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For nearly 44 years, Plumer’s Principles & Practice of Infusion Therapy has retained its position as the most reliable, complete source of information addressing intravenous therapy for practicing clinicians, educators, and students. Completely updated and revised to meet the changing needs of our professional practice, this ninth edition, like its predecessors, provides the most current base of knowledge available to those who share the responsibility of ensuring high-quality infusion care to patients in diverse clinical settings.
The practice of infusion therapy is a multifaceted one. Infusion therapy is at the core of patient care. Our practice continually evolves as a result of changing patient care delivery systems, the impact of managed care, reengineering of the health care system, and the impact of integrated health care delivery systems. These changes have had a dramatic impact on our professional practice as we move on the continuum from care delivered in the acute care environment to care delivered in alternative sites. One thing remains unchanged, however, and that is the continuous need for an unprecedented high level of expertise for delivering infusion therapy.
Plumer’s Principles & Practice of Infusion Therapy, ninth edition, has been updated and reorganized to produce a resource that clearly exceeds these needs. The addition of even more boxes, tables, safety and legal issues, step-by-step directions, nursing alerts, tables, and references to the World Wide Web and evidence-based practice create an easy-to-use format with easy-to-access references. With a focus on the Licensed Independent Practitioner (LIP), you will recognize the changes that have been implemented. An integrated approach to content results in a streamlined five-section organization. Part 1 reviews the history of infusion therapy, risk reduction and performance improvement, legal safeguards, nursing role and responsibilities, application of the Infusion Nurses Society Standards of Practice, and Nurse and Patient Education. New content addresses shared governance models, knowledge sharing, mentoring, and applications for Magnet Recognition.
Part 2 has undergone extensive change. Now addressing assessment and monitoring, this section has been expanded to encompass fluid and electrolyte balance, principles of parenteral fluid administration, relevant anatomy and physiology, laboratory data, ongoing monitoring, and complications and nursing interventions as well as evidence-based infusion practice. A new section on sentinel events and reflex sympathetic dystrophy discusses the challenging clinical outcomes that we now face.
Part 3 has been renamed Clinical Decision Making. In this section, we present current information about infusion equipment and safety; methods for assessing product and equipment needs; short peripheral lines; central vascular access; and expanded approaches to access and monitoring, which encompasses intra-arterial, reservoir, subcutaneous infusion, intraventricular and intraosseous routes. New contributing authors have created a user-friendly section that meets your continuous learning needs.
Patient-Specific Therapies are addressed in the revamped Part 4. A plethora of talented contributing authors has created the most current and complete source of information available today. Mary E. Hagle led a team of clinical experts that completely updated the section on blood and blood component therapy, including factor II and factor V Leiden disorders, consistent with the dramatic changes in practice and the revised standards. The addition of a new coauthor to the chapter on pain expanded on the solid base of information created by
x Preface
Barbara St. Marie, emphasizing practical aspects of care, IV conscious sedation, and continuous local anesthesia. The chapter on pharmacology applied to infusion therapy has been updated with an emphasis on therapeutic monitoring and drug level ranges.
Part 5 addresses Special Populations. The pediatric infusion therapy chapter has new co-authors who have updated Anne Marie Frey’s original work. Infusion therapy in the older adult and across the continuum of care rounds out this section. And finally, the future of infusion nursing has been renamed The Future of Infusion Nursing: A Global Approach, with a focus on the growth of the specialty worldwide. Thus, we proudly offer you an updated, state-of-the-art ninth edition.
Revised to meet the needs of the clinician responsible for delivering high-quality infusion care, regardless of the clinical setting in which care is provided, Plumer’s Principles & Practice of Infusion Therapy, ninth edition, retains its place as the most essential tool available in infusion practice today. May you enjoy it and gain value from it.
Sharon M. Weinstein, MS, RN, CRNI®, FACW, FAAN
acknowleDGMents
Plumer’s Principles & Practice of Infusion Therapy, ninth edition, is the result of the collaborative efforts of its original authors, Ada Lawrence Plumer and Faye Cosentino, and the contributions of veteran authors Anne Marie Frey and Barbara St. Marie, Mary E. Hagle, and myself. This edition welcomes a coauthor, Mary E. Hagle and the contributions of a team of collaborators from multiple national medical centers. We are so grateful to them for their valuable contributions to this text, and for the contributions that they have individually and collectively made to our professional practice. I would also like to thank the manufacturers of infusion products and equipment for their information and assistance, as well as the authors and publishers who permitted use of their copyrighted materials in producing this text.
A special thank you to Lisa Marshall for her encouragement, support, and technical assistance in developing a superior manuscript—one that readily supports the Plumer name. Thanks are extended to William Eudailey, PharmD and to the late David Blaess, RPh, who served as my mentors and who taught me to apply the principles gleaned from Plumer’s book to my daily practice. Men of vision, they gave me the opportunity to explore the world of infusion therapy.
There are so many professionals in the infusion specialty whose names are synonymous with quality; these individuals are seasoned professionals as well as novices. You will continue to generate passion for infusion therapy in those with whom you work for years to come. You may have been taught by one of your mentors or colleagues; you, in turn, have the responsibility to teach others. We must develop future generations of leaders in the infusion specialty practice; we must think globally with a vision for the future. Thus, once again, all proceeds from the ninth edition of Plumer will go to the Global Education Development Institute, an organization whose mission is to foster the professional and personal growth of nurse leaders in developing countries.
And so, to the countless numbers of infusion specialty nurses throughout the world who promote quality outcomes each and every day of their lives, regardless of the clinical setting in which care is delivered, this book is for you.
Finally, thanks to my husband Steve, and to my family, for delighting in and acknowledging my continuing passion for infusion therapy. — SMW
Infusion therapy is not done in isolation, nor is advancing our practice, professional development, or creating a text that serves as a resource for nurses new to infusion therapy or experts from different areas. It has been a pleasure promoting a team of clinicians to share their expertise from all areas of practice that support infusion therapy. It is a privilege to work with Sharon again and bring a new edition to realization.
Grateful appreciation is extended to Mark and my family for their questions, humor, and limitless support to advance quality and safety in health care and infusion therapy. —MEH
sPecial acknowleDGMents
As Plumer’s reaches 44 years as the premier source of information in infusion therapy, it is appropriate to recognize the woman who first penned this text. The name Ada Plumer is synonymous with infusion therapy. A leader, pacesetter, and cofounder of the professional society, Plumer set the tone for our professional practice, served as a mentor to many nurses, and encouraged excellence in the delivery of intravenous nursing care. Ms. Plumer wrote, “In spite of the increasing use and importance of parenteral therapy, little training is required of the average therapist to carry it out. It is considered sufficient by some that the therapist be able to perform a venipuncture. This does not contribute to the optimal care of the patient whose prognosis depends upon intravenous therapy. The purpose of this book is to present a source of practical information essential to safe and successful therapy.” Ada Plumer was a visionary; little could she know that the knowledge base would expand to such a critical level, and that infusion nurses would advance from novice to expert, continuing to educate nurses through publication of their findings, their practices, and their research.
From my first entry into this rapidly changing field to today, I have used Plumer’s book as a reference, a guide, and a bible for professional practice. Plumer’s retains its position today as the only complete source of information available to the practicing clinician, student, and educator. The success of the current edition is attributed to Plumer … the growth of our practice is likewise a result of her initial efforts; we remember her with great respect. Many thanks from all of us in whom you have instilled a passion for excellence in infusion nursing practice.
Contributors v
Preface ix
Acknowledgments xi
Special Acknowledgments xiii
List of Tables xix
Part 1 oVerView of infusion theraPy 1
1 History of Infusion Therapy 3
Early History and Methodology 3
The Infusion Nurses Society, Inc. 9 Infusion Nursing in the 21st Century 11
2 Minimizing Risk and Enhancing Performance 13
Professional Nursing Practice and Legal Safeguards 13
Professional Nursing and Performance Improvement 21
3 Nursing Role and Responsibilities 37
Role Delineation 37
Scope of Practice 38
Collaborative Role of the Nurse 38
Role of Infusion Nursing Teams 38
Resource Nurse 39
Mentor 40
Educator and Knowledge Sharer 41
Barriers 41
Overcoming the Barriers 41
The Evolving Role of Knowledge Sharer 41
The Innovator 42 Magnet Team Member 42
Shared Governance 44
Advocate 45
Researcher 46
Role as a Leader 46
IV Department Considerations 47
Impact of Cost Containment on Teams 51
The Future of Infusion Nursing 52
4 Standards of Practice 56
The Standards 56
Nursing Practice 56
Patient Care 59
Documentation 59
Infection Prevention and Safety Compliance 59
Site Care and Maintenance 60
Infusion-Related Complications 60
Other Infusion-Related Procedures 60
Infusion Therapies 60
5 Nurse and Patient Education 64
Knowledge Sharing 64
The Infusion Nurse 65 Infusion Nurses’ Education, Competency, and Professional Development 66
Education for Patients Receiving Infusion Therapy 77
Conclusion 83
Part 2 clinical assessMent anD MonitorinG 89
6 Anatomy and Physiology Applied to Infusion Therapy 91
Vascular Anatomy and Therapeutic Goals 91
Systems and Organs Involved in Infusion Therapy 93
7 Diagnostic Testing and Values 108
Clinical Significance of Blood Collection for Testing 108
Practice Standards in Testing 109
Collecting Blood and Blood Components 111
Common Laboratory Tests 117
Complementary and Alternative Medicine 137
8 Fluid and Electrolyte Balance 142
Overview of Physiology 142
Objectives of Fluid and Electrolyte Therapy 157
Fluid and Electrolyte Disturbances in Specific Patients 159
Summary 169
9 Principles of Parenteral Administration 173
Parenteral Fluids 173
Kinds and Composition of Fluids 176
Nursing Focused Assessment 190
Clinical Disturbances of Water and Electrolyte Metabolism 195
10 Complications and Nursing Interventions 203
Understanding Complications 203
Local Complications 204
Systemic Complications 213
Additional Hazards: Particulates 228
Ongoing Monitoring and Precautions 237
11 Evidence-Based Infusion Practice 245
Practice Based on Evidence 245
Evidence-Based Practice 246
Creating a Culture of Evidence-Based Practice 249
Steps for Practice Based on Evidence 249
Evidence-Based Practice and Outcomes 259
Part 3 clinical Decision MakinG 265
12 Infusion Delivery Systems and Safety 267
From Idea to Inception 267
Safety Principles and Selection of Equipment 270
Equipment Safety and Use 297
13 Peripheral Venous Access 303
Infusion Therapy with Short Peripheral Catheters 303
Patient Preparation for Peripheral Venous Access 304
Considerations for Short Peripheral Catheter Infusion 307
Vein Selection 309
Initiating Peripheral Venous Access with Short Catheters 312
Midline Catheters 328
Phlebotomy for Therapeutic Purposes 330
14 Central Venous Access 335
Central Venous Access 335
Indications for Central Venous Access Devices 338
Overview of CVAD Types 339
Education and Training for Health Care Personnel 345
Infection Prevention and Control 345
Central Venous Access Device and Site Selection 346
Preparation for CVAD Insertion 349
Insertion of the Central Venous Catheter 350
CVAD Descriptions 355
Implanted Ports 361
Implanted Infusion Pump 365
Maintenance of Central Venous Access Devices 366
Complications of Central Venous Catheters or Devices 378
Nursing Practice: Skilled, Knowledgeable, and Safe 387
15 Expanded Approaches to Access and Monitoring 391
Significance of Expanded Access 391
Arterial Blood Sampling and Pressure Monitoring 392
Peripheral Arterial Catheters and Monitoring 398
Purpose and Use of Arterial Blood Gas Analysis 401
Hemodialysis/Renal Replacement Therapy 417
Intraosseous Infusion Devices 420
Ventricular Reservoirs 422
Part 4 Patient-sPecific theraPies 427
16 Parenteral Nutrition 429
History of Parenteral Nutrition 429
Overview of Parenteral Nutrition 430
Indications for Treatment 431
Nutritional Assessment 433
Decision for Nutritional Support 441
Nutritional Requirements 441
Parenteral Nutrition Solutions 445
Administration of Parenteral Nutrition 452
Nursing Management 459
Patient Surveillance 461
Complications of Parenteral Nutrition 463
Home Parenteral Nutrition 472
17 Blood and Blood Component Therapy 480
Blood and Blood Component Therapy—21st Century Considerations 481
Basic Immunohematology 483
Pretransfusion Testing, Blood Donation, and Blood Preservation 485
Whole Blood 489
Red Blood Cells 490
Platelets 493
Granulocytes 495
Plasma 496
Summary 526
18 Pharmacology Applied to Infusion Therapy 530
Administering Drug Therapy by the Intravenous Route 530
Advantages of the Intravenous Route 531
Disadvantages of the Intravenous Route 534
Safeguards to Minimize Hazards of Administering Intravenous Drugs 539
19 Antineoplastic Therapy 553
Role of the Intravenous Nurse in Chemotherapy/Biotherapy Education 553
Safe Preparation, Handling, and Disposal of Chemotherapeutic and Biologic Agents 564
Overview of Antineoplastic Therapy 571
Systemic Drug Delivery Technique 608
Complications of Chemotherapy Administration 620
Hypersensitivity and Generalized Anaphylactic Reaction 622
Management of Side Effects 635
20 Pain Management 651
Role of Nurses in Pain Management 651
Definitions of Pain 656
Mechanisms of Pain 660
Pain Management Strategies for the Infusion Nurse 660
Documentation of Pain: The Fifth Vital Sign 676
Part 5 sPecial PoPulations 685
21 Pediatric Infusion Therapy 687
Infusion Therapy in Infants and Children 687
Psychosocial Stages of Development 687
Physiologic Stages of Development 697
Infusion Therapies for Neonates and Children 707
Conditions and Disease States 711
Types of Access 715
Infusion Equipment 734
Alternate-Site Infusion Therapy 736
22 Infusion Therapy in an Older Adult 743
Demographics: An Aging Population 743
The Older Adult Patient as a Health Care Consumer 745
Access and Equipment 751
IV Therapy Maintenance and Monitoring 753
Summary 754
23 Infusion Therapy across the Continuum of Care 757
The Evolving Health Care Environment 757
Influence of Managed Care 758
Home Health Care 759
Hospice 776
Subacute Care Facilities 777
The Infusion Suite or Ambulatory Infusion Center 778
Long-Term Care 779
Future Infusion Technology for Alternate Care Programs 780
24 The Future of Infusion Nursing: A Global Approach 784
Overview 784
Strategic Partnering 785
Nursing Image 785
The Environment 786
Shifting Paradigms 792
International Migration 793
A Global Perspective 793
Excellence 793
A Solid Past and a Secure Future 794
Answers to Review Questions 799
Glossar y 801
Index 808
list of tables
Table 1–1 Twentieth‐ and Twenty‐First‐Century Progress in Infusion Therapy 5
Table 2–1 Sources of Standards of Care Related to Infusion Therapy 15
Table 2–2 Advancing Patient Safety: 14 Years of Advancing the Evidence 23
Table 2–3 Simple Rules for the 21st Century Health Care System 24
Table 2–4 The IOM Quality Chasm Series 25
Table 2–5 National Patient Safety Standards Related to Infusion Therapy 28
Table 2–6 National Quality Indicators 31
Table 3–1 Barriers of Knowledge Sharing 41
Table 3–2 Reassessing the Role of the Infusion Team 44
Table 3–3 The Magnet Characteristics of a Professional Practice Environment Forces of Magnetism 1983 (McClure) 45
Table 3–4 Simulation Teaching Models 52
Table 4–1 Phlebitis Scale 61
Table 5–1 Curriculum Plan and Content for Care of the Patient with a Peripherally Inserted Central Catheter (PICC) 68
Table 5–2 Simulation Case Worksheet and Scenario 72
Table 5–3 Example of Competency Assessment Form 76
Table 5–4 Infusion Nurse Certification and Providers 78
Table 5–5 Patient Care Education Content Based on Setting 80
Table 5–6 Patient/Caregiver Education Resources for Medication 82
Table 5–7 Patient Teaching Evaluation Tool 83
Table 6–1 Layers of the Epidermis 93
Table 6–2 Layers of the Dermis 94
Table 6–3 Determining the Appropriate Peripheral Venipuncture Site 103
Table 7–1 Standards for Diagnostic Testing 110
Table 7–2 Selected Laboratory Values 118
Table 7–3 Examples of Conversions to Système International (SI) Units 120
Table 7–4 Advantages and Disadvantages of aPTT and Anti‐Xa Monitoring 132
Table 7–5 Recommended Laboratory Evaluation for Suspected Underlying Hypercoagulable State 133
Table 7–6 Clinically Important Interactions of St. John’s Wort (SJW) 138
Table 7–7 Herb or Supplement and Drug‐Type Interactions with Possible Effects 139
Table 8–1 Intracellular and Extracellular Concentrations and Related Serum Values 153
Table 8–2 Plasma Electrolytes 153
Table 8–3 Fluid and Electrolyte Maintenance Requirements 158
Table 8–4 Differentiating Acidosis from Alkalosis 159
Table 8–5 Selected Nursing Diagnoses for Postoperative Patient After Abdominal Surgery 165
Table 8–6 The Burn Patient Receiving Parenteral Fluid Therapy 166
Table 8–7 Rule of Nines for Estimating Burned Body Area in Adults 167
Table 8–8 Factors Contributing to Development of DKA or HHNC in Susceptible Persons 169 xix
xx list of tables
Table 9–1 Results of Infusion of Fluids with Different Tonicities 175
Table 9–2 Contents of Selected Water and Electrolyte Solutions 189
Table 21–8 Assessment: Parameters for Determining the Level of Dehydration 702
Table 21–9 Significant Laboratory Values for the Patient Receiving Parenteral Nutrition 706
Table 21–10 Parameters for Blood Component Therapy 708
Table 21–11 Types of Infusions Administered for the IO Route 717
Table 21–12 Commonly Used Peripheral Sites 722
Table 21–13 Routine Care and Maintenance of the Infusion Site 728
Table 22–1 The Aging of the Body’s Systems 747
Table 22–2 Special Techniques for IV Insertion in the Older Adult Patient 752
Table 23–1 Medicare Payment Rates for Intravenous Drug Infusions across Settings, 2012 761
Table 23–2 Select Examples of Home Infusion Codes 762
Table 23–3 Comparison of TJC, ACHC, and CHAP 768
Table 23–4 Patient Education: A Spanish Language Reference 772
Table 24–1 Ten Trends to Watch That Impact Nursing 787
Table 24–2 Qualities of a Good Mentor 792
Table 24–3 Terminology Associated With Knowledge Management 794
Overview O f i nfusi O n Therapy
Sharon M. Weinstein
Chap T er
History of Infusion Therapy
Hypotonicity Isotonic Parenteral Pyrogens
Safety Quill and Bladder Standards of Practice
early hisTOry and MeThOdOlOgy
Almost 400 years have passed since the discovery of blood circulation. William Harvey's 1628 research stimulated increased experimentation, and he found that the heart is both a muscle and a pump.
renaissance period
In 1656, Sir Christopher Wren, the famed architect of St. Paul's Cathedral in London, injected opium intravenously into dogs. Wren, known as the father of modern intravenous (IV) therapy, used a quill and bladder. In 1662, Johann Majors made the first successful injection of unpurified compounds into human beings, although death resulted from infection at the injection site.
In 1665, an animal near death from loss of blood was saved by the infusion of blood from another animal. In 1667, a 15-year-old Parisian boy was the first human to receive a transfusion successfully; lamb's blood was administered directly into the boy's circulation by Jean Baptiste Denis, physician to Louis XIV (Cosnett, 1989). The enthusiasm aroused by this success led to promiscuous transfusions of blood from animals to humans with fatal results, and in 1687, by an edict of church and parliament, animal-to-human transfusions
Key Ter M s
were prohibited in Europe. Nearly 150 years passed before serious attempts were again made to inject blood into people.
The 19th Century
James Blundell, an English obstetrician, revived the idea of blood transfusion. In 1834, saving the lives of many women threatened by hemorrhage during childbirth, he proved that animal blood was unfit to inject into humans and that only human blood was safe. Nevertheless, there were safety concerns, and complications persisted, with infections developing in donors and recipients. With the discovery of the principles of antisepsis by Pasteur and Lister, another obstacle was overcome, although reactions and deaths continued.
The first recorded attempt to prevent coagulation during transfusion was in 1821 by Jean Louis Prévost, a French physician who, with Jean B. A. Dumas, used defibrinated blood in animal transfusions (Cosnett, 1989).
In the middle to late 19th century, increased knowledge of bacteriology, pharmacology, and pathology led to new approaches. Ignaz Semmelweis, a Viennese obstetrician, was the first to correlate the effect of hand washing on prevention of infection. Semmelweis is credited with a 90% reduction of maternal deaths between 1846 and 1848. Meanwhile, chemist Louis Pasteur was proving that bacteria were living microorganisms, although his ideas were challenged by many researchers and practitioners.
In 1889, William Halsted of the Johns Hopkins Hospital, in cooperation with Goodyear Rubber Company, introduced the use of surgical gloves in the operating theater. Ten years later, the use of rubber gloves was widely accepted as a means of protecting patients and physicians (Sutcliff, 1992).
In 1896, the H. Wulfing Luer Company of France developed the Luer connection, allowing the head of a hypodermic needle to be easily attached and detached from a glass syringe. This connection, which is composed of tapering male and female components, is still used today to attach various pieces in an IV line. These interlocking pieces allow practitioners to change IV bags, add additional drip lines, and attach the IV tubing to the needle with minimal discomfort to the patient.
French physiologist Claude Bernard is credited with experimental injection of sugar solutions into dogs. The precursor to modern nutritional support, Bernard's experiments were followed by the subcutaneous injection of fat, milk, and camphor by Menzel and Perco in Vienna. Work in nutritional support remained at a standstill for many years.
Twentieth-Century advances
In the 20th century, IV therapy advanced rapidly. Blood transfusions and parenteral fluids, which bypass the intestines, were administered, and parenteral nutrition became possible as well. Moreover, nurses became skilled in both administering and monitoring infusions.
Pa TI en T Safe T y
Patient safety has been a concern since the 19th century.
Transfusion Therapy
In 1900, Karl Landsteiner proved that not all human blood is alike when he identified four main classifications. In 1914, sodium citrate was found to prevent blood from clotting (Cosnett, 1989), and since then, rapid advances have been made (Table 1-1).
TwenTieTh- and TwenTy-firsT-CenTury prOgress in infusiOn Therapy
year significant advancement
1900 Karl Landsteiner discovered three of four main blood groups
1914 Sodium citrate was first used to preserve blood
Hydrolyzed protein and fats were administered to animals
1925 Dextrose was used as an infusate
1935 Marriot and Kekwick introduced slow-drip method of transfusion
1937 Rose identified amino acids essential for growth
1940 Disposable plastic administration sets were developed
1945 flexible intravenous (IV) cutdown catheter was introduced
1950 Rochester needle was introduced
1960 Peripherally inserted catheter lines were introduced in intensive care areas
1963–1965 first success with hyperalimentation at the University of Pennsylvania
1964 first disposable intravenous catheter introduced by Deseret
1970 Centers for Disease Control (CDC) guidelines for IV therapy were published first edition of Plumer's Principles and Practice of Intravenous Therapy was published
1972 access with implanted ports was introduced
1972 The american association of IV nurses was organized by ada Plumer, Marguerite Knight, and colleagues
1973 The professional society name was changed to reflect a more inclusive audience—national Intravenous Therapy association (nITa)
Broviac tunneled catheter was introduced
1976 fat emulsions were used for nutritional support
1980 nITa Standards of Practice was published
nITa national Office opened
IV nurse Day was recognized by U.S. House of Representatives
1981 CDC Guidelines were revised and published
1982 Implantable ports were used for long-term access
first IV teaching program in People's Republic of China
1983 Home blood transfusion initiated
Osteoport was developed
1984 Core Curriculum for Intravenous nursing was published
1985 Intravenous nurses Certification Corporation offered its first credentialing examination (CRnI)
1986 Use of patient- controlled analgesia increased
(Continued)
Table 1-1
Table 1-1 TwenTieTh- and TwenTy-firsT-CenTury prOgress in infusiOn Therapy (Continued)
year significant advancement
1987 Development by the Centers for Disease Control and Prevention (CDC) of “standard precautions”
1987 nITa changed its name to the Intravenous nurses Society (InS)
1990
1992
1995
Safe Medical Device act and food and Drug administration Device Reporting regulations published
InS Revised Standards of Practice published
U.S. food and Drug administration issued alert concerning needlestick injuries
Occupational Safety and Health guidelines for handling cytotoxic drugs published
1996 LPnI examination offered to LPn/LVns by InS
CDC Guidelines revised and published
1998 InS celebrated its 25th anniversary (Houston, TX)
1999 Journal of Intravenous nursing offered Ce/recertification units
2000 Core Curriculum for Intravenous nursing , 2nd edition, published
Revised Standards of Practice published
InS Policies and Procedures Manual published
CRnI exam Preparation Guide & Practice Questions published first public member added to the InS board of directors
2001 The organization's name again changed to the Infusion nurses Society reflecting the expansive role of the infusion nursing specialist
2002 Publication of the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections supporting the use of trained personnel
2003 Core Curriculum for Infusion nursing , 3rd edition, published Infusion nurses Society celebrates its 30th year
2004 Infusion nurses Society Standards for adult Patients published
2005 Revised Infusion nurses Standards of Practice published
2006 Plumer's Principles and Practice of Intravenous Therapy, 8th edition, published
2006
2006
Revised Infusion nurses Standards of Practice published
Initiation of central line bundling recommendations by the Institute for Healthcare Improvement
2011 Policies and Procedures for Infusion nursing , 4th edition, published by the Infusion nurses Society
2011 2012
Revised Infusion nurses Standards of Practice published Policies and Procedures for Infusion nursing of the Older adult published by the Infusion nurses Society
2013 Infusion nurses Society celebrates its 40th year where it began
2014 Plumer's Principles and Practice of Infusion Therapy, 9th edition, published with a name change to reflect current practice and a co-author
In 1911, Dr. Ottenberg of New York demonstrated the use of donor blood; his theory that safe transfusion was possible from a donor whose serum agglutinated the recipient's red blood cells was readily accepted. Dr. Ottenberg further suggested that it was unsafe to use a donor whose red blood cells were acted on by the recipient's serum. These research findings evolved into the universal donor concept still valid today.
Hugh Leslie Marriot and Alan Kekwick, English physicians, introduced the continuous slow-drip method of blood transfusion; their findings were published in 1935 (Cosnett, 1989).
The Rh factor was discovered in 1940, and the American Association of Blood Banks was formed in 1947. The invention of the first cell separator in 1951 introduced component therapy (for more information, see Chapter 19).
parenTeral fluids
Administration of parenteral fluids by the IV route has been widely used only since the late 1950s. The difficulty in accepting this procedure resulted from the lack of safe fluids. The fluids then in use contained substances called pyrogens, proteins that are foreign to the body and not destroyed by sterilization. These caused chills and fever when injected into the circulation. The 1923 discovery and elimination of pyrogens led to safer and more frequent IV administration of parenteral fluids. In 1925, the most frequently used parenteral fluid was normal saline (0.9% sodium chloride). Because of its hypotonicity, water could not be administered IV and had to be made isotonic. A certain percentage of sodium chloride added to water achieved this effect (Cosnett, 1989). After 1925, dextrose was used extensively to make isotonic fluids and provide a source of calories.
By 1939, Dr. Robert Elman infused a solution of 2% casein hydrolysate and 8% dextrose without adverse effects; thus began the movement toward development of protein hydrolysates.
infusion nursing
Massachusetts General Hospital is credited with many firsts in medical history. The first nurse to hold the title “IV nurse” is known to have practiced at this Boston hospital. That nurse, Ada Plumer was a cofounder of the National Intravenous Therapy Association (NITA), along with Marguerite Knight, infusion nurse at Johns Hopkins Hospital. The NITA is now known as the Infusion Nurses Society (INS). Ms. Plumer was also the original author of this text.
Early on, IV nurses were responsible for phlebotomy, transfusion therapy, venipuncture, and maintaining equipment. Emphasis was placed on the technical responsibility of maintaining the infusion and keeping the needle and tubing apparatus patent. The sole requisite for being an IV nurse was the ability to perform a venipuncture skillfully.
At the time, IV therapy was limited to use in surgery and treating dehydration. Infusates were administered through rubber administration sets and 16- to 18-gauge steel needles strategically placed in the antecubital fossa and secured with an arm board.
As knowledge of electrolyte and fluid therapy grew, more parenteral fluids became available, and additional knowledge was then needed to monitor the fluid and electrolyte status of the patient. The nurse assigned to the patient in need of IV therapy was expected to have a working knowledge of fluid and electrolyte balance and to assess the
“whole” patient in terms of fluid needs. Normal saline was no longer the only electrolyte fluid. Today, more than 200 commercially prepared IV fluids are available to meet patients' needs.
parenTeral nuTriTion
W. C. Rose identified amino acids in 1937, leading to the development of protein hydrolysates for human infusion. A whole new approach to IV therapy and a respite to the starving patient evolved between 1963 and 1965, when members of the Harrison Department of Surgical Research at the University of Pennsylvania showed that sufficient nutrients could be given to juvenile beagles to support normal growth and development (Cosnett, 1989). This led to what is known today as total parenteral nutrition (TPN).
In the mid-1960s, as a result of animal TPN research, Stanley Dudrick developed the first formula for parenteral nutrition, a method by which sufficient nutrients are administered into the central vein to support life and maintain growth and development.
Fats as a calorie source were also studied, but the adverse reactions proved too severe, and the U.S. Food and Drug Administration banned the use of fats in the United States in 1964. A refined product derived from soybean and safflower oil was approved for administration in 1980.
Home TPN was introduced in 1983. Research into the use of antioxidants, the role of amino acids, and indications for medium-, short-, and long-chain triglycerides in TPN continues today (Grant, 1992).
early infusion devices and equipmenT
Until and even into the 1950s, IV sets consisted of steel reusable needles with a stylet inside to keep the lumen open. The plastic revolution evolved when Dr. David Massa, an anesthesia resident at the Mayo clinic, shortened a 16-gauge Becton Dickinson needle and inserted another steel needle as an inner stylet. A polyvinyl chloride catheter was placed over the needle and was attached to a metal hub via a crimp band. Thus, the first “over-the-needle” configuration was developed (Rivera, Strauss, vanZundert, & Mortier, 2005). After several iterations, it became the Rochester needle, a resinous catheter on the outside of a steel introducer needle. Available only as a 16-gauge, the entire unit measured 5 mm or 2 inches. On successful insertion, the catheter was slipped off the needle into the vein and the needle was removed. Desert Pharmaceutical Co. introduced the Intracath in 1958, minimizing the need for surgical cutdown; the first disposable device, the Angiocath was introduced in 1964. McGaw Laboratories introduced the first small vein set with foldable wings in 1957; this product is still known today as a winged infusion needle.
Dudrick adapted the subclavian approach for the administration of high concentrations of dextrose and proteins in 1967. Expansion of this concept led to the creation of the Broviac catheter, initially designed for use in pediatrics; a larger size (Hickman) was developed for the adult population. Since the 1980s, tunneled and nontunneled catheters have enhanced central venous access. The port soon followed, and totally implanted access devices are now used routinely. The peripherally inserted central catheter (PICC) was introduced in the last quarter of the 20th century.
The first IV fluid containers were made of glass. Plastic bags were introduced in the 1970s. Because they do not require air venting, these containers reduced the risks of air
embolism and airborne contamination. Today, plastic is the primary container for IV fluids, whereas glass containers are used when fluid stability in plastic is a concern.
Pa TI en T Safe T y
Plastic bags were introduced in the 1970s. Because they do not require air venting, these containers reduced the risks of air embolism and airborne contamination.
In the mid-1940s, disposable plastic IV administration sets became available and eventually replaced the reusable rubber tubings. Manufacturers have continued to keep pace with demands for technologically advanced products that ensure patient safety and reliability in the delivery of infusion therapy. Polypropylene, nylon, and Dynaflex are some of the more common materials from which that IV tubing is made. As plastics, these synthetic materials can be manufactured to meet this need; they are flexible, strong, and leakproof and do not react with the chemicals transported through them. Manufacturers of IV tubing have the capacity to create tubing of various thicknesses consistent with specifications given to them.
The use of electronic infusion devices to assist in controlling flow has changed the face of infusion nursing by improving the safety and accuracy of the process and reducing adverse events. Many devices can now be connected to the institution's information system and thus enhance electronic documentation.
progress in Clinical practice
In the 1970s, tremendous scientific, technologic, and medical advances occurred, and IV therapy gained recognition as a highly specialized field. Nurses performed many of the functions formerly reserved for the medical staff—intra-arterial therapy, neonatal therapy, and antineoplastic therapy. Professional societies were established to provide a forum for the exchange of ideas, knowledge, and experiences, with the ultimate goal of raising standards and increasing the level of patient care.
On October 1, 1980, the United States House of Representatives recognized the profession and declared an official day of honor for IV nurses: “Resolved, that IV Nurse Day be nationally celebrated in honor of the National Intravenous Therapy Association, Inc., on January 25 of each year.” The proclamation was presented by the Honorable Edward J. Mackey from the Fifth Congressional District of the Commonwealth of Massachusetts (Gardner, 1982).
Today, the infusion nurse with responsibility for PICC insertion is often involved in the reading of x-ray films to ensure placement. This has allowed timelier implementation of orders and improved patient care.
The infusiOn nurses sOCieTy, inC.
The INS has continued to grow worldwide. Educational offerings have expanded to include advanced studies in an effort to meet the needs of the advanced practitioner. INS is the premier resource for infusion education and knowledge sharing.
PART 1 Overview of Infusion Therapy
Credentialing
The Infusion Nurses Certification Corporation (INCC) has credentialed thousands of nurses across the globe. Professional IV nurses are encouraged to prepare for the credentialing process through educational programming, webinars, the INS Knowledge Center, clinical nursing forum, a revised core curriculum, the society's professional journal, clinical textbooks, and published Standards of Practice. Box 1-1 describes the vision, mission and values of the INCC.
There are nine core content areas of the examination including technology and clinical application, fluid and electrolyte therapy, pharmacology, infection control, transfusion therapy, antineoplastic and biologic therapy, parenteral nutrition, performance improvement, and pediatrics. Successful completion of the examination results in the nurse being awarded the CRNI designation. Recertification is obtained through reexamination or validation of clinical practice and documentation of 40 recertification units earned during the previous 3-year period.
Because delivery of IV therapy permeates all clinical settings, the role of the IV nurse is now well established as integral to multidisciplinary, high-quality care in all practice settings (Baranowski, 1995). The growth of this specialty practice has expanded the roles of IV nurses nationally and internationally. IV nurses are constantly striving to find new and more efficient ways to perform their services in an integrated health care environment.
vision
Certification, by InCC, is the standard of excellence that nurses will seek in order to provide optimal infusion care that the public expects, demands, and deserves.
Mission
InCC promotes excellence in infusion nursing certification by:
• Developing and administering a comprehensive, evidence-based program
• advocating the importance of the CRnI credential
• Supporting continuous infusion nursing education and research values
integrity — We are committed to providing a psychometrically sound, legally defensible certification program.
p ublic p rotection — We support the role certified nurses play in promoting optimal health outcomes and ensuring that our program is driven by the needs of the public.
excellence — We are committed to providing a program of high quality and are dedicated to a process of continuous improvement.
Retrieved from http://www.incc1.org/i4a/pages/index.cfm?pageid=1
BOX 1-1 infusiOn nurses CerTifiCaTiOn COrpOraTiOn
infusiOn nursing in The 21st CenTury
Nurses continue to lead the labor sector throughout the United States, and advancedpractice nursing has grown dramatically (Kalisch & Kalisch, 1995). In the January/ February 2007 issue of Health Affairs, Dr. David I. Auerbach and colleagues estimated that the U.S. shortage of registered nurses (RNs) will increase to 340,000 by the year 2020. The study is titled “Better Late than Never: Workforce Supply Implications of Late Entry into Nursing” (Auerbach, 2007). According to the latest projections from the U.S. Bureau of Labor Statistics (2005) published in the Monthly Labor Review, more than 1.2 million new and replacement nurses will be needed by 2014. Government analysts project that more than 703,000 new RN positions will be created through 2014, which will account for two-fifths of all new jobs in the health care sector. With new graduates producing a relatively new workforce in many institutions, there will be an increasing need for IV resource experts.
The challenge for nurses is to effect health policy through use of their knowledge and skills. Wakefield (1999) stated that the value assigned to nursing will be based on a standard that measures how the profession effects access and achieves the highest-quality care at the lowest cost. Infusion therapy has evolved from a form of treatment for the most critically ill to a highly specialized form of treatment used for 90% or more of all hospitalized patients. No longer confined to the hospital setting, infusion therapies are now delivered in alternative care sites such as the home, skilled nursing facilities, and physician offices.
Infusion nursing is now recognized as a highly specialized practice. During the last 60 years, the role of the nurse in infusion therapy has evolved tremendously. The 21st century infusion nurse is responsible for integrating the holistic principles of medicine and nursing, management, marketing, education, and performance improvement into the patient's plan of care. Clinical expertise is of utmost importance (INS, 2011).
review Questions Note: Questions below may have more than one right answer.
1. The clinical use of amino acids led to the development of which of the following?
A. Antioxidants
B. Home total parenteral nutrition
C. Protein hydrolysates
D. Triple-mix fluid
2. The initial role of the IV specialist included which of the following?
A. Phlebotomy
B. Crossmatching of blood
C. Maintaining equipment
D. Maintaining IV lines
3. Three of the four main blood groups were discovered by:
A. Karl Landsteiner
B. Florence Seibert
C. William Halsted
D. W. C. Rose
4. The first national certification examination for nurses was offered in:
A. 1983
B. 1985
C. 1988
D. 1991
5. Primary fluids in use in the mid-1950s included:
A. Lactated Ringer's injection
B. 5% Dextrose in water
C. 0.9% Sodium chloride (normal saline)
D. 0.45% Sodium chloride (half-normal saline)
references and selected readings Asterisks indicate references cited in text.
*Auerbach, D. (2007). Better late than never: Workforce supply implications of late entry into nursing. http:// content.healthaffairs.org/cgi/content/abstract/26/1/178
*Baranowski, L. (1995). Presidential address: Take ownership. Journal of Intravenous Nursing, 18(4), 163.
*Cosnett, J.E. (1989). Before our time: The origins of intravenous fluid therapy. Lancet, 4, 768–771.
*Gardner, C. (1982). United States House of Representatives honors the National Intravenous Therapy Association, Inc. Journal of the National Intravenous Therapy Association, 5(1), 14.
*Grant, J.P. (1992). Handbook of total parenteral nutrition (3rd ed., pp. 21–29). Philadelphia, PA: W.B. Saunders. Griffith, J.M., Thomas, N., & Griffith, L. (1991). MDs bill for these routine nursing tasks. American Journal of Nursing, 90(10), 65–73.
*INS (2011). Role of the infusion nurse in clinical practice. http://www.ins1.org/i4a/pages/index. cfm?pageid=3563
*Kalisch, P.A., & Kalisch, B.J. (1995). The advance of American nursing (3rd ed.). Philadelphia, PA: J.B. Lippincott.
*Rivera, A.M., Strauss, K.W., vanZundert, A, & Mortier, E. (2005). The history of peripheral intravenous catheters: How little plastic tubes revolutionized medicine. Acta Anaesthesiologica Belgica, 56, 271–282, http://www.sarb.be/fr/journal/artikels_acta_2005/artikels_acta_56_3/acta_56_3_rivera.pdf
Salsberg, E., Wing, P., & Brewer, C. (1998). Projecting the future supply and demand for registered nurses. In E. O'Neil & J. Coffman (Eds.), Strategies for the future of nursing. San Francisco, CA: Jossey-Bass.
*Sutcliff, J. (1992). A history of medicine. New York: Barnes & Noble.
*Wakefield, M. (1999). Nursing's future in health care policy. In E. Sullivan (Ed.), Creating nursing's future (pp. 41–49). St. Louis, MO: Mosby.
*U.S. Bureau of Labor Statistics (November 2005). Monthly Labor Review, www.bls.gov/opub/mlr/2005/11/ art5full.pdf
Sharon M. Weinstein
Minimizing Risk and Enhancing Performance
Benchmarking Competence Competency
Culture of safety Documentation
External drivers
Licensed Independent Practitioner
Malpractice Outcomes
Patient Safety Performance Improvement
Plan of Corrective Action
Regulating Agencies
Sentinel Event
professional nursing praCtiCe and legal safeguards
The goal of safe infusion care is to minimize risk and improve outcomes. The key factor in this process is ensuring patient safety. Each chapter in this edition addresses patient safety. This chapter focuses on a broader view and the need to create and maintain a culture of safety
The law and its interpretation can lead to doubts and questions regarding the legal rights and obligations of nurses to administer infusion therapy. Legal standards are an integral component of a performance improvement (PI) program. As infusion practice becomes more complex and specialized, and as infusion experts gain international acceptance, nurses are becoming more involved in procedures formerly performed solely by physicians/licensed independent practitioners (LIPs). Because violation of the Medical Practice Act is a criminal offense, infusion nurses need to be well versed on the subject and the law, not only to protect themselves but also to ensure safe outcomes for their patients.
