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IV Therapy

Def: administration of fluids or meds thru a vein. This route is the fastest and poses the greatest danger.

Nurse Role:

  1. NAIIà d/c an IV, can prime the tubing, but nurse has to give them the bag. Does not monitor IV or check IV site.
  2. RN & LPN à can do venipuncture for a peripheral line (scalp in a baby also) and administer meds. Can give piggy backs and push meds. Hospitals regulate policies to what the LPN can do. EX: CCH does not allow LPN to push meds.
  1. Central Line: puts fluid directly into right atrium. Most common is the subclavian line.

    2. Category I:

    RN to give meds thru.

    Category II:

    RN to draw blood from.

    RN to d/c.

    LPN to give meds thru.

    LPN to draw blood from.

    LPN to d/c.

  2. PIC Line: in anticubital space. Category II for RN to start.
  3. Hickman and Port-o-cath: put in for long term med use. Surgically d/c.

Reasons for IV fluids:

  1. To replace fluids and electrolytes. Can be done thru IV fluids and electrolyte therapy. To correct deviation from a normal state. EX: dehydration.
  2. To replace blood.
  3. TPN: high concentration of dextrose which gives more calories. Liposin: also called lipids which is a fat emulsion piggy back.
  4. Maintenance: to sustain the balance they already have. EX: NPO.

An intravascular access can also be started to a KVO state. This is used to administer meds. Usually 50-30 cc/hr. This is called Hep-lock or Saline well.

Know all when MD orders fluids:

  1. Identify correct solution.
  2. Be familiar with equipment.
  3. Know all procedures to initiate, start, regulate, and maintain.
  4. Be able to identify problems and how to correct.
  5. How to d/c.

2 types of fluids:

  1. Colloids: thick suspensions. EX: blood. Need to use a larger bore needle.
  2. Crystalloids: nutrient and electrolyte solutions.

Volumes come in 50, 100, 250, 500, and 1000. Smaller are sued to administer meds or for peds.

Extracellular fluid compartment: interstitial and intravascular.

Intracellular fluid compartment: in the cells. Most of the body’s fluid is intracellular.

Osmolarity: concentration of electrolytes and other osmotically active particles in blood and other body fluids.

 

 

 

 

  1. Isotonic: (stays where you put it) expands intravascular compartment only. Good for patients who have rales.

    2. Lactated ringers

    Ringers injection

    Normal saline

    D5W

  2. Hypotonic: (pulls out) shifts fluid and electrolytes out of intravascular hydrating intracellular and interstitial.

    3. ½ normal saline

    1/3 normal saline

    D2 ½ W

    This would be ordered for the dehydrated person.

  3. Hypertonic: (pulls in) draws fluid into the intravascular dehydrating intracellular and interstitial.

D5 ½ NS

D5 NS

D5 LR

Before using, inspect your bag.

Micro set has 60gtt/ml.

Macro set has 10 - 20gtt/ml.

Back check valve will not allow anything to go past it.

Filter: some lines will need one for TPN.

Purpose for adding meds to large volumes: to maintain a constant level of med used or administer meds that need diluting. Ex: KCL is irritating to the veins.

Equipment:

MAR

Sterile med

Diluent

Correct IV solution

Alcohol

Sterile syringe (5-10cc)

1 to 1 ½ inch, 20 to 21 gauge needle

Procedure:

Verify order

Confirm med and solution compatible

Prepare med

Locate injection port

Clean with alcohol

Inject med

Attach a med lable

Add meds :

Close clamp

Clean port

Inject med

Lable

For glass bottleà take top off or remove cap on vent to insert without needle.

Purpose of priming is to replace air with fluid.

Tubing is changed q 24-72 hours (so are the sites).

Bag of fluid can only hang for 24 hours.

Starting the IV:

Have all equipment ready.

Give brief discription.

Give restriction on activities.

Put in non-dominant hand if able.

Allow client to express concerns.

24g à peds or NB

18g à best for blood

16g à trauma

20g à most commonly used

Tourniquet should be 2 to 6 inches above the injection site.

Clean with alcohol in circular motion.

Make sure needle comes apart from catheter.

Stick direct (on top) or indirect (to the side).

Blood return lets you know you are in.

Advance ¼ inch more.

Put 2x2 under hub.

Push in cath and remove needle at same time while occluding vein.

Attach fluids.

Release tourniquet.

Make sure it runs and them clamp.

Apply tegaderm over hub.

Tape down.

Loop other tubing up and tape.

Date/time/initial.

Procedure to maintain:

If you find an error, check order first.

Observe your rates every hour.

If rate is too fast, slow it down and ovserve for fluid overload (edema, increased BP, increased HR, crackles, SOB) and call MD.

If too slow, recalculate gtt rate and put it where it should be, never try to catch it up.

May use a time strip for a gravity infusion. Put a piece of tape on the bag and put the time for how ever much should be out at that time.

Note condition of the site.

Can lower bag to see blood in line.

If bleeding you may just need to tighten the fluids to the hub.

Teach client to avoid twisting and call when infusion stops.

Changing IV tubing:

Typically all changed at one time every 3 days if no problems arise.

  1. Tubing but not site:

    2. Prime new bag

    Cut off infusing IV

    Untape

    Occlude vein so won’t bleed back

    Put on new tubing

  2. Regulate IV not on a pump:

Know how to calculate cc/h using your watch.

Reason for hanging a piggy back: to be able to administer different meds at different times, maintain peak med levels, administer slow and dilute in large volume.

Reason for IV pushes: to get fast results and is administered in the port closest to the client. Be sure to look up med to know how fast it needs to be pushed. If doing thru a hep-lock use the SAS method. If you piggy back thru a hep lock, use the primary tubing set.

To Discontinue:

Use clean gloves.

Close roller clamp.

Put 2x2 over site.

Pull catheter straight out.

Examine catheter tip.

Document if catheter in tact.

Cover wound.

Also document site appearance and intake.

Anatomy of the vessels:

Remember the arteries pulsate. Veins are superficial and arteries are deeper.

There are 3 layers.

  1. Tunica Intima: inner layer. Elastic lining. Has valves in the veins which keep fluid going toward heart. The lining has a smooth layer of flat cells. This is where trauma happens when starting IV’s and clots form.
  2. Tunica Media: middle layer. Has nerve fibers. Vasoconstriction and vaso dilation takes place. Cold meds will be painful.
  3. Adventitia: outer layer. Areolar connective tissue. Will feel a little pop at this layer. In an artery, this is thicker.

Circulatory system:

  1. Pulmonary à right ventricle to heart and lungs back to left atrium.
  2. Systemic à larger or the 2 systems. Consists of aorta, arteries, veins and capillaries.

Must have an order to start an IV in the feet or legs. More problems with phlebitis and blood clots.

Metacarpal à good place. The veins lie between bones and joints that give a natural splint.

Cephalic à radial side of forearm. Accomadates a large catheter.

Basilic à on pinky side of forearm.

Median à another good choice.

Anticubital à not a good choice because you will bend it. Located in joint flexion, dislodge easily, and infiltrate easily. However, they are large and used in emergencies.

When selecting a vein, try to put in non dominant hand. Choose one that is naturaly splinted by a bone. Do not use mastectomy side, or fracture side. Inspect by palpation. Should not feel hard.

Systemic Complications:

  1. Fluid overload à same as circulatory overload. Too much, too fast.

    2. S&S: SOB, edema, increased RR, abnormal lung sounds, increased BP, cough, neck vein distention, variance for I&O (more in than out).

    Prevention: monitor I&O, be aware of client history. Carefully monitor infusion flow rates, may need to use pump or volutrol or hang smaller bags.

    Treatment: slow IV down, do assessment, elevate HOB, call MD. MD may order Lasix.

  2. Air Embolism à caused by air bubbles that accumulate and block pulmonary capillaries. Associated commonly with central lines. Important to get air out. Can cause shock and death.

    3. S&S: dyspnea, cyanosis, hypotension, weak rapid pulse, loss of consciousness, chest, choulder or low back pain.

    Prevention: be sure connections are tight, lure locks should be tight.

    Treatment: clamp central line and get new tubing.

  3. Septicemia à presence of pathogenic bacteria that invades the blood stream. Caused by a break in aseptic technique or contaminated equipment.

    4. S&S: chills, fever, general mallaise, h/a, backache, increased pulse and resps.

    Prevention: sterile technique, inspect fluids, don’t hang over 24 hours, use sterile technique for add mixtures, good handwashing.

    Treatment: symptomatic.

  4. Speed shock à speeding it up when it is behing, may be a bolus.

S&S: facial flushing, h/a, chest tightness, symptoms of shock.

Prevention: use a pump.

Treatment: show IV down and call MD.

Local complications:

1. Infiltration à leakage of luid from a vein into surrounding tissue. Most common complication. First sign is complaints of tightness. Discomfort, swelling, and cool to touch. Chemo will cause tissue to slough off if infiltrated.

Treatment: d/c and relocate.

Elevate extremity and fluid should absorb in 2 or 3 days. Be sure to tell your client this. Also known as extravasation.

Prevention: monitor IV closely, use appropriate size catheter, don’t start at joint flexions, securing well with tape, relocate according to policy, if in doubt, relocate.

2. Phlebitis à inflammation of the vein r/t a chemical or mechanical irritation. Causes: meds, irritating drugs, not anchoring correctly. Incidence increases the longer it has been in.

S&S: redness and warmth.

Prevention: same as infiltration.

Treatment: warm compress (must have MD order) and take it out.

3. Thrombo phlebitis: presence of a clot plus inflammation. An get a thrombosis from any injury to inner lining of the vein.

S&S: local pain, redness along vein path, warmth, fever, malaise, immobility of extremity.

Prevention: prevent trauma during insertion, observe sites q hr, check med additives for compatability, never irrigate an IV.

Treatment: d/c, relocate, elevate, MD may order heat.