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CENTRAL PHILIPPINE UNIVERSITY NURSING REVIEW CENTER

 In Collaboration with
A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY
2nd Floor Sommerset Bldg., Lopez Jaena St., Jaro, Iloilo City
Tel No.: (033) 320-2728; 09106547262

FUNDAMENTALS OF NURSING NURSING

PRINCIPLES OF INTRAVENOUS THERAPY AND BLOOD TRANSFUSION
PROF. RENNARD DE PERIO

I. Purpose and uses of IV therapy

II. Types of Solutions

1. ISOTONIC SOLUTIONS – have the same osmolality as body fluids
Nursing Implications:

2. HYPOTONIC SOLUTIONS- are more dilute solutions and have a lower osmolality than body fluids,
cause the movement of water into cells by osmosis
Nursing Implications:

3. HYPERTONIC SOLUTIONS – a solution that has a higher osmolality than body fluids, cause
movement of water from the cells into the ECF
Nursing Implications:

4. COLLOIDS – also known as “plasma expanders”

Nursing Implications:

ISOTONIC SOLUTIONS HYPERTONIC HYPOTONIC COLLOIDS

SOLUTIONS SOLUTIONS
0.9% sodium chloride 3% Sodium Chloride 0.45% sodium chloride Dextran
(normal saline); 0.9% NS (normal saline); (3% NS) (normal saline); ½ NS

5% dextrose in water 5% sodium chloride 0.225% sodium chloride Albumin

(D5W) (but (normal saline); (5% NS) (normal saline) ; (1/4 NS)
PHYSIOLOGICALLY
HYPOTONIC)
5% dextrose in 0.225% 10% dextrose in water 0.33% sodium chloride
saline (D5W/ ¼ NS) (D10W) (normal saline) ; (5% NS)

Lactated Ringer’s (LR) 5% dextrose in 0.45%

sodium chloride (normal
saline); D5W/ ½ NS)

5% dextrose in lactated
ringer’s (D5LR)

III. Intravenous Devices/ Equipment

I. IV Cannulas
1. Butterfly sets
2. Plastic Cannulas
II. IV gauge- the smaller the gauge number, the larger the diameter of the needle or cannula
III. IV containers -
IV. IV Tubing
V. Drip chambers
1. Macrodrip
2. Microdrip
VI. Filters
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VII. Needleless infusion device

- include recessed needles, plastic cannulas, and one way valves; these systems decrease the
exposure to contaminated needles
VIII. Intermittent Infusion Device
- are used when intravascular accessibility is desired for intermittent administration of medication
by IV push or IV piggyback
IX. Electronic IV Infusion Device/ IV infusion pumps
- Control the amount of fluid infusing and should be used with central venous lines, arterial lines,
solutions containing medications and parenteral medication.
o Parts of an IV set
1. Container (glass, plastic) 6. Secondary port
2. Air vent with filter 7. Piggyback port
3. Insertion spike 8. Roller clamp
4. Drip chamber 9. Clamp
5. Tubing

Types of Infusion
1. Peripheral – usually used for short periods of time
2. Central- (central veins) – used for long-term IV therapy or parenteral nutrition, client is receiving IV meds
that are damaging to vessels (e.g chemotherapy)
3. Continuous- given at a 24 period consistently
4. Intermittent – only given at specific periods of time

Venipuncture sites
 Peripheral veins – metacarpal (metacarpal area), basilic (ulnar area) and cephalic (radial area) –
commonly used for intermittent or continuous infusions.
o Complications of peripheral vein insertion: phlebitis infiltration/extravasation, thrombosis,
infection/sepsis
 Central Veins – subclavian or jugular vein – commonly used for long term access
o Complications of central venous cather insertion: hemothorax or pneumothorax ,cardiac
perforation, thrombosis, infection.
 Peripherally Inserted Central Venous Catheter (PICC) –basilic or or cephalic vein just above or below
the antecubital space of the right arm
o Complications of PICC: Phlebitis

Principles/ Guidelines in vein selection:

1. Use distal veins of the arm first.
2. Use the client non dominant arm whenever possible.
3. Select a vein. Utilize veins that are in are easily palpated, feels soft and full, naturally splinted by a
bone, large enough to allow adequate circulation around the catheter.
Peripheral sites to avoid:
 Edematous extremity
 An arm that is weak, traumatized, or paralyzed
 The arm on the same side as a mastectomy
 An arm that has an atriovenous fistula or shunt for dialysis
 A skin area that is infected
Principles in starting IV therapy
RA 7164 allows the nurse to initiate IV therapy but it is still a dependent nursing action.
1. Important things to check: order, type and amount of the solution, condition and expiration date of the
solution, IV rate, purpose and duration of the therapy, medications to be added and compatibility with
the solution
2. Keep the spike sterile until insertion.
3. Hang the container at least 1 meter or 3 feet above the client’s head.
4. Squeeze the chamber until it is half full.
5. Prime the tubing to prevent entry of air.
6. Select a vein (refer to previous discussion)
7. Dilate the vein by placing it in a dependent position and placing a tourniquet 6 inches above insertion
site. Be sure to check for the presence of distal pulse indicating that the tourniquet is not too tight.
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8. Techniques to dilate the vein: arms in dependent position, tourniquet, stroking in the direction of the
venous blood flow, clenching and unclenching the fist and light tapping. Applying a warm towel is the
last resort.
9. Clean the site in circular motion using PovI; wait for at least one minute.
10. Insert the needle at 15-30 degree angle
11. Connect tubing to catheter tightly.
12. Secure the catheter with hypoallergenic tape or use a transparent dressing.
13. Splint the hands.
14. Label the IV tubing with the date and tie of attachment and your initials.

IV care and monitoring

1. Central catheters/PICC
 Always use aseptic technique in handling the catheter.
 Dressing is changed prn (when soiled) or every 3 days.
 Assess site for signs of infection or dislodgement by comparing external catheter length every day.
 Before infusing, flush catheter with NSS. After the infusion the catheter is flushed with NSS together with
heparin (based on doctor’s order).
 Do not take BP on arm with the PICC site
 Signs of catheter dislodgement: increase or decrease in external catheter length, palpitations, neck or
ear pain.

2. Peripheral catheters
 If a wrong solution is being infused, slow down the infusion to KVO rate instead of stopping it.
 Check the IV rate every hour and compare against infusion schedule. For rate orders of 150 mL/hr
and above, assess the client every 30 minutes.
 If the rate is too slow or too fast, just regulate to ordered rate of infusion.
 Maintain the drip chamber half full and the height of the solution to at least 3feet.
 Be sure to check for kinks in the tubing.
 The tubing must not below insertion site as it will slow down the infusion.
 If the infusion stopped do the following in sequence, (1) assess for kinks, (2) rule out possible
catheter dislodgement by lowering the solution down and observing for backflow or attempting to
withdraw blood from the piggyback port; lastly (3) asses for possible catheter thrombosis by instilling
a small amount of NSS.
 Be sure that connections are tight and tubing is intact to prevent leakages.
3. Managing infiltration/extravasation (infiltration caused by a vesicant drug)
 It is a condition caused by catheter dislodgement or the formation of a hole in the vessel wall causing
fluid/drugs to flow in to the interstitial tissues causing localized edema/swelling that is pale, cool and
painful.
 Upon ruling out infiltration, immediately stop the infusion and withdraw vesicant drugs near the
insertion site; apply warm compress and notify the physician.
4. Managing phlebitis
 It is the inflammation of the vein caused by mechanical or chemical trauma that could lead to
thrombosis. Manifestations include swelling that is red, warm and painful.
 Same management with infiltration.

Changing IV solutions and tubing and discontinuing IV therapy

1. Principles
 IV solutions must be changed q24hours
 IV tubing and catheter is changed q48-96 hours
 Close the infusion line before discontinuing IV.
 Withdraw the catheter in an angle in line with the vein.
 Apply pressure for 2-3 minutes
 Make sure catheter is intact upon withdrawal, if not notify physician

BLOOD TRANSFUSION PRINCIPLES

I. Blood groups  Rh group: + and –
 ABO: A, B, AB (universal  2 important components in blood
receiver), O (universal donor) compatibility: antigen and antibodies
II. Cultural consideration
 Jehovah’s witness and Christian science do not advocate receiving blood and blood products; blood
expanders are permitted.
III. Blood typing and crossmatching
 The first step the nurse must take before BT is to ensure that the blood has undergo BTCM.
 Blood typing is identifying the donor and recepient’s ABO and Rh group.
 Crossmatching includes mixing the donor and recepient’s group to find out if minor
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IV. Blood products

 Whole blood: must be infused within 4 hours; given in extreme cases of acute hemorrhage to replace
all blood components
 PRBC: must be infused within 2 hours; given to treat anemia(Hgb <9 g/dL) and controlled and gradual
bleeding (like in cases of surgeries)
 Autologous PRBC: must be donated 4 weeks before elective surgery.
 Platelets: infused within 30 minutes for platelet below 10,000 or 20,000.
 FFP: infused within 4 hours; given to expand plasma volume but mainly to provide clotting factors for
patient’s with elevated PT time.
 Cryoprecipitate: contains clotting factors plus fibrinogen.

V. Principles of blood transfusion

1. Use gauge 16 or 18 needle to initiate access.
2. Use blood set (drop factor of 15)
3. Infuse 0.9% NaCl (PNSS) as piggy back; if patient’s current IV fluid is not PNSS, change solution and
flush tubing accordingly. Set PNSS at KVO.
4. The two main electrolyres affected in blood administration are K and Ca.
5. Important things to check before transfusion: BTCM results, signed informed consent, blood component
ordered, amount, serial number, expiration date, blood type label.
6. Conduct a baseline cardiopulmonary assessment before the transfusion.
7. Transfuse the blood within 30 minutes after obtaining it from the blood bank. The patient may suffer from
sepsis or hyperkalemia if transfusion is delayed by more than 30 minutes.
8. Verify patient’s identity by asking him/her to state his/her name and by checking the ID band.
9. Start the transfusion at 5-10 mL/min (2-3 macrodrops/min) for the first 15 minutes.
10. Stay with the client for the first 15 minutes of transfusion.
11. Monitor vitals q15min x 1st hours, q30min x 2nd hour and qH x 3rd and 4th hour.
12. After 15 minutes increase the transfusion to designated rate by dividing the total amount of blood by 4
hours.
13. Monitor for transfusion reactions.

VI. Transfusion reactions

Reaction Pathophysiology
Hemolytic reaction Antigen-antibody incompatibility causing
RBC clamping (agglutination) and
hemolysis leading to decrease in
circulating RBC and damage to the blood
vessels of different organs of the body.
Anaphylaxis Immune system reacts with blood
component transfused
Overload Sudden and excessive increase in blood
volume leading to heart failure
Sepsis Transfusion of contaminated blood (Gram
negative bacteria)
TRALI (transfusion Client’s immune system reacts with blood
related acute lung transfused causing inflammation in the
injury) lungs
Manifestations
Backache, headache and chest pain
Fever, vomiting
Tachycardia and hypotension
Mild: pruritus, urticaria (rushes),
facial puffiness
Severe: hypotension,
bronchospasm and dyspnea
Mild: s/s of fluid overload
Severe: s/s of heart failure mainly
left sided heart failure
Fever
s/s of septic shock
s/s of acute pulmonary edema or
acute respiratory respiratory distress
syndrome.

Priority Nursing Actions to take in a Client Experiencing Transfusion Reaction:

1. Stop the transfusion
2. Change the intravenous (IV) tubing down to the IV site & keep the IV line open with PNSS.
3. Notify the health care provider and blood bank.
4. Stay with the client, observing signs and symptoms and monitor VS q5min.
5. Prepare to administer emergency meds as prescribed. (antihistamines, vasopressors, fluids and
corticosteroids)
6. Obtain laboratory specimen as prescribed, esp. urine.
7. Return the blood bag, tubing, attached labels, and transfusion record to the blood bank.
8. Document the occurrence, actions taken and the client’s response.
References:
 Kozier & Erb’s Fundamentals of Nursing, 8th Edition, Vol. 2
 Saunders Comprehensive Review, 6th Edition by Linda Anne Silvestri, PhD, RN
 Potter P, Perry A, Stockert P, Hall: A Fundamentals of Nursing, ed 8, St. Louis, 2013, Mosby.
 NCLEX-RN Review, 3rd Ed, Alice M. Stein, RN, MA & Judith C. Miller, RN, MSN
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