IV Therapy Flashcards
Purpose of IV Therapy
- maintain fluid, electrolyte and energy demands
- prevent fluid and electrolyte imbalances
- administer blood and blood products
- administer total parenteral nutrition
- administer prescribed IV medications (i.e. antibiotics)
- to have venous access in case of emergency (KVO-keep vein open)
Nursing Responsibilities (IV)
a. assess need for IV therapy
b. assess IV site
c. assess/maintain prescribed IV flow rate
d. assess patient response to IV therapy
e. prevent complications associated with IV therapy
Signs and Symptoms of Fluid volume deficit (FVD)
- loss > 2.2 lbs in 24 hr
- decreased b/p
- tachycardia
- slow cap refill
- dry skin and mucous membranes
- decreased skin turgor
- thirst (late sign)
- decreased urine output
- confusion/restlessness (very late sign)
Signs and Symptoms of Fluid volume excess (FVE)
- gain < 2.2lbs in 24 hr
- bound pulse
- distended neck veins
- abnormal lung sounds (crackles)
- edema
Vascular Access Devices
a. Peripheral Vascular Access Devices (PVADs)
SHORT TERM USE
b. Central Vascular Access Devices (CVADs)
LONG TERM USE
1. central venous catheters
- meds that irritate veins, i.e. chemotherapy
- poor peripheral veins
- large volume of fluids
- emergency
2. Implanted infusion ports
- implanted underneath skin
3. Peripherally inserted central catheters (PICC)
- through peripheral vein and through to the vena cava
Equipment
a. IV cannulas (16G, 18G, 20G, 22G, 24G)
b. tourniquet
c. gloves
d. antiseptic swabs
e. IV dressing (transparent occlusive)
Common Peripheral IV sites
median cubital, cephalic (hand), great saphenous vein (foot)
- choose non-dominant hand
- most distal site possible in case vein punctures
- feet in infant and children only
- feet in adult may cause clot or venous return issues
- avoid anywhere with infection or thrombosis
- 70% alcohol or chlorhexidine to clean site
Changing an IV dressing
- change as per organizational policy
- hand hygiene
- apply gloves
- be careful not to dislodge catheter when removing old dressing
- assess IV site
- clean site in circular motion
Considerations in Older Persons
- use smaller gauge needle (22-24g)
- choose site that does not interfere with ADLs
- use minimal tourniquet pressure
- lower angle of insertion
- apply traction to skin below insertion site
- use protective device
IV Fluids
Crystalloids
- contains solutes that mix, dissolve and cross semi-permeable membranes, smaller molecule
a. NaCl
b. Dextrose
c. Lactated ringer’s
Colloids
- contain proteins or starch that do not cross semi-permeable membranes, remain in extracellular space/intravascular fluid
- increase vascular volume
a. blood
b. plasma proteins
c. pentastarch
Total Parenteral Nutrition (TPN)
- nutritionally adequate solution
a. glucose
b. nutrients
c. other electrolytes
Crystalloid IV Solutions
Isotonic
- same osmolarity as blood
- expands fluid volume without fluid shift between compartments
i. e. normal saline (0.9%), dextrose 5% in water (D5W), LR
uses: increase or replace vascular volume from vomiting, diarrhea
Hypotonic
- lower osmotic pressure
- moves fluid into cells, causing them to enlarge, hydrates the cell
i. e. 0.45% NS, 0.225% NS
uses: cellular dehydration (risk: hypovolemia, hypotension)
Hypertonic
- higher solute concentration
- pulls fluid out of cells, causing them to shrink
i. e. D10W, 3-5% NS, D5LR
uses: cerebral edema, severe hyponatremia
Body fluids
Intracellular fluid
- fluid within the cells
0 60% of body fluids
Extracellular fluid
- fluid outside of cells
a. interstitial (between cells and outside vessels)
b. intravascular (blood plasma)
c. transcellular (cerebrospinal fluid, peritonea, synovial and GI tract)
Common Additives
- potassium chloride KCl (red writing) always runs through infusion bump, never directly inserted used to treat vomiting, diarrhea can result in death - multivitamins (banana bag)
IV Tubing
Macrodrip - 10 or 15 gtts/mL
Microdrop - 60 gtts/mL
- a lot more precise!
- critical care and peds
Buretrols
volume control device, reduces risk of an increased volume being infused
Regulating IV Flow Rate
- manual regulation using roller clamp
- electronic infusion devices (EIDs) - infusion bumps
(Infusion volume x drop factor)/time in minutes = gtt/min
Follow rounding principle
*unless solution needs to be infused especially slowly, then round down
Factors influencing flow rate
- patency of IV catheter
- patency of IV tubing
- height of solution
- restrictive IV dressing
- position of extremity
- infiltration (solution goes into surrounding tissue and not vein itself)
IV Maintenance
- keep the system sterile, alcohol swab and hand hygiene
- 10ml of air or less, as little as possible
- assist patient with self-care activities
- assess IV infusion and site regularly
- change solution when there is ~50 mls remaining
Infiltration
IV fluid (non-vesicant) enters subcutaneous space but not vein itself
symptoms: swelling, pallor, coolness, pain, leakage from IV site
prevention: avoid area of flexion, observe site frequently, advise pt to report any swelling or tenderness
intervention: discontinue IV, raise affected extremity to promote venous return, apply warm compress for 20 mins
Extravasation
Vesicant medications/fluids enter subcutaneous space
i.e. chemotherapy, epinephrine
symptoms: burning or pain at IV site, swelling, coolness, blistering or skin sloughing, leakage from IV site
prevention: avoid small veins and area of flexion, give vesicant meds last, adhere to proper administration techniques
intervention: discontinue IV unless administering antidote, notify md, elevate extremity, apply warm or cool compress (as per manufacturer indication)
Phlebitis
Inflammation of the vein, can result in blood clots and emboli
symptoms: pain, edema, redness along the vein, warmth
prevention: avoid flexion, dilute meds as per instruction, be especially careful with certain meds with chemicals added or antibiotics
intervention: discontinue IV, apply warm compress
Infection
symptoms: redness and possible discharge at IV site, elevated temperature
prevention: use aseptic technique, hand hygiene before any contact with infusion system, clean injection ports before use
intervention: discontinue IV and notify MD, remove device and culture site/catheter as ordered, monitor vitals
Bleeding/bruising
risk factors: patients receiving heparin, patient with bleeding disorders
interventions: apply pressure dressing at the site
Fluid Overload
Occurs when fluids are given at a higher rate and in a larger volume than the body can absorb or excrete
complications: HTN, heart failure, pulmonary edema
treatment will depend on severity
- fluid management
- medication administration
- diuretics
Air embolism
Presence of air in the vascular system that travels into the right ventricle and/or pulmonary circulation
symptoms: SOB, cough, neck/should pain, anxiety, light headedness, hypotension, increased HR
prevention: ensure drip chamber is 1/3-1/22 full, ensure IV connections are secure, remove air by priming tubing
intervention: occlude source of air entry, trendelenburg position, oxygen, vitals, notify MD
Advantages of IV route
- Rapid response
- Effective absorption
- Accurate titration
- Can be stopped immediately in case of adverse reaction
Disadvantages of IV route
- Solution and drug incompatibilities
- physical or pharmaceutical incompatibility
- chemical incompatibility (foaming, crystal forming)
- therapeutic incompatibility (make another more/less potent) - Immediate adverse rection
- Long-term use damages intima (layer around lumen)
Preparing IV Medications
a. aseptic technique
b. independent, double-check of calculated, high or unusual doses and high-alert drugs
c. know key information
d. reconstitute powdered drugs
e. dilute medication in suitable amount of compatible solution
f. label IV bag
g. check compatibility (IV compatibility wall chart)
Administering IV Medications
a. asses patient - vital signs!
b. check IV site first
c. follow 10 rights and 2 checks using MAR
- what you are giving, why you are giving it
d. observe closely for s&s of adverse reaction
Continuous infusions
Mixture within large volume of IV fluid in primary site
a. pre-mixed: heparin drip, morphine drip, KCl added
b. added by RN: morphine drip, multivitamins
Direct injection (IV push or bolus)
Inject directly into vein without IV line or through an existing infusion line
- clamp infusion tube above the injection port to ensure meds go into the body
- luer-lock technology
only certain RNs are able to give IV push drugs (ICU, emerg, PACU)
Admixture: Adding Meds to IV bag
- use aseptic technique (clean injection port!)
- inject through port using syringe
- mix well
- often pre-prepared
- label
Piggy back of mini bag infusions
Piggy-back (add a line or secondary medication set) through:
a. primary IV
b. device such as saline or heparin lock
Principles:
- ensure compatibility of secondary extension tubing
- secondary bag is higher
- use roller clamp on primary line to set flow rate
- prime secondary bag by lowering bag, let fluid from primary bag flow into secondary tubing to let air out
Intermittent Infusion Devices (saline or heparin locks)
IV catheter that is threaded into a peripheral vein, flushes with saline and then capped off for later use
Minimal amount of fluid for patient
Protects privacy
Must be flushed after each use, prevent blood clotting
Types of Saline Locks (Needle-less access)
- Prepierced septum/blunt cannula
- Luer-activated device
- Valve technology - positive pressure caps
used for CVAD
caps redirects a small amount of fluid into the internal catheter tip to prevent blood reflux into the lumen
Flushing
*Check patency first!
Saline > Administration of Meds > Saline
- use 10mL diameter syringes pre-filled with normal saline
PVAD (saline lock) flushed with at least 3mL of NS before and after administration of medications and prior to locking
Standard 3mL - 55ps
BD Posiflush 3mL - 19.75o
Turbulent Flush Technique
Push-pause (start-stop) flushing method
- allows flushing solution to “scrub” inside of device wall
- promotes removal of blood/fibrin
- important for CVAD
Positive Pressure Locking Technique
To prevent blood reflux from the vein into the lumen of the VAD, prevent occlusions
Maintain a forward motion on the syringe plunger as the syringe is removed form the access/injection site or slide clamp as you push last 1-2ml
Other methods
a. administering IV meds via buretrol
- inject into buretrol
b. PCA (patient controlled analgesia)
- patient self dosing: monitor!
- subcu, IV or epidurally
IHI Suggestions for reducing ADEs
- standardized IV solutions
- pre-mixed solutions
- smart infusion pumps
- label
Troubleshooting (IV not working)
a. check site for infiltration
b. check for kinks or leaks
c. reposition arm
d. . increase flow rate
e. lower bag below arm to check for blood return
f. raise IV pole
g. check that clamps are open
Adverse or Allergic Reaction
a. stop medication immediately
b. follow guidelines for response, assessment and reporting
c. notify MD
d. document allergy in health care record
e. let the patient know!
Discontinuation of Peripheral IVs
a. close all clamps prior to discontinuation
b. remove tape and site dressing, stabilize catheter while doing this
c. apply light pressure and withdraw catheter, keep hub parallel to skin
d. apply pressure for 2-3 minutes
e. cover site with gauze or bandage
f. inspect catheter tip for intactness
