IV Therapy Flashcards
Large Volumes
- Continuous
- Over 3 hours
- Example 100mL/hr
Fluid bolus
- Patient is dehydrated; has N/V, hypotension
- Short period of time
- Less than 1 hour
Meds mixed in large bags of fluids
- K+Cl (potassium chloride)
- Vitamins
- TPN
IVPB
- Small amount of solution (25-100mL)
- Contains a medication that is “piggybacking” onto the main line
- Intermittent
- Aren’t ran continuously
IVP
- Meds are pushed directly into the vein
- Need to: verify compatibility, know if it needs to be diluted and what to dilute in, how fast to push the meds
- Typically narcotics
- NEVER push K+
Vascular Access Devices
- Short Peripheral Catheter
- Midline Catheter
- Peripherally Inserted Central Catheter (PICC)
- Nontunneled Percutaneous Central Venous Catheter (CVC)
- Tunneled Catheters
- Implanted Ports
- Hemodialysis Catheters
Delegation
- UAP/CNA CANNOT administer IV fluids, meds, or blood
- LPN CAN administer IV fluids, IVPB medication
- LPN CANNOT do IVP, or narcotics (PCA)
- IVP medications MUST BE given by RN
- Blood products MUST BE started, initiated, and followed up by a RN
Autoguard IV catheter
- Yellow is mellow 24g
- Blue is for you 22g
- Pink you seeee 20g
- Green is mean 18g
- The larger the # the smaller the diameter
- 14-16g is very large (surgery, trauma)
- Standard surgery = 18g
- Most therapy is given with 20g
- 22g used when the patient veins cant support a 20g
- 24g-26g used on children and elderly
- Anytime a patient says its tingling, you are in the nerve and need to get the IV out
- Stay away from hand if they have a lot of action
- Move from distal to proximal, may even need to move to other arm
AccuVein
Used when having a hard time finding a good vein
Midline Placement
- Basilic Vein (PREFERRED)
- Tip no further than axilla vein
- Used most often without the ultrasound
- Ultrasound allows to go to deeper veins
- Allows for demodulation of fluids
- Mixed solutions
- May be called a mini-stick
PICC
- Double lumen = 2 ports
- Triple lumen = 3 ports
- Basilic or cephalic
- Placed above the AC
- Sterile dressing needs to be changed every 7 days
- Can be left in for several months
- No BP on that arm
- DO NOT USE until placement is confirmed by x-ray
- Flushed every shift 10cc
- Can infuse TPN
- Can be used to draw blood, need to change the caps with each blood draw
CVC Non-tunneled
- Greater risk for infection
- Tip is in the superior vena cava (SVC)
- Used for less than 6 weeks
- Don’t typically see at home
- Placement confirmed by x-ray
- Sterile dressing change every 7 days
- Have patient take a deep great and hold when removing
- Will need to apply sterile dressing after CVC is removed
- May be placed in trandelenburg during insertion
- sutured in place
- Can be removed by nursing staff
CVC Tunneled
- Point of entry is not directly in the vein
- Cuff is coated by antibiotic solution
- Sutured in place
- Cuff gets inflated to help keep it in place
- Used for longer periods of time
- Requires surgery for insertion and removal
- Inserted by physician or advanced practice nurses
Complications of CVC
- Pneumothorax: air being introduced into the pleural cavity causing the lung to deflate
- Hemothorax: Blood being introduced into the pleural cavity
- Hydrothorax: Fluid and air being introduced into the pleural cavity
- COPD patients are at a higher risk for pneumothorax, hemothorax, and hydrothorax
- Air embolism: bubble of air, acts like a clot/stroke
- Arterial Puncture: hitting the artery
- Catheter migration/dislodgment
- Catheter rupture
- Lumen occlusion: opening of end of cannula is obstructed by clot or web of clot
- Central Line-Related Bloodstream Infections (CLRBI): purulent draining around the site, needs to be d/c & sent down to lab, may need to also culture the site
Port a Cath
- Must use a Huber needle
- Cancer patients
- Strict sterile technique when accessed
- Can be double lumen or single lumen
- Come in various sizes
- Placed in upper chest wall, possible upper extremity
- Designed to not “core”, designed to slice through and when removed, the material will self-close
Huber Needle
- 45 degree angle needle
- Needed to access a port a cath
Isotonic IV Fluids
- Be careful on patients who are at risk for overload (renal & cardiac patients)
- Usually used with burn patients
- No push into or pull out of the cells
- D5W
- NS: should be the only thing used when giving blood products. Need to prime the tubing for blood products with NS
- LR: contains k+
Hypotonic IV Fluids
- Pushes fluid into the cells
- Puts patients at risk for phlebitis & infiltration
- Moving into the cells & expanding them
- Use cautiously with burns
- 1/2 NS
Hypertonic
- Pulls fluid out of the cells
- Monitor blood sugar levels
- D5 1/2 NS
- D5 NS
- D10W
IV Fluids
- Be sure to check the date on the fluids
- Make sure the bag is not leaking
- If it doesn’t look right, don’t hang it
- IV solutions should be changed every 24 hours
8 Rights of Medication
1) Right time
2) Right patient
3) Right medicine
4) Right dose
5) Right route
6) Right documentation
7) Right effect
8) Right education
Before administering drugs
- 8 Rights of medication
- Current medications
- Diagnosis = why are they getting this drug?
- Comorbities = multiple disease process, will this interfere with the additional diseases
- Lab values
- Drug levels: Normal drug levels for that specific medication (coumadin, K+, etc.
- CBC Values: What’s their blood count? Is this going to affect something? RBC, WBC, Platelets
- CMP Values: complete metabolic panel
IVPB
- 25mL to 250mL IV bag
- Short tubing
- Connects to the upper “Y-Port”
- Primary infusion or intermittent
- Hung higher than the primary infusion
- Primary infusion can be placed on hold while IVPB is infusing
Complications of IV therapy (Local)
Local = right there in a small area, right at the site
- Cellulitis
- Phlebitis
- Infiltration/Extravasation
- Hematoma
- Ecchymosis
- Site infection
- Nerve damage
Cellulitis
- Inflammation of the cells or surrounding tissue of the site
- Inflammation of subcutaneous connective tissue
S&S:
- Swollen
- Redness
- Warm to touch
- Pain
- Edema
- Induration
- Red streaking
- Fever (systemic)
- Chills (subjective)
- Rigor - see them shaking (objective)
- Malaise - general feeling of not feeling well
To avoid Cellulitis:
- Avoid lower extremities
- NEVER use the lower extremity of a diabetic patient
- Use surgical aseptic technique
- Rotate sites every 72 hours
Treatment:
- Discontinue the infusion and remove the catheter
- Elevate the extremity
- Apply warm compresses 3-4 times/day
- Obtain a specimen for culture at the site & prepare the catheter for culture if drainage is present
- Administer: antibiotics, analgesics, antipyretics
Phlebitis
Inflammation of the vein from mechanical or chemical (medication) trauma
S&S:
- Throbbing, burning, or pain at the site
- Increased skin temp
- Erythema
- Red line up the arm with a palpable band at the IV site
- Swollen
- Fibrin can be activated
- Can start a thrombus
Cause:
- Catheter too large for the vein size
- Veins become inflamed by irritating or vesicant solutions or medications (typically phenergan, K+)
Treatment:
- Promptly discontinue the infusion and remove the catheter
- Elevate the extremity
- Apply warm compresses 3-4 times/day
- Restart the infusion proximal to the site or in another extremity
- Culture the site and catheter if drainage is present
Infiltration
- Fluid is leaking out of the vein and into the interstitial spaces
- Escape of fluids or drugs into the subcutaneous tissue
S&S:
- Cool to touch around the site
- Swollen
- Pale, pallor, white - may bruise after awhile
- Induration: elevated area
- Firm
- Pain
- Burning
- Necrosis of the tissue
- Damp dressing
Causes:
- Catheter unsecured
- Incorrect catheter size
- Vesicants
Treatment:
- Stop the infusion and remove catheter
- Elevate the extremity
- Encourage active range of motion
- Apply warm or cold compress
- Restart the infusion proximal to the site or in another extremity
Extravasation
- When an IV catheter becomes dislodged & meds infuse into the tissues
- Pain
- Stinging
- Burning
- Swelling
- Redness at the site
Hematoma
Blood leaking out
Hema = Heat; apply heat to area
Ecchymosis
- Pin point rash
- May be seen along area of IV or tourniquet placed
- Bruising
Site infection
Change site
Systemic
Body wide, through the whole system
Air embolism
- When d/c line or IV
- Air is in the tubing
Catheter embolism
- Part of it breaks off
Circulatory overload
- Body has too much fluid and can’t handle it
MUST
- Monitor the site every 2 hours
- Flush the IV every shift
Fluid Volume Overload Signs and Symptoms
- Weight gain: CHF patients must be weighed daily
- Elevated BP
- Increased HR
- Increased respirations
- Distended neck veins
- Decreased electrolyte levels
- Generalized edema
- Decreased HCT
- Decreased BUN
- Bounding pulse
Fluid Volume Deficit Signs and Symptoms
- Weight loss
- Decreased salivation
- Decreased output
- Dry, cracked lips
- Poor skin turgor (check near clavicle for peds & elderly)
- Increased HCT
- Increased BUN
- Thready (light) pulse
Hematoma
- Collection of blood
- Blood leaking out
- Subcutaneous hematoma: most common complication
- Can be a starting point for other complications: thrombophlebitis and infection
- Greater than 10mm
Hematoma Signs & Symptoms
- Discoloration of the skin
- Site swelling and discomfort
- Inability to advance the cannula all the way into the vein during insertion
- Resistance to positive pressure during the lock flushing procedure
Hematoma Causes
- Nicking the vein
- D/C the IV without applying adequate pressure
- Applying the tourniquet too tightly above a previously attempted venipuncture site
- Leaving the tourniquet on too long
Hematoma Treatment
- Applying pressure after IV catheter removal
- Use warm compress and elevation after the bleeding stops
- Hema = heat; apply heat
Colloid solutions
- Packed Red Blood Cells (PRBCs)
- Platelets
- Fresh Frozen Plasma
- Albumin
- Cryoprecipitate
- Must be 18g or 20g - if too small, will damage or rupture the RBCs and that would then excrete K+ into the system and cause K+ overload
RN responsibility before blood infusion
- Verify consent
- Verify with another RN
- Name and blood bank number
- ABO and Rh type of patient
- ABO and Rh type of donor
- Expiration time
- Unique facility identifier
- Lot number
- EDUCATE on procedure/adverse reaction symptoms
- Vital signs prior to start infusion
- Complete the blood transfer w/in 4 hours of removal from refrigeration
- Exam blood for discoloration or cloudiness
Blood products FAQs
- Blood products can only be given with NS
- Jehovas witness do not accept any blood - need to be aware of religious preferences. If religion doesn’t allow blood transfusions, MUST get a consent form
- Plasma and serum are the same thing and that is what the RBCs are floating in
- Albumin given to pull fluid back into the peripheral spaces
Adverse reactions ACTIONS
1) STOP the transfusion
2) Check VS
3) Infuse NS
4) Notify MD
5) DO NOT dispose of blood
6) Document
Adverse reaction signs with transfusions
- Dyspnea
- Wheezing
- Cyanosis
- Chest tightness
- Hypotension
- Flank pain
- Anxiety/restlessness
- Headache
- Tachycardia
- Chills
- Fever
- Flushing
- Itching
- N/V
- “Impending Doom”
- Laryngeal edema
RN responsibility during infusion
- Use proper tubing
- Administer blood products using NS
- Remain w/patient for at least the FIRST 15 MIN
- EDUCATE on adverse reactions symptoms
- Infuse product at ordered rate
- Monitor VS
- Document
Rn responsibility after infusion
- Dispose of bag and tubing properly in RED bag
- Place RED hazard bag in proper bin
- Document
- Educate
- Watch for post-transfusion complications
Transfusion-associated graft-versus-host-disease
TA-GVHD
- Occurs in immunosuppressed/immunocompetent patients (diabetes, cancer, HIV)
- Manifestations usually occur w/in 1-2 weeks after transfusion
- Thrombocytopenia (low platelet count)
- Anorexia
- N/V
- Chronic hepatitis
- Weight loss
- Recurrent infection
Autologous Blood Transfusion
- Collection and transfusion of ones own blood
- Usually done before a surgery
- Eliminates compatibility problems
- Fresh packed RBCs can be stored for 40 days
- Rare types of blood may be frozen for 10 years
Complications
- Transfusion reaction
- circulatory overload (elevation in bp due to increased blood volume, blood was given too fast. Can cause heart failure and pulmonary edema-excess fluid in the lungs); can give IV lasix
- Septicemia (infection of the blood, blood poisoning) by bacteria or toxins
- Iron overload - delayed complication that has received several transfusions or a patient with low platelets (thrombocytopenia)
- Disease transmission - Hep C: will start to see symptoms w/in 4-6 weeks
- Hyperkalemia: stored blood might lyse=break in the bag and then be transfused causing hyperkylemia
- Citrate toxicity - due to preservative placed in the blood as a coagulant (primarily a result of hypocalcemia)
- Hypocalcemia