NURS 2028 Quiz 1 Review

Nursing Lab Skills (George Brown College)

WEEK 1
INTRAVENOUS THERAPY
RATIONAL FOR IV THERAPY
• Replace/correct fluid and electrolyte balance
• Maintain or restore fluid volume (shock/dehydration)
• Route for medication administration
• Transfusion of blood or blood components
• Provision of nutritional support (TPN & Lipids)
• Normal fluid and electrolyte balance is essential for normal bodily function
TYPES OF IV FLUIDS
• A patient’s medical needs will determine which type of IV fluid is ordered
• IV fluids are commonly categorized according to their tonicity
WHAT IS TONICITY?
• Tonicity: a measure of the osmotic pressure gradient between two solutions separated by a semi-
permeable membrane
• The tonicity of an IV solution affects fluid transport across the semipermeable membrane of the cell
• Low concentration of solute in a solution causes fluid to move into the cell where there is higher
concentration of solute
• High concentration of solute in a solution causes fluid to move out of the cell to the extracellular
fluid
• The type of IV solution that a doctor orders is based on the desired fluid shifts
TONICITY
IV FLUID CATEGORIES BASED ON TONICITY
COLLOIDS CRYSTALLOIDS
• Colloid IV solutions contain larger molecules (protein or starch) that cannot diffuse through semi-
permeable membranes of the capillary walls
• Contain solutes of high molecular weight which causes the fluid to remain within the patient’s
vascular system
• Crystalloid IV solutions contain small molecules that easily diffuse through semi-permeable
membranes of the capillary walls
• They are further categorized depending upon their relative tonicity compared to blood plasma.
There are 3 types of crystalloid solutions:
1. Isotonic
2. Hypotonic
3. hypertonic
COLLOID IV SOLUTIONS
EXAMPLES:
• Blood and blood products (5% albumin, FFP)
• Synthetic colloids (Voluven, Pentaspan, Dextran)
WHAT ARE THEY USED FOR?
• Useful for expanding intravascular volume and raising blood pressure
• Indicated for clients who are malnourished and cannot tolerate large infusions of fluids
ADMINISTERING COLLOID SOLUTIONS - NURSING CONSIDERATIONS
• Assess allergy history - although rare, colloid solutions can cause allergic reactions. Inquire about
previous IV fluid reactions
• Use a large bore angiocath (18 gauge) for colloid solutions
• Obtain baseline data prior to administration (vital signs, edema, lung sounds, heart sounds).
Continue monitoring during and after infusion
• Monitor patient’s response: look for signs of hypervolemia, hypertension, dyspnea, crackles in lungs,
and edema
• Monitor coagulation indexes as colloid solutions can interfere with platelet function and increase
bleeding times
CRYSTALLOID IV SOLUTIONS (further categorized according to their tonicity)
ISOTONIC
Have the same concentration of solutes as blood plasma
HYPOTONIC
Have a lesser concentration of solutes as blood plasma; fluid enters the cell
HYPERTONIC
Have a greater concentration of solutes as blood plasma; fluid is drawn out of the cell
ISOTONIC IV SOLUTIONS:
• have the same concentration of solutes as blood plasma; “normal” osmolarity
• do not cause cells to lose or gain fluid
• are the least irritating to the endothelial lining of the vein wall
• keep the amount of fluid crossing the semi-permeable membrane in and out of the cell in equilibrium
• stays within the vascular system
EXAMPLES:
• 0.9% saline, Lactated Ringer’s, D5W
WHAT ARE THEY USED FOR?
• Used to restore extracellular fluid volume due to dehydration, blood loss, surgery)
HYPOTONIC SOLUTIONS HYPOTONIC IV SOLUTIONS:
• have a lesser concentration of solutes than blood plasma
• shift water extracellularly to intracellularly via osmosis
• cause cell swelling; cell can burst or lyse
• can hydrate cells which reduces fluid in the circulatory system
EXAMPLES:
0.45% NS (1/2 NS); 0.225% NS (1/4 NS); 0.33% NS (1/3 NS)
WHAT ARE THEY USED FOR?
• Usually used to treat cellular dehydration, and to replace cellular fluid (such as in diabetic
ketoacidosis or hyperosmolar hyperglycemia)
USE WITH CAUTION!
• Watch for decreased circulatory volume as extracellular fluid enters cell to re-hydrate it.
• Never give hypotonic solutions to patients at risk for increased intracranial pressure (can cause fluid
to shift to brain tissue)
• Never give hypotonic solutions to patients with extensive burns or trauma (they are already
hypovolemic); can deplete their fluid volume
HYPERTONIC IV SOLUTIONS:
• have a greater concentration of solutes than blood plasma
• cause fluid to shift from the intracellular compartment to the extracellular compartment via osmosis
which will cause the cell to shrink
EXAMPLES:
• 3% Saline, 5% Saline, 10% Dextrose in Water (D10W), 5% Dextrose in 0.9% Saline, 5% Dextrose in
0.45% saline, 5% Dextrose in Lactated Ringer’s
WHAT ARE THEY USED FOR?
• Used very cautiously (usually in the ICU) to decrease edema (cerebral, pulmonary, peripheral)
• Prefer to give hypertonic solutions through larger veins (central venous line) due to their
vesicant effects and risk of infiltration.
ASSESSING YOUR PATIENT WITH AN IV
• Doctor’s order
• Is the correct solution hanging? • Correct rate
• Assess IV site, tubing, and bag every 1-2 hours
• Document intake and output at the start and end of shift (or ordered frequency)
• Document amount already infused from the bag
• Document amount to be absorbed (TBA)
• Identify any issues or complications and intervene as needed
NURSING ASSESSMENT OF FLUID & ELECTROLYTE STATUS
• Daily weights
• Intake & output
• Lab values
• Urine Specific Gravity, Hematocrit, Electrolytes, BUN, creatinine (eGFR)
• Assess for altered LOC
Overload signs
• Periorbital & peripheral edema, ascites, anasarca, crackles in lungs, polyuria, diuresis, hypertension,
tachycardia, tachypnea, altered mental status
Deficit signs
• Dry mucous membranes, sunken orbits, depressed fontanelle,
concentrated urine, decreased output, hypotension, tachycardia, altered mental status
TYPES OF IV ADMINISTRATION SETS
MACRO-DRIP SET (comes as 10, 15, or 20 gtts/mL size)
MICRO-DRIP SET (only comes as 60 gtts/mL size)
MACRO-DRIP AND MICRODRIP (what’s the difference?)
MACRO-DRIP TUBING:
• Delivers 10, 15, 20 gtts/mL IV solution
• Number of drops per mL (Drop factor) is found on the tubing package
• Used to administer large volumes of IV fluids or to infuse fluids more quickly
MICRO-DRIP TUBING:
• Delivers 60 gtts/mL IV solution (only comes in this size)
• Tubing is narrower, so it produces smaller drops
• Used to administer small or very precise amounts of fluid where precision in the flow rate is essential
• Used primarily for neonates or pediatric patients
VOLUME PER HOUR CALCULATION WHEN USING AN IV PUMP
FORMULA:
Total volume = Volume per hour
Total time
DOCTOR’S ORDER:
• IV NS 1000 mL over 8 hours
• IV NS 1000 mL over 12 hours
DRIP CALCULATION WHEN RUNNING BY GRAVITY
To run by gravity, need to calculate number of drops per minute using either 10, 15 or 60 drop per mL
tubing
FORMULA:
Volume (mL/hr.) x drip factor (tubing) = Rate (drops/min) Time (60min)
DOCTOR’S ORDER: NS 100 ml/hour to be given using 10gtt/mL tubing
100mL/hr. X 10gtts/mL = 17gtts/min
60 min
Calculate doctor’s order for drip factor of 15gtts/mL and 60 gtts/mL What rate would you set for an IV
pump?

WEEK 2
INTRAVENOUS THERAPY ADMINISTRATION
PERIPHERAL IV INSERTION – Fluids and medications can be administered through catheter
THE ROLE OF THE NURSE
Authority - Do you have a doctor’s order to initiate an IV?
Competence - Do you have the knowledge, skill, and judgement to perform the task?
Safety - Are you able to anticipate and report adverse effects?
PURPOSE OF IV THERAPY
• To provide fluid when patient is unable to take in enough fluids by mouth
• To provide medications, electrolytes, salts, vitamins, minerals, and glucose
• To provide access when medications need to be administered rapidly
ASSESSMENT AND PLANNING
How long will this IV be needed?
Where will I insert the IV?
What supplies will I need?
What will the IV line be used for?
How do I prepare my patient?
HOW DO I PREPARE MY PATIENT?
• Introduce yourself
• Identify your patient
• Explain what you are going to do
• Assess if there are any potential patient related factors that may affect your IV insertion
PATIENT RELATED FACTORS TO CONSIDER PRIOR TO INITIATING IV
PATIENT ANXIETY
Pain management
Hand dominance/patient preference
First time needing an IV
MEDICAL CONDITIONS
Bleeding tendencies
Disease or injury to extremities
Allergies
tatus of veins
AGE RELATED FACTORS
Skin turgor
Status of veins
Elderly
Child/neonate
Dehydration
WHAT SUPPLIES WILL YOU NEED?
• Gloves
• Local anesthetic (if needed)
• Tourniquet
• Towel or pad
• Antiseptic swabs (2% chlorhexidine gluconate preferred)
• Angiocath (IV catheter size based on vein size and purpose)
• Transparent semi-permeable membrane dressing (TSM) such as Tegaderm
• Tape, gauze
• Arm splint (if required)
• IV fluid, primed IV tubing, and/or saline lock extension set
• Pre-loaded syringe with sterile normal saline for flushing
THE ANGIOCATH
• IV catheters come in various sizes and lengths
• 14, 16, 18, 20, 22, 24 gauge
• The higher the number the smaller the catheter
WHERE TO INITIATE THE IV
DO
• Use distal veins first
• Use non-dominant arm
• Consider patient preference
• Choose a vein that is soft and easily palpated
• Choose a vein that is large enough for the catheter
DO NOT
• Do not use veins that are tortuous, sclerosed, inflamed or injured
• Do not initiate into veins that were recently used
• Do not use areas of flexion
• Do not use veins that are compromised or have valves that are close to the insertion site
• Do not use veins on an injured extremity
COMMON SITES FOR PERIPHERAL IV’S – Inner arm, Dorsal surface of hand, Dorsal surface of the
feet
TYING THE TOURNIQUET AND CHOOSING A VEIN
• Place patient’s arm in a dependent position
• Tourniquet should be placed 10-15cm above intended venipuncture site
• Massage or stroke the vein distal to the site in the direction of venous flow
• Ask the patient to clench and unclench their fist
• Lightly tap the vein
HOW TO INSERT THE CATHETER
• Refer to skills checklist
• Refer to textbook pages 1041-1050, skill 40-1 “Initiating a Peripheral Intravenous Infusion”
• PIV insertion skill will be reviewed and practiced in lab
• PIV dressing application and removal of dressing will be reviewed and practiced in lab
• Discontinuing a PIV will be reviewed and practiced in lab
SALINE LOCK
• Saline locks are short term access devices.
They are used:
• to access the site for intermittent infusions
• to maintain access in case of emergency
• Flushing and locking required to maintain patency – usually ordered BID
• Turbulent flow (stop/start) technique is used
• Catheter is ‘locked’ or clamped after flushing
• If agency permits, a student nurse may flush a saline lock with their clinical instructor or supervising
staff nurse present
COMPLICATIONS DURING IV INSERTION
ROLLING VEIN
• Hold skin taut to stabilize the vein during insertion
NO BLOOD RETURN
• Do not re-insert the stylet into the catheter if you have activated it as this could damage the
catheter
• A catheter that has been removed from the skin due to no blood return cannot be reused
COMPLICATIONS DURING IV INSERTION
HEMATOMA
• Blood flowing into surrounding tissues upon insertion of catheter
What to do?
• Release tourniquet, remove catheter, apply pressure over
• Reattempt should be at another site on opposite limb
INFILTRATION
• Localized swelling, discomfort, pallor, coolness at site
when flushing following insertion of catheter
What to do?
Requires removal of catheter to prevent further trauma site
DRESSING AND DISCONTINUING AN INFUSION SITE
• If IV is site intact and infusing well but the dressing is coming off redress the site
• If IV needs to be removed because
• catheter is dislodged
• complications
• no longer needed
then consider the need to restart the IV
• Can the drug route be changed to avoid another IV? – Suppository, PO, etc. based on Pt’s
tolerance.
• After catheter is removed, assess catheter tip to ensure it is intact
• Document
TIPS TO REMEMBER
• Using therapeutic communication with your patient prior to insertion can help ease anxiety
• If you are unsuccessful after 2 attempts, ask another health professional to attempt
• Can use technology to help locate difficult veins (if available)
• Dressings should be transparent to allow for visualization of the insertion site
• Should use a splint to stabilize areas of flexion
• Dressings can stay on for 48-96 hours depending on agency policy
COMPLICATIONS ASSOCIATED WITH IV ADMINISTRATION
• Fluid overload
• Fluid deficit
• Electrolyte abnormalities
Local complications (at site of insertion)
• pain
• phlebitis
• Infiltration
• tissue damage (fluid irritation to veins and surrounding tissue)
• septicemia
IV THERAPY
The greater the deviation from normal serum pH the greater the potential for vein irritation, pain, and
inflammation along the vein.
Medication Examples:
• penicillin
• acyclovir
• cephalosporins
• diazepam
• amphotericin
• potassium
• vancomycin
IV THERAPY VESICANTS
IV vesicants are medications/solutions that can cause severe tissue damage if they leak into
the subcutaneous tissue
• KCL intravenous additives
• Contrast medium
• Antineoplastics
• Calcium solution
• Nitroprusside
• Viblastine
• Doxorubicin
HOW TO PREVENT VEIN DAMAGE:
• Dilute medication, if safe for patient (renal, cardiac)
• Infuse slowly
• Use larger blood vessels such as a Central Line or PICC line
TROUBLESHOOTING COMPLICATIONS
• Bleeding/Bruising
• Phlebitis
• Infection
• Infiltration
• Extravasation
• Pain
• Accidental dislodgement of catheter
• Broken catheter
• Errors
- Rate or Drug Related
BRUISING
• IV bruising occurs during or after IV therapy when the punctured vein wall allows the blood to enter
the skin and pool inside it
• The outer layer of skin absorbs the blood resulting in the discoloration
NURSING INTERVENTIONS:
• Place ice or cold pack on the site for 10-20 minutes at a time
• Patient can shower or bathe as usual
• Be gentle around the affected site for a few days
PHLEBITIS
Inflammation of vein related to irritation, caused by:
•chemical –from IV fluid / medications
•mechanical – IV catheter
•infection at the site
SYMPTOMS:
• Swelling, redness along course of vein (streaking), pain, erythema, warmth, palpable venous cord
• May develop thrombus at the site of irritation à thrombophlebitis, embolus
NURSING INTERVENTIONS FOR PHLEBITIS
• Frequent assessment & early intervention to avoid phlebitis
• Stop drug/infusion, discontinue IV
• Elevate arm to minimize swelling
• Apply warm, moist compress
DOCUMENT:
• Use a phlebitis scale for documentation
• Document the site accurately (baseline information for later comparison)
• Continue assessment for progressive pain at the site
• Notify physician of phlebitis site and if prescribed medication was finished
Set up new system and restart IV as ordered
•New IV site should be on the other arm, away from irritated site
PHLEBITIS SCALE
• A phlebitis scale provides a consistent standardized scale to assess and document the severity of
phlebitis
• Measured in grades (0-5)
LOCALIZED INFECTION OF IV SITE
•Can spread systemically
•Patient may be hyperthermic, or hypothermic (in the very young and old), monitor carefully for
systemic response (septic shock)
•IV site is red and painful
•Drainage – may be serous or purulent
NURSING INTERVENTIONS FOR LOCALIZED INFECTION
• Stop IV and remove catheter immediately
• Notify MD - may need topical and/or systemic antibiotic
• Culture catheter tip and or wound drainage, if requested by MD
• Clean IV site carefully and assess for discharge
• Set up new system and restart IV (new IV site should be on the other arm, away from infected site)
• Document assessment findings, interventions, and evaluation
INFILTRATION
Leakage of non-irritating fluids into surrounding tissues
Limb may be:
—Swollen (from increased tissue fluid)
—Cool
—Pale
—Tender
—Leaking clear or serous fluid from catheter IV site
—Pain (pain increases as infiltration continues)
NURSING INTERVENTIONS FOR INFILTRATION
• Stop infusion
• Discontinue IV
• Set up new system and restart IV
• New IV site should be on the other arm, away from the infiltration site
• Apply a warm compress/heat to facilitate absorption
• Remove any restricting items (i.e., ID band, watch, rings)
• Elevate arm
• Notify MD (not urgent unless circulation is compromised)
• Documentation and incident reporting as policy dictates
EXTRAVASATION
• Infiltration of irritant/vesicant fluids into the surrounding tissue
• Can be caused by infiltration of chemotherapy drugs, nitroglycerine, adrenalin, dopamine, TPN,
KCL, antibiotics)
• May be due to vein puncture or increased pressure
• Causes tissue damage
POTENTIAL OUTCOMES:
• Pain redness, irritation
• Tissue necrosis
• Loss of limb
NURSING INTERVENTIONS FOR EXTRAVASATION
STOP INFUSION IMMEDIATELY!
• Withdraw any fluid from IV cannula if possible but do not remove (antidote may be given)
• Notify physician & pharmacy immediately
• Warm or cold compress depending on drug
• Antidote given depending on drug
• Document thoroughly – skin condition, area, take measurements, advise wound care team
(If available) for treatment options
• consider if photo should be taken
• Patient/family will need to be notified
• Set up new IV system and restart new IV as required
• New IV site should be on the other limb, away from extravasation site
TROUBLESHOOTING
What if?
• Bubbles in tubing
• IV is running too slow or not at all
• IV is running too fast
• Wrong solution
• Wrong rate
BUBBLES IN THE IV TUBING
POTENTIAL CAUSES:
• Container has run dry
• Loose connections
• Air in syringe during saline lock flush
Air in tubing can result in an air embolus - this can be fatal, especially in a Central Venous Line
SYMPTOMS OF AIR EMBOLUS:
• Cyanosis, loss of consciousness • Weak rapid pulse, drop in BP
• Respiratory distress
IV RUNNING SLOW OR NOT FLOWING
• Check height of IV fluids relative to patient
• Should be 90cm above insertion site
• Lower bag below insertion site, check for blood back flow (means catheter is in the vein)
• Check tubing for kinks (multiple potential sites)
• Check position of catheter – patient position, taping and securement of catheter at insertion site
• Check site for complications: infiltration, redness, phlebitis
• Check roller clamps
• Check rate – pump or manual (gravity): is it set correctly?
CASE EXAMPLE: IV RUNNING BEHIND SCHEDULE
FORMULA:
Amount that should infuse - Amount already infused Hours remaining in the shift
You are working an 8-hour shift. On your initial assessment @ 0730 hrs., Mr. Tutu’s IV of NS has 800
mL to be absorbed (TBA). It is to run @ 100mL/hr. When you re-assess him @ 0930 hrs., there is 750
mL TBA.
• What has happened?
• What effect might this have on your patient?
• What interventions are appropriate?
• Are there clients for whom it would not be safe to increase their IV rate?
CASE EXAMPLE: IV RUNNING AHEAD OF SCHEDULE
FORMULA:
Amount that should infuse – Amount already infused
Hours remaining in the shift
You are working an 8-hour shift. The doctor’s order states to run an IV of NS @ 100mL/hr.
On your initial assessment @ 0730, Mr. Tutu’s IV of NS has 800 mL TBA. When you go to re-assess
him @ 0830, there is 600 mL TBA.
• What has happened?
• What effect might this have on your patient?
• What interventions are appropriate (assessments, changes to the IV rate)?
WHAT TO DO WHEN YOU FIND THE INCORRECT SOLUTION RUNNING?
• Slow rate to a minimum
• Assess client
• Verify orders
• Get correct solution
• Notify physician
• Follow incident reporting procedure for hospital/agency
• Documentation
WHAT TO DO WHEN YOU FIND THE INCORRECT RATE RUNNING?
• Slow rate to a minimum
• Assess client
• Verify orders
• Notify physician
• Increase or decrease IV flow rate dependent upon patient’s condition and/or doctor’s new order
• Follow incident reporting procedure for hospital/agency
• Documentation
CRITICAL THINKING QUESTIONS
• Mr. Tutu has a urine output of 300 mL over the 12-hr. shift. He has one episode of vomiting of 250
mL. What is his total output for the 12 hrs.?
• Mr. Tutu receives a bolus infusion of 200 mL of NS over 1hr then an infusion of NS at 100 mL/hr. He
then receives one piggyback dose of Dimenhydrinate in 50 mL of NS over 30 minutes. What is his
total fluid intake for the 12 hrs.?
• What is Mr. Tutu’s fluid balance for the 12 hrs.?
• Does Mr. Tutu have a positive or negative balance?
Week 3
Central Venous Access Devices (CVAD)
❖ Peripherally Inserted Central Catheters (PICC)
❖ Hypodermoclysis
❖ CVAD Central Venous Access Device
Why Use a CVAD?
• Stability: can remain in situ for weeks to years, eliminating need for repeat peripheral venipuncture
• Rapid Hemodilution: vast blood flow through vena cava rapidly dilutes infused solutions;
particularly important for hypertonic solutions that are irritating to walls of smaller vessels
• Safety: less potential for extravasation with infusion of vesicants
• Multi-lumen Configurations allows for multiple infusions to run concurrently
•Home IV Therapy: convenience, lower health care cost
• Blood Sampling: allows for samples to be withdrawn; fewer venipunctures
TYPES OF CVADs
PICC – Peripherally Inserted Central Catheter
-inserted peripherally, tip is centrally located in SVC
Tunneled Central Catheter
-portion of catheter is surgically threaded under the skin, anchoring the catheter, and reducing
infection risk
Implanted Venous Access Devices (Ports)
-a chamber is implanted in subcutaneous tissue with an attached catheter tunneled into the Internal
Jugular Vein, tip rests in SVC
Percutaneous Central Venous Catheters (non-tunneled, temporary) -sutured directly into the vein
(internal jugular or femoral)
Examples:
▪ Non- Tunneled vs Tunneled Catheter
▪ Implanted VAD (Port)
▪ Peripherally Inserted Central Catheters (PICC)
Objectives for PICC care
1. Identify the purpose, advantages, disadvantages, and complications associated with PICC lines
2. Anticipate and prevent complications
3. Perform sterile PICC dressing change
4. Identify assessment and documentation requirements
What is a PICC line?
u Long flexible catheter inserted into the cephalic, median cubital, basilic by the antecubital space and
advanced into the subclavian vein or the superior vena cava, closer to the heart
u Procedure can be done by a physician or specially trained RN
u Right arm typically used u May be sutured in place
u Placement verified by x-ray
u Usually stabilized with sterile clips and sterile dressing
What is a PICC line used for?
u Used for patients with chronic diseases when long-term IV therapy is needed such as
chemotherapy drugs
u Used when treatment is long-term
u Used for administration of TPN and Lipids
u Useful when frequent blood transfusions or long-term blood sampling needs to be done
u Used for IV fluids that are potentially irritating to smaller veins
PICC line benefits
u Decreases the discomfort of many needle sticks from blood draws or medication administration
u Multiple lumens allows for multiple treatments to run simultaneously
u Allows for IV medications that are potential irritants to smaller veins
u Reduced risk of infiltration
u Can remain in place for an extended period of time for patients in hospital settings or at home
u Allows client to have greater freedom for ADL
PICC line disadvantages
u Accidental damage or migration due to small lumen size
u Weekly sterile dressing changes take time
u Risk of infection or blood clots more serious due to proximity to heart
u Although there are many products available to protect the PICC line, the arm may not be
submerged in water
u May not suit active people
u May alter body image
Before you begin PICC line care…
u Authority
Do you have the authority? Is there a doctor’s order, or special requirements for this dressing?
u Competence
Do you have the knowledge, skill, and judgment to perform this task?
u Safety
Are you able to anticipate and report adverse events?
Assessment
u Inspect insertion site for signs of infection, phlebitis, skin integrity
u Check to see if dressing is dry and intact
u Measure wing-to-tip of the PICC line daily and compare measurement to patient’s chart
u If suspect 2cm or more migration of PICC line, all fluids/meds stopped, and x-ray done to verify
placement
u PICC line may be flushed by specially trained nurse to verify patency
PICC line dressing change
u Always use aseptic technique u Wear full PPE
u Patient should wear a mask
u Fresh PICC line dressings changed 24 hours post-insertion
u Gauze dressings changed every 48 hours
u TSM dressing changed every 5-7 days if clean, dry, and intact
u TSM dressing changed PRN if becomes soiled or peeling
What supplies will I need?
u Emergency repair kit (including shodded hemostat) u Goggles/face shield
u Mask (mask for patient too if they are unable to keep head turned away)
u Sterile gloves
u Chlorohexidine gluconate swabs or solution
u Transparent semipermeable dressing (TSM) (i.e., Tegaderm)
u Sterile dressing kit (drapes/towels, sterile forceps, gauze)

Cleaning
u Chlorhexidine gluconate is preferred cleaning solution to clean insertion site (2% chlorohexidine
gluconate has been shown to decrease catheter-related bloodstream infections, RNAO BPG)
u clean skin using a back-and-forth and up and down (#hashtag) u Allow site to air dry
Type of cleaning solution and Scrubbing time
2% chlorhexidine gluconate with alcohol - 30 seconds
2% chlorhexidine gluconate without alcohol - 2 minutes
Povidone iodine - 2 minutes
70% isopropyl alcohol - Has no bactericidal effect, dries on application, dries skin
What to report
u Signs of infection u Signs of phlebitis
u Line migration greater than 2cm from wing to tip of PICC line
u Signs and symptoms of thrombosis (pain, edema of arm, shoulder or neck, redness, warmth,
difficulty flushing or infusing, engorged veins
Troubleshooting complications
Complication/problem
Patient is agitated during procedure (potential to affect sterile field)
Patient has allergies to cleaning solution or dressings
Dressing is starting to peel off prior to day 7
Line is longer than documented external length
Drainage is noted under dressing
PICC line has broken
Nursing Interventions -
Documentation
u Assessment findings of insertion site
u Skin integrity beneath Tegaderm dressing u Use standardized phlebitis scale
u Length of external catheter (compare to chart)
u Assessment findings of chest and neck for engorged veins and/or difficulty with movement
u Any signs of local or systemic infection (fever, chills, hypotension)
u Date and time dressing was changed u Patient’s tolerance of dressing change
Prior to patient discharge
u Assess clients understanding and address any concerns
u Referral to community agency, if applicable
u Provide education regarding care of PICC line and how to troubleshoot complications
u Provide emergency contact numbers u Education regarding activity restrictions
u Ensure that medical follow-up arrangements have been made

Hypodermoclysis
❖ A less invasive alternative to IV Therapy for mild dehydration
❖ Hypodermoclysis (clysis) involves inserting a small-gauge needle to infuse isotonic fluids into the
subcutaneous space
❖ Also known as a subcutaneous infusion
Advantages
u Prevention/treatment of mild dehydration without use of IV
u Can be used out of hospital, in some instances (i.e., LTC home)
u Can be short term (i.e., replace fluids during illness, administer medication)
u No risk of vascular infection or thrombosis
Disadvantages
u Not appropriate for all patients (renal, cardiac, coag disorders)
u Contraindicated in those who are in severe shock, requiring an IV
u Not appropriate for those who need electrolytes (potassium never added)
Procedure
u Prepare the site by cleaning the area with chlorhexidine, using clean gloves
u Insert a small gauge needle into the subcutaneous tissue:
u Appropriate sites:
u abdomen (preferred), at least 4 cm away from umbilicus,
u outer upper arms,
u upper back between the scapulae
u anterior aspect of the thighs only (not lateral)
u anterior upper chest (avoiding breast and axilla)
u Avoid sites that are highly vascular, bony prominences, or edematous areas
u Do not insert the needle into the muscle
Assessment and patient teaching
Technique
Disinfect site
Insert butterfly needle into subcutaneous tissue
Clearly label dressing, dressing tubing and pump as “subcutaneous infusion”
Hypodermoclysis sites
u Anterior aspect of upper arms
u Anterior abdominal wall (4cm from umbilicus) u Anterior aspect of thigh
u Under the scapula, avoiding bony prominences u Anterior chest wall, avoiding breast tissue
u Site chosen needs to be free from edema, rashes, bruising, scar tissue, or masses
u Note: lateral thigh is no longer an approved site
Solution and rate
uIsotonic fluids are the preferred solutions
u0.9% Sodium Chloride
uLactated Ringer’s solution
uAdministration rate:
uDepends on the patient’s needs and tolerance
u for older adults, the rate and volume of subcutaneous administration shouldn’t exceed those used
for IV Infusion
uFluids have been infused at rates of 1,500 ml over 24 hours
Site rotation
U Plan to rotate the infusion site every 24 to 48 hours or after 1.5- 2L of fluid have been administered
Adverse reactions:
U Rare and usually avoidable
U Complications can include pruritus, burning, or leaking at the site; erythema; edema; induration;
bleeding; or infection