iv manual-12-15-03

PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY

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PRINCIPLES AND PRACTICE OF

INTRAVENOUS THERAPY


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TABLE OF CONTENTS

Advantages of Intravenous Therapy .........................................................................................3 The Five Rights of Medication Administration ........................................................................4 Aseptic Technique ........................................................................................................................5 Reducing Risks of Infection ........................................................................................................7 Anaphylactic Shock ......................................................................................................................8 Emergency Care for Anaphylaxis ............................................................................................10 Antidotes for Reactions to Medications ..................................................................................11 Emergency Equipment ..............................................................................................................12 Complications of IV Therapy ....................................................................................................13 Symptoms of Fluid Deficit and Fluid Excess ..........................................................................17 Fluid Assessment ........................................................................................................................17 Preventing Complications of IV Therapy ...............................................................................18 Fluids ............................................................................................................................................19 Method for Estimating Osmolarity ..........................................................................................21 Selecting Equipment ..................................................................................................................25 Rates of Administration .............................................................................................................27 Calculating Flow Rates ..............................................................................................................28 Needle Sizes ................................................................................................................................29 Intramuscular Injections ............................................................................................................30 Pre Treatment Assessment ........................................................................................................31 The Physician’s Order ................................................................................................................33 Patient Teaching .........................................................................................................................34 Selecting A Site ............................................................................................................................35 Applying The Tourniquet .........................................................................................................40 Methods of Venous Distension .................................................................................................41 Caring For Patient Comfort .......................................................................................................42 Preparing the Solution ...............................................................................................................43 Steps in Preparing For Venipuncture ......................................................................................45 Documentation ............................................................................................................................46 Some Indications For Basic Vitamin Therapy ........................................................................48 Osmolarity Chart For A Sample Chelation Treatment .........................................................49 Protocol Ideas ..............................................................................................................................51 Vitamins .......................................................................................................................................52


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ADVANTAGES OF INTRAVENOUS THERAPY

• Bioavailability is immediate.

• Absorption into the blood stream is complete and reliable.

• Large doses can be delivered at a continuous rate.

• There is no first pass effect in the liver.

First-pass effect: Whenever the route of administration is such that there is an organ of elimination between the administration site and the systemic circulation, there is the potential for a first-pass effect. This is sometimes referred to as presystemic elimination. The consequence of the first-pass effect is that the fraction of drug reaching the systemic circulation is substantially reduced. After oral administration, all of the drug must pass through the liver before reaching the systemic circulation. This results in exposure to drug metabolizing enzymes prior to the drug reaching the systemic circulation. An example is nitroglycerin, which is totally inactivated by the liver. Its first pass effect is 100% complete.

DISADVANTAGES OF INTRAVENOUS THERAPY

Life threatening adverse reactions may occur if medications are administered to rapidly.

There is increased risk of complications such as extravasation, vein irritation, systemic infection and air embolism.


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THE FIVE RIGHTS OF MEDICATION ADMINISTRATION

1) Right Medication for the

2) Right Patient in the

3) Right Dose by the

4) Right Route at the

5) Right Time

Be informed about medications patients are to receive, including dosages, actions, desired effects, length of treatment and responsibilities of care as it directly relates to the use of the medication.


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ASEPTIC TECHNIQUE

• Sterile or aseptic technique excludes pathogens. By definition it is the absence of infectious microorganisms on living tissue. Complete destruction of all living organisms is sterilization. Aseptic technique is imperative. Bacterial and fungal contamination of solutions must be avoided.

• Wash hands thoroughly with soap and water before opening and preparation of parenteral fluids. Wash hands for 1 - 2 minutes and dry with a paper towel. Do not handle anything other than IV supplies during the procedure or wash and dry hands again prior to handling the equipment.

• Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Always hold sterile objects above the level of the waist. This will help ensure keeping the object in sight and prevent accidental contamination.

• IV admixtures should be prepared in an isolated clean area. Medications should be prepared in an area that permits complete concentration because distraction increases the risk of human error.

• To keep the equipment sterile do not touch any part of the equipment that will come in contact with IV medication or the blood stream.

• Avoid coughing, sneezing, breathing, laughing, talking or reaching over sterile equipment.

• Never walk away from or turn your back on opened sterile equipment.

• Consider an object contaminated if you have any doubt of its sterility.

• Store medications according to the manufacturers instructions.

• Be aware if the medication is a single or multidose dose vial. Discard any leftover medication from a single dose vial.

• If performing home therapy do not allow pets around the equipment.

• Introduction of extraneous particles must be avoided. Particles introduced into the vein travel to the right atrium of the heart, through the tricuspid valve and into the right ventricle. From there they are pumped into the pulmonary artery and on through branches of arteries that decrease in size until the particles are trapped in the massive capillary bed in the lungs where the capillaries measure 12 microns in diameter. Five microns, the size of an erythrocyte suspended in fluid has been suggested as the largest allowable size for a particle in the pulmonary capillary bed. Particles larger than 5 microns are recognized as potentially dangerous because they are likely to become lodged. Particles as large as 300 microns can pass through an 18-gauge cannula. If occlusion of a small arteriole inhibits oxygenation or normal metabolic activities, cellular damage or tissue death may occur. A particle that is not biologically inert may incite an inflammatory reaction, a neoplastic response, or an antigenic, sensitizing response.


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Needles may cut out fragments of rubber stoppers and accidentally inject them into the solution. Entry into a port with a small gauge needle may help prevent compromise of the port’s integrity; however smaller needles may encourage particles that are difficult to see on inspection. Smaller particles may be of a size capable of passing through the winged infusion set. A solution that on inspection contains fragments of rubber must be discarded.

• Proper illumination permits visualization of particulate matter.

• Check solutions and additives for expiration dates. Outdated medications may have a loss of stability or potency.

• Clean tops of multidose vials with povidone iodine, then wipe with alcohol.

• Medications should be administered through injection ports after disinfecting them.

• Wear clean disposable gloves for any patient procedure involving puncture of skin. Wear gloves when touching blood or bodily fluids and for handling items or surfaces contaminated with blood or bodily fluids. Wash hands or other skin surfaces immediately and thoroughly if contaminated with blood or bodily fluids. Change gloves after each patient contact. Consider all clients as potentially infected. Look after yourself.

• To prevent needle stick injuries never recap used needles or bend or remove from disposable syringes.

• A sharps container should be available for disposal of needles and syringes.


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REDUCING RISKS OF INFECTION

PROTECTING YOUR PATIENT

• Wash your hands before touching any IV equipment or fluids and before

• Clean the venipuncture site with an approved antiseptic, either 70% isopropyl alcohol or povidone-iodine solution.

• Check the equipment before using it. Check solutions for particulate matter and the expiry dates.

• Never reuse a catheter or needle.

• Always cover venipuncture site with a sterile dressing.

PROTECTING YOURSELF

• Treat every patient as potentially infected with HIV or HBV.

• Always use disposable needles.

• To prevent needle stick injuries never bend or break needles, recap them, separate them from the syringe or manipulate them in any way.

• Wear gloves whenever you work with IV infusions.

• Wash hands before and after use of IV equipment. Wash hands immediately if they come in contact with blood or other bodily fluids.


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ANAPHYLACTIC SHOCK

The most common causes of anaphylactic shock are drugs and bee stings. At least 1% of the general population are at risk of developing anaphylactic shock due to bee stings. Anaphylactic shock is considered a grave medical emergency. Severity of the reaction is inversely related to time elapsed between exposure and onset of symptoms. In other words, the shorter the time before symptoms appear, the greater the risk of a fatal reaction. Onset may occur within minutes or seconds.

SIGNS AND SYMPTOMS

Skin

• Itching and burning of the skin with flushing of face, neck and chest

• Cyanosis around lips

• Swelling of eyes, face and tongue

• Paleness

• Swelling of peripheral blood vessels

Heart and Circulation

• Weak, rapid, irregular pulse, with possibility of cardiac arrest

• Low blood pressure

• Dizziness

• Restlessness

• Severe headache, pounding in ears

• Weakness and fainting

Respiratory Tract

• Painful tightness in chest

• Difficulty breathing, respiration rate of less than 10 or more than 20

• Wheezing, crowing breathing

• Swelling of mouth, tongue or throat leading to airway obstruction

• Anxiety

Gastrointestinal

• Nausea

• Vomiting

• Abdominal cramps

• Diarrhea


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SECURE AND MAINTAIN AN OPEN AIRWAY

If the patient is responsive use a nasopharyngeal airway. An oropharyngeal airway should be used only on an unresponsive patient.

The advantages of nasophyngeal airways are they are not likely to stimulate vomiting, can be used in a patient with clenched teeth, or injury or swelling to tongue mouth or lips.

NASOPHARYNGEAL AIRWAY INSERTION PROCEDURE

• Select the proper size. The diameter should be slightly smaller than the nostril. The length should be a bit longer than the distance from the tip of the nose to the ear lobe. If the airway is too short it will not go past the tongue to keep the airway open. If it is too long it will enter the esophagus and fill the patient’s stomach with air.

• Lubricate the airway with a sterile water soluble lubricant, preferably one that contains a topical anesthetic (xylocaine gel) for patient comfort. If no lubricant is available use water. Do not use Vaseline or other petroleum based lubricant, they will damage the nasopharyngeal mucosa and cause breakdown of the plastic.

• Push the tip of the nose up and gently insert the tube through the larger nostril. Forcing the tube into place has the potential to damage the tissues or to kink the tubing. If resistance is met, withdraw the tube and try the other nostril.

• If the patient is responsive have him exhale through his nose with his mouth closed. You will feel air flow through the tube if it is correctly placed.

• Administer 100% oxygen at a high flow rate.

• Commence CPR if indicated. Stay current with CPR techniques. A review course should be taken once a year.


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EMERGENCY CARE FOR ANAPHYLAXIS

• Call 911. Ask for advanced life support for an anaphylactic reaction.

• Maintain an open airway.

• Administer patient’s own medication, such as Ventolyn or antihistamine if taken.

• Administer Benadryl elixir 20 ml, swallow 15 ml and hold 5 ml under the tongue or inject Benadryl 50 mg IV or deep IM.

• Epinephrine should be kept on hand but only used in life threatening situations. Administer .3ml SC, IM or IV and watch closely for a response. If necessary administer the rest of the ampoule .3m1 at a time. More than one ampoule may be required. Epinephrine IV produces an immediate and intensified response. It should be administered IV only in life threatening situations here the SC or IM routes are impractical or have proven ineffective. Following IV administration epinephrine disappears rapidly from the blood stream.

• Elevate the legs so that gravity can help improve the blood supply to the heart. Keep head and shoulders raised for breathing difficulty.

• Loosen clothing at neck, waist and any other binding area.

• Start IV bag of normal saline with large bore catheter, before patient goes into shock. Shock will reduce peripheral blood flow and make starting an IV very difficult.

• Keep patient warm, but be careful not to overheat.

• Remain calm and in control. Keep the patient still and calm. Shock is aggravated by excessive handling. Reassure the patient frequently..

• Monitor and document state of consciousness, respiration rate, pulse and blood pressure at 5 minute intervals. Observe carefully for potential vomiting.


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ANTIDOTES FOR REACTIONS TO MEDICATIONS

• Epinephrine for relief of hypersensitivity reactions.

• Benadryl for early symptoms of respiratory distress and skin manifestations.

• Valium for convulsions.


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EMERGENCY EQUIPMENT TO HAVE ON HAND

• Oxygen

• Bag and mask

• Benadryl

• Epinephrine

• Nasophyngeal airways

• Oropharygeal airways

• Xylocaine gel

• Normal saline bags

• Large gauge catheters

• Juice and crackers


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COMPLICATIONS OF IV THERAPY

INFILTRATION

Infiltration is infusion or seepage of IV solution or medication into the extravascular tissue. Infiltration occurs when the venipuncture needle penetrates both walls of the vein or becomes fully or partially dislodged from the vein. This allows IV fluid to flow into the surrounding tissues until swelling blocks the needle opening. Infiltration may also occur if the needle has not been positioned correctly in the vein when initially inserted. The seriousness of infiltration is related to the type of fluid, the concentration and the amount of fluid infiltrated. Tissue necrosis and sloughing may occur if the infusing fluid is caustic to the tissue. Vitamin C and DMPS are highly irritating fluids.

Clinical Manifestations and Prevention Tips

An infiltration is characterized by pain and edema at the insertion site and coolness of the adjacent skin. An absence of blood back flow when the bag is lower than the limb is another sign of infiltration. The gravitational flow of the IV may be sluggish. If an infiltration is suspected place a tourniquet above the IV site if the IV continues to flow by gravity an infiltration has occurred. Once an infiltration has been identified the IV should be discontinued immediately. Ice will decrease further edema and pain. Moist heat will facilitate the absorption of fluid at grossly infiltrated sites. Apply Traumeel ointment to reduce pain. If in doubt about needle placement check for blood back flow.

QUICK ASSESSMENT METHODS FOR DETERMINING INFILTRATION

Infiltration is the most common problem associated with intravenous therapy. The practitioner should be vigilant in instructing the patient and remaining still and relaxed and checking the needle site from time to time.

1. Check site for swelling, a bleb at needle site and coolness of skin. Stop flow of infusion. Insert needle into injection port and gently draw back. Blood should return into the tube.

2. Stop flow of infusion. Lower back to below the level of the infusion site. Blood should return into the tube. This method is not always 100% accurate because there may be a partial infiltration in which case the needle bevel has only partially perforated the vein. In this case some of the infusate may enter the vein and some collect in adjacent tissue. Although a blood return is present the tissue is infiltrated.

3. To double check: Stop flow of infusion. Gently apply tourniquet above needle site. Slowly start infusion. The tourniquet should stop flow of infusion. If infusion continues chances are very good the infusion is collecting in tissues adjacent to the needle site.


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THROMBOPHLEBITIS

Phlebitis is the inflammation of a vein and thrombosis is the formation of a clot in the blood vessel. The vein may be injured during the venipuncture or by movement of the needle during therapy. Irritation of a vein may occur as a result of irritating or incompatible IV additives, use of a vein that is too small for the IV flow rate or use of a needle size too large for the vein size. A sluggish flow rate may cause a clot formation.


In the early stages of phlebitis the patient may complain of pain at the needle site. If the practitioner does not intervene by changing the needle site, the injury progresses to pain at the needle site and along the vein. In later stages thrombophlebitis appears as a vein that is sore, hard, cord like and warm to the touch. A red line above the venipuncture site is the major sign of thrombophlebitis. The patient may spike a temperature. Phlebitis may predispose the patient to local infection, which may progress to systemic infection. Other symptoms include sluggish flow rate and edema in the limb. Upon assessment of thrombophlebitis the needle should be immediately removed. Application of a warm compress will increase client comfort. Preventative measures include firm stabilization of the infusion device, adequate dilution of irritating additives and use of a small gauge needle for infusion of caustic medications. A small needle lumen allows blood to circulate around the needle and further dilute the medication. IMPORTANT: Never try to irrigate the line. You may flush a clot into the blood stream causing an embolus.

CATHETER EMBOLISM

A catheter embolism is a free floating or dislodged fragment of a catheter in the circulatory system. This usually occurs with flexible catheters rather than with needles, but may occur with coring of rubber stoppers from multi-dose vials. If using an over the needle catheter possible causes of embolism are withdrawing the catheter before the needle or attempting to rethread a catheter with a needle.


Signs and symptoms of a catheter embolism include a decrease in blood pressure, discomfort along the vein, a weak rapid pulse and cyanosis and unconsciousness. The IV should be immediately stopped. A tourniquet should be applied above the site. You may be able to prevent the embolus form migrating further. An x-ray may be required to determine if fragments are present and surgical removal of the fragments may be necessary.

HEMATOMA

Hematoma is the seepage of blood into the extravascular tissue. A hematoma may occur when clients with coagulation defects are undergoing IV therapy, when anticoagulant therapy is being administered to a patient, or when sufficient pressure is not applied to the site post therapy.


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A hematoma is characterized by discoloration of the tissue at the IV site. Upon initiation of therapy palpate the vein and slowly advance the needle to prevent puncturing of both vein walls. Assess the site frequently for signs of hematoma and discontinue the treatment if edema appears. When discontinuing the IV apply pressure for 5 minutes.

INFECTION OF VENIPUNCTURE SITE

Infection at the venipuncture site is a result of a break in aseptic technique. The organisms most commonly involved are staphylococcus aureus, klebsiella, serratia, pseudomonas aeruginosa. These organisms can be transferred to the infusion site through poor aseptic technique either during IV insertion or secondary to the use of contaminated equipment.


An infected site appears red, sore and edematous and may contain discharge that is purulent and foul smelling. If the infection is not treated septic phlebitis may occur leading to systemic infection. Wash hands thoroughly before starting any IV procedure. Clean the site, apply antimicrobial ointment, cover with sterile gauze, treat systematically.

SYSTEMIC INFECTION

A systemic infection is an infection of the blood stream and like local infection is caused by poor aseptic technique.


A client with systemic infection will exhibit a sudden rise in temperature and pulse with chills and shaking. Blood pressure will decrease. Assess for sources of infection such as urine, sputum and blood. If any part of the system is accidentally disconnected, don’t rejoin it. Instead replace the parts with sterile equipment.

AIR EMBOLISM

An air embolus is the entry of a bubble into the client’s circulatory system. An air embolism can occur if the IV container becomes empty, if air enters the IV tubing or is not initially purged from the tubing or if the IV connections become loose allowing air to enter.


A client experiencing an air embolism will have a sudden drop in blood pressure, cyanosis, a weak rapid pulse leading to loss of consciousness. The client should be turned onto the left side with the head lower than the heart. This position may keep the embolism on the right side of the heart and may relieve pulmonary vascular obstruction. The pulmonary artery will then absorb small air bubbles. Administer O2.


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Purging Air From The IV Line

• Stop flow of infusion.

• Clamp IV line below the injection port.

• Insert a sterile needle (no syringe) into the injection port and hold over a receptacle.

• Open flow valve and allow air to escape through needle over receptacle.

• When air is purged remove needle from port and resume flow of infusion.

SPEED SHOCK

Speed shock is a rapid change in the venous system usually resulting in hypertension. Administering infusions or boluses too quickly can cause speed shock.


The client may exhibit flushed face, headache, tight feeling in the chest and an irregular pulse. In extreme cases loss of consciousness leading to shock and cardiac arrest may occur. Discontinue drug infusion and begin an infusion of 5% dextrose at a KVO rate for emergency treatment.

ALLERGIC REACTION

An allergic response may be a local or generalized response to tape, cleansing agent, medication, solution or intravenous device.


Symptoms may include local responses such as a wheal, redness or itching at the needle site. In the case of a systemic reaction the client may complain of itching, runny nose, tearing, bronchospasm, wheezing or truncal rash. Prevention lies with good assessment. The patient should be treated symptomatically with antihistamines and hypoallergenic supplies. In the case of anaphylaxis discontiunue the infusion immediately. Maintain an open airway. Keep the vein open with normal saline or D5W. Administer 0.2 to 0.5 ml of 1:1000 epinephrine subcutaneously every 3 to 4 minutes as required.

CIRCULATORY OVERLOAD

Circulatory overload is an excess of fluid disrupting the fluid homeostasis caused by infusion of fluid at a rate greater than the patient’s system is able to accommodate.


A patient suffering from fluid overload may complain of shortness of breath and cough or moist lung sounds may be auscultated. Blood pressure may be elevated and edema and puffiness may be observed around eyes and in dependent areas. See Symptoms of Fluid Excess and Deficit. Prevention lies with good pretreatment assessment. Treatment includes ensuring the client is in a comfortable sitting position to ensure ease of breathing and administration of oxygen and a diuretic if required.


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SYMPTOMS OF FLUID DEFICIT

• weight loss

• lowered body temperature

• increased or decreased pulse

• decreased blood pressure,

• includes postural hypotension

• sunken eyes, decreased tearing

• decreased salivation

• dry cracked lips

• furrows in tongue

• cold limbs

• decreased urine output

• increased serum osmolarity

SYMPTOMS OF FLUID EXCESS

• weight gain

• elevated blood pressure

• bounding pulse not easily obliterated

• jugular distention

• increased respiratory rate

• moist crackles or rhonchi

• edema of dependent parts, check sacrum

• puny eyelids, periorbital edema

• slow emptying of hand veins when arm raised

• reduced serum osmolarity

FLUID ASSESSMENT

An assessment of the client’s current and past use of medications is important. The ingredients in many drugs especially over the counter drugs are often overlooked as sources of sodium, postassium, calcium, magnesium and other electrolytes. There are many prescription drugs that could cause fluid and electrolyte problems. Examples include diuretics prescription and herbal, corticosteroids and electrolyte supplements. The client should be questioned about any primary disease that could cause fluid and electrolyte imbalances such as renal disease, diabetes mellitus, ulcerative colitis and respiratory disease. Extremes of climate and activity may alter the body’s fluid requirement. Clients who live alone may not satisfy their body’s need for balanced fluid and electrolytes because they may not adequately prepare meals or drink enough fluids. Client’s diets should be assessed to discover if he has been on a special diet such as vegetarian - low protein, weight loss diet especially with weight loss supplements, or fad diets. There is no unique physical examination to assess fluid and electrolyte balance, but some common abnormal assessment findings give clues to imbalances.


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PREVENTING COMPLICATIONS FROM IV THERAPY

• Use aseptic technique.

• Inspect all fluids and equipment before use.

• Use preservative free vitamins within 24 hours.

• Do not irrigate plugged needles or catheters.

• Remove non-functioning sets and needles.

• Avoid using veins of lower extremities.

• Never apply positive pressure when infusing fluids.

• Be alert to signs of circulatory overload.

• Avoid speed shock.

Phlebitis

• Do not use veins over an area of joint flexion.

• Anchor cannulas well to prevent motion and reduce risk of introducing microorganisms into puncture wound.

• Adequately dilute medications.

• Use a needle or cannula smaller than the vein.

• Remove needle or cannula for erythema (redness of the skin caused by congestion of the capillaries, occurring with skin injury, inflammation or infection), induration (abnormal hardness), tenderness by palpation of venous cord or nonfunctioning needle.

Infiltration

• Check questionable extremity against normal extremity.

• Apply a tourniquet tightly enough to restrict venous flow proximal to the injection site. If the infusion continues regardless of the venous obstruction, extravasation is evident.


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FLUIDS

Body fluids exist in two compartments separated by capillary walls and cell membranes. Two thirds of bodily fluids exist inside the cells and is called intracellular fluid and one third exists outside the cells and is called extracellular fluid. For fluid balance the distribution between the two compartments must remain relatively constant.

Osmosis is the movement of water molecules through a selectively permeable membrane from an area of higher water concentration to an area of lower water concentration.

Osmotic pressure is the pressure required to prevent movement of pure water into a solution containing solutes when the solutions arc separated by a selectively permeable membrane. The greater the solute concentration of the solution the greater its osmotic pressure.

The osmolality of blood plasma is 290 milliosmoles per litre. Intravenous fluids considered in the isotonic range have an osmolality of 280-310 mOsm/L. Intravenous fluids with an osmolality significantly higher than 290 (+50) are considered hypertonic, while fluids with a significantly lower osmolality (- 50) arc considered hypotonic.

Tonicity of fluid infused into the circulation has a direct effect on the physical well being of the patient. Hypertonic fluids increase the osmotic pressure of the blood plasma, drawing fluid from the cells. Excessive infusion of hypertonic fluids can cause cellular dehydration. Hypotonic fluids lower the osmotic pressure causing fluid to invade the cells which can cause water intoxication. Isotonic fluids can cause excess extraccllular fluid volume which can result in circulatory overload.

ISOTONIC SOLUTIONS

If the normal shape of a red blood cell is to be maintained, the cell must be placed in an isotonic solution. This is a solution in which the total concentrations of water molecules and solute molecules are the same on both sides of the selectively permeable membrane. The concentration of solute and water in the extraccllular fluid must be the same as the concentration inside the intracellular fluid. Under normal circumstances a 0.85% NaCl solution is isotonic for red blood cells. In this condition, water molecules enter and exit the cell at the same rate, allowing the cell to maintain its normal shape.

An isotonic solution possess the same osmolarity as serum and other body fluids. Because the solution does not alter osmolarity it stays where you put it, inside the blood vessel The solution expands this compartment without pulling fluid from any other compartment.

Isotonic solutions

• expand the intravascular department.

• monitor patient for signs of fluid overload especially if he has hypertension or congestive heart failure. See fluid overload chart.


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Red blood cells may be greatly impaired or destroyed if placed in solutions that deviate significantly from the isotonic state. Patient safety and comfort is best achieved by utilizing a solution which falls within the isotonic range.

HYPOTONIC SOLUTIONS

When red blood cells are placed in a solution that has a lower concentration of solutes and a higher concentration of water the solution is called hypotonic. In this condition water molecules enter the cells faster than they leave causing the red blood cells to swell and eventually burst. The rupture of red blood cells in this manner is called hemolysis. Sterile water is a strongly hypotonic solution.

Administer hypotonic solutions carefully. These solutions can cause a shift of fluid from blood vessels into cells, with the potential to cause cardiovascular collapse from intravascular fluid depletion and increased ICP from fluid shift into brain cells. Do not give hypotonic solutions to patients at risk of third space fluid shifts, patients suffering from burns, trauma, arthritis, low serum protein levels, malnutrition or liver disease.


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METHOD FOR ESTIMATING THE OSMOLARITY OF AN IV SOLUTION

1. For each component of the mixture multiply the volume in milliliters of that component times the value of the milliosmoles present in the component.

2. Add the products obtained in step 1 for each of the components in order to determine the total number of milliosomoles in the mixture.

3. Add together each of the volumes in order to obtain an estimate of the final total volume of the mixture.

4. Divide the total number of milliosmoles from step 2 by the total volume form step 3, then multiply by 1000 to obtain an estimate of the osmolarity of the mixture of the solution in milliosmoles per litre.


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DESCRIPTION mOsm/ml

Ascorbic Acid (Sodium Ascorbate) 2.67 Ascorbic Acid 5.80 B- complex 100 2.14 B- complex with “C” and “B-12” 2.14 Calcium Gluconate 0.72 Chromium 0.03 Copper 0.01 Cyanocobalamin (B-12) 0.45 Dexapanthenol (B-5) 0.85 Dextrose 2.52 Dimethylsulfoxide 0.01 Disodium EDTA 1.34 Folic Acid 0.20 Heparin 0.46 Hydroxycobalamin (B- 12) 0.31 Lidocaine 0.15 Magnesium Chloride 2.95 Magnesium Sulfate 4.06 Manganese 0.87 Molybdenum 0.80 Multi Trace Elements (MTE-4) 0.05 Potassium Chloride 4.00 Procaine Hydrochloride 0.28 Pyridoxine (B-6) 1.11 Sodium Bicarbonate 1.79 Sodium Chloride 0.31 Thiamine (B-1) 0.62 Sterile Water 0.00 Zinc 0.11

SOLUTIONS

5 % Dextrose 0.25 Lactated Ringers 0.28 0.45 % Sodium Chloride 0.16 0.9% Sodium Chloride 0.31 Sterile Water 0.00 3 % Amino Acid 0.41 15 % Amino Acid 0.45 5.5 % Amino Acid 0.58 8.5 % Amino Acid 0.89


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HYPERTONIC SOLUTIONS

A hypertonic solution has a higher concentration of solutes and a lower concentration of water than red blood cells. An example of a hypertonic solutions a 10% NaCI solution. In such a solution water molecules move out of the cells faster than they can enter, canning the cells to shrink. This situation is called crenation.

SOLUTION OSMOLARITY

Isotonic

Lactated Ringer’s 275 mOsm/L

0.9% sodium chloride (normal saline) 308 mOsm/L

D5 W 260 mOsm/L

Hypotonic

0.45% saline 154 mOsm/L

0.33% saline 103 mOsm/L

dextrose 2.5% in water 126 mOsm/L

sterile water 0 mOsm/L

Hypertonic

dextrose 5% in 0.45% saline 406 mOsm/L

dextrose 55 in normal saline 560 mOsm/L

dextrose 5% in Lactated Ringer’s 575 mOsm/L


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Common I.V. therapy solutions

Benefits possible from administration

Conditions requiring precautions

carbohydrates in water (e.g. 5% dextrose in water)

• Prevents dehydration • Prevents and treats ketosis • Promotes sodium diuresis

(particularly following excessive administration of electrolyte solution)

• Supplies calories (for energy) • Supplies water (for body

needs)

• Water intoxication • Patient’s undergoing blood

transfusion • Patient’s undergoing

neurosurgical procedure

carbohydrates in sodium chloride solution (e.g. 5% dextrose in half-strength saline)

• Promotes diuresis • Corrects excessive fluid loss

(due to perspiration) • Prevents alkalosis • Provides calories and sodium

chloride

• Renal insufficiency • Edema from cardiac.

hepatic, or renal disease

sodium chloride solution (e.g. 0.9% sodium chloride solution)

• Treats alkalosis • Corrects excessive fluid loss • Treats diabetic acidosis • Treats adrenocortical

insufficiency • Treats vomiting from pyloric

stenosis

• High sodium and chloride plasma concentrations

• Dehydration • Hyponatremia • Edema

Ringer’s solution (contains sodium, chloride, potassium. and calcium)

• Treats dehydration from reduced water intake, vomiting, or diarrhea

• Treats mild alkalosis • Treats hypochloremia

• Addison’s disease • Severe potassium or

calcium deficiency

lactated Ringer’s solution (contains sodium, potassium, calcium, chloride, and lactate)

• Treats dehydration • Restores normal fluid after

extracellular fluid shift (from burns, infection, etc.)

• Moderates metabolic acidosis (from renal insufficiency, infant diarrhea, diabetic ketosis)

• Hepatic disease • Anoxia • Addison’s disease • Severe metabolic acidosis • Severe metabolic alkalosis

multiple electrolyte solution (contains sodium, potassium. magnesium, chloride, lactate, phosphate)

• Replaces daily electrolyte, extracellular and water loss

• Replaces gastric contents lost through gastric suctioning or vomiting

• Severe renal disease • Diabetes insipidus • Severe hepatic disease

plasma volume expanders (contains dextran, sodium, chloride)

• Temporarily increases blood volume lost from trauma, hemorrhage, burns, surgery, or anesthesia

• Dextran allergy

Credits to: Managing I.V. Therapy, Nursing Photo Book, 1981, Editorial Director Jean Robinson, Publisher Eugene W. Jackson.


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SELECTING EQUIPMENT

FLUID CONTAINERS

Two basic types of fluid containers exist. They are glass and plastic. Plastic bags are the most widely used container but glass must be used for medications that are absorbed by plastic such as insulin and diazepam. Glass bottles are evacuated and quickly pull in injected additives. They must be vented to allow outflow of fluid. A vented administration set provides sufficient air intake to enable the fluid to flow. In a closed system only filtered air is allowed into the container. In an open system unfiltered air enters the bottle through a plastic tube in the container. Venting can be achieved through inserting a 22 gauge needle into the rubber stopper of the bottle. Risks involved using a glass container include coring of the rubber stopper and particulate matter entering the fluid, air embolism and airborne contamination. Plastic containers are the most popular. They are easily transported with minimal risk of damage and arc easily disposed o£ Because plastic does not require air venting and they collapse as air flows out, risk for air embolism and contamination is greatly reduced. Plastic bags are susceptible to accidental puncture, creating a port of entry for microorganisms. Punctures may not be readily detected and all bags should be inspected visually and squeezed to determine patency.

Check the container for size and correct fluid. Make note of the expiry date. Fluids should never appear cloudy, turbid or separated. Discard out dated fluids, any kind of damaged container and any fluids that are not clear.

ADMINISTRATION SETS

Selection of an administration set depends on the type and rate of infusion and the type of solution container. Types of administration sets include basic, add a line and volume control. For our purposes here only the basic administration set will be discussed. Administration sets come with two types of drip systems, microdrip and macrodrip. A macrodrip set delivers large quantities at rapid rates (10 -20 gtt/ml). Increased viscosity causes the size of the drop to increase. A set that delivers 15 gtt/ml will deliver 10 gtt/ml when blood is administered. A microdrip system delivers a smaller amount with each drop e.g. (60 gtt/ml). Microdrip systems are usually used for pediatrics or adults requiring closely regulated amounts of fluids.

A basic administration set consists of a spike at one end, a drop orifice at the other end, a drip chamber, one or more injection ports, a roller clamp and a needle adapter. Sets range in length from 70ʺ to 110ʺ long. The roller clamp is used to adjust the flow rate which invariably changes after the rate is regulated.

VENIPUNCTURE DEVICES

Selecting a device depends on the length of time the device will stay in place, the type of solution used and the type of vein available.

Over-the needle catheters are available in 14 - 26 gauge sizes from 1 to 2 inches in length. They consist of a plastic outer catheter and an inner needle that extends beyond the


26

catheter. The needle pulls out after insertion leaving the catheter in place. The advantages of using this device are: it allows the patient greater freedom of movement and infiltration occurs less frequently. Disadvantages are: these devices are more difficult to insert. If an unsuccessful attempt is made to insert the catheter, a new catheter should be used for a repeat attempt in order to avoid shearing of plastic from the catheter and potential plastic embolus. Cost of over-the-needle catheters is approximately $1.80.

Winged infusion sets, commonly called butterflies, are the easiest intravascular device to insert. They arc available in sizes 16-27 gauge and are about 3/4 inch long. Using a small gauge ensures a slow infusion rate that cannot be speeded up by the patient Tubing varies in length up to 12 inches. Use of a 12 inch tubing may reduce the need for an administration extension set. Butterflies arc used for short term therapy and are ideal for single IV push injections. Disadvantages of butterflies are the risk of infiltration is greater than with a catheter and adequate veins must be available. Cost of butterflies is about $0.75 each.


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RATES OF ADMINISTRATION

Cardiac and renal status of the patient play a vital role in determining the rate of administration of intravenous fluids. Rapid infusion of fluids may cause an expanded blood volume, overtaxing an impaired heart and renal damage causes fluid retention. Because there is frequently some degree . of cardiac and renal damage in the elderly, fluids are administered slowly to prevent increased venous pressure, pulmonary edema and congestive heart failure.

FACTORS AFFECTING THE FLOW RATE

Height of Bag – Because intravenous fluids run by gravity the height of the container will influence the drip rate. The container should be hung 3 feet above the infusion site. Any change in gravity by raising or lowing the container will cause a change in the drip rate.

Change In Position of Cannula – A change in the position of the cannula may push the bevel of the needle against the wall of the vein reducing the flow rate. To remedy the problem try pulling back on the catheter slightly (about 1/8 inch) or rotate gently. Rotating a butterfly puts the patient at risk for injury to the vein, triggering infiltration or thrombophlebitis. In some cases flow may be restored by changing the angle of the cannula. Elevate it slightly with a cotton ball or gauze pad. Ensure that the solution is flowing freely before adjusting the rate.

Clot in Cannula – Any temporary stoppage of the infusion may cause a clot to form at the end of the cannula, causing partial or complete obstruction. Clot formation may also occur if and increase in venous pressure in the infusion arm forces blood back into the cannula. This problem is caused by restriction of venous circulation related to 1) blood pressure cuff left on the arm 2) restraints such as tight clothing on or above the cannula 3) patient position puts pressure on the infusion arm. To remedy the situation close the flow clamp and try aspirating the clot with a syringe on the catheter hub. This procedure is not likely to work with a small gauge butterfly. Never try irrigating a clogged IV with a syringe and solution. This increases the risk of propelling the clot into the blood stream. If you arc not able to successfully aspirate the blood clot the IV must be discontinued and restarted in another vein.


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CALCULATING FLOW RATES

The number of drops required to deliver 1 ml of intravenous solution varies with the type of infusion set used and the manufacturer. A standard macrodrip set delivers from 10-20 drops/ml. A macrodrip set delivers about 60 drops/ml and is usually used for pediatric patients. The manufacturer clearly labels the number of drops/ml on the outside of the package.

Volume of infusion (in ml) X drop factor in drops/ml = drops/min time of infusion(in minutes)

1. After calculating the required drip rate hold your watch next to the drip chamber to allow simultaneous observation of the time and drops.

2. Release the clamp to the approximate flow rate desired and count the drops for 1 minute to account for drip rate irregularities. Continue to adjust the clamp and count drops until the rate is accurate.

3. If the flow rate slows significantly avoid increasing the rate to catch up. Adjust the rate to the infusion to the desired rate.


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NEEDLE SIZES

14 - 20 gauge are large bore needles used for blood, drawing up viscous medications. 18 gauge needles are most convenient for drawing up vitamin C and are preferred for blood draws and major autohemotherapy (ozone). Smaller gauge needles may cause hemolysis when blood cells are drawn through a too small opening

22 - 25 gauge most suitable sizes for IM injections. 22 gauge is the size most frequently used in hospitals for IM injections. 25 gauge is more comfortable for the patient. 23 guage winged infusion sets are the most popular for in office infusions. 25 gauge may be used to help regulate a slow flow rate for chelation treatments.

30 gauge is the smallest commercially available needle and is used for subcutaneous injection. Some physicians believe it to be the kindest needle to use for IM injection for children. This is debatable because more pressure must be applied to force fluid through the small opening, causing a sharp jet of fluid to be introduced into the muscle.

NEEDLE LENGTH

A 1 inch long needle is generally adequate for IM injections. In obese patients a 1.5 inch needle is required to ensure injection into the muscle rather than the fatty tissue. Muscle tissue has more capillaries to take up medications than does fatty tissue. For subcutaneous injection 0.5 inch is preferred and for intravenous injection 1 inch ensures a solid position in the vein.


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INTRAMUSCULAR INJECTIONS

• Gather equipment together, ampoule, alcohol swab, needle and syringe.

• Wash hands thoroughly.

• Draw medication into syringe.

• Choose injection site: upper outer quadrant of left or right buttock. mid third of thigh. upper arm four fingers from top of shoulder.

• Wipe injection area with alcohol swab and allow to dry.

• Remove needle cap by pulling it straight off

• Hold syringe in your dominant hand, between thumb and first finger (hold like a pencil), and quickly dart the needle in at a 90 degree angle. NOTE: A one inch needle goes all the way in except a small tip at the end of the needle where it joins the hub, which is left exposed. In case of needle breakage the needle can be pulled out.

• As soon as the needle is in place, use your nondominant hand to hold the lower end of the syringe (end closest to the patient). Use your dominant hand to operate the plunger.

• To determine whether the needle is in a blood vessel aspirate slowly by pulling back on the plunger. If blood is present in the syringe remove the needle, hold pressure on the site until bleeding stops and choose a new site for injection.

• If no blood is aspirated inject the solution slowly.

• Remove the needle and gently massage the injection site with a dry swab.


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PRE TREATMENT ASSESSMENT

A complete review of systems should be done with special attention paid to:

• Allergies. Eczema, urticaria, allergic rhinitis, insect hypersensitivity, food and inhaled sensitivities.

• Screening tests such as hematocrtit, chem screen, lipid profile, occult blood, urinanalysis, creatnine clearance etc.

• Diet including nutritional intake for past 24 hours, dietary restrictions, supplements, average intake of caffeine.

• Usual weight and any recent weight changes

• Current medications, alcohol, tobacco and recreational drug use, type, amount, duration of use.

• Self and family history of diabetes, tuberculosis, heart disease, high blood pressure, stroke, kidney disease, cancer, arthritis, anemia, headaches, epilepsy, mental illness, chronic infectious disease.

• Skin rashes, lumps, bumps, bruises and their origin, itching dryness, colour changes and changes in hair or nails.

• Eyes glaucoma, pain, redness, excessive tearing, cataracts, vision and corrective lenses.

• Ears hearing, tinnitus, earaches, infection, discharge.

• Nose and sinuses current or frequent colds, nasal congestion, discharge, itching, nosebleeds, hayfever, allergies, sinus problems.

• Mouth and throat. Condition of teeth, tongue and gums, bleeding, sore tongue, frequent sore throats, hoarseness, herpes simplex.

• Respiratory. Cough, sputum, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last chest xray.

• Cardiac. Hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, nocturnal dyspnea, edema, heart screening tests, leg cramps, intermittent claudication, varicose veins, hemorrhoids, thrombophlebitis.

• Urinary. Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of the urinary stream, hesitancy, incontinence, urinary infections, stones.

• Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness, tingling, tremors or other involuntary movements.

• Musculoskeletal. Joint or muscle pain or stiffness, arthritis, gout, back pain, weakness, limited range of motion.


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• Hematologic. Anemia, easy bruising or bleeding, past transfusions and any possible reactions.

• Endocrine. Thyroid problems, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria.

• Psychiatric. Nervousness, tension, mood including depression and memory

• Transcultural and age considerations. African Americans have a smaller skin fold thickness in their arms than Caucasians do and their arm veins may be closer to the surface. In older patients small veins become more fragile and friable, but larger veins become sclerotic.


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THE PHYSICIAN’S ORDER

• Infusion route

• Type of access device

• Type of base solution

• Specific medication and additives

• Rate of infusion

• Dosage

• Frequency of administration


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PATIENT TEACHING

Many patients have feelings ranging from slightly apprehensive to totally terrified about any therapy involving needles or blood. To help reassure your patient, before you begin therapy, teach your patient what to expect during and after therapy. Thorough patient teaching can reduce patient anxiety, making therapy easier to initiate for you and easier for the patient to tolerate. Before commencing therapy tell your patient the following:

1. Describe the procedure including a description of what intravenous means. Tell your patient intravenous means a needle or catheter will be placed in his vein. Explain that fluid containing nutrients or medications will flow from the bag or bottle through the tubing then through the needle and into his vein.

2. Give him a time frame for how long it will take for the fluid to infuse. Tell him how much and what type of fluid he will receive and what type of nutrients and medications he will receive. Explain to him what this therapy will do for him and why he needs to have it.

3. Tell him the fee for this service and how often you expect him to repeat it.

4. Mention that he may feel transient pain during the insertion of the needle, but this pain will pass once the catheter or needle is in place.

5. Tell him the IV fluid may feel cold at first. Explain that the fluid is at room temperature which is cooler than body temperature. Reassure him by telling him if he feels discomfort from the coolness a heat source will be placed around his arm.

6. Tell him to report any discomfort experienced after the needle is in place and the fluid is flowing. Tell him how frequently you or an assistant will be checking on him. Tell him how to call for assistance should he need to.

7. Explain any restrictions such as any restrictions on movement, remaining seated, keeping his arm still etc. Can he eat, drink, or read books? Suggest he void before the therapy is initiated.

8. Teach the patient how to care for the line. Tell him not to kink, put pressure on, or pull on the tubing, or remove the container from the pole. Tell him he should call staff if the flow rate speeds up or slows down suddenly.

9. Explain that removing the line is a simple procedure. Tell him to apply pressure to the needle site for a minimum of three minutes, until bleeding stops and you will check the site before he is released. Reassure him that once the IV is discontinued he will have normal use of the involved limb.

10. Ask him if he has any unanswered questions or concerns.


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SELECTING A SITE

• Assess both upper extremities.

• Accessibility must be considered, but the most prominent vein is not always the best choice. A vein may be prominent because it is sclerosed. The vein of choice should feel firm, round, elastic and engorged. Some veins appear suitable at first but, feel hard, knotty and small on palpation. To palpate a vein place one or two fingers over the vein and apply light pressure. Release pressure to assess elasticity and refilling. Some veins feel and look suitable but are not easily cannulated because their lumens are irregular or narrowed by scarring, causing difficulty advancing the cannula. A patient who has been recently hospitalized should be expected to have fewer suitable veins.

• Select a vein in the non-dominant arm preferably.

• Never choose a vein over an edematous site.

• If the infusion is acidic or caustic choose a vein away from joints, covered by plenty of subcutaneous tissue.

• Ensure the vein can accommodate the cannula.

• To acquire a highly developed sense of touch palpate before every cannulation.

• Visualize the vein in your mind’s eye.

• For most adults veins in the hands will be your first choice. If problems arise with infiltration, proximal sites remain available. Veins in the lower arm are also a good choice, leaving the patient’s hands free.

• Consider your skill at venipuncture.


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SITES TO AVOID

• veins over a previous IV infiltration site.

• veins below a phlebitic area.

• sclerosed or thromboses veins.

• areas of skin inflammation, disease, bruising or scarring.

• an arm affected by radical mastectomy, edema, blood clot or infection.

• arteries are rarely damaged during venipuncture because they are located deeper than veins. In the anticubital fossa veins and arteries lie close together increasing the risk of damage to an artery.

• Before performing any venipuncture palpate for arterial pulsation (this occurs even after a tourniquet is applied unless the tourniquet is applied to tightly) to locate nearby arteries.


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SITES OF LAST RESORT

• Veins on the inner aspect of the wrist and arms may be used but are thin walled and associated with bruising, phlebitis and infiltration.

• Avoid the anticubital fossa because the catheter will interfere with arm flexion. Damage to this site may cause future difficulty with blood sampling.

• Cannulation of veins of the legs, feet and ankles can compromise circulation in the legs and cause thrombosis or embolism. If you must use one of these sites the dorsum of the foot and the saphenous vein of the ankle are the sites of choice.


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Dorsal Digital Veins

• Flow along lateral portion of fingers and are joined to each other by communicating branches. Available for IVs accommodating a small gauge IV catheter (25 gauge)

• Need to be properly supported with a tongue blade or hand board

• Usually not very stable and not a primary site choice

Metacarpal Veins

• Formed by union of digital veins (dorsal venous area)

• Ideal position for IV use - primary choice IVs

• Venipuncture should be started at the most distal point on the extremity

• Proper support is needed after IV infusion is initiated to prevent movement of IV catheter

• Veins are thin with inadequate tissue and muscle support in the elderly

Cephalic Vein

• Flows upward along the radial border of the forearm producing branches to both surfaces of the forearm

• Because of their size and location, they provide an excellent site for IV infusion

• Readily accommodates large gauge IV catheters

• Is available for venipuncture in the upper arm region

Accessory Cephalic Vein

• Originates from either a plexus on the back of the forearm or dorsala accessory cephalic venous network

• Branches off from the cephalic vein just above the wrist and flows vein back into the main cephalic vein at a higher point

• Readily accommodates large gauge IV catheters

Basilic Vein

• Originates in the ulnar portion of the dorsal venous network

• Ascends along the ulnar portion of the forearm. It curves toward the anterior surface of the arm just below the elbow. It meets with the median cubital vein below the elbow

• Is available for venipuncture above the antecubital fossa in the upper arm region

• Often overlooked because of its inconspicuous position


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Median Antebrachial Vein

• Arises from the venous plexus on the hand and extends along the ulnar side on the anterior surface of the forearm. It empties into the basilic vein or median cubital vein.

• It is not always easily seen.

Median cephalic and median basilica veins

• Located in the antecubital fossa. It should be a last resort site for blood draws and is not a favorable site for prolonged infusions.

Veins of the Hand

1. Digital Dorsal veins

2. Dorsal Metacarpal veins

3. Dorsal venous network

4. Cephalic vein

5. Basilic vein

Veins of the Forearm

1. Cephalic vein

2. Median Cubital vein

3. Accessory Cephalic vein

4. Basilic vein

5. Cephalic vein

6. Median antebrachial vein


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APPLYING THE TOURNIQUET

• Choose a tourniquet that can be easily tied, doesn’t roll, stays flat and releases easily.

• A blood pressure cuff may be used in place of a tourniquet. Inflate the cuff then release it until the pressure drops to just below the diastolic pressure.

• Place the tourniquet under the patient’s arm about 6 inches above the chosen site. Position the arm in the middle of the tourniquet.

• Bring the ends of the tourniquet together, placing one on top of the other.

• Holding one end on top of the other lift and stretch the tourniquet and tuck the top tail under the bottom tail, without allowing the tourniquet to loosen.

• Tie the tourniquet smoothly and snugly, being careful not to pinch the patient’s skin or pull his am hair.

• Leave the tourniquet in place no more than two minutes. If you are not ready in this time release the tourniquet and reapply in a few minutes.

• The tourniquet should be snug but not uncomfortably tight and should not impede circulation. Check the patient’s radial pulse. If you can’t feel it the tourniquet is too tight and must be loosened. A tourniquet that is applied too tightly or kept in place too long may increase bruising, especially in elderly patients with fragile veins.

• Once the tourniquet is in place have the patient open and close his fist 5 or 6 times to distend the vein.

• Gently pat or flick the skin over the vein to increase venous distention.

• Stroke the skin upward toward the tourniquet.

• If the vein remains small and unfirm release the tourniquet and reapply a little tighter and closer to the selected site.


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METHODS OF VENOUS DISTENTION

• Apply a broad tourniquet over selected site.

• Apply an blood pressure cuff inflated to 50 or 60 mm Hg or to just below diastolic pressure. You should be able to feel a pulse when the cuff is inflated.

• Have patient clench fist five or six times.

• Allow arm to hang in dependent position

• Tap lightly distal to proposed site.

• Apply moist heat to entire extremity.


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CARING FOR PATIENT COMFORT

For complaints of pain at needle site or aching arm:

• Stop flow and assess the site and extremity.

• Look for swelling, bruising, unusual tissue firmness, blood leaking from needle site.

• Try starting flow at a slower rate. Consider slight repositioning of needle to alleviate pressure on vein wall.

• Check temperature of room, arm and infusion. Consider covering patient with a blanket and applying a warm towel to the arm.

• Make sure head and neck are supported and the patient is in a position of comfort. Encourage friends and family to keep patient company. Provide entertainment such as music, reading materials or TV. Offer a glass of water.


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PREPARING THE SOLUTION

1. Place bag on a hook or IV pole being careful not to contaminate the injection port. Use sterile procedure. No coughing, sneezing, talking, laughing or breathing close to the injection port, needle or syringe. No waving uncapped needle around. If the needle touches the outside of the cap it is contaminated. Check the bag for leaks, pin holes or particulate matter. If any of these are present the bag is contaminated and not suitable for use.

2. Wearing gloves, draw up exact amount of additive and inject into the bag being careful not to inject any air with the additive. Gloves are worn to protect hands from acidic or caustic add mixture such as vitamin C. Vitamin C is viscous and an 18 gauge needle is most effective for drawing it up. When injecting more than one additive with the same syringe be careful not to cross contaminate the additives, especially with heparin.

3. Remove the protective cap from the administration set insertion port.

4. Close the clamp of the administration set.

5. Remove the protective cover from the spike and holding the bag firmly with one hand push the spike straight into the bag. Do not twist the spike, coring may occur leaving particulate matter in the bag.

6. Squeeze the drip chamber until it is half full. The tube will fill with air if the chamber is not half full.

7. Aim the distal end over the sink or receptacle and open the roller clamp. Most solution sets will allow the flow of fluid without removing the protective distal cover.

8. Open the clamp slowly to allow solution to flow through the tubing to remove air. Too quick a release of the clamp will cause air bubbles to form in the tubing.

9. Once air is purged from the line, close the clamp.

10. Attach the winged infusion set and purge air from the set.

11. Tape winged infusion set tubing to the bag carefully so as not to contaminate the needle.

12. Add homeopathics as a bolus after the solution is infusing. Ensure enough vitamin solution is left in the bag to flush homeopathics through the line.


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PREPARING THE SOLUTION

1. Place the bag on a hook or IV pole, being careful not to contaminate the injection port.

2. Inject additives.

3. Remove the protective cap from the administration set insertion port.

4. Close clamp of administration set.

5. Remove the protective cover from the spike and holding the bag firmly with one hand quickly insert the spike.

6. Squeeze the drip chamber until it is half full.

7. Aim the distal end over the sink or receptacle and open the roller clamp. Most solution sets will allow flow of fluid without removing the protective distal cover.

8. Open the clamp to allow solution to flow through the tubing to remove air.

9. Close the clamp once air is purged from the line.

10. Attach the winged infusion set and purge air from set.


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STEPS IN PREPARING FOR VENIPUNCTURE

1. Explain the procedure to the patient to reduce anxiety. Anxiety products a vasoconstrictive response.

2. Thoroughly wash hands.

3. Wear gloves.

4. Apply heat.

5. Palpate vein with same two fingers to become practiced at locating deep veins.

6. Prepare skin with iodine 1-2% or 70% isopropyl alcohol. Cleanse the site working in a circular motion outward to a diameter of 2 inches to 4 inches to remove skin bacteria that might otherwise be introduced into the vascular system. Alcohol should be applied with moderate friction for one minute and should stay on the skin for 30 seconds to become effective.

7. Once the skin has been cleansed do not touch it again.

8. Apply tourniquet above the intended puncture site to distend the vein. Check for distal pulse. If it is not present release the tourniquet and reapply with less tension to prevent arterial occlusion.

9. Hold the patient’s arm or hand in your left hand using your thumb to anchor the vein and keep the skin tight.

10. Place the needle (bevel up position) in line with the vein about ½ inch below the level of entry. Bevel up position produces less trauma to the skin and vessel.

11. Tell the patient you are about to insert the needle.

12. Gently push the needle through the skin at a 45 degree angle until you meet resistance. Lower the angle of the needle and slowly pierce the vein. You will feel a pop when the needle enters the vein.

13. When you observe blood flash back in the tubing you can be sure you are in the vein. Tilt the needle slightly upward to prevent injury to the posterior vein wall and advance the needle further into the vein.

14. Release the tourniquet.

15. Open the administration set clamp slightly and check for free flow or infiltration. If there is any sign of infiltration close the clamp immediately.

16. Tape the winged infusion set and tubing in place. Loop the tubing on the extremity and secure with tape. The loop allows some slack in case of tension on the line which could dislodge the needle.

17. Ask the patient if he is comfortable. Tell him how frequently you will be checking on him and what to do if he has concerns.

18. Document the procedure.


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DOCUMENTATION

1. Size and type of device used.

2. Date and time of start and finish of infusion. Also label time on bag.

3. Type of solution.

4. Type of additives.

5. Patient assessment BP, pulse etc.

6. Site accessed.

7. Complications, patient response, interventions.

8. Condition of the site at discharge from office.


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Name:

Date IV Fluid

BP Before

BP After Pulse Resp

rate Site

1 Site

2 Start time

Stop time Weight Waist Comments


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SOME INDICATIONS FOR BASIC VITAMIN THERAPY

Depression and chronic fatigue – B vitamins act as an anti-depressant and improve energy.

Asthma – magnesium relaxes bronchial tree smooth muscle, B12 relieves asthma.

Urticaria and seasonal allergy – vitamin C acts as an antihistamine and decreases inflammation and edema.

Muscle spasm – magnesium for muscle relaxer.

Acute and chronic bacterial and viral infections – vitamin C reduces inflammation and is a strong immune stimulant.

Hypertension – magnesium relaxes smooth muscle in arteries, vitamin C and B5 support adrenals, B6 is a diuretic, B complex relaxes the nervous system.

Glaucoma and macular degeneration – vitamin C is a weak chelator, magnesium relaxes smooth muscle in arteries causing a decrease in eye pressures and an increase in blood flow to the eyes.

AN EXAMPLE OF A BASIC VITAMIN AND MINERAL THERAPY

Product Volume in mls Millisosmole per ml

Total Milliosmoles

Sterile Water 250 ml 0.00 0.00

Ascorbic Acid 500 mg/ml 11 ml 5.80 63.8

B Complex 100 1.0 2.14 2.14

B6 pyridoxine 100 mg/ml 1.0 1.11 1.11

B5 dexpanthenol 250mg/ml 2.0 0.85 1.70

Folic Acid 5 mg/ml 1.0 0.20 0.20

Magnesium chloride 200 mg/ml 4.0 2.95 11.80

Expected osmolarity

299.07 Total volume

270 mls Total

milliosmoles 80.75


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OSMOLARITY CHART FOR A SAMPLE CHELATION TREATMENT

Product Volume in mls

Millisosmole per ml

Total Milliosmoles

Sterile Water 500ml 0.00 0.00

Ascorbic Acid 500 mg/ml 16 ml 5.80 92.80

B Complex 100 1.0 2.14 2.14

B6 pyridoxine 100 mg/ml 1.0 1.11 1.11

B5 dexpanthenol 250mg/ml 2.0 0.85 1.70

Magnesium chloride 200 mg/ml 10.0 2.95 29.50

EDTA 150 mg/ml 20.0 1.34 26.80

Hydroxycobalamin 1 mg/ml 2.0 0.31 0.62

Sodium Bicarb 8.4% 10.00 2.0 20.00

Expected osmolarity

310.8

Total volume

562.00 mls

Total milliosmoles

174.67

Divide the total number of milliosmoles by the total volume then multiply by 1,000 for an estimate of the osmolarity of the mixture in milliosmoles per litre.

174.67/562.0 X 1,000 = 310.8

HERPES

Vitamin C and zinc both stimulate the immune system and stimulate tissue repair. B vitamins support nervous tissue. Infusions containing zinc may irritate the small veins. Assess patient for pain several times during infusion. A variety of homeopathics may be used singly or in combination as a bolus push into the injection port. A few examples include: herpes nosodes, echinecea, mezereum, ranunculus, rhus tox, sempervivum tectorum.


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Additive Dose Volume Millisomoles per ml

Extended Millisosmoles

Sterile water 250 ml 0.00 0.00

Ascorbic Acid 500 mg 11.00 ml 5.80 63.80

B Complex Multidose 1.0 ml 2.14 2.14

Dexpanthenol 250 mg 2.0 nil 0.85 1.70

Magnesium chloride 200 mg 5.00 2.95 14.75

Pyridoxine 100 mg 1.0 1.11 1.11

Zinc trace metal l mg 10.00 0.11 1.10

Total 280.00 ml 84.6

Expected osmolarity

300.0


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PROTOCOLS

Liver and gall bladder

• licorice • vitamin C • zinc • B vitamins • Heel Hepar Comp • Pasco Cholo Injectopas

Impotence

• vitamin combination • zinc • Sanum Ginkgokehl • Sanum Mucokehl • Heel Testis Comp • Pasco Calycast

Angina

• Magnesium • Heel Cor Comp • Pasco Cor Comp Forte

Hypertension

• B5 • Magnesium • Heel Cor Comp • Heel Rauwolfia

Asthma

• Magnesium • Vitamin C • Heel Spascupreel • Pasco Asthma I and II Injectopas

Herpes virus

• vitamin C • licorice • zinc • Heel Mezereum, Ranunculus, Herpes simplex nosode, zoster nosode,

Sempervivum Tectorum, Echinecea Comp • Pasco J Injectopas for neuritis and neuralgia • Procaine / Lidocaine infiltrated s.c.


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VITAMINS

As a result of the growing interest of the public in alternative medicine and in becoming more responsible for their own well being many people arc taking large doses of vitamins daily, often without medical supervision. Thousands of people have made a return to good health with a combination of diet and supplements and what’s more vitamin and mineral supplements arc often more effective than drugs and surgery. Even though nutrients arc safer than conventional drugs we must still be careful with their use. Because nutritional therapy and research is still in its infancy many questions remain unanswered.

VITAMIN B1 THIAMIN PH 2.5 TO 4.5

BENEFITS

• Keeps mucous membranes healthy.

• Maintains normal functions of nervous system, muscles and heart.

• Aids in treatment of herpes zoster.

• Promotes normal growth and development.

• Treats beri-beri.

• Replaces deficiency caused by alcoholism, cirrhosis, overactive thyroid, infection, breast feeding, absorption disease, pregnancy, prolonged diarrhea, bums.

• Neuritis and polyneuritis of any etiology.

• Plays a leading role in carbohydrate metabolism.

DEFICIENCY SYMPTOMS

• Chronic peripheral neuritis.

• Beriberi which may or may not be associated with heart failure and edema. In dry beriberi the patient complains of weakness, stiffness and is unable to walk more than a short distance. As the disease progresses, the ankle jerk reflex is lost and muscular weakness spreads upwards. The affected muscles become tender and numb. There is pronounced foot drop and wrist drop. In the final stages the patient becomes bed ridden and even slight pressure from bedclothes causes considerable pain. In wet beriberi the heart is affected with dilatation of the arterioles, rapid blood flow and increased pulse rate and pressure and increased jugular pressure leading to right sided heart failure and edema. There is high concentration of circulating pyruvate and lactate and a fall in the concentration of ATP in the heart.


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• Acute pernicious beriberi in which heart failure and metabolic abnormalities predominate.

• Wernicke’s encephalopathy with Korsakoff’s psychosis, a thiamin responsive condition associated with alcoholism and narcotic abuse.

• Anorexia.

PRECAUTIONS

• There is no evidence of any toxic effect of high intakes of thiamin although high parenteral doses have been reported to cause respiratory depression in animals and anaphylactic shock in human beings.

• Thiamin is not commonly administered IV, IM is preferred.

• Rarely administered alone, more often as part of a multiple B vitamin.

• Intradermal test recommended for suspected sensitivity.

• Protect from freezing and from light.

USUAL DOSE

Up to 100 mg daily. May be given by direct IV (100 mg or fraction thereof over 5 minutes) or added to most IV solutions or IM.


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VITAMIN B2 RIBOFLAVIN PH 5.0 TO 6.0

BENEFITS

• Redox cofactor in energy yielding metabolism.

• Maintains healthy mucous membranes lining respiratory, digestive, circulatory and excretory tracts when used in conjunction with vitamin A.

• Maintains integrity of nervous system, skin and eyes.


• Aids in treatment of infections, stomach problems, burns, alcoholism, liver disease.

• Activates pyridoxine.

• Acts as a component for two enzymes - flavin mononucleotide and flavin adenine dinucleotide.

DEFICIENCY SYMPTOMS

• Impairment of lipid metabolism. There is an increase accumulation of triglycerides in the liver with an increase in liver weight in proportion to body weight, which leads to an impairment of growth.

• Cracks and sores at the comers of the mouth.

• Inflammation of tongue and lips.

• Eyes over sensitive to light and easily tired.

• Itching and scaling of skin around nose, mouth, scrotum, forehead, cars and scalp.

• Trembling.

• Dizziness.

• Insomnia.

• Slow learning.

• Itching, burning and reddening of eyes and damage to cornea of the eye.


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PRECAUTIONS

• Mixing with baking soda destroys riboflavin.

• Assess for allergy.

• Because of its low solubility and limited absorption from the GI tract, riboflavin has no significant or measurable toxicity by mouth. Nigh parenteral doses (300 - 400 mg/kg body weight) there may be crystallisation of riboflavin in the kidneys because of its low solubility. Use caution with large doses in patients with chronic kidney failure.

USUAL DOSE

RDA 1.2 - 1.8 mg/day. Usually B complex injectables supply 2 mg/ml.


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VITAMIN B3 NIACIN / NIACINAMIDE

BENEFITS

• Maintains normal function of skin, nerves and digestive system

• Reduces cholesterol and triglycerides in the blood.

• Corrects niacin deficiency.

• Dilates blood vessels.

• Treats vertigo and ringing in the cars.

• Prevents premenstrual headache.

• Treats pellagra. Pellagra is characterized by a photosensitive dermatitis, typically with a butterfly pattern over the face. Similar lesions occur in areas not exposed to the sun but subject to pressure such as knees, elbows, wrists and ankles. Advanced pellagra is accompanied by dementia and depressive psychosis and maybe diarrhea. Left untreated pellagra is fatal.

• Precursor of NAD and NADP.

• In larger doses niacin is used in orthomolecular psychiatry as a treatment for schizophrenia.

DEFICIENCY SYMPTOMS

• Pellagra

• Muscle weakness

• General fatigue

• Loss of Appetite

• Headaches

• Swollen, red tongue

• Skin lesions, including rashes, dry scaly skin, wrinkles, course skin texture, dermatitis

• Diarrhea

• Irritability

• Dizziness

• Behavioral symptoms - apathy, anxiety, depression, hyperirritability, mania, memory deficits, delirium, emotional liability.


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PRECAUTIONS

• Modest doses causes a marked vasodilation with flushing, burning and itching of the skin.

• Large single doses may cause sufficient vasodilation to lead to hypotension

• Side effects wear off considerably after several days taking niacin.

• At intake in excess of 1 gram niacin/day there is evidence of toxicity. Changes occur in liver function tests, carbohydrate tolerance (increases blood sugar) and uric acid metabolism, all are reversible on withdrawal of niacin.

• Sustained release preparations are associated with more severe liver damage and clinical liver failure than simple preparations.

• Contraindicated in active acute peptic ulcer.

• Potentiates some antihypertensive drugs.

• Begin therapy with small doses and increase gradually.

USUAL DOSE

• - 100 mg 2 or more times in 24 hours may be given. RDA 6.6 mg/day.

• The body manufactures niacin from tryptophan. Assuming that 60 mg of tryptophan is equivalent to 1 mg of dietary niacin, this suggests that an average diet provides 8.75 mg niacin equivalents/1000 kcal from tryptophan alone - significantly more than the RDA.

• In injectable B complex niacin appears in the form of niacinamide at a concentration of 100 mg/ml.

• Undiluted niacin given intravenously should be given at a rate not to exceed 2 mg or fraction thereof over 1 minute.


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VITAMIN B5 PANTOTHENIC ACID

Pantethine is the stable form of pantotheine, the active form of pantothenic acid. Pantothene is the preferred therapeutic substance because it a shorter pathway from pantethine to CoA than that of pantothenic acid to CoA.

BENEFITS


• Fundamental component of CoA.

• Aids in release of energy from foods.

• Involved in the transport of fatty acids to and from cells and accelerates fatty acid breakdown in the mitochondria.

• Pantethine reduces serum triglyceride and cholesterol levels and increases HDL levels. Beneficial to angina patients.

• Improves symptoms of osteoarthritis.

• Stimulates healing.

• Supports adrenal glands and alleviates stress.

• Treats constipation.

• Relieves allergies.

• Treats fatigue.

• Enhances cholinergic function, reduces loss of memory and cognitive impairment in some patients.

• Postoperatively for prevention of ileus.

• Growth factor for lactobacillus bulgaricus.

DEFICIENCY SYMPTOMS

Lack of one B vitamin usually means lack of other nutrients. Pantothenic acid is usually given with other B vitamins if there are symptoms of any B deficiency including the following:

• Skin problems

• Sleep disturbance

• Arthritis

• Adrenal atrophy

• Allergies


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• Mental fatigue

• Muscle spasms

• Shortness of breath

PRECAUTIONS - none known

Pantothenic acid occurs everywhere in animal and plant tissue. It is so widely distributed that deficiency in humans is highly unlikely. Pantothenic has a very low toxicity. Intakes of up to 10 g of calcium pantothenate/day (compared with a normal intake of 2 - 7 mg/day have been given for up to six weeks with no apparent dl effects.

USUAL DOSE

Pantothenate is usually administered as the calcium salt and is employed in combination with other B vitamins. It may be given orally, IM or IV in doses of 5 to 100 mg.


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VITAMIN B6 PYRIDOXINE PH 2.0 TO 3.8

BENEFITS

• Participates in multi-enzyme systems, chemical reactions of proteins and amino acids.

• Promotes normal red blood cell formation.

• Maintains chemical balance among body fluids.

• Regulates excretion of water. Excellent diuretic.

• Helps in energy production and resistance to stress, enhances mood.

• Co-enzyme in carbohydrate, protein and fat metabolism

• Treats PMS symptoms.

• Helps with gestational diabetes and diabetes.

• Reduces adverse effects of estrogen medication (birth control pills and estrogen replacement therapy).

• Reduces level of prolactin, reduces breast milk in nursing mothers with congested breasts.

• Relieves morning sickness.

• Relieves nausea.

• Treats isoniazid CM medication) toxicity.

• Stimulates immune system.

• May prevent or relieve diabetic neuropathy.

• Reduces frequency of renal calculi in susceptible individuals by aiding the patient’s ability to maintain calcium oxalate in solution.

• Relieves some joint pain and muscle spasm.

• Vitamin B6 may be useful in the treatment of the following: acne, alcoholism, anemia, asthma, carpal tunnel, depression, diabetes, heart disease, hyperactivity, kidney stones, lupus, PMS.

DEFICIENCY SYMPTOMS

• In women B6 deficiency may be caused by an over supply of estrogen. One of the consequences is depression, a symptom frequently seen in women on the pill or suffering from PMS symptoms. B6 deficiency can result in inadequate production of serotonin, which can lead to depression.

• B6 deficiency is one of the factors promoting atherosclerosis.

• Depressed immunity, reduction in number and activity of lymphocytes, shrinkage of thymus gland and decreased thymic hormone activity.


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Other deficiency symptoms Include:

• weakness

• mental confusion

• irritability

• nervousness

• poor coordination

• hyperactivity

• anemia

• skin lesions

• discoloration of tongue

• muscle twitching

• kidney stones

• Behavioral - depression, irritability

PRECAUTIONS

• B6 may cause insomnia if taken late in the day.

• Deteriorates in excessive heat.

• May inhibit lactation.

• Excessive doses may elevate SGOT.

• Excessive doses may cause nerve damage.

• Large doses in utero may cause pyridoxine-dependency syndrome in the newborn.

• Inhibits phenobarbital and phenytoin.

• Contraindicated in known sensitivity to pyridoxine.

• In rare cases doses over 200 mg daily may be toxic.

USUAL DOSE

10 - 100 MG/24 hours. May be given by direct IV administration undiluted or added to most IV solutions and given as an infusion If given undiluted administer 50 mg or fraction thereof over one minute.


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VITAMIN B12

Vitamin B12 is supplied in two injectable forms; hydroxocobalamin and cyanocobalamin Hydroxocobalamin is the preferred form to use because its effects are longer lasting and it does not contain the cyanide component of cyanocobalamin. For patients requiring ongoing regular treatment of B 12, cyanide accumulation can become a problem over time.

BENEFITS

• stress

• depression

• digestive disturbances

• treats some kinds of nerve damage

• treats diabetic and peripheral neuropathy

• treats restless legs, pernicious anemia, some allergies, menstrual disorders, skin problems, fatigue, mental symptoms

• prevents B12 deficiency in vegan vegetarians and persons with absorption difficulties

• improves memory and teaming ability

• increases energy

Deficiency Symptoms

• Alzheimer’s disease symptoms

• psychosis

• shortness of breath

• pernicious anemia

• fatigue

• weak and tingling arms and legs

• skin problems

USUAL DOSE

Given intramuscularly, allopathic practitioners will usually give no more than 1000 mcg per month The rationale being that B 12 is stored in the liver allowing for a potential overdose. Vitamin B12 is a water soluble vitamin. In a search of literature there were no reported cases of vitamin B12 overdose. There is a very low incidence of B12 toxicity even with large amounts up to 1000 mcg daily. To produce a noticeable improvement of symptoms for the patient, a dose of 2000 mcg IV and 3000 mcg IM is required.


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VITAMIN C ASCORBIC ACID PH 5.5 TO 7.0

BENEFITS

• Preoperative and postoperative maintenance of optimal health.

• Increased vitamin requirements or replacement therapy in severe bums, extensive injury and infections.

• Deficient intestinal absorption of water soluble vitamins.

• Hemovascular disorders.

• Promotes healthy capillaries, gums and teeth.

• Delayed fracture and wound healing.

• Aids iron absorption.

• Treats urinary tract infections.

• Forms collagen in connective tissues, prevents wrinkling.

• Reduces allergic reactions.

• Prevents scurvy.

DEFICIENCY SYMPTOMS

• Scurvy – muscle weakness, swollen and bleeding gums, loss of teeth, tiredness, depression, irritability, bleeding under skin.

• Shortness of breath.

• Digestive difficulties.

• Easy bruising.

• Swollen painful joints.

• Nosebleeds.

• Anemia: weakness, tiredness, paleness.

• Frequent infections.

• Slow wound healing.

• Behavioral symptoms – lassitude, hypochondriasis, depression, hysteria.


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PRECAUTIONS

• Bowel flush is diagnosis for vitamin C saturation.

• Antagonizes anticoagulants.

• There is much controversy and debate over whether large doses of vitamin C cause renal calculi.

• Use caution in cardiac and renal patients. Sodium content may contribute to fluid retention and congestive heart failure.

• Use caution in renal calculi/colic patients.

• Side effects, temporary dizziness and faintness occur with too rapid injection.

• Test for allergy in sensitive patients.

USUAL DOSE

Up to 6 grams over 24 hours, may be administered in diluted IV infusions. Given undiluted 100 mg or fraction thereof over 1 minute.


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FOLIC ACID PH 8.0 TO 11.0

BENEFITS

• Promotes normal red blood cell formation.

• Maintains nervous system, white blood cells, intestinal tract, sex organs, normal patterns of growth.

• Treats anemia due to folio acid deficiency.

• Involved in the synthesis of amino acids and DNA.

DEFICIENCY SYMPTOMS

• Irritability.

• Weakness.

• Lack of energy.

• Sleep difficulties.

• Forgetfulness and confusion.

• Megaloblastic anemia.

• Indicated in alcoholism, sprue, celiac disease, pregnancy, GI anomalies, fish tapeworm infestation.

PRECAUTIONS

• Oral or IM administration is adequate in most cases. Do not administer IV to children.

• Obscures the peripheral blood picture and prevents the diagnosis of pernicious anemia.

• Folic acid is inhibited by depressed hematopoiesis, alcoholism and deficiencies of vitamins B6, B12, C, and E. Side effects arc almost non-existent. Some slight flushing or feeling of warmth may occur and anaphylaxis may occur.

USUAL DOSE

1 mg daily and 5 mg infrequently. May be given IM or IV in solution or undiluted.


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CALCIUM GLUCONATE PH 6.0 TO 8.2

BENEFITS

• Participates in metabolic functions necessary for normal activity of nervous, muscular and skeletal systems.

• Plays important role in normal heart function.

• Helps utilization of vitamin B 12.

• Promotes use of amino acids.

• Lowers phosphate concentrations in people with kidney disease.

• Acts as a natural tranquilizer.

• Antidote to magnesium sulfate.

• Used in calcium deficiency caused by hypoparathyroidism, osteomalacia, vitamin D deficiency, preeclampsia and uremia.

DEFICIENCY SYMPTOMS

• Osteoporosis.

• Osteomalacia, frequent fractures.

• Muscle contractions and cramps.

• Convulsive seizures.

• Low backache.

PRECAUTIONS

• Necrosis and sloughing can occur with IM or SC injections or extravasation Confirm patency of vein and observe needle site for signs of infiltration.


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MAGNESIUM SULFATE PH 5.5 TO 7.0

BENEFITS

• Aids bone growth.

• Bronchodilator, treats asthma.

• Relieves angina pain.

• Relaxes tight muscles and muscle spasm.

• Relieves night time leg cramps.

• Regulates normal heart rhythm.

• Conducts nerve impulses.

• CNN depressant.

• Useful as a laxative in large doses.

• Useful as an antacid in small doses.

• Can improve glucose tolerance in insulin resistant patients.

• Indicated for malnutrition, excessive GI losses due to severe diarrhea or prolonged vomiting, malabsorption syndrome, liver cirrhosis, diabetic acidosis, chronic alcoholism deficiency following use of diuretics.

DEFICIENCY SYMPTOMS

• Confusion and delirium.

• Irritability.

• Nervousness.

• Headaches.

• Hypertension.

• Skin problems.

• Hardening of soft tissues.


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PRECAUTIONS

• Contraindicated in cases of renal insufficiency. Over time excessive doses can be toxic.

• May cause bradycardia and hypotension if given in too large doses or too quickly intravenously.

• Overdose symptoms include drowsiness, heart block and respiratory depression.

• Treatment for overdose is 5 to 10 mEq of calcium gluconate (10 -20 ml of calcium gluconate).

USUAL DOSE

Given orally magnesium may be given to bowel tolerance at a rate of 500 mg hourly. For severe hypomagnesemia 5 Gm (40 mEq). May be given undiluted or in solution. Check BP pre and post IV.

iv manual-12-15-03

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