Infusion therapy, fluid balance

and blood transfusion

 Content
• Administration of medication through catheter
• Infusion therapy pumps
• Fluid balance
• Blood transfusion technique
 Intravenous injections and infusions
The introduction of medication or solutions into the circulatory system
via a peripheral or central vein
• Continuous infusion - the intravenous delivery of a medication or fluid
at a constant rate over a prescribed time period, ranging from several
hours to several days to achieve a controlled therapeutic response
• Intermittent infusion - the administration of a small-volume infusion,
25–250 mL, over a period of between 15 minutes and 2 hours. This
may be given as a specific dose at one time or at repeated intervals
during 24 hours
• Direct intermittent injection also known as intravenous push or bolus
injection, involves the injection of a drug from a syringe into the
injection port of the administration set or directly into a VAD
 Administration of medication through catheter

EQUIPMENT
• IV solution, as prescribed
• Medication administration record (MAR) or
computer-generated MAR (CMAR)
• IV administration set
• Label for infusion set (for next change date)
• Electronic infusion device (if appropriate)
• Time tape and/or label (for IV container)
• Clean gloves
• Additional personal protective equipment (PPE)
• IV pole
IV administration set
EQUIPMENT - IV solution
 Other Equipment

• Extension sets are used to add length

• Stopcocks (used to direct flow), usually three- or four-
way devices. These tend to be used in critical care but
are discouraged in the general setting due to misuse
and contamination issues
 Types of Pumps
• Syringe Pump are low-volume, high-
accuracy devices designed to infuse
at low flow rates. The plunger of a
syringe containing the substance to
be infused is driven forward by the
syringe pump at a controlled rate to
deliver it to the patient
• Anaesthesia Pumps are syringe
pumps designed for delivery of
anaesthesia or sedation and must
only ever be used for that purpose.
They should be restricted to
operating theatres or critical care
units and should be clearly labeled
Volumetric pumps
Patient-controlled analgesia pumps
• The PCA pump can dispense a bolus
dose, with an initial bolus - a loading
dose
• This may benefit patients as the
onetime dose is significantly higher than
a demand dose in order to achieve
immediate pain relief
 Gravity infusion devices
• Gravity infusion devices depend entirely on gravity to deliver the
infusion. The system consists of an administration set containing a
drip chamber and a roller clamp to control the flow, which is usually
measured by counting drops
• The rate of administration of a continuous or intermittent infusion
may be calculated from the following equation:
Volume to be infused Drop rate
Time in hours X 60 minutes = Drops per minute
 Push Administration
• Intravenous (IV) push is the rapid administration of a small volume of
medication into a patient's vein via a previously inserted IV catheter
• This method is used when a rapid response to a medication is
required, or when the medication cannot be administered via the oral
route
• Before administrating IV push, it is important to confirm the correct
placement of the IV catheter, because the push medication can cause
irritation and damage to the lining of the blood vessel and to
surrounding tissues
• The patients need to be closely monitored after the drug has been
administered, and any error can be especially dangerous
 Essential equipment

• Clinically clean tray containing the prepared drug(s) to be

administered
• Patient’s prescription chart
• Protective clothing as required by hospital policy for
administering drugs
• Clean dressing trolley
• Sterile needles and syringes
 Pre-procedure

• Explain and discuss the procedure with the patient

• Before administering any prescribed drug, check that it is due and has
not been given already
• Before administering any prescribed drug check the prescription
• Prepare the drug for injection
• Prepare a 20 mL syringe of 0.9% sodium chloride (or compatible
solution) for injection
• Collect the other equipment and place it on the bottom of
the trolley
 Procedure

• Identify the patient

• Open the sterile dressing pack and 2% chlorhexidine swab and empty onto pack
• Decontaminate hands
• If a peripheral device is in situ, remove the bandage and dressing
• Inspect the insertion site of the device
• Observe the infusion, if in progress
• Check whether the infusion fluid and the drugs are compatible. If not, change
the infusion fluid to 0.9%sodium chloride to flush between the drugs
• Sanitize hands
• Place a sterile towel under the patient’s arm.
• Apply gloves and clean the injection site with a 2% chlorhexidine swab and allow
to dry
 Procedure
• Switch off the infusion
• If a peripheral device is in situ , gently inject 0.9% sodium chloride (not
necessary if the patient has a 0.9% sodium chloride infusion in progress)
• Open the roller clamp of the administration set fully. Inject the drug at a
speed sufficient to slow but not stop the infusion and inject the drug
smoothly in the direction of flow at the specified rate
• Dispose needles and syringes are disposed immediately into sharps container
• Observe the insertion site of the device throughout
• Blood return and/or ‘flashback’ must be checked frequently throughout the
injection (that is, every 3–5 mL) but other signs and symptoms must be taken
into consideration
 Procedure
• Switch off the infusion
• If a peripheral device is in situ , gently inject 0.9% sodium chloride (not
necessary if the patient has a 0.9% sodium chloride infusion in progress)
• Open the roller clamp of the administration set fully. Inject the drug at a
speed sufficient to slow but not stop the infusion and inject the drug
smoothly in the direction of flow at the specified rate
• Dispose needles and syringes are disposed immediately into sharps container
• Observe the insertion site of the device throughout
• Blood return and/or ‘flashback’ must be checked frequently throughout the
injection (that is, every 3–5 mL) but other signs and symptoms must be taken
into consideration
 Procedure
• Consult the patient during the injection about any discomfort
• If more than one drug is to be administered, flush with 0.9% sodium chloride
between administrations by restarting the infusion or changing syringes
• At the end of the injection, flush with 0.9% sodium chloride by restarting the
infusion or attaching a syringe containing 0.9% sodium chloride
• After the final flush of 0.9% sodium chloride, adjust the infusion rate as
prescribed
• If a peripheral device is in situ , cover the insertion site with new sterile low-
linting swab and tape it in place
• Apply a bandage
• Assist the patient into a comfortable position
 Post Procedure
• Dispose used syringes with the needle, unsheathed. Do not
disconnect needle from syringe prior to disposal
• Other waste should be placed into the appropriate plastic bags
• Record the administration on appropriate charts
 Fluid balance

In nursing practice, this term refers to the procedure of measuring fluid

input and output to determine fluid balance
In the human homeostatic state, the intake of fluids equals fluid excreted
from the body, thereby maintaining optimal hydration
Bodily water/fluid is essential to life and vital for:
• controlling body temperature
• the delivery of nutrients and gases to cells
• the removal of waste
• acid/base balance
• the maintenance of cellular shape
 Essential equipment

• Fluid balance chart

• Appropriate pumps for fluid or feeding
• Measuring jugs (with volume indicators)
• Non-sterile gloves, apron, goggles
• Urometer
• Bedpan/commode
• Scales
 Post-procedural considerations

• Every hour, the findings of fluid input/output monitoring

should be recorded
• Any deficit or change in fluid balance should be reported
• Any imbalance noted will require action and a
management plan
 Complications
• Correct fluid balance monitoring is essential in the successful
management of actual or potential fluid balance disturbances
• Over- or underestimation of the fluid status could lead to
incorrect management, resulting in fluid overload
(hypervolaemia), dehydration (hypovolaemia) and/or
electrolyte disturbances, all of which will ultimately lead to
organ dysfunction
 Fluid overload/hypervolaemia

• Underestimating the fluid balance may lead to continued or

increased administration of IV fluids, which if monitored
incorrectly could result in circulatory overload
• Excess IV fluid administration is not the only cause of
circulatory overload, which can also result from acute renal
failure, heart failure and intake of excessive sodium
 Hypovolaemia/dehydration
• Dehydration refers to a negative fluid balance, when the
fluid output exceeds the fluid intake
• Overestimation of the fluid balance may lead to
inadequate replacement of lost fluids
• Dehydration can, however, be caused by a loss of fluids to
‘third spaces’ such as ascites or lost due to a reduction in
colloid osmotic pressure, losses which are not easy to
account for
 Blood Transfusion

• Blood transfusion is the administration of a blood component- or

plasma-derived product to the patient.
• Blood is a raw material from which different therapeutic products are
made
ABO Blood Groups
 Rh blood groups

• Rh blood group has surface antigens, which are another

essential system used in transfusion therapy
• The Rh D antigen is the most immunogenic of the Rh
antigens
• Approximately 85% of Caucasians have the D antigen and are
therefore Rh positive and 15% lack the D antigen and are Rh
negative
 Indications for red cells

• Increased loss of red blood cells

• Decreased production of red blood cells
• Increased destruction of red blood cells
• Increased demand for red blood cells
• Increased production of abnormal red blood cells
Indications for platelets
• Platelet transfusions are indicated in the prevention and treatment of
haemorrhage in patients with thrombocytopenia or platelet function
defects
 Steps

• Blood product request

• Blood sampling: pre-transfusion
• Blood components: collection and delivery to the clinical
area
Blood product request
 Essential equipment
• Written order for blood component
transfusion
• Intravenous access - blood components may
be administered through a peripheral cannula
or via a central venous access device
• Blood administration set with 170–200 μm
macroaggregate filter (should be changed at
least every 12 hours or after every second
unit for a continuing transfusion)
• Infusion devices
• Either gravity or electronic infusion devices
may be used for the administration of blood
components
 Pre-procedure
Action
• Check that the component has been correctly ‘prescribed’, including
any special requirements such as irradiated or CMV-negative blood,
and if the patient requires any other medications, for example
diuretic, premedication
• Check that the patient’s baseline vital signs, temperature, pulse,
blood pressure and respirations have been recorded
• Conduct a visual inspection of the component to be used for signs of
clumping, discoloration, damage or leaks
• If there are any discrepancies at this point do not proceed until they
have been resolved
 Pre-procedure

• Identify the patient by asking them to state the following information:

(a) First name
(b) Surname
(c) Date of birth
If the patient is unable to positively identify themselves then
verification can be given by a carrier or relative. This information must
match the wristband exactly
• Check the details given against the patient’s name band and the
patient details on the blood component
 Pre-procedure

• Check that the information on the compatibility label matches the

details on the blood component, check expiry date, unique
component donation number, blood group on the component label
against the laboratory-produced label. Check special requirements
have been met
• If there are any interruptions during this checking procedure, the
entire process should be restarted from the beginning
• If there are any discrepancies at this point do not proceed until they
have been resolved
 Procedure
• Prime the set with blood/blood components unless there are concerns
about patency of the device, then prime with 0.9% sodium chloride
• Set up infusion via a volumetric infusion pump if appropriate. Check the
infusion pump and settings prior to use
• Set the desired infusion rate as indicated by the blood component being
used and the patient’s condition
 Procedure

• Observe and monitor the patient throughout the transfusion

episode. If there are any concerns, undertake additional
observations as appropriate
• Record the finish time of each unit. All units must be
completed within 4 hours of removal from storage
• Take and record the patient’s observations on completion of
each unit, ensuring that post-transfusion observations are
performed within 60 minutes of completion of the unit
 Post-procedure

• Record the time the transfusion finished and the volume of the
component transfused on the patient’s fluid balance chart
• Carefully file all transfusion documentation in the patient’s clinical
record. In line with local policy, return information on the final fate of
each blood component to the hospital transfusion laboratory
• Return any unused blood components to the laboratory promptly
 Complications
• Transfusion-associated graft-versus-host disease (onset occurs 1–2 weeks after
transfusion, max 30 days, and the condition is predominantly fatal)
• Bacterial infections
• Viral infections
• Sepsis (a serious life-threatening condition, sometimes referred to as septic shock, and
requires urgent medical attention)
• Transfusion-related acute lung injury (TRALI) is usually caused by antileucocyte
antibodies reacting against donor leucocytes. The antigen/antibody reaction can result
in leucoagglutination” causing severe respiratory distress
• Urticaria is caused by the recipient reacting to protein in the donor plasma,
characterized by localized oedematous plaques, hives and itching and is usually
mediated by histamines
• Transfusion reactions (minor or major)
• Acute anaphylactic reactions
 Thank you for your attention!

This presentation does not represent the

studying material

Reading: The Royal Marsden Manual of

Clinical Nursing Procedures. Part 2. Chapter 7. Part
4. Chapter 12, p. 747