Week 11/12 - IV Therapy Flashcards
Purposes of IV Therapy (6)
- To maintain fluid, electrolyte and energy demands
To prevent fluid and electrolyte imbalances - To administer blood and blood products
- To administer TPN (total parenteral nutrition)
- To administer prescribed IV medications (ex: antibiotics)
- To have venous access in emergency situations: TKVO (to keep vein open) or KVO (keep vein open)
Nursing responsibilities for IV therapy (5)
- 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
Two types of vascular access devices
Peripheral Vascular Access Devices (PVADs)
Central Vascular Access Devices (CVADs)
Peripheral Vascular Access Devices (PVADs)
Short term use
Central Vascular Access Devices (CVADs)
- Long term use
- Medications and solutions irritating to veins
- Peripheral access is limited or contraindicated
- Large volumes of fluid
Angle of inertion of IV cannula
30 degrees
Age-related considerations for IV therapy (6)
- Use a smaller gauge needle (22 – 24g)
- Choose site that does not interfere with ADLs
- Use minimal tourniquet pressure
- Lower angle of insertion
- Apply traction to the skin below insertion site
- Use a protective device
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
Cystalloids
IV Fluid
Contain solutes that mix, dissolve and cross semi-permeable membranes easily.
Examples:
Na Cl (electrolytes)
Dextrose
Lactated Ringer’s
Colloids
IV Fluid
- Contain proteins or starch that do not cross semi-permeable membranes.
- Remain in extracellular space/intravascular fluid
- Used to increase vascular volume
Examples:
Blood
Plasma proteins
Pentastarch
Total Parenteral Nutrition (TPN)
Nutritionally adequate solution
Glucose
Nutrients
Other electrolytes
Can be given continuously or intermittently.
Almost exclusively infused by central line.
Isotonic solution
Same osmolarity as blood
Expands fluid volume without causing fluid to shift between compartments
Used when we need to increase intravascular volume (e.g. diarhea, vomiting, shock)
Hypotonic solution
Lower osmotic pressure
Moves fluid into cells, causing them to enlarge (hydrates cells)
Used to treat cellular dehydration (e.g., dialysis or pts on diuretics)
Hypertonic solution
Higher solute concentration (osmolarity)
Pulls fluid away from cells, causing them to shrink (dehydrates)
Used when clients have cerebral edema, severe hyponatremia
Short-term use only.
Examples of isotonic solutions
Normal Saline (0.9%)
Dextrose 5% in water (D5W)
Lactated Ringer’s (LR)
Examples of hypotonic solutions
- 45% NS
0. 225% NS
Examples of hypertonic solutions
Dextrose 10% in water (D10W)
3-5% NaCl/NS
D50.45%NaCl
D5LR
Considerations for hypertonic solutions
Risk of fluid overload
Considerations for isotonic solutions
Risk of fluid overload
Considerations for hypotonic solutions
Monitor for hypovolemia (fluid is leaving vessels and going into cells, resulting in hypovolemia and hypotension)
Careful with pts with increased intracranial pressure, because we
don’t want fluid to shift into cell of brain tissue.
Common additives to IV solutions
Potassium Chloride (KCl) - must be given carefully (lethal)
Multivitamins
Macrodrip IV tubing
Primary Infusion IV Tubing
10 or 15 ggt/mL
Used for all routine IVs in adult setting
gtt
drop
Microdrop IV tubing
Primary Infusion IV Tubing
60 ggt/mL
Used in peds and neonatal and critical care to give IV volume with increased precision
Buretrols
- volume control devices
- used in peds to avoid fluid overloading
This chamber can be filled with a smaller volume than the IV bag… but it’s used less and less in practice
Two ways to regulate IV Flow Rate
Manual regulation using roller clamp (Drops/min aka ‘drip rate’)
Electronic infusion devices (EIDs)/Infusion pumps (mls/hour)
Complications of incorrect flow rate
Too slow = fluid deprivation; potential for catheter to clot
Too fast = fluid overload
Factors that influence flow rate (6)
Patency of IV catheter Patency of IV tubing Height of solution Restrictive IV dressing Position of extremity Infiltration (infusion into surrounding tissue)
Troubleshooting an IV (6)
- Check site for infiltration
- Check for kinks
- Reposition arm
- Lower bag below arm to check for blood return
- Raise IV pole
- Check that slide clamp & roller clamp are open
Complications of IV Therapy (7)
Infiltration Extravasation Phlebitis Infection Bleeding/Bruising Fluid Overload Air Embolism
Infiltration
IV fluids (non-vesicant) enter the subcutaneous space
Characterized by: Swelling Pallor Coolness Pain (in some cases) Change in IV flow rate Leaking from IV site
Extravasation
Vesicant medications/fluids enter the subcutaneous space
Characterized by:
- Burning or pain at IV site
- Swelling
- Coolness
- Blistering or skin sloughing
- Change in IV flow rate
- Leaking from IV site
Phlebitis
Inflammation of the vein
Characterized by:
- Pain
- Edema
- Redness (may travel along the vein)
- Warmth
Can result in blood clots and emboli
Infection
Characterized by:
- Redness and possible discharge at IV site
- Elevated temperature
Bleeding/Bruising
Risk Factors:
- Patients receiving heparin
- Patients with bleeding disorders
Nursing interventions:
- Apply a pressure dressing at the site
Fluid Overload
Occurs when fluids are given at a higher rate or in a larger volume than the body can absorb or excrete.
Possible complications: hypertension (HTN), heart failure, and pulmonary edema
Treatment will depend on severity (ex: fluid management and/or medication administration)
Air Embolism
Presence of air in the vascular system that travels into the right ventricle and/or pulmonary circulation.
Characterized by: SOB Cough Neck/shoulder pain Anxiety/feelings of doom Light headedness Hypotension Increased HR
Infection: prevention and interventions
Prevention:
- Use aseptic technique during IV insertion
- Perform hand hygiene before any contact with the infusion system or the patient
- Clean injection ports before each use
- Follow your institution’s policy for dressing changes and changing of the solution and administration set.
Nursing interventions:
- Stop the infusion and notify the physician
- Remove the device, and culture the site and catheter as ordered
- Monitor the patient’s vital signs
Air Embolism: prevention and interventions
Prevention:
- Ensure drip chamber is 1/3 -1/2 full
- Ensure IV connections are secure
- Remove all air when priming tubing
Nursing interventions:
- Occlude source of air entry (if known)
- Trendelenburg position (if not contraindicated)
- Oxygen
- Vital signs
- Notify physician
Advantages of IV medication (5)
Rapid Response Effective Absorption Accurate titration Less discomfort Can be stopped immediately
Disadvantages of IV medication (4)
- Solution and drug incompatibilities
- Immediate adverse reactions
- Can result in the most serious outcomes of medication errors
- Long-term use damages vessel intima
Physical or pharmaceutical incompatibility
When multiple additives are combined
Results in precipitate and cloudiness; can result in occlusion and can be fatal
Chemical incompatibility
When two drugs are mixed so potency of their active ingredients is changed
Therapeutic incompatibility
When two incompatible medications are given at the same time
Infusion methods for IV meds (5)
- Continuous infusions
- Piggy-back or mini bag infusions
- Intermittent infusions
- Direct injection (IV push/bolus)
- Other methods:
- volume control (buretrols)
- PCAs
- Syringe and smart pumps
ENtry-to-practice competency: “Above the drip chamber”
All RNs can give IV drugs “above the drip chamber”
Continuous Infusions
- Given continuously
- May or may not contain medication
- Mixture within large volume of IV fluid
Pre-mixed: heparin drip, morphine drip, KCl added
Added by RN: morphine drip, multivitamins and more
Tandem IV set-up
- Equal height to primary infusion
- Simultaneous infusion with primary line (like a splitter)
- Monitor closely to ensure primary line doesn’t back up into tandem line
Piggy-back of mini-bag infusion
Piggy-back (Add-a-Line or secondary medication set) through:
- Primary IV
- Device such as saline or heparin lock
Piggy-back set-up: which bag is higher and why
“Secondary IV” hung alongside primary or main-line and is attached to mainline through injection port below mainline IV.
Used for medications, smaller volumes (50-250cc). Intermittent that we want to interrupt the mainline, and then we want the primary IV to resume once it has finished.
Since we want secondary to infuse first, we hang it HIGHER than mainline generating higher pressure and preventing the primary line from infusing.
Infuse ONE-AT-A-TIME
Intermittent Infusion Devices (Saline or Heparin Locks)
“Infusion-Port-Adapters”
For medication administration at specific times (not continuously)
Some clients only need an intermittent infusion. Can use extension set or lock so IV can be disconnected between doses.
Advantages of Intermittent Infusion Devices (3)
- Freedom for client
- Cost savings
- Minimal amount of fluid for patient
Disadvantages of Intermittent Infusion Devices (2)
- Must be flushed after each use
- Can clot easily if blood backs up
Positive Pressure Caps
Used for CVADs
Caps redirects a small amount of fluid into the internal catheter tip when the tubing or syringe is disconnected from the device hub preventing blood reflux into the lumen
Use of Positive Pressure Locking Technique
To prevent blood reflux from the vein into the lumen of the VAD – thus preventing fibrin build up, clots and device occlusions
How to apply Positive Pressure Locking Technique
Maintain a forward motion on the syringe plunger as the syringe is removed from the access/injection site. If there is a slide clamp on extension tubing, close it while you are injecting the saline.
Direct IV injections (IV push or IV bolus)
Administration of medication directly into vein via lock (no IV line) OR through an existing infusion line via port
Speed shock
Serious, potentially fatal, systemic reaction when a foreign substance is RAPIDLY introduced into the circulatory system.
Direct IV should be given over 1-2min.
Symptoms:
syncope, headache, flushed face, chest tightness, irregular pulse, hypotension shock or cardiac arrest can occur
Flushing Method
S-A-S
Saline (S)
Administration of med (A)
Saline (S)
Volume per flush is 3-5ml
*Check IV patency first!
When to flush (6)
- After blood sampling
- When converting from continuous to intermittent therapies
- Before and after medication administration
- Before and after administration of blood components
- Before and after intermittent IV therapy
- For maintenance of a dormant device
*q12h
Turbulent Flush Technique
Start-stop method to clean inside the device (push-pause)
Administering IV Medications Via Buretrol
Volume controlled device for very small doses
PCA (Patient-Controlled Analgesia)
Volume controlled device where pt controls the dose
Maintains a steady and constant level of pain control
Not okay for people with confusion or memory loss
Syringe Pumps
For small medication volume (5 ml/hr or less)
- IVPiggy-Backed into primary line or lock
- Convenient, compact, battery-operated
Smart Pumps
Have safety features with dose error reduction software to reduce medication error.
