ACTION RATIONALE
Action/Rational 1. Check health care provider's 1. Ensures accurate insertion of IV
e order for an IV, and identify needle.
client.
2. Wash hands; put on mask and 2. Reduces the transmission of
gown, if needed. microorganisms.
3. Organize all equipment at 3. Ensures smooth procedure
bedside. without accidents or
contamination.
4. Explain procedure and reason 4. Information decreases anxiety.
the IV needle is being inserted.
5. Inspect potential veins to be 5. Promotes ease of placement of
used (see Figure 8-3-2): IV needle.

 Place a tourniquet  Distends vein to allow

around the upper arm visual and tactile
close to the axilla. examination.
 Examine the veins as  To assess blood return in
they dilate. veins.
 Palpate the vein to test  To assess fragility of
for firmness. veins.
  Release the tourniquet.
6. Select vein for venipuncture:
 Use most distal part of
the vein first.
 Avoid bony
prominences.
 Avoid client's wrist or
hand.
 Avoid client's dominant
hand and arm.
 Avoid an extremity with
decreased sensation.
 Avoid an area of skin
affected by a rash or
infection.
7. Select appropriate gauge
butterfly needle.
8. Prepare supplies:
 Place towel on table for
supplies.
 Place supplies on towel.
 Open needle adapter
end of IV tubing set.
9. Clip hair on skin at site if
necessary.
10. Ask client to rest arm in a 10. Allows better venous dilation and
dependent position, if possible.
11. Put on disposable gloves.
12. Prepare insertion site:
 Place absorbent drape
under the arm.
 Scrub the insertion site
with 3 alcohol swabs
then 3 povidone-iodine
 Prevents engorgement of
blood.
6.  If the vein is later
damaged, the proximal
part can be used.
 Increases client comfort.
 Bending of the wrist or
hand increases the risk of
infiltration or phlebitis.
 Allows freedom of
movement.
 Promotes earlier detection
of infiltration.
 Decreases risk of
infection.
7. Chooses needle necessary to
puncture vein.
8. Provides a clean working surface
for an efficiently performed
procedure.
9. Ensures adherence of dressing
and that removal is less painful.
Shaving should be avoided as it
causes microscopic abrasions
that increase the risk of infection.
visibility.
11. Reduces transmission of
microorganisms.
12.  Reduces transmission of
microorganisms.
 Alcohol removes fat on
the skin and vigorous
scrubbing in circular
motion with povidone-
iodine removes bacteria.
Using a separate swab
 swabs or chlorhexidine
alcohol antiseptic
solution (see Figure 8-3-
3).
 Follow institution
protocol for cleaning
insertion site regarding
use of iodine or
chlorhexidine alcohol.
 Allow the antiseptic
solution to dry.
13. Apply tourniquet 5 to 6 inches 13. Tourniquet is needed to allow the
above the insertion site.
 Secure it tightly enough
to occlude venous flow,
not arterial flow.
 Check presence of distal
pulse.
14. Perform the venipuncture: 14.
 Anchor the vein by
placing thumb over vein
and stretching the skin
against the direction of
insertion 2 to 3 inches
distal to the site.
 Grasp the wings of the
butterfly needle and
insert the butterfly
needle at a 20 to 30°
angle with the bevel up
slightly distal to the
venipuncture site
(see Figure 8-3-4).
 Watch for a blood return
through the tubing of the
butterfly needle.
 Verify needle placement
in a vein, not artery.
 Advance the butterfly
needle into the vein until
the hub rests at the
and starting in the middle
of the site working
outward prevents bacteria
from being reintroduced to
the site.
 Many institutions have
switched to chlorhexidine
alcohol swabs as clients
may be sensitive to
iodine.
 Povidone-iodine or
chlorhexidine alcohol
must be dry to be
effective.
vein to engorge for easier
venipuncture.
 Decreased arterial flow
prevents venous filling.
 Ensures arterial flow is
present.
 Stabilizes the vein for
ease of venipuncture.
 Prevents puncture of
posterior wall of vein.
 Venous pressure from
tourniquet causes
backflow of blood into
tubing.
 Some veins are close to
an artery. Arterial blood is
bright red and pulses.
 Ensures the IV needle is
in the vein and proper
placement of the IV
needle.
 Re-establishes venous
blood flow.
 venipuncture site
(see Figures 8-3-
5 and 8-3-6).
 Release the tourniquet.

15. Attach IV tubing to butterfly 15.  Maintains IV needle

needle. placement.
 Reduces blood loss.
 Stabilize the needle with  Prompt initiation of
one hand. infusion maintains
 Connect needle adapter patency of IV.
of IV set to hub of
butterfly needle tubing.
 Begin infusion at slow
rate to keep vein open.

16. Secure needle in place 16.  Ensures needle's safe

(see Figure 8-3-7): position.
 Controls bleeding and
 Place tape over the prevents infection. Allows
wings of the butterfly visualization of site.
needle.
 Place transparent
dressing over insertion
site and secure.

17. Remove gloves and dispose of 17. Reduces transmission of

all used materials. microorganisms.
18. Place label with date and time 18. Provides information to schedule
of insertion and size and gauge next dressing change.
of needle on the dressing.
19. Wash hands. 19. Reduces transmission of
microorganism

Inserting a Butterfly Needle - Post-Skill

   
Evaluation:  The IV was inserted into the vein without complications and
remains patent.
 The IV site is without signs or symptoms of infiltration.
 The IV was started and is infusing with a minimum of trauma
and discomfort to the client.

   
   
Documentation: Nurses' Notes
 
Note the following:
 

 Date and time IV was started

 Type and gauge of needle used
 Insertion site
 Type of dressing placed over site
 Any unusual occurrences during the IV insertion
 Type and rate of fluid

   

   
   
Variations

   
Geriatric Variations:  The veins of elderly clients may be more fragile so care must be
taken not to traumatize them with the tip of the needle.
 Be careful to use only minimal pressure of the tourniquet
because of fragile skin and veins.
 Use a 5 to 15° angle when inserting the needle as the elderly
client's veins are more superficial.

   

   
Pediatric  In neonates, veins of the scalp and feet can be used.
Variations:  Use the smallest gauge needle possible according to the IV
therapy needed.
 Special precautions are needed to maintain an IV intact in very
young clients. Restraints may be required to immobilize the IV
site.
 Allow older children to select the IV site in order to increase
cooperation and control.

   

   
Home Care  The butterfly needle can be inserted in the home by a nurse.
Variations:  A more secure dressing may be necessary if the client is active.
 Ensure that containers for proper disposal of equipment are in
 place.

   

   
Long-Term Care  Butterfly needles are not generally used for long-term IV
Variations: therapy.
 If a butterfly needle is placed for a long-term IV, the site should
be inspected frequently for infiltration.

   

Inserting a Butterfly Needle - Common Errors

   
Possible Blood is noted in the tubing of the butterfly set after the venipuncture, but
Errors: when the needle is advanced, a resistance is felt and no more blood flows
into the tubing.
   

   
Prevention: Be sure to advance the needle carefully at a 20 to 30° angle so it does not
puncture through the vein. If this error does occur, pull back on the needle. If
a brisk blood return in the tubing is seen, secure the needle to the skin. If no
blood return is seen, the IV may need to be restarted in another site.
   

   
Nursing Tips:  Methods to promote venous dilatation are:
o Stroking the extremity from distal to proximal below the
proposed venipuncture site
o Opening and closing the fist
o Light tapping with two or three fingers over the vein
o Applying a warm washcloth or other heat to the extremity

 Be sensitive to the client's dominant arm and need for some

movement.
 Use the smallest gauge possible for pediatric and elderly clients with
fragile veins.
 Always insert the IV needle in the direction of venous return (toward
the heart) to avoid damaging the venous valves.

   

   
   
Critical Thinking Skill

   
Introduction: Clients with small veins may require a small-gauge needle. Using a butterfly
needle gives the nurse more control guiding it into a vein. The needle is also
shorter so it may be less frightening to pediatric clients or people from
another culture.
   

   
Possible Mrs. Nguyen was admitted to the emergency room with complaints of
Scenario: abdominal pain. The emergency room physician ordered a complete blood
count (CBC) and chemistry panel and then ordered an abdominal
computerized tomography (CT) scan. The nurse noted that the woman's
veins were quite small and delicate.
   

   
Possible The nurse caring for Mrs. Nguyen felt that butterfly needles were never
Outcome: appropriate to use because of the frequency of venous trauma and
infiltration. He attempted to gain IV access using a 21-gauge venous
catheter. When he inserted the venous catheter, there was a blood
flashback. However, when he attempted to advance the venous
catheter, the vein tore and bled into the surrounding tissue. The nurse
made three attempts at starting the IV using a 21-gauge venous
catheter without success. Mrs. Nguyen became increasingly upset and
agitated with each failure. Finally the nurse asked another staff
member to try to start the IV.
 
The nurse chose a 21-gauge butterfly needle. She used it to draw the
blood samples and then connected it to an IV solution of normal saline
and set it at a rate to keep the vein open. When the client was sent for
a CT scan, she had a vein open to be used for contrast dye.
   

   
Prevention: Keep in mind the reason for the IV, when choosing an insertion site and
infusion equipment. When the nurse realized that the client's veins were too
fragile to sustain the passage of an over-the-needle catheter, he should have
re-evaluated the client's needs and his approach. Recognizing that the IV
access was only required for a short time, the nurse could have saved the
 client undue trauma by changing to a butterfly needle sooner.
   

   
Performing Venipuncture (Blood Drawing) - Overview of the Skill

   
Overview: Obtaining a sample of blood through venipuncture is a commonly
used procedure for many diagnostic tests. Blood test results are a
source of valuable information to screen clients for disease, to
evaluate the progress of therapy, and to monitor the well-being of the
client. The nurse is often required to obtain a variety of specimens. As
some specimens require special handling, it is important for the nurse
to be familiar with the particular test that is ordered.
 
There are three primary methods of obtaining blood specimens:
venipuncture, skin puncture, and arterial stick.
 
Venipuncture is the most common method and involves inserting a
large-bore needle into a vein. The nurse attaches either a syringe or a
vacutainer tube for the collection of the blood specimen. Skin
puncture is the easiest way to obtain a small specimen from the
finger, toe, or heel. A lancet is used for the puncture and a drop of
blood is collected through a capillary tube. An arterial stick is the most
complicated and requires special assessment skills and techniques.
As with any procedure, it is important that nurses review their
employer's policies and procedures as well as their state's nurse
practice act.
   

   
Assessment: 1. Determine which test(s) is ordered and be familiar with any special
conditions associated with the timing of the collection or the handling
of the specimen. Many specimens may be collected at very specific
times, that is, prior to or after administration of a drug, while the
patient is NPO, or after fasting. Other specimens may require special
handling; that is, ice is used to transport ammonia levels; heparinized
collection containers are needed for platelet counts; and so
on. Using a damaged vein may cause further injury to the vein.
A compromised site may not provide an adequate amount of
blood for the specimen and may lead to another venipuncture
for the client.
2. Assess whether the bed itself needs cleaning prior to placing clean
sheets on it. Reduces the transmission of microorganisms.
 3. Assess the integrity of the veins that may be used in the procedure.
Identify any conditions that may contraindicate venipuncture. Avoid
veins injured by infiltration or phlebitis or compromised by surgery
(i.e., modified radical mastectomy). In addition, drawing samples
from sites near IV infusion solutions may alter the composition
of the blood sample.
4. Review the client's medical history to determine if there are any
expected complications from the venipuncture. Clients with a
history of abnormal clotting disorders, low platelets, or related
disorders (hemophilia) may be at risk for increased bleeding at
the site or hematoma formation.
5. Determine the client's ability to cooperate with the procedure. Many
clients are fearful of needles- especially children-and additional
help may be needed. Very young children may need to have the
extremity restrained during the procedure.
6. Review the physician's or qualified practitioner's order. Check for
appropriateness of the test as well as the frequency of the test.
Critically ill clients may require frequent blood tests and
venipuncture. Combining tests and carefully evaluating
frequency may reduce unnecessary blood loss for the client.

   

   
Diagnosis:  Deficient Knowledge, related to the purpose of the blood sample and
the procedure
 Risk for Infection
 Impaired Tissue Integrity-risk of bleeding and hematoma at the site
 Anxiety related to the procedure

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-1-1):
Needs:
 

 Disposable gloves
 Alcohol swabs
 Rubber tourniquet
 Sterile 2 × 2 gauze pads
 Band-Aid or adhesive tape (precut)
 Appropriate blood collection tubes
 Labels for each collection tube with the appropriate client information
included
  Completed laboratory requisition forms
 Needle/equipment disposal container
 Small pillow or folded towel to support the extremity if needed
 Syringe method: sterile needles: 20 to 21-gauge for adults, 23 to 25-
gauge butterfly for older adults, 23 to 25-gauge butterfly for children
 Vacutainer method: Vacutainer tube with needle holder; sterile
double needles (20 to 21-gauge for adults, 23 to 25-gauge for
children)

   

   
Expected 1. Venipuncture site will show no evidence of continued bleeding or
Outcomes: hematoma.
2. The venipuncture site will show no evidence of signs and symptoms
of infection.
3. The laboratory test will be properly acquired and appropriately
handled after collection.
4. The client will be able to discuss the purpose of the test and describe
the procedure.
5. The client will report minimal anxiety associated with the procedure.

   

   
Client 1. Explain the purpose of the test.
Education 2. Describe the procedure for collection. Show the client the equipment.
Needed: 3. Explain the sensations the client will experience with the tourniquet
placement, alcohol swab, and needle stick.
4. Explain when the client may expect results from the diagnostic tests.
5. Instruct the client to apply direct pressure to the venipuncture site
postprocedure for 3 to 5 minutes. Clients with bleeding disorders
should be instructed to alert health care providers of those specifics
prior to any procedures. They should also expect to apply pressure
to the site for at least 5 minutes.
6. Teach the client deep-breathing techniques for relaxation prior to any
procedure. This will provide the client with some "control" in the
situation and also provide the client with some distraction during the
procedure.
7. Teach the young child how to "draw blood" on a toy before
performing the procedure on the child. Play therapy is commonly
used in pediatrics as a way to help reduce anxiety in the child.
Including a favorite toy into the action helps the child see what the
procedure involves.
8. Explain to the client that the site may be slightly sore for a day or two
following the stick. Encourage the client to report any symptoms that
may be of concern.

Performing Venipuncture (Blood Drawing) - Implementation—Action/Rationale


Implementation ACTION
Action/Rationale 1. Greet client by name and
validate client's identification.
2. Explain the procedure to the
client (see Client Education
Needed).
3. Wash hands.
4. Bring equipment to bedside or 4. Provides an organized approach
client exam room. Transfer to the procedure.
client to the procedure room,
especially for small children, as
it is important to keep their
hospital room a "safe haven."
5. Close curtain or door.
6. Raise or lower bed/table to
comfortable working height.
7. Position client's arm; extend
arm to form a straight line from
shoulder to wrist. Place pillow
or towel under upper arm to
enhance extension. Client
should be in a supine or semi-
Fowler's position.
8. Apply disposable gloves.
9. Apply the tourniquet 3 to 4 9. Tourniquet provides improved
inches above the venipuncture
site. Most often the antecubital
fossa site is used. The
tourniquet should be able to be
removed by pulling the end with
a single motion.
10. Check for the distal pulse. If
there is no pulse felt, then the
tourniquet is applied too tightly
and must be reapplied more
loosely.
11. Have client open and close fist
RATIONALE
1. Proper client identification
ensures safety for the client and
the nurse.
2. Client rights dictate that any
action be explained to the client.
The client always has the right to
refuse a procedure. Information
decreases anxiety.
3. Reduces transmission of
microorganisms.
5. Provides privacy.
6. Maintains good body mechanics
for the nurse during the
procedure.
7. Helps stabilize the arm. The bed
should support the client's body
(when possible) in case client
should feel faint during the
procedure.
8. Reduces the risk of infection to
both the client and the nurse
(Standard Precautions).
visibility of the veins as they
dilate in response to decreased
venous return of blood flow from
the extremity to the heart.
10. If the pressure is too tight, it may
impede arterial flow to the
extremity.
11. Increases the venous distension
 several times, leaving fist
clenched prior to venipuncture.
12. Maintain tourniquet for only 1 to 12. Prolonged time may increase
2 minutes.
13. Identify the best venipuncture
site through palpation; the ideal
site is a straight prominent vein
that feels firm and slightly
rebounds when palpated.
Palpate potential site.
14. Select the vein for
venipuncture. (If the tourniquet
has been on too long, release it
and let the client rest for 1 to 2
minutes before reapplying the
tourniquet.)
15. Prepare to obtain the blood 15.
sample. Technique varies
depending on equipment used:
 Syringe method: Have
syringe with appropriate
needle attached.
 Vacutainer method:
Attach double-ended
needle to vacutainer
tube and have the
proper blood specimen
tube resting inside the
vacutainer. Do not
puncture the rubber
stopper yet.
and enhances visibility of the
vein. Vigorous motion, however,
may result in hemoconcentration
of the specimen.
client discomfort and alter some
laboratory results (i.e., falsely
elevated serum potassium).
13. Straight, intact veins are easier to
puncture. A thrombosed vein is
rigid, or rolls easily, and is difficult
to stick.
14. Allowing the client to rest
increases client comfort and
ensures accurate laboratory
results.
 A needle with a very
factorsrisk can damage
the red cells as the blood
is drawn and lead to
inaccurate test results.
 The long end of the
needle is used to
puncture the vein and the
short end enters the blood
tube.

16. Cleanse the venipuncture site
with alcohol swab or
chlorhexidine alcohol using a
circular method at the site and
extending the motion 2 inches
beyond the site (see Figure 8-1-
2). Allow the alcohol to dry.
17. Remove the needle cover and
warn that client will feel the
needle stick for a few seconds.
16. The alcohol solution and
mechanical cleaning motion
cleans the skin surface of
bacteria that may cause infection
at the site. Allowing the alcohol to
dry reduces the stinging
sensation that the client may
experience.
17. Clients will be better able to
control their reaction if they know
what to expect.
18. Place the thumb or forefinger of 18. Helps stabilize the vein during
the nondominant hand 1 inch insertion.
below the site and pull the skin
taut.
19. Hold syringe needle or 19. This angle reduces the chance of
vacutainer at a 15 to 30° angle penetrating though the vein
from the skin with the bevel up. during insertion. The needle
causes less trauma to the skin
and vein when the bevel is up
during insertion.
20. Slowly insert needle/vacutainer 20. Prevents puncture through the
(see Figure 8-1-3). other side of the vein.
21. Technique varies depending on 21.  If blood does not appear,
equipment used: the needle is not in the
vein.
 Syringe method: Gently  Pushing the needle
pull back on syringe through the stopper
plunger and look for breaks the vacuum and
blood return. Obtain causes the flow of blood
desired amount of blood into the collection tube.
into the syringe. Failure of blood to appear
 Vacutainer method: Hold in the collection tube
indicates the vacuum in
vacutainer securely and
advance specimen tube the tube has been lost or
the needle is not in the
into needle of holder. Be
careful not to advance vein.
the needle into the vein.
The blood should flow
into the collection tube.
After the collection tube
is full, grasp the
vacutainer firmly,
remove the tube, and
insert additional
specimen collection
tubes as indicated
(see Figures 8-1-
3 and 8-1-4).

22. After the specimen collection is 22. Reduces bleeding from pressure
completed, release the when the needle is removed.
tourniquet.
23. Apply 2 × 2 gauze over the 23. Positions the gauze for removal
puncture site without applying and helps to gently prevent the
pressure and quickly withdraw skin from pulling with the needle
the needle from the vein. removal.
24. Immediately apply pressure 24. Direct pressure stops the
over the venipuncture site with bleeding and minimizes formation
 the gauze for 2 to 3 minutes or
until the bleeding has stopped.
Tape the gauze dressing over
the site (or apply the Band-Aid).
25. Syringe method:
 Using one hand, insert
the syringe needle into
the appropriate
collection tube and allow
vacuum to fill. You may
also remove the stopper
from each vacutainer
collection tube, remove
the needle from the
syringe, fill the tube, and
replace the stopper.
of a hematoma. You may avoid
using tape or a Band-Aid if after
applying pressure no bleeding is
present. Many clients are
sensitive to tape and its removal
can be painful.
25. Using a one-handed method to fill
the syringe helps reduce the
chance of needlestick injury.
 This alternative method
allows you to control the
speed and amount of fill in
the collection tubes.

26. If any of the blood tubes contain 26. Ensures that the additive is
additives, gently rotate back properly mixed throughout the
and forth 8 to 10 times. specimen.
27. Inspect the client's puncture site 27. Keeps site clean and dry.
for bleeding. Reapply clean
gauze and tape if necessary.
28. Assist client into a comfortable 28. Provides comfort and safety for
position. Return bed to low the client.
position with side rails up if
appropriate.
29. Check tubes for any external 29. Prevents contamination to other
blood and decontaminate with equipment and personnel.
alcohol as appropriate.
30. Check tubes for proper labeling. 30. Ensures the specimens are
Place tubes into appropriate properly identified.
bags/containers for transport to
the laboratory.
31. Dispose of needles, syringe, 31. Prevents spread of disease and
and soiled equipment into needlestick injury.
proper container.
32. Remove and dispose of gloves. 32. Reduces transmission of
microorganisms.
33. Wash hands after the 33. Reduces transmission of
procedure. microorganisms.
34. Send specimens to the 34. Facilitates timely handling of
laboratory. specimens and accurate results.
Performing Venipuncture (Blood Drawing) - Post-Skill

   
Evaluation:  Venipuncture site shows no evidence of continued bleeding or
hematoma.
 Venipuncture site shows no signs or symptoms of infection.
 The laboratory test is properly acquired and appropriately
handled after collection.
 The client is able to discuss the purpose of the test and describe
the procedure.
 The client reports minimal anxiety associated with the
procedure.

   

   
Documentation: Nurses' Notes
 

 Record the date and time of the venipuncture, the site used for
the procedure, any complications, the tests obtained, and the
disposition of the specimens.
 Note the client's reaction to the procedure and the condition in
which the client was left (i.e., bed lowered with side rails up).

   
   
   
Variations

   
Geriatric Variations:  Older clients often have very fragile veins or veins that roll. Vein
integrity is very important to access and veins need to be
secured carefully before venipuncture.
 These clients may also need direct pressure post-needle-stick
for a longer period of time as they are prone to bruising and
hematoma development.

   

   
Pediatric  Dorsal surfaces of the hands and feet are the most frequently
Variations: selected venipuncuture sites in children.
 Select a site that requires the least amount of restraint for the
child/infant.
 Have another nurse (not the parent) assist you with restraint of
the child during the procedure as necessary.
 Scalp veins may be used for neonates or infants, but this site is
often the least desired site by the parent.
 Use topical transdermal numbing medications at least 30
minutes prior to the needle stick.

   

   
Home Care  Teach the client/caregiver to recognize signs and symptoms of
Variations: infection or phlebitis and to report pain, redness, or significant
bruising.
 Home care clients who have been on infusion therapy for a long
period of time will often provide the nurse with information
related to which veins are the "best" to use for venipuncture.
Evaluate the sites carefully and include the client's preferences
when possible.

   

   
Long-Term Care  These clients may be scheduled for venipuncture on a regular
Variations: basis and may also have vein preference or poor venous
access at some sites. Consider the client's suggestions carefully
and listen to what the client tells you; often an experienced
client is right.
Performing Venipuncture (Blood Drawing) - Common Errors

   
Possible
Piercing through the other side of the vein during venipuncture.
Errors:
   

   
Prevention: Hold the syringe and needle at a 15 to 30° angle from the client's arm with
the bevel up. This position should reduce the chance of penetrating both
sides of the vein.
   

   
Possible Sample results diluted from IV fluids near the site of venipuncture.
Errors:
   

   
Prevention: Select a site away from the IV infusion site. An alternative may be to stop the
infusion during the venipuncture procedure (depending on the therapy and
the venous access used).
   

   
Nursing Tips:  Apply warm packs (wet compresses or dry chemical packs) for 10 to
15 minutes to the site, allowing for venous distension and easier
visual location of the site.
 Neonates and infants may need to be wrapped in a warm blanket or
placed under an infant warming light for 10 to 15 minutes before
attempting venipuncture to facilitate visual location of sites.
 The client should be in a comfortable, relaxed position.
 The nurse should approach the client with confidence, as this will
reduce the client's anxiety level.
 For obese clients with difficult veins to locate, create a visual image of
venous anatomy and use palpation to guide you through
venipuncture.
 With experience the nurse will feel the vein "pop" as the needle
enters.
 Avoid any site that pulsates with palpation as this indicates the site is
an artery.
 To avoid prolonged use of the tourniquet, release it as you prepare
the site and then reapply it before the actual venipuncture.

   
   
   
Critical Thinking Skill

   
Introduction: Understanding the specific requirements for collection of blood specimens is
crucial. Failure to do so may result in inaccurate results, which can lead to
errors in treatment of the client or a repeat of the venipuncture test.
   

   
Possible The home care nurse received orders to draw a cyclosporine level on Mr.
Scenario: Jones. Mr. Jones was day 42 postallogeneic blood cell transplant and
receiving infusions of cyclosporine every 12 hours for the prevention of graft-
versus-host disease. Mr. Jones was independent with his infusion
administration and had scheduled nursing visits for laboratory draws twice a
week. The nurse scheduled a visit to draw the blood for 11 . The drug level
was collected and the specimen dropped off to the transplant center for
processing.
   

   
Possible The home care nurse received the cyclosporine level results the following
Outcome: day and called Mr. Jones's physician with the results. Upon receiving the
results, the physician was alarmed that the cyclosporine level was so high
and concerned that Mr. Jones might have symptoms of toxicity. During
further discussion with the nurse, it was determined that the cyclosporine
level was drawn 2 hours after Mr. Jones had completed his morning infusion.
   

   
Prevention: Cyclosporine levels are drawn prior to the next dose. As with many drug
levels, the timing of the blood sample in relation to the dose is essential for
accurate results. In this case, the home care nurse should have instructed
Mr. Jones to hold his morning dose of cyclosporine until after the blood
sample. The home care nurse would then schedule the visit in accordance
with the scheduled timing of the dose.
   

   
Preparing the IV Bag and Tubing - Overview of the Skill

   
Overview: An IV solution is a method of correcting or preventing a fluid and
electrolyte disturbance. Clients who are acutely ill, are NPO after
surgery, or have severe burns are a few examples of those who
 require IV therapy.

The solution in an IV bag is ordered by the health care provider

according to the client's needs and is changed at least every 24
hours. The tubing is used to connect the solution in the IV bag with
the client's IV catheter or needle. The IV tubing should be changed
every 48 hours and when the IV catheter is changed. These changes
in solution and tubing are recommended to decrease the risk of
infection.

There are many brands and types of IV tubing available. It is

important to be familiar with the types you will be using most often.
Tubing varies according to the number of ports required, for example,
a primary tubing set may have no ports or multiple ports. Secondary
tubing is used to add or "piggyback" another solution into a primary
set. Blood transfusions require specific tubing with a filter. Tubing
used in a controller is specific to the type of machine. Tubing size
varies between brands and affects the drops (gtts) of solution for each
cc, for example, macrodrops can vary from 10, 15, or 20 gtts per cc.
Microdrops are 60 gtts per cc. The nurse must be aware of the drop
size in order to accurately calculate the IV flow rate.
   

   
Assessment: 1. Check the health care provider's order for the IV to be infused and
rate of flow to ensure accurate administration.

2. Review information regarding the solution and nursing implications in

order to administer the solution safely.

3. Check all additives in the solution and other medications so that

there will be no incompatibilities with the solution.

4. Assess the patency of the IV to ensure that the solution will enter
the vein and not the surrounding tissue.

5. Assess the skin at the IV site so that the solution will not be
administered into an inflamed or edematous site, which could
cause injury to the tissue.

6. Assess the client's understanding of the purpose of the IV

infusion so that teaching can be tailored to client's needs.

   

   
Diagnosis:  Impaired Skin Integrity
 Risk for Infection
 Deficient Knowledge, regarding the IV infusion

   

   
   
Planning

   
Planning Equipment Needed: (see Figure 8-4-1)
Needs:

 Disposable gloves
 IV solution in a bag
 IV tubing as ordered
 Sterile 2 × 2 gauze

   

   
Expected 1. The IV tubing will be replaced without compromising the sterility of
Outcomes: the system.
2. The new IV tubing will infuse the new solution without leaks or air
bubbles.
3. The new IV solution will infuse at the prescribed rate.
4. The client will be able to discuss the purpose of the IV therapy.

   

   
Client 1. Teach the client the rationale for the IV therapy.
Education 2. Teach the client the type of solution and additives he is receiving.
Needed: 3. Instruct clients to report any swelling or pain at the IV site.
4. The client should know the rationale for changing the tubing.
5. Instruct the client to notify the nurse if any leaking from the tubing
occurs.

Preparing the IV Bag and Tubing - Implementation-Action/Rationale

   
Implementation ACTION RATIONALE
Action/Rationale 1. Check health care 1. Ensures accurate administration
provider's order for the IV of the solution.
 solution.

2. Wash hands. 2. Reduces the transmission of

microorganisms.

3. Check client's identification 3. Ensures medication is given to

bracelet. the correct client.

4. Prepare new bag by 4. Allows for quick, smooth

removing protective cover. preparation. Ensures that the
Check the expiration date solution is sterile.
on the bag and assess for
cloudiness or leakage.

5. Open new infusion set. 5. Prevents fluid from leaking after

Unroll tubing and close IV bag is spiked.
roller clamp.

6. Spike bag with tip of new 6. Promotes rapid flow of solution

tubing and compress drip through new tubing without air
chamber to fill halfway bubbles.
(see Figures 8-4-2, 8-4-3,
and 8-4-4).

7. Open roller clamp, remove 7. Removes air from tubing.

protective cap from the end Prevents entry of air into the
of the tubing, and slowly venous system, a cause of air
flush solution completely embolus. If fluid enters tubing
through tubing. too rapidly air bubbles occur.

8. Close roller clamp and 8. Prevents fluid from leaking and

replace cap protector. maintains sterility of tubing.

9. Apply clean gloves. 9. Reduces the transmission of

microorganisms.

10. Remove old tubing and 10.

replace with new tubing:

  Place sterile 2 x 2 gauze Absorbs fluids that may drip

under IV catheter or during the procedure,
heparin lock. preventing contamination of
surrounding areas.
   Stabilize hub of catheter or
needle and gently pull out
old tubing.
  Quickly insert new tubing
into hub of catheter or
needle.
  Place sterile 2 x 2 gauze
under IV catheter or
heparin lock.
  Open roller clamp to
establish flow of IV solution.
  Re-establish drip rate
(see Figure 8-4-5).
  Apply new dressing to IV
site.
Prevents accidental dislodging
of catheter or needle.
Prevents backflow of blood or
the entrance of air into the vein.
Absorbs fluids that may drip
during the procedure,
preventing contamination of
surrounding areas.
Prevents catheter occlusion and
maintains IV flow at prescribed
rate.
Maintains IV flow at prescribed
rate.
Provides protection from
infection and accidental
dislodgement.

11. Discard old tubing and IV 11. Prevents accidental

bag. transmission of microorganisms.

12. Remove gloves and 12. Reduces transmission of

dispose with all used microorganisms.
materials.
13. Apply a label with date and 13. Allows for planning of next
time of change to tubing. change.
Calculate intravenous drip
rates and begin infusion at
prescribed rate.

14. Wash hands. 14. Reduces transmission of

microorganisms.

Preparing the IV Bag and Tubing - Post-Skill

   
Evaluation:  The IV tubing was replaced without compromising the sterility of
the system.
 The new IV tubing is infusing the new solution without leaks or
air bubbles.
 The new IV solution is infusing at the prescribed rate.
 The client is able to discuss the purpose of the IV therapy.
   

   
Documentation: Flow Sheet

 Note date, time, and name of IV solution started.

 Note date and time IV tubing was changed.

Intake and Output Record

 Note how much fluid was left in the IV bag to determine the
amount of intake.

   

   
   
Variations

   
Geriatric Variations: Older clients and clients with heart failure or renal failure develop fluid
imbalances more quickly. Accurate rates of infusion are crucial to
prevent fluid overload or dehydration.
   

   
Pediatric Small children may develop fluid imbalances more quickly because of a
Variations: larger extracellular fluid volume. Accurate infusion rates are essential in
small children to prevent dehydration or fluid overload.

Intravenous fluid rates are often prescribed for children based on their
body weight. Most formulas used to calculate children's IV flow rates
are based on the child's weight in kilograms. Most American institutions
report weights in pounds. Be aware of the need to convert or report all
weights in kilograms.

The IV tubing connections should be very secure. Even sick children

are active and may inadvertently disconnect tubing.
   

   
Home Care  An approved receptacle needs to be provided for used IV
Variations: tubing.

 Assess the home care setting. Teach the client or the caregiver
to prepare the new IV bag and tubing in a clean area to reduce
 the risk of contamination.

   

   
Long-Term Care If the long-term care client will be cared for primarily by aides, the aides
Variations: must be taught how to respond to incidents involving the IV site and
infusion set. They need to know what to do if the IV tubing should come
apart, if the solution bag becomes contaminated or is empty, and even
what to look for to assess if something is not right with the IV infusion.
   

Preparing the IV Bag and Tubing - Common Errors

   
Possible The tubing is contaminated by a needle piercing through it during an IV
Errors: piggyback injection.
   

   
Prevention: Be sure to identify the port for the IV piggyback injection and carefully
puncture only the port and not the tubing. If the error does occur, stop the IV
piggyback administration of the medication. Remove the needle and replace
the cap over the needle to maintain sterility. Stop the IV flow. Obtain new
tubing for the IV solution and change it using sterile technique. Discard the
contaminated tubing, place fresh IV solution and tubing, and proceed to
administer the IV piggyback medication.
   

   
Nursing Tips:  Be sure the tape at the IV site is loosened so it is easier to change the
tubing.

 Place a towel under the arm of the IV site where the tubing will be
changed in order to keep the linen clean in case of blood leaking from
the needle during IV tubing change.

 A special gown with snaps at the seams makes changing tubing

 easier.

   

   
   
Critical Thinking Skill

   
Introduction: The IV tubing should be changed every 48 hours in order to decrease the risk
of infection. It should also be changed after infusion of blood products as it
can become occluded with the viscous solutions.
   

   
Possible A client has an IV of D5W infusing at 75 ml/hr when the physician orders two
Scenario: units of packed red blood cells.
   

   
Possible The nurse prepares the blood bag by spiking it with new tubing, filling the
Outcome: tubing, and piggybacking it into the current IV. She shuts the D5W off and
runs the blood in through the current IV tubing. Because the nurse was not
aware that blood products are not compatible with dextrose solutions, the red
cells are hemolysed as they flow through the tubing, which previously
contained D5W, the transfusion must be discontinued and discarded.
   

   
Prevention: The nurse prepares the blood with tubing designed for blood transfusions.
She checks the hospital policy regarding blood transfusions and realizes that
normal saline should be used to prime the blood tubing and to flush it
following the transfusion. She carefully prepares the new tubing, double
checks the blood bag with a second nurse, and changes from the D5W
tubing to the blood tubing. As the previous IV will resume after the transfusion
of blood is completed, the nurse obtains a sterile cap to cover the end of the
D5W tubing to maintain its sterility when she attaches the blood tubing. The
nurse needs to know which solutions are compatible with other medications
or blood products and if an IV solution will be used later in order to prevent
contamination.
   
Setting the IV Flow Rate - Overview of the Skill

   
Overview: Setting the rate of an IV infusion according to the health care
provider's order is the responsibility of the nurse after he or she has
established a patent IV. The flow rate can be controlled by the roller
 clamp on the IV tubing or by an infusion pump. It is important for the
rate to be accurate to prevent complications in fluid balance. A rate
that is too fast can result in fluid overload, which is potentially serious
in clients with cardiovascular, renal, or neurologic impairment as well
as in very young or very old clients. If an infusion is set too slow, the
vein may clot or the more serious complication of circulatory collapse
in a dehydrated or severely injured client who required large volumes
of fluid could develop.
 
Sudden changes in the rate of infusion may be accidental or
positional. A confused client may loosen the roller clamp or get
tangled in the IV tubing. A client who gets up to walk may experience
an increase in the IV rate. Changes in flow rate can occur with tubing
and a roller clamp or infusion devices.
 
An infusion pump is an electronic device used to deliver a prescribed
amount of fluid over a period of time in milliliters per hour. Pumps may
have a drop sensor that counts each drop of fluid and sounds an
alarm if the flow rate differs from what is programmed. An alarm
sounds when the bag is empty or when pressure increases in the
system, as in the case of an infiltrated IV.
 
An IV controller delivers fluid by gravity so the bag must be at least 36
inches above the IV site. The number of drops per minute as well as
the IV tubing size and viscosity of the fluid are necessary to calculate
the actual volume delivered per hour. The controller cannot force fluid
into the vein like a pump so infiltrations are detected more quickly.
However, the sensitivity of the pump system increases the number of
alarms caused by client movement.
A volume control device is a calibrated chamber placed between the
IV bag and the drip chamber so that a small volume of IV fluid (<200
ml) can flow into the chamber and then infuse without danger that the
whole bag will be infused into the client.
   

   
Assessment: 1. Check the health care provider's order for the IV to be infused and
rate of flow to ensure accurate administration.
2. Review information regarding the solution and nursing implications in
order to administer the solution safely.
3. Assess the patency of the IV to ensure that the solution will enter
the vein and not the surrounding tissue.
 4. Assess the skin at the IV site so that the solution will not be
administered into an inflamed or edematous site, which could
cause injury to the tissue.
5. Assess the client's understanding of the purpose of the IV
infusion so that client teaching can be tailored to his needs.

   

   
Diagnosis:  Excess Fluid Volume
 Risk for deficient Fluid Volume
 Deficient Knowledge, related to the IV infusion

   

   
   
Planning

   
Planning Equipment Needed:
Needs:
 

 Watch with a second hand

 IV solution in a bag
 IV tubing
 IV infusion pump (optional) (see Figure 8-5-1A)
 Volume control device (optional) (see Figures 8-5-1B and 8-5-1C)
 Paper and pencil

   

   
Expected 1. The fluid will be infused into the vein without complications.
Outcomes: 2. The IV catheter will remain patent.
3. The fluid and electrolyte balance will return to normal.
4. The client will be able to discuss the purpose of the IV therapy.

   

   
Client 1. Teach the client the rationale for the IV therapy.
Education 2. Teach the client the hourly flow rate of the fluid.
Needed: 3. Teach the client the significance of the alarm if an infusion device is
used.
4. Teach the client and caregiver to count the drops per minute.
 5. Instruct clients to report any swelling or pain at the IV site.
Setting the IV Flow Rate - Implementation—Action/Rationale
Implementation ACTION
Action/Rational 1. Check health care provider's
e order for the IV solution and
rate of infusion.
2. Wash hands.
3. Check client's identification
bracelet.
4. Prepare to set flow rate:
 Have paper and pencil
ready to calculate flow
rate.
 Review calibration in
drops per milliliter
(gtt/ml) of each infusion
set.
5. Determine hourly rate by
dividing total volume by total
hours.
RATIONALE
1. Ensures accurate administration
of the solution.
2. Reduces the transmission of
microorganisms.
3. Ensures medication is given to
the correct client.
4.  A nurse unfamiliar with IV
fluid rates should
calculate the rate at first.
 Drops per milliliter vary
with manufacturer and
tubing type. Macrodrip
tubing varies from 10 to
15 gtt/ml. Microdrip tubing
generally delivers 60
gtt/ml.
5. Provides a prescribed hourly rate
with no sudden increases or
decreases. The formula for
calculation is:ml/hr/60 min =
 Example 1: ml/min

The order reads 1000 ml

D5W with 20 mEq KCl over 8
hours:
1000 ml/8 hr = 125 ml/hr
Example 2:
Three liters are ordered for
24 hours:
3000 ml/24 hr = 125 ml/hr

6. Mark a length of tape placed on 6. Provides a visual check of the

the IV bag with the hourly time fluid infused to be sure the rate is
periods according to the rate. correct.
7. Calculate the minute rate based 7. The nurse can use the formulas
on the drop factor of the to calculate how many drops per
infusion set:Drop factor × minute will be infused, and can
ml/min = gtt/min(ml/hr × drop adjust the rate for a change in
factor)/60 min = gtt/min(hourly tubing (macrodrip, microdrip).
rate × drop factor)/infusion time
in minutes = ggt/min

 Microdrip example:
(125 ml × 60 gtt/min)/60
min = 7500 gtt/60 min =
125 gtt/min
 Macrodrip example:
(125 ml × 15 gtt/ml)/60
min = 31 gtt/min

8. Set flow rate: 8.  Ensures that infusion is

 For regular tubing
without a device: Count
drops in drip chamber
for 1 minute while
watching second hand
of watch and adjust the
roller clamp as
necessary (see Figure
8-5-2).
 For an infusion pump:
Insert the tubing into the
flow control chamber,
select the desired rate
(generally calibrated in
administered as ordered.
 Pumps the solution
through the tubing at the
rate set.
 The controller works by
gravity.
 The amount of fluid in the
volume control chamber
depends on the amount of
fluid to be infused per
hour:
50 cc/hour = 50 to 100 cc
of fluid
100 cc/hour = 100 to 200
 cc's per minute), open cc of fluid
the roller clamp, and
push start button.
 For a controller: Place IV
bag 36 inches above the
IV site, select the
desired drops per
minute, open the roller
clamp, and count drops
for 1 minute to verify
rate.
 For volume control
device: Place device
between IV bag and
insertion spike of IV
tubing, fill with 1 to 2
hours amount of IV fluid,
and count drops for 1
minute (see Figure 8-5-
3).

9. Monitor infusion rates and IV 9. Infusion devices may fail.

site for infiltration.
10. Assess infusion when alarm
sounds.
11. Wash hands.
Setting the IV Flow Rate - Post-Skill
10. Alarms on infusion devices signal
when a drip has not been
sensed. It can be caused by an
empty IV bag, a kink in the
tubing, a clotted needle, an
infiltrated IV, or another
malfunction of the device.
11. Reduces the transmission of
microorganisms.

   
Evaluation:  The fluid is infusing into the vein without complications.
 The IV catheter remains patent.
 The fluid and electrolyte balance returned to normal.
 The client is able to discuss the purpose of IV therapy.

   

   
Documentation: Flow Sheet
 

 Date and time IV solution was started

  Rate of infusion in drops per minute and milliliters per hour
 Any changes in the IV rate

 
Nurses' Notes
 

 Client's response to the IV therapy

 Changes in condition caused by a complication in the IV
infusion

   

   
   
Variations

   
Geriatric Variations:  Older clients and clients with heart failure or renal failure are at
greater risk for fluid overload.

   

   
Pediatric  Small children may develop fluid imbalances more quickly
Variations: because of a larger extracellular fluid volume.
 A volume control device is recommended for small children.

   

   
Home Care  Clients and caregivers can be taught to control the rate of an IV
Variations: infusion.
 The nurse should be in the home to teach the client and
caregiver how to use an infusion device after checking the
equipment.
 Be sure electronic equipment is properly grounded.

   

   
Long-Term Care  Infusion devices can be used in the long-term care facility. Be
Variations: sure health care workers know how to use and care for the
infusion pump.
Setting the IV Flow Rate - Common Errors

   
Possible The infusion cassette is not snapped completely into place in the infusion
Errors: pump. The alarm sounds whenever the pump is turned on and no fluid is
infused.
   

   
Prevention: Be sure the correct tubing for the infusion pump is placed according to the
manufacturer's instructions. Infusion devices and tubing vary widely and, if
the tubing is improperly loaded, the infusion device will not work correctly and
will continue to sound the alarm.
   

   
Nursing Tips:  Have the tape ready to mark the hours of infusion on the IV bag.
 Anticipate the client's need for IV fluid so the next bag is ready to
hang before the current one is finished.
 Watch for kinks in the IV tubing or other impediments to the infusion
of the fluid.
 Remember not to depend entirely on an infusion pump or controller as
they can fail.
 Always check IV infusions with a watch and monitor the tape on the IV
bag to ensure the correct rate is being delivered.
 Do not write directly on the plastic IV bag. Some ink may migrate
through the plastic and contaminate the IV fluid.

   

   
   
Critical Thinking Skill

   
Introduction: Setting an IV infusion rate is part of delivering the prescribed fluid to the
client. Knowledge of the size of tubing, the formulas used for calculating the
number of drips per minute, and assessment of the client are all vital in
successful administration of IV fluid.
   

   
Possible A nurse reads the physician's order "D51/2NS 1000 ml over 12 hours" and
Scenario: calculates a rate of 83 ml/hr and marks the tape on the IV bag accordingly.
The nurse selects an IV set and calculates the rate to be 13 to 14 gtt/min.
 After counting the drops while watching the second hand, the nurse sets the
roller clamp to match the drops. However, upon returning an hour later, 120
ml has infused instead of 83 ml.
   

   
Possible The difference of 40 ml has not made a difference in the client's assessment,
Outcome: but the nurse must explore the reason why more IV fluid has infused than
wanted. The nurse looked more closely at the IV tubing and realized that the
set delivered 15 gtt/ml instead of 10 gtt/ml. The calculation was correct for 10
gtt/ml instead of 15 gtt/ml.
   

   
Prevention: The nurse must look carefully at the product being used for an IV infusion in
order to make the correct calculation.
   

Assessing and Maintaining an IV Insertion Site - Overview of the Skill

   
Overview: Assessing a vein for an IV insertion requires knowledge of the
anatomy of the veins of the upper extremities to determine the
appropriate vein for the therapy ordered. It also requires the
assessment knowledge of a healthy vein. A healthy vein is one that is
round, firm, elastic, and engorged, without hardened, bumpy, or
flattened areas. For most adults the first option for IV placement is in
the hand or the large veins of the forearm, preferably in the
nondominant hand. Appropriate veins would include the metacarpal,
cephalic, basilic, and median veins using the most distal portion of the
vein first. Areas to avoid when placing the IV include arms that have
had previous mastectomy, edema, superior vena cava (SVC)
syndrome, cerebrovascular accidents (CVAs), infections, previous
phlebitis, invading neoplasms, hematomas, should be included in the
assessment. Intravenous solutions with electrolytes and medications
can have irritant properties that would require more frequent IV
monitoring. Assessing an established IV site requires knowledge
about the length of time since the insertion, the condition of the
dressing, and the site itself. The site should be without redness,
swelling, pain, or discharge. When palpating the vein, it should have
the characteristics of a healthy vein without signs of infection or
phlebitis.
   

   
Assessment: 1. Review the order for IV therapy: Identify potential side effects from
medication actions, and fluid rate. Consult drug reference books or
pharmacists for information. Decreases the risk of medication
errors.
2. Identify potential risk factors for your client's condition that might
indicate fluid and electrolyte imbalances. Allows targeted
assessment and monitoring.
3. Assess for dehydration: sunken eyes, dry skin, mucous membranes,
flattened neck veins, vital sign changes, inelastic skin turgor,
decreased urine output, behavior changes, and confusion. Allows
intervention to increase fluids and reduce dehydration.
4. Assess for fluid overload: periorbital edema, distended neck veins,
auscultation of crackles or rhonchi in lungs, changes in vital signs,
and level of consciousness. Allows intervention to decrease
fluids.
5. Determine the client's risk for developing complications from IV
therapy: very young or very old, heart or renal failure. Allows the
procedure to be modified if needed and promotes targeted
assessment to look for signs of risk related problems.
6. Observe IV site for complications, that is, signs of infection, phlebitis,
or infiltration: redness, swelling, pallor, or warmth at the IV site and
surrounding tissue, and bleeding or drainage. Allows interventions
to reduce further damage.
7. Observe IV site for patency by briefly compressing the IV cannulated
vein above the site. Note slowing or momentary cessation of IV rate
with a positive blood return. Provides ongoing assessment of
current patency status. Allows early detection of changes.
8. Assess the client's knowledge regarding the need for the IV
therapy. Allows for teaching, including information and
education regarding medications, fluid needs, and signs of IV
site irritation or phlebitis.

   

   
Diagnosis:  Impaired Tissue Integrity. Risk for inflammation caused by indwelling
peripheral IV site
 Risk for Impaired Skin Integrity
 Risk for Infection, caused by indwelling peripheral IV site
 Excess Fluid Volume
 Deficient Fluid Volume

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-6-1):
Needs:
 

 Clean gloves
 Gauze dressing
 Tape
 Nursing documentation record

   

   
Expected 1. The client will have a patent IV, without signs of infection or
Outcomes: inflammation.
2. The client's fluid and electrolyte imbalances will return to normal and
will be maintained.
3. The client will be able to report signs of inflammation or infiltration.
4. The client's IV rate will be administered and maintained per order.
5. The client's IV dressing will remain intact, clean, and dry.

   

   
Client 1. Explain to clients the reason they need IV fluids or medications.
Education 2. Describe to the client the signs of inflammation or infiltration of IV.
Needed: 3. Advise client to use nurse call light for assistance when getting out of
bed.

Assessing and Maintaining an IV Insertion Site - Implementation—

Action/Rationale

Implementation ACTION
Action/Rational 1. Review health care provider's
e order for IV therapy.
2. Review client's history for
medical conditions or allergies.
3. Review client's IV site record
and intake and output record.
4. Wash hands.
5. Obtain client's vital signs.
6. Check IV fluid for correct fluid,
additives, rate, and volume at
RATIONALE
1. Ensures accuracy in the
administration of IV therapy.
2. Decreases risk of fluid overload
and allergic reactions.
3. Assesses for potential problems
with fragile IV sites and fluid
balance.
4. Decreases transmission of
microorganisms.
5. Assesses for changes in
cardiovascular system.
6. Ensures client is receiving correct
therapy.
 the beginning of your shift
(see Figure 8-6-2).
7. Check IV tubing for tight 7. Ensures that no fluid leaks from
connections every 4 hours. tubing and connections.
8. Check gauze IV dressing hourly 8. Ensures there is no sign of
to be sure it is dry and intact infiltration or infection at IV
(see Figure 8-6-3). insertion site.
9. If the gauze is not dry and 9. Ensures there is no sign of
intact, remove the dressing and inflammation or infection at IV
observe site for redness, site.
swelling, or drainage.
10. If an occlusive dressing is used, 10. Ensures there is no sign of
do not remove the dressing inflammation or infection at IV
when assessing the site. site.
11. Observe vein track for redness, 11. These are early signs of phlebitis
swelling, warmth, or pain hourly. or infiltration.
12. Document IV site findings in the 12. Provides documentation of
nursing record or flow sheet. frequent IV site observation.
13. Wash hands. 13. Decreases transmission of
microorganisms.
   
Assessing and Maintaining an IV Insertion Site - Post-Skill

   
Evaluation:  Nurse should observe the IV site on an hourly basis to avoid
complications of phlebitis and infiltration.
 Have the client report signs and symptoms of redness, swelling,
and pain to the nurse.

   

   
Documentation: Flow Sheet
 

 Name of IV solution with additives

 Hourly rate of fluids
 IV site condition
 Time checked
 Initials/signature of nurse

 
Nurses' Notes
  

 Client's response to the IV therapy

 Changes in condition caused by a complication in the IV
infusion

   

   
   
Variations

   
Geriatric Variations:  Elderly clients have more fragile veins and need extra careful
assessment for signs of infiltration.
 Veins in elderly clients tend to "blow" much more easily than
those of younger clients.
 When you tape an IV on an elderly person, try not to use too
much tape. Use the least abrasive tape available to reduce the
irritation to the skin.
 Be careful when removing tape as you may pull the skin off.

   

   
Pediatric Play therapy can be used with a child to help him or her understand the
Variations: IV therapy. Play with the child as the child tapes and maintains an IV
(without needles) on a doll or teddy bear. As you do, explain what is
happening in simple terms appropriate for the child's age. Remind the
child that this is one of the things nurses do to help sick people get
better.
   

   
Home Care  Educate the caregiver to recognize signs and symptoms of
Variations: infiltration or phlebitis in any IV therapy. Make sure the caregiver
knows who to call, day and night, for assistance and is
comfortable calling as soon as symptoms appear.
 Make sure the caregiver can see well enough to recognize
subtle skin changes. You may wish to enroll a second caregiver
to specifically check the IV site.

   

   
Long-Term Care  A peripheral IV insertion site is not frequently chosen for long-
Variations: term IV therapy.
  In clients who must have short-term IV infusions repeated over
many months or years, assess for anticipatory anxiety, fear, or
body image disturbances. Be especially aware of how these
psychosocial factors develop over time secondary to pain,
anxiety, and restricted mobility from IV therapy.

   

Assessing and Maintaining an IV Insertion Site - Common Errors

   
Possible
Not seeing the IV site clearly when assessing for irritation or infiltration.
Errors:
   

   
Prevention: Use enough light when assessing the IV site and vein path.
   

   
Possible Not catching an irritation or infiltration early.
Errors:
   

   
Prevention: If you question the IV site, increase the frequency of assessment.
   

   
Nursing Tips:  Be organized. Review the orders before examining the client's IV so
you do not have to go back and check.
 Bring supplies with you for the assessment: gauze, tape, scissors,
gloves.
 As you complete your assessment of the client's IV, incorporate
teaching the client the signs and symptoms to report.
  Document every hour how the IV site looks and how the IV is
functioning.

   

   
   
Critical Thinking Skill

   
Introduction: Look at the example of how a nurse prevents a large infiltration of an IV by
thoroughly assessing the site and the surrounding tissue.
   

   
Possible A dehydrated client came into an outpatient infusion setting to receive IV
Scenario: fluids for nausea and vomiting for the past 36 hours following a
chemotherapy treatment. The physician ordered 1 liter of normal saline (NS)
to be given over 2 hours and repeated if the client's blood pressure and pulse
showed postural changes after the first liter. Compazine 10 mg IV was also
ordered for nausea. An IV site was placed on the distal forearm of the client's
nondominant left arm on the second attempt. The nurse noted the client's
veins to be flat and fragile from previous IV treatments and/or dehydration.
The nurse initiated the NS IV drip at 500 ml/hr and went to obtain the
Compazine injection to help the client's nausea. The nurse drew up the
Compazine in a syringe and then diluted the medication with 10 cc of NS
because she knew Compazine to be irritating to veins. The nurse
administered the medication slow IV push and asked the client to report any
symptoms or burning or pain at the site. The nurse completed the
administration of the medication and checked for a blood return in the IV. The
blood return was present, but not as brisk as when the IV fluids were started.
The nurse turned off the IV for a moment to see if a spontaneous blood return
would appear after such rapid fluid rate. There was a blood-tinged solution
present at the IV site. The nurse left the IV clamped and began to assess the
tissue proximally from the site. The IV was in a small vein on the backside of
the forearm where there tends to be more fleshy tissue surrounding the
veins. The vein did not look swollen; however, the tissue felt cool and had
lost color. On closer examination there was a slight thickness to the skin that
was not present previously. The IV was discontinued and the nurse asked a
colleague to assist her in starting a new IV site because she had already
attempted 2 IVs on this client.
   

   
Possible If the nurse had not persisted in the evaluation of the IV site and recognized
Outcome: the subtle changes in the client's IV rate and site, the client would likely have
received a large infiltration caused by the rapid rate at which the fluids were
infusing. This would have eliminated the left arm extremity for possible IV
 sites on a client who did not have many easily accessible IV sites.
   

   
Prevention: The nurse prevented the infiltration by closely monitoring the IV rate and site
as well as diluting a medication known to be irritating to the veins.

Changing the IV Solution - Overview of the Skill

   
Overview: An IV solution is a method of replacing fluids or correcting an
electrolyte imbalance. Clients who are acutely ill, are NPO after
surgery, or have severe burns are examples of those who require IV
therapy. Other clients require an IV solution infused slowly to keep the
vein open (KVO) so that an IV medication can be administered every
4, 6, or 8 hours or venous access can be maintained.
 
The type of solution in an IV bag is ordered by a health care provider
according to the client's needs. Changes in solution are ordered when
the client's condition changes. To maintain sterility of the IV solution,
the bag of solution is changed at least every 24 hours. Some
solutions need to be changed more frequently because of the
instability of some of the additives.
   

   
Assessment: 1. Check the health care provider's order for the IV to be infused, rate
of flow, and any medications to be given to ensure accurate
administration.
2. Review information regarding the solution and nursing implications in
order to administer the solution safely.
3. Check all additives in the solution and other medications so there
will be no incompatibilities within the solution.
4. Assess the patency of the IV to ensure that the solution will enter
the vein and not the surrounding tissue.
5. Assess the skin at the IV site so the solution will not be
administered into an inflamed or edematous site, which could
cause injury to the tissue.
 6. Assess the client's understanding of the purpose of the IV
infusion so client teaching can be tailored to his or her needs.

   

   
Diagnosis:  Impaired Skin Integrity
 Risk for Infection
 Deficient Knowledge, related to the IV infusion

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-7-1):
Needs:
 

 Disposable gloves
 IV solution in a bag
 Additives as ordered
 IV tubing
 Alcohol swab (if needed)

   

   
Expected 1. The ordered solution will be infused into the client's veins without
Outcomes: complications.
2. The IV catheter will remain patent.
3. The client will be able to discuss the purpose of the IV therapy.
4. The solution infused will not harm the client because of additive
incompatibilities or additive decomposition.

   

   
Client 1. Teach the client the rationale for the IV therapy and need to change
Education the solution.
Needed: 2. Teach the client the type of solution and additives he or she is
receiving.
3. Instruct the client to report any leakage of the bag of IV solution.
4. Instruct the client to report if the solution is at a low level.

Changing the IV Solution - Implementation—Action/Rationale
Implementation ACTION
Action/Rational 1. Check health care provider's
e order for the IV solution.
2. Wash hands and put on clean
gloves.
3. Check client's identification
bracelet.
4. Prepare new bag with additives 4. Laboratory tests may reveal a
as ordered by health care
provider.
 Plan for new bag to be
hung at least 1 hour
before it is needed.
 Change solution when
an hour's infusion of
solution remains in the
IV bag (see Figure 8-7-
2).
5. Be sure drip chamber is at least 5. Prevents entry of air into IV
half full (see Figure 8-7-3).
6. Change IV solution:
 Move roller clamp to
stop flow of fluid.
 Remove old IV bag from
IV pole and hang new
bag.
 Spike new bag with
tubing (see Figure 8-7-
4).
 Re-establish prescribed
flow rate.
7. Check for air in tubing.
 If air bubbles are
present, close the roller
clamp. While stretching
RATIONALE
1. Ensures accurate administration
of the solution.
2. Reduces the number of
microorganisms.
3. Ensures IV solution is given to
the correct client.
need for potassium, insulin, or
magnesium.
 Reduces clot formation in
vein caused by empty IV
bag.
 Prevents air from entering
tubing and vein from
clotting from lack of flow
of fluid.
tubing while bag is being
changed.
6.  Prevents fluid in drip
chamber from emptying
while changing solutions.
 Prepares equipment.
 Maintains sterility of
solution.
 Prevents clotting of vein.
7. Reduces risk of air embolus.
 the tubing, flick the
tubing with the finger
and watch the bubbles
rise to the drip chamber.
 If a large amount of air is
in the tubing, insert a
needle with an empty
syringe into a port below
the air (see Figure 8-7-
5) and allow the air to
enter the syringe as it
flows to the client
(see Figure 8-7-6).

8. Empty remaining fluid from old 8. Disposes of excess fluid.

IV if needed (see Figure 8-7-7). Reduces risk of spilling large
amounts of fluid in waste can.
9. Remove gloves and dispose of 9. Reduces transmission of
all used materials. microorganisms.
10. Apply a label with date, time, 10. Allows for planning of next
and type of solution. change.
11. Wash hands. 11. Reduces transmission of
microorganisms.
   

Changing the IV Solution - Post-Skill   Evaluation:

 The ordered solution infused into the client's vein without complications.
 The IV catheter remained patent.
 The client is able to discuss the purpose of the IV therapy.
 The solution infused did not harm the client because of additive incompatibilities
or additive decomposition.

    Documentation:
Flow Sheet
 

 Date and time new IV solution was started

 Initials of nurse changing solution

 
Intake and Output Record
 

 Amount of fluid infused from old solution

 Amount of new solution hung

 
Nurses' Notes
 

 Any unusual findings or client teaching

      Variations   Geriatric Variations:

 Pay special attention to assessing the IV insertion site. A good time for that extra
check is when you are changing the solution.

    Pediatric Variations:

Intravenous pump alarms can cause both anxiety and fear in younger and older
children. Changing the IV solution is a good opportunity to teach children about the
alarms. Remind children that the alarm going off is not an emergency and does not
mean that they are in danger or becoming sicker.
    Home Care Variations:

 An approved receptacle needs to be provided for used IV bags and tubing.

 The client or caregiver must be taught how to mix the IV solution if additives are
required.
 The client or caregiver must be taught how to assess the new IV solution for
breaks in sterility or contaminants.

    Long-Term Care Variations:

 Monitor the client's laboratory results so that adjustments to the IV solution can
be made if needed.

    
Changing the IV Solution - Common Errors

   
Possible
The IV solution is not ready when the nurse needs it for a client.
Errors:
   

   
Prevention: The nurse should anticipate when the new IV solution will be needed and be
sure it is ordered from the pharmacy. If this error does occur, slow the IV drip
rate so that the IV bag will not run dry, following institution protocol. Obtain
the new bag when ready and proceed to hang the IV solution.
   

   
Nursing Tips:  Anticipate the need for the next bag of IV solution to avoid the risk of
an IV clotting because of the solution running out.
 Keep in mind the client's laboratory results and need for fluid to be
sure the correct solution is given.

   

   
   
Critical Thinking Skill

   
Introduction: Most IV solutions are commercially made or prepared by the pharmacist. It is
the nurse's responsibility to hang them at the correct time.
   

   
Possible On a busy surgical unit, the nurse had several postoperative clients to admit.
Scenario: One client, a young man who did not speak English, took longer than usual to
assess and get settled. When the nurse returned to the first client, he noticed
that the IV bag was empty and the fluid was halfway down the tubing. There
was a small amount of blood at the hub of the IV needle.
   

   
Possible As the nurse spiked the new bag he had previously brought into the room
Outcome: and hung it from the IV pole, he watched for the fluid to start to flow through
the tubing. When this did not happen right away, he checked the client's IV
insertion site. As he was inspecting the IV insertion site, he did not notice that
the IV had started to infuse. The tubing was still half full of air. The nurse
glanced up in time to see the air infusing into her client. Unsure of what to do,
he removed the IV bag from the pole and held it below the level of the IV
insertion site. Unfortunately, by the time he had accomplished this, the air
had already infused into the client. Luckily there was not enough air in the
tubing to cause an air embolism and the client was fine.
   

   
Prevention: As the nurse was inspecting the IV site, he noticed the air start to infuse
through the venous catheter. He immediately pinched off the IV tubing and
 closed the roller clamp to prevent any further air from infusing into the client.
He then used a syringe inserted into the lowest injection port to aspirate the
air in the tubing. The nurse was reminded to always keep the roller clamp
closed when the patency of an IV site is in question.
   
Discontinuing the IV and Changing to a Saline or Heparin Lock - Overview of the
Skill

   
Overview: A heparin or saline lock, also known as an intermittent infusion
device, is a small plastic device with a resealing rubber entry that is
screwed onto the hub of the existing IV catheter or butterfly needle
tubing. It is used to "cap" the IV to maintain patent access to the vein
without the necessity of running IV fluids into the body. Historically,
heparin was used in these devices and, hence, became known as a
"heparin lock." Research has shown that saline is adequate to keep IV
lines patent, and that heparin may potentially interact with
medications. Furthermore, in rare cases clients may be sensitive to
heparin. In certain circumstances, such as with central lines, heparin
may be indicated. For the purpose of this skill, "saline lock" will be
used. "Saline flush" is another term used by some institutions.
Heparin locks are regularly flushed with a heparin solution or normal
saline to prevent clotting. They come in both needle and needleless
styles, depending on the system used in the institution.
 
Saline locks are generally placed in two circumstances. First, when
the client's need for continuous infusion of fluid or frequent medication
changes, the IV line can be discontinued and plugged with a saline
lock without losing access to the vein. Second, saline lock IV access
sites are placed to provide access to the vein in situations where the
client requires IV medications, but does not need continuous fluid
infusions.
 
Saline locks are used to deliver IV medications into the vein. They can
be quickly reattached to IV tubing in emergency situations when IV
solutions or larger volumes of medication are required. Finally, saline
locks are kept for emergency cases when quick administration of
medications into the vein can be life saving. Changing to a saline lock,
when possible, helps improve client mobility, as clients can walk and
move without the IV stand, pump, and tubing.
   

   
Assessment: 1. Check the health care provider's order for the discontinuation of the
IV or the insertion of the saline lock to ensure appropriate
placement of the saline lock.
2. For existing IVs, assess the patency of the IV to ensure that the
saline will enter the vein.
3. For existing IVs, assess the skin at the IV site so the saline will not
be administered into an inflamed or edematous site, which
could cause injury to the tissue.
4. Check the client's drug allergy history as an allergic reaction could
occur rapidly and be fatal.
5. Assess the client's understanding of the purpose of the saline
lock so client teaching can be tailored to his or her needs.

   

   
Diagnosis:  Risk for Infection
 Impaired Skin Integrity
 Deficient Knowledge, related to the use and care of a saline lock

   

   
   
Planning

   
Planning Equipment Needed:
Needs:
 

 Disposable gloves
 Syringe, 3 to 5 ml
 Sterile needles, 25-gauge
 Antiseptic swab (usually alcohol unless control line)
 Syringe with saline flush solution
 Intermittent infusion device (see Figure 8-8-1)
 Transparent dressing, if required

   

   
Expected 1. The IV is discontinued and saline lock placed without complications.
Outcomes: 2. The IV site remains patent and free of swelling and inflammation.
3. The IV will be changed to a saline lock with a minimum of trauma
and discomfort to the client.
4. For new sites, the IV needle is inserted into the vein and the saline
lock is attached with a minimum of trauma and discomfort to the
 client.

   

   
Client 1. Teach the client the rationale for maintaining the IV patent with a
Education saline lock.
Needed: 2. Teach the client to report any changes at the IV site, bleeding, or
displacement of saline lock.

   

Discontinuing the IV and Changing to a Saline or Heparin Lock - Implementation

—Action/Rationale

Implementation ACTION
Action/Rational 1. Check health care provider's
e order to discontinue IV and to
insert a saline lock.
2. Wash hands and put on clean
gloves.
3. Check client's identification
bracelet.
4. Explain procedure and reason
for discontinuing IV to client.
5. Prepare supplies at bedside:
RATIONALE
1. Ensures accurate placement of
saline lock.
2. Reduces the number of
microorganisms.
3. Ensures correct procedure is
performed for the client.
4. Information decreases anxiety.
5. Ensures smooth procedure.

 Syringe with saline

 Syringe with heparin
 Saline lock

6. If inserting a new saline lock: 6. Priming the extension tubing

Prime the extension tubing with prevents air from being forced
saline and place the saline lock into the vein.
on it. Follow the procedures for
starting an IV, including
assessing and preparing the
site, inserting the over-the-
needle-catheter (ONC)
(see Figure 8-8-2) or butterfly
needle, and obtaining a blood
 return. Do not attach the
needle/ONC to the IV tubing.
Instead, attach the ONC to the
extension tubing. Dress the site
(see Figure 8-8-3) per protocol.
If inserting a new saline lock,
prime extension tubing with
solution and place connector in
the hub of the angiocatheter.
For needleless systems follow
steps of manufacturer. In a
spring-loaded, retractable
needle system, press the button
after a flashback of blood is
observed. To ensure needle
separation, turn angiocatheter
360° at the hub before inserting
the catheter into the vein.
Advance the catheter and
attach to extension tubing with
the addition of a one-way
needleless safety valve, which
has been flushed with solution.
Secure with dressing as per
institution protocol.
7. If discontinuing an IV and 7. Stops the flow of the fluid in the
converting to a saline lock: Stop IV tubing.
IV infusion.

 For IV tubing, roll clamp

to close IV tubing.
 For infusion pump, turn
switch to off.

8. Place saline lock: 8. Places the saline lock.

 Open sterile package

with needleless adapter
saline lock.
 For existing IV, loosen
IV tubing and remove.
 Screw saline lock into
hub of tubing
(see Figure 8-8-4).
 To check for patency
remove cap from one-
way valve following
vigorous scrubbing with
 alcohol at the
connection site. Connect
needleless Leur-locking
syringe to the valve.
Inject solution into IV
site per protocol, using
gentle pulsating motions
to create turbulence.
Remove syringe and
replace sterile cap at
end of tubing.

9. Check for patency of IV: 9. Ensures the IV is patent so that

the saline lock will function.
 Clean saline lock with Flushing with saline clears the
antiseptic solution lock.
(usually alcohol wipe).
 Insert saline syringe with  Flushing should be done
25-gauge needle into slowly.
center of diaphragm.  Assess for pain to ensure
(Needleless system will site is patent.
not require needle.)
 Pull back gently on
syringe and watch for
blood return.
 Inject saline slowly into
lock (see Figure 8-8-5).
 Assess client's pain at
site.

10. Keep lock patent with heparin or 10. Ensures patency of saline
normal saline. Every 8 hours: lock.Only use heparin if
prescribed as "flush with heparin"
 Clean the rubber or if institutional policy requires it.
diaphragm with an Needleless system reduces risk
antiseptic swab (not of needle sticks.
applicable if needleless
system).
 Insert the syringe or
needleless adapter with
heparin or saline into the
diaphragm.
 Inject heparin or saline
slowly into lock
(see Figure 8-8-6).

11. Remove the syringe or 11. Reduces transmission of

 needleless adapter from the microorganisms. Reduces risk of
diaphragm and swab it with an needle sticks.
antiseptic swab. Discard needle
or adapter in sharps container.
12. Assess the site for any signs of 12. Detects problems with the site
leakage, irritation, or infiltration that need additional assessment
(see Figure 8-8-7). and intervention.
13. Remove gloves and dispose 13. Reduces transmission of
with all used materials. microorganisms.
14. Wash hands. 14. Reduces transmission of
microorganisms.

Discontinuing the IV and Changing to a Saline or Heparin Lock - Post-Skill

   
Evaluation:  The IV is discontinued and the saline lock placed without
complications.
 The IV site remains patent and free of swelling and
inflammation.
 The IV was changed to a saline lock with a minimum of trauma
and discomfort to the client.

   

   
Documentation: Nurses' Notes
 

 Note date and time IV was discontinued and saline lock was
placed.
 Note any unusual findings at insertion site.
 Document type of solution in lock (heparin or saline).

 
Flow Sheet
 

 Note date and time IV was discontinued.

 
Medical Administration Record
 
  Chart solution infused every time lock is flushed.

 
Intake and Output Record
 

 Record the amount of IV solution left in the bag when the IV was
changed.

   

   
   
Variations

   
Geriatric Variations:  Elderly clients may need special skin care and tape if a saline
lock is used for an extended time.
 The veins of elderly clients may be more fragile and need more
frequent changes of an IV with a saline lock.

   

   
Pediatric  Giving a medication to a child through an established IV with a
Variations: saline lock may be less traumatic than an IM or subcutaneous
injection.
 Special precautions need to be taken to maintain a saline lock
intact in very young clients.

   

   
Home Care  The client or caregiver must be taught how to use and maintain
Variations: a saline lock.
 Equipment for disposing of IV materials needs to be
established.

   

   
Long-Term Care  Saline locks are not usually appropriate for long-term IV access.
Variations: A permanent central line is often more appropriate in these
circumstances.
Discontinuing the IV and Changing to a Saline or Heparin Lock - Common Errors

   
Possible
When flushing a saline lock, there is swelling around the needle.
Errors:
   

   
Prevention: Be sure to assess the IV for patency before flushing the saline lock. If
swelling does occur, stop pushing the saline lock. Pull back on the plunger to
check for a blood return. If there is none, remove the needle and saline lock
and start an IV in another site. When you are sure the needle is in the vein,
attach a new saline lock and flush with saline.
   

   
Nursing Tips:  Sometimes no blood will return from a saline lock even though it is
patent. Removing the screw-on cap, using sterile technique, may
result in a blood return if the saline lock is patent. If in doubt, restart
the saline lock at a new site.
 Be sure the IV site is visible and free of tape or dressing while
checking for patency.
 Remember, a saline flush must inject enough saline to fill the entire
set from the injection port to the needle tip.
 In some situations, such as with certain central lines, heparin may be
used. Use heparin solution designated for flush and follow institution
protocol.
 Replace the heparinized solution each time the heparin lock is used.
 If the drug to be administered through the saline lock is incompatible
with heparin, flush the entire heparin lock set with normal saline
before and after the medication is administered, then flush with
heparin. Some institutions no longer flush heparin locks with a heparin
solution. Some studies suggest that flushing with normal saline alone
will maintain the patency of a heparin lock.

   

   
   
Critical Thinking Skill

   
Introduction: A saline lock needs to be checked for patency just as much as an IV catheter
that has fluid infusing. If it is not patent, it has no value to the client.
   

   
Possible A client has had a saline lock for 24 hours after his IV fluids were
Scenario: discontinued. The routine flushing of the saline lock has proven it to be
patent; however, the last time it was flushed, the nurse felt some resistance.
The nurse pulled back on the syringe to check for blood, and there was only
a small amount of pinkish fluid that returned.
   

   
Possible The nurse reasoned that the saline lock flushed without obvious signs
Outcome: of infiltration and the client was not getting any medication via the
saline lock. The nurse decided to check the saline lock again later and
perhaps restart it then. As the shift ended the nurse was giving a report
to the oncoming shift and remembered about the saline lock. The
nurse reported these concerns to the oncoming nurse. The nurse who
assumed this client's care assessed the saline lock prior to flushing it
and noticed that the entire insertion site was red and swollen. The site
was hot to the touch and the client was complaining of pain at the site.
The nurse changed the saline lock site and placed a warm, moist
compress on the reddened area. The nurse noted the inflamed area
and reported it to the next shift for continued observation.
 
The nurse realized that the saline lock was not fully patent and would
not function well if a medication needed to be administered. The nurse
checked with the physician, who advised starting a new IV as the client
still needed a patent venous access.
   

   
Prevention: As the nurse was inspecting the IV site, he noticed the air start to infuse
through the venous catheter. He immediately pinched off the IV tubing and
closed the roller clamp to prevent any further air from infusing into the client.
He then used a syringe inserted into the lowest injection port to aspirate the
air in the tubing. The nurse was reminded to always keep the roller clamp
closed when the patency of an IV site is in question.

Administering a Blood Transfusion - Overview of the Skill

   
Overview: A blood transfusion is the IV administration of a component of blood
or whole blood. Red blood cells are given as whole blood or packed
red blood cells; they may be modified by leukocyte reduction to
prevent antibody formation or irradiation to prevent graft-versus-host
disease in immunocompromised clients. Components used for clients
with alterations in coagulation are fresh frozen plasma (FFP),
 cryoprecipitate, factors VIII and IX concentrates, and platelets.
Components to enhance the immune system are granulocytes and
immune serum globulin (IgG). Colloid components to treat
hypoproteinemia or hypovolemia are plasma protein fraction and
albumin. The most commonly used blood components are packed red
blood cells, platelets, or FFP.
 
A client may require a transfusion for the following reasons: to
increase blood volume after surgery, trauma, or hemorrhage; to
increase the number of red blood cells in a client with severe anemia;
to provide platelets to clients with low platelet counts caused by
treatment with chemotherapy; to provide clotting factors in plasma; for
patients with hemophilia, von Willebrand's disease, or disseminated
intravascular coagulopathy (DIC); or to replace plasma proteins such
as albumin.
 
The nurse should know why the health care provider has ordered a
specific blood product to be given and the policies and procedures for
giving that product. The nurse must know how to give the blood
product and what adverse reactions to monitor in the client.
   

   
Assessment: 1. Assess the client for the indication of the blood product to be given,
that is, low hematocrit or platelet count. This will enable more
specific evaluation of response to the transfusion.
2. Verify the health care provider's order for the type of blood product to
be given. Only he or she may order blood products because of
legal regulations.
3. Review the client's transfusion history, especially any reactions or
pretransfusion medications to be given. If prior reaction has
occurred, premedications can be given to prevent a subsequent
reaction.
4. Review the baseline vital signs in the client's medical record to
compare with vital signs during the transfusion. Changes in
baseline may indicate a transfusion reaction.
5. Assess the type, integrity, and patency of the venous access in
place so the transfusion will be completed without infiltration of
the IV.
6. Verify that a large-bore catheter (18 or 19-gauge) is to be used. This
prevents hemolysis as red blood cells are large and will not flow
through a small-bore needle.
7. Review institution policy and procedure for the administration of
blood productions. Each institution has its own policies to ensure
safe administration of blood products.
 8. Ensure that the client has signed an informed consent release that
includes potential risks and benefits.

   

   
Diagnosis:  Risk for Infection
 Potential for Excess Fluid Volume related to volume of transfused
blood product
 Impaired Gas Exchange related to anemia
 Risk for Injury: bleeding related to bleeding disorders
 Deficient Knowledge, related to transfusion procedures
 Pain related to transfusion reaction

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-9-1):
Needs:
 

 Blood administration set and filter

 Intravenous solution of 0.9% sodium chloride (normal saline)
 Disposable gloves
 Infusion pump if compatible with the specific blood product
 Tape
 Leukocyte-depleting filter, if ordered
 Pressure bag, if needed
 Blood warmer, if needed

   

   
Expected 1. The client receives the blood component transfusion without any
Outcomes: adverse reactions or has adverse reactions successfully managed.
2. The client demonstrates desired benefit from transfusion as evident
by relief of symptoms or improvement in specific hematologic values.
3. The client describes the purpose and procedure for transfusion of a
blood component.
4. The client describes the possible complications of a blood
transfusion.

   
   
Client 1. Teach the client the rationale for the blood transfusion, the
Education anticipated length of the transfusion, and the need for frequent vital
Needed: sign monitoring while the transfusion is running.
2. Instruct the client to notify the nurse if he or she experiences any
signs of reaction such as itching, swelling, dizziness, dyspnea, chest
pain, or infiltration of the IV.
3. Teach the client and caregiver about the signs and symptoms of
long-term reactions, such as delayed hemolysis and the need to
report them to the health care provider immediately.

Administering a Blood Transfusion - Implementation—Action/Rationale

Implementation  
Action/Rational
e ACTION
1. Verify the health care provider's
order for the transfusion.
2. If a venipuncture is necessary,
refer to Skill 8-1.
3. Explain procedure to the client.
4. Review side effects (dyspnea,
chills, headache, chest pain,
itching) with client and ask him or
her to report these to the nurse.
5. Have the client sign consent
forms.
6. Obtain baseline vital signs.
7. Obtain the blood product from the 7. Prevents bacterial growth and
blood bank within 30 minutes of
initiation.
8. Verify and record the blood
product and identify the client
with another nurse (see Figure 8-
9-2):
 Client's name, blood
group, Rh type
RATIONALE
1. Blood must be ordered by a
health care provider.
2. Ensures a patent and adequate
IV for infusion of blood.
3. Ensures that client understands
procedure and decreases
anxiety.
4. Prompt reporting of a side effect
will lead to earlier
discontinuation of transfusion
and minimize the reaction.
5. Most institutions require the
client to sign a consent form.
6. Allows detection of a reaction
by any change in vital signs
during the transfusion.
destruction of red blood cells.
8. Strict verification procedures will
reduce the risk of administering
blood products to the wrong
client. If there is an error during
this procedure, notify the blood
blank and do not administer the
product.

 Cross-match compatibility
  Donor blood group and
Rh type
 Unit and hospital number
 Expiration date and time
on blood bag
 Type of blood product
compared with health
care provider's order
 Presence of clots in blood
9. Instruct client to empty the
bladder.
10. Wash hands and put on gloves.
11. Open blood administration kit and 11. Closed roller clamps prevents
move roller clamps to "off"
position.
12. For Y-tubing set:
 Spike the normal saline
bag and open the roller
clamp on the Y-tubing
connected to the bag and
the roller clamp on the
unused inlet tube until
tubing from the normal
saline bag is filled. Close
clamp on unused tubing.
 Squeeze sides of drip
chamber and allow filter to
partially fill (see Figure 8-
9-3).
 Open lower roller clamp
9. A urine specimen after initiation
of the transfusion will be
needed if a transfusion reaction
occurs.
10. Ensures patency of saline
lock.Reduces transmission of
microorganisms and, therefore,
risk of transmission of {human
immunodeficiency virus} (HIV),
hepatitis, or blood-borne
bacteria.
accidental spilling of blood.
12.  The Y-tubing allows the
nurse to switch from
infusing normal saline to
blood. This is especially
helpful when multiple
transfusions are given.
Follow institutional
guidelines for the
number of units that can
be given before tubing
needs to be changed.
Dextrose solutions are
not used with blood
transfusions as they can
clot the donor blood.
 A correctly filled drip
chamber enables an
 and allow tubing to fill with
normal saline to the hub.
 Close lower clamp.
 Invert blood bag once or
twice. Spike blood bag
and open clamps on inlet
tube to allow blood to
cover the filter completely
(see Figure 8-9-4).
 Close lower clamp.
13. For single-tubing set:
 Spike blood unit.
 Squeeze drip chamber
and allow the filter to fill
with blood (see Figure 8-
9-5).
 Open roller clamp and
allow tubing to fill with
blood to the hub.
 Prime another IV tubing
with normal saline and
piggyback it to the blood
administration set with a
needle and secure all
connections with tape.
14. Attach tubing to venous catheter
using sterile precautions and
open lower clamp.
15 Infuse the blood at a rate of 2 to
5 ml/min according to the health
accurate drip count.
 Removes all air from
tubing system.
 Prevents waste of IV
fluid.
 Equal distribution of
cells prevents clumping,
which can lead to
clotting of cells. Fragile
blood cells may be
damaged if they drop on
an uncovered filter.
 Prevents blood from
flowing until tubing is
attached to venous
catheter.
13.  Attaches tubing to blood
unit.
 A correctly filled drip
chamber enables an
accurate drip count.
 Prevents air from being
forced into the vein.
 The blood product
should not be piggy-
backed into the normal
saline line to avoid
forcing blood cells
through both a needle
and a venous catheter.
14. Allows the blood product to be
infused into the client's vein.
15. Packed red blood cells usually
run over 1 1/2 to 2 hours; whole
 care provider's order. blood runs over 2 to 3 hours.
16. Remain with client for first 15 to 16. If a reaction occurs, it generally
30 minutes, monitoring vital signs happens during the first 15 to
every 5 minutes for 15 minutes, 30 minutes. Changes in vital
then every 15 minutes for 1 hour, signs can warn of a transfusion
then hourly until 1 hour after the reaction.
infusion is completed, or per
institution policy.
17. After blood has infused, allow the 17. The client will receive all the
tubing to clear with normal saline. blood that is left in the tubing.
18. Appropriately dispose of bag, 18. Reduces transmission of
tubing, and gloves. Wash hands. microorganisms.
19. Document the procedure. 19. Ensures accurate records.

Administering a Blood Transfusion - Post-Skill

   
Evaluation:  Observe for signs of transfusion reaction.
 Observe client and laboratory values to determine response to
transfusion.
 Monitor clients for signs and symptoms of fluid overload.

   

   
Documentation: Nurses' Notes
 

 Record patient name, ID number, blood component and

component number, names of individuals verifying blood
component, name of individual starting and ending transfusion,
start and end times, volume transfused, and reaction, if any.
  Record date, time, type and amount of the blood product
administered.
 Document the condition of the venous access site and patency
of the IV
 Describe client's response to transfusion, including change in
laboratory values and improvement of symptoms.

 
Intake and Output Record
 

 Record volume of blood component transfused and urine

output, if appropriate.

 
Medical Administration Record
 

 Record additional medications given to prevent or manage

transfusion complications; for example, acetaminophen,
diphenhydramine, furosemide.
 Document diagnosis and treatment of any transfusion reactions.

   

   
   
Variations

   
Geriatric Variations:  
Elderly clients may require longer infusion time because of
decreased cardiac function in order to avoid fluid overload.
Geriatric clients with a history of heart disease or hypertension
may have an increased risk of fluid overload related to the
transfusion.
Elderly clients may have more fragile veins. Venous access may
be more difficult, and these clients may be at a higher risk for IV
infiltration.
   

   
Pediatric The first 50 ml of blood should be given slowly over 30 minutes. If
Variations: no reaction occurs, the rate can be increased.

A newborn's blood is cross-matched with the mother's serum,

which may have more antibodies than the newborn's. This will
make an incompatibility more apparent.
Pediatric infusion doses and rates are calculated by body weight.
Volume of blood products may be divided into several units
containing small volumes.
   

   
Home Care  
Variations:
The blood component should be transported in an insulated
container with ice according to the blood bank guidelines. The
transfusion should be started as quickly as possible after leaving
the blood bank.
If the nurse is alone, she or he should be meticulous in cross-
checking the unit of blood with the client to ensure correct
administration of the product.
The nurse must plan to have trained personnel available to
monitor the client during the entire transfusion and for 1 hour after
the transfusion in order to assess for a transfusion reaction.
Assessing a client's eligibility to have a transfusion administered
at home include no previous transfusion reactions, no angina or
CHF, and being alert and oriented in order to report any
symptoms of a reaction.
Policies of the home health agency regarding administration of
blood products in the home include preparation by the nurse,
client eligibility, location of client in relation to the blood bank,
blood transport and storage, disposal of biohazardous materials,
and emergency procedures.
Blood component transfusions may be carried out in a home
setting. Nurses in this setting should be knowledgeable and
prepared to treat acute transfusion reactions with standing orders
to avoid the delay of contacting a health care provider or
transporting the client for treatment.
   

   
Long-Term Care Personnel working in long-term care settings where blood is not
Variations: frequently administered may need to review blood transfusion policies
and procedures prior to the transfusion.
   
Administering a Blood Transfusion - Common Errors

   
Possible
The IV infiltrates halfway through the transfusion.
Errors:
   

   
Prevention: Assess the gauge of the IV and its patency before starting the transfusion. If
this error does occur, stop the transfusion. Start a new IV in a different
extremity if possible. Restart the transfusion and observe the client for a
transfusion reaction.
   

   
Possible Blood backs up into the bag of normal saline.
Errors:
   

   
Prevention: Clamp the normal saline bag before spiking the blood bag. If this error does
occur, clamp the tubing to the normal saline bag and the blood bag. Obtain a
new bag of normal saline. Remove the normal saline bag with the blood in it,
and spike the new bag of normal saline. Open the clamp to allow the blood to
flow out of the tubing and the normal saline to flow.
   

   
Nursing Tips:  
Have all equipment prepared before ordering the blood from the blood
bank.
Use a pressure bag to increase the flow rate if the primary goal is
volume replacement and a client is bleeding.
Maintain another IV line if other fluids or medications are needed
during the transfusion.
Rotate the bag to prevent clumping of cells.
A transfusion of packed RBCs requires planning and scheduling. A
current type and cross-match specimen must be processed; the health
care provider must obtain informed consent; IV access must be
 established; and premedication must be administered, if appropriate.
Unless an emergency, a planning process of several hours should be
anticipated.
Medications should never be added to a blood product. If the client is
receiving multiple IV medications on a strict schedule (e.g., antibiotics),
consider starting a second IV line for a lengthy blood transfusion.
Blood products should not be transfused simultaneously or
immediately preceding or following medications also capable of
causing allergic-type reactions. Distinguishing the etiology of the
reaction could be difficult.
Electromechanical infusion devices should be used for blood products
only if they have been tested and approved for blood component
infusion by the manufacturer.
External pressure infusion cuffs may help speed a slow transfusion
drip. However, do not exceed 300 torr when pressure transfusing an
RBC product. Check with the manufacturer of specific venous access
devices to determine how much pressure can be applied to a
transfusion through the device.
To avoid bacterial growth, do not leave a blood filter hanging for more
than 4 hours.
   

   
   
Critical Thinking Skill

   
Introduction: Some clients require more than one unit of packed RBCs and more than one
type of blood component.
   

   
Possible Two units of packed RBCs, one unit of single donor platelets, and four units
Scenario: of FFP are ordered for an immunocompromised client who is actively
bleeding. The client's hematocrit is 24%, and he is bleeding from his nose
and upper gastrointestinal tract. Which blood product should be given first
and in what order needs to be determined, as all of the products ordered
need to be given so that the bleeding will slow down or stop and the
laboratory values will return to normal.
   

   
Prevention: The nurse will need to plan the schedule of the blood products in order of
 importance and according to the physician's orders. As the platelets and the
FFP take a shorter time to infuse and will help correct the coagulation
problem, it may be beneficial to give them first. The packed RBCs each take
2 hours to infuse so they can be given later.
   
Assessing and Responding to Transfusion Reactions - Overview of the Skill

   
Overview: A transfusion reaction can be caused by blood that is incompatible,
blood that is contaminated, or a blood component that is infused too
rapidly. It can also be caused by an allergic sensitivity to the
leukocytes, the platelets, or the plasma protein components of the
blood or the potassium or citrate preservative in the blood.
 
The types of reactions range from symptoms that appear within the
first 15 minutes, such as fever, chills, and skin rash, that can progress
to hypotension, shock, or a delayed reaction that can occur several
days or weeks later.
 
The first type of transfusion reaction is an acute hemolytic reaction
caused by an ABO incompatibility in which an antigen-antibody of the
recipient responds to blood of the donor who has a different antigen.
This may be related to the client's ABOblood type or the Rh factor.
For example, people with type A blood cells produce anti-B antibodies
in their plasma, so administering a unit of type B blood would cause
the body to reject it with their anti-B antibodies. In the same manner,
the Rh factor is an antigenic substance in the red blood cells (RBCs)
of most people; they are Rh positive. If Rh-positive blood is given to
an Rh-negative person, the Rh-negative antibodies will hemolyze or
destroy the transfused RBCs. Intravascular hemolysis releases
hemoglobin leading to hemoglobinemia or hemoglobinuria. The RBCs
that are destroyed can damage the kidneys, which may progress to
renal failure. The coagulation system is also stimulated so the clotting
cascade causes small clots to form in the circulating blood, which sets
disseminated intravascular coagulation (DIC) in motion. A hemolytic
reaction can be delayed for weeks or months but is still caused by
antibodies reacting with their corresponding antigens other than the
ABO system.
 
The second type of transfusion reaction is a febrile nonhemolytic
reaction caused by the recipient's antibodies reacting with the
transfused white blood cells, platelets, or plasma proteins.
  
The third type is an allergic reaction caused by a reaction to one or
more donor plasma proteins.
 
The fourth type of reaction is a reaction to citrate. Citrate is an
anticoagulant used as a preservative in blood products. When
combined with serum calcium in the recipient, it produces
hypocalcemia, which causes tingling in the mild reaction to muscle
spasms in a severe reaction.
 
The fifth type is rare: an anaphylactic reaction. It may occur when
immunoglobulin A (IgA) proteins are given to an IgA-deficient recipient
who has developed IgA antibodies.
 
Other reactions can be septic shock caused by a blood product that is
contaminated by bacteria or an endotoxin. The risk of acquiring a
blood-borne infection is minimal as all blood products are tested by
serology before being distributed for use. Infections that can be
transmitted through blood products and not produce symptoms until
weeks later are malaria, hepatitis, and human immunodeficiency virus
(HIV). Hepatitis, for instance, has an incubation period of 1 to 6
months.
Graft-versus-host disease (GVHD) occurs in an immunocompromised
recipient when donor lymphocytes recognize the recipient's cells as
foreign and attack them. Blood products for these clients are usually
irradiated to kill the lymphocytes and prevent this reaction.
   

   
Assessment: 1. Assess for symptoms of an acute hemolytic reaction, including fever
with or without chills, chest and lumbar pain, hypotension, dyspnea,
oliguria or anuria, and abnormal bleeding. Early detection allows
for implementation of appropriate treatments.
2. Assess for a nonhemolytic reaction, which includes symptoms of
fever, chills, flushing, headache, muscle pain, anxiety. Early
detection allows for implementation of appropriate treatments.
3. Assess for an allergic reaction: flushing, hives, or itching or an
anaphylactic reaction in which symptoms of respiratory distress,
chest pain, hypotension, abdominal cramps, vomiting and diarrhea,
shock, loss of consciousness, or cardiopulmonary arrest will be
present. Early detection allows for implementation of
appropriate treatments.
 4. Assess for a citrate reaction, including circumoral tingling,
hypotension, nausea, vomiting, or cardiac dysrhythmias. Early
detection allows for implementation of appropriate treatments.
5. Assess for sepsis, which includes symptoms of chills, fever,
vomiting, diarrhea, hypotension, and shock. Early detection allows
for implementation of appropriate treatments.
6. Assess for circulatory overload, noting dyspnea, cyanosis, severe
headache, elevated systolic blood pressure, tachycardia, jugular vein
distention, crackles, and elevated central venous pressure. Assess
for hypothermia and cardiac dysrhythmias caused by cold blood
cooling the right ventricle and affecting the conduction system. Early
detection allows for implementation of appropriate treatments.
7. Assess for GVHD in the immunocompromised client who may
present with fever, skin rash, diarrhea, bone marrow suppression,
and liver dysfunction. Continued assessment is important to
detect reactions and begin appropriate treatment.
8. Assess for a delayed hemolytic reaction: continued anemia despite
receiving a transfusion, or hepatitis that may present weeks after the
transfusion with weakness, fatigue, nausea, and
jaundice. Continued assessment is important to detect reactions
and begin appropriate treatment.

   

   
Diagnosis:  Decreased Cardiac Output
 Excess Fluid Volume
 Risk for Infection
 Hypothermia
 Pain
 Diarrhea
 Impaired Gas Exchange
 Impaired Skin Integrity

   

   
   
Planning

   
Planning Equipment Needed (see Figure 8-10-1):
Needs:
 

 Disposable gloves
 IV tubing
 Stethoscope
 Saline basal IV solution
  Sphygmomanometer
 Thermometer

   

   
Expected 1. The client will have a normal temperature and no chills.
Outcomes: 2. The client will have normal tissue perfusion and cardiac output.
3. The client will be calm and comfortable.
4. The client will show no signs of infection.

   

   
Client 1. Instruct the client on which symptoms should be reported to the
Education nurse immediately.
Needed: 2. Ask the client to verbalize previous experience with transfusions.
3. Assure the client of the measures taken to ensure safe blood
products.
4. Assure the client that he or she is being carefully monitored for a
possible reaction.
5. The client is given the call light and is able to verbalize potential
adverse reaction symptoms.

Assessing and Responding to Transfusion Reactions - Implementation—

Action/Rationale

Implementation ACTION
Action/Rationale 1. Immediately stop the
transfusion.
2. Using gloved hands, remove
tubing with blood and replace
with new tubing.
3. Maintain a patent IV with
normal saline. Do not use any
solutions containing dextrose.
4. Obtain vital signs including
oxygen saturation.
5. Remove gloves and wash
hands.
6. Notify health care provider of
client's transfusion reaction,
including vital signs and specific
symptoms with severity of
RATIONALE
1. Reduces risk of further reaction.
2. Prevents blood in the tubing from
being infused.
3. Ensures fluids or medications can
be given in the event of
anaphylaxis. Dextrose is
incompatible with blood.
4. Assesses client's hemodynamic
stability.
5. Maintains aseptic technique.
6. Transfusion reactions need
prompt medical attention with
efficient, accurate communication
of the event.
 reaction and time frame. Know
protocol to follow. Clients may
need oxygen and to be placed
in Trendelenburg position if
shock occurs.
7. Monitor client's vital signs at 7. Assesses client's
least every 15 minutes cardiopulmonary status.
(see Figure 8-10-2).
8. Read the blood component bag 8. Client may have received
to ensure that the correct unit incompatible blood intended for
was given to the correct client. another client.
9. Administer medications as 9.  Antihistamine given IV
prescribed: counteracts some allergic
responses.
 Diphenhydramine  Stimulates alpha
 Epinephrine receptors and beta
receptors in the
 Broad-spectrum sympathetic nervous
antibiotics system and decreases
 Intravenous fluids respiratory distress in
anaphylactic reactions.
 Given when bacterial
sepsis is suspected.
 Counteracts symptoms of
septic shock.

10. Start cardiopulmonary 10. Prompt resuscitation may reverse

resuscitation if indicated. cardiopulmonary arrest.
11. Obtain two blood samples from 11. First sample is for cross-match to
arm opposite transfusion ensure that the correct ABO
(see Figure 8-10-3). matched blood was given. In the
second sample, the serum is
tested for free hemoglobin, which
indicates hemolysis.
12. Return the remaining blood and 12. A sample of the blood will be
tubing to blood bank. cross-matched with the client's
samples before and after the
transfusion to check for any error
in crossmatching.
13. Obtain first voided urine (within 13. Hemoglobinuria occurs with
1 hour of reaction). hemolysis so the urine may be
red or black. Renal damage
requires prompt treatment to
promote diuresis and prevent
renal tubular damage.

Assessing and Responding to Transfusion Reactions - Post-Skill

   
Evaluation:  Observe the client's response to discontinuing the transfusion
and reaction to medications or other treatment administered.
 Observe for worsening of symptoms that could lead to a severe
reaction and cardiopulmonary arrest.

   

   
Documentation: Nurses' Notes
 
Note:
 

 Date, time, and type of reaction that occurred

 Time the charge nurse and health care provider were notified
 Response of the client after discontinuing the transfusion
 Response to the treatment given for the reaction
 Time the blood and urine specimens were sent to the blood
bank

 
Medical Administration Record
 

 Medications and intravenous fluids given for the reaction

 If client is being discharged, provide written instructions of
symptoms to monitor along with follow-up health care provider
appointment.
 Do not allow the client to drive if any medications were given
that could cause sedation.

   

   
   
Variations

   
Geriatric Variations:  Sodium citrate reactions can occur in clients with inadequate
bone stores of calcium, clients with osteoporosis or bony
tumors, or clients whose mobility is limited.
  In clients with poor cardiac function, the rate of a blood
transfusion is critical in preventing cardiac overload.

   

   
Pediatric  Children may react quickly to fluid overload unless the IV rate is
Variations: carefully controlled.
 Citrate reactions can occur in infants receiving exchange
transfusions.

   

   
Home Care  Nurses working in the home setting must be meticulous in
Variations: transporting, preparing, and verifying that the correct blood is on
hand prior to administering it to the client.
 The nurse in the home setting must know the signs and
symptoms of transfusion reactions, and closely watch for any
symptoms that could signal the onset of a transfusion reaction.
The nurse must know the proper steps to obtain help for the
client, or transport, if necessary, should a transfusion reaction
occur.
 Nurses working in the home setting must follow policies and
procedures of the home health agency regarding administration
of blood products.

   

   
Long-Term Care  Personnel working in long-term care settings, where blood is not
Variations: frequently administered, should review common symptoms of
transfusion reactions prior to administering blood or blood
products.

   
Assessing and Responding to Transfusion Reactions - Common Errors

   
Possible The nurse did not give the patient premedications because he or she did not
Errors: look for a history of transfusion reactions in the medical record.
   

   
Prevention: Assess the medical record and ask the client about his or her experience with
transfusions before preparing the transfusion.
   
   
Possible The name on the blood bag is different from the medical record.
Errors:
   

   
Prevention: Assess the correct spelling of the client's name on the medical record. If this
error does occur, do not give the blood. Call the blood bank to report the error
in the spelling of the name and follow the hospital policy for returning the bag
for correction.
   

   
Nursing Tips:  Organize your time so that you can remain with the client for the first
15 minutes of the transfusion.
 Have emergency medications at the bedside.
 Remember that anaphylactic reactions have two distinct features: the
reaction occurs after only a few millimeters of blood or plasma has
been infused and there is no fever.
 Review emergency measures such as cardiopulmonary resuscitation
before starting a transfusion.

   

   
   
Critical Thinking Skill

   
Introduction: The occurrence of a hemolytic reaction is life-threatening. Every precaution
should be taken both in the laboratory where the type and cross-matching of
the donor blood with the client's blood is done and while initiating the
transfusion to ensure that the client and blood unit are identified correctly.
   

   
Possible The client was scheduled to have two units of packed RBCs. The first one
Scenario: was completed without complications. The second unit was identified slightly
differently from the first. Specifically, the last name was spelled "Smith" on
the unit of blood and "Smythe" on the medical record and the client's
wristband identification. The nurse started the transfusion as the other
numbers and names were spelled correctly. Seven minutes after starting the
second unit the client complained of pain in his back and feeling warm and
weak.
   
   
Possible The hemolytic reaction could progress and result in oliguria and renal failure.
Outcome: Hemolysis could lead to DIC and uncontrolled hemorrhage.

   

   
Prevention: If there is any variation in spelling of names, client identification numbers, or
type of blood including Rh factor of blood, it must be returned to the blood
bank. Only accurately identified cross-matched units of blood are safe to give
a client. Check the blood components at the bedside and include the client in
checking the name when applicable.
   

Central Venous Catheter Insertion: Assisting - Overview

Central venous catheters (CVCs) are inserted to measure and obtain

Overview: RAP and CVP with jugular or subclavian catheter placement. Clinically
useful information can be obtained about right ventricular preload,
cardiovascular status, and fluid balance in patient's who do not require
pulmonary artery pressure monitoring. CVCs also are placed for infusion
of vasoactive medications, total parenteral nutrition, and hemodialysis
access. In addition, CVCs are used to administer medication and
intravenous (IV) products to patient's with limited peripheral IV access.
Indications for a CVC include the following: blood loss, hypotension,
hemodialysis access, administration of total parenteral nutrition or other
hyperosmolar solutions, lack of peripheral venous access, assessment
of hypovolemia or hypervolemia, right ventricular ischemia or infarction,
 monitoring CVC pressures, long-term infusion of medications, placement
of pulmonary artery catheters, and placement of transvenous
pacemakers. Site selection is based on the vasculature of the patient.
The most common sites include the internal jugular veins, subclavian
veins, and the femoral veins. The type of catheter inserted and purpose
of insertion should be considered. Catheters may be single lumen or
multiple lumen. CVCs may be inserted for monitoring, infusion of
medications, or parenteral nutrition.
CVP can be measured using a water manometer system or via a
hemodynamic monitoring system.
The CVP provides information regarding right heart filling pressures and
volume. The normal CVP is 2 to 6 mm Hg. Electrocardiogram (ECG)
monitoring is essential in determining an accurate interpretation of the
CVP.
Individuals who perform this procedure should have the following
prerequisite knowledge:

 Anatomy and physiology of the cardiovascular system

 Anatomy and physiology of the vasculature and adjacent structures of
the neck and groin
 Basic dysrhythmia interpretation
 Advanced cardiac life support (ACLS) knowledge and skills
 Understanding of a, c, and v waves
 Principles of aseptic technique

Central Venous Catheter Insertion: Assisting - Outcomes

 The placement of the CVC is successful.

Expected  If infusing IV solution, the solution infuses without problems.
Outcomes  The a, c, and v waves are identified if hemodynamic monitoring
is used.
 CVP measurement is determined if hemodynamic monitoring is
used.
  Pain or discomfort during/after the insertion procedure
Unexpected  Pneumothorax, tension pneumothorax, hemothorax, or
Outcomes hydrothorax
 Right ventricular placement of the catheter
 Sterile thrombophlebitis
 Nerve injury
 Infection
 Cardiac dysrhythmias
 Misplacement of the catheter (e.g., carotid artery, subclavian
artery)
 Hemorrhage; arterial puncture or laceration
 Hematoma
 Venous air embolism
 Catheter embolism
 Pulmonary embolus
 Cardiac tamponade
 Sepsis
 Heparin-induced thrombocytopenia or thrombosis

central Venous Catheter Insertion: Assisting - Assessment and Preparation

 Ensure that the patient and family understand preprocedural

Preparation teaching. Answer questions as they arise, and reinforce information
as needed.
 Ensure that informed consent was obtained.
 If needed, perform endotracheal or tracheostomy suctioning on
ventilated patients before the procedure.
 Place a rolled towel vertically between the scapulae if the subclavian
approach is going to be used.
 The patient's legs may need to be positioned slightly apart if the
femoral approach is going to be used.

 CVP insertion kit

Supplies  Face masks, surgical caps, goggles (shield and mask combination
may be used), sterile gloves, and sterile gowns
 Moisture-proof underpad
 Antiseptic solution (e.g., chlorhexidine-based preparation)
 Nonsterile gloves
  Sterile large drapes and/or towels
 Catheter of choice (single, dual, or triple lumen), usually supplied
with insertion needle, dilator, syringe, and guidewire
 1% lidocaine vial without epinephrine
 One 25-G 5/8-inch needle
 0.9% sodium chloride, 10 to 30 ml
 Number 11 scalpel
 Syringes: one 10- to 12-ml syringe, two 3- to 5-ml syringes, two 22-
G, 1½-inch needles
 Large package of 4 x 4 gauze sponges
 Three-way stopcock
 Suture kit (hemostat, scissors, needle holder)
 3-0 or 4-0 nylon suture with curved needle
 Skin protectant pads or swabsticks
 Roll of 2-inch tape
 2 2 gauze pad or transparent dressing

Additional equipment as needed includes the following:

 Hemodynamic monitoring system

 IV solution with Luer-Lok administration set for IV infusion
 Luer-Lok extension tubing
 Rolled towel
 Bedside monitor and oscilloscope including pulse oximeter for
continuous monitoring
 Supplemental oxygen supplies
 Emergency resuscitation cart readily accessible with airway and
cardiac equipment

1. Assess the patient's vital signs and pulse oximetry.

Assessment 2. Assess the patient's cardiac and pulmonary status.
3. Assess the patient's coagulopathic status or recent anticoagulant or
thrombolytic therapy.

Central Venous Catheter Insertion: Assisting - Procedure

1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

2. Prepare the IV solution or flush solution.

 Rationale: Prepares the infusion system.

3. The prime IV tubing and/or the hemodynamic monitoring system.

Rationale: Prepares the infusion system and/or the monitoring system.

4. Place a moisture proof pad under the selected site of insertion.

Rationale: Avoids soiling of the bed.

5. Don sterile gloves, surgical caps, face masks, caps, and goggles or face shields.

Rationale: Reduces the transmission of microorganisms; standard precautions.

6. Assist, if needed, with cleansing of the intended insertion site with antiseptic solution
(e.g., 2% chlorhexidine-based preparation).

Rationale: Mechanical friction physically removes microbes. Antiseptics

chemically destroy microbes.
The patient's skin should be physically clean before the application of an
antiseptic solution. Organic material may inactivate antiseptic agents.

a. Subclavian insertion: scrub shoulder to contralateral nipple line and from neck to
nipple line See Figure 1 .
b. Jugular vein insertion: scrub midclavicle to opposite border of the sternum and
ear to a few inches above the nipple line See Figure 1 .
c. Femoral vein insertion: scrub femoral area in a 4 to 6-inch area.

8. Allow the area to dry; then cover with a sterile towel.

Rationale: Protects the cleansed area from contamination until the insertion
procedure begins.

8. Ensure that all individuals in the immediate area of the bedside wear a face mask.

Rationale: Prevents the transmission of microorganisms.

9. Turn or instruct the patient to turn his or her head away from the insertion site.

Rationale: Prevents the transmission of microorganisms.

10. Remove the sterile towel from the insertion site.

 Rationale: Exposes the area for the sterile preparation.

11. While the physician or advanced practice nurse completes the skin preparation, ensure
patient comfort by explaining what is happening at the time.

Rationale: Reduces anxiety and encourages cooperation.

Continue providing support and comfort throughout the procedure.

a. Application of the antiseptic solution will be cold and wet.

b. Injection of the local anesthetic may burn or sting as the tissue is being
infiltrated.

13. Place the bed in a 15 to 25-degree Trendelenburg position.

Rationale: Provides venous dilatation and increases central venous pressure to

reduce the risk for air embolism.
May be contraindicated in certain patients (e.g., those with increased
intracranial pressure, elevated venous pressure, respiratory or cardiac
compromise).

13. Monitor the heart rate, respiratory rate and rhythm, pulse oximetry, and any patient
response to the procedure See Figure 1 .

Rationale: Assessment may indicate occurrence of complications or inadequate

pain control.

14. During insertion, again ensure that the patient's head is turned away from the side
where the guidewire and the catheter are being advanced.

Rationale: Reduces contamination and may avoid malpositioning of the catheter.

15. Observe the cardiac monitor while the guidewire and catheter are advanced, and inform
the physician or advanced practice nurse immediately if a dysrhythmia occurs.

Rationale: Advancement of the guidewire or catheter into the heart may induce
cardiac dysrhythmias.
Tall, peaked P waves may be identified as the catheter tip enters the right
atrium or if the guidewire has been advanced too far into the right atrium.
Dysrhythmias may resolve with withdrawal of the guidewire or catheter. If
the dysrhythmia continues, antidysrhythmic medications may be required.

16. A scalpel is used to increase the skin access; the vessel is then dilated using a wider
diameter tool (dilator), which is placed over the wire and burrowed into the skin to allow
 easy access for the catheter into the vessel. Instruct the patient that there may be a
sensation of pressure as the dilator is inserted.

Rationale: Prepares the patient for what to expect during the procedure.
Adequate sedation and local anesthetic agent use may also assist with
patient comfort and position.

17. Once the catheter is placed and blood return ensured, assist with flushing the lumens
with normal saline and connecting the IV or hemodynamic monitoring tubing to the
catheter.

Rationale: Maintains aseptic technique. Immediate connection of the IV or

monitoring system to the catheter prevents air embolism.
Ensure a tight connection to prevent accidental disconnection. Luer-Lok
devices prevent an accidental disconnection.

18. If monitoring:

Rationale: Prepares the hemodynamic monitoring system, and assesses the

central venous pressure waveform.

a. Level the air-fluid interface and zero the system.

b. Observe the waveform.
c. Obtain a waveform strip.
d. Measure the pressure.

20. Apply an occlusive dressing.

Rationale: Prevents catheter-related infections.

20. Reposition the patient in a comfortable position.

Rationale: Head-tilt position is no longer necessary.

Remove the towel roll, if used.

21. Obtain a chest x-ray film.

Rationale: Ensures that the catheter is placed and that there is no pneumothorax
present.
Infusions (especially total parenteral nutrition and chemotherapeutic
agents) should not be initiated until catheter placement is confirmed.
 22. Discard used supplies in appropriate waste containers, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

The physician or advanced practice nurse who inserted the catheter
should dispose of all sharp objects into the sharps container.

Central Venous Catheter Insertion: Assisting - Post Procedure and Variations

1. Monitor the patient's vital signs and pulse oximetry, and assess
Post Procedure level of consciousness before the procedure, after the
procedure, and as needed during the procedure.

Rationale: Identifies signs and symptoms of complications

and allows immediate interventions.
Abnormal vital signs, low pulse oximetry value,
changes in level of consciousness, or airway
compromise should be reported if they persist
despite nursing interventions.
2. If the catheter was placed for obtaining CVP measurement,
assess the waveform.

Rationale: Ensures that the catheter is in the proper

location for monitoring. Allows assessment of a, c,
and v waves and measurement of pressure.
Abrupt and sustained changes in pressure or
abnormal waveforms should be reported if they
persist despite nursing interventions.

3. Observe the catheter site for bleeding or hematoma every 15 to

30 minutes for the first 2 hours after insertion.

Rationale: Postinsertion bleeding may occur in a patient

with coagulopathies or arterial punctures, multiple
attempts at vein access, or with the use of through-the-
needle introducer designs for insertion.
Bleeding or hematoma, especially with the internal
jugular or femoral approach, should be reported if
they persist despite nursing interventions. Subclavian
bleeding is more difficult to detect.

4. Assess heart and lung sounds before and after the procedure.

Rationale: Abnormal heart or lung sounds may indicate

cardiac tamponade, pneumothorax, or hemothorax.
Decreased blood pressure, increased CVP and/or
pulsus paradoxus, diminished or muffled heart
sounds, or absent or diminished breath sounds
unilaterally should be reported if they persist despite
nursing interventions.

5. Monitor for signs and symptoms of complications [See Table

1].

Rationale: May decrease mortality if recognized early.

Signs and symptoms of complications should be
reported if they persist despite nursing interventions.
  Patient and family education
Documentation  Vital signs
 Catheter location
 Medications administered
 Date and time of procedure
 Catheter type
 Lumen size
 Length of catheter inserted and length remaining outside the
insertion site
 Nursing interventions
 Fluids administered
 Hard copy of the waveform with analysis, if possible
 Patient tolerance of procedure
 Type of dressing applied
 Any unexpected outcomes encountered and the interventions
taken
 Placement confirmed by chest x-ray

 Explain the procedure to the patient and family, and reinforce

Patient Education information given.
 Explain the required positioning for the procedure and the
importance of not moving during the insertion.
 Explain the need for sterile technique and that the patient's
face may be covered.

Table 1: Complications of Central Venous Catheter Insertions

Complications Clinical Treatment Prevention
Manifestations
Pneumothorax Sudden respiratory Confirmation by Proper patient
distress chest x-ray preparation,
Chest pain Symptomatic sedation as
Hypoxia/cyanosis treatment necessary proper
Decreased breath Small patient positioning
sounds pneumothorax: Adequate hydration
Resonance to Bedrest O2 status
percussion pneumothorax Technique and
greater than 25%: angel of the
Chest tube needle/catheter on
Cardiopulmonary insertion
support Avoid multiple
 passes with the
needle
Clinical skilled and
experienced in
insertion technique
Tension Most likely to occur Treatment must be Proper patient
pneumothorax in patient's on rapid and preparation
ventilatory support aggressive Sedation as
Respiratory distress Immediate air necessary
Rapid clinical aspiration followed Proper patient
deterioration by chest tube positioning
Cyanosis Cardiopulmonary Adequate hydration
Jugular venous support status
distention (may not Reduction of PEEP
be present with to less than or equal
severe hypovolemia) to 5 cm ofH2O at the
Hypotension time of venipuncture
Decreased cardiac Technique and
output angle of the
needle/catheter on
insertion
Avoid multiple
passes with the
needle
Clinician skilled and
experienced in
insertion technique
Use of peripherally
inserted central
venous catheter
Delayed Slow onset of Confirmation by Proper patient
pneumothorax respiratory chest x-ray film preparation
symptoms Chest tube Sedation as
Subcutaneous Cardiopulmonary necessary
emphysema support Proper patient
Persistent pleuritic positioning
chest or back pain Adequate hydration
status
Reduction of PEEP
to less than or equal
to 5 cm of H2O at
the time of
venipuncture
Technique and
angle of the
 needle/catheter on
insertion
Avoid multiple
passes with the
needle
Clinician skilled and
experienced in
insertion technique
Use of peripherally
inserted central
venous catheter
Hydrothorax Dyspnea Stop infusion Proper patient
Chest pain Confirmed by chest preparation
Muffled breath x-ray film; contrast Sedation as
sounds injection may be necessary
High glucose level of helpful Proper patient
chest drainage Cardiopulmonary positioning
Low-grade fever support Adequate hydration
status
Technique and
angle of the
needle/catheter on
insertion
Avoid multiple
passes with the
needle
Clinician skilled and
experienced in
insertion technique
Use of peripherally
inserted central
venous catheter
Placement of
catheter tip in lower
superior vena cava
Aspiration of blood
prior to catheter use
to confirm vascular
placement
Hemothorax Respiratory distress Confirmation by Correct
Hypovolemic shock chest x-ray film coagulopathies
Hematoma in the Chest tube before insertion
neck with jugular Thoracotomy for Adequate hydration
insertion arterial repair of status
indicated Avoid multiple
 passes with the
needle
Evaluation by
Doppler studies or
venogram of
suspected
thrombosis from
prior cannulation
before insertion
Arterial Return of bright red Application of Correct
puncture/laceration blood in the syringe pressure for 3-5 coagulopathies
under high pressure minutes or as before insertion
Pulsatile blood flow needed to promote Adequate hydration
on disconnection of hemostasis status
the syringe following removal of Avoid multiple
Arterial waveform the needle passes with the
pressures when Evaluate head of needle
catheter is bed if Evaluation by
connected to hemodynamically Doppler studies or
transducer system stable venogram of
Arterial saturation of Chest tube as suspected
sample sent for indicated thrombosis from
blood gas analysis Thoracotomy for prior cannulation
Deterioration of arterial repair if before insertion use
clinical status: indicated of small-gauge
Hemorrhagic shock needle to first locate
Respiratory distress the vein
Bleeding from
catheter site may or
may not be
observed
Deviation of trachea
with large
hematoma in the
neck
Hemothorax may be
detected on chest x-
ray film
Bleeding/hematoma Bleeding from Application of Correct
: venous or arterial insertion site pressure to the coagulopathies
bleeding Hematoma insertion site before insertion
formation not likely Thoracotomy for Adequate hydration
to be seen with arterial repair status
subclavian approach Tracheotomy for Avoid multiple
Bleeding may occur tracheal deviation passes with the
 internally without from hematoma needle at
visible evidence With the femoral venipuncture
Tracheal approach, manual Use of small-gauge
compression pressure slightly needle to first locate
Respiratory distress above the the vein
Carotid compression inadvertent arterial Controlling femoral
puncture site bleeding
immediately may
prevent large blood
loss or hematoma
formation
Cardiac Cardiac Withdraw the guide Avoid entry into the
dysrhythmias dysrhythmias wire or catheter heart with the guide
Premature atrial from the heart; wire
contractions dysrhythmias Observe cardiac
Atrial fibrillation or should stop if the monitor; tall peaked
flutter cause was P waves can be
Premature mechanical in identified as the
ventricular nature catheter tip enters
contractions Pharmacologic the right atrium
Supraventricular treatment of
tachycardia persistent
Ventricular dysrhythmias
tachycardia
Sudden
cardiovascular
collapse
Air embolism Symptoms depend Stop airflow Adequate hydration
on amount of air Position patient on status
drawn in, especially left side in Head-down tilt or
with spontaneous Trendelenburg Trendelenburg
breathing patients position position during
Sudden Oxygen catheter insertion
cardiovascular administration Use of small-bore
collapse Air aspiration: needle for insertion
Tachypnea, apnea, transthoracic Application of
tachycardia needle or thumb over needle
Hypotension, intracardiac or catheter hub
cyanosis, anxiety catheter during
Diffuse pulmonary Cardiopulmonary disconnection;
wheezes support needle or hub
“Mill wheel” churning should not be
heart murmur exposed longer
Neurologic deficits, than 1 second
paresis, stroke, Advancement of
 coma catheter during
Cardiac arrest positive-pressure
cycle in patient's on
ventilatory support
Avoid nicking of
catheter with careful
suturing technique
Avoid catheter
exchange from
large-bore catheter
(pulmonary artery)
to smaller catheter
Use of Luer-Lok
connections
Minimal risk with
peripherally inserted
central venous
catheter
Catheter Pain in ear or neck Make sure bevel of Proper patient
malposition Swishing sound in insertion needle is positioning
ear with infusion positioned Anthropometric
Sharp anterior chest downward (toward measurement for
pain feet of patient) prior accurate
Pain in ipsilateral to placing guidewire intravascular
shoulder blade Repositioning of catheter length
Cardiac dysrhythmia catheter with Avoid use of force
Observation on guidewire or new when advancing the
chest x-ray film venipuncture catheter
Signs or symptoms Catheter removal Use of a guidewire
may be absent or blunt-tipped stylet
No blood return on
aspiration
Catheter embolism Cardiac Location of Use of “over a
dysrhythmias fragment on guidewire”
Chest pain radiograph (Seldinger) insertion
Dyspnea Transvenous technique
Hypotension retrieval of catheter Extreme caution
Tachycardia fragment with use of through-
May be clinically Thoracotomy the-needle catheter
silent designs; never
withdraw a catheter
through the needle
Use of guidewire or
stylet within a
catheter that is
 inserted through a
needle
Cardiac tamponade Retrosternal or Treatment must be Catheter tip
epigastric pain rapid and position; Parallel to
Dyspnea aggressive the walls of the
Venous Discontinuation of superior vena cava
engorgement of face infusions through 1 to 2 cm above the
and neck the central line junction of the
Restlessness, Aspiration through superior vena cava
confusion the catheter and right atrium
Hypotension, Emergency Use of soft, flexible
paradoxical pulse pericardiocentesis catheters
Muffled heart Emergency Minimal risk with
sounds thoracotomy peripherally inserted
Mediastinal central venous
widening catheter
Pleural effusion
Cardiac arrest
Tracheal injury Subcutaneous Emergency Clinician skilled and
emphysema reintubation (for experienced in
Pneumomediastinu punctured insertion techniques
m endotracheal tube Use of peripherally
Air trapping between cuff) inserted central
the chest wall and Aspiration of air in venous catheter
the pleura mediastinum
Respiratory distress
with puncture of
endotracheal tube
cuff
Nerve injury Patient complains of Remove catheter if Clinician skilled and
tingling/numbness in suspected brachial experienced in
arm or fingers plexus injury insertion technique
Shooting pain down Minimal risk with
the arm peripherally inserted
Paralysis central venous
Diaphragmatic catheter
paralysis (phrenic
nerve injury)
Sterile Potential Application of heat Strict aseptic
thrombophlebitis complication of the for 48 to 72 hours technique during
peripherally inserted Removal of catheter insertion
central venous catheter
catheter
Redness,
 tenderness, swelling
along the course of
the vein
Pain in the upper
extremity or
shoulder
Pulmonary Potential Spiral chest Avoid catheter
embolism complication of tomogram (CT) exchange in veins
catheter exchange Lung perfusion with thrombosis
Often clinically silent scan
Chest pain, Cardiopulmonary
Dyspnea, coughing, support with large
tachycardia, anxiety, pulmonary
fever embolism

Central Venous Catheter Insertion: Performing (Advanced Practice) - Overview

Central venous catheters are inserted to measure and obtain (RAP) and
Overview: CVP with jugular or subclavian catheter placement. Clinically useful
information can be obtained about right ventricular preload,
cardiovascular status, and fluid balance in patient's who do not require
pulmonary artery pressure monitoring. Central venous catheters also are
placed for infusion of vasoactive medications, total parenteral nutrition,
and hemodialysis access. In addition, central venous catheters are used
to administer medication and intravenous (IV) products to patient's with
limited peripheral IV access, as well as to provide access for pulmonary
artery catheters and transvenous pacemakers.
The CVP can be particularly helpful after major surgery and during active
bleeding. It can be helpful in differentiating right ventricular failure from
left ventricular failure. The CVP is commonly elevated during or following
right ventricular failure, ischemia, or infarction because of decreased
compliance of the right ventricle while the pulmonary artery wedge
pressure is normal. The CVP value is low if the patient is hypovolemic;
venodilation also decreases CVP. The CVP provides information
regarding right heart filling pressures and right ventricular function and
volume.
The CVP can be measured using a water manometer system or via a
hemodynamic monitoring system. The CVP waveform is identical to the
RAP waveform. Normal CVP value is 2 to 6 mm Hg.
Central venous access may be obtained in a variety of sites [See Table
 1]. The risk for pneumothorax is minimized by using an internal jugular
vein. The preferred site for catheter insertion is the right internal jugular
vein. The right internal jugular vein is a straight shot to the right atrium.
The right or left subclavian veins are also sites for central catheter
placement. Placement of a central catheter through the right subclavian
vein is a shorter and more direct route than the left subclavian vein,
because it does not cross the midline of the thorax. Femoral veins may
be accessed but have the strong disadvantage of forcing the patient to
be on bed rest with immobilization of that leg, and there is an increased
risk for infection with placement in the groin.
Individuals who perform this procedure should have the following
prerequisite knowledge:

 Normal anatomy and physiology of the cardiovascular system

 Clinical and technical competence in central line insertion and suturing
 Understanding of principles of sterile technique
 Anatomy and physiology of the vasculature and adjacent structures of
the neck, groin, and arm
 Competence in chest-x-ray interpretation
 Advanced cardiac life support (ACLS) knowledge and skills
 Understanding of a, c, and v waves

Table 1: Sites, Complications, and Success Rates

Access Site Complications Success Rates (%)

Internal jugular vein
Right subclavian vein
Left subclavian vein
Carotid artery puncture 60-90
Carotid artery cannulation
Pneumothorax 70-98
Tension pneumothorax
Thoracic duct puncture
Decreased success rate
with inexperience
Pneumothorax 70-98
Tension pneumothorax
Thoracic duct puncture
Decreased success rate
with inexperience
 Femoral vein Infection 75-99
Arterial puncture
Failure rate during
hypotension and shock
Inability to thread central
catheters

Central Venous Catheter Insertion: Performing (Advanced Practice) - Outcomes

 Successful placement of the central venous catheter

Expected  If infusing IV solution, the solution infuses without problems
Outcomes  The a, c, and v waves identified in hemodynamic monitoring
 CVP measurement determined

 Pain or discomfort during the insertion procedure

Unexpected  Pneumothorax, tension pneumothorax, hemothorax, or
Outcomes chylothorax
 Nerve injury
 Sterile thrombophlebitis
 Infection
 Cardiac dysrhythmias
 Misplacement (e.g., carotid artery, subclavian artery)
 Inadvertent lymphatic or thoracic duct perforation
 Hemorrhage
 Hematoma
 Venous air embolism
 Pulmonary embolus
 Cardiac tamponade
 Sepsis
 Heparin-induced thrombocytopenia or thrombosis

Central Venous Catheter Insertion: Performing (Advanced Practice) - Assessment

and Preparation
  Ensure that the patient and family understand preprocedural
Preparation teaching. Answer questions as they arise, and reinforce information
as needed.
 Obtain informed consent.
 Prescribe sedation if needed.
 Place the patient in a supine position, and prepare the area with an
antiseptic solution (e.g., 2% chlorhexidine-based solution).
 If the patient is obese or muscular and the preferred site is the
internal jugular vein or subclavian vein, place a towel posteriorly
between the shoulder blades.
 Place sterile drapes over the prepped area.

 CVC insertion kit

Supplies  Teflon®-coated or antimicrobial/antiseptic impregnated catheter of
choice(single, dual, or triple lumen) usually supplied with insertion
needle, dilator, syringe, guidewire
 Large sterile drapes or towels
 1% lidocaine without epinephrine
 One 25-G 5/8 needle
 Large package of 4 x 4 gauze sponges
 Suture kit (hemostat, scissors, needle holder)
 0 or 4-0 nylon suture with curved needle
 Three-way stopcock
 Syringes: one 10- to 12-ml syringe, two 3- to 5-ml syringes, two 22-
G, 1½-inch needles
 Masks, caps, goggles (shield and mask combination be used), sterile
gloves, and sterile gowns
 Number 11 scalpel
 Skin protectant pad or swab stick
 Roll of 2-inch tape
 Dressing supplies
 Moisture proof underpad
 Antiseptic solution (such as 2% chlorhexidine-preparation)
 Nonsterile gloves
 0.9% sodium chloride, 10 to 30 ml.

Additional equipment as needed includes the following:

 Hemodynamic monitoring system 

 IV solution with Luer-Lok administration set for infusion
 Luer-Lok extension tubing
 Bedside monitor and oscilloscope with pulse oximetry
 Supplemental oxygen supplies
  Emergency equipment
 Package of alcohol pads or swabsticks
 Package of povidone-iodine pads or swabsticks
 Heparin flushes
 Needleless caps
 Arm board

1. Determine the patient's medical history of

Assessment pneumothorax/emphysema.
2. Determine the patient's medical history of anomalous veins.
3. Assess the intended insertion site.
4. Assess the patient's cardiac and pulmonary status.
5. Assess vital signs and pulse oximetry.
6. Assess electrolyte levels.
7. Assess the patient for heparin sensitivity or allergy.
8. Assess coagulopathic status or whether the patient has recently
received anticoagulant or thrombolytic therapy.

Central Venous Catheter Insertion: Performing (Advanced Practice) - Procedure

1. Determine the anatomy of the access site.

Rationale: Helps ensure proper placement of the catheter.

Catheter placement on the right side is preferred to avoid cannulation of
the thoracic duct.

2. Wash hands, and don caps, masks, sterile gowns, goggles or face shields, and gloves
for all health care personnel involved with the procedure.

Rationale: Reduces the transmission of microorganisms and body secretions.

Prepares for sterile technique.

3. Check landmarks again for the intended catheter insertion site.

Rationale: Ensures proper placement of the catheter.

4. Estimate the length of the catheter needed. This can be done by holding the catheter
from the insertion site to the sternal notch.

Rationale: Helps ensure proper placement.

Internal Jugular Vein See Figure 2

1. Locate the carotid artery by palpation.

Rationale: Helps prevent placing the introducer in the carotid artery.

2. Identify the jugular vein, and mark it if necessary.

Rationale: Identifies the intended insertion site.

3. Instruct the patient to turn his or her head away from the insertion site.

Rationale: Helps identify the landmarks.

Turn the patient's head if the patient is unable to.

4. Place the patient in a 15- to 25-degree Trendelenburg position.

Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins
to help identify the correct site.

5. Identify the internal jugular vein from the triangle between the medial aspect of the
clavicle, the medial aspect of the sternal head, and the lateral head of the
sternocleidomastoid muscle See Figure 2.

Rationale: A high entry can be made from a posterior approach, a lateral

approach, an anterior approach, or a central approach.
The midanterior approach may be preferred in an obese patient. The
posterior approach may present a slightly higher risk.

6. Administer a local anesthetic and locate the internal jugular vein with a small needle 3
to 4 cm above the medial clavicle and 1 to 2 cm within the lateral border of the
sternocleidomastoid muscle.

Rationale: Provides patient comfort and aids in insertion.

7. Attach a 3-ml or 5-ml syringe with 2 or 3 ml of 1% lidocaine (without epinephrine) to the

18-G needle. Align the needle with the syringe parallel to the medial border of the
clavicular head of the sternocleidomastoid muscle. Aim at a 30-degree angle to the
frontal plane over the internal jugular vein, toward the ipsilateral nipple.

Rationale: Helps to anesthetize below the subcutaneous tissue. If the needle

bevel is directed medially, the bevel aids in directing the guidewire medially.

8. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

 placement. This technique uses a dilator and guidewire.

9. Puncture the skin, and advance the needle while maintaining slight negative pressure
until a free flow of blood is obtained.

Rationale: Slight negative pressure helps to ensure placement into the vein and
decreases the risk for air embolism and pneumothorax.
If a free flow of blood is not obtained, remove and redirect the needle 5 to
10 degrees more laterally.

10. After a free flow of blood is obtained, have the patient hold his or her breath or hum
while the syringe is detached, and insert the soft-tipped guidewire 10 to 15 cm through
the needle. Remove the needle, wipe the guidewire with the sterile 4 x 4 gauze, and
instruct the patient to breathe normally.

Rationale: A free flow of blood indicates the needle is in the vessel. Holding the
breath or humming decreases the risk for air embolus. Wiping the guidewire dry
eases manipulation.

11. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at
the insertion site.

Rationale: Eases the insertion of the dilator through the skin.

12. Insert the dilator through the skin, over the guidewire, until 10 to 15 cm of wire extends
beyond the dilator. Remove the dilator.

Rationale: The dilator enlarges the vessel and skin opening, easing the insertion
of the catheter.

13. Insert the catheter over the guidewire until 10 to 15 cm of wire extends beyond the
catheter. Remove the guidewire. Advance the catheter. Note the catheter length at the
insertion site.

Rationale: Helps identify the location.

14. Aspirate and flush the ports with normal saline.

Rationale: Prevents clotting of the catheter

15. Connect to the hemodynamic monitoring system or intravenous fluid.

Rationale: Necessary for pressure monitoring and maintaining catheter patency.

16. Suture the catheter in place.

 Rationale: Secures the catheter.
Some institutions use stat locks or a sutureless mechanism for securing
the catheter.

17. Apply an occlusive, sterile dressing.

Rationale: Decreases the risk for infection.

Some institutions use stat locks or a sutureless mechanism for securing the
catheter.

18. Return the patient to a neutral or head-up position

Rational: Provide comfort.

19. If monitoring, identify the appropriate waveforms.

Rational: Ensures accurate monitoring of values.

20. Assess lung sounds and obtain a chest x-ray film.

Rational: Confirms placement and assesses for pneumothorax.

The radiograph needs to be read before administration or total parenteral
nutrition or chemotherapeutic agents.

21. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of micro organisms; standard

precautions.
Subclavian Vein See Figure 4

1. Identify the junction of the middle and medial thirds of the clavicle. The needle insertion
should be 1 to 2 cm laterally.

Rationale: Identifies landmarks for catheter placement.

Access from the right side is preferred to avoid inadvertent puncture of the
thoracic duct.

2. Depress the area 1 to 2 cm beneath the junction with the thumb of the nondominant
hand and the index finger 2 cm above the sternal notch.

To avoid the subclavian artery, select a puncture site away from the most
lateral course of the vein, and do not aim too posteriorly.

3. Administer a local anesthetic and locate the vein with a 21- to 25-G needle directed to
 the index finger at a 20- to 30-degree angle.

Rationale: Provides patient comfort and assists patient cooperation and ease of
insertion. Extends the vein to ease the location.

4. Instruct the patient to turn his or her head away from the insertion site.

Rationale: Helps identify the landmarks.

Turn the patient's head if he or she is unable to.

5. Place the patient in a 15- to 25-degree Trendelenburg position.

Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins
to help identify the correct site.

6. Insert the needle under the clavicle and "walk down" until it slips below the clavicle into
the vein while maintaining negative pressure within the syringe until free-flowing blood
is returned See Figure 5.

Rationale: Decreases the risk for pneumothorax. Slight negative pressure helps
to ensure placement into the vein and decreases the risk for air embolism and
pneumothorax.
Insert at a 45-degree angle to prevent pneumothorax. If it is difficult to
depress the needle down, the needle may be bent to form an arc. For the
elderly: the subclavian vein may be more inferior. Avoiding a too lateral or
too deep a needle insertion can reduce the risk for pneumothorax.

7. When a free flow of blood is returned, turn the bevel to the 3 o'clock position. Once in
the vein, remove the syringe and insert the flexible guidewire after asking the patient to
hum or hold his or her breath.

Rationale: A free flow of blood indicates a vein is entered. Turning the bevel
helps the guidewire advance to the correct position. Holding the breath or
humming decreases the risk for air embolus.

8. Insert the guidewire 10 to 15 cm through the needle. Remove the needle, and wipe the
guidewire with a sterile 4 x 4 gauze.

Rationale: Wiping the guidewire eases the manipulation of the guidewire.

If the guidewire insertion is not smooth, it may be in the internal jugular
vein.

9. Advance the dilator over the guidewire with a light twisting motion.
 Rationale: This aids dilation of the subcutaneous tissue to ease insertion and
prevents the formation of a false channel.

10. Remove the dilator from the wire.

11. Insert the catheter of choice over the guidewire; then remove the guidewire.
12. Aspirate and flush the ports with normal saline.

Rationale: Ensures blood return, and maintains catheter patency.

13. Suture the line in place.

Rationale: Secures the catheter.

14. Connect the catheter to the hemodynamic monitoring system or to intravenous fluid.

Rationale: Necessary for pressure monitoring and catheter patency.

15. Apply an occlusive, sterile dressing to the site.

Rationale: Decreases the risk for infection.

16. If monitoring, identify appropriate waveforms.

Rationale: Ensures accurate monitoring of values.

17. Assess lung sounds, and obtain a chest x-ray film.

Rationale: Confirms placement and assesses for pneumothorax.

The radiograph must be read before administration of total parenteral
nutrition or chemotherapeutic agents.

18. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of microorganisms; standard

precautions.
Femoral Vein See Figure 1

1. Identify the anatomy, including the femoral artery (remember "NAVEL").

Rationale: NAVEL is an acronym for remembering the anatomy (Nerve, Artery,

Vein, Empty space, Ligament; from lateral to medial).

2. Administer a local anesthetic and locate the vein with a 21- to 25-G needle lateral to the
femoral artery. Aim the needle at a 20- to 30-degree angle.
 Rationale: Anesthetizes the area to provide patient comfort.

3. Attach a 3- or 5-ml syringe with 2 or 3 ml 1% lidocaine without epinephrine to the 18-G

needle.

Rationale: Anesthetizes the area to provide patient comfort.

4. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

placement. This technique uses a dilator and guidewire.

5. Puncture the skin and advance the needle while maintaining slight negative pressure
until a free flow of blood is obtained.

Rationale: Negative pressure helps to identify a free flow of blood and ensures
proper placement into the vein.
If a free flow of blood is not obtained, remove and redirect the needle 5 to
10 degrees more laterally.

6. After a free flow of blood is obtained, detach the syringe and insert a soft-tipped
guidewire through the needle 10 to 15 cm. Remove the needle and wipe the guidewire
with a sterile 4 x 4 gauze.

Rationale: A free flow of blood indicates that the vessel has been accessed.
Wiping the guidewire eases the manipulation of the guidewire.

7. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at
the insertion site.

Rationale: Eases insertion of the introducer through the skin.

8. Insert the dilator over the guidewire until 10 to 15 cm of wire extends beyond the
sheath. Advance the dilator through the skin.

Rationale: The dilator dilates the vessel and skin to assist in the ease of the
catheter insertion.

9. Remove the dilator.

10. Insert the catheter of choice over the guidewire and into the vein; then remove the
guidewire.
11. Aspirate and flush the ports with normal saline.

Rationale: Ensures blood return and maintains catheter patency.

12. Suture the catheter in place.

 Rationale: Secures the catheter.
Some institutions use sutureless systems.

13. Connect to the hemodynamic monitoring system or to intravenous fluid.

Rationale: Necessary for pressure monitoring and catheter patency.

14. Apply an occlusive, sterile dressing.

Rationale: Decreases the risk for infection.

May be gauze or transparent, semipermeable sterile dressing.

15. Identify the appropriate waveforms.

Rationale: Ensures the accurate monitoring of values.

16. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of microorganisms, standard

precautions.
Arm Vein See Figure 6

1. Identify the median basilic vein.

Rationale: Identifies the site for catheter placement.

The basilic vein is deeper and ascends along the ulnar surface of the
forearm, joined by the median cubital vein in front of the elbow.

2. Further patient preparation includes applying a tourniquet to locate the vein. Abduct the
selected arm 30 to 45 degrees, and secure it on a flat, padded arm board resting on a
flat surface.

Rationale: Aids preparation and allows for engorgement of the vessel.

3. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

placement. This technique uses a dilator and guidewire.

4. Apply a venous tourniquet to the upper arm. Maintain traction on the skin distal to the
insertion with one hand; puncture the vein with the needle bevel up at a 15- to 20-
degree angle.

Rationale: Allows better visualization of veins. Helps with insertion, and prevents
 the needle from penetrating too deeply.
Do not attempt to place a central venous catheter in a vein that cannot be
seen or palpated.

5. When blood appears in the needle, insert the guidewire into the vein approximately 2 to
4 cm beyond the tip.

Rationale: Ensures appropriate placement of the catheter.

If resistance is met, do not force the catheter to advance. Withdraw the
catheter 2 to 3 cm, rotate it, and readvance it.

6. Release the tourniquet, and advance the guidewire several centimeters. Remove the
needle; wipe the guidewire with a sterile 4 x 4 gauze.

Rationale: Eases manipulation of the guidewire.

7. Insert the catheter of choice over the guidewire. Remove the guidewire. Note the
centimeter marking at the skin.
8. Aspirate and flush the ports with normal saline.

Rationale: Maintains line patency.

9. Suture in place.

Rationale: Secures the line.

10. Connect to intravenous fluid.

Rationale: Maintains line patency.

11. Apply an occlusive, sterile dressing to the insertion site.

Rationale: Reduces the incidence of infection.

12. Immobilize on an arm board.

Rationale: Ensures that minimal movement of the catheter and sheath occurs.

13. Discard supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Central Venous Catheter Insertion: Performing (Advanced Practice) - Procedure

1. Determine the anatomy of the access site.

Rationale: Helps ensure proper placement of the catheter.

Catheter placement on the right side is preferred to avoid cannulation of
the thoracic duct.

2. Wash hands, and don caps, masks, sterile gowns, goggles or face shields, and gloves
for all health care personnel involved with the procedure.

Rationale: Reduces the transmission of microorganisms and body secretions.

Prepares for sterile technique.

3. Check landmarks again for the intended catheter insertion site.

Rationale: Ensures proper placement of the catheter.

4. Estimate the length of the catheter needed. This can be done by holding the catheter
from the insertion site to the sternal notch.

Rationale: Helps ensure proper placement.

Internal Jugular Vein See Figure 2

1. Locate the carotid artery by palpation.

Rationale: Helps prevent placing the introducer in the carotid artery.

2. Identify the jugular vein, and mark it if necessary.

Rationale: Identifies the intended insertion site.

3. Instruct the patient to turn his or her head away from the insertion site.

Rationale: Helps identify the landmarks.

Turn the patient's head if the patient is unable to.

4. Place the patient in a 15- to 25-degree Trendelenburg position.

Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins
to help identify the correct site.
5. Identify the internal jugular vein from the triangle between the medial aspect of the
clavicle, the medial aspect of the sternal head, and the lateral head of the
sternocleidomastoid muscle See Figure 2.

Rationale: A high entry can be made from a posterior approach, a lateral

approach, an anterior approach, or a central approach.
The midanterior approach may be preferred in an obese patient. The
posterior approach may present a slightly higher risk.

6. Administer a local anesthetic and locate the internal jugular vein with a small needle 3 to
4 cm above the medial clavicle and 1 to 2 cm within the lateral border of the
sternocleidomastoid muscle.

Rationale: Provides patient comfort and aids in insertion.

7. Attach a 3-ml or 5-ml syringe with 2 or 3 ml of 1% lidocaine (without epinephrine) to the

18-G needle. Align the needle with the syringe parallel to the medial border of the
clavicular head of the sternocleidomastoid muscle. Aim at a 30-degree angle to the
frontal plane over the internal jugular vein, toward the ipsilateral nipple.

Rationale: Helps to anesthetize below the subcutaneous tissue. If the needle

bevel is directed medially, the bevel aids in directing the guidewire medially.

8. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

placement. This technique uses a dilator and guidewire.

9. Puncture the skin, and advance the needle while maintaining slight negative pressure
until a free flow of blood is obtained.

Rationale: Slight negative pressure helps to ensure placement into the vein and
decreases the risk for air embolism and pneumothorax.
If a free flow of blood is not obtained, remove and redirect the needle 5 to
10 degrees more laterally.

10. After a free flow of blood is obtained, have the patient hold his or her breath or hum
while the syringe is detached, and insert the soft-tipped guidewire 10 to 15 cm through
the needle. Remove the needle, wipe the guidewire with the sterile 4 x 4 gauze, and
instruct the patient to breathe normally.

Rationale: A free flow of blood indicates the needle is in the vessel. Holding the
breath or humming decreases the risk for air embolus. Wiping the guidewire dry
eases manipulation.
11. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at
the insertion site.

Rationale: Eases the insertion of the dilator through the skin.

12. Insert the dilator through the skin, over the guidewire, until 10 to 15 cm of wire extends
beyond the dilator. Remove the dilator.

Rationale: The dilator enlarges the vessel and skin opening, easing the insertion
of the catheter.

13. Insert the catheter over the guidewire until 10 to 15 cm of wire extends beyond the
catheter. Remove the guidewire. Advance the catheter. Note the catheter length at the
insertion site.

Rationale: Helps identify the location.

14. Aspirate and flush the ports with normal saline.

Rationale: Prevents clotting of the catheter

15. Connect to the butor intravenous fluid.

Rationale: Necessary for pressure monitoring and maintaining catheter patency.

16. Suture the catheter in place.

Rationale: Secures the catheter.

Some institutions use stat locks or a sutureless mechanism for securing
the catheter.

17. Apply an occlusive, sterile dressing.

Rationale: Decreases the risk for infection.

Some institutions use stat locks or a sutureless mechanism for securing the
catheter.

18. Return the patient to a neutral or head-up position

Rational: Provide comfort.

19. If monitoring, identify the appropriate waveforms.

Rational: Ensures accurate monitoring of values.

 20. Assess lung sounds and obtain a chest x-ray film.

Rational: Confirms placement and assesses for pneumothorax.

The radiograph needs to be read before administration or total parenteral
nutrition or chemotherapeutic agents.

21. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of micro organisms; standard

precautions.
Subclavian Vein See Figure 4

1. Identify the junction of the middle and medial thirds of the clavicle. The needle insertion
should be 1 to 2 cm laterally.

Rationale: Identifies landmarks for catheter placement.

Access from the right side is preferred to avoid inadvertent puncture of the
thoracic duct.

2. Depress the area 1 to 2 cm beneath the junction with the thumb of the nondominant
hand and the index finger 2 cm above the sternal notch.

To avoid the subclavian artery, select a puncture site away from the most
lateral course of the vein, and do not aim too posteriorly.

3. Administer a local anesthetic and locate the vein with a 21- to 25-G needle directed to
the index finger at a 20- to 30-degree angle.

Rationale: Provides patient comfort and assists patient cooperation and ease of
insertion. Extends the vein to ease the location.

4. Instruct the patient to turn his or her head away from the insertion site.

Rationale: Helps identify the landmarks.

Turn the patient's head if he or she is unable to.

5. Place the patient in a 15- to 25-degree Trendelenburg position.

Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins
to help identify the correct site.

6. Insert the needle under the clavicle and "walk down" until it slips below the clavicle into
the vein while maintaining negative pressure within the syringe until free-flowing blood is
 returned See Figure 5.

Rationale: Decreases the risk for pneumothorax. Slight negative pressure helps
to ensure placement into the vein and decreases the risk for air embolism and
pneumothorax.
Insert at a 45-degree angle to prevent pneumothorax. If it is difficult to
depress the needle down, the needle may be bent to form an arc. For the
elderly: the subclavian vein may be more inferior. Avoiding a too lateral or
too deep a needle insertion can reduce the risk for pneumothorax.

7. When a free flow of blood is returned, turn the bevel to the 3 o'clock position. Once in
the vein, remove the syringe and insert the flexible guidewire after asking the patient to
hum or hold his or her breath.

Rationale: A free flow of blood indicates a vein is entered. Turning the bevel
helps the guidewire advance to the correct position. Holding the breath or
humming decreases the risk for air embolus.

8. Insert the guidewire 10 to 15 cm through the needle. Remove the needle, and wipe the
guidewire with a sterile 4 x 4 gauze.

Rationale: Wiping the guidewire eases the manipulation of the guidewire.

If the guidewire insertion is not smooth, it may be in the .

9. Advance the dilator over the guidewire with a light twisting motion.

Rationale: This aids dilation of the subcutaneous tissue to ease insertion and
prevents the formation of a false channel.

10. Remove the dilator from the wire.

11. Insert the catheter of choice over the guidewire; then remove the guidewire.
12. Aspirate and flush the ports with normal saline.

Rationale: Ensures blood return, and maintains catheter patency.

13. Suture the line in place.

Rationale: Secures the catheter.

14. Connect the catheter to the hemodynamic monitoring system or to intravenous fluid.

Rationale: Necessary for pressure monitoring and catheter patency.

15. Apply an occlusive, sterile dressing to the site.

 Rationale: Decreases the risk for infection.

16. If monitoring, identify appropriate waveforms.

Rationale: Ensures accurate monitoring of values.

17. Assess lung sounds, and obtain a chest x-ray film.

Rationale: Confirms placement and assesses for pneumothorax.

The radiograph must be read before administration of total parenteral
nutrition or chemotherapeutic agents.

18. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of microorganisms; standard

precautions.
Femoral Vein See Figure 1

1. Identify the anatomy, including the femoral artery (remember "NAVEL").

Rationale: NAVEL is an acronym for remembering the anatomy (Nerve, Artery,

Vein, Empty space, Ligament; from lateral to medial).

2. Administer a local anesthetic and locate the vein with a 21- to 25-G needle lateral to the
femoral artery. Aim the needle at a 20- to 30-degree angle.

Rationale: Anesthetizes the area to provide patient comfort.

3. Attach a 3- or 5-ml syringe with 2 or 3 ml 1% lidocaine without epinephrine to the 18-G

needle.

Rationale: Anesthetizes the area to provide patient comfort.

4. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

placement. This technique uses a dilator and guidewire.

5. Puncture the skin and advance the needle while maintaining slight negative pressure
until a free flow of blood is obtained.

Rationale: Negative pressure helps to identify a free flow of blood and ensures
proper placement into the vein.
If a free flow of blood is not obtained, remove and redirect the needle 5 to
10 degrees more laterally.
6. After a free flow of blood is obtained, detach the syringe and insert a soft-tipped
guidewire through the needle 10 to 15 cm. Remove the needle and wipe the guidewire
with a sterile 4 x 4 gauze.

Rationale: A free flow of blood indicates that the vessel has been accessed.
Wiping the guidewire eases the manipulation of the guidewire.

7. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at
the insertion site.

Rationale: Eases insertion of the introducer through the skin.

8. Insert the dilator over the guidewire until 10 to 15 cm of wire extends beyond the
sheath. Advance the dilator through the skin.

Rationale: The dilator dilates the vessel and skin to assist in the ease of the
catheter insertion.

9. Remove the dilator.

10. Insert the catheter of choice over the guidewire and into the vein; then remove the
guidewire.
11. Aspirate and flush the ports with normal saline.

Rationale: Ensures blood return and maintains catheter patency.

12. Suture the catheter in place.

Rationale: Secures the catheter.

Some institutions use sutureless systems.

13. Connect to the hemodynamic monitoring system or to intravenous fluid.

Rationale: Necessary for pressure monitoring and catheter patency.

14. Apply an occlusive, sterile dressing.

Rationale: Decreases the risk for infection.

May be gauze or transparent, semipermeable sterile dressing.

15. Identify the appropriate waveforms.

Rationale: Ensures the accurate monitoring of values.

16. Discard supplies, and wash hands.

 Rationale: Decreases the risk for transmission of microorganisms, standard
precautions.
Arm Vein See Figure 6

1. Identify the median basilic vein.

Rationale: Identifies the site for catheter placement.

The basilic vein is deeper and ascends along the ulnar surface of the
forearm, joined by the median cubital vein in front of the elbow.

2. Further patient preparation includes applying a tourniquet to locate the vein. Abduct the
selected arm 30 to 45 degrees, and secure it on a flat, padded arm board resting on a
flat surface.

Rationale: Aids preparation and allows for engorgement of the vessel.

3. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

placement. This technique uses a dilator and guidewire.

4. Apply a venous tourniquet to the upper arm. Maintain traction on the skin distal to the
insertion with one hand; puncture the vein with the needle bevel up at a 15- to 20-
degree angle.

Rationale: Allows better visualization of veins. Helps with insertion, and prevents
the needle from penetrating too deeply.
Do not attempt to place a central venous catheter in a vein that cannot be
seen or palpated.

5. When blood appears in the needle, insert the guidewire into the vein approximately 2 to
4 cm beyond the tip.

Rationale: Ensures appropriate placement of the catheter.

If resistance is met, do not force the catheter to advance. Withdraw the
catheter 2 to 3 cm, rotate it, and readvance it.

6. Release the tourniquet, and advance the guidewire several centimeters. Remove the
needle; wipe the guidewire with a sterile 4 x 4 gauze.

Rationale: Eases manipulation of the guidewire.

7. Insert the catheter of choice over the guidewire. Remove the guidewire. Note the
centimeter marking at the skin.
 8. Aspirate and flush the ports with normal saline.

Rationale: Maintains line patency.

9. Suture in place.

Rationale: Secures the line.

10. Connect to intravenous fluid.

Rationale: Maintains line patency.

11. Apply an occlusive, sterile dressing to the insertion site.

Rationale: Reduces the incidence of infection.

12. Immobilize on an arm board.

Rationale: Ensures that minimal movement of the catheter and sheath occurs.

13. Discard supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Arm Vein See Figure 6

1. Identify the median basilic vein.

Rationale: Identifies the site for catheter placement.

The basilic vein is deeper and ascends along the ulnar surface of the
forearm, joined by the median cubital vein in front of the elbow.

2. Further patient preparation includes applying a tourniquet to locate the vein. Abduct the
selected arm 30 to 45 degrees, and secure it on a flat, padded arm board resting on a
flat surface.

Rationale: Aids preparation and allows for engorgement of the vessel.

3. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter

placement. This technique uses a dilator and guidewire.

4. Apply a venous tourniquet to the upper arm. Maintain traction on the skin distal to the
insertion with one hand; puncture the vein with the needle bevel up at a 15- to 20-
degree angle.
 Rationale: Allows better visualization of veins. Helps with insertion, and prevents
the needle from penetrating too deeply.
Do not attempt to place a central venous catheter in a vein that cannot be
seen or palpated.

5. When blood appears in the needle, insert the guidewire into the vein approximately 2 to
4 cm beyond the tip.

Rationale: Ensures appropriate placement of the catheter.

If resistance is met, do not force the catheter to advance. Withdraw the
catheter 2 to 3 cm, rotate it, and readvance it.

6. Release the tourniquet, and advance the guidewire several centimeters. Remove the
needle; wipe the guidewire with a sterile 4 x 4 gauze.

Rationale: Eases manipulation of the guidewire.

7. Insert the catheter of choice over the guidewire. Remove the guidewire. Note the
centimeter marking at the skin.
8. Aspirate and flush the ports with normal saline.

Rationale: Maintains line patency.

9. Suture in place.

Rationale: Secures the line.

10. Connect to intravenous fluid.

Rationale: Maintains line patency.

11. Apply an occlusive, sterile dressing to the insertion site.

Rationale: Reduces the incidence of infection.

12. Immobilize on an arm board.

Rationale: Ensures that minimal movement of the catheter and sheath occurs.

13. Discard supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Central Venous Catheter Insertion: Performing (Advanced Practice) - Post

Procedure and Variations
 1. Perform cardiovascular, peripheral vascular, and hemodynamic
Post Procedure assessments immediately before and after the procedure and
as the patient's condition necessitates.

Rationale: Assess for signs of adequate perfusion; air

embolism may present with restlessness; patient may
present with decreased level of consciousness if the
catheter is advanced into the carotid artery.
This includes:

a. Level of consciousness

Rationale: Change in pressure may indicate

change in volume status.

b. Vital signs, central venous waveform, central venous

pressure

Rationale: Changes in the waveform may indicate

change in right ventricular function or catheter
migration.
Change in level of consciousness, changes in
vital signs, or abnormal waveforms or
pressures should be reported if they persist
despite nursing interventions.

2. Monitor the site for hematoma and hemorrhage.

Rationale: If the patient is coagulopathic, a pressure

dressing may be required.
Bleeding that does not stop or hematoma and/or
expanding hematoma should be reported if they
persist despite nursing interventions.

3. Assess heart and lung sounds before and after the procedure.

Rationale: Abnormal heart or lung sounds may indicate

cardiac tamponade, pneumothorax, chylothorax, or
hemothorax.
Diminished or muffled heart sounds or absent or
diminished breath sounds unilaterally should be
 reported if they persist despite nursing interventions.

4. Assess results of chest x-ray film.

Rationale: Ensures adequate placement and identification

of pneumothorax, if present.
Abnormal x-ray film results should be reported if they
persist despite nursing interventions.

5. Monitor for signs of complications.

Rationale: May decrease mortality and morbidity if

recognized early.
Signs and symptoms of complications should be
reported if they persist despite nursing interventions.

6. Follow institution guidelines for changing CVC.

Rationale: CVCs are changed according to CDC

guidelines when an infection is suspected, when the CVC
is placed in the femoral vein, or when the catheter is
placed emergently.
Signs or symptoms of catheter infection should be
reported if they persist despite nursing interventions.

 Patient and family education

Documentation  Signature on informed consent form
 Insertion of central venous catheter
 Insertion site of central venous catheter
 Vein selected and type and size of catheter placed
 Right atrial pressure and CVP waveform
 Central venous pressure values after insertion
 Centimeter marking at the skin
 Patient response to the procedure
 Confirmation of placement (e.g., chest x-ray film)
 Occurrence of unexpected outcomes
 Additional nursing interventions
  Explain the need for the CVC insertion, and assess patient and
Patient Education family understanding of CVP.
 Explain the procedure and the time involved.
 Explain the need for sterile technique and that the patient's
face may be covered.
 Explain the benefits and potential risks for the procedure.

Inserting and Maintaining a Nasogastric Tube - Overview of the Skill

   
Overview: Nasogastric (NG) tubes are used for several purposes, including
feeding for nutrition when the client is comatose, semiconscious, or
unable to consume sufficient nutrition orally. Nasogastric suction
tubes are used for decompression of gastric content after
gastrointestinal surgery, and to obtain gastric specimens for diagnosis
of peptic ulcer. Tubes are used for irrigation to clean and flush the
stomach after oral ingestion of poisonous substances. Finally, NG
tubes are used to document the presence of blood in the stomach,
monitor the amount of bleeding from the stomach, and identify the
recurrence of bleeding in the stomach.
 
The two most commonly used NG tubes are the single-lumen Levin's
tube and the double-lumen Salem sump tube.
The gastrointestinal tract is considered to be a clean area rather than
a sterile one. The procedure to place an NG tube is performed using
clean technique unless it is performed in conjunction with
gastrointestinal surgery.
   

   
Assessment: 1. Assess client's consciousness level to determine the ability of the
client to cooperate during the procedure.
2. Check the client's chart for any previous medical history of nostril
surgery or injury or unusual nostril bleeding. Reduces risk of injury
from the tube.
3. Use a penlight to assess nostrils for a deviated septum. Facilitates
choice of nostril and size of tube.
4. Ask the client to breathe through each nostril occluding the other with
a finger. Facilitates choice of nostril and decreases chance that
tube will interfere with respirations.
5. Assess for latex allergy. Prevents reaction to latex and
determines need to use latex-free tubes and gloves.

   
   
Diagnosis:  Imbalanced Nutrition: Less Than Body Requirement
 Swallowing Impairment
 Risk for Aspiration
 Risk for Diarrhea
 Imbalanced Oral Mucous Membranes
 Risk for Deficient Fluid Volume
 Pain
 Impaired Skin Integrity

   

   
Planning

   
Planning
Needs:
   

   
Client 1. Inform the client of the purpose of the NG tube.
Education 2. Explain the procedure of insertion and any expected discomfort.
Needed: 3. Establish and clarify a "hand signal" to indicate the need to
temporarily stop the NG insertion.
4. Explain how the client can cooperate during tube insertion, especially
by swallowing water when asked to do so.
5. Explain potential complications, such as diarrhea, mouth dryness,
and nostril irritation.
6. Review the skills and procedures of maintaining tube.
7. Instruct to chew on ice chips to satisfy the basic need to eat (if there
is no fluid intake restriction).
8. Encourage physical activity to enhance gastrointestinal mobility (if
there is no activity restriction).
9. If a client with dentures is conscious, encourage client to wear the
dentures to maintain the normal shape of the oral cavity.

   

   
Inserting and Maintaining a Nasogastric Tube - Implementation - Action/Rationale   Implementation
Action/Rationale

ACTION RATIONALE

1. Review client's medical history. 1. To assess for any nostril surgery and
abnormal bleeding.
2. Assess client's consciousness and ability to 2. Decreases anxiety and promotes
understand. Explain the procedure and cooperation.
develop a hand signal (see Figure 6-1-2).

3. Prepare the equipment, putting tissues, a cup 3. Facilitates an efficient procedure.

of water, and an emesis basin nearby
(see Figure 6-1-3).

4. Prepare the environment; raise the bed and 4. Facilitates insertion and prevents back
place it in a high Fowler's position (45 to 60 strain.
degrees). Cover the chest with a towel.

5. Wash hands and then put on gloves. 5. Practices clean technique.

6. Use a penlight to view the client's nostrils. 6. Choosing the more patent nostril for
Assess client's nostrils with penlight and have insertion decreases discomfort and
the client blow nose one nostril at a time unnecessary trauma.
(see Figure 6-1-4).

7. Using the NG tube, measure the distance 7. Determines the approximate amount of
from the tip of the nose to the earlobe and tube needed to reach the stomach.
then to the xiphoid process of the sternum and
mark this distance on the tube with a piece of
tape (see Figure 6-1-5).

8. Lubricate first 4 inches of the tube with water- 8. Facilitates passage into the naris.
soluble lubricant.

9. Ask the client to slightly flex the neck 9. Makes insertion easier.
backward.

10 Gently insert the tube into a naris (see Figure 10. Promotes passage of tube with minimal
. 6-1-6). trauma to mucosa.

11 Ask the client to tip the head forward once the 11. Tipping the head forward facilitates
. tube reaches the nasopharynx-this is usually passage of the tube into the esophagus
where the client starts to gag. If the client instead of the trachea. Tube may
continues to gag, stop a moment. stimulate gag reflex. Allows the client to
rest, reduces anxiety, and prevents
vomiting.

12 Advance the tube several inches at a time as
. the client swallows water or ice chips
(see Figure 6-1-7).
12. Assists in advancing the tube past the
oropharynx. The action of swallowing
facilitates the insertion process. With
each swallow, the tracheal opening is
closed to prevent inspiration.

13 Withdraw the tube immediately if there are 13. Prevents trauma to bronchus or lung.
. signs of respiratory distress.

14 Advance the tube until the taped mark 14. Enables the tube to reach the stomach.
. reached (see Figure 6-1-8).

15 Wipe or wash body oils off tip of nose and 15. Prevents tube displacement.
. allow to dry. Split a 4-inch strip of tape
lengthwise 2 inches. Secure the tube with the
tape by placing the wide portion of the tape on
the bridge of the nose and wrapping the split
ends around the tube (see Figure 6-1-9). Tape
to cheek as well if desired (see Figure 6-1-10).

16 Check the placement of the tube: 16. Ensures correct placement. A

. "whoosh" sound will be heard if the
 Attach the syringe to the end of the tube is correctly placed. (A pH below 4
tube and rapidly inject 30 cc of air and indicates the tube is in the stomach; a
at the same time auscultate over the pH range of 6-7 indicates intestinal
epigastric area (upper left quadrant); sites.) Amount of air varies for pediatric
see Figure 6-1-11). client and if client has had gastric
 Aspirate for gastric content, assess the surgery.
color and quality of the content. If
required, measure with pH indicator
strip (see Figure 6-1-12). Follow
protocol regarding re-insertion of
contents versus discarding.
 Prepare the client for X-ray check-up,
if prescribed.

17 Connect the distal end of the tube to suction, 17. Establishes an appropriate pathway for
. draining bag, or adapter according to the intervention.
purpose of this nursing intervention
(see Figure 6-1-13).

18 Secure the tube with tape, or with rubber band 18. Enhances the level of comfort and
. and safety pin, to client's gown or bed sheet. secures the tubing system.

19 Remove gloves, dispose of contaminated 19. Implements the principles of infection

. materials in proper container, and wash control.
hands.

20 Position client comfortably and place the call 20. Decreases client's anxiety and provides
. light in easy reach. access to help if needed.

21 Document procedure. 21. Records implementation of intervention

. and promotes continuity of care.

Maintaining a Nasogastric Tube

 22 Wash hands and apply gloves. 22. Reduces the transmission of
. microorganisms.

23 Follow the steps in Action 16 to check the 23. Prevents complications from
. proper tubing position before instilling dislocation of the tube.
anything per NG tube or at least every 8
hours.

24 Assess for signs that the tube has become 24. Prevents complications from the loss of
. blocked, including epigastric pain and beneficial effects from the tube.
vomiting, and/or the inability to pass
medications or feedings through the tube.

25 Remember never to irrigate or rotate a tube 25. Rotation or irrigation may disturb
. that has been placed by the health care incisions.
provider during gastric or esophageal surgery.

26 Provide oral hygiene and assist client to clean 26. Enhances client's comfort and the
. nares daily. integrity of skin and nose mucosa.

27 Remove gloves, dispose of contaminated 27. Reduces the transmission of

. materials in proper container, and wash microorganisms.
hands.

     

Inserting and Maintaining a Nasogastric Tube - Post-Skill

   
Evaluation:  Client's nutritional status improves, as indicated by increased
body weight, physical strength, and mental status.
 Client's nutritional needs are met with the assistance of tube
feeding.
 Client maintains a patent airway, as evident by absence of
coughing, no shortness of breath, and no aspiration.
 Client does not have diarrhea caused by nasogastric feeding.
 Mouth mucous membranes remain moist and intact.
 Client maintains a normal fluid volume, as evident by good skin
texture, muscle tone, and blood volume.
  Client's comfort level increases.
 Skin around the tube remains intact, with no redness or blisters.

   

   
Documentation: Nurses' Notes
 

 Document the type of NG tube inserted, the naris used, how the
client tolerated the procedure, and the methods used to verify
placement.
 Document care provided to the client to increase comfort of the
NG insertion naris.
 Note any unusual findings.

 
Intake and Output Record
 

 Note the amount of fluid the client drank to aid insertion of the
NG tube.
 Note the amount of gastric contents removed for testing.

   

   
Variations

   
Geriatric Variations:  For elderly clients who wear dentures, oral hygiene and denture
care should not be overlooked simply because an NG tube is in
place.

   

   
Pediatric  Dispose of or securely tape any small parts such as plastic
Variations: connectors or plugs, to prevent small children from accidentally
aspirating or swallowing them.
 Amount of air needed to assess placement is proportionate to
client's size.
   

   
Home Care  Periodically assess the family member's ability to check the
Variations: placement of the tube, check residual gastric contents,
administer tube feedings, or connect the tube properly with
suction.

   

   
Long-Term Care  Teach family members or caregivers to assess client's
Variations: nutritional status and assess for any sign of complications
related to the NG tube.

   

Inserting and Maintaining a Nasogastric Tube - Common Errors

   
Possible The nurse is unable to auscultate air bubbles but assumes the NG tube is in
Errors: place.
   

   
Prevention: If you are unable to verify NG tube position by auscultating air, use another
method of verification. Attempt to aspirate gastric contents. If you are unable
to verify NG tube placement, do not instill anything through the tube. Notify
the client's health care provider. Send the client for an X-ray to verify
placement if this is within institutional guidelines.
   

   
Nursing Tips:  Adjust the height of the bed to eliminate back strain.
 Prepare the split tape before putting on gloves.
 This can be an anxiety-provoking procedure. Good communication
skills decrease anxiety and promote the client's cooperation.
 The size of the NG tube used depends on client size, client history of
damage to the structure of the nose, and the purpose of the
procedure.
 Tincture of benzoin (if iodine allergy is not present) may be used to
prep the skin on the bridge of the nose. This acts as an adhesive as
well as a skin prep.
 Carefully observe client's verbal and nonverbal responses during the
entire procedure.
  When feasible, engage family members or caregivers to assist in NG
tube insertion.
 Remove air used to check tube placement if NG tube is not connected
to suction.

   

   
Critical Thinking Skill

   
Introduction: Nurses must be able to evaluate the effectiveness of NG tube insertion,
maintenance, or removal.
   

   
Possible The family of your home care client has been assisting in her care, including
Scenario: the care of her feeding tube. You have educated them on the tube and its
placement. Although they state they secured the tube in a proper place and
the end of the tube is currently positioned higher than the stomach, you
observe the tube is filled with gastric content.
   

   
Possible Client has a continuous risk for infection, electrolyte imbalance, and potential
Outcome: aspiration.

   

   
Prevention: Assess that the caregiver is properly securing the end of the tube at a level
higher than the stomach. Assess the client's vital signs and respiratory
pattern for infection, electrolyte imbalance, or aspiration. Re-educate the
caregivers on assessing for correct tube placement, and review with them
common situations where the tube might move.
   

   

Assessing Placement of a Small-Bore Feeding Tube - Overview of the Skill

   

Overview: Clients with a small-bore feeding tube must have placement of the
tube verified at time of insertion and every shift to prevent
 insertion/migration of the tube into the esophagus, trachea, or lungs
and aspiration of feeding. Placement of a feeding tube is easy to
disrupt because the tubes are small, flexible, and secured only with
tape on the nose. There are three effective methods of verifying
placement.
 
The first method is to inject air through the feeding tube and
simultaneously auscultate the air bubble over the stomach. The
second is to aspirate a sample of gastric contents and check pH
levels. Finally, the most precise way to verify placement is to obtain
an abdominal X-ray.
   

   

Assessment: 1. Assess client for any signs of respiratory distress such as choking,
coughing, shallow breathing, or decreasing oxygen
saturations. These symptoms could be indicative of aspiration of
the feeding tube.
2. Check for a tape marker on the tube, near the nose, which
indicates the length of tube inserted. If tube has become
displaced, marker will be farther away from nose.
3. Assess sputum for distinguishing features that would indicate
aspiration, such as blue color (tube feeding formula is mixed with
blue food coloring to distinguish feeding from normal white
sputum). Blue sputum could signify aspiration of feeding, which
could lead to pneumonia.
4. Assess for latex allergy. Determines need for latex-free tube.

   

   

Diagnosis:  Imbalanced Nutrition: Less Than Body Requirements

 Risk for Aspiration

   

   

Planning
   

Planning Needs: Equipments Needed:

 Syringe: 30 or 50 cc for adults, 5 or 10 cc for pediatrics (varies with

size)
 Stethoscope
 pH testing equipment (see Figure 6-3-1).
 Progress notes/flow sheets

   

   

Expected 1. The client's feeding tube will be intact in the ordered area of the GI
Outcomes: tract.
2. The client will not experience aspiration secondary to tube feedings.

   

   

Client Education 1. Explain reason for verifying placement.

Needed: 2. Explain steps of procedure.
3. Answer questions from client/family.
4. Instruct client to notify staff immediately if experiencing respiratory
distress or blue sputum.
5. Explain purpose of X-rays, if needed.

Assessing Placement of a Small-Bore Feeding Tube - Implementation - Action/Rationale

   

Implementation ACTION RATIONALE

Action/Rational
e 1. Wash hands and apply clean 1. Practices clean technique.
gloves.

2. Prepare equipment; put pH 2. Promotes efficiency.

 testing equipment nearby.

3. Clamp the tube feeding 3. Prevents wasting of feeding.

infusion if it has already been
running (see Figure 6-3-2).

4. Locate the connection between 4. To disconnect the tubing.

the feeding tube and feeding
bag tubing (see Figure 6-3-3).

5. Disconnect infusion tubing 5. Prevents contamination of tubing.

from feeding tube and attach a
cap to tubing and feeding tube
(see Figure 6-3-4).

6. Draw 30 to 50 cc of air into 6. Provides enough air to hear an air

syringe. bubble as it is inserted.

7. Attach syringe to proximal end 7. Allows for insertion of air.

of feeding tube.

8. Place diaphragm of 8. Facilitates accurate auscultation.

stethoscope in epigastric area
over stomach: upper left
quadrant near midline.

9. Inject air quickly into feeding 9. Facilitates auscultation of air rush.

tube and listen for air rush.

10 If unsuccessful in hearing rush 10 Air bubbles may be difficult to hear

. of air, repeat Actions 6 to 9. It . because of client position or gastric
may be necessary to reposition contents. Decrease risk of
stethoscope over stomach, use distention and discomfort.
more air, or inject more slowly.
Remove air.

11 Use syringe to aspirate 11 To provide gastric contents for

. approximately 10 ml of gastric . visual inspection and pH testing.
contents (see Figure 6-3-5).

12 Check the contents and obtain 12 The pH of the fluid aspirate can
. pH level (see Figures 6-3- . help to verify tube placement.
6 and 6-3-7).
 The pH reading can be
 pH below 4 means tube altered by the presence of
is in stomach. medication or formula, so pH
 pH range of 6 to 7 should be tested after the
means tube is in client's stomach has been
empty for approximately 1
 intestine.
hour.

13 Assess the color of aspirate 13 Gastric contents may be green, tan,

. (see Figure 6-3-8).
. off-white, bloody, or brown.
Intestinal contents may be clear
yellow or bile-colored. Pleural
contents may be tan, off-white, or
pale yellow.

14 If unable to aspirate contents 14 X-ray is most precise method of

. or unsure of results of . verifying placement of tube in
visualization, call health care stomach. Keep health care provider
provider and consider informed of progress.
confirmation with X-ray.

15 Record method of verification 15 Provides continuity for other staff

. and results of placement in . and legal documentation.
flow sheets/progress notes.

16 If placement in stomach is 16 Ensures adequate nutrition and

. verified, reattach feeding . consistent prevention of aspiration.
tubing and resume tube
feedings (see Figure 6-3-9).
Recheck placement in 4 hours
if feeding is continuous.

17 Wash hands. 17 Reduces transmission of

. . microorganisms.

   

Assessing Placement of a Small-Bore Feeding Tube - Post-Skill

   
Evaluation:  The client's feeding tube continues to be intact in the ordered
area of the GI tract.
 The client has not experienced aspiration secondary to the tube
feedings.

   

   
Documentation: Nurses' Notes
 

 Document the time and method of verification of tube

placement.
 Note the color of any aspirate and the pH if it was tested.
 Note any unusual findings or suspicion of migration.
 If migration is suspected or placement cannot be verified, note
the interventions implemented.
 Record the client's condition and responses to tube; especially
be alert for signs and symptoms of possible aspiration.

   

   
Variations

   
Geriatric Variations:  Older clients may have problems with confusion. Secure the
tubing well and monitor the client closely.

   

   
Pediatric  Infants will require less air for the injection into stomach. Use a
Variations: pediatric stethoscope and a smaller syringe.
 Because of the much smaller anatomy of a child, a feeding tube
has a much shorter distance to migrate before it is in the
trachea or lungs. Be sure to assess the tube feeding placement
prior to instilling anything into the feeding tube or at least every
4 hours during a continuous feeding.

   

   
Home Care  Teach family members to verify tube placement when
Variations: administering tube feedings.
 Teach the client or caregivers what to do if tube migration is
suspected.

   

   
Long-Term Care  Clients with long-term respiratory conditions may cough
Variations: intensely enough to dislodge a feeding tube. Be sure to assess
tube placement regularly.
 Be sure the staff members caring for a tube feeding client are
aware of the signs and symptoms of aspiration and tube
migration.
 Teach the staff what to do and whom to notify if they believe a
feeding tube has migrated into the pulmonary tree.

   
Assessing Placement of a Small-Bore Feeding Tube - Common Errors

   
Prevention: Keep the stethoscope firmly in place over the epigastric region. If you are
unable to hear air rush, always re-assess or ask a coworker to assist. Use
one hand for syringe and one hand to hold diaphragm of stethoscope.
   

   
Nursing Tips:  Elevate the bed to a height that is good for you.
 A 50-ml syringe works best if you expect a large amount of aspirate.
 Involve the client; ask client to hold the tubing if you need help.
 Remove tube and replace if unable to verify placement in stomach or
small intestine.
 Re-evaluate placement before starting a new feeding or giving
boluses, every 4 hours while continuously feeding, or every shift when
the tube is not in use.
 Keep the client's head elevated at 30° while receiving feeding to
prevent aspiration.
 Small, thin may collapse with attempted aspiration. The inability to
aspirate anything via the feeding tube is not necessarily an indication
of a misplaced tube. Use a second method to verify placement.
 Always check placement before anything is injected into tube.

   

   
Critical Thinking Skill

   
Introduction: Feeding tubes are generally secured only by tape to the nose and face. It is
easy to disconnect or completely remove a tube.
   

   
Possible Clara is an 80-year-old woman who is now disoriented and restless at
Scenario: midnight. Upon arrival, her nurse discovers Clara with a respiratory rate of
35, productive cough of blue-tinged sputum, and the tape marker on her
feeding tube pulling a fair distance away from her nose. The tape, which
 secured the tube to her nose, has been pulled off.
   

   
Possible When the nurse tries to verify placement, she is unable to hear the air rush.
Outcome: The nurse removes the feeding tube and pages the doctor to the room
immediately. She assesses for additional signs and symptoms of aspiration.
   

   
Prevention: Secure the tube well with tape to the nose, a transparent dressing over the
tube on the cheek or forehead, and tape around the tubing secured to the
gown. Observe confused clients very closely and restrain as needed to
prevent injury and aspiration.