Editing Nursing Skills and Procedures (section)

== Basic Intravenous Therapy ==

=== Site selection and insertion ===
Choose the most distal appropriate site in a nondominant upper extremity and move proximally with subsequent attempts, so that a failed site does not compromise a vein below it. Avoid areas of flexion, the antecubital fossa when other options exist, veins in an extremity with an arteriovenous fistula or graft, the side of a mastectomy with lymph node dissection, an extremity with lymphedema, a paralyzed or postcerebrovascular accident limb, and sites distal to a previous infiltration or phlebitis. Lower extremity veins are avoided in adults because of thrombosis risk.

Gauge selection: 14 to 16 for trauma and rapid volume resuscitation, 18 for blood products and surgery, 20 as a general-purpose adult size and acceptable for blood, and 22 to 24 for fragile, elderly, or pediatric veins. Prepare the skin with chlorhexidine using friction and let it dry completely; drying time is what kills organisms. Apply a tourniquet 10 to 15 cm above the site for no longer than a minute or two, insert bevel up at about 10 to 30 degrees, advance the catheter off the needle after blood return, release the tourniquet, connect and flush, and secure with a sterile transparent dressing labeled with date, time, gauge, and initials.

Peripheral catheters are changed based on clinical indication rather than a fixed schedule in most current guidance, and any catheter inserted under emergency conditions with questionable asepsis is replaced as soon as feasible.

=== Fluids ===
* Isotonic fluids such as 0.9 percent sodium chloride and lactated Ringer stay in the extracellular space and expand circulating volume. Used for hypovolemia and shock. Watch for fluid overload in heart failure and renal disease. Normal saline is the only solution compatible with blood products. Lactated Ringer is avoided in significant liver disease and in hyperkalemia caution contexts.
* Hypotonic fluids such as 0.45 percent sodium chloride shift water into cells. Used for cellular dehydration and hypernatremia. Contraindicated in increased intracranial pressure and in burns, where they worsen edema.
* Hypertonic fluids such as 3 percent sodium chloride, dextrose 10 percent, and dextrose 5 percent in 0.9 percent sodium chloride pull fluid into the vascular space. Used for severe hyponatremia and cerebral edema. Infuse slowly through a large vein with frequent neurologic and sodium monitoring, and watch for fluid overload.
* Dextrose 5 percent in water is isotonic in the bag but becomes effectively hypotonic once the dextrose is metabolized, so it is not used for resuscitation and is avoided in patients at risk for cerebral edema.

Potassium chloride is '''never''' given by intravenous push and is always diluted and infused by pump, with typical peripheral concentration and rate limits and continuous monitoring; rapid potassium administration causes fatal dysrhythmia.

=== Complications and immediate actions ===
* '''Infiltration''': nonvesicant fluid leaks into tissue. Coolness, pallor, swelling, slowed rate, and no blood return. Stop the infusion, discontinue the catheter, elevate the limb, and apply a warm or cool compress per protocol.
* '''Extravasation''': the same event with a vesicant such as a vasopressor or many chemotherapy agents. Stop the infusion, leave the catheter in place initially, aspirate residual drug, notify the provider, and give the specific antidote such as phentolamine for norepinephrine extravasation. This causes tissue necrosis.
* '''Phlebitis''': redness, warmth, pain, and a palpable cord along the vein. Discontinue, apply warm compress, and restart in the opposite extremity.
* '''Local or bloodstream infection''': purulence at the site, fever, chills. Discontinue, culture as ordered, and notify.
* '''Fluid overload''': dyspnea, crackles, jugular venous distension, bounding pulse, rising blood pressure, and weight gain. Slow the infusion to keep the vein open, raise the head of the bed, administer oxygen, notify the provider, and anticipate a diuretic.
* '''Air embolism''': sudden dyspnea, chest pain, hypotension, tachycardia, and altered mental status. Clamp the line, place the patient on the left side in Trendelenburg to trap air in the right ventricular apex, administer 100 percent oxygen, and notify the provider immediately.
* '''Speed shock''': systemic reaction to a bolus given too rapidly, with flushing, headache, chest tightness, irregular pulse, and possible cardiac arrest. Stop the infusion and support the patient.
* '''Catheter embolism''': suspected when the removed catheter tip is not intact. Apply a tourniquet high on the extremity, place the patient on the left side, and notify immediately.

=== Central venous access ===
Central venous access devices include nontunneled central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters. Tip position in the lower superior vena cava must be confirmed radiographically before first use. Central access is required for vesicants, parenteral nutrition, solutions with high osmolarity, and long-term therapy.

Infection prevention bundle: hand hygiene, maximal sterile barrier precautions at insertion, chlorhexidine skin antisepsis with full drying time, optimal site selection with the femoral site avoided in adults, scrubbing the needleless connector for the specified time before each access, sterile dressing changes at defined intervals or whenever the dressing is damp, loose, or soiled, and daily review of whether the line is still necessary. Prompt removal of an unnecessary line is the most effective single measure.

Air embolism prevention during insertion and removal of a central catheter: position the patient supine or in Trendelenburg when the anatomy allows, have the patient perform the Valsalva maneuver or exhale during removal, and apply an occlusive petroleum-based dressing to the exit site afterward, keeping the patient flat briefly. Immediately after subclavian or internal jugular insertion, the nurse assesses for pneumothorax, watching for sudden dyspnea, chest pain, diminished breath sounds on the affected side, and tracheal deviation.

Flushing uses a pulsatile push-pause technique with preservative-free normal saline, and clamping is timed to maintain positive pressure appropriate to the connector type. A blood return should be present before administration; absent return may indicate a fibrin sheath or thrombus and is reported rather than forced. Never use a small syringe such as 1 or 3 mL to force a clot, because the smaller barrel generates dangerously high pressure and can rupture the catheter.

=== Blood administration ===
Verify a signed consent and a patent large-gauge access, prime only with 0.9 percent sodium chloride using Y-tubing with a filter, and complete a two-person verification of the patient identifiers, blood type, unit number, and expiration. Obtain baseline vital signs, begin slowly, and remain with the patient for the first 15 minutes because most severe reactions occur early. Recheck vital signs per policy and complete the unit within four hours.

If a transfusion reaction is suspected, stop the transfusion immediately, disconnect the blood tubing and maintain the line with normal saline using new tubing, assess the patient and take vital signs, notify the provider and blood bank, and return the unit and tubing with a post-transfusion blood and urine specimen. Acute hemolytic reaction presents with fever, chills, flank or back pain, hypotension, and dark urine. Febrile nonhemolytic reaction produces fever and chills. Allergic reaction produces urticaria and itching, and anaphylaxis produces bronchospasm and hypotension. Transfusion-associated circulatory overload produces dyspnea and crackles, while transfusion-related acute lung injury produces hypoxemia and bilateral infiltrates without volume overload.