31 August 2011 IV Therapy Nancel Dumlao INTRAVENOUS THERAPY

INTRODUCTION
Intravenous Therapy insertion of a needle/catheter/ cannula into a vein, based on the physicians written prescription those who are allowed to give: trained registered nurses lead by ANSAP (Association of Nursing Service Administration of the Philippines) PHILOSOPHY: to maintain fluid volume and electrolyte homeostasis GOALS: replace/maintain body stores of water, protein, vitamins, electrolytes restore acid-base balance restore blood volume components avenue for drug administration monitor central venous pressure provide nutrition while resting the GI tract LEGAL ASPECTS: protocols governing special training on administration of IVT for RNs 1991 RA 7164(old)/9173(new) Sec 27 (a) defines scope of nursing practice nursing care includes but not limited to traditional innovative approaches in nursing IM/IVT injections IV injection shall include administration of drugs, fluid and electrolytes, blood and blood products. It shall include insertion of needles/butterfly in IV infusions. guidelines to be formulated by: BON PNA ANSAP PRC BON Resolution No. 08 IVT Training to be prescribed by ANSAP Civil Code of the Philippines (Article 3) Acts and omission punished by law are felonies. These are committed by means of deceit (DOCO) and fault (CULPA) deceit performed with deliberate intent fault wrongful acts resulting from negligence lack of foresight/ lack of skill requisites of felony are: act of omission punishable by law REQUIRED COMPETENCIES: hand washing VS assessment standard precautions principles of aseptic technique medication calculations medication administration ROLES AND RESPONSIBILITIES OF A NURSE IN ADMINISTRATION OF IVT: validate doctors order for IVT

perform venipuncture, insert stylet and cannula, except TPN and cut down (extremity edema, pitting = cut portion of vein then insert IV) prepare, monitor, terminate IVF solution incorporation of IV meds (collaborative) administer blood products as ordered by physician recognize solution and med incompatibilities (ex. Phenytoin do not administer to dextrose with sugar because it will crystallize) maintain and replace sites, tubings, and dressings in accordance with established procedures regulate flow rates of solution, medicines, blood and blood components utilize knowledge and proficient techniques in the use/care/maintenance and evaluation of IV equipment nursing management of TPN (most common: NUTRIPACK contains lipids, CHO, and milk solution protein) discuss basic concepts out-patient, home IV care implement infection control protocols related to IVT accurate and complete documentation (cardex, chart, IV sheet) PRINCIPLES OF PHYSIOLOGICAL ASSIMILATION OF INFUSION SOLUTIONS Tissue cells (erythrocytes, neurons, etc.) are surrounded by a semi-permeable membrane = cytoplasm, cell wall, cell membrane Osmotic pressure: water moves through semipermeable membrane from weaker to storage concentration of solute; the end result is equilibrium Extracellular components fluids primarily include plasma and interstitial fluid if there is an in hydrostatic pressure = edema (hypertonic) principle: hydrostatic pressure should be = oncotic pressure

TYPES OF IVF FLUIDS

ISOTONIC SOLUTIONS: PNSS (0.9%) replenish bodily fluid losses treat shock: NS + blood (hypovolemic) diluent for IV meds for hemorrhage Lactated Ringers (aka Plasma expander) replace electrolyte losses replenish isotonic bodily fluid losses correct metabolic acidosis Blood Component Albumin 5% Plasma all blood components are hyperkalemic in nature D5W (an isotonic solution like NS) replenish water and isotonic bodily fluid losses provide calories (d/t exercise) diluents for IV meds HYPOTONIC SOLUTIONS: (to expand shrink cells) Normal Saline/Sodium Chloride 0.45% or 1 1/2 0.33% (Pedia)

1 //carengreyes

 exert less osmotic pressure than that of blood

For patient who cannot take drugs orally (coma)

plasma causes dilution of plasma solute concentration forces water movement into cells HYPERTONIC SOLUTIONS: PNSS (0.3%/0.5%) D5 0.9% PNSS D5 0.45% NaCl D5LR D10W D50W Hyperalimentation solutions (TPN) Albumin Vamin hyperglycemic exerts high osmotic pressure than of blood plasma increase the solute concentration of plasma (form cell to vascular space) cells will then shrink be careful: may result to pulmonary edema (especially cardiac/renal cases)

or IM (coagulation disorders)
cost effective

TOTAL PARENTERAL NUTRITION (TPN)

method for providing nutrition IV thus bypassing the GI tract; going directly to venous compartments usually use larger veins (central vein, superior vena cava) INDICATIONS: GI disorders malabsorption of the bowel CA/chemotherapy/radiotherapy anorexia nervosa burns/draining wounds rest the GIT (fistula, inflammatory bowel disease) COMPLICATIONS: mechanical (CV catheter insertion) air embolism thrombosis pneumothorax infection: glucose supports bacterial growth (reinsert IV every 15 mins) hyperglycemia fast administration hypoglycemia slow administration fluid overload nausea, headache, lethargy

TYPES OF IV ADMINISTRATION
IV PUSH (BOLUS): administration of a med from a syringe directly into an ongoing IV infusion may also be given into a vein by way of an intermittent access device (saline/heplock) saline administer meds saline heparin 10% solution (SASH) Indications: emergency: rapid quicker response to medication is required (Furosemide/Digoxin) limit IM injections avoid drug incompatibility problems

Precautions/Recommendations: Before administration MDs drug order dilute drug determine the correct (safest) administration check drug-drug compatibility assess IV line assess patient condition and ability to tolerate drugs assess patency of IV line by the presence of blood return lower running IV bottle withdraw with syringe before injecting meds pinch IV tubing gently watch patient reaction to drug watch for major and minor adverse effects vesicants are given through the side part of a running IV infusion know hospital policies on how, when, by whom IV push meds **The nurse is ultimately accountable for the drug that she administers. Always confirm unfamiliar drugs or unusual doses 10 Rights of Administration: Drug Patient Dose Route Time Documentation Patient education Drug history Drug allergies Drug drug/Drug - interaction CONTINUOUS OF INTERMITTENT INFUSION USING INFUSION CONTROL DEVICES: given through traditionally bags of solution and tubing with or without flow rates regulators IV, intra-arterial, intra-thecal spiral infusion may be accomplished through the external pump General Considerations: Advantages can infuse large/small volumes of fluid with accuracy has alarm warning less nursing time in readjusting flow Disadvantages needs special tubing (added cost) infusion pumps will continue in infuse despite the presence of infiltration Nursing Responsibilities: remember that machines is only as effective as the operator monitor regularly for complications follow the manufacturers instruction on tubing insertion double check the flow rate flush all air out of the tubing before insertion

2 //carengreyes

 explain purposes Types: Electronic flow rate regulators Indication chemotherapy infant and pedia therapies hyperalimentation (protein products) using hypertonic solutions ex. Albumin, Vamin F&E on patient at risk for the overload most meds Battery powered ambulatory infusion pumps Freon-controlled spring pump (implanted) Computer-programmable pump (implanted) INTERMITTENT INFUSIONS: Intermittent access device (saline lock) periodic IV meds use Heparin, Saline flush (2ml) Piggyback IV administered med by way of the fluid pathway of an established primary infusion line Drug may be given on an intermittent basis through a primary infusion Central Venous Access Device (CVAD) Peripherally inserted central catheter (PICC) inserted into one of the peripheral veins in the upper arm and ends in a large vein of the heart

NURSING ROLE IN IVT

Selecting a vein check doctors order (except in emergency) explain select a vein suitable for venipuncture: back of hand: metacarpal vein avoid digital veins if possible this site permits arm movement cant use vein higher than the arm if problem occurs in this site forearm: basilica/cephalic vein inner aspect of elbow, antecubital fossa median basilica median cephalic ankle: great saphenous vein foot: venous plexus of dorsum dorsal venous arch medical marginal vein central veins: jugular, femoral are used when meds and infusions are: hypertonic/highly irritating requiring rapid high volume dilution when peripheral blood flow: Diminished (shock) peripheral vessels are not accessible (obese patients) when CVP monitoring is desired when moderate/long-term fluid therapy is suspected **nursing alert! do not use medial/basilic/cephalic veins for chemotherapy; it will lead to

extravasation, poor healing, resulting in impaired joint movement Methods of distending a vein manual compression clench fist massage tourniquet BP cuff tap the vein site dependent arm position heat to needle site Selecting stylet/catheter use the smallest gauge cather suitable for the type and location of the infusion gauge 16 gray gauge 17 white gauge 18 green gauge 20 pink gauge 22 blue gauge 24 yellow parts: flashback chamber luer lock plug luer connector needle grip injection port ca catheter hub and wings catheter valve bushing IV Flow Rate

Tubing change check your institutional protocol for the time of tubing change standard is 48-72 hours (every 3 days) label Gerontological Alert! veins are prone to collapse more danger in fluid overload Pedia Alert! neonates and infants do not have as many accessible veins as adults do veins used are: hands, feet, antecubital, scalp also prone to fluid overload

VERNIPUNCTURE USING NEEDLE/CATHETER

EQUIPMENTS: admin set IV fluid IV pole/stand extension tubing IV insertion kit tourniquet tape: 1 inch wide aseptic swab arm board dressing, transparent clean gloves

3 //carengreyes

equipments (googles, mask optional) ASSESSMENT: review accuracy and completeness of doctors order assess for clinical factors that could be affected by the IVF administration peripheral edema body weight dry skin and mucous membranes distended neck veins irregular pulse BP changes auscultation of crackles/ronchi poor skin turgor decrease urine output behavioral changes (restlessness, confusion) check arm placement preference assist risk factors child/elderly cardiac/renal ailment skin lesion infections use of anticoagulants decrease platelets assess patient understanding/purpose of IVT SETTING UP: wash hands/prepare equipments check sterility and integrity of the IV solution, IV set and other devices place IV label on IVF bottle; signed by RN patient name room number solution drug incorporated bottle sequence duration, time and date explain procedure open the seal of the IV infusion aseptically and disinfect the rubber part open IV administration fill drip chamber

protective

large bore needle or catheter use prolonged needle or catheter use clot formation Clinical Manifestations tenderness/pain along the vein swelling, warmth, and redness at the infusion site Preventive measures anchor securely change the insertion use large veins for irritating fluids dilute irritating fluid Nursing intervention cold compress first 24 hours and warm compress to succeeding hours BACTEREMIA Causes phlebitis contaminated equipment/solutions prolonged placement of an IV non sterile IV cross contamination immunosuppressed patient Preventive Measures use strict aseptic technique maintain integrity of solution Nursing intervention stop and remove VS, WBC (as ordered) culture and sensitivity test of bacteria CIRCULATORY OVERLOAD Cause delivery of excessive amounts of IV fluid High Risk elderly, infants, patient with

heart/renal insufficiency

COMPLICATIONS OF IVT
INFILTRATION Cause IV cannula is out of vein resulting to infusion of fluid into the surrounding tissue Clinical Manifestation swelling, blanching, and coolness of surrounding skin and tissue fluid flowing more slowly or ceasing absence of blood backflow in IV catheter and tubing Nursing Interventions STOP and REMOVE the IV needle/catheter restart IV in the other arm apply warm compress to promote venous return elevate document THROMBOPHLEBITIS Causes injury to vein during: venipuncture

Clinical Manifestation BP, PR, CVP engorged jugular veins HA anxiety shortness of breath coughing tachypnea pulmonary crackles chest pain (if history of CAD) Preventive Measures monitor I and O, IV flow rate closely monitor high risk px Nursing Interventions KVO (10 15gtts/min) raise the patients bed for pulmonary congestion document closely monitor for worsening congestion AIR EMBOLISM Causes air enters catheter and travels to the heart air in tubing by IV push or infused by infusion pump Clinical Manifestation drop in BP, PR

4 //carengreyes

 cyanosis, tachypnea rise in CVP changes in mental status, loss of consciousness

Preventive Measures clear all air fluid before infusion to px change solution container before they run dry secure all connections change IV tubing during expiration Nursing Interventions put on left side and lower head of bed notify physician oxygen reassure the patient document HEMORRHAGE Cause loose connection of tubing inadvertent removal of peripheral or central catheter anticoagulant therapy Clinical Manifestation oozing/tickling of blood from IV site/catheter hematoma Preventive Measures cap all central lines with luer-lock tape all catheter securely; transparent dressing put pressure site for 2-5 minutes upon removal of cannula (ex. anticoagulant therapy) VENOUS THROMBOSIS vein becomes partially or fully occluded by a thrombus Cause infusion of irritating solutions infection on site clot formation in vein Clinical Manifestation slowing of IV infusion/inability to flow blood from the central line swelling and pain on IV site Preventive Measures dilute substances ensure superior vena cava catheter to placement for irritating solutions Nursing Interventions stop and notify anticoagulants heat elevate of affected extremity antibiotics reassure patient and institute appropriate therapy

insert needle and syringe into rubber port distal to air and aspirate to remove air BACKFLOW OF BLOOD fluid above the level of catheter site and the level of the heart check security of tubing connection check that infusing fluid has not run out and that catheter is in a vein, not an artery (note pulsation of blood in tubing) IV IS POSITIONAL (runs well only when arm/hand is in a certain position) stabilize IV site FLUID LEAKING AROUND PUNCTURE SITE discontinue IV and restart in another site place warm soak over infected site reassess frequently

DOCUMENTATION
Provides: accurate description of care serve as legal protection mechanism to record data health insurance Data recorded: size, type, length of cannula/needle name of person who inserted cannula date/time of insertion IVF type, meds, flow rate, duration location, condition of insertion site complications health teaching signature

TROUBLE SHOOTING
DRIP CHAMBER IS OVERFILLED close regulator clamp turn fluid container upside down squeeze fluid from drip chamber until half-full or slightly below AIR INSIDE THE TUBING check inadequacy of fluid level in drip chamber and security of tubing connections

5 //carengreyes