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Test 1- WALDEN

1. PURPOSE- To access the venous circulation in order to draw blood for laboratory screens
and diagnostic tests or to administer fluids, electrolytes, medications, blood, blood
products ,and nutritional supplements.

Indicated for situations when oral or other parenteral routes are not

Continuous IV administration

Intermittent IV is used primarily for IV medication administration

Bolus increase in medication immediately

IV medications bypass the enzymatic process of the liver

Nursing Responsibilities

Knowing IV sets and their functions

Calculating IV drip rates

Mixing and diluting medications in IV fluids

Knowing the medications, purposes, and side effects

Nursing Responsibilities continued

Assessment of the client, site, infiltration, rates, adverse reactions, therapeutic actions

IV route is the fastest onset of medication administration, however, once injected, the medication
can not be retrieved

IV route could provide a direct route for contamination with pathogens

Closely monitor the client for adverse reactions

IV Considerations

Is fluid loss severe or life-threatening?

What is missing?

What is current health status? Co- morbidities: cardiac, renal, liver, pulmonary, I & O
Daily weight – fluids calculated on changes in current weight

*Two kilograms of weight gain is equivalent to 2 liters of fluid gain

5 pounds = 2.5 liters fluid

Restoring fluids by IV

Why: fluid/ blood loss, precautionary

Large IV ideal but…. Difficult to find a vein

Small bore initially- large (18-20GA) once fluids reestablished

IV pump to regulate infusion and decrease risk of too rapid an infusion

Monitor sites, solution, and outcomes frequently

Restoring fluid risks

Renal, cardiac, pulmonary overload

Overflow diuresis without cellular replacement

Hypernatremia with diuresis

Dilution of electrolytes

1. Goal: Correct or prevent fluid & electrolyte disturbances
Allows for direct access to the vascular system, permitting the infusion of
continuous fluids over a period of time
Must be continuously regulated because of continuous changes in the client’s fluid
& electrolyte balance.

2. Types of IV catheters:
Peripheral Venous Catheters
Central venous catheters (central lines)
Peripherally inserted central venous catheters (PICC lines)
Central hemodialysis catheters

A. Peripheral Catheters:
-Common type- over the needle catheter
Color coded
Tip should be radiopaque
-Less common- through the needle catheter
Potter page 446- 447

Read regarding flow rate, sites, large gtt

Flow factor and micro drip factor for slow IV infusions as PEDs.

EID (Electronic infusion device)

Gather supplies

Assess patient for safe site

Common sites in adult veins in hands and arms

See & Know figure 15 – 5 pg446 PP Basic.


Sites to avoid

Areas of inflammation



Mastectomy sides

IV grafts sites

Avoid adult foot

Use most distal when possible, allowing proximal sites for subsequent venipuncture

Elderly Perry Potter Basic 447 box 15 – 3

Use of tourniquet

Site to avoid

Gauge to use

Insertion angle

Flow rate for IV medication

Skin barrier recommendation

Use of netting to secure

Avoid restraints precaution

Mental status assessment


Gauge and Fluid Rate

24 gauge (yellow) = 15-25ml/min

22 gauge (blue) = 26-36 ml/min

20 gauge (pink) = 50-65 ml/min (maintenance rate)

18 gauge (green) = 85-105 ml/min

(when large bolus rapid infusion needed)


22 – 24 gauge

Tourniquet may not be necessary

Position hand dependent

No slapping see box 15- 3 page 447 Techniques.

Remember geriatric care.

Central venous catheters

“central lines”

Multilumen or single lumen non-tunneled

Lumens (“pigtail”) different length and color (1,3,4)

MD or NP to insert

Sutured to skin

Longer term catheters as compared to peripheral

Non-tunneled catheter

Sterile dressing changes by RN / LPN q 3-7 days or PRN

Maintenance (flushing Q shift)- RN

Central lines cont.


Blood sampling

CVP monitoring

Continuous/ intermittent drug infusions

Diagnostic testing

Simultaneous infusion of several medications

Viscous or high-volume fluids / blood

TPN (total parenteral nutrition)

PICC IV access (alternate access)

Peripherally inserted central catheters (arm)

Longer catheter, terminates at subclavian vein

Longer term than peripheral IV caths (7days to 3 months)

Must be specially trained RN

Sterile technique

Function and maintenance is same




The PICC affords a greater hemodilution which decreases the risk of phlebitis and infiltration so
stays in longer.


May be used to infuse hyper – osmolor fluids as TPN, Blood, chemical irritants and vesicants.

Central hemodialysis catheters

Subclavian, jugular, or femoral catheter

Temporary vascular access

Two ports - blue and red

Used for acute hemodialysis

MD to insert

Sutured to skin

Special training to access

Accountability and Infusion Therapy

The RN is accountable for knowing

What is ordered

Why it is intended

Impact on the patient

Any possible side effects

How to administer the infusion

How to maintain the infusion

How to discontinue properly

How to document appropriately

RN Responsibilities

“The RN remains accountable and responsible for all delegated tasks and must have a clear
knowledge of the nursing scope of practice relative to assessment, planning, implementation, and
evaluation of infusion therapy, as well as legal responsibilities associated with delegation of
nursing care activities.” (INS, 2000)

RN’s Responsibilities

Delegate certain nursing tasks to licensed and unlicensed personnel

Still responsible for tasks delegated

Must evaluate others competency, instruct them, and verify proper training
Responsibilities may vary among states and employers


Nurse is responsible to verify compatibility of fluids with medication administered via IV

Or if a Medication is in the IV fluid and a drug is given intermittently

Nurse must make certain fluids and drugs are compatible.

IV Therapy
RN vs. LPN

“…..responsibilities include administering medications and treatments prescribed by a licensed

or otherwise legally authorized physician.”

“…..responsibilities include administering medications and treatments, under the direction of a

licensed registered nurse or a licensed or otherwise legally authorized physician.”

No IV medications

Nurse responsible to

Observe clinet

Report any reactions

Take measures necessary to avoid complications

Assess IV site on adult every 2 hours

Pediatric and High alert medication more often)

Check point

A client has a continuously running peripheral infusion.

The physician orders a piggyback antibiotic infusion 4 times a day. In order to administer the
antibiotic, the nurse should do which of the following:


1 start a new IV access for the piggyback antibiotic so no compatibility issues occur

2. start a new IV site to prevent fluid volume overload

3. Increase the IV fluid rate to dilute the antibiotic infusing piggyback

4. Check to see if the antibiotic is compatible with the soluitions infusing.


RBCs in isotonic solution



Adding medications to bag- labeling

Spiking bag, filling drip chamber

Priming (bleeding) line

Accessing ports on line

Running piggyback (secondary) with primary line

Fluid compatibility

Connecting tubing and priming lines

Open transfusion set

Insert IV tubing spike into opening of bag of fluids

Remember to keep ends sterile!!

Compress drip chamber to 1/3 full

Prime by opening roller clamp- all air bubble should be removed- then close roller clamp

Tap to remove small air bubbles

All lines must be primed including PRN loops

Flushing a saline lovk

Use approximately 1 ½ times the amount of fluid that the tubing will hold in order to flush the

USE sterile (aseptic ) technique to prevent complications as infection.

Intermittent IV Therapy
IV Therapy that is ordered frequently for short periods of time.


Rocephin 1gm IVPB Q 12 hours x 6 doses.

Demerol 25mg IVP Q 4-6 hours PRN pain.

IV push (IVP) or IV piggyback (IVPB, secondary)

Requires tubing and site change q 48-72 hours

Frequent site monitoring

Fluid infused recorded on chart q shift

IVP (IV push medications)

Check order

Prepare medications and check compatibility with fluids

Assess site

Select port proximal to patient

Clean port with alcohol swab

Flush with 10ml of NS before medication

Insert/attach medication syringe

Occlude IV tubing above port (pinch)

Pull back gently to aspirate blood return (may not get)

Inject medication in designated time frame (look up in drug book)

Release tubing if fluids running - if saline lock, flush with 10ml of NS and lock

Small volume needs to hang higher


Draw up correct dose into a 10mL syringe.

Verify dose with second nurse

Then add additional saline to syringe to equal 10 mL


Lets think

1 mL/ over 1 minute

Let’s see that is ¼ mL/ in 15 seconds

So every 15 second interval push ¼ of a mL. This way we are more controlled and more precise
with a push over one minute.

How long will it take to give

2 mL over one minute?

1 mL over two minutes.

OK: Tell me how would you divide this to deliver the push in a controlled slow process????

Continuous IV Therapy

IV therapy that continues over a long period of time.

EX: D51/2 NS @ 75ml/hr

Requires frequent site monitoring

Fluid infused documentation (q 8 hours)

IV Tubing change q 72 hours

Site change q 48-72 hours

* Tubing and site change may vary depending on agency policy.


“KVO” or “TKO” = flow at rate to Keep Vein Open or To Keep Open

Often will see this order:

IV NS @ KVO rate

IV RL TKO rate

What do you do? There is no established minimal flow for KVO/TKO

*****Clarify MD’s order*****

May be anywhere from 30-100ml/hr but this must be specified by MD.


Introducing a concentrated dose directly into systemic circulation quickly

Into tubing port or saline lock

Rate of administration (bolus) varies from drug to drug

May be fluids or medications

Rate for fluids should be included in MD’s order

IV solutions 101

Two basic categories:

First category:

Crystalloids: contain water, dextrose, and or electrolytes

Used to treat fluid and electrolyte imbalances

IV solutions

Second basic categories:

Colloids: referred to as:

plasma expanders or volume expanders

Increased osmotic pressure in comparison with crystalloids

Colloids remain in vascular space longer and are used for volume expansion

Volume expanders

Include: Colloids, dextran, and hetastarch.

Colloids are protein solutions as albumin, plasma, and Plasmanate ( prepared by pharmaceutical

Volume Expanders

Albumin is the most abundant plasma protein in humans

USES: Albumin 5% rapid volume expansion and mobilize interstitial edema


Volume Expansion

Others are Dextran, synthetic colloid made of glucose-

Mobilizes interstitial edema

Hetastarch (Hespan) Made from corn.

Mobilizes interstitial edema

Volume expanders

Plasma plasmanate (Plasma protein fraction

Contains human plasma proteins in Normal Saline (NS).

Increases serum colloid osmotic pressure

Types of intravenous solutions


Normal Saline (NS) & Ringers Lactate(RL)

Dextrose in water (D5W)


0.45% Normal Saline

0.33% Saline

2.5% Dextrose


Total Parenteral Nutrition (TPN)

Dextrose in Normal Saline (D5NS)

Dextrose in .45 Normal Saline (D5 ½ NS)

Isotonic “Same as blood”

Isotonic Solutions
Liver converts lactate to bicarbonate- watch pH, liver function

Has same osmolality as body fluids

Hydrates all cells without affecting movement of fluid- NO SHIFT

Expand IV compartment

Watch for overload

Used most commonly for ECF volume replacement

Isotonic solutions

Expand only ECF (IVC) no net loss or gain.

L/R contains Na KCl Cl Ca and Lactate

Same concentration as blood.


NaCl used to replace both fluid and sodium losses or

Vascular replacement in hypovolemic shock.



Hydrates cells

Can cause sudden shift

Cardiovascular collapse

Increased ICP

Not for treatment of head injury, trauma, neurosurgery, burns


Hypotonic fluid pushes fluid into cell

Contains more water than electrolytes

So, are there concerns with HYPOTONIC Solutions?

Push fluid into cells : Why might we see mental status change?

Why is D5 W isotonic in the bag

AND HYPOTONIC in the vein

Glucose enters the vascular compartment

Is then rapidly metabolized by the LIVER thus

Leaves water in vascular compartment.



Dehydrates cells and interstitial compartments

Watch for venous overload

Not for patients with kidney failure, heart disease

Hypertonic soulutions

Expand ECF (IVC) (Draws fluid into vein)

Used to treat:


(low volume)

Hypo natremia

(low sodium)

D 50 W

Very hypertonic.

Push slowly

Let’s recall Assessment

How do we watch for FVO (Fluid volume overload)?

Lung sounds

Serum Sodium Level



What else??

Other hypertonic solutions

D 10 W or greater

Central lines should be used. To avoid shrinkage of RBCs.

IV SALINE solutions

NS (0.9 % Na CL)


3% NaCl

5% NaCl

Contains sodium and chloride in water



Fluid loss

Sodium depletion

Dextrose (dextrose in water)


D10 W


Replace calories as carbohydrates

Prevent dehydration
Maintain water balance

Promote sodium diuresis

Dextrose in Saline


D51/2 NS

D10 NS

Promotes diuresis

Correct moderate fluid loss

Prevent alkalosis

Provides calories and sodium chloride


Lactated Ringers

Ringers Lactate

Contains Na, Cl, K, Ca, and lactate

Replaces fluid lost in vomiting, or GI suction,

Treat dehydration

Restore normal fluid balance

IV Additives

Vitamins & KCL are frequently added to IV Solutions

Verify adequate urine output before administering KCL

K*Under no circumstances can potassium chloride (KCL) be given IV push. A direct IV infusion
of KCL is fatal.

So Ms Verhoff if KCL is an electrolyte in the body

Why verify KCL doses?

Why are there no KCL push?

Why is an EID used for concentrated bolus administered.

What is a concentrated bolus.


Nutritional adequate hypertonic solution consisting of glucose and other nutrients and
electrolytes given through an indwelling peripheral or central line

Used as intervention in severe cases of malnutrition.

TPN ??????

Why should we monitor Glucose every 6 hours?

Why should we not allow the solution container of TPN run out?

Why should we closely monitor T P R and B/P? WBC? Infusion site? Why is asepsis so vital?


Demonstration in lab

Equipment and Supplies

IV catheter (24GA, 22GA, 20GA, 18GA, 16GA)

IV start kit (drape, cleaning and antiseptic preps, dressings, tape, label, tourniquet, transparent


Tubing if fluids ordered, fluids ordered

Injection cap (PRN adapter) or IV loop (pigtail)

Sharps container


Volume regulator

Purpose and Selection of IV supplies

IV Catheter


Conventional or safety
Fluids vs. PRN lock (saline or heparin)

Tubing and extension

Medication/ Blood administration

Pumps, dial-a-flow, volume control device (gravity)


Allergy to iodine, latex, or tape

Arm board

Transparent dressing/ tape

Practice correctly

Assessment for initiating IV therapy

Assemble correct supplies

Review MD’s order

5 rights

Assess for clinical factors/ conditions

Assess previous experience/ expectations

Consider future treatments

Allergies/ lab data (betadine tape)

Planning for initiating IV therapy (goals)

F & E Balance and VS will return to normal

IV line will be patent

Site will be benign

Client will understand purpose

IV site selection

Age and status of patient

Purpose of the infusion

Duration of therapy

Condition of patient’s veins

Location of previous site(s)

Most common in lower arm and hand. If possible use the non-dominant hand/arm

Hand and arm

IV site location

Most distal in nondominiant arm

Clip hair – do not shave

Avoid bruises, scars

Large vein

Consider activity

Medical history

Children, adults

Other options as above

Implementation of IV therapy

Comfortable position, change gown

Wash hands

Open sterile packages using sterile aseptic technique

Prepare IV solution, open infusion set, spike bag, and prime line, cap, or pigtail

Place roller clamp in “off” position

Identify accessible vein and apply tourniquet (4-6 “ above proposed site)

Apply gloves

Prep site and allow to dry

Methods to distend veins

Place hand dependent

Use distal vein to proximal

Warm compress

Check arterial pulse to ensure adequate blood flow to fill veins

When prep wipe according to policy:

(P/P say distal to proximal)


Do not blot– this removes antimicrobial properties

SO how do we know how fast to regulate the flow rate??

Count drops 15 seconds x 4 = gtts / minute

Regulate flow rate

Adjust rate as prescribed by health care provider

Too slow = vein clots /occlude line or client goes into circulatory /CV collapse

Too fast = Fluid volume excess (FVE)

Calculate rates on paper.


9. Perform venipuncture at 20-30 degree angle.

Look for blood return “flash” in the chamber. Lower the needle and advance ¼”

Stabilize cath and release tourniquet, apply firm pressure with index finger 1 ¼” above insertion

Remove needle- do not recap

Connect tubing or PRN adaptor and flush

Secure IV catheter

Discard supplies

Label IV site- initials, date, time, size of catheter

Patient teaching
Document procedure

Patient Teaching

When to call the nurse

Redness, pain, blood, dressing loose

Flow stops, blood in tubing

IV pump alarm

Ambulate with IV pole, movement

Ask for assistance when needed.


# of attempts (If several may chart “multiple attempts”)

Type of fluid and flow rate

Insertion site (Location)

Size (GA) of catheter

When infusion begun

Remember if it is not documented- IT DID NOT HAPPEN


22GA IV catheter

2 attempts

L wrist

D5 ½ NS at 100/hr

Blood drawn

“1500 22GA IV to L wrist x 2 attempts, blood drawn and sent to lab, D5 ½ NS @100 ml/hr per
pump. Site clear, no redness or edema. -------------------------------------------------N Nurse RN


Anytime you do anything with a patient’s IV (hang fluids, give medications), always check the IV
site. If the IV is not functional, then you are doing nothing for the patient. OR you may be
damaging tissue!!!!!

IV Management

Observe site every 1-2 hours, document Q 4H and PRN

Look at amount infused

Count drip rate, pump function

Check patency

Check insertion site

Observe client every hour and PRN to determine response to therapy




IV Management cont.

Change site Q 48-72 hours or PRN

Must move proximal to previous site.nge IV tubing Q 72 hours or PRN

Dressing changes Q 48-72 hours or PRN

Wet, soiled, loosened, removed

Flush with 10 ml NS before and after meds

Check sites frequently.


Complications of IV therapy




Pulmonary embolus

Air embolus
Circulatory overload

Phlebitis (thrombophlebitis)

Definition: Inflammation of a vein, often accompanied by formation of a clot

S & SX: Indicated by pain, increased skin temp, erythema along path of vein (cord along vein)

Clots may occur

TX: Stop infusion and discontinue IV

Elevate extremity, warm moist compresses

Restart new IV if IV therapy is needed

Rotate sites Q 48-72H

Causes: Drug irritation, trauma to vein, infection, stasis, immobilization, IV catheter in place too


Definition: process in which a fluid passes through the tissues

S & SX: Indicated by swelling and possible pitting edema, pallor, coolness, pain at insertion site,
possible decrease or absent flow rate

TX: Stop infusion and discontinue IV.

Restart IV in new location if IV therapy indicated

Warm compresses and elevation of extremity

Causes: IV catheter not in vein, in surrounding tissue



DO not elevate arms

DO not apply cold or warm compress

Notify health care provider and follow instructions.


Definition: collection of blood in tissue or skin due to trauma, aka: bruise

S & SX: discoloration, pain, localized edema to site

Usually self limiting

TX: Initially moderate pressure may reduce amount of bruising

Causes: trauma or incomplete hemostasis after surgery


Can occur around venipuncture site and under skin

Common in clients on heparin, ASA

Apply pressure dressing to site and document

ELEVATE ^ arm site above heart and apply pressure.

Pulmonary embolism

Occlusion of the portion of the pulmonary blood vessels by a clot that is carried from the point of
origin. (somewhere else)

May be lethal

S & SX: appear late, tachypnea, dyspnea, anxiety, fretfulness, and CP. Possibly hypoxemia,
diaphoresis, syncope, crackles, fever, murmurs

NEVER FORCE Flush or Irrigate IV LINE

Pulmonary embolism

Sources: deep calf, tumors, air, fat, heart arrhymias, bone marrow, post-op major operations,
prolonged sitting

Blood flow is obstructed in the lung which leads to decreased profusion of the lung and decreased
cardiac output

TX: O2, anticoagulant therapy


Venous Air Embolism (VAE)

Definition: entry of air into venous circulation

Causes: Secondary to trauma, IV tubing not primed

Large amts of air in vascular system- leads to cardiac arrest

S & S: sudden dyspnea, tachycardia, heart murmur, hypotension, decreased LOC, CP,
circulatory shock, sudden death

TX: place in L lateral Trendelenburg position, 100% O2. THIS TOO IS AN EMERGENCY!!!

Circulatory Overload

Circulatory overload occurs when fluid is administered more rapidly than the circulatory system

S/S: cough, dyspnea, HTN, pulmonary edema, JVD, HA, crackles

Causes: Fluid overload, renal or liver failure

Interventions: slow IV to KVO rate, elevate HOB, O2, VS, notify MD, diuretics

Clients at increased risk:


Infants & Children

Presence of Disease (Cardiac, Renal, etc.)

Outcomes of IV therapy

Maintain or restore fluid balance

Maintain or replace electrolytes

Provide a source of calories/ nutrients

Administer drugs

Blood Transfusions

Why?- tx of anemia due to acute blood loss or chronic conditions

Risk: hemolytic transfusion reactions and possibility of contracting infectious diseases (Hep B,
HIV, CMV, EBV, West Nile virus)

MD must consider potential risks and alternative interventions

Written order: blood component, volume, rate of infusion

When a client is to receive blood, the nurse is largely responsible for its safe administration.


ABO- type of antigen components that RBC’s have.

Type A = A antigen

Type B = B antigen

Type AB = both

Type O = none

Rh- antigenic substance present in RBC’s

If have = Rh+

If do not have = Rh-

Autologous transfusion

Collect blood from client prior to expected surgical procedure, reinfuse client with blood in

Salvage blood in surgery and administer.

Autologous- donate own blood.

Blood Components

Whole Blood


Platelets (PLT’s)

Fresh Frozen Plasma (FFP)


Granulocyte Concentrations


Clotting Factors
Other volume expanders

Whole Blood

Used in exsanguinations(Bleeding) patient

Contains all blood products

Usually contains 400 ml +-

USED when both volume and cells are needed

Whole Blood

RBC, plasma, plasma proteins with 63 ml of anticoagulant.

500 ml/unit

ABO identical and Rh factor must match

Rarely indicated

Outcomes: prevention/ resolution of hypovolemic shock and anemia

Risk: volume overload


Red blood cells with anticoagulant-preservative (no clotting factors)

Unit size- 250 to 400ml/unit

ABO compatible, Rh factor match

Given frequently blood loss- surgery, trauma

80% plasma has been removed.

Outcomes: resolution of anemia


Given for acute and chronic anemia ,

Blood loss

Desired over whole blood in cardiovascular & renal compromised, and elderly clients because
PRBCs contain less fluid volume.
Platelets (PLT)

Platelets= Play a role in blood coagulation, hemostasis, and blood thrombus formation.

ABO and Rh factor compatibility recommended (contain few RBC)

Special filters for platelets

Outcomes: prevention/resolution of bleeding due to thrombocytopenia or PLT dysfunction


Usually given in pools of 6 – 10 units

USES: low platelet counts, coagulopathies; 1 unit may increase platelet count by 6000 units

Fresh Frozen Plasma (FFP)

Plasma= liquid part of blood. Medium for transporting substances. Colorless when free of cells.

Contains plasma globulin, antibodies, clotting factors.

ABO compatibility, Rh factor no match

Still has disease transmission risk

Outcomes: decreased coagulation times

Fresh frozen Plasma

Used to replace clotinf factors after multiple transfusions ( > 6 units of PRBCs);

Coumadin intoxication

Replaces clotting factors,


A patient presents to ER after being involved in a MVA, B/P is 70/50, HR 138, R. 44, the patient
has an opened chest wound and has lost a lot of blood. Pt’s Hgb is 6.0. The M.D. orders two units
of blood STAT. Which intervention would be appropriate at this time?

A.) type and cross match for blood

B.) give two units of type O blood stat

C.) draw blood, band pt with appropriate blood band an send to lab,

D.Start hypotonic fluids and continue to monitor pt.


Antihemophilliac factor VIII and factor XIII


Contains no RBC and a small volume of plasma

ABO compatibility not needed

Outcomes: correction of factor VIII, vWF, XIII and fibrinogen deficiency, cessation of bleeding


Components = clotting factors

USES: hemophilia, fibrinogen deficiency,


Plasma Derivatives

Albumin- albumin, globulin and other proteins

Antibodies destroyed during processing- compatibility not a factor

Rapid infusion may cause hypotension, but 25% albumin can cause a significantly increased
blood pressure because of its ability to draw fluid into the intravascular space

Cannot transmit hepatitis or HIV infection due to the pasteurization process used to prepare

Outcomes: maintain/ acquire adequate blood pressure and volume support

Clotting Factors

Large pools of plasma

Factors VIII and factor IX

ABO and Rh compatibility not important- RBC’s destroyed during processing

Outcomes: hemostasis due to increased factor activity.

Other volume expanders

Dextran and Hetastarch are synthetically prepared molecules.

Infrequently used due to cost

Outcome: promote circulatory volume and tissue perfusion by rapidly expanding plasma volume

Not a substitute for blood or its components

Volume expanders

Remain in vascular space and increase osmotic pressure

Plasma expander include dextran, hetastarch and plasma albumin



Albumin is available in 5 % and 25 %

5 % albumin expands vascular space mL for mL

25 % draws additional fluid from interstitium.



Obtain venous access

Validate Vital signs

Request blood release

Confirm blood acceptability

Infuse blood

Monitor during the transfusion

Watch for transfusion reaction

Vials must be labeled and a label on pt arm to match.


An informed consent MUST be obtained and documented prior to blood administration

Explanation to the client or family member of medical indications for homologous (homologous
vs. autologous) transfusion and its benefits, risks, and alternatives

Assess client history for any previous transfusions and client’s response

Need large bore IV (20 gauge or larger)

May use a 22 GA for adults with small veins or children- not best option

Can use a VAD (central line), but a large volume of refrigerated blood infused rapidly into the
ventricle can cause cardiac dysrhythmias

Warming the blood can reduce the risk of this complication


Rapid infusion with cold blood can cause dysrrhythmia

IF NECESSARY TO use small guage may need to ask lab to split unit into two bags. Smaller
needle can be used for platelets, albumin and clotting factors.

Blood Release

Before going to blood bank, several things must be done: prime blood tubing with NS only and
start NS at KVO, take VS, premedicate if ordered, “banding” the patient

Blood must be picked up from the blood bank by an RN

The name and identification number of the recipient must be provided and a permanent record
of this info maintained in blood bank

Blood bank is refridgerator

There is a book with lot numbers and patient identification data.


30 minute window

Blood must be started within thirty minutes of obtaining unit from lab

USE BLOOD TRANSFUSION TUBE with micro aggregate filter

D5W and LR can cause hemolysis USE NORMAL SALINE. Lewis 731.


Most crucial phase

Blood is first verified in the blood bank and RN by checking ABO and Rh compatibility. This is
done by checking the bag against the medical record and forms issued by blood bank
Second check is done at bedside by 2 RNs; compare name, number, ABO, Rh compat., blood

Check date

Inspect bag for leaks, clots, excessive air

The worst reactions to blood are usually due to misidentification of blood or client


Must use blood tubing with filter.

Empty to full


90% of hemolytic transfusion reactions are from improper patient to product identification


Blood transfusion IFs

Usually infuse blood PRBCs over 2 – 4 hours (4 hours if at risk for FVE)

IF blood not complete in 4 hours return unit to lab.

IF patient cannot tolerate volume, specify time frame and have lab split blood unit into two bags
in lab.

If, Rapid infusion, bllod may chill patient, consider blood warmer.

Religion and blood:

Right to refuse.


Blood tubing should be already hanging; usually a Y-type that contains a 170-mm filter designed
to trap fibrin clots, and other debris that accumulates during blood storage

Must administer within 30 minutes after receiving from blood bank

Change tubing every 4-6 hours or per policy, may transfuse 2 units with same tubing

Blood should be infused per pump

No other medications to be given in same tubing- EVER (Lewis pg 731)

Blood warmers may be used for rapid infusions to prevent hypothermia


First 10-15 min are the most critical

Stay with the patient during first 15 min or more

Initial flow rate 20-30 gtts/ min ( 50 mL)

If ABO incompatibility exists or a severe allergic reaction, anaphylaxis, occurs, it is usually w/in
first 50 ml; start transfusion slowly and closely monitor pt; then increase rate to prescribed rate.

Instruct client to report anything unusual- nausea, chills, burning sensations, HA


250 – 300 mL of PRBCs over 2 – 4 hours if over 2 hours then 125 mL hour, if over 4 then 63 mL

If 50 mL of blood to infuse in first 15 minutes houw man mL / minute should infuse??

2 mL x 15 minutes = 30 mL in 15 minutes 3 mL x 15 = 45 mL in 15.


Take and record VS before transfusion begins then every 5 min for first 15 min, then every hour
until 1 hour after transfusion

Rate varies: platelets, plasma, & cryoprecipitate can be infused rapidly

To avoid septicemia, infusion should not exceed 4 hours (infuse over 2 hours generally)

Detailed documentation


Acute or delayed systemic reaction to incompatible blood

Allergic- sensitivity to foreign plasma

Febrile-Sensitization to donor cells (WBC, PLT, PP)

Hemolytic- Infusion of ABO incompatible cells

Anaphylactic- Infusion of IgA proteins to IgA deficient patient

Other reactions

Infections from blood transfusion include reaction to




See Lewis 732 – 722

Page 475


While receiving a unit of packed red blood cells, the patient develops chills and a temperature of
102.2. The nurse should

A.) Notifies the physician and the blood bank

B.) Stops the transfusion and removes the IV catheter.

C.) Adds a leukocyte reduction filter to the blood administration set.

D.)Recognize this as a mild allergic transfusion reaction and slows the transfusion.

Reaction is suspected


Keep vein open with normal saline

Obtain vital signs

Notify MD and Lab

Infiltration Phlebitis

obtaining blood, be certain patent vein.

Start new IV site and remember blood goes in under 4 hour period, consider: “Is the needle
gauge large enough?”

What if??
What if the rate of infusion slows without signs of infiltration??

Suggest flush line with sterile normal saline.

What if?

Signs and symptoms of FVE as short of breath or crackles occurs???

Stop or slow the infusion

Elevate the HOB

Vital signs

Notify MD

Anticipate Diuretic/ Morphine sulfate


Allergic Transfusion Reaction see Techniques 968.

Frequency 1%

S & Sx: Urticaria, flushing, itching, (no fever)

Mgt: antihistamines, transfusion may continue

Prevention: treat prophylactically with antihistamines & acetaminophine

epinephrine, corticosteroids for severe reaction

Febrile Transfusion Reaction

Frequency: 0.5-1%

S & SX: fever and/or pulmonary symptoms, sudden chills and fever, HA, flushing, anxiety,
muscle pain

Mgt: If fever and/or pulmonary symptoms- DO NOT resume infusion, treat shock, give

Prevention: Consider leukocyte products which have been filtered, washed or frozen.)

Acute Hemolytic Transfusion Reaction

Frequency: 1:25,000

S & SX: chills, fever, <BP, flushing, tachycardia, tachypnea, hypotension, vascular collapse,
ARF, shock, cardiac arrest, DEATH

Mgt: Send blood and UA samples to lab for testing, maintain BP, Foley to measure output,
possible dialysis

Prevention: **Check and double check, then check again.** (MISS Labeled specimens)

So Mrs Verhoff, why do some people react to blood transfusions?

Antibodies in the recipients blood react to donor’s antigens on RBCs.

Causes cells to agglutinate which obstructs capillaries and blocks blood flow.

Hemoglobin is filtered by Kidney and is found in u/a. Hgb may obstruct renal tubules leads to
acute renal failure > DIC> Death.


Signs and symptoms of a hemolytic transfusion reaction include all of the following: choose all
that apply;

A.) chills, fever, flushing

B.) low back pain

C.) tachycardial, tachyphea, hypotension, vascular collaspe

D.) acute renal failure, shock, cardiac arrest, death

E. None of these are a hemolytic reaction

Critical Thinking

Ten minutes after a transfusion of PRBC’s begin infusing your formerly afebrile 26 year old
client has a temperature of 101.6 and feels tightness in the chest. What is the first thing you

Why is first voided urine collected to send to the lab?

First voided urine is collected and sent to lab to check for hemoglobinuria with hemolytic
reactions. Assess for damage to kidney.

Blood transfusion reaction intervention continue

Consider need for antihistamine

Vasopressors, fluids, steroids, CPR u/a specimen

What if????

If reaction is suspected, should nurse turn saline on and allow saline to flow through tubing?

Why hang saline with blood transfusion and not dextrose?

Answer: Dextrose cause coagulatio of donor blood.

Anaphylactic Transfusion Reaction

Frequency: 1:150,000

S & SX: anxiety, urticaria, wheezing, dyspnea

progressing to cyanosis, shock, cardiac arrest

Mgt: Stop transfusion, CPR if needed, have Epinephrine ready for injection

Prevention: Given blood from IgA deficient donors or plasma wash

DO NOT restart transfusion

Delayed transfusion reactions

Delayed hemolytic

Hepatitis B and C


Iron Overload

West Nile Virus

May occur weeks to months after the transfusion.

Blood Collection

Blood specimen collection

Most commonly used diagnostic aids in the care and evaluation of clients

Yield valuable information about nutritional, hematological, metabolic, immune and biochemical

Screen for early signs of disease, plot current treatment course, and monitor response to therapy

May be performed by RN, or other trained personnel

Types of blood collection

Venipuncture- inserting a hollow bore needle into the lumen of a large vein to obtain a specimen.

Vaccutainer tube- allows the drawing of multiple blood samples

Capillary puncture- least traumatic, uses sterile lancet to puncture a vascular area a finger, toe,
or heel

Types cont.

Arterial blood gas- diagnosis of respiratory disorder. Arterial puncture (radial or brachial)

Blood cultures- aid in detecting bacteria in the blood. Two cultures from two different sites.
Before antibiotic therapy is started


Usually from radial artery

Allen test

Do not let air enter syringe

Submerge syringe in cup of ice immediately before transport to lab

Apply pressure x 5 minute to site longer if on anticoagulant

Peak and Trough

Lab value drawn for specific drugs that measure therapeutic levels at the drugs “peak” time and
“trough” time.

Usually done with certain antibiotics

EX: Vancomycin

Blood collection supplies

Alcohol or antiseptic swab

Clean gloves

Sterile gauze pad (2 x 2)


Adhesive bandage or tape

Blood tubes

ID labels for tubes

Lab requisition

Plastic bag

20-25 GA butterfly

Sterile syringe

Vaccutainer tube

Sterile double ended needle 20-25GA

Anaerobic and aerobic culture bottles

Supplies depend on what blood tests are ordered

Consider- before you stick

Anticipate client’s anxiety

Assess for any possible risks

Is the patient able to cooperate?

Contraindicated sites?

Some specimens require special collection requirements- know facility policy

Which tube do I use?

Purple - blood cell counts (CBC)

Solid red - drug levels in blood

Speckled red - chemistry/ electrolyte levels

Blue - clotting times

Green - cardiac specific



Blood draw procedure

Gather supplies

Wash hands

Provide privacy, position patient

Apply tourniquet (1 min max)

Apply gloves

Determine best site- straight, prominent vein

Cleanse site and allow to dry

Pull skin taut, hold needle at 15-30 degree angle with bevel up

Procedure cont.

Slowly insert into vein- feel the “pop”

Withdraw blood while keeping needle stabilized

Release tourniquet when blood collected

Apply sterile pressure dressing

Dispose of supplies properly

The Blood draw and the IV line

If new IV, draw blood from hub before flushing

If it is an old IV line- TOO BAD

When drawing blood for lab, avoid the arm with the IV – it may alter lab results

If have to use same arm, turn off fluids for 10 minutes and use site distal to IV if possible

Handling Blood Specimens

Rotate blood tubes gently after draw

Label specimen with initials, date, and time

Place in biohazard specimen bag

Transport to lab with gloves on in timely manner

****Agency policies will vary*****

Disposal of materials

Needles- sharps

If not saturated with blood may go into regular garbage. If saturated with blood must go into
biohazard receptacle.

IV fluid bags can go into the garbage when drained, tubing must go in biohazard container

Blood collection demonstrated in lab



From IV site

Small world

Positive fluid displacement. CLAVE