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Intravenous Therapy

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The introduction of fluid through a patient's veins. -Most dangerous route of med administration -Medication is placed directly into the blood stream -Medications cannot be recalled nor can you slow the action of the medication -Used during medical emergencies

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Purposes for IV therapy

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-Preventing or correcting fluid disturbances -Administering medications(long and short term therapies) -Administering nutrition(ie-total parenteral nutrition) -Administering electrolytes (is-potassium and sodium) -Administering blood and blood products -Monitoring patient's hemodynamic status and other vital statistics -Taking blood samples

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Administration Variations

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-Medications within IV solution(bag) -Continuous infusion -Medications via bolus or IV push -Single injection of concentrated solution or medication -Medications via intermittent infusion -IVP (secondary line piggy backed into primary line) -Buretrol -Individual bag -Syringe (in a pump)

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CDC Recommendations for Needleless Systems

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-All health care setting must use some type of needleless systems. -Blunt cannula versus syringe method (recessed connection port)

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Compatibility of Medications and IV Solutions

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-It is essential to check compatibility of medications and IV solutions -Check solution compatibility with the primary IV line solution to be used (ie-is Gentamycin compatible with 0.9% NS?) -Check compatibility of medication with flush to be used -Check if using secondary set up for 2 or more medications, then asses compatibility and flush with compatible solution between medications -Always check IVPB left hanging before hanging new medication. Are they the same? -Sources to use to check compatibility include: Compatibility charts, web online sources like Lexicomp and Micromedix

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Types of IV Lines Peripheral Catheters

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Used for: -Fluid and/or electrolyte replacement -Short term nutrition -Medications

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Types of IV Lines Midline Peripheral Catheters

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-Typically 6-8 inches in length -Placed in the basilic or cephalic vein deep in the upper arm

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Types if IV Lines Central Venous Access Devices

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-Devices accessing large veins (subclavian, internal jugular, or vena cava) -Used for: *prolonged nutrition and medications *Something that needs maximum hemodilution *When peripheral access is not available

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How Can Central Venous Access Devices Be Inserted?

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-Peripherally-Via basilica, cephalic, or brachial vein (called a PICC line) -Directly into a large vein-Hickman or Groshong, which can access subclavian vein) -Surgically, such as with implanted ports-under the skin connected to a catheter accessing a major vein.

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Common Solutions Administered IV Isotonic Solutions

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5% Dextrose in Water: -Supplies about 170 cal/liter and contains 50 grams of glucose -Hyponatremia can occur when using excessive amounts -May be used for IVPB med administration 0.9% NaCl (Normal Saline) -Not desired for routine maintenance-provides Na & Cl only -Can be used to temporarily expand extracellular compartment -May be used for IVPB med administration and blood administration Lactated Ringer's -Contains multiple electrolytes in about the same concentration as plasma -May be used to treat hypovolemia

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Common Solutions Administered IV Hypotonic Solutions

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0.33% NaCl (1/3 strength) -Provides Na, Cl, and free water 0.45% NaCl (1/2 strength) -Provides Na, Cl, and free water -May be used to treat hypernatremia (dilutes Na gradually)

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Common Solutions Administered IV Hypertonic Solutions

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5% Dextrose in 0.45% NaCl -May be used to treat hypovolemia -Used to maintain fluid intake 10% Dextrose in water -Supplies 340 cal/liter -Used for peripheral parenteral nutrition (PPN) 5% Dextrose in 0.9% NaCl -Replaces nutrients and electrolytes -Van be used temporarily to treat hypovolemia

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Saline Locks

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-Capped IV _Intermittent venous access -Used for administration of medications intermittently for patients who do not need IV fluids for hydration or nutrition -Allows more freedom of movement for patients -Requires regular flush to maintain patency ( -Saline is used to flush periodically. If used for medication use to flush before and after giving medications -Can check patency by checking blood return (gentle aspiration, then injecting saline)

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Process for Using a Saline Lock

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-Inspect and lightly palpate the IV insertion site -Flush the saline lock with 2Ml of sterile normal saline -Attach the IV tubing to the saline lock at the posiflow connector -Unclamp the slide clamp on the short tubing T-extension

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What parts of the IV Administration Set Must Remain Sterile?

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-Spike(going into IV bag) -End going into hub of catheter

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What is the Drop Factor?

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The drops coming out of spike assemble into the tub's drip chamber that equal a mL of solution. -Drop factor information can be found of IV tubing packages -This information is necessary to calculate/regulate flow rate

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Macro Drip

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is a larger drop of 10, 15, or 20 gtts/mL

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Micro Drip

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(Mini drip) is a smaller drop of 60 gtts/mL, sometimes 50 gtts/mL with a needle in the drip chamber

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Blood tubing

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10 gtts/mL and has double spikes

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What should you assess about the IV solution prior to administration?

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-Type -Clarity of solution -No particles should be in the solution -Expiration dates -No leaks in the bag -Volume of bag

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Time Tapes

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are used to monitor fluid infusing on an hourly basis.

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Prior to hanging a new IV solution bag without changing the administration set, what should be assessed?

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-Solution currently hanging -Time strip (is the IV out on time?) -Tubing -Site (Swelling, redness, tenderness, dryness, dressing) -Compare arms bilaterally -Do not hang a new bag on a bad site!

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What factors would affect the flow rate of a free hanging IV (an IV being administered by gravity)?

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-Height of the IV solution in relation to the patient insertion site -B/P of the patient -Patient's position -Patency of catheter and/or tubing (kinks, knots, clots) and site (infiltration or phlebitis)

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How often should the nurse assess an IV being infused via gravity?

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Ideally every hour, if IV not on time, nurse can then make minimal adjustments in flow rate.

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How does the nurse know an IV being infused via gravity is running on time?

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Looking at the time tape

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What is the first action of the nurse when they notice the IV is running behind?

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Assess the IV insertion site for any possible problems

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If the IV is running behind and the nurse didn't find any problems with the insertion site, what factors must the nurse consider before "catching up" the IV?

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-Must assure by increasing flow rate, you are not placing the patient at risk. -Increasing flow rate can tax a patient's circulatory, respiratory, and/or renal systems -Some solutions must never be "caught up" due to being too dangerous for the patient -

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Only increase the flow rate to "catch up" a solution if:

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-safe for patient's circulatory, respiratory, and renal status. -Safe solution being infused -Consistent with unit protocol -Increased rate does not exceed 25% of original flow rate

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What should the nurse consider before decreasing the flow rate of an IV?

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Flow rate must be maintained so that the vein will stay open for gravity hung IV with adult patient. This is about 50 mL/hour

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Components of the physician order with IV

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Should include: Fluid type Time frame of infusion (mL/hr or mL in ___time period

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With IV the nurse is responsible for:

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Selecting IV catheter type -Site for venipuncture -IV administration set -Infusion equipment -Initiating and monitoring the IV therapy

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How to maintain strict aseptic technique

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-Keep spike sterile by keeping hands behind the wings and not touching the tip of tubing going into the catheter hub -Access connection ports with sterile equipment and use alcohol before access

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What temperature should IV fluids be administered?

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Room temperature Refrigerated medications/solutions should stand at room temperature before administration

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Maintain occlusive dressing on IV

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-Sterile, semi permeable transparent dressing like tegaderm or opsite remains on site as long as catheter is in -Never put a new bag or administration set on a site that is bad

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Electronic Infusin Pumps

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-Control IV infusion rates via bag and tubing(tubing runs through pump) or syringe (syringe in pump) -Used for any type of IV -For those institutions that do not routinely use pumps for all IVs, pumps are reserved for more dangerous medications or solutions (IV fluids); younger or older patients; critical patients; or for Ivs flowing at very slow or very fast rates -All pumps run differently. If you change units within the same institution, don't assume IV will be the same. Some may be mL/hour, others may be drops/min, and some volume VTBI

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How will you know that your IV is on time when an electronic infusion pump is being used to control the flow rate?

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-My opinion-use timed tape, even though you are using an electronic pump

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What reasons do electronic pumps alarm?

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-Occlusion -Air in the line -Volume to be infused is complete/has been reached -Low flow

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How do you make the other nurses on your unit happy?

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-don't leave the shift with empty or near empty bags up -change bags so that the next shift can get acclaimmated -if 100 mL up or less, change the bag, better to waste it then have the IV run dry. *Exception to this general rule is TPN or fluids that contain medications, do not waste or change these ahead of time.

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Documenting fluid intake when pt is on IV therapy

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-Record intake of all IV fluids -Patient on IV therapy for fluid replacement will be on I&O

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What information should you report to the next shift in regards to your patient on IV therapy?

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-IV solution type -IV flow rate -Site assessment (temp, color, location, tenderness) -Intactness of IV site -IV line patency -Any pain at site -How much IV solution is left up -When IV solution is due out or to be infused

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IV site care

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- sites are covered with sterile, semi permeable transparent dressing or sterile gauze. -An anchor may be placed on catheter hub under the dressing-stat lock -Regardless of the type of dressing, dressing must be changed if damp, loose, or soiled

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Transparent dressings

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-allow visualization -help secure the catheter -Prevent microorganisms from getting into IV insertion site -Are changed only when the IV site is changed, typically every 72-96 hours

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Gauze dressing

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-used if pt cannot tolerate transparent dressing -used when site is oozing/bleeding -Used when client diaphoretic and transparent dressing will not stay intact. -changed according to agency policy

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If an anchor is used, when do you change it?

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ONLY if it becomes soiled, loose, or damp

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Guidelines for IV site matinance

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-Visually inspect site and extremity routinely -compare extremities bilaterally -Ask pt to report any tenderness -Investigate s/s of infection -Documentation -cultures not routinely ordered due to colonized microorganisms harbored at catheter tip -No topical ointments to insertion site-can cause fungal infection and microorganism resistance -Do not get insertion site wet -Check compatibility of catheter and administration equipment -Clean IV injection ports with 70%alcohol or iodophor prep before assessing system -Change cam on capped IV every 72 hours -Check blood return with a peripheral IV site -

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Checking for blood return with a peripheral IV site

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-lack of blood return doesn't necessarily mean that the IV is not patent -Checking for blood return at peripheral site when catheter is in a peripheral vein by aspirating with syringe can collapse the vein wall into the tip of the catheter, not reliable -Check blood return by lowering the bag below the insertion site, pinching administration set near the catheter, or putting pressure above vein

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What to document with maintenance of the IV?

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IV insertion Dressing change Site assessments

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If the drip chamber is completely filled while preparing an IV tubing and bag for infusion, what is the correct action of the nurse?

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Invert the IV bag and squeeze the excess fluid out of the drip chamber back into the bag.

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If air bubbles are above the IV lines first connection posiflow port, how can you easily remove them?

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-closing the roller clamp, stretching the tubing downward, and taping the tubing with your finger so the bubbles will rise to the drip chamber

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If there is a larger amount of air in the tubing:

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-swab the medication port on the tubing below the air with an antimicrobial solution and attach a syringe to the port below the air -clamp the tubing below the access port -aspirate the air from the tubing via syringe -remember that air bubbles can be reduced if tubing is primed slowly with fluid

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The patient with an IV infusion develops an unexplained fever with chills and a rising pulse rate. What could be the cause for these sypmtoms?

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-sepsis -contamination at site or with solution/cares

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What are the symptoms of sepsis?

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Fever with chills Rising pulse rate redness and tenderness at site Malaise Vital sign changes

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What are the appropriate nursing intervention with sepsis?

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Discontinue IV Send all equipment to be cultured Culture site Notify MD Monitor patient Start new IV Antibiotic treatment will be ordered

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Phlebitis

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Inflammation of the vein

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What are the syptoms of phlebitis?

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red, tender, warm, edema especially above the insertion site.

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What are the nursing interventions with phlebitis?

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Discontinue IV, restart the IV on the other extremity

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Thrombus

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Clot in the vein

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Thrombophlebitis

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Clot and inflammation -Do NOT run IV fluid into or massage a phlebitis, this can cause clot to dislodge Discontinue IV site in question restart at another site warm moist compress

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Infiltration

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When IV fluid escapes into SQ tissue

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What are the sypmtoms of infiltration?

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-Swelling -Tenderness -Coolness -Pale -Decreased flow rate

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Why should the nurse assess for infiltration at the location of the IV site bilatereally?

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The whole arm can swell vs swelling at just the site

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Nursing intervention with infiltration

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-d/c IV -warm moist compress Restart another IV at a different site -Decrease movement of new IV

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What can cause an IV solution to not flow properly, what things should you assess on the IV bag, tubing, and sites?

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-Site -Arms bilaterally -IV tubing (patient not lying on the tubing and it is not kinked) -Check for closed clamping -Catheter itself (taping adjusted) Check for return of blood (catheter patency) -check position of insertion site related to IV bag

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What are the reasons IV therapy is discontinued?

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-pt is tolerating oral intake -therapy is complete -IV meds have been discontinued -The site is longer intact -IV line is no longer patent

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Process for discontinuing IV

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-clamp the IV tubing -inspect the IV site -remove the IV dressing -withdraw the IV catheter -Apply pressure to the IV site with a sterile 2x2 gauze -check for bleeding -Cover the site with a second 2x2 gauze or bandaid

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Speed Shock

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Substance infused too rapidly

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Speed shock symptoms

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-Tachycardia -possible chills -apprehension -back pain -fainting -Headache -Dyspnea (most common)

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Speed shock treatment and prevention

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-discontinue med -keep IV in, just slow down the TKO -notify MD -monitor patient-vitals, respiratory status Prevention-Time tape IV bag

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Fluid overload

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too much fluid infusing into circulatory system

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Symptoms of fluid overload

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-SOB -JVD -hypertension -dyspnea

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nursing treatment for fluid overload

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-raise HOB and slow IV (TKO) -gather assessment data and monitor vital signs and cardiopulmonary status -contact MD

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Air Embolus

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Air infuses into the circulatory system

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Causes of Air Embolus

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Air in line Poor priming Loose connections

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Symptoms of air embolus

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-Respiratory distress -Hypotension -Color changes -Change in LOC

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Treatment for Air Embolus

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-Stop more air-pinch/clamp line or tighten connection -place pt on left side trendelenberg -Call code for immediate assistance -Monitor vital signs including pule ox

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Solution and tubing changes for adults

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Peripheral IVs, tubing, and IV site changed every 72-96 hours, except for IVs placed in emergency room or outside the facility -Typically IV tubing and IV site changed at 48 hours

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Solution and tubing changes for children

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-IV site is only changed when clinically indicated to do so or per facility policy -Once IV is in, it is kept in, but site visualized as per facility policy

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CDC recommendation with tube and solution

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-Blood tubing every 4 hours and/or after two units -Lipid every 12 hours -TPN q 24 hours -TPN with lipids in them every 24 hours -When priming IV tubing, make sure to time and date it

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