iv therapy complete

8/3/2019 IV Therapy Complete

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GEORGE MICHAEL P. LIM, RN, MN-NAS

Corporate Chief For Nursing

Director, TRAINING AND STAFF DEVELOPMENT


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INDICATIONS/PURPOSES:

Establish or maintain a fluid or electrolyte balance

Administer continuous or intermittent medication

Administer bolus medication

Administer fluid to keep vein openAdminister blood or blood components

Administer intravenous anesthetics

Maintain or correct a patients nutritional state

Administer diagnostic reagents

Monitor hemodynamic functions


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Drop factor

1. Macrodrop gtt; 15gtt/ml

2. Microdrop mgtt; 60 mgtt/ml


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FLUID & ELECTROLYTES

Fluid compartments:1. Cells

2. Blood vessels

3. Tissues space

Types of Fluid:

1. Intracellular Fluid 2/3 or 70% of the body fluid2. Extracellular Fluid 1/3 or 30% of the body fluid

1/4 intravascular

3/4 interstitial fluid


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functions of water:

1. Transporting nutrients to cells and wastes from cells

2. Transporting hormones, enzymes, blood platelets, andred and white blood cells

3. Facilitating cellular metabolism and proper cellularchemical functioning

4. Acting as a solvent for electrolytes and nonelectrolytes

5. Helping maintain normal body temperature

6. Facilitating digestion and promoting elimination

7. Acting as a tissue lubricant

(-) Effect of water loss: every 2% to 5% water loss --> 30%decrease in work performance.


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Electrolytes

Active chemicals that carry positive (cations)and negative (anions) electrical charges

Major cations: Major anions: Sodium

Potassium

Calcium

Magnesium

Hydrogen ions

Electrolyte concentrations differ in the fluid

compartments

Chloride

Bicarbonate

Phosphate

Sulfate

Proteinate ions


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Electrolytes (cont.)

Major cation in ECF

Sodium

Major cation in ICF

Potassium


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Physiological functions in

the body:1. Promote neuromuscular irritability

2. Maintain body fluid osmolarity3. Regulate acid-base balance

4. Distribute body fluids between the

fluid compartments


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Regulation of Fluid

Movement of fluid through capillary walls dependson:

Hydrostatic pressure

Pressure exerted on the walls of blood vessels Osmotic pressure

Pressure exerted by the protein in the plasma

The direction of fluid movement depends on thedifferences of hydrostatic and osmotic pressure


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Regulation of Fluid (cont.)

Osmosis

Diffusion

Filtration

Active transport
http://osmosis.ppt/http://diffusion.ppt/http://filtration.ppt/http://active%20transport.ppt/http://active%20transport.ppt/http://filtration.ppt/http://diffusion.ppt/http://osmosis.ppt/


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INTRAVENOUS SOLUTIONS

Isotonic Solutions:

Type:

- Normal Saline 0.9% NaCl

- D5W: acts as a hypotonic solution in the body

- Ringers Solution

- Lactated Ringers Solution

Nursing Responsibilities:- Expands the intravascular compartment.

- Monitor for fluid overload.

- avoid D5W if at risk with increase ICP
http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/http://comments%20and%20responibilities%20for%20isotonic%20solutions.ppt/


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Hypotonic Solution:

Type:

- 0.33% NaCl

- 0.45% NaCl

- 2.5% Dextrose

Nursing Responsibilities:

- these solutions shift fluid from the intravascularcompartment into the cells

- contraindicated for clients with increased ICPbecause of shift into the brain cells

- also contraindicated for clients who are at riskfor 3rd-space fluid shifts
http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/http://comments%20and%20responsibilites%20for%20hypotonic%20solutions.ppt/


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Hypertonic Solutions:

Types:

- D5 0.45%NaCl - 3.0% NaCl

- D5NSS - Sodium Bicarbonate 5%

- D5LR

Nursing Responsibilities:

- expands the intravascular compartment

- contraindicated for clients with kidney andheart problem

- contraindicated for clients who are dehydratedbecause it draws fluid from the intravascular

compartment


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Electrolyte Solutions:

contain varying amounts of cations and anions

includes:

- 0.9% NaCl

- Ringers Solution: with Na, Cl, Ca, & K

- Lactated Ringers Solution: same as above withlactate. Lactate is salt of lactic acid that is metabolized inthe liver to form HCO3

saline solutions are frequently used as initialhydrating solutions

multiple electrolyte solutions approximate the ionicprofile of plasma and are used to prevent dehydration orto restore or correct fluid and electrolyte imbalances


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Nutrient Solutions:

contain some form of carbohydrate

(dextrose and glucose) and water

water is supplied for fluidrequirements while carbohydrate is forcalories and energy

useful in preventing dehydration and

ketosis but do not provide sufficientcalories for wound healing, weight gain ornormal growth in children


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Alkalinizing Solutions:

administered to counteract metabolicacidosis.

example: Lactated Ringers Solution

Acidifying Solutions:

administered to counteract metabolicalkalosis.

example: 0.45% NaCl and 0.9 % Nacl


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Blood Volume Expander:

used to increase the volumeof blood following severe loss of

blood or loss of plasma

examples: dextran, human

serum albumin


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PERIPHERAL VENIPUNCTURE SITES

- site chosen varies with clients age, the length of

time the infusion to run, the type of solution used.ARM:

- cephalic vein - accessory cephalic vein

- basilic vein - median cubital vein- median antebrachial vein - radial vein

HAND:

- basilic vein - dorsal venous network- cephalic vein - dorsal metacarpal veins

FOOT:

- great saphenous vein - dorsal plexus


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Venipuncture sites

The site chosen for venipuncture

varies with:

Age

Length of time of infusion is to

run The type of solution used

Condition of the veins


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Venipuncture sites

The metacarpal, basilic and cephalic veins arecommonly used for intermittent andcontinuous infusions

Although the basilic and median cubital veinsin the anticubital space are convenient sitesfor the venipuncture, they are usually used for

blood draws, bolus injections of medicationsand insertion sites for a PICC


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GUIDELINES FOR VEIN SELECTION

- use distal veins of the arm first

- use the clients non-dominant arm wheneverpossible

- use veins in the feet and legs only when arm

veins are inaccessible, since they are more proneto thrombus formation and subsequent emboli

- select a vein that:

a. is easily palpated and feels soft and fullb. is naturally splinted by bone

c. is large enough to allow adequate

circulation around the catheter


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- avoid using the following veins:

a. those areas that are highly visible

since they tend to roll away from the needle

b. those damaged by previous use,phlebitis, infiltration or sclerosis

c. those continually distended withblood or that have been knotted or tortous

d. veins of surgically compromised orinjured extremity because of possibleimpaired circulation and discomfort for theclient


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INTRAVENOUS EQUIPMENT

- infusion set tubing, specify if for adult, child

or for blood transfusion- sterile parenteral solution - clean gloves

- IV pole - tourniquet

- antiseptic swab - IV catheter

- adhesive or non-allergenic tape

- antiseptic ointment such as Betadine

- gauze squares or other appropriate dressings

- arm splint if required

- towel or pad


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INFUSION

SET &

EQUIPMENT


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VOLUMETRIC SET


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HEPARIN LOCK


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STARTING INTRAVENOUS INFUSION


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STARTING INTRAVENOUS INFUSION

1. Check the doctors order. Verify the type of solution, the

amount to be administered and the rate of the infusion.

2. Take the initial assessment of the client. (Vital signs,skin turgor, bleeding tendencies, disease or injuries of

the extremity, status of the veins)

3. Explain the procedure to the client.

4. Provide any scheduled care before establishing the

infusion to minimize movement of the affected limb

during the procedure.

5. Prepare the equipment. Check the clarity, expirationdate and sterility of the IV solution as well as the tubing

and the venipuncture set or IC catheter.

6. Do handwashing.


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7. Open and prepare the infusion set aseptically.

a. Remove the tubing from the container and

straighten it out.

b. Slide the tubing clap along the tubing until itis just below the drip chamber.

c. Close the clamp/regulator.

d. Leave the ends of the tubing with plastic capuntil the infusion is started.

8. Open the seal of the IV solution and disinfectthe port with cotton balls with alcohol.


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9. Spike the solution container aseptically.

a. Remove the plastic cap of the spike and insertit to the solution.

b. Follow agency protocols regarding insertion. Itis recommended though, that twisting motionbe not applied while inserting the tubing to

the bottle.

10. Hang the solution container on the IV pole.Adjust the pole so that the container issuspended about 1 meter above the clientshead.

11. Partially fill the drip chamber with solution.Squeeze the drip chamber gently until it is half

full.

12. Prime the tubing.


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12. Prime the tubing.

a. Remove the protective and hold the tubing over acontainer. Maintain sterility of the end of the

tubing and the cap.b. Release the clamp and let the fluid run through the

tubing until all the bubbles are removed. This isdone to prevent air from entering the client.

c. Re-clamp the tubing and replace the tubing capwhile maintaining sterility.

13. Apply appropriate labels to the solution container.Include the clients name, solution, drugs

incorporated, date, time infusion started and IVFregulation.

14. Apply a timing label on the solution container.

15. Wash hands again if necessary.


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16. Select and prepare the venipuncture site.Starting at the distal end of the vein, select a siteby palpating accessible veins.

17. Dilate the vein:

a. Place the arm in a dependent position or lowerthan the clients heart. Gravity slows venous

return and distends the vein.

b. Apply tourniquet firmly to about 4-6 inchesabove the venipuncture site. It should be tight

enough to obstruct venous flow but not so tightto occlude the arterial flow.

c. Check by palpating the radial pulse.


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18.Put on clean gloves, and clean thevenipuncture site with the povidone-iodine or

alcohol. Use circular motion going from thecenter towards the outside of the venipuncturesite. Permit the solution to dry into skin beforeinsertion.

19.Insert the IV catheter and initiate the infusion.

20.Tape the catheter. Commonly used is the Umethod but methods may vary according to

manufacture.

21.Dress and label the venipucture site andtubing according to agency policy.


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22. Ensure appropriate infusion flow.

23. Label the IV tubing.

24. Document relevant data including

assessments.

REGULATING INTRAVENOUS FLOW RATES


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REGULATING INTRAVENOUS FLOW RATES

nurse should first determine the drop factor of theinfusion set used. It is printed on the packaging of the

infusion set.

to calculate the flow rates, nurse must know thevolume of the fluid to be infused and the specific timefor the infusion

millimeters per hour: volume to be infused

total time of the infusion

drops per minute: total infusion X drop factor

# of hours to infuse X 60 minutes

electronic infusion devices (EID) devices thatregulate the infusion depending on the presets selected


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FACTORS INFLUENCING

FLOW RATESposition for the forearm

position and patency of the tubing

height of the infusion bottle

possible infiltration or fluid leakage

relationship of the size of the IVcatheter to the size of the vein


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MONITORING AN INTRAVENOUS INFUSION

observe the rate of flow every hour

inspect the patency of the IV tubing and needle

observe the tubing for pinches or kinds of obstructionto flow

open the drip regulator and observe for a rapid flow(rapid flow would indicate patency)

regulate the infusion after checking patency

lower the IVF bottle below the insertion site to note

blood backflow

inspect the insertion site for fluid infiltration, dislodgedneedle, phlebitis or bleeding


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teach the client ways to maintain the infusionsystem:

- call for assistance if:

a.The solution is not dripping

b.The venipuncture site is swollen

c.There is a sudden change in the flow rate

d.The solution container is nearly empty

e.There is blood in the IV tubing

- avoid sudden twisting or turning of the arm wherethe insertion site is

- avoid stretching or placing tension on the tubing

- document all relevant information


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TROUBLESHOOTING IV PROBLEMS

PROBLEM ACTION1. IV off Schedule Figure rate to finish over remaining time ( if >3cc/hr, consult

physician

2. Incorrect

Solution

Slow rate to a minimum while initiating change to correct

solution assess patient. Notify Physician

3. Flow stopped To reestablish Flow:

Look for obstruction of tubing and correct if present

Open regulator completely, move to new position, and regulate

again if flow begins

Reposition arm

Place bottle lower than needle to see if blood flows back, which

would indicate tubing is patent

Gently raise needle hub. If this starts to flow, support hub with

cotton ball or gauze.

Pinch off tubing close to arm above soft rubber section of tube

then squeeze firmly

Obtain sterile needle & syringe. Insert into injection port closestto needle. Pinch off tubin s rin e and as irate. Then o en flow.

PROBLEM ACTION


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4. Tubing Kinked Straighten tubing and check flow rate again

5. Bubbles in tubing For a few small bubbles high in tubing:

Turn off flow - Stretch tubing downward

Flick tubing with fingers - Start flow rate & regulate

For large amount of air high in tubing:

Turn off flow

Insert sterile open needle into injection port to close air

Open flow slowly - Start flow & regulate

For air low in tubing, below last port:

Turn off flow - Obtain sterile needle & syringe Insert into last port closest to patient

Pinch tubing distal to the port & close it off

Aspirate air into syringe

Start flow rapidly to flush out blood

Regulate flow

6. Drip Chamber full of

fluid

For flexible drip chamber:

Pinch off tubing - Invert container

Squeeze fluid back into container - Hang up bottle

Release tubing


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CHANGING AN IV SOLUTION

1. Verify the doctors order for the IV solutionto follow.

2. Explain the procedure to the client andassess IV site for complications. Check the

date of the IV insertion. Ideally, insertionsite should be changed every 72 hours.

3. Wash hands before and after the procedure.

4. Prepare the necessary materials. Check thesterility of the IV solution.


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5. Place the necessary labels on the IVsolution.

6. Open and disinfect the rubber port of theIV solution to follow.

7. Close the clamp or kink the tubing justbelow the drip chamber, then remove theexisting bottle, and then spike thesolution to follow aseptically.

8. Open the clamp or un-kink the tubing andregulate the new solution as prescribe.


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COMPLICATIONS OF IV THERAPY

COMPLICATION MANIFESTATION NURSING

INTERVENTIONSINFILTRATION - blanching of the

skin

- edema

- swelling- pain at site

- cool to touch

- decrease infusion

- apply, tourniquetabove the infusionsite, if infusioncontinues to drip, it

is infiltrated

- discontinue IV,reinsert in a newsite

- apply warmcompress toincrease fluidabsorption

- apply steriledressing

- elevate arm

PHLEBITIS d di ti IV
http://infiltration.ppt/http://infiltration.ppt/http://phlebitis.ppt/http://phlebitis.ppt/


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PHLEBITIS - redness

- heat

- swelling IV site- possible pain

- red line along thecourse of vein

- discontinue IV

- reinsert newsite

- apply warmcompress

THROMBO

PHLEBITIS

- pain

- swelling

- redness, warmth

around IV site orpath of the vein

- fever]

- leukocytosis

- d/c IV;reinsert IV onthe other

extremity- apply warmcompress

- elevate arm
http://phlebitis.ppt/http://phlebitis.ppt/


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HEMATOMA - ecchymosis

- STAT IV siteswelling

- leakage of

blood at the IVsite

- d/c IV, reinsertin oppositeextremity

- apply pressure

with steriledressing

- apply ice bag for24 hours thenwarm compress

CLOTTING decrease IV d/c IV
http://hematoma.ppt/http://hematoma.ppt/


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CLOTTING - decrease IVflow rate

- backflow of

blood into IVtubing

- d/c IV

-dont irrigate or milkthe tubing

-dont increase therate or hang it higher

-dont aspirate theclot from the cannula

- urokinase may beused

PYROGENIC

REACTION

- fever, chills

- gen. malaise- N/V

- head & backache

- d/c IV STAT

- monitor V/S- notify the physician

- retain IV equipmentfor culture study


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AIREMBOLISM

- dyspnea

- cyanosis

- hypotension- tachycardia

- loss ofconsciousness

- d/c IV STAT

- turn client tothe left sidewith head down

- ad. O2

- notify the

physicianCIRCULATORY

OVERLOAD

- SOB; increase BP

- restlessness

- coughing

- frothy sputum

- crackles

- engorge neck veins

- slow IVF rate

- monitor V/S

- notify thephysician


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DISCONTINUING IV INFUSIONS

Infusions are discontinued for one of the 3

reasons:

a. the clients oral fluid intake and hydrationstatus are satisfactory, so that no further IV

solutions are orderedb. there is a problem with the infusion that

cannot be fixed

c. the medications administered byintravenous route are no longer required

STEPS IN DISCONTINUING IV INFUSION


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STEPS IN DISCONTINUING IV INFUSION

1. Verify doctors order to discontinue Iv infusion or IV

medications.2. Assess and inform the patient of the order.

3. Prepare the necessary materials:

a. IV trayb. Sterile cotton balls with alcohol. Supply with

pick-up forceps

c. Sterile-dressing depends on hospital policy

d. Antiseptic solution

e. Plaster

f. Kidney basin


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10. Inspect IV catheter for completeness.

a. Check the IV catheter if it is intact.

b. Report broken catheter to the nurse in chargeor the physician immediately.

c. If the broken piece can be palpated, apply a

tourniquet above the insertion site.

11. Discard all waste materials including the IVcannula depending on hospital protocols.

12. Document the discontinuance, status of theinsertion site, and integrity of IV catheter.


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ALTERNATE VENOUS ACCESS

DEVICES1. Implantable Venous Access Devices

- used in the management of client with

chronic illness who require long term IVtherapy

- this device provides repeated access to the

central venous system while avoiding traumaand complications of multiple venipunctures

2 Central Venous Catheter


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2. Central Venous Catheter

- a catheter inserted into a large vein locatedcentrally into the body like in the vena cava orin the right atrium

- tubing is radio-opaque so that it will show upon x-ray for continuation of its placement

Insertion sites include:

a. subclavian: infraclavicular approach

supraclavicular approach

b. internal jugular vein

c. peripheral vein


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TYPES OF CENTRAL VENOUS ACCESSDEVICES

1. Peripheral Inserted Central Catheter (PICC)

- venipuncture is performed above or below

the anticubital fossa into the basilic, cephalic,or axillary veins of the dominant arm

- tip of the catheter is in the superior venacava or brachiocephalic veins

- may stay in place for up to 6 months


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2. Midline Catheter (MLC)

- increases in size 2 hours after insertion andbecomes softer

- venipuncture is 2-3 finger breaths above theantecubital fossa into thecephalic, basilic, or

median cubital vein

- tip of the cathete is between the antecubitalfossa and the head of the clavicle

- may stay in place of 1-8 weeks


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Complications:

- thrombosis - bleeding

- phlebitis - vascular perforation

- air embolism - infection

Nursing Care:

- change dressing 2-3 times a week, and whenwet or non-occlusive

- flush line after each infusion or every 12 hourswith 5-10 ml of normal saline followed by 1 mlHeparun (100/ml)

- anchor catheter securely

3 Percutaneous Central Catheters


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3. Percutaneous Central Catheters

- inserted through the subclavian vein

- triple lumen central catheter

a. distal lumen - G. 16: use to infuse/drawblood samples

b. middle lumen - G. 18: used for TPN infusionsc. Proximal Port - G. 18: used to infuse or draw

blood and administer medications

- extreme right atrial catheters Hickman/Broviac &

Groshong

- subcutaneous port Huber needle used to accessport through skin

Insertion:


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- place supine in head-low position: dilates thevessels and prevents air embolism

- patient turns head away from site duringprocedure

- while catheter is being inserted, patient

performs Valsalva maneuver

- antibiotic ointment and transparent dressingapplied using sterile technique

- verify position of tip of catheter by x-ray

- each lumen is secured with Leur-lock cap, andlabeled to indicate location (proximal, middle,distal)

Nursing Care:


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Nursing Care:

- site or catheter changes every 4 weeks

- each lumen flushed initially then twice a day withdiluted heparin to ensure patency

- flushed also after each infusion, specimen withdrawalor when disconnected

- never use force to flush catheter if resistance met,notify physician

- dressing changes every 2-3 times a week and PRN place in low fowlers position

- nurse and patient should wear mask

- alcohol and iodine swabs are used to clean site

change IV tubing every 2 4 hours

iv therapy complete

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