Cheever K.H.I.V. Therapy Demystified: A Self-Teaching Guide

CHAPTER:3

Intravenous

Therapy

Delivery

Systems

53

B.

A

po>lien.

;.

'"

m;«""

*' I. V.

~u,,,,,,,

M •

tale

of

I~

mLJh.

"Tho

I.

V,

adm;n;..,.."'"

oeIlIu

0 drop f

......

if

12 dropohnL I..,..· mony

drop<

p«

mi"",.

mu

...

be

,;,

..

oed

'"

ochitv<

,he

preJCribed

inr",,,,,,

.-1

(0)

11

drop.tmin

(

b)

.lOdrnpoI .... n

(e)

31

drnpoImon

(d)

4l

drnpoImon

9.

A pob<III.;'1O m:c.",

...

LV,

toI"'

..........

."

I~

ratA."Tho LV.

ad",

..

",.,."",

oeI

""".

drop

facIor

of

20

IlmpoImL llow ......,.

mop.

"....

...............

be

g1nO<d

10

octooe-.,!he

prucribed

..

r""""

_ ?

(0)

11

drnpoImll'

Ib) .lOdrnpoImll'

(e)

31

"""""m'n

Id) 42 """""m,n

10. A

po>lien.

;'10

"""','"

on

I. V.

ooIu",,",

...

I'M<

."

100

mlAI.

"Tho

I.

V.

admin;!I.nI"'"

""

""'

0 drop (0<1'"

of

10

"""""mL

. II.,... many

mop.

"....

mi""

..

mu

..

be ,;,,.,«i1O ochi",'. ,he

preJCribtd

infu.iocI

~?

(0)

17

drnpolmln

(b)

.10

drnpolmln

(e) 31 drnpolmln

(d) 42 drnpolmin

II.

A p«l;.'ri< I"'.icn' " '0

r«:<;"<

In

I.

V,

..,Iu'~'"

0' •

rIl

'.

of

6()

mllh

. n.e

I.

V.

adm;n;

"""i""

.....

hI

••

~"'"

rIC''''

of

6()

drnpolmL. II

"",

lIWly drops

p<f

m;,",1<

m,," be

li,,,,,ed

'0

ochi

....

,he ","""ribed inr".;""

ntl<7

(0)

33

drnpolmin

(b)

~

drnpolmln

(e)

6()

drnpolmln

(d)

67

dropo!m;n

I.V.

Therapy

Demystified

12.

A pedi

..

ri<

I"'i<n'

i,

'0

....,.,i,

..

an

LV.

solu,Koa

.,

• ",o.

of

80

mlih,

n.e

LV. odmini

..

""ioo

oe' has • drop

[""'or

of

'\0 drop<lmL H",,' many drops

per

mi

nu,.

mll," be

,itr.lle<i

'0

""hie,'e Ihe prescribed

infu<Koa

""e?

(

0)

B drop<lmin

(b)

'ill

drop<lmin

(c) 6Odrop<lmin

(d)

67

drop<lmin

13,

A pedi.,ri<

I"'i<n'

i.

'0

....,.,i,

..

an

LV.

solu,Koa

.,

•

"',.

of

40

mlih,

n.e

LV. odmini.,,,,,ioo oe'

h.as

• drop

[""'or

of

'\0 drop<lmL

How

many drops

per

mi

nu,.

mll., be ,itr.l,ed

'0

"",hie,'e Ihe prescribed inf",Koa

"".?

(

0)

B drop<lmin

(b) 'iIldrop<lmin

(c

) 6Odrop<lmin

(d)

67

drop<lmin

14,

A pedi.,ri<

I"'i<n'

i,

'0

....,.,i,

..

an

LV. solu,Koa'" ",o.

of

'\0

mlih,

n.e

LV. odmini

..

""ioo

oe' has • drop

[""'or

of

60

drop<lmL

H",,'

many drops

per

mi

nu,.

mll., be

,itr.lle<i

'0

""hie".

Ihe

prescribed inf",Koa

"'

,

.?

(

0)

B drop<lmin

(b)

'ill

drop<lmin

(c) 6Odrop<lmin

(d)

67

drop<lmin

IS,

In,,..,ollOO. pump.

(

0)

f<>lure

.

"';"'y

of

>l.ITnS.

(b)

I\o\o·by~,..,i'y,

(c

) can

ino.rbre

with """" ,UO<brd

LV

. admini"""Koa

....

.

(d) llse

••

pring-coil

ml"Ciwli..-n,

CHAPTER

4

Peripheral

Intravenous

Therapy

learning Objectives

Afte,

oompletin~

this chapter. the

I.""""

"'ill

Di>cu," NI1Imon iooicatioru for initi

>t

i

nS

>nd

rruoin""ning perip/>e",1

in

t

..

,..,,,.,...

(IV)

!he",!,),.

Unde

..

uod

,be

SlOps

required '0 ini,i

.te

•

J><rip/>er:al

I.

V.

Ii

...

Diff"",n';."

beIW",,"

commonly u.oo peripheral

'000II'

or"""

<lev;"'. in

terms

of

Ib.;r

physical

1<>1ure

••

nd

'beir

indication>

fOf

""'.

Identify metho<ll

'/1>

1 may

pr<wKle

stlIbilily

to

on

I.

V.

orre

..

devie<.

D=:rire

the

'lel"

""Iuired to change

>II

LV.

infu,ioo

""'"p.

to change

..

I.

V.

"""'"

.ite

dn=ing.

and

to

di

5COll

,

im",

an

I.

V,

odmini.tr.ttioo setup.

"

I.V.

Ther

apy

Dem

ystified

rl

Ke

y T

erms

Steel_wingoo infusion

d..v;re.

Over ·the-needle cathe

..

"

Short c.lhctors

Mid

l

i""

cathe'en

S.li

...

locb

Indications for Peripheral

Intravenous (!.V.) Therapy

1he

.....

,

common

;00"''';00

ro.

initiating

LV.

lhe",I'Y

by

a periphenol "'DOllS

aoceu

roo

..

is

to

tre

..

or

pre,cn'

fluid

.nd

electrolyte

di,,"rNoce

S.

In

""""

in".~'.

!he infu,ioo

ftu,,1<

of

c~

typ;cally ate t

),pe.

of

..,lu,iOO5 referred to

..

cT)·"alloilb.

Le..

commonly ""lected type.

of

infu,ion fluid< could be emloid"

lodic

..

,,,,,,,

fo.-

..

I«ling

common

cfp

••

lloid

.00

collojd ..,I",ions are

di",",sed

in

Chapters 7 and 8. respect;,

..

ly.

Initialing "".iphe ... 1

LV.

""'~

.1",

""'Y

be indic

..

..t

to replace

or

>uppl."",,,,

blood

oompone"'"

100,<";00, for admini.,oring

Ntllmoo

blood components are

di",",sed

in

OIaptef

9.

AooIher common i",bcatioo

fOf

initialing

LV,

ther2p)'

i.

to

administer medications by !he

LV

. root<. iocluding intermi''''"lly administered

medic

..

;"".

(e.g

..

I.

V,

push me<ljcation>.

LV,

··piU),

bac'

"

medic.,;"",)

and

root,n""",ly

infused medicalK>m. wlUch ore deocribed in more de

LaiI

in Ch>pter

11.

In

gener.ll.

if

the I""ien' t.., • <en,,,,1

lV,

occe

..

de>ice in pl""e. i, is preferred

'0

administor blood components and

m.ny

rood",

..

i"",

by

the cen, ... 1 roule ...

,her

than perij>he ... lly. loo",

.tioos

fa-

cen'n.1

lV

. 'ber:apy are

discu.sed

in

Ch2p<or~.

How.,>or, if the jWien'

doe>

001

mv., .

",n""llV.

orce"

device al",>dy in pl""e.

p<fij>her.ll roole.

fr_n'ly

are

con.idered

,ufficien' for ochie"ing the inlended

the"""'"''''

effOCl

.imply

bec.use

'here

are more

inhe",n'

ri,b

a»ociated

with

ini'ialing and mointoining ""n,,,,1

lV.

,,,"",,,

orc

.".

route>

than

perij>he",1

lV.

"""""

roole. ,

A moch

Ie

..

common

ioo",

..

ioo fa" initiating

lV,

the",py

by

a perij>henl roole

i,

to

deh""

peripber.ll I"'",n,o",1 nutrition,

Cen,

... 1

I,V,

l

ine.

are

ind"'ated

most

commonly

..

the

'"2>Cu

i:u deli ...

,!)'

route

for porent

o",1

nutrie"'

..

. 00

,hi,

i.

discu.sed

in more dctail in

empter

10. It i,

geoenlly

001

j><>5Sib

le to infu

..

,ufflcient

thi

ly c.loric requirements for

most

I"

tienl> through the perij>her.ll

rrule.

bu,this

i.

possible

'0

achieve via t

he

centr.ll rou'e,

CHAPTER

4 PertpheralintravenOu5 Therapy

57

Initiating

I.V.

Therapy

IIlo

Prio<

'"

ini'

....

nm

I.V

'he~

.....

""

.........

~fy

th>t

an

~

poncri~

orda"

t...

_

"·n"""

by

•

phyoici

..

<II"

""'"'

od........n.prKtft

cl

i

nician

rKOJIIOzed

by the

..........

rup«\l'"

.....

bowd

of

nUBin,

...

baY

..

, the

_y

'0 prno:ribe

,tll<

')11<

of

i"""'

....

ioul

tbt<apy

.'

Authorized _

pnc6<-e

cI"uciano

....

y

i",,_

._

pno<t<"'-'>.

......

.....

h.ivn

.......

_

....

01"

pllpOi:

................

Spoc,/ic

,of_

i.

the orda"

.......

ioclaodo

I'>tirno

.......

r..:aoon

inf"",*;""

SpocifH:

typo

of

......

_

0I'II0mI

RMeof

.........

~

S

......

. ".r

5p<'<iji£

"'!«-tiM

,,,,,,

""'"

"..

JNlff

<J(

""

",*,

..

JltJtt"U

p<"npMF<lII.

~

rlwnqry

ilt<:1

....

patinol

ulnupiM

iIIf--.

spt<".~

'YP'

<J(

MJI

••

"",,-

~

no.

......

>houId

pt/I<r

all the

<qt>.prnent

'"'1"'.-...1

to

..

,""".

><=OS

and

oWn'';"

....

I.V. Ii

...

pnor to

.",.rin

,

,II<

pal ........

r<>Otn

. Th,,,,,!uiprnent ,ypically

indlldti

....

foIJoo.i"ll:

Pre.rnOOI

J.V

. 101",ion

bag

l>an!i"ll Oft

an

l. V. pole ,h

..

i.

"""t>N."tNI

to

J.

V.

'"I>n,

tit

..

i.

primM.

or

~u.<llt<l

"·,,h '

''''

IOlu'""'. Th

..

I.

V .

.."up

....

y

be

<:00

,.

,,:1«1

to

on

1.'1.

pump

or

'0

""len'''''

'uh,ns

,Ju

t

<ont.iou

oddi,ioruol

capp<d

.,"'".

port

•.

Chopt.,

) tlt>cribe,

IH>w

to

..

1t<:1

..

tI

..,t

up this

equipmm'

prope,ly.

VeOO<l.

a<:c

...

d<vice

of

"hot«

(e

.s

.. oi,

..

,

"i"ll."~tI

.,..d

l

o.

Of

ov<,

.

....

·

n<"<dlc

".thctcn).

Sinll •• usc toom""","

Pov_iodi

....

,,~

..

ick.

ond

.k<>hol

...

~

..

kh

.

I

""""'

....... dr=.in,

~i,

""",';nins .""'" 0 ...... o.partnt

.....

;p.rm.

.

bIe

mnnbnne

or

..mlo

,.u'"

and

-.l1c1Jen

..

'"po

.

T

_.

1

1O

roll and pia«:

"""'"'

,II<

pot;.

....

ann.

if

noce<UI}".

Dnpe

10

pbcc

ut"Kk-r

,he

pot;...

.......

.

I>i>p»ahl< ...........

Ie

p:rvu

.'

"

I.V.

Ther

a

py

Demystified

PATIENT

PREPARATION

C<>fJ\p<lOn

t adult

""''''"''

prescribed LV.

lhenpy

should

rully "00e

....

00 the

intended P"'P"""

of

,he .her2p)'. the anticipated length

of

time lhal the therapy will

ooo.in"". and

,"',!here

are

..,....

ri,h

in",h"ed

wi

th

,hi,

thenpy.

Pa,io"

,

",ho

are

pre",ribed

LV.

ther"PY

should

und"",W>d boIh

ill

""""i.led

ri,b.nd

il>

""""fits,

Prescribing

I.

V.

lher2p)'

i.

",,,,,,,ed

fo.-

p,"",n"

whose po«n.ial """"filS oolweigh

the

potm,i.1

ri,1<>

of

ther2p)'.

Any

ad,-""..,

"..,01S

Ill

..

moy

be

asooci

..

od

with.be

infusion.

or

wi

lh

the ,..,"",,, acce

..

dc,i.ces _book!

be

di......,.,d with patients

prescribed l.V, lher2p)' lief,"", il

i.

begun so that they

""'y

m:oke

fully informed

deci,ion,.

hen

when

it

i.

the

optn"'"

of

dinici

...

t

ha

t ini.ialinS

LV

.

the~y

i.

much more

""""fiei"

,ru."

Iwmful

to the

p,,,;,",.

deci,ion.

m:oJ.

by

compel"'"

patients

10

ref",,",

"".Un"n'

must

be

honored

..

leg.lly bindin8.

Most age ocie,

""I"

ire

that

I"

'

i,o'

informed consent

be

obtained

prior

to

;n","ion

of

''''''''1>

~

de,'ice •. Stand",d 10

of

the Sraodard,

of

Pracl;a

promulp

t

od

by

the Infu,ion Nu

...

, Soc""Y (2006) reoommeoo. that informed

"""",n'

I><

obtained

from

.11

compe"'"'

adul'

pal;"n"

!'rio.-

to ini'iation

of

I.

V.

'her2p)'

.'

In

iMWlCe'

"here

the p>'ien' is eithe,

001

compete"'

'0

give

rome",

0.-

i • • child

0<

adol"".n

'.

the patiern',

leg:al

repre.cn'ali

,"

mu"

give

NfI«n'

pric4'

'0

ini'ialing I. V. ther2p)'.

Mos

'

ethici".

og"'" that

"hil.

obt.ain

i

ng

consen'

of

school_

.ged

chiklren

or

adol"",.n"

i.

not

legally

'equ

i

red

prio<

'0

performing "ny invasive inte,

...

n'ions

011

,hem, thei,

""",",

"""",hele

..

mould

I><

>olici,oo.

SELECTION

OF

VENOU

S

ACCES

S

SITE

S

• Sever.ol ge,..,ral conven,ions are followed

ro.

'" leelioo

of

opproprialc periphonl

",n(

...

ace

....

ite-. i""looi

ng

the following;

Vei

ns Ioc.ted

in

tl><

upper ex,remiti

••

are

".,

tly preforred •• """

...

>ite

•.

[)i".1

>0Il00.

"""."

..

ile>

are tried before

pro.inW

"""eo,

>i

....

Acr

....

ite, t

h>t

l

ie

o>or

poin"

of

fl«iOll

.I>oukl

be

»oided.

Sites tha,

ore

il"ibtor;ai

to

"'her

'''Il00'

==

de>;"

-.

Ilr1.nov.noo.

shunts

.•

i

...

of

lymph:It;" compromi

..

(e.g"

il"il.ter.ol_to-axillary l),mph

oode di.section from

.....

,ectomy). and

.....

damaged

by

phkbiti • •

nd

t"mm.

>hould

I><

.voided

If

p<><Sible.

ve

i

Wl

OIl

the nondomin""t ..,..,

or.

preferred

fi,,'

_line acce

..

•

ile>

",'h,,,

,Iwl

..

in.

on the domill2llt

",",.

"

Common

..

1lOII.:occe

..

>ite,

i""

lude the dorsal

me1>o<.1J"ll

>.in •. the ceplWic

".in

. •

nd

the Nsilic ,..,in (Fig. 4_1), with t

he

more

disal

.itc.

preferred

0

..

' the

CHAPTER

4 PertpheralintravenOu5

Therapy

59

-.

-

f

lll

. " 4·1

An

..

_ ......

of

u ...

~n,

II1II

<lraio

die

"""'"

ri!hI

utrrmOty_

(. ) Suportlclol

.~,

..

(~)

IJ<q>

>ei

...

(Uo<o ... '1'"

poomt

......

from...."

00

Gruft

KM

:

11_" A",,_,.

"""

011

. N ....

YtMt.

~1cGrtw

·

lIill

fI,p

fAu<

.......

=

:,

7'_)

mou

proximal

.i

' ••. ·

1n

in".oc:u

,,"'1>0:

...

1"'''llherall,

V,

II«<U

must

1>0:

...

.

blWOOO

''''''rge",1y

('.1

..

in

<II><.

of

''''un'''

.nd

.n..:k).

Il>o:n

11>0:

tarv

•.

""""

...

".dily

"I'P""'nt

ODd

""ce

..

ibl<

vcin<

with,n

11>0:

,n1«ubil.Ol f

.....

"'"

,.itml<

fint_li

...

•

ites"

(FIj!.

4--2).

V.i",

...

-

"hi"

11>0:

"nl<aob,tol ro

..

,

i"",udt

tl>o:

mrd,

..

«pIIol",

and

mrdi

..

<ubital vein

""

SELECTION

OF

VENOUS

ACCESS

DEVICES

In

~

"'"'"

OR t

wo

type>

of

vc""'"

oca:

..

<ltvitn

thoI

mi&h1

1>o:

..

1<ct<d

for

J:UrunJ

"..,ph<nl

t.v

. _ .

n.e.c

;""1

.........

I .

...

,

,~

inf."""

<i<vicn aod

"'

....

_tI>t:_DNd

I<

<atM

......

'"

I.V.

Therapy Demystified

'-'gU

r<

4

·2

Ve;ns

<>fill<

OIItocL.t>ial

r.,.,..

(Uoe<l

,,'jill

ponniWon

fr<wn

".,1>00 SE

v"""/o,

Ace..,.,

l',;oc;pkJ

and

P"",';c •. Jrd ed. SL

Looio:

MooIIy. 1996.)

Steel-Winged Infuston Devices

St

.....

..

ing

od

inr"';on

d

..

i<

..

(JOm<1

ime. referred to as

/Jolt,,!!>-

nudk.)

are

;ooie.ted

for one_time ,nfu,ion

of

[,V. medioations

""","

th2n

roalinuoo.

i"f",ions

of

""Iu,

iom

or

medications,- Althougb it

i,

e •• i

..

to

gain l.V, """"OS wi,h

""""

dev~,

,hon with

",..,,

_the_

oeedl.

Call>cters.

it

i.

moch more diffirul

llO

mainlain

l.V,

~

pa"ocy

and

".bilily

wi

th

"""I

.I<'ing..t infusioo device.

ro.

more

th.n

U

houn,

""

lIleir

"'"

fC4"

more

lIwI

a

fow

minute. to hours

i.

nco

..

:hucated.

Fig ..... 4_3 di'pl.

y.

a >leel.

"ing..J

iofu.;"" devic

•.

n.... device.

'md

to

be

a,

..

ila

M"

in a

..

riely

of

gauge.

(G)

,ho,

Ntllmonly

""'ge

from 19 to B G. The

,mall

..

,he number

of

!he gauge. the larger

i,

Ill<

fll"Cdlc

bore.

'"

19_G

device. are

the large>"bored

.00

23-G device. are the .rruolle,,·bored ...... I_winged infu.ion

<lev;""

•.

They are ""mKlerod short perip/lenl <levi"".

bec.use

the length

of

the

ooedl.

i.

""'Y'

~

,han 3 inche •.

Ove

r-the-Needle Catheters

O

...

,.·

,h

.·

n

...d

l .

..

,hri

...

are

lh<

most

commonly

u...t

peripher.d

I.V,

""""'

..

device>,

1be",

devices fealure a Deedle

"ylet

thai.

i.

aI...,hed to • fl

..

h

ctwnbe"

1be

stylct h ••

an

,,,,.,,,by

of

an

o"',

·

lh<

·

....

dle c.th<tef thot has an .ttached hub

d."ice

that remains

..

ternal to t

be

patient

.fte,

the cathete,

i.

pl

><e<l

in

the

acr.,....t

ve

i

n.

{her

·tbe·needle

co"""."

at.

d

..

,ified

...

hon cat hoi

...

if

the catbeters are

3 incbes

a"

Ie

..

in

length and midli

...

<a

th.,

.,."

if tbe catbetef's

.re

bet ...

een

3 and

8 ioche> long

.'

Most

catbete"

uoed fa" this purpose

are.1on

co"""e",

Midline

COtheteB

typically

.re

re",,,"ed fa"

u'"

in patients

"'00

are hospitalized and require

CHAPTER

4

Peripherallntravenou5

Therapy

~

--'

''

'--a.=

:::-

......

1-

__

,

...

F

Ip

..

~

..!

s

......

....,...

___

. (u ....

wlIft

prrnoi

....

I

...

_

A.

Sa)dn

~

.

Kad<t

B.

f.tI>OL

~,

..

"

..

..,

. ,

....

,

<!

1<.,....,

.

........

UJ¥<

_

RMt.

NI

1'roftIi<e.

1I

.1l.

:!OOI

.

lol6O

.)

fmru<'nl

..

"'

....

of

ptriphoral I.V ......

ku

ot

fot

p'''.n

..

"'110

mj"~

at

Ic&<l

I

,,=

k

am

up

to

~

,,'

..

h

.,c

1.

V,

infu.ion

III<~

."

In

sm<ral.

il

i.

p"'fam;!

lhal

both

>Iloo

....

midI!"" "

..

he

.....

1>0

rad.",... .... •

TIle

..

"

..

11<

........

.

"";1>bl<

in

g.

ug

••

lho<

rulge (rom

I

~

10

2~

G,

"

In g

....

IllI

.•

<all>o

..

,

i,

..

l«tN

S<I

llul

il

i.

<>f

III<

.mall<><

,".ge

.00

icngth

'"

acromplilll

it<

intonded purpos

•.

' l..ugor.bnrN

COI

Ilet

........

rc><

...

..J for

l"'ll"'

"'

i

ns.

"h",h

"00

to

1>0

"'OIN

""""

p.m,n,.lIy

.

TIle

larget the boro. the

...

ier il

i.

to

inf.""

fluid. r2pidly.

and

the

...

i.,

il

i.

10

1I'M,f.," blood

romf'OOC""

"ithout

<

ou

,ing

the blood

«II.

'"

he,noryu, In '

.......

1. pack

ed

ml

blood

",,110

<bould

1>0

inf.sed

.i

••

I'<noo.

OC«<.

<ltv....,

0..

i.

no!

.m.

l

lcrltw.

18

or

20

G."

Fig.",

4-4

""'"", • • «lmmon

."..,

.the-......tk

catloc1cr

de"i«

.

"

I.V.

Therapy

Demystified

GAINING

VENOUS

ACCESS

WITH

A

SHORT

OVER-THE-NEEDLE

CATHETER

1h<

nu""

should

"'p

l

"n

the

J><OCNure

10

the

palion,

prio<

to

rommeocing

the

procedure to gain

'"DOllS

.,",."

••

Any patien' .Ilergies or hYP"""n,itiviti

.........

kI

be

...,en

.ined.

"'peei.lly

iodi

De

.Ilelll;'"

or

I

....

a1lergie •. so that .

,"'!>hI.

a1l<matc .n.imicrobial ""hllion.

weh

'"

chlom.,Kli"..

nuy

be ",lectoo

Of

>0

'hat

oonl

...

, glov<.

may

be

dooned

'"

~,

"

11><

I""ient'.

orm...oo

no!

be ",

••

hed

in

><I,

..

"""

of

the

pr~"re

"ole

..

i.

it

"j,ibly

<!iny.-

n..

clini.eian ....... Id

"""h

hi.

or

ber

hand> . igoroo.ly with

soap

and

,,"'or

prior

to

beginning the procedure.-

The

I.

V.

bag

.nd

,ubing

..

,up that

h2s

been

primed

as pre"iou.ly de",ribed

in

Ch2p<or

3

i.

,."

at

the pa'ient'. hed.ide,

aDd

the

l.V,

'""ft<"

kit ,hal i

ocloo..

,he

",..,,

_

,""-oeedI.

o.theter

is

opened,

.Ithough

the

>!orih,y

of

the

Deed

le "yle< . nd cathete, must

be

maintained. The nu

....

pre.,....

"

.....

1 2_ioch

'lIips

of

flOfl:I.!lergenic lap<

of

>Ol)'ing ,,·idl

....

with

.......

V.

,och

wide

and

OIhe

..

of

I inch "'id'lL n.e preferred procedu",1 "'I" for obt.ining LV.

aoceu

include !he following;

A .ingle_use lOOmi'l""t i • • pphed to the p>lient". "I'P'"

>rm

0<

"I'P'"

pooioo

of

the

fore"""

.'

It i.

"Whed

tightly eoough to

j»!ti

.

lly_met

'000""

flow but oot

..,

tight

..

to

_ruet

>rtori>! fl",,'. The p>tiont"

..

,m

then

i,

<bngled in > depeudent position

fO<

' pp<o,ima<ely 1_2 min",,,,,

The I"'tient

fIIlIy

be

odvi..-d to

rruoke

a fist to funllef

enc<>Yr:age

,'enoo.

dist"n,ioo. "

Cheever K.H.I.V. Therapy Demystified: A Self-Teaching Guide

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