IV therapy Flashcards
1
Q
Purpose of IV therapy
A
- To maintain fluid, electrolyte & energy demands
- To prevent fluid and electrolyte imbalances
- To administer blood and blood products
- To administer TPN (total parental nutrition)
- To administer prescribed IV medications (ex: antibiotics)
- To have venous access in emergency situations: KVO (keep vein open)
2
Q
Nursing responsibilities of IV therapy
A
- Assess need for IV therapy
- Assess IV site
- Assess/maintain prescribed IV flow rate
- Assess patient response to IV therapy
- Prevent complications associated with IV therapy
3
Q
Fluid volume deficit (FVD) signs/symptoms
A
- Loss > 2.2lbs in body wt in 24hr
- Decreased B/P
- Tachycardia
- Slow cap refill
- Dry skin and mucous membranes
- Decreased skin turgor
- Thirst (later sign)
- Decreased urine output
- Confusion/restlessness (very late sign; only with severe deficit)
4
Q
Fluid volume excess (FVE) signs/symptoms
A
- Gain > 2.2lbs in body wt in 24hr
- Bounding pulse
- Distended neck veins
- Abnormal lung sounds (e.g., crackles)
- Edema (often present in extremities, in the ankles)
5
Q
Types of vascular access devices
A
1) Peripheral Vascular Access Devices (PVADs)
2) Central Vascular Access Devices (CVADs)
- Central Venous Catheters (CVC)
- Implanted infusion ports
- Peripherally inserted central catheters (PICC)
6
Q
Peripheral vascular access uses
A
- Short term use
7
Q
Central vascular access uses
A
- Long term use
- Medications and solutions irritating to veins
- Peripheral access is limited or contraindicated
- Large volumes of fluid
8
Q
Central venous catheter (CVC)
A
Reasons we use
- For longer term use as well as for administration of medications that are irritant to the veins
- Patient has poor peripheral veins; cant find anywhere to put
- Large volumes of fluid
- Emergency situation need to secure immediate access
- Inserted by MD or NP; usually RN doesn’t insert
- Be mindful of infection; at high risk, make sure to assess regularly for sign/symptoms
- Infection indications; redness, swelling, purulent discharge, pain, fever
Other complications
- Penumothorax
- Arterial puncture during insertion
- Hemmorrage
- Cardiac tampinade
- Risk of nerve injury during insertion
- Occlusion
- Most have a tip that lies in the lateral portion of the superior vena cava
- Inserted through different major vessels, but tip consistent
9
Q
Implanted infusion port (CVC)
A
- Implanted underneath the skin
- Accessed with specialized types of needles
- Found in special care; i.e. oncology
- Lower risk of infection; not exposed to air
10
Q
Peripherally inserted central catheters (PICC)
A
- Central lines inserted through a peripheral vein; usually somewhere in the arm
- Long catheter; tip goes into the superior vena cava
- Mindful of infection; good hand hygiene, good aseptic technique
- Potential for CLABSI (central-line associated blood stream infections)
11
Q
IV equipment
A
- IV cannulas (Sizes: 16G, 18G, 20G, 22G, 24G)
- Tourniquet
- Gloves
- Antiseptic swabs
- IV Dressing (transparent occlusive)
12
Q
Common peripheral IV sites
A
- Inner arm/hands/feet
- Choose patient non-dominant hard
- Choose most distal site possible; if accidentally punctured, “blowing the vein” and no longer good – have to use distal to it instead of proximal
- Peds often use feet; not for adults patients, increased risk of clot formation in feet, in infants/small children not the same risk; older adults tend to have less venous return in lower extremities as well
- Avoid anywhere that has signs of infection, thrombosis, blood clot, if patient has graft/fistula for dialysis we don’t want to go in there
13
Q
How to clean IV site before insertion
A
- Cleaning with cholorhexine solution or 70% alcohol
- Circulation motions for 30 seconds then let dry for 2 minutes
- Once site has been cleaned, we don’t want to touch it afterwards
- Use alcohol swab as a marker so you don’t touch it again
14
Q
IV catheter/cannula
A
- Angle in insertion is 10-30 degrees
- Variety of different gages; smaller the number the large the diameter
- Only plastic tube gets left behind, the needle get taken out
- Flashback chamber; right site if blood appears in it
How do you decide on size of cannula?
- Size of the patient; their veins; older adults/children use 24G
- Viscosity of fluid you’re infusing
- Volume of fluid you’re infusing
- Diagnostic testing; CAT scans with IV contrast; department will have specifications of diameter (usually 18G)
15
Q
IV dressing
A
- Dressing transparent to monitor and assess the site of insertion
- Also prevents organisms from entering the site
16
Q
Changing an IV dressing
A
- Dressings are changed as per organizational policy
- Perform hand hygiene
- Apply gloves
- Remove old dressing being careful not to dislodge IV catheter
- Assess IV site
- Remove any additional tape and adhesive
- Clean site in a circular motion, working outwards with antiseptic swab, allow to dry
- Apply new dressing and secure with tape.
- Document as per policy (e.g., in chart and on dressing if required)
17
Q
IV considerations: older persons
A
- Use a smaller gauge needle (22 – 24g)
- Choose site that does not interfere with ADLs
- Use minimal tourniquet pressure (over clothes)
- Lower angle of insertion
- Apply traction to the skin below insertion site
- Use a protective device
- Older adults have smaller veins and poor venous return
Want to minimize shearing forces on the skin itself; tourniquet on top of clothing - Traction on the skin; pulling downwards on the site while inserting
- Protective site; help protect it from getting knocked out while moving, etc.
- Arm board; limb placed on board and taped on to minimize movement
18
Q
Types of IV fluids
A
1) Crystalloids
2) Colloids
3) TPN
19
Q
IV fluids: crystalloids
A
- Contain solutes that mix, dissolve and cross semi-permeable membranes
- Smaller molecules
- Most common
- Examples;
NaCl
Dextrose
Lactated Ringer’s
20
Q
IV fluids: colloids
A
- Contain proteins or starch that do not cross semi-permeable membranes
- Large molecules
- Remain in extracellular space / intravascular fluid
- Used to increase vascular volume (expand the vessel)
- Examples;
Blood
Plasma proteins
Pentastarch
21
Q
IV fluids: total parenteral nutrition (TPN)
A
- Nutritionally adequate solution
- Typically 2 bags; yellow and lipid bag
- Exclusively infused via central line access, not peripherally
- Examples;
Glucose
Nutrients
Other electrolytes
22
Q
Types of crystalloid IV solutions
A
Isotonic:
- Same osmolarity as blood
- Expands fluid volume without causing fluid to shift between compartments
- Create constant pressure within and outside cells
- Cells won’t shrink or swell in response; stay the same size
Hypotonic:
- Lower osmotic pressure
- Moves fluid into cells, causing them to enlarge
- Cause fluid to shift into intracellular space
- They hydrate the cells
Hypertonic:
- Higher solute concentration
- Pulls fluid away from cells, causing them to shrink
- Draw water out of intracellular space into extracellular space
- They dehydrate the cells
23
Q
Body fluids: intracellular vs extracellular
A
Intracellular Fluid
- Fluid within the cells
- Accounts for 60% of body fluids
Extracellular Fluid
- Fluid outside of the cells
- Interstitial; between the cells and outside of the vessels
- Intravascular; blood plasma
- Transcellular; cerebrospinal fluid, peritoneal, synovial and GI tract
24
Q
Common IV isotonic solutions
A
Uses:
- Volume replacement
- Treat diarrhea, vomiting, shock, resisitation
- Possibility of fluid overload
Examples:
- Normal Saline (0.9%)
- Dextrose 5% in water (D5W)
- Lactated Ringer’s (LR)
25
Q
Common IV hypotonic solutions
A
Uses:
- Lower solute concentration, causing fluid to shift into cells
- Cellular dehydration (e.g., dialysis patients on diuretics)
- Monitor patient for hypovolemia and related hypotension
- Also want to use caution in patient who have any increase in intracranial pressure; don’t want shift fluid into cells of brain tissue
Examples:
- 0.45% NS
- 0.225% NS
26
Q
Common IV hypertonic solutions
A
Uses:
- Higher levels of solutes; draw fluid out of cells and into extracellular/intravascular cells
- Not used very much in practice
- Careful with hypertonic solution; can easily cause fluid overload
- Short term use
- Treats cerebral edema, severe hyponatremia (low sodium)
Examples:
- Dextrose 10% in water (D10W)
- 3-5% NaCl/NS
- D50.45%NaCl
- D5LR
27
Q
Common additives to IV solutions
A
Potassium Chloride (KCl)
- KCl used fairly commonly; be careful when using because it can result in death (failed arythermias)
- Compound used in USA for lethal injections
- Typically administer from pharmacy or comes in pre-mixed bag
- Red writing; K involved, careful with administration
- Never administer KCl as push; always run through infusion, want to use pump when using KCL to ensure correct amount
Multivitamins
- Yellow solution
- Mix on unit; according to instruction
- “banana bag”
Physician’s Order:
ex: 0.9NS with 20meq KCl/1000cc at 125ml/hr
28
Q
Structure of an IV pole
A
Primary bag
- Two ports; one that gets spikes and in injection port
- Drip chamber; 1/3-2/3 full of fluid; leave enough space to count drips as coming down
- Back flow valve; stops fluid from going back up into bag
- Port to attach another IV bag to or to get air out of line
- 2 types of clamps; slider clamp and roller clamp (used to regulate flow)
- Port closest to patient; used to flush IV line with saline to ensure it’s working
29
Q
IV tubing
A
Macrodrip
- (10 or 15 gtts/mL)
- Find information to which type of tubing you have on the IV packaging
- Typically found in adult settings
Microdrip
- (60 gtts.mL)
- More precise than macro drip
- Make sure we’re not touching the spike before it goes into the bag and the cap
- When priming IV; keep both clamps closed to prevent accidently letting it go
30
Q
Buretrols
A
- Buretrol or volume control device.
- This chamber can be filled with a smaller volume than the IV bag.
- Reduces risk of an increased volume being infused.
- Attached to the IV tubing
- Sits right underneath the IV bag
- Purpose is to manage the amount of fluid we are giving to the patient
- Commonly in past in peds
- Don’t over fluid the patient
- Now with more advanced syringe and pumps we are seeing these less
31
Q
Regulating the IV flow rate
A
Two ways to do this
- Manual regulation using roller clamp
- Electronic infusion devices (EIDs)
i. e. Infusion pumps
Why properly regulate IV flow rate?
- If too slow we might be depriving patient of fluid they need, or IV the is administered really slowly can clot more easily
- Too fast can result in fluid overload
32
Q
How to regulate the IV flow rate (formula)
A
(Infusion volume x drop factor)/ time in minutes = gtt/min
33
Q
Regulating the flow rate: electronic infusion devices
A
- If not using manual regulation use IV pump to regulation the flow
- ID or electronic diffusion devices
- Used positive pressure to manage the flow
- Seen commonly now
- Alarms for air in line; fluid running out of bag; line occlued
- Tons of different models
- Want to make sure pump used for peds/neonatal patients or older patients at risk of volume overload
