Post on 06-Dec-2015
description
Previous Next
Intravenous Fluid and
Blood Transfusion
Bryan Romulus T. Savellano RN MANFaculty/Clinical Instructor
Our Lady of Fatima University - Antipolo
Previous NextPrevious Next
Basic Intravenous Therapy90-95% of patients 90-95% of patients
in the in the
hospital receive hospital receive some type some type
of intravenous of intravenous therapy.therapy.
Previous Next
INTRAVENOUS THERAPY• It is the infusion of fluid into vein.•The therapeutic goal is
maintenance, replacement, treatment, diagnosing, and palliation
(Supportive treatment which relieves but not cure disease e.g. DM )
Previous Next
Purposes of IV Therapy
• To provide parenteral nutrition• To provide avenue for dialysis• To transfuse blood products• To provide avenue for diagnostic testing• To administer fluids and medications with
the ability to rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.
Previous Next
IV Administration
• Administer into circulatory system• Large volume infusions: 250mL to 1000 mL• Bolus injection: IV push• Volume-controlled infusions: 50 mL to 250
mL– Piggyback– Volume-control set– Mini-infusion pump
Previous Next
ISOTONIC
–Used to expand blood volume•Normal saline or 0.9% NaCl
•Lactated Ringers
Previous Next
• Isotonic solutions have an osmotic pressure equal to that of the cells of the body.
Previous Next
HYPOTONIC Solution• Has lower concentration than the body
fluids.• These are fluids that have a lower osmotic
pressure than the cell. It causes body fluids to shift out of the blood vessels & into the cells & interstitial space.
• They are administered for cellular hydration e.g ½ NS, 0.45% NaCl, 0.3% NaCl.
Previous Next
•Hypotonic solutions have a lower osmotic pressure than that of the body cells
Previous Next
HYPERTONIC Solution
• Has higher concentration than body fluids . Examples are: D10W, D50W,D5LR, D5NM
• Have a greater concentration of solutes than plasma
Previous Next
Hypertonic Solutions has an osmolarity higher than that of serum.
It draws fluid into the intravascular compartment from the cells and interstitial compartment
Previous Next
Overview: IV Insertion
• Use needle with catheter sheath– 20-22 gauge typical for adult– If blood transfusion anticipated , use
18 or 20 gauge• Most IV solution sets deliver 15 drops
per mL, or 60 drops per mL(microdrop)• IV solution should be clear; cloudy
solutions may indicate contamination
Previous Next
IV sites• Peripheral
– Metacarpal: top of the hand– Basilic & Cephalic typically used on
forearm– Consider type of solution to be infused
• Central– IVs inserted into subclavian or jugular
vein
Previous Next
Factors to consider•For I.V therapy that is to
continue for several days, start with the most distal location available and move up as necessary.
•For an obese patient the hand veins may be the only accessible site.
Previous Next
Precautions for IV Sites
•Avoid–Bony prominences–Legs & feet–Mastectomy arm–Operative arm– Injured arm
Previous Next
Technique cont.• Sites to avoid:• Veins below previous I.V. infiltration or
phlebetic sites.- Sclerosed or thrombosed veins.- Areas of skin inflammation, bruising or breakdown.
• An arm affected lymphedema, node dissection after mastectomy, thrombosis, cellulitis or infection.
• Arm with an arteriovenous shunt or fistula.
Previous Next
Cannulation Devices
• http://www.qub.ac.uk/cskills/iv_cannulation/different sizes.jpg
Previous Next
Documentation IV Start
• Number of attempts• Type of fluid• Insertion site• Type and size of catheter or needle• Flow rate• Response to IV• Record response to IV fluid, amount
infused integrity and patency of system every 1-2 hours
Previous Next
Equipments:– Safety catheter needle– Tourniquet– Povidone-iodine swabs– Alcohol swabs– Gloves– Towel– Transparent dressing– Tape– IV tubing & solution bag– IV pole
Previous Next
Previous Next
IV Flow Rate• Nurse responsible for flow rate
maintenance– Can result in fluid overload
leading to cardiovascular, renal or neurological impairment
• Controlled by roller clamp, controller device or IV pump, & affected by client position
• Controller device & roller clamp work with gravity (must be 36 inches above site)
Previous Next
Macrodrops and Microdrops
Previous Next
Prevention of IV site infection
– Wash Hands– Use sterile technique– Change IV solution q 24
hrs– Change IV site every 48 to
72 hours– Change IV tubing every 48
hours– Use gloves & sharps
containers– Check agency policy
Previous Next
Client Education• Teach
– S&S of infection or problems
– When to call for help– How to prevent IV
from clotting or being pulled out
– Arm positioning– Walking with IV pole
Previous Next
IV Site Complications
• Assess IV site for: – Infection: redness, warmth,
swelling & pain; possible fever, & site discharge
– Infiltration: redness, edema at the site, burning pain, coldness, fluid will not flow by gravity
– Blood backflow does not always mean IV not infiltrated
Previous Next
Other IV Complications
• Allergic reaction• Circulatory overload• Air embolism• Infiltration/
Extravasation• The most common cause is damage to the wall during insertion or
angle of placement
Previous Next
•Hematoma•Thrombophlebitis•Venespasm•Occlusion•Infection•Embolism
Previous Next
IV CALCULATIONS
REGULATING YOUR IV FLOW RATE
CALCULATIONS OF INFUSION RATES
GENERAL FORMULA:
Total VolumeTotal Hours
x gtt / ml Calibration 60 Minute / Hour
= gtt / minute
Looking for gtts/min
For ADULT (MACRO)
Total Amount of Fluids in ml X Drop Factor (15 gtts/ml) = gtts/min
Total Hours to be regulated in hr 60 mins/hr
For PEDIA (MICRO)
Total Amount of Fluids in ml X Drop Factor (60 ugtts/ml) = gtts/min
Total Hours to be regulated in hr 60 mins/hr
INTRAVENOUS FLOW RATE
EXAMPLE : To give 50 ml of antibiotic solution IV in 30 minutes, what should the infusion rate be in drops per minute? The infusion is calibrated for 60gtt/ml.
You know:1. gtt/ml calibration = 60 ugtt/ml2. Total ml to be administered = 50ml3. Total hours of infusion = 0.5H
To solve:Substitute in the formula:
X 60gtt/ml 60min/hour
50ml0.5hour
= 100gtt/min
Previous NextPrevious Next
Blood transfusi
on
Previous Next
BLOOD TRANSFUSION The introduction of whole blood or components
of the blood (plasma, serum, erythrocytes or platelets) into the venous circulation
ABO BLOOD GROUP SYSTEM Blood Types Antigen Antibodies
Type A (41%) A Anti-B Type B (10%) B Anti-A Type AB (4% ) A, B none (universal
recipient) Type O (45%) none Anti-A, Anti-B
(universal donor)
Previous Next
Hematologic systemWBC (Leukocytes)WBC (Leukocytes)
NeutrophilNeutrophil
MonocytesMonocytes
EosinophilsEosinophils
BasophilsBasophils
Previous Next
LymphocytesLymphocytes
T LymphocytesT Lymphocytes
B LymphocytesB Lymphocytes
RBCRBC
PlateletPlatelet
Previous Next
Blood transfusion• To increase O2 carrying capacity of
blood as in anemia• To replace circulating blood volume
or as volume expansion for cases of hemorrhage
• Provision of protein• Provision of coagulation factors• To prevent bleeding if there’s
platelet deficiency• To combat infection if there’s
decrease WBC
Previous Next
Nursing Mgt & principles in Blood Transfusion
•Proper refrigeration •Proper typing & cross
matching –Type O – universal donor–AB – universal recipient–85% of people is RH (+)
Previous Next
Materials needed:1. IV tray2. Compatible BT set3. IV catheter/needle g 18/194. Plaster5. Tourniquet6. Blood product7. Plain NSS8. IV stand9. Gloves
Previous Next
1. Aseptically assemble all materials needed:– Filter set– Isotonic or PNSS or .9NaCl to prevent
Hemolysis– Hypotonic sol – swell or burst– Hypertonic sol – will shrink or crenate– Needle gauge 18 - 19 or large bore
needle to prevent hemolysis.
Previous Next
2. Instruct another RN to recheck the following –Pts name–blood typing & cross typing
–expiration date–serial number
Previous Next
3. Check blood unit for presence of bubbles, cloudiness, dark in color & sediments – indicates bacterial contamination.
Previous Next
4. Never warm blood products – may destroy vital factors in blood.– Warming is done if with
warming device – only in EMERGENCY! For multiple BT.
– Let blood still within 30 minutes under room temp only!
Previous Next
5. Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for more than 2 hours can start to deteriorate.
6. Avoid mixing or administering drug at BT line – leads to hemolysis
Previous Next
7. Regulate BT 10 – 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
8. Monitor VS before, during & after BT especially q15 mins for 1st hour. – q5min for 1st 15min.– Majority of BT reaction occurs within
1h.
Previous Next
8. Maintain the transfusion rate FWB PRBC FFP, Platelets – fast drip9. Monitor adverse reaction10. Document the following a. blood component and number b. infusion started and ended c. client reaction
Previous Next
BLOOD TRANSFUSION REACTIONSH – hemolytic ReactionA – allergic ReactionP – pyrogenic ReactionC – circulatory overloadA – air embolismT - thrombocytopeniaC – citrate intoxication – expired blood-hyperKH- hyperkalemia
Previous Next
HEMOLYTIC REACTIONdonor blood is incompatible
with the recipient’s blood - most fatal, may present
chills, diaphoresis and back pains
Previous Next
• NURSING MANAGEMENT– Stop BT– Notify Doc– Flush with plain NSS– Administer isotonic fluid sol – to
prevent shock– Send blood unit to blood bank for
reexamination– Obtain urine & blood samples of pt &
send to lab for reexamination– Monitor VS & Allergic Rxn
Previous Next
Allergic reactions• rashes and itchiness, dyspnea,
bronchospasm due to sensitivity in foreign proteins in plasma
• SIGNS AND SYMPTOMS– Fever/ chills– Urticaria/ pruritus– Dyspnea– Laryngospasm/ bronchospasm– Bronchial wheezing
Previous Next
ALLERGIC REACTION • NURSING MANAGEMENT• Stop BT• Notify Doc• Flush with PNSS• Administer antihistamine –
diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
Previous Next
• If (+) Hypotension – anaphylactic shock administer – epinephrine
• Send blood unit to blood bank• Obtain urine & blood samples – send to lab • Monitor VS & IO• Adm. Antihistamine as ordered for Allergic
Rxn, if (+) to hypotension – indicates anaphylactic shock
• administer epinephrine• Adm antipyretic & antibiotic for pyrogenic Rxn
& TSB
Previous Next
Pyrogenic Reaction
• fever and chills due to sensitivity to leukocyte or platelet antigen – most common
• SIGNS AND SYMPTOMS– Fever/ chills– tachycardia– Headache– palpitations– Dyspnea
Previous Next
•Nsg Mgt:– Stop BT– Notify Doc– Flush with PNSS– Administer antipyretics, antibiotics– Send blood unit to blood bank– Obtain urine & blood samples – send to lab – Monitor VS & IO– Tepid sponge bath – offer hypothermic blanket
Previous Next
Circulatory Overload:• SIGNS AND SYMPTOMS• Dyspnea• Orthopnea• Exertional discomfort
• NURSING MANAGEMENT• Stop BT• Notify Doc. Don’t flush due pt has circulatory
overload.• Administer diuretics
Previous Next
Priority cases1ST- Hemolytic reaction- due to
hypotension- attend to destruction of Hgb – O2 brain damage
2ND- Circulatory Overload3RD- Allergic Reaction4TH- Pyrogenic
Previous Next
PUTLA MO.ANEMIC KA NOH?!
IKAW NANGI-NGITIM KA NA! CYANOTIC KA!INTUBATE KITA!
04/18/23 06:04Hans Christian Fabrigas Vitug65
Characteristics of normal stool
Yellow or golden brown d/t bile pigment derivative known as STERCOBILIN or FECAL UROBILINOGEN
Aromatic upon defecation d/t INDOLE and SCATOLE which are products of fermentation and putrefaction in the large intestines
Soft and formedCylindrical1-2 times a day to 1 every 2-3 days
04/18/23 06:04Hans Christian Fabrigas Vitug68
Problems in Fecal Elimination Pattern
Constipationfluid intake 1,500-2,000 mlsHigh fiber dietPattern for defecationResponse immediately to the urge to defecate
Minimize stressLaxatives
04/18/23 06:04Hans Christian Fabrigas Vitug69
Problems in Fecal Elimination Pattern
Fecal ImpactionP-assage of liquid fecal seepageA-absence of bowel movement for 3 to 5
daysS-ubjective feeling of abdominal fullness
or bloatingA-norexia and body malaiseH-ardened fecal mass is palpatedN-ausea and vomiting
04/18/23 06:04Hans Christian Fabrigas Vitug70
Problems in Fecal Elimination Pattern
Fecal ImpactionM-anual extraction I-ncrease fluidsS-ufficient bulk in dietA-dequate activity and exercise
04/18/23 06:04Hans Christian Fabrigas Vitug71
Problems in Fecal Elimination Pattern
DiarrheaB-ananaR-iceA-ppleT-oast
04/18/23 06:04Hans Christian Fabrigas Vitug72
Problems in Fecal Elimination Pattern
Anti diarrheals A-D-AA-bsorbentsD-emulcentsA-stringents
04/18/23 06:04Hans Christian Fabrigas Vitug73
Administering enemas:
Purpose: to relieve constipation, to relieve constipation, administer meds, to evacuate feces
Types:
cleansing enema
carminative enema
retention enema
return flow enema
non retention
retention enema 04/18/23 06:04Hans Christian Fabrigas Vitug74
H-H-I-S-OIsotonic 500-1000 ml of saline
15 to 20 mins
Soapsuds 500-1000 ml with 3-5 ml of soap
10 to 15 mins
Oil 90 to 120 ml
Lubricates the feces and the colonic mucosa
½-3 hours 04/18/23 06:04Hans Christian Fabrigas Vitug77
04/18/23 06:04Hans Christian Fabrigas Vitug78
Cleansing enema
stimulates peristalsis by irrigating the colon and rectum or by distending the intestine with volume of fluid introduced.
04/18/23 06:04Hans Christian Fabrigas Vitug79
High Enemato clean as much of the colon as possible. 1000 ml of solution is introducedLow enemaclean the rectum and sigmiod colon, 500 ml of solution is introduced
04/18/23 06:04Hans Christian Fabrigas Vitug80
Carminative enema
relieve of flatuence, 60-180 ml of fluid
04/18/23 06:04
Retention Enemaoil 90-120 ml12” above the rectumtemp 105-110 Ftime of retention 1-3 H until desired effect is obtained
04/18/23 06:0482
Non retentiontap water 500-1000
soap sud (20ml of castile soap in 500-1000ml/ normal saline
9ml of NACL to 1000ml water
hyperrtonic soln/ fleet enema
04/18/23 06:04Hans Christian Fabrigas Vitug
Non retention18 inches
115-125F, time of retention
5-10 mins
NURSING CONSIDERATION IN ENEMA ADMINISTRATION
Check doctors order
Provide privacy
Promote relaxation
Position the client
Choose appropriate size of tubeADULT FR 22-23
CHILDREN FR 14-18
INFANT- FR 12
04/18/23 06:04Hans Christian Fabrigas Vitug84
NURSING CONSIDERATION IN ENEMA ADMINISTRATION
LUBRICATE 5cm or 2 inches of rectal tube
Allow to flow, to prime
Insert 3-4 inches in rotating motion
Introduce slowly to prevent sudden stimulation of peristalsis
Abdominal cramps- stop temporarily by clamping, until peristalsis relaxes
04/18/23 06:04Hans Christian Fabrigas Vitug85
NURSING CONSIDERATION IN ENEMA ADMINISTRATION
After induction, press buttocks together to inhibit urge to defecate
Ask client to either able to use toilet (instruct not to flush), otherwise offer bed pan
Repeat until bowel is clearDocument
04/18/23 06:04Hans Christian Fabrigas Vitug86