Intravenous fluids 8.

Regulate IV every 15-20 minutes to

ensure patency
These are liquids given to replace water, sugar
9. Observe potential complications
and salt that a person may need when he is not
10. Discontinue if in doubt of patency
able to do so orally.
11. At the first of redness or tenderness,
Types: stop infusion
12. Document your patient’s condition and
 Isotonic interventions.
 Hypotonic
 Hypertonic Complications:
Isotonic solution I. Infiltration in the needle is out of vein and
Has the same concentration as the body fluids. fluids accumulate in the subcutaneous
Example: tissues.
 Normal saline solution Assessment:
 Lactated ringer’s solution  Pain
 Swelling
Hypotonic solution  Skin is cold at needle site
Has lower concentration than the body fluids.  Pallor of the site
Example:  Flow or rate decreased or has stopped
 0.45 NaCl solution  Absence of backflow of blood into the
 0.3 NaCl solution tubing as the IV fluid is put down or the
IV tubing is kinked.
Hypertonic solution Nursing intervention
Has higher concentration than the body fluids.  Change the site of needle
Example:  Apply cold compress cold to cold
 D5LR II. Circulatory overload results from
 D10W administration of excessive volume of IV
 D5NSS fluid.
 D5NM Assessment:
 Headache
Nursing responsibility:  Flushed skin
1. Verify doctor’s order  Rapid pulse
2. Know the type, amount and indication  Increased BP
of IV therapy  Weight gain
3. Practice strict aseptic technique  Syncope or fainting
4. Inform client and explain purpose of IV  Pulmonary edema
therapy  Increased venous pressure
5. Prime IV tubing to expel air. This will  Coughing
prevent air embolism  Shortness of breathing
6. Clean the insertion site of IV needle  Tachypnea
from the center to the periphery with  Shock
cotton balls with alcohol Nursing intervention
7. Change IV site every 3 days  Slow infusion to KVO at 10 gtts/min
 Place patient on high fowlers position
  Administer diuretics bronchodilator as  Do not allow IV bottle to run dry
ordered  Prime the IV tubing before starting
infusion
Drug overload  Turn the patient to left side in the
The patient receives an excessive amount of Trendelenburg position to allow air
fluids containing drugs to rise in the right side of the heart.
Assessment: This prevents pulmonary embolism
 Dizziness  Note do not irrigate the IV because
 Shock this could push clot into the
 Fainting systemic circulation
Nursing intervention
 Slow infusion to KVO rate Nerve damage may result from the tying the
 Monitor V/s and signs of difficulty of arm too tight to the splint
breathing Assessment:
 Numbness of fingers and hands
Superficial thrombophlebitis. It is due to Nursing interventions:
overuse of a vein. Irritating solutions or drugs,  Massage area and move shoulder
clot formation and large bore catheters. through its rom
Assessment:  Instruct the patient to open and close
 Pain along the course of vein hand several times each hour
 Vein may feel hard and cordlike  Note: apply splint with the fingers free
 Edema and redness at needle insertion to move
site
 Arm feels warmer than the other arm Speed shock may result from administration of
Nursing intervention: IV push medications rapidly.
 Change the iv site every 72 hours  To avoid speed shock and possible
 Use large veins for irritating fluids cardiac arrest, give most IV push
 Stabilize venipuncture at area of flexion medications over 3-5 minutes
 Apply warm compress this will relieve
pain and inflammation warm skin-warm Blood transfusion
compress Purpose:
1. To administer required blood
Air embolism component to the patient
Air manages to get into the circulatory system. 2. To restore blood volume
5010 ml of air or more cause air embolism 3. To improve oxygen-carrying capacity of
Assessment: the blood
 Chest, shoulder or back pain
 Hypotension Blood components
 Dyspnea  Packed red blood cells: replacement
 Cyanosis product used for blood transfusion.
 Tachycardia Transfused if patient has lost a large
 Increased venous pressure amount of blood
 Loss of consciousness  White blood cells: infusion rate is 1-
Nursing interventions: 2ml/min for the 1st 15minutes then
 increased to 4ml/min not to exceed 4
hours of transfusion
 Fresh whole blood: severe traumatic
hemorrhage. Also contains hemoglobin
necessary for oxygen transport
 Platelets: plays a major role in clotting
factors. Platelets are tiny blood cells
that help your body form clots to stops
bleeding. This transfusion usually takes
30-60 minutes per unit or 15 to 30
minutes
Nursing interventions:
1. Verify doctor’s order. Inform client and
explain the purpose
2. Check for cross matching and blood
typing to ensure compatibility
3. Obtain and record baseline vital sign or
cp statis
4. Practice strict asepsis when preparing
5. At least 2 nurses must check the label of
the blood
6. Warm the blood at room temperature
7. Identify client properly.
8. Use needle gauge 10 or 19
9. Use BT set with filter
10. Start infusion slowly at 10gtts/min.
remain at the bedside monitor closely
the first 15-20 minutes during
transfusion
11. Monitor vital signs
12. Do not mic medications with blood
transfusion
13. Administer 0.9% NaCl before during and
after BT
14. Administer BT for 4hours (whole blood
packed RBC) for plasma and platelets
cryprecipitate transfuse 20–30-minute
clotting factors can easily be destroyed.
15. Observe for potential complications
16. Record and document
Complications of blood transfusion
1. Allergic reaction-sensitivity to plasma
protein or donor antibody which reacts
with recipient antigen.
Assessment:
 Flushing
 Rash, hives
 Pruritus
 Laryngeal edema, difficulty of
breathing-death
2. Febrile, non-hemolytic-hypersensitivity
to donor white cells, platelets and
plasma protein. This is the most
symptomatic complication of blood
transfusion.
Assessment:
 Sudden chills and fever
 Flushed skin, headache
 Anxiety
3. Septic shock-caused by the transfusion
of blood components contaminated by
bacteria.
Assessment:
 Rapid onset of chills
 Vomiting, marked hypotension
 High fever
4. Circulatory overload-administration of
blood volume at a rate of greater than
the circulatory system can
accommodate
Assessment:
 Rise in venous pressure, dyspnea
 Crackles of rales
 Distended neck vein
 Cough
 Elevated BP
5. Hemolytic reaction-caused by infusion
of incompatible blood products
Assessment:
 Low back pain (first sign). Inflammatory
response to the kidneys to incompatible
blood
 Chills feelings or fullness, bleeding,
vascular collapse acute renal failure
  Tachycardia flushing tachypnea
hypotension
Nursing interventions:
1. Stop blood transfusion immediately
2. Start an IV line (0.9NaCL)
3. Collect urine specimen
4. Monitor vital signs
5. Report immediately
6. Make relevant document