Intravenous Fluid

and
Blood Transfusion
Bryan Romulus T. Savellano RN MAN
Faculty/Clinical Instructor
Our Lady of Fatima University - Antipolo

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Basic Intravenous
Therapy

90-95% of patients
in the
hospital receive
some type
of intravenous
therapy.

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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 )
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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.
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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
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ISOTONIC

Used to expand blood

volume
Normal saline or 0.9%
NaCl
Lactated Ringers
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 Isotonic
solutions have
an osmotic
pressure equal
to that of the
cells of the
body.
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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 NS, 0.45% NaCl, 0.3% NaCl.
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 Hypotonic
solutions have
a lower osmotic
pressure than
that of the
body cells

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HYPERTONIC Solution
Has higher concentration than
body fluids . Examples are:
D10W, D50W,D5LR, D5NM
Have a greater concentration
of solutes than plasma

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Hypertonic Solutions
has an osmolarity
higher than that of
serum.
It draws fluid into the
intravascular
compartment from
the cells and
interstitial
compartment
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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
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 Peripheral

IV sites

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

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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.
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Precautions for IV Sites

Avoid
Bony prominences
Legs & feet
Mastectomy arm
Operative arm
Injured arm
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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.
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Cannulation Devices

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http://www.qub.ac.uk/cskills/iv_cannulation/different sizes.jpg

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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
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Equipments:

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Safety catheter needle

Tourniquet
Povidone-iodine swabs
Alcohol swabs
Gloves
Towel
Transparent dressing
Tape
IV tubing & solution bag
IV pole

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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)
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Macrodrops and
Microdrops

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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
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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
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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

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Other IV Complications
Allergic reaction
Circulatory overload
Air embolism
Infiltration/Extravasation

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The most common cause is damage to the wall during insertion or angle
of placement

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Hematoma
Thrombophlebitis
Venespasm
Occlusion
Infection
Embolism
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IV CALCULATIONS

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REGULATIN
G YOUR IV
FLOW
RATE

CALCULATIONS OF INFUSION RATES

GENERAL FORMULA:

Total Volume x gtt / ml Calibration = gtt / minute

Total Hours
60 Minute / Hour

INTRAVENOUS FLOW RATE

Looking for gtts/min
For ADULT (MACRO)
Total Amount of Fluids in ml X
Total Hours to be regulated in hr

Drop Factor (15 gtts/ml) = gtts/min

60 mins/hr

For PEDIA (MICRO)

Total Amount of Fluids in ml X
Total Hours to be regulated in hr

Drop Factor (60 ugtts/ml) = gtts/min

60 mins/hr

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/ml
2. Total ml to be administered = 50ml
3. Total hours of infusion = 0.5H
To solve:
Substitute in the formula:
50ml
0.5hour

60gtt/ml
60min/hour

100gtt/min

Blood
transfusi
on
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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)
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Hematologic system
WBC (Leukocytes)
Neutrophil
Monocytes
Eosinophils
Basophils

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Lymphocytes
T Lymphocytes
B Lymphocytes
RBC
Platelet

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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 theres
platelet deficiency
To combat infection if theres
decrease WBC
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Nursing Mgt & principles in

Blood Transfusion

Proper refrigeration
Proper typing & cross
matching
Type O universal donor
AB universal recipient
85% of people is RH (+)
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Materials needed:
1.
2.
3.
4.
5.
6.
7.
8.
9.
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IV tray
Compatible BT set
IV catheter/needle g 18/19
Plaster
Tourniquet
Blood product
Plain NSS
IV stand
Gloves
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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.
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2. Instruct another RN to
recheck the following
Pts name
blood typing & cross
typing
expiration date
serial number
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3. Check blood unit for

presence of bubbles,
cloudiness, dark in
color & sediments
indicates bacterial
contamination.
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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!
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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

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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.

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8. Maintain the transfusion rate

FWB
PRBC
FFP, Platelets fast drip
9. Monitor adverse reaction
10. Document the following
a. blood component and number
b. infusion started and ended
c. client reaction

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BLOOD TRANSFUSION REACTIONS

H hemolytic Reaction
A allergic Reaction
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired bloodhyperK
H- hyperkalemia
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HEMOLYTIC REACTION
donor blood is incompatible
with the recipients blood
- most fatal, may present
chills, diaphoresis and back
pains

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 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

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Allergic reactions

rashes and itchiness, dyspnea,

bronchospasm due to sensitivity in
foreign proteins in plasma
SIGNS AND SYMPTOMS

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Fever/ chills
Urticaria/ pruritus
Dyspnea
Laryngospasm/ bronchospasm
Bronchial wheezing

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ALLERGIC REACTION

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NURSING MANAGEMENT
Stop BT
Notify Doc
Flush with PNSS
Administer antihistamine
diphenhydramine Hcl (Benadryl).
Give bedtime.SE-Adult-drowsiness.
Child-hyperactive
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 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
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Pyrogenic Reaction
fever and chills due to sensitivity to
leukocyte or platelet antigen most
common
SIGNS AND SYMPTOMS

Fever/ chills
tachycardia
Headache
palpitations
Dyspnea

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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

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Circulatory Overload

SIGNS AND SYMPTOMS

Dyspnea
Orthopnea
Exertional discomfort

NURSING MANAGEMENT
Stop BT
Notify Doc. Dont flush due pt has circulatory
overload.
Administer diuretics
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Priority cases
1ST- Hemolytic reaction- due to
hypotension- attend to destruction
of Hgb O2 brain damage
2ND- Circulatory Overload
3RD- Allergic Reaction
4TH- Pyrogenic

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PUTLA MO.
ANEMIC KA
NOH?!

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IKAW NANGINGITIM KA NA!

CYANOTIC KA!
INTUBATE KITA!

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65

Hans Christian Fabrigas Vitug

10/11/15 14:11

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 formed
Cylindrical
1-2 times a day to 1 every 2-3 days
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Hans Christian Fabrigas Vitug

10/11/15 14:11

Problems in Fecal Elimination Pattern

Constipation
fluid intake 1,500-2,000 mls
High fiber diet
Pattern for defecation
Response immediately to the
urge to defecate
Minimize stress
Laxatives
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Hans Christian Fabrigas Vitug

10/11/15 14:11

Problems in Fecal Elimination Pattern

Fecal Impaction
P-assage of liquid fecal seepage
A-absence of bowel movement for 3 to 5
days
S-ubjective feeling of abdominal fullness or
bloating
A-norexia and body malaise
H-ardened fecal mass is palpated
N-ausea and vomiting
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Hans Christian Fabrigas Vitug

10/11/15 14:11

Problems in Fecal Elimination Pattern

Fecal Impaction
M-anual extraction
I-ncrease fluids
S-ufficient bulk in diet
A-dequate activity and
exercise
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Hans Christian Fabrigas Vitug

10/11/15 14:11

Problems in Fecal Elimination Pattern

Diarrhea
B-anana
R-ice
A-pple
T-oast
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Hans Christian Fabrigas Vitug

10/11/15 14:11

Problems in Fecal Elimination Pattern

Anti diarrheals A-D-A

A-bsorbents
D-emulcents
A-stringents
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Hans Christian Fabrigas Vitug

10/11/15 14:11

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
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Hans Christian Fabrigas Vitug

10/11/15 14:11

H-H-I-S-O
Isotonic 500-1000 ml of saline
15 to 20 mins
Soapsuds
soap

500-1000 ml with 3-5 ml

of

10 to 15 mins
Oil

90 to 120 ml

Lubricates the feces and the

mucosa
-3 hours

colonic

Cleansing enema
stimulates peristalsis by
irrigating the colon and
rectum or by distending
the intestine with
volume of fluid
introduced.
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Hans Christian Fabrigas Vitug

10/11/15 14:11

High Enema
to clean as much of the colon
as possible. 1000 ml of
solution is introduced
Low enema
clean the rectum and sigmiod
colon, 500 ml of solution is
introduced

Carminative enema

relieve of
flatuence, 60180 ml of fluid

Retention Enema
oil 90-120 ml
12 above the rectum
temp 105-110 F
time of retention 1-3 H
until desired effect is
obtained

10/11/15 14:11

Non retention
tap water 500-1000

soap sud (20ml of castile soap in

500-1000ml/ normal saline
9ml of NACL to 1000ml water
hyperrtonic soln/ fleet enema
82

10/11/15 14:11

Non retention
18 inches

115-125F, time of
retention
5-10 mins
Hans Christian Fabrigas Vitug

10/11/15 14:11

NURSING CONSIDERATION IN
ENEMA ADMINISTRATION
Check doctors order
Provide privacy
Promote relaxation
Position the client
Choose appropriate size of tube
ADULT FR 22-23
CHILDREN FR 14-18
INFANT- FR 12
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Hans Christian Fabrigas Vitug

10/11/15 14:11

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

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 clear
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