The Nurse’s Roles and Responsibilities in IVI Therapy,

Blood and Blood Products Administration

Presenter : Jennifer Savariau Morris R.N. BSc, R.M.,Lecturer,

Phlebotomist

Objectives of Discussion

• Define intravenous infusion• Indications for IVI therapy• Types of IVI therapy• Supplies and equipment needed• Site selection• Procedure involved

Objectives of Discussion

• Nursing responsibilities before, during and after IVI therapy

• Complications of IVI therapy• Intravenous therapy calculations

What is an Intravenous Infusion

What is an Intravenous Infusion

A solution administered into a vein through an infusion set that includes a plastic or glass vacuum bottle or bag containing the solution and tubing connecting the bottle/ bag to a branula/ catether in the patient's vein.

What is IVI Therapy

• Intravenous infusion therapy is the administration of drugs by inserting a hypodermic needle directly into a vein and allowing medication to run through it.

(IV push)

Indications for IVIs

Indications for IVIs

• To correct electrolyte imbalances• Administration of medications• Administration of blood and blood • products• Administration of total parenteral Nutrition• Haemodynamic monitoring

Indications for IVI Therapy

• Blood sampling• Chemotherapy

Types of IVIs

• Volume expanders (crystolloids and colloids)

• Blood based products• Blood substitutes (Gelafusine)• Medication• Nutrition

Volume Expanders• Colloids• Solution that contain large molecules that do not pass

through the cell membranes.• When infused they remain in the intravascular space and expand the intravascular volume and they draw fluid from the extravascular space because of their higher oncotic pressure

Volume Expanders

• Crystalloids• Solutions that contain small molecules that

flow easily across the cell membranes allowing for transfer from the

bloodstream into the body cells and tissues. This will increase fluid in the intravascular and interstitial space

Volume Expanders

Fluids can be further classified into1.Isotonic2.Hypotonic3.Hypertonic

Isotonic Solutions

• Most IV therapy solutions are isotonic. Isotonic solutions are designed to match the makeup of your intracellular fluid and are equal in osmotic pressure inside

and outside your cells. This prevents any fluid shifting in and out of your cells.

Examples of Isotonic Solutions

• Dextrose 5% in water (D5W), • Lactated Ringer's solution • Normal Saline Solution (0.9% sodium

chloride.)• Ringer’s Solution

Indications for Normal Saline

• Fluid volume deficit eg. Haemorrhage severe vomiting diarrhea

• Shock• Mild hyponatremia• Metabolic acidosis• Resusitation efforts• Blood administration

Indications for Ringers Lactate of Hartman’s solution

• Burn injuries and trauma• GI tract fluid losses• Acute blood loss or hypovolemia• Fistula drainage

Indications for 5% Dextrose Water

• Low blood sugar• Insulin shock• Dehydration• Nutritional support• Diluent for medications

Indications for Ringers Solution

• Burns • Trauma • Surgery

Hypotonic Solutions

• Hypotonic solutions have lesser tonicity than that of the ICF because it has lesser solute concentration. ICF becomes more concentrated, it pulls water from the

ECF, thus, makes the cell swell.

Types of Hypotonic Solutions

• 0.45% NaCl (half strength normal saline)•

0.33% NaCl ( one third strength normal saline)

•2.5% Dextrose in water

Indications for Hypotonic Solutions

Purpose:•used to provide free water and treat cellular dehydration.•Note: Free water is desirable to aid the kidneys in elimination of solute via urine output.

Hypertonic Solutions

• Hypertonic solutions have solute concentration in ECF greater than that of the ICF. Therefore, it pulls fluids out of the ICF and the cell shrinks.

Types of Hypertonic Solutions

• D5 in 0.45% NaCl ( 5% Dextrose in half strength normal saline)

• D5LR (5% Dextrose in Lactated Ringer's Solution)• D10W ( 10% Dextrose in water)• D50W50 (50% Dextrose in 50 ml of water)

Indications for Hypertonic Solutions

• Hypertonic solution draws fluids from the ICF causing cells to shrink and ECF to expand.

• Given to patients with hyponatremias (Na deficits) with edema.

Indications for Solutions

• Aside from being isotonic, hypotonic & hypertonic. IVF may also come in a form of nutrient solution, electrolyte solution, alkalizing solution & acidifying solution....

Supplies and Equipment Needed

• Needles and syringe• Branula • Intravenous Fluid • Intravenous Tubing• Tape• Cleaning apparatus

Site Selection

Veins of the arm Antecubital fossa •1. Cephalic vein•2. Basilic vein•3. Median antebrachial vein Dorsum of the hand (dorsal digital network) Wrist Forearm (cephalic, antebrachial)

Site Selection

• Veins of the hand

Site Selection

Veins of the foot•Great saphenous vein•Lesser saphenous vein•Dorsal venous arch

Site Selection

• Extra jugular vein (if necessary)• Scalp veins

Quick Note

• Use veins that provide ease of access• Non dominant limb• Avoid joint areas• If lower extremities and the scalp can be avoided do so• Choose an area that can accommodate the branulae• Try to select straight veins

Procedure Involved

• Select a suitable vein for venepuncture.

• Prepare the venepuncture site.

Procedure Involved

(1) Apply a constricting band two inches above the venepuncture site. The constricting band should be tight enough to occlude venous flow, but not so tight that distal pulses are lost.

Procedure Involved

(2) Select and palpate a prominent vein.

(3) Cleanse the skin with an alcohol swab using a spiral motion starting with the

entry site and extending outward about two inches. Allow the site to dry.

(4) Don gloves.

Procedure Involved

• d. Perform the venepuncture.

• (1) Using your non-dominant hand, pull all local skin taut to stabilize the vein.• (2) With your dominant hand, position the distal bevel of the needle up and insert the branula into the vein at approximately a 30 degree angle.

Procedure Involved

• (3) Continue inserting the needle until blood is observed in the flash chamber of the catheter.

• (4) Decrease the angle to 15 to 20 degrees and carefully advance the cannula approximately 0.5

centimeter farther.

Procedure Involved

• (5) While holding the needle stationary, advance the catheter into the vein with a twisting motion. Insert the catheter all the way to the hub.

• (6) Place a finger over the vein at the catheter tip and put pressure on the

vein to prevent blood from flowing out the catheter.

Procedure Involved

• (7) Remove the needle while maintaining firm catheter control.

• e. Remove the constricting band.

• f. Obtain venous blood samples as required.

Procedure Involved

• g. Attach the administration tubing to the branula hub while maintaining

stabilization of the hub with the non- dominant hand.

Procedure Involved

• h. Open the flow-regulator clamp and observe for drips in the drip chamber. Allow the fluid to run freely for several seconds.

• Note: You may drop the solution bag lower than the casualty's heart to observe for a back flash of blood to verify catheter placement.

Procedure Involved

• i. Adjust to the desired flow rate.

• j. Clean the area of blood, if necessary, and secure the hub of catheter with

tape, leaving the hub and tubing connection visible. Make a

small loop in the IV tubing and place a second piece of tape over the first to secure the loop.

Procedure Involved

• k. Apply a 2x2, a 4x4 micropore tape over the venipuncture site.

• l. Label a piece of tape with date and time the IV was initiated, the catheter size, and your initials. Secure the tape over the dressing.

Procedure Involved

• m. Monitor the casualty and continues to observe the venipuncture site for signs of infiltration. Discontinue the infusion if signs of infiltration are observed.

• n. Remove your gloves and disposes of them appropriately.

Procedure Involved

• Document the procdure in the patient’s notes

Types of Vascular Access Devices

• Peripheral branula: short term use inserted into the peripheral veins of arms and foot (48-96 hrs)

• Midline catheters: designed for short term use, inserted peripherally up to 20cm into the vein

Types of Vascular Access Devices

• Peripherally inserted central catheter (PICC) used medium term to long term for total parenteral nutrition

• Percutaneous central venous catheter• Hickman line( Long term use)

Nursing Responsibilities

• Patient should be correctly identified and consent where applicable explained and signed

• Procedure explained for cooperation• The medical order is verified by a second nurse• Observe the rights of the patient

Nursing Responsibilities

• Use aseptic techniques to keep devices free from infection

• Ensure devices used in are undamaged• Ensure IV fluid is within its expiry date• Ensure IV administration is via a closed system

Nursing Responsibilities

• Any problems encountered during siting of IV is recorded or reported

• The infusion rate is calculated properly• The patients vital signs is done and their condition closely monitored• Maintain patency of the line

Nursing Responsibilities

• All actions are documented in the patients notes and on the fluid balance chart

Complications of IVI Therapy

• Phlebitis• Thrombophlebitis• Infiltration and extravasation• Infection• Circulatory overload• Anaphylaxis/allergic reactions

IVI Calculation

• Formula: • Volume (mL)• Time (min)x Drop Factor (gtts/mL) = Y

(Flow Rate in gtts/min)

Break Time!!!!!

• Two minutes water break.

Objectives of Discussion

• Define Blood• Blood types and grouping• Define Blood products• List types of Blood products• Labeling of the Blood bag• Storage and handling of Blood• Define Blood transfusion• Indications for Blood transfusions

Objectives of Discussion cont’d

• Nursing responsibilities prior to, during and after Blood transfusion

• Post transfusion reactions• Nursing responsibilities• Ethical issues related to Blood transfusion

Define Blood

Blood The fluid circulating through the blood vessels and,

carrying nutriment and oxygen to body cells, and removing

waste products and carbon dioxide It consists of plasma and the formed elements (erythrocytes, leukocytes, and

platelets)

 

Blood Types and GroupingPatient (Rh Positive) Donor

Packed Cells O Positive O Positive or Negative

A Positive A Positive or NegativeO Positive or Negative

B Positive B Positive or NegativeO Positive or Negative

AB Positive Any Group

Plasma O Any Group

A A , AB

B B, AB

AB AB

Blood Types and GroupingPatient (Rh Negative) Donor

Packed Cells O negative O Negative

A Negative A Negative

B Negative B Negative

AB Negative AB Negative

Blood Types and Grouping

• Universal Donor is ‘O’ (negative) which gives to all groups and receives only from itself

• Universal Recipient is ‘AB’ and receives blood from all groups and can give only to itself

Blood Transfusion Scenario

A patient who is A positive is hemorhaging during surgery. From your knowledge of blood typing and grouping which group would you select?

AB Positive O Negative B Positive

Define Blood Products

Blood Products The constituents of whole blood that are

used in replacement therapy

Types of Blood Products

Whole Blood Packed Red Blood Cells Plasma Cryoprecipitate Platelets Clotting Factors (VIII, IX)

Define Blood Transfusion

Blood transfusion is generally the process of receiving blood products into one's circulation intravenously

Indications For Blood Transfusions

To replace blood lost during surgery or in haemorrhage

To replace a deficiency of specific blood componients e.g. erythrocytes

To increase the oxygen-carrying capacity of the blood as is Anaemia To increase the intravascular volume in shock

Information on Blood Bag

• Identification number• Client’s name• Blood group• Rhesus factor• Expiry date

Why is this information important

Storage of Blood

Blood

Componient Shelf life Stored

Temperature (degrees celcius)

Fresh Whole Blood

35 days 20 - 24 (RT)2 - 6

Platelets 5 days 20 – 24

Fresh Frozen Plasma

12 months - 25 or below

Cryoprecipitate 12 months -25 or below

Red Blood Cells 35 - 42 days 2 – 8

Storage and Handling of Blood

Whole blood and packed cells can be out of the Blood Bank refrigerator for up to 6 hours

It should be kept in a cool area eg a air conditioned room Do not store platelets in a refrigerator

Storage and Handling of Blood

Do not place blood in a domestic refrigerator or freezer

Do not filter platelets during transfusion Use filter for plasma, red blood cells and cryoprecipitate during transfusion Do not store blood until its expiration date has passed

Storage and Handling of Blood

FFP must not be thawed unless there is surety of use

Allow all frozen products to thaw until they have reached room temperature Do not thaw frozen products by running them under the pipe or boiling it. Use a blood warmer

Storage and Handling of Blood

Do not transfuse cold blood Do not give blood to a patient that was

prescribed for another patient because they have the same blood group

If the unit of blood is not used please return the unit to the Blood Bank or Laboratory

Storage and Handling of Blood

Do not continue transfusion for more than 3 hours especially if the blood flow is unsatisfactory.

Transfusion Record

• Patient name• Location• Date of Birth• Age• Sex• Patient blood group• Unit number• Product name

Transfusion Record

• Volume• Expiry date• Condition of the unit• Date of order• Issue date• Verification of information• First nurse• Second nurse

Transfusion Record

• Starting date and time• Stop date and time• Volume transfused• Chart for vital signs 15 mins, 30 mins, 1 hour, 2 hour, 3 hour at completion• Nurse Id number for each section

Nurses Responsibilities for Blood Transfusions

The patient should be fully informed about the procedure and any questions should be answered

Ask if the patient has had a transfusion or transfusion reaction in the past The consent form should be explained and signed prior to administration

Nurses Responsibilities for Blood Transfusion cont’d

The patient’s mobility will be restricted during transfusion so patient comfort should be ensured

Wash hands and don gloves The unit of blood should be checked by at least two persons to ensure the right patient and it is the correct blood type for transfusion

Nurses Responsibilities for Blood Transfusion cont’d

Note the expiration date on the unit of

blood. Observe for clots or abnormal particles or cloudiness

Start intravenous infusion with 0.9% Normal Saline Use a 18 or 19 inch branulae

Nurses Responsibilities for Blood Transfusion cont’d

Take baseline vital signs prior to beginning transfusion Inform the patient to report an chills, itching, rash,

or unusual symptoms. Start the infusion of the blood product and record the time Start administration of blood slowly no more than 2 ml/min for the first 15 minutes or as required

Nurses Responsibilities for Blood Transfusion cont’d

Check vital signs every 5 minutes for first 15 minutes, 30 minutes, 1 hour and every hour until completion

Observe the patient for reactions such as flushing, dyspnoea, itching, hives or rash Maintain the prescribed flow rate as ordered

Nurses Responsibilities for Blood Transfusion cont’d

Stop blood transfusion and allow infusion of normal saline if a reaction is suspected

Notify the physician and the Blood Bank. Return all blood bag to the Blood Bank along with blood samples (red and purple top) urine sample If unable to return blood bag promptly store at 1- 6 C/ 24 hours

Nurses Responsibilities for Blood Transfusion cont’d

If no reactions are observed infuse with 0.9% Normal Saline on the

completion of the transfusion Document administration of blood and clients reactions if any

Transfusion Reaction Report Form

• Patient’s Name• Sex • Blood group• Blood product• Unit number

Transfusion Reaction Report Form

• Transfusion date• Who started the transfusion• Volume infused• Who ended the transfusion

Transfusion Reaction Report Form

• Nurses observation• What was done• Other information (lab)

Post Transfusion Reactions

Minor Blood Reactions• Fever• Itching

Post Transfusion Reactions

Nursing Responsibilities• Stop transfusion and inform the doctor of findings• Give 0.9% NaCl slowly KVO• Give antipyretic • Give antihistamine• Monitor temperature and itching

Post Transfusion Reactions

Nursing Responsibilities• Wait for symptoms to subside• On the advise of the Doctor continue blood transfusion

Post Transfusion Reactions

Allergic Reaction• Hives • Itching• Anaphylaxis

Post Transfusion Reactions

Nursing Responsibilities• Stop transfusion immediately and keep

vein open with normal saline• Notify Physician stat• Administer antihistamine as ordered parenterally as necessary

Post Transfusion Reactions

Febrile Reaction• Fever and chills• Headache• Malaise

Post Transfusion Reactions

Nursing Responsibilities• Stop transfusion immediately and keep

vein open with normal saline• Notify physician• Treat symptoms

Post Transfusion Reactions

Haemolytic Transfusion Reaction• Immediate onset• Facial flushing• Fever, chills• Headache• Low back pain• Shock

Post Transfusion Reactions

Nursing Responsibilities• Stop infusion immediately and keep vein

open with normal saline• Notify physician stat• Obtain blood samples from site• Obtain first voided urine• Treat shock if present• Send unit, tubing and filter to the lab

Post Transfusion Reactions

Nursing Responsibilities cont’d• Draw blood sample for serologic testing

and send urine specimen to lab

Post Transfusion Reactions

Circulatory Overload• Dyspnoea• Dry cough• Anxiety• Weak pulse• Cyanosis• Pulmonery oedema

Post Transfusion Reactions

Nursing Responsibilities• Slow or stop infusion• Monitor vital signs• Notify physician• Place the patient in an upright position

Post Transfusion Reactions

Bacterial Reaction• Fever• Hypertension• Dry, flushed skin• Abdominal pain

Post Transfusion Reactions

Nursing Responsibilities• Stop infusion immediately• Obtain culture of client’s blood and return blood bag to lab• Monitor vital signs• Notify physician• Administer antibiotics as prescribed stat

Ethical Considerations Related to Blood Transfusion

• Religious beliefs• Signed statement if treatment is refused

Questions Anyone

Nurses!!!

“ Be not afraid of greatness. Some are born great, some achieve greatness, and others have greatness thrust upon them.” ― William Shakespeare

Shine !!! Wherever You Are

References• http://medical-dictionary.thefreedictionary.com/intravenous+infusion• http://us-mg6.mail.yahoo.com/neo/launch?.rand=51qo1pt6c91ti• http://en.wikipedia.org/wiki/Intravenous_therapy• http://www.wisegeek.com/what-is-intravenous-infusion-therapy.htm• http://www.slideshare.net/kholeif/iv-fluid-therapy-types-indications-dose

s-calculation• http://voices.yahoo.com/iv-therapy-isotonic-solutions-are-6707862.html?

cat=5

• http://www.drugs.com/mtm/dextrose-5-in-water-injection.html• http://nursingreference.blogspot.com/2009/01/intravenous-fluids.html• http://nursing411.org/Courses/MD0553_Intravenous_Infusions/1-06_Intr

avenous_Infusions.html+&cd=3