Intravenous therapy

Chapter 41 Intravenous therapy

Nan D. McIntosh

CHAPTER CONTENTS

Introduction 401

Learning outcomes 401

Factors to note 402

Intravenous infusions 402

Observations and complications 403

Dos and don’ts 404

Blood transfusions 404

Factors to note 404

Observations and complications 406

Dos and don’ts 408

Platelet transfusion 408

Factors to note 408

Observations and complications 409

Dos and don’ts 409

Parenteral nutrition 409

Factors to note 409

Observations and complications 410

Dos and don’ts 412

INTRODUCTION

Intravenous infusions for fluid replacement and drug administration are commonplace in the paediatric ward, whereas blood transfusion, platelet administration and parenteral nutrition (PN) are seen more commonly in haematology, intensive care and neonatal units. The use of home PN has also increased to enable children with a variety of congenital and acquired gastrointestinal conditions to be cared for at home. Maintaining optimal function of intravenous infusions is of primary importance in children’s nursing, as fluid overload and electrolyte imbalance are potentially life-threatening and the frequent re-siting of intravenous cannulae is stressful to the child and family (Fitzsimons 2001). Nurses must demonstrate and maintain their competency when administering any type of infusate to a child or young person (NMC 2008). This includes psychological care of the child/young person prior to and during the procedure (Morris 2006). Coping methods such as play and distraction therapy can reduce fear and anxiety (see Ch. 10).

FACTORS TO NOTE

• Body surface area differs in children and adults, with the infant and child having a proportionally greater body surface area than the adult. There is also a different distribution, e.g. the head constitutes 20% of the infant’s body surface area compared with 7–9% of the adult’s (Willock & Jewkes 2000).

• The proportion of body weight that consists of water is greater in the infant and child; 75–80% of the newborn’s body weight is attributed to fluid compared with approximately 60–70% in adolescents. This reduces to between 50% and 60% in the adult, with females having slightly more body fluid.

• Body fluids are distributed between the intracellular and extracellular compartments. In adults, intracellular body fluid normally constitutes around two-thirds (67%) of total body fluid. The extracellular compartment constitutes the remaining third (33%). The extracellular fluid consists of plasma, lymph, interstitial fluid, bone water and connective tissue water. In infants and children, the majority of body fluid is found in the extracellular compartment; approximately one-half of this is exchanged daily to maintain homeostasis (Clancy & McVicar 2002).

• As a result of this distribution, dehydration will occur more quickly in the infant/child.

• Care should be taken when siting an intravenous cannula to be used for infusion of fluids to ensure that the child’s dominant hand is not used.

• The intravenous site must never be covered. This ensures that the site can easily be observed at all times for extravasation. Routine removal of any bandaging for observation may result in the cannula being dislodged.

• A suitable size of intravenous cannula should be selected that not only reflects the size of the child’s vascular access but also the intended use.

• Intravenous administration sets may or may not have an ‘in-line’ burette. It is preferential to use a set with an ‘in-line’ burette for both neonates and toddlers, as this will minimise the amount of fluid that the child receives should there be free flow of fluid (Dougherty 2002).

As there are numerous types of infusion pump available, the nurse must be educated and competent in the use of the device and have regular updates when new pumps are introduced into the workplace (NPSA 2004).

INTRAVENOUS INFUSIONS

The delivery of intravenous fluids is common within acute paediatric settings. Normally used to maintain hydrational status, intravenous infusions can also be used to administer drugs (Dougherty 2002, RCN 2007). Selection of the intravenous cannula site is important (see Ch. 33); sites should be chosen that present the best calibre vein and that can also be suitably immobilised. Once the intravenous cannula is inserted and secured, the intravenous infusion can be commenced.

METHOD

1. Identify the child/young person, verify the prescription and explain the need for the infusion and the procedure to the child and parent/carer (obtain verbal/written consent, dependent upon local guidance).

2. Ensure that hands are clean and dry.

3. Intravenous fluid should be checked by two members of the registered nursing staff (or as per local policy) against the medical prescription chart.

4. The expiry date and the batch number on the bag should be recorded on an intravenous infusion recording sheet or as per local policy.

5. Priming of the intravenous administration set is an aseptic procedure and care must be taken to avoid touching the spike or contaminating the system.

6. Remove the intravenous administration set from the sterile packaging.

7. Remove the in-line burette (if required) from the sterile packaging.

8. Insert the intravenous spike of the administration set into the exit line on the sterile burette ensuring that no key parts are touched (Rowley & Laird 2006).

9. Close all roller clamps attached to the burette and administration set.

10. Insert the spike of the burette into the appropriate port of the intravenous fluid bag. Note: If the intravenous fluid is in a bottle, the spike should be inserted into the appropriate place in the rubber stopper and an air inlet inserted. Clean the rubber stopper with 70% isopropyl alcohol (e.g. Mediwipes) and allow to dry prior to insertion of the spike and air inlet.

11. Fill the burette (if used) with around 20–30 mL of fluid by opening the roller clamp; then close the clamp.

12. Half fill the in-line bubble of the administration set with fluid by gently squeezing the bubble to expel air into the burette.

13. Open the clamp and allow fluid to flow into the administration set, thus expelling the remaining air. Once fluid has reached the end of the administration set, close the clamps and ensure that all air has been expelled.

14. Place the administration set into the intravenous infusion pump as per manufacturer’s instructions.

15. Check patency of the child’s intravenous cannula.

16. Attach the administration set to the child’s intravenous cannula and secure with surgical tape.

Note: Non-sterile tape should not be placed directly over the insertion site (see Ch. 33).

17. Immobilise the child’s limb if necessary with a splint, ensuring that the intravenous cannulation site can be easily observed.

18. Set the rate of infusion, as prescribed, on the infusion pump. Open all clamps and commence the infusion. Record time of commencement on appropriate chart.

OBSERVATIONS AND COMPLICATIONS

• Check the intravenous cannula insertion site, venous pressure (read from some computerised infusion pumps), volume infused, rate at which the fluid is infused and type of infusate hourly.

• Observe the intravenous cannula insertion site for signs of redness and swelling. The area approximately 2.5 cm (1 inch) above and below the insertion site should be easily observed.

• If the child complains of pain or there are signs of intravenous infiltration, stop the infusion immediately and report to medical staff. Infiltration can be graded, indicating the degree of possible damage to tissues (Table 41.1).

• Record the volume infused and the rate on a fluid balance chart.

• A running total of fluid infused should be maintained. This provides an accurate hourly fluid intake.

Table 41.1 Grading for intravenous infiltration

Grade	Manifestations
I	Painful intravenous site. No signs of swelling or redness
II	Painful site. Slight swelling, inflammation. Good pulse and capillary refill below infiltration site. No blanching evident
III	Painful site. Marked swelling with blanching and skin cool to touch. Good pulse below infiltration site with brisk capillary refill
IV	Very painful site. Marked swelling with blanching of skin. Skin cool to touch, pulses absent below infiltration with slow capillary refill (>4 s). Skin breakdown or necrosis may be present; however, this may be delayed

Infiltration may not traverse through all stages. Infiltration at Grade IV is possible on first detection. IV extravasation monitoring audit available online at: www.extravasation.org.uk

BLOOD TRANSFUSIONS

Transfusion of blood or blood products is performed in children for a variety of reasons, including anaemia, acute haemorrhage, haematological disease, following surgery and in other acute and chronic conditions.

Advances in both surgery and medicine have been made possible partly through the availability of blood and blood products (McClelland 2001). The Serious Hazards of Transfusion reporting scheme (SHOT) is a confidential, anonymous reporting system for transfusion errors and severe transfusion reactions. The report emphasises the vital role of correct checking of component and patient details at every step in the transfusion process. It deals with the main practical aspects of blood and blood components (fresh frozen plasma, platelets, cryoprecipitate) with particular emphasis on a safe approach to the confirmation of component and patient identity. The aim is to ensure that the right blood is given to the right patient at the right time, every time (SHOT, RCN 2005). The recommendations are in keeping with the ‘Guidelines for the Administration of Blood and Blood Components and the Management of Transfused Patients’, drawn up by the Blood Transfusion Task Force (2005).

FACTORS TO NOTE

• Erythrocytes (red blood cells) are formed in the red bone marrow from haemocytoblasts. As the red blood cell matures it loses its nucleus and caves in on both sides, giving the characteristic biconcave disc shape.

• The usual life span of a red blood cell is 120 days. Once the cells grow old, their membranes become fragile and rupture, the contents being phagocytosed by the macrophages in the spleen, liver and bone marrow.

• The balance of production and destruction is equal under normal homeostasis.

• The main function of red blood cells is to transport oxygen, bound to haemoglobin, to all cells of the body. Other functions include the transport of waste carbon dioxide and the maintenance of blood pH.

• Fetal haemoglobin has a greater affinity for oxygen than adult haemoglobin, which is suitable for the fetal environment. Towards the later stages of pregnancy, the fetus begins to develop adult haemoglobin. The neonatal haemoglobin level is higher than that of children.

• Whole blood transfusion will replenish the volume, red blood cells and oxygen-carrying capacity of the blood. Packed red blood cells, referred to as packed cells, consist of blood in which some 80% of plasma has been removed. A packed cell transfusion aims at replenishing red blood cell mass and thus the oxygen-carrying capacity of the blood; however, a packed cell transfusion will not replenish volume (BCSH 2004, BTS 2007).

• Whole blood transfusion is normally reserved for exchange transfusion for rhesus incompatibility, severe haemorrhage with depletion of coagulation factors and situations where more appropriate blood products are not readily available (UK Blood Transfusion and Tissue Transplantation Services 2003).

• Washed red cells have had the plasma proteins, leucocytes and platelets removed by rinsing with a special solution; this decreases the chance of transfusion reaction. This type of prepared blood may be used in children who have frequent blood transfusions (BTS 2007).

• Following bone marrow transplant, children require to have blood products irradiated.

• Blood should be stored at 4°C; therefore it must be refrigerated in a specialised blood refrigerator. Blood can be stored for up to 36 days, after which it will have to be discarded (BCSH 2004).

• The blood transfusion should be commenced within 30 min following the arrival of blood from the blood bank (McClelland 2001, BTS 2007, Montgomery & Kumar 2008).

• There are no clear guidelines for the use of blood warmers and the decision is the responsibility of the consultant on each individual patient. This decision may be influenced by the temperature of the patient receiving the transfusion (i.e. hypothermic), the amount of blood being transfused, the duration of the transfusion, or patients with an antibody in their plasma which causes haemolysis when the temperature lowers (e.g. cryoglobulinaemia). A blood warmer actively warms the transfusion during administration by using tubing coils in a water bath. This may be performed during exchange transfusions or to prevent air embolism (Smith 2001, RCN 2005).

• Blood should be transfused over 4 hours Transfusions exceeding this time may become contaminated with bacteria. If the volume of blood cannot be transfused within 4 hours, it should be divided into smaller volumes (paedipacks) and stored accordingly in the blood bank until required (BCSH 2004, RCN 2005, BTS 2007).

Only gold members can continue reading. Log In or Register to continue

Related

Stay updated, free articles. Join our Telegram channel

Tags: Practices in Childrens Nursing

Mar 7, 2017 | Posted by admin in NURSING | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access