Chapter 13 Intravenous Infusion and Blood Transfusion
Slide 2
SECTION ONE Intravenous Infusion Definition:IV infusion is a
method that a large volume of solution is infused into vein to
correct fluid and electrolyte disturbance solution ; passage
(infusion set); vein
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Intravenous Infusion IV infusion is a serious and complex
responsibility that requires the nurse: proficiency in performance
familiarity with the anatomy involved mindful use of principles of
asepsis expertise in prevention, management of complications that
may occur with treatment
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Intravenous Infusion Fluids are medications--IV infusion
requires a physician s order the type and amount of fluid
administered will be based on types of patient s need the patient s
age general health status the results of laboratory tests
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Types of solutions There are many methods of classification
according to their osmolality in relation to normal blood plasma
according to their purpose Hypotonic fluids Isotonic fluids
Hypertonic fluids Nutrient solutions Electrolyte solutions Volume
Expanders
Slide 6
Hypotonic fluids have lower osmolality than plasma to correct
dehydration as they move from blood vessels into the cells examples
are 0.45 % NaCl, 0.2 % NaCl, or 5%GS excessive infusion can cause
water intoxication
Slide 7
Isotonic fluids have the same effective osmolality as plasma to
expand the intravascular space to correct hypovolemia as in shock
examples are lactated Ringer s, 0.9 % ( normal ) saline(0.9%NaCl),
5 % dextrose in normal saline(5%GNS). 1.4%NaHCO 3 excessive
infusion can cause circulatory overload and pulmonary edema
Slide 8
Hypertonic fluids have greater osmolality than plasma to pull
fluid from cells and the interstitial space into the intravascular
space to relieve edema examples are >5 % dextrose solutions,
colloidal products such as dextran, 3 % saline ( rarely used ).
excessive infusion can cause cellular dehydration and circulatory
overload or diuresis.
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Nutrient solutions contain some form of glucose and water for
calories and fluids replacement examples are 5 or 10 dextrose in
water Hypertonic ( >10 percent dextrose ) parenteral nutrition
solutions are irritating to peripheral veins and so must be infused
into central veins.
Slide 10
Electrolytes solutions contain varied amounts of cations and
anions examples are normal saline Ringer s solution, and lactated
Ringer s solution commonly be used to restore vascular vo1ume
particularly after trauma or surgery also be used to replace fluid
and electrolytes for patients with continuing losses for example
gastric suction or wound drainage
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Volume expanders be used to increase the blood volume following
severe loss of blood or loss of plasma examples are dextran plasma
and human serum albumin
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Clinical routine In clinic, prepare fluids fall into the
following three categories: Crystalloid Solution Crystalloid
Solution Colloidal Solution Colloidal Solution Parenteral Nutrition
Solutions Parenteral Nutrition Solutions
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Crystalloid Solution have small molecular weights and stay in
blood vessel for a short time maintain the balance of fluids in
intracellular and extra- cellular correct the fluids and
electrolytes disturbance commonly used crystalloid solutions are
Dextrose in Water Solutions Isotonic Electrolytes Solutions
Alkaline solutions Hypertonic Solutions
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Dextrose in Water Solutions Be used for fluids and calories
replacement decreasing the consumption of albumen and preventing
the production of ketone glucose is decomposed quickly in body,
usually doesn t cause hypertonic and diuretic effects Clinically
there are usually 5 GS and 10 GS (25%GS; 50%GS rarely used)
Slide 15
Isotonic Electrolytes Solutions be used in electrolytes
replacement Loss of body fluids usually is accompanied with
disturbance of electrolytes So, the balance of fluids and
electrolytes must be maintained during fluids replacement examples
are o.9 NaCl Ringer s isotonic solution and 5% GNS
Slide 16
Alkaline solutions NaHC0 3 in Water Solutions Be used in
correcting acidosis, and regulating of acid-base balance NaHC0 3 Na
+ and HCO 3 - HCO 3 - + H + H 2 CO 3 C0 2 +H 2 O Commonly used
solutions are 5 NaHC0 3 and 1.4 NaHC0 3 Solutions. Sodium Lactate
in Water Solutions The concentrations of the solution usually used
in clinic are 11.2 and 1.84%.
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Hypertonic Solutions be used for diuretic and dehydration
purposes increase osmolality of blood plasm pulling fluids into
plasma reduce the edema of tissues can decrease intracerebral
pressure and improve the function of central nervous system
Clinically mannitol 20% sorbitol 25 and dextrose 25 -50 in water
solutions are often used
Slide 18
Colloidal Solution have large molecular weight can stay in
blood for a long time can maintain plasma colloid osmotic pressure
effectively expand the blood volume improve microcirculation
elevate the blood pressure examples are dextran plasma substitutes
blood products
Slide 19
Dextran It is water-soluble polysaccharide of high molecular
polymer moderate molecular dextran : elevate plasma colloid osmotic
pressure expand blood volume small molecular dextran : reduce the
viscosity of blood decrease the accumulation of erythrocytes
improve microcirculation and tissue perfusion volume and prevent
the formation of thrombosis
Slide 20
Plasma Substitutes can expand vascular volume and cardiac
output greatly can be used with whole blood in acute massive
hemorrhage examples are 706 (hydroxyethylamylum) povidone and
oxypolygelation
Slide 21
Blood Products can elevate colloid osmotic pressure expand
vascular volume provide protein and antibody help with tissue
repair and enhance immunity of body
Slide 22
Parenteral Nutrition Solutions be intravenously given to the
patients who are unable to get nutrition via gastrointestinal tract
or have inadequate intake of nutrients provide calories proteins
vitamins and minerals and maintain the balance of nitrogen main
compositions : amino acids fatty acids vitamins minerals high
concentration of glucose and water commonly used solutions :
multiple amino acids solutions, fat emulsions
Slide 23
sequence principle of solution transfusion First crystalloid
solutions then colloidal solutions First sodium chloride solutions
then dextrose in water solutions first fast then slow, rather
shortage than overload rather acid than alkaline Potassium
solutions properly
Slide 24
Sites of Venipuncture Peripheral Superficial Vein veins in
dorsal hands : the first choice for adult patients median cubital
basilic cephalic veins :drawing blood bolus injections of
medication PICC The saphena veins in legs and veins in dorsal feet
are not the first choice because of the danger of thrombosis caused
by the vein valve Veins in dorsal foot are commonly used for
children but are avoided in adults because of the danger of
thrombophlebitis Veins in the Scalp : for infants Subclavian
External Jugular:for central venous access
Purposes To correct or prevent fluid and electrolyte
disturbances resulted from illnesses, altered fluid intake, or
prolonged episodes of vomiting or diarrhea. To increase the blood
volume, maintain blood pressure following severe loss of blood,
severe burns, or shock. To supply medication to cure diseases for
rapid effectiveness. To supply nutrient substances to promote wound
healing, weight gain and positive nitrogen balance for patients
with chronic consuming illness, inability to intake, digest or
absorb a diet. To establish a lifeline for rapidly needed
medications.
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Preparation Nurse 1. Review the physician s order in patient s
record. 2. Evaluate patient s age and medical status. Evaluate
patient s renal status and other pertinent lab data (e.g.,
electrolyte, serum glucose ). 3. Wash hands and wear mask. patient
1. Verify patient s identity. 2. Explain the procedure and purpose
Ask the patient to void 3. Position the patient for comfort and
optimal visibility for skill performance.
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Preparation Environment: cleanness, commodiousness and
brightness equipment: Medical tray Antiseptic solution Sterile swab
Tourniquet infusion Pad Adhesive tape File and vial opener IV
solution and medication Bottle bag Infusion set kidney-shaped
tray
Slide 29
Procedures and Key Points 1.Check and right the bed number the
patient s name medication name concentration dosage date and usage
the quality of solution(the cap of bottle, the expiration date,
deposition cloudiness foreign matter, any cranny on the bottle s
body) 2. Complete the medication label and stick it to the solution
container
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3. Add medications into solution 4.Insert the infusion set 5.
Prepare the equipment and take them to the bedside Check again 6.
Discharge air
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7.Select the venipuncture site(pad, tourniquet ) 8.Sterilize
the venipuncture site Prepare adhesive tape. 9.Check again. 10.
venipuncture The wizened The obese The elderly The dropsical
(edema)
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11.fixation 12. Regulate the flow rate 13. Check again. 14.
Disposure after operation (equipment,patient) 15. Change bottles
16. Disposure after infusion (equipment,patient)
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Cautions 1. Follow the principles of asepsis and check system
strictly to prevent infection and mistakes. 2. Arrange the sequence
of IV fluids rationally according to the patient s need. Assign
medications according to the therapeutic principles and the half
life of medications. 3. Protect and use veins reasonably (usually
from small veins) to patients who need long-term IV infusion.
Slide 34
Cautions 4. Prevent air embolism by ejecting air thoroughly in
infusion set, changing fluid bottles and withdrawing the
venipuncture needle in time. 5. Assess for compatibility of
medications. Ensure the needle have been inserted into vein before
administration irritative or special medications. 6. Master the
flow rate strictly. 7. Assess during infusion carefully in order to
find the problems and settle the problems on time. Document the
result after assessment.
Slide 35
Education 1. Tell the patient don t regulate the flow rate
optionally. 2. Introduce the signs and symptoms of complications
with IV reactions, ask patient call nurse in time when he find the
signs of IV reaction. 3. Instruct the patient to report any blood
in the tube a stoppage in the flow or increased discomfort 4.
Intensify mental nursing to patient who need long- term IV
infusion.
Slide 36
Evaluation Assess the status of the skin and dressing of IV
site by observing whether there is heat pain redness or swelling
Whether the IV flows smoothly and whether the flow rate is
consistent with what is ordered Check the information to ensure the
right medication administered Signs and symptoms of complications
with intravenous infusion Patient s knowledge about medication and
infusion Ability to perform self-care activities.
Slide 37
Regulating the Infusion Flow Rate Calculate the Flow Rate
Common Infusion Control Device
Slide 38
Calculate the Flow Rate Total time of infusion (h) = Total
infusion vo1ume (m1) drop factor (drops/m1) Drops per minute 60
Drops per minute= Total infusion vo1ume (m1) drop factor (drops/m1)
Total time of infusion (min)
Slide 39
Calculate the Flow Rate Slow flow rate is suitable for the
elderly infants and patients with diseases in heart, 1ungs or
kidney When hypertonic solutions solutions containing potassium or
solutions containing medications for raising blood pressure are
infused the flow rate also should be slow When a patient with
normal heart and lung function has severe dehydration the flow rate
should be rapid
Slide 40
Common Infusion Control Device Clamp:be easy to operate ; not
precise Infusion Pump: exert positive pressure on the tubing or on
the fluid to ensure measured amount of fluid is infused uniformly
in a given time has a drop sensor, and an alarm that will sound if
drops are not detected at the appropriate rate VCD
Slide 41
The Usage of Infusion Pump
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Assessing during infusion The responsibilities of nurses in
assessment are keeping the system sterile changing solution tube
and dressings on time assisting the patient with self-care
activities so as not to disrupt the system ; instruct the patient
to report any blood in the tube a stoppage in the flow or increased
discomfort
Slide 46
Common Problems during Infusion and Methods to Treat Slow Flow
Rate or No Infusion Too Large Volume of Solution in Chamber Too
Small Volume of Solution in Chamber The Surface of Liquid Fall down
Automatically assess the site and the infusion rate at least once
an hour
Slide 47
Slow Flow Rate or No Infusion Infiltration occlusion of the IV
Needle or Catheter hyperkinesia of Vein Too Low Hydrostatic
Pressure
Slide 48
Infiltration Cause:the needle dislodge from the vein and fluid
exude in the subcutaneous space Signs: insertion site becomes
swollen clammy, and painful Alternative nursing actions:
:discontinue IV and establish a new line at a new site
Slide 49
occlusion of the IV Needle causes: there are clots at the tip
of the needle the needle tip is against the vein wall (flexed
joint-wrist, elbow ) narrowing the tubing may exist too-tight IV
dressing a kink in the tubing measures: assess : lowering the IV
container below the level of the IV insertion site, opening the
roller clamp thoroughly, and observing for a blood return
Alternative nursing actions: inspect the area around the insertion
site loose the IV dressing check the tubing change the position of
the needle handle or extremity
Slide 50
hyperkinesia of Vein Causes: extremity is exposed in cold
environment for a long time the temperature of the fluid is too low
Alternative nursing action: warm the extremity
Slide 51
Too Low Hydrostatic Pressure Raise the solution container
increase hydrostatic pressure increase the flow rate
Slide 52
Too Large Volume of Solution in Chamber Causes:compress the
drip chamber too many times or too hard when discharging air from
tubing Alternative nursing actions: (3 methods)
Slide 53
Too Small Volume of Solution in Chamber Causes: compressing
chamber with less force or fewer times too late when changing the
IV solution during continuous infusion Alternative nursing
actions:
Slide 54
The Surface of Liquid Fall down Automatically Causes: the
tubing and chamber is not airtight Alternative nursing actions:
check the whole infusion set system to see if there is untight
connection of every part or cranny in infusion set if necessary the
tube system should be changed
Slide 55
Complications of Intravenous Therapy and Intervention Fever
Phlebitis Thrombosis and Thrombophlebitis Circulatory overload
reaction Air Embolism Infiltration Local Allergic Reactions
Infection or Inflammation at the Insertion Site
Slide 56
Fever Causes: allergic reactions to a medication or IV fluid
impureness of the solution incomplete sterilization of the
equipment no strict application of aseptic techniques during
starting an IV Symptoms and signs: feel cold trembling and with
increased body temperature to 38 to 40 or higher Systematic
reactions may be present such as nausea vomiting headache and
tachycardia
Slide 57
Fever Preventions inspect the quality of solutions the package
of intravenous set and date of sterilization carefully
Interventions reduce the flow rate or stop infusion and notice the
physician immediately Give physical cold therapy to patient with
T> 39 Administer the antiallergic medication according to
physician s order if necessary. Keep the residual solution
medication and equipment for the laboratory test
Slide 58
Phlebitis Thrombosis and Thrombophlebitis Causes: irritation to
the lining of blood vessels chemical irritation to tissues by IV
solutions or medications mechanical irritation to tissues by the
needle or catheter localized allergic reaction to the indwelling
catheter or needle local infection by undemanding sterile
performance during initiating infusion
Slide 59
Phlebitis Thrombosis and Thrombophlebitis Symptoms and Signs
feel pain in local site with increased skin temperature swelling
over the vein redness traveling along the path of the vein in some
cases systemic reactions may be present such as fever chill
Slide 60
Phlebitis Thrombosis and Thrombophlebitis Preventions To follow
sterile principles strictly and protect the 1ocal site from
contamination Irritating medication should be diluted thoroughly
and infused slowly The needle should be secured firmly to prevent
the needle sliding out of the vein
Slide 61
Phlebitis Thrombosis and Thrombophlebitis Interventions
Discontinue infusion and start IV at another vein Apply warm
compresses with 50 magnesium sulphate Use physical therapy of
ultrashort wave on local site If there is infection use antibiotics
according to physician s order
Slide 62
Circulatory overload reaction --acute pulmonary edema Causes:
receive a too large volume and a too rapid administration of IV
solutions a sudden increase of circulating blood volume and too
heavy cardiac load
Slide 63
Circulatory overload reaction --acute pulmonary edema Symptoms
and Signs: chest pressed shortness of breath cough, frothy or
pinkish sputum facial paleness diaphoresis neck vein distention
rales in the lungs rapid heart rate arrhythmia rapid weight gain
pitting edema and tachycardia
Slide 64
Circulatory overload reaction --acute pulmonary edema
Preventions maintain the appropriate flow rate during the infusion,
especially for the patient with heart failure the elderly and
children Avoid rapid flow rate at night because of nocturnal
decrease in renal function
Slide 65
Circulatory overload reaction --acute pulmonary edema
Interventions slow the rate of infusion or stop the infusion
immediately notify the physician assume a Folower s position with
the feet dangling at the bedside if the patient s condition is
allowed apply oxygen administration with greater flow rate, put 20
to 30 ethanol solution into humidified bottle administer the
sedative vasodilators antiasthma digitalis and diuretics to the
patient according to the physician s order apply tourniquet to
limbs of the patient in alternation in order to reduce the venous
return if necessary
Slide 66
Air Embolism Causes did not eject air in infusion system
thoroughly ; infusion set is not air tight did not eject air in the
tubing below the chamber on time after changing the solution
container do not alter the bottle or withdraw the needle on time
when the patient receives pressure infusion or pressure blood
infusion
Slide 67
Air Embolism Symptoms and Signs feel discomfort in chest or
pain under the sternum with the presence of decreased blood
pressure cyanopathy tachycardia increased venous pressure and
unconsciousness Clear and continuous bubble sound can be
auscultated
Slide 68
Air Embolism Preventions inspect the quality of infusion set
connect every part tightly ejecting air in tubing thoroughly check
the tubing below the chamber to make sure no air after changing the
bottle of solution appoint a nurse to watch the patient with press
infusion have patient place head below heart level or perform
Valsalva maneuver while changing tubing on central venous
lines
Slide 69
Air Embolism Interventions help the patient to turn on left
side with head down administer oxygen therapy with high flow rate
for the patient monitor vital signs and notify the physician
Slide 70
Local Allergic Reactions Causes Individuals may demonstrate
sensitivity to antiseptic solutions or tape used to secure the
catheter Indwelling catheters and needles may also cause allergic
reaction Preventions and Interventions assess allergic history of
the patient very carefully change some supplies which can cause
allergic reactions administer antianaphylaxis medication based on
the physician's order if necessary
Slide 71
Infection or Inflammation at the Insertion Site Causes
Microorganisms gain access to the tissue and circulatory system
through the tip of needle or cannula device inserted during
venipuncture Microorganisms enter later by migration along the
interface between the catheter and tissue Symptoms and Signs the
local tissue may have redness edema heat pain and perhaps exudation
The patient may have systemic reactions such as fever
Slide 72
Infection or Inflammation at the Insertion Site Preventions
Using aseptic technique for all IV-related care; keeping dressing
dry; changing dressing on time Interventions remove IV to another
site if necessary apply cool compress to site as ordered by the
physician elevate limb and observe for signs of sepsis
Purposes Apply to the patients that have difficult to puncture
and need long-term IV infusion. Provide an easy access for
intermittent infusions or IV administration. Protect patient s
veins from damnification of repeated venipuncture.
Slide 75
Preparation Nurse Review the physician s order in patient s
record. Evaluate patient s age and medical status. Evaluate patient
s renal status and other pertinent lab data (e.g., electrolyte,
serum glucose ). Wash hands and wear mask. patient Verify patient s
identity. Explain the procedure and purpose Ask the patient to void
Position patient for comfort and optimal visibility for skill
performance.
Slide 76
Preparation Environment: cleaning, commodious, bright Equipment
: Medical tray Antiseptic solution Sterile swab Tourniquet Pad
Crystal adhesive tape File and opener IV solution and medication
Medical card Infusion set Bottle bag Kidney-shaped tray Sterile
gloves Intravenous indwelling needle
Slide 77
Slide 78
Procedures 1. Check and right 2. Complete the medication label
3. Add medications into solution 4. Insert the infusion set 5.
Prepare the equipment and take them to the bedside Check again 6.
Discharge air
Slide 79
Procedures 7. Wear gloves, prepare IV indwelling needle Check
the quality of the IV indwelling needle take out the indwelling
needle sterile the heparin cap insert spike of infusion set into
the heparin cap discharge again Close the clamp protect the
indwelling needle
Slide 80
Procedures 8. Select the venipuncture site (1) Place a pad
under the extremity (2) Apply a tourniquet firmly 10 to 15cm above
the venipuncture site 9. Sterilize the venipuncture site (>10cm)
10.Check again.
Slide 81
Procedures 11.Intravenous injection (1) Use the left hand to
pull the skin taut against the vein, h old the needle with right
hand, insert the needle and catheter through the skin and into the
vein (2) Once blood appears in the lumen of the catheter, reduce
the angle of the needle until it is almost parallel to the skin
advance the needle 0.2cm, then withdraw the needle 0.5cm, advance
the catheter and needle until the whole catheter is in vein Hold
the catheter shaft steady, withdraw the needle.
Slide 82
Procedures 12. Fixation release fist, tourniquet and clamp Open
the sterile adhesive tape bag, take out the crystal adhesive tape,
and secure the injection site hermetically. Loop the tubing near
the site of entry fix with adhesive tape, and write down the date
of installation on the tape 13. Regulate the flow rate 14. Check
again.
Slide 83
Procedures 15. Disposure after operation 16. Change bottles 17.
Disposure after infusion After infusion close the roller clamp
withdraw the needle from the heparin cap, sterile the heparin cap
and seal the catheter with 0.9%NS in positive pressure Close the
Luer Lock of primed IV catheter set to peripheral cannula Help the
patient to have a comfortable position Record the volume of fluid
infused and the time of the discontinuation Dispose of the
equipment in proper manner Wash hands. Document relevant data
Slide 84
Cautions 1. Follow the principles of asepsis and check system
strictly to prevent infection and mistakes. 2. Keep the injection
site cleaning. Observe the injection site carefully in order to
find the complications and settle them on time. 3. Seal the
catheter with positive pressure after infusion to prevent occlusion
of the catheter or thrombophlebitis. 4. The catheter s indwelling
time is commonly about 3 to 5 days 5. Instruct the patient to take
self-care. Avoid to energize and press excessive. Avoid the
catheter to be pulled out when change clothes.
Purposes 1. Measurement of central venous pressure (CVP) 2.
Apply a venous access when no peripheral veins are available 3.
Administration of vasoactive medications which cannot be given
peripherally 4. Administration of hypertonic solutions including
total parenteral nutrition.
Slide 87
Preparation Nurse: Review the physician s order in patient s
record. Evaluate patient s age and medical status. Evaluate patient
s renal status and other pertinent lab data (e.g., electrolyte,
serum glucose ). Evaluate patient s mental status and cooperation
status. Evaluate the venipuncture site. Wash hands and wear
mask.
Slide 88
Preparation patient: Verify patients identity. Explain the
procedure and purpose to reduce the patients anxiety and tension.
Position patient for optimal visibility for skill performance.
Environment: must be cleaning, commodious and bright
Slide 89
Preparation Equipment: Medical tray Antiseptic solution Sterile
swab Crystal adhesive tape File and opener IV solution and
medication Medical card Infusion set Bottle bag Kidney-shaped tray
local anaesthetic Sterile venipuncture package Sterile gloves
Slide 90
Procedures Steps 1 to 6 are the same as described in Peripheral
Intravenous Infusion 7. Select the position 8. Select insertion
site and sterile the skin 9. Open the sterile venipuncture package,
wear sterile gloves, and drap the area 10. Infiltrate the skin and
deeper tissues with local anaesthetic 11. Insert the catheter and
cover with a sterile dressing 12. Connect with infusion set
Slide 91
Procedures 13. Regulate the flow rate 14. Check again. 15.
Disposure after operation 16. Change bottles 17. Disposure after
infusion Seal the catheter with a small volume of dilute heparin (
100 U/ml ) into the lumen. Clamp catheter lumen using online slide
clamp. Stuff the needle hub hole with a sterile injection cap.
Catheter insertion site protection and stabilization are
accomplished by regular antimicrobial cleaning and sterile dressing
changes every day.
Slide 92
Procedures 18. Infusion again Remove the sterile injection cap,
sterile the needle hub hole, connect with infusion set, unclamp
lumen, then initiate IV infusion. 19. Withdraw the catheter The
lumen of the catheter connect with a syringe, withdraw the catheter
while pump the syringe, press the insertion site for several
minutes. Sterile the local skin with 75% ethanol solution, and
cover it with sterile dressing.
Slide 93
Cautions 1. Follow the principles of asepsis and check system
strictly to prevent infection and mistakes. 2. Select the insertion
site carefully. 3. Intensify evaluation during infusion. Flush the
catheter with dilute heparin ( 100 U/ml ) if return blood appears
in the catheter to prevent occlusion.
Slide 94
Cautions 4. Seal the catheter with positive pressure after
infusion to prevent occlusion of the catheter. Clot appears in the
catheter should be sucked use a syringe to avoid to be pushed into
blood circulation. 5. To stabilize and protect catheter site to
prevent contamination or dislodgement. Observe the injection site
carefully in order to find the complications and settle them on
time.