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3846 FM i-xxii 02/01/14 9:49 AM Page iMANUAL OFI.V.TherapeuticsEvidence-Based Practicefor Infusion Therapy6th E D I T I O NLynn Dianne Phillips, MSN, RN, CRNI Professor EmeritusButte CollegeButte Valley, CaliforniaNursing Education ConsultantPresidentInfusion Nurses Society 2009–2010Lisa Gorski, MS, HHCNS-BC, CRNI , FAANClinical Nurse SpecialistWheaton Franciscan Home Health & HospiceMilwaukee, WisconsinPresidentInfusion Nurses Society 2007–2008
3846 FM i-xxii 02/01/14 9:49 AM Page iiF. A. Davis Company1915 Arch StreetPhiladelphia, PA 19103www.fadavis.comCopyright 2014 by F. A. Davis CompanyCopyright 2014 by F. A. Davis Company. All rights reserved. This book is protected bycopyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any formor by any means, electronic, mechanical, photocopying, recording, or otherwise, without writtenpermission from the publisher.Printed in the United States of AmericaLast digit indicates print number: 10 9 8 7 6 5 4 3 2 1Acquisitions Editor: Thomas A. CiavarellaDirector of Content Development: Darlene D. PedersenProject Editor: Echo K. GerhartElectronic Project Editor: Sandra GlennieCover Design: Carolyn O’BrienAs new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have doneeverything possible to make this book accurate, up to date, and in accord with accepted standardsat the time of publication. The author(s), editors, and publisher are not responsible for errors oromissions or for consequences from application of the book, and make no warranty, expressed orimplied, in regard to the contents of the book. Any practice described in this book should beapplied by the reader in accordance with professional standards of care used in regard to theunique circumstances that may apply in each situation. The reader is advised always to checkproduct information (package inserts) for changes and new information regarding dose andcontraindications before administering any drug. Caution is especially urged when using new orinfrequently ordered drugs.Library of Congress Cataloging-in-Publication DataPhillips, Lynn Dianne, 1947- author.Manual of I.V. therapeutics : evidence-based practice for infusion therapy/Lynn Dianne Phillips,Lisa Gorski. — Sixth edition.p. ; cm.Manual of I.V. therapeuticsManual of intravenous therapeuticsIncludes bibliographical references and index.ISBN 978-0-8036-3846-4I. Gorski, Lisa A., author. II. Title. III. Title: Manual of I.V. therapeutics. IV. Title: Manual ofintravenous therapeutics.[DNLM: 1. Infusions, Intravenous—methods—Examination Questions. 2. Infusions, Intravenous—methods—Handbooks. 3. Infusions, Intravenous—nursing—Examination Questions. 4. Infusions,Intravenous—nursing—Handbooks. WB 39]RM170615’.6—dc232013045751Authorization to photocopy items for internal or personal use, or the internal or personal useof specific clients, is granted by F. A. Davis Company for users registered with the CopyrightClearance Center (CCC) Transactional Reporting Service, provided that the fee of .25 per copy ispaid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that havebeen granted a photocopy license by CCC, a separate system of payment has been arranged. Thefee code for users of the Transactional Reporting Service is: 978-0-8036-3846-4/14 0 .25.
3846 FM i-xxii 02/01/14 9:49 AM Page iiiI want to dedicate this edition of the Manual to the supportive, lovingfriends I have had the good fortune to know through the Infusion NursesSociety: Mary Alexander, Michelle Berreth, Ann Corrigan, Beth Fabian,Lisa Gorski, Roxanne Perucca, Ofelia Santiago, Marvin Siegel, andMary Walsh. I am truly blessed. To Lisa, it has been a pleasure havingyou co-author this edition. You have been an excellent author, and thisedition is better than ever because of you!Additionally, as always, to nursing students—you are our future!Lynn PhillipsFirst of all, I want to thank Lynn for asking me to co-author thisedition of the Manual—it was a joy to work together! I dedicate thisbook to my husband John, my parents John and Audrey Morrill, andmy children Ben and Amanda Gorski, who have loved me and havesupported me in all my professional endeavors. And also to mycolleagues in the Infusion Nurses Society, who make a differenceevery day by supporting our Standards of Practice to ensure that ourpatients receive the best possible care.Lisa Gorski
3846 FM i-xxii 02/01/14 9:49 AM Page ivInvestin yourfuture!The nursing resources you’ll turn to every day.now and throughout your career!Buyyour SUPER DUO today!1. Visit us online atwww.fadavis.com2. Call 800.323.3555 (US)or 800.665.1148 (CAN)
3846 FM i-xxii 02/01/14 9:49 AM Page vPREFACEManual of I.V. Therapeutics: Evidence-Based Practice for Infusion Therapy, Sixth Edition,provides comprehensive information on infusion therapy for the nursing studentand practicing nurse. Continuing with this edition is the focus on evidence-basedpractice (EBP), defined as the conscientious use of current best evidence in makingdecisions about patient care. Evidence-based practice includes research evidence inthe form of systematic reviews and clinical practice guidelines to a clinician’sknowledge, judgment, and experience and de-emphasizes practice based on tradition and ritual. EBP is important to any nurse performing infusion therapy becauseof the rapidly expanding dimensions of the nurse’s role, the ongoing introductionof new infusion devices and techniques, and the evolving research supporting theimportance of nursing interventions in improving patient safety and reducing therisk of infusion-related complications. The sixth edition continues to address pediatric and the older adult patients in a separate section in each chapter. This textbook incorporates the 2011 Infusion Nurses Society Standards of Practice and the2011 Centers of Disease Control and Prevention (CDC) guidelines for prevention ofintravascular catheter-related infections.This self-paced, comprehensive text presents information ranging from asimple to a complex format, incorporating theory into clinical application. Theskills of recall, nursing process, critical thinking, and patient education arecovered, along with detailed summaries, providing the foundation one needs tobecome a knowledgeable practitioner. The psychomotor skills associated withinfusion therapy are presented in step-by-step procedures with rationales basedon standards of practice at the end of the chapters.Each chapter includes accompanying objectives, defined glossary terms thatare bolded within the text, a post-test, a summary of chapter highlights, and a critical thinking case study. Icons and special boxes are used throughout each chapterto key the reader to websites, patient education, home care issues, cultural considerations, and standards of practice. Skill Checks, 100 test questions, PowerPointpresentations, and math calculations tests are included in the DavisPlus facultyancillaries and can be used in the educational setting, as well as in agencies, forvalidating competencies of nurses in infusion skills. The icons used in this sixthedition are as follows: NOTEEBP Identifies key points of theory contentIdentifies Nursing Fast Facts, which are set in italics and shadedwithin the chapter for important nursing practice informationIdentifies relevant studies in Evidence-Based Practice (EBP)v
3846 FM i-xxii 02/01/14 9:49 AM Page vivi PrefaceIdentifies WebsitesIdentifies Nursing Points of CareIdentifies Home Care IssuesIdentifies Patient Education informationIdentifies a media link, which refers to DavisPlus, and is located inthe critical thinking case study and post-test sections at the end ofeach chapterINS StandardIdentifies Infusion Nurses Society (INS), Standards of PracticeThe sixth edition of this textbook is organized from foundations of practicefollowed by basic practices for all nurses and concludes with specialty infusionpractices. The first three foundations chapters are designed to provide informationto the reader on nursing practice related to infusion therapy (nursing process applied to infusion therapy, legal and ethical responsibilities, evidence-based practicebackground, and performance improvement), infection prevention and occupational hazards, and fundamentals of fluid and electrolyte balance.The subsequent seven chapters provide the essential solid foundation in infusion therapy practices, including parenteral solutions, infusion equipment, peripheral and central vascular access techniques and management, complications,medication infusion, and infusion calculations. This sixth edition has incorporatedrecurring displays for cultural and ethnic-related issues. Key concepts for nursingpractice are identified as “Nursing Fast Facts,” and “Note ” identifies an importanttheory concept.The last two chapters encompass the additional topics of transfusion therapyand parenteral nutrition. The DavisPlus website contains questions based on standards of practice and follows the guidelines of the INS Core Curriculum for certification. It includes guidelines for discussion and answers to the case studies, andadditional math calculations problems and answers. It also provides the learnerwith web-based ancillaries, an additional 50 interactive flash cards for learningterminology, interactive case studies, and web links for further research.We hope this new edition provides you, whether you are a practicing healthcare professional or a student, with valuable insights into the safe practice ofinfusion therapy and a reference for this rapidly advancing field.Lynn Phillips and Lisa Gorski
3846 FM i-xxii 02/01/14 9:49 AM Page viiCONSULTANTSMichelle Gricar, MS, RN, RMAClinical Nurse Specialist–WheatonFranciscan Healthcare St. FrancisMilwaukee, WisconsinMary McGoldrick, MS, RN, CRNI Home Care and Hospice Consultant–Home Health Systems, Inc.Saint Simons Island, GeorgiaMark Hunter, RN, CRNI Senior Product ManagerPeripheral Vascular AccessCareFusionVernon Hills, IllinoisHeather Moore, RN, BSNManager, Maternal/Child ProgramWheaton Franciscan Home Health& HospiceMilwaukee, WisconsinElizabeth Krzywda, MSN, APNP, NP-CNurse Practitioner–Medical College ofWisconsinMilwaukee, WisconsinDeb Richardson, RN, MS, CNSOwner/President–Deb Richardson &AssociatesHouston, Texasvii
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3846 FM i-xxii 02/01/14 9:49 AM Page ixREVIEWERSSharon L. Bateson, MSN, RN, B-CProfessor of NursingSierra CollegeRocklin, CaliforniaLaura L. Benton, RN, MSN, EdFaculty, Nursing Skills Lab ManagerHondros College Nursing ProgramsFairborn, OhioFaith Chennette,MSN, OCN, CNE, CPHN, RN-BCNursing FacultyCollege of Western IdahoNampa, IdahoSusan M. Hampson,MS, RN, APN, FNP-BC, CNEAssistant ProfessorSchool of NursingSaint Xavier UniversityChicago, IllinoisDiane Madsen, BSN, MA, PhD, RNNursing FacultyPueblo Community College–FremontCampusCanon City, ColoradoJudy Mahan, RN, MSDirector, Allied HealthFeather River CollegeQuincy, CaliforniaRox Ann Sparks,RN, MSN, MICN, LNCProfessor, Assistant DirectorVocational NursingMerced CollegeMerced, Californiaix
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3846 FM i-xxii 02/01/14 9:49 AM Page xiACKNOWLEDGMENTSThe authors would like to acknowledge the following:The nurses in the specialty practice of infusion therapyAt F. A. Davis:Tom Ciavarella, Nursing Acquisitions Editor, who assisted in the final development of this manual.Echo Gerhart, Project Editor, Nursing, who as project consultant helped bringthis vision to reality.Sam Rondinelli, Production Manager, for guiding this manuscript through theproduction process.Robert G. Martone, Publisher, Nursing, whose foresight brought the project toF. A. Davis.And. . . .Cassie Carey, Senior Production Editor at Graphic World IncAppreciation is also expressed to the following companies who providedproduct information, pictures, and illustrations:3M Medical Division, St. Paul, MNAngioDynamics, Marlborough, MABaxter Healthcare Corporation, Round Lake, ILB. Braun Medical Inc., Bethlehem, PABD Medical, Sandy, UTCareFusion, San Diego, CACatheter Connections, Salt Lake City, UTCenorin, Kent, WACenturion, Williamston, MICook Medical, Bloomington, INC. R. Bard Inc., Salt Lake City, UTInfusion Nurses Society, Norwood, MAInterrad Medical, Plymouth, MNI.V. House, Inc., Chesterfield, MOIvera Medical Corporation, San Diego, CAJ&J Wound Management, Division of Ethicon, Inc., Somerville, NJLippincott Williams & Wilkins, Philadelphia, PAMediVisuals, Inc., Dallas, TXMoog Medical Devices Corp., Salt Lake City, UTNorfolk Medical Products, Inc., Skokie, ILPall Medical, Port Washington, NYRGB Medical Imagery, Delaware, OHxi
3846 FM i-xxii 02/01/14 9:49 AM Page xiixii AcknowledgmentsSmiths-Medical Critical Care, Inc., Carlsbad, CATangent Medical, Ann Arbor, MITransLite LLC, Sugar Land, TXVidacare, San Antonio, TXVueTek Scientific, Gray, ME
3846 FM i-xxii 02/01/14 9:49 AM Page sing Competency 6Sources of Evidence 10Two Examples of Evidence Rating Scales 11Elements of Informed Consent 26Most Frequently Reviewed Sentinel Event Categoriesin 2012 28Organs of the Immune System 54Types and Functions of White Blood Cells 57Factors Associated with Increased CentralLine-Associated Bloodstream Infection (CLABSI) Risk 67Microorganisms Most Frequently Encountered 71Common Tests for Evaluating the Presence orRisk of Infusion-Related Infections 90Sharps Safety Devices and Recommendations 92Percentages of Total Body Fluid in Relationto Age and Gender 117Regulators of Fluid Balance 128Summary of Laboratory Evaluation for Fluidand Electrolyte Imbalances 133Quick Assessment Guide for Fluid Imbalances 140Comparison of Electrolyte Composition in FluidCompartments 142Critical Guidelines for Administration of Potassium 154Critical Guidelines for Removal of Potassium 157Critical Guidelines for Administration of Magnesium 167Clinical Problems Associated with ElectrolyteImbalances 173Summary of Acute Acid–Base Imbalances 185Contents of Available Intravenous Fluids 214Quick-Glance Chart of Common I.V. Fluids 216Common Colloid Volume Expanders 227Smart Pump Features 294Infusion Pump Risk Reduction Strategies for Clinicians 297Comparison of Artery and Vein 315Selecting an Insertion Site for SuperficialVeins of Dorsum of Hand and Arm 318xiii
3846 FM i-xxii 02/01/14 9:49 AM Page xivxiv 8-18-2Phillips 16-Step Peripheral-Venipuncture Method 320Tips for Selecting Veins 327Phillips Multiple Tourniquet Technique 330Transillumination 331Techniques to Assist with Difficult Venous Access 333Recommended Gauges 337Conversion Chart: Rate Calculation 351Summary of Steps in Initiating Peripheral l.V. Therapy 353Components of the Pediatric Physical Assessment 363Pediatric Infusion Sites 364Flushing Guidelines for Pediatric Patients 369Tips for the Older Adult with Fragile Veins 375Duties of the Nurse or Phlebotomist 409Blood Collection Tray Contents 411Order of Draw for Multiple Tube Collections 435Measurements of Veins (Adult) 468Conditions Affecting Vascular Access Device SitePlacement 471Flushing Protocols 496Comparison of Central Venous Catheters 498Summary of Care and Maintenance of CentralVascular Access Devices 510Neonatal and Pediatric Flushing Protocols 511Types of Phlebitis 546Factors Increasing Risk for Phlebitis 547Phlebitis Scale 549Infiltration Scale 557Factors That Increase Risk for Extravasation Injury 560Local and Systemic Complications of PeripheralIntravenous Therapy 567Central Venous Catheter BloodstreamInfection Prevention 572Summary of Complications of Central Venous Access 599Advantages and Disadvantages of IntravenousMedication Administration 619Patient Risk Factors for Oversedation and RespiratoryDepression with Patient-Controlled Analgesia 631Epidural and Intrathecal Medications 657Monitoring Parameters for the Patient Receivingan Intraspinal Infusion 659Eight Rights of Medication Administration 663ABO Blood Grouping Chart 687ABO Compatibilities for Red Blood Cell Components 687ABO Compatibility for Fresh Frozen Plasma 310-410-511-111-211-3Tables
3846 FM i-xxii 02/01/14 9:49 AM Page -5 XVBlood Types by Population 688Blood Conservation Methods 701Summary of Common Blood Components 717Steps in the Administration of a Blood Component 723Risks of Transfusion Therapy 735Summary of Transfusion Reactions 736Components of a Nutritional Assessment 773Physical Findings Associated with Deficiency States 777Dextrose Solutions for Parenteral Nutrition 780Components of Parenteral Nutrition Order Form 788Complications Associated with PN 801
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3846 FM i-xxii 02/01/14 9:49 AM Page xviiCONTENTSINBRIEF1 Professional Practice Concepts for InfusionTherapy 12 Infection Prevention and Occupational Risks 493 Fundamentals of Fluid and Electrolyte Balance 1134 Parenteral Solutions 1985 Infusion Equipment 2406 Techniques for Initiation and Maintenanceof Peripheral Infusion Therapy 3097 Phlebotomy Techniques 4068 Techniques for Initiation and Maintenanceof Central Vascular Access 4629 Complications of Infusion Therapy: Peripheraland Central Vascular Access Devices 54010 Infusion Medication Safety, Methods,and Routes 61211 Transfusion Therapy 68212 Parenteral Nutrition 766xvii
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3846 FM i-xxii 02/01/14 9:49 AM Page xixCONTENTSCHAPTER 1Professional Practice Conceptsfor Infusion Therapy 1Introduction 4Delivery of Quality Care 5Nursing Process Re
Nursing Faculty Pueblo Community College–Fremont Campus Canon City, Colorado Judy Mahan, RN, MS Director, Allied Health Feather River College Quincy, California Rox Ann Sparks, RN, MSN, MICN, LNC Professor, Assistant Director Vocational Nursing Merced College Merced, California 3846_FM_i-xxii 02/01/14 9:49 AM Page ix
