1. IV Therapy C Washington RN, MSNEd

2. IV Therapy Administration of fluids, electrolytes, nutrients, or medications by the venous route Clients receiving IV therapy require constant monitoring for complications

3. Intravenous Therapy

5. Indication for IV Therapy Establish or maintain a fluid or electrolyte balance Administer continuous or intermittent medication Administer bolus medication Administer fluid to keep vein open (KVO) Administer blood or blood components

6. Indication for IV Therapy Administer intravenous anesthetics Maintain or correct a patient's nutritional state Administer diagnostic reagents Monitor hemodynamic functions

7. Major Types of IV Fluids Isotonic Fluids – increases extracellular fluid volume O.9% NS-expands intravascular volume 5% dextrose & water-lowers serum Na+

9. Fluid stays within the intravascular space

11. Risk of fluid overload, esp in patients with CHF & HTN

13. Hypotonic Fluids Lowers the osmotic pressure and causes fluid to move into cells O.45% NS-maintains level of plasma sodium & chloride

15. Used for dehydrated and dialysis patient on diuretic therapy

18. Hypotonic fluids Contain a lower number of molecules than serum Fluid shifts from the intravascular space to the interstitial space (represented by the green arrows). Decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it) which then causes fluid to move into the cells.

19. Green arrows represent fluid movement, not molecule movement

20. Hypertonic Fluids Increases osmotic pressure, drawing fluid from cells D5% in 0.45% NS-provides sodium chloride

21. Hypertonic fluids> 295 mOsm/kg Higher osmolarity than serum Stabilize blood pressure, increase urine output, and reduce edema. Rarely used in the prehospital setting Dangerous in the setting of cell dehydration Examples: 9.0% NS, blood products, and albumin

22. Hypertonic Solution Pulls fluid & electrolytes from the intracellular & interstitial compartment into the intravascular compartment

23. Hypertonic fluids Contain a higher number of molecules than serum Increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.

24. Fluid shifts from the interstitial space to the intravascular space

25. Crystalloid Ideal for patients who need fluid replacement. Used as a replacement to support blood pressure from blood loss Examples: Lactated Ringer's (LR), NS (normal saline)

26. Crystalloids

27. Colloids Draw fluid from the interstitial & intracellular compartments into the vascular compartment Reduce edema (pulmonary or cerebral edema) while expanding the vascular compartment. Examples: albumin and steroids

28. Initiating Intravenous Therapy

29. Starting an IV is an art-form which is learned with experience accumulated after performing many IVs. Some patients are easy but many are difficult.

30. IV Equipment Peripheral IV & Heparin locks – establish a venous route in those clients whose condition may change rapidly Vascular Access Devices – allow long-term IV therapy

31. Steel Needles: Butterfly catheter Deliver small quantities of medicines Deliver fluids via the scalp veins in infants Draw blood samples (although not routinely, since the small diameter may damage blood cells). Small gauge needles

32. Over the Needle Catheters Example: peripheral IV catheter. This is the kind of catheter you will primarily be using.

33. A Word About Gauges Gauge is the diameter of catheter The smaller the diameter, the larger the gauge A 22-gauge catheter is smaller than a 14-gauge catheter The greater the diameter, the more fluid can be delivered

34. A Word About Gauges To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter

35. A Word About Gauges To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

36. Veins of the Hand Digital Dorsal veins (1) Dorsal Metacarpal veins (2) Dorsal venous network (3) Cephalic vein (4) Basilic vein (5)

37. Veins of the Forearm Cephalic vein (1) Median Cubital vein (2) Accessory Cephalic vein (3) Basilic vein (4) Cephalic vein (5) Median antebrachial vein (6)

39. Failed cannulation attempts of antecubital veins can cause problems in the event of a successful cannulation further down

42. The tendons that control the thumb can obscure the vein

44. Points to Remember Dorsal veins are often quite handy Metacarpals splint cannulae well They can be quite small. If the patient is elderly, look elsewhere Lack of turgor in the skin & loss of subcutaneous tissue make it quite difficult to cannulate these veins

46. Avoid areas where cannulation or venipuncture has previously taken place

48. Choose a vein that has a firm, round appearance or feel when palpated

50. Inspect the fluid bag: desired fluid fluid is clear bag is not leaking bag is not expired

52. Do not let the ends of the tubing become contaminated.

53. Close the flow regulator (roll the wheel away from the end you will attach to the fluid bag).

55. Prepare the IVF administration set If you overfill the chamber, lower the bag below the level of the drip chamber and squeeze some fluid back into the fluid bag. Hold the fluid bag higher than the drip chamber of the administration set Squeeze the drip chamber once or twice to start the flow. Fill the drip chamber to the marker line (approximately one-third full).

57. Let it run into a trash can or even the (now empty) wrapper the fluid bag came in.

59. Turn off the flow & place the sterile cap back on the end of the administration set (if you've had to remove it).

61. Apply a tourniquet high on the upper arm

62. It should be tight enough to visibly indent the skin, but not cause the patient discomfort

63. Have the patient make a fist several times in order to maximize venous engorgement

66. If you cannot easily see a suitable vein, you can sometimes feel them by palpating the arm using your fingers (not your thumb)

67. The vein will feel like an elastic tube that "gives" under pressure

69. If after a meticulous search no veins are found, then release the tourniquet from above the elbow and place it around the forearm and search in the distal forearm, wrist and hand

70. If still no suitable veins are found, then you will have to move to the other arm.

72. Clean the entry site carefully with the alcohol prep pad

73. Allow it to dry. Then use a betadine swab.

74. Allow it to dry. Use both in a circular motion starting with the entry site and extending outward about 2 inches.

76. Perform the venipuncture To puncture the vein, hold the catheter in your dominant hand With the bevel up, enter the skin at about a 30 to 45 degree angle and in the direction of the vein Use a quick, short, jabbing motion After entering the skin, reduce the angle of the catheter until it is nearly parallel to the skin

78. Many people use their thumb for this. Pull the skin distally toward the wrist in the opposite direction the needle will be advancing.

79. Be careful not to press too hard which will compress blood flow in the vein and cause the vein to collapse

81. Perform the venipuncture

82. Perform the venipuncture

84. Carefully watch for the flashback to occur

85. If you are still not within the vein, advance it again in a 2nd attempt to enter the vein

87. place gauze over the skin puncture site

88. withdraw the catheter

89. tape down the gauze

92. The hub of the catheter should be all the way to the skin puncture site.

93. The plastic catheter should slide forward easily.

95. If Successful Release the tourniquet

97. Remove the needle from within the plastic catheter.

98. Dispose of the needle in an appropriate sharps container.

99. NEVER reinsert the needle into the plastic catheter while it is in the patient's arm!

102. If Successful Label the IV site with the date, time, and your initials. Monitor the infusion for proper flow into the vein (in other words, watch for infiltration).

103. IV Therapy: Sample IV Orders 1 L 5%D/0.45 NaCl with 20 mEq KCL at 125cc/hr 1000 ml D5 ½ NS with 20 mEq KCL every eight hours 1000 ml D5 ½ NS with 20 mEq KCL to run in 8 hrs

104. Flow Rates: Microdrip sets Allow 60 drops (gtts) / mL through a small needle into the drip chamber Good for medication administration or pediatric fluid delivery

105. Flow Rates: Macrodrip sets Allow 10 to 15 drops / mL into the drip chamber Great for rapid fluid delivery Also used for routine fluid delivery and KVO

106. Flow Rates How much fluid do you want your patient to receive each hour? “Keep the Vein Open” (KVO), infusing IVF slowly to keep the vein patent, small amount of volume infused Faster flow rate are expressed in mLs/hr Maintenance“ amount: NS at 125 ml/hr Your patient would receive 125 mL of fluid every hour

108. This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute.

109. To do this, you must know what size administration set you are using (micro or macrodrip).

111. IV Therapy: IV Label Amount & Type of solution Additives & their concentrations Rate & duration of IV therapy Expiration date Initials of pharmacist who prepared Pt’s name & room # Date & time started RN initials

112. IV Therapy: Documentation Type of fluid & flow rate Insertion site location (L forearm, R hand, L antecubital) State of IV site (swelling, reddness, pain) Patient’s response to therapy IV intake on I & O flow record

114. Peripheral IV and PICC line Assessment

115. pain (palpation)

116. discoloration: redness, bruise

117. swelling

118. induration

120. IV Therapy: Nursing Care Monitor IV site & infusion every 2 hours Pt age, size, status, c/o discomfort, teaching Intake & Output No IV solution hung > 24 hrs Monitor for complications

121. IV Therapy: Nursing Care Change IV site, dressing, tubing per institution policy (standard q 72-96 hrs No application of antimicrobial ointment on catheter site Prevent neddle stick injury Standard precautions

122. Complications of IV Therapy Phebitis Pain, increased skin temp, erythema, along path of vein

123. Complications of IV Therapy Infection IV site red, swollen, warm, tender; purulent foul smelling drainage

124. Complications of IV Therapy Hematoma Discolored area/bruising around IV site, pain, swelling

125. Complications of IV Therapy Infiltration Swelling, possible pitting edema, pallor, coolness pain at site, decrease flow

126. Complications of IV Therapy Extravasation - inadvertent administration of a vesicant substance into the tissues can have disastrous outcome.

127. Complications of IV THerapy Circulatory overload Air Embolism

128. Complications of IV Therapy FVD Decreased urine output, dry mucous membranes, hypotension, tachycardia FVE Crackles, SOB, edema

130. bleeding disorder

131. disconnection of IV

132. catheter from tubingCath embolism ↓BP pain along vein weak, tready, rapid pulse cyanosis of nail beds/circumoral unconsciousness

134. Lightheadedness/dizziness; chest tightness; facial flushing, irregular pulse

135. Allergic reaction

137. Discontinue an IV (cont) Place a 4 x 4 gauze over the site Gently slide the plastic catheter out of the patient's arm Use direct pressure for a few minutes to control any bleeding. Place a band aide over the site.

139. Volume-control administration set

140. Intermittent infusion by piggyback or partial fill

142. Check site for complications (redness, swelling, tenderness)

143. Check for blood return

145. Intermittent Therapy: Saline Lock

146. Intermittent therapy (saline lock) Swab injection port with alcohol at each step. S: flush with 2 ml saline. A: administer medication at prescribed rate using a short needle with a gauge equal to or smaller than catheter (25 g, 1/2 in). S: flush with 2 ml saline (maintain positive pressure to prevent blood back-up into catheter). Not required if drug compatible with heparin. H: flush with 10-100 units heparin if required by facility policy.

148. Squeeze drip chamber; fill halfway with solution.

149. Run fluid through tubing.

152. Attach 20 g 1-inch needle to tubing, if a needleless system is not being used. Insert needle into injection port.

153. Regulate rate with control and watch to count drops.

154. When medication absorbed, main line will start to drip again.

157. Cleanse injection port with alcohol or other appropriate cleanser

158. Unless otherwise recommended, turn off primary IV bag; flush with saline if indicated

160. Do not purge when attached to client

161. Prior to connecting IV to client, check to determine if tubing allows gravity free-flow

162. If it does be sure to turn off regulator

164. Do not turn off alarms.

165. Follow manufacturer's directions for deactivating alarm and starting IV flow

166. Explain regulator and alarms to client

168. Central Line

170. Quinton Catheter

171. Portacath

172. DVD Resources/Lab Practice Venipuncture Establishing an IV Infusion Electronic Infusion Pump Regulating IV Flow Rate Discontinuation of a Peripheral IV line

173. Initiating IV Access Complete Virtual IV Tutorial Practice weekly for IV insertion competency

174. Mr. Watson Lives in a SNF Dx: Pneumonia Receiving IV antibiotics Peripheral IV site C/O arm hurting at IV site, especially with IV antibiotic What would be your best action at this time?

175. Mr. Watson What possible complications may explain his discomfort?

176. Mr. Watson IV discontinued Restarted in other arm Started infusion at 50 ml/hr

177. Mr. Watson 1000ml infused/1 hr C/O SOB puffiness around eyes Engorged neck veins Crackles both lower lobes BP 154/96

178. Mr. Watson Another nurse tells you that the client is experiencing speed shock because the saline went in too fast Do you agree? Explain your answer. What should you do at this time?

179. A patient, being discharged, will need to receive antibiotic therapy for an additional three weeks. The peripheral vascular access device that would be the best for this patient would be:

180. 1. A peripheral short catheter. 2. A winged steel infusion set. 3. A midline catheter. 4. A PICC line.

181. A patient receiving parenteral fluids is prescribed an intravenous medication to be infused every 6 hours. Which of the following infusion devices should the nurse use for this medication?

182. 1. Stop cock 2. Extension set 3. Elastomeric balloon 4. Secondary administration set

183. The staff development department is planning an annual skills review day for the basics of intravenous therapy. If the Infusion Nursing Standards of Practice are being followed, the purpose of this skills day would be to:

184. 1. Ensure that all nurses follow Standard Precautions. 2. Preserve the patient’s right to safe quality care and protect the nurse who administers infusion therapy. 3. Ensure that the nurses are in compliance with all regulatory agencies. 4. Ensure that the nurses’ skill levels are adequate.

185. A patient is prescribed parenteral fluid therapy. Which of the following should the nurse do first?

186. 1. Wash hands. 2. Gather the equipment to insert the peripheral access device. 3. Prepare the flush to use once the peripheral access device is in place. 4. Review the procedure with the patient and obtain consent.

187. A patient receiving parenteral fluid therapy complains of the arm “feeling cold” and the dressing “feeling tight.” What should the nurse do?

188. 1. Check for a blood return in the catheter. 2. Stop the infusion and remove the catheter. 3. Turn off the infusion, reposition the catheter. 4. Change the dressing and observe the site.