Administration of IV fluids, blood and blood products

Circulatory Overload

Cause --Infusing excessive IV fluids or administering fluids too fast Signs/Symptoms --Weight gain --Edema --Crackles --Hypertension --Distended neck veins

Documentation of IV Fluids

Charted on Intake and Output (I&O), and in some facilities on medication record (MAR) or electronic record (look at pic)

D5 ½ NS

--5% dextrose in 0.45% saline --Hypertonic --Common maintenance fluid --Same as 0.45% NaCl except provides 170 calories/L --KCl often added for maintenance or replacement

Continuous Infusion

--Adding medication to large-volume primary fluids --Safest and easiest way Advantages: ---Drug is infused over long period of time - consistent delivery of drug Disadvantage: ---Danger of infusing too much fluid --Most of time pharmacy will pre-mix these

Methods of IV Medication Administration

--Continuous infusion --IV push or bolus --Intermittent infusion -----Piggyback --Volume-control infusion sets

Electronic Infusion Devices(Pump)

--Many different manufacturers of Pumps --Special tubing provided by each manufacturer --Rate is entered and read electronically -----Is entered ml/hour --Must have for fluids that need to be strictly regulated Pediatrics...

Gravity Flow Infusion

--Rate of flow is calculated manually --Calculated in gtt/min instead of ml/hour --Not as accurate!!

Infiltration

Leakage of non-vesicant IV solution or medication into the extravascular tissue.

IV Orders

Prescriber orders must specify: 1. Name of the IV solution 2. Name of the medication to be added (if any) 3. Amount (volume) to be administered 4. Time period during which the IV is to infuse

Calculating Microdrips

60 gtt/1ml Because there are 60 minutes in one hour, the number of microdrops per minute is equal to the number of ml/hr. Example: 75ml/hour = 75 microdrops/min

IV equipment

A 22-gauge catheter is appropriate for adult fluid maintenance. A 16- to 18-gauge catheter is used when administration of blood or blood products is necessary or anticipated (e.g., during surgery). A 22- to 24-gauge catheter may be necessary with an older adult, a child, or any patient with small or fragile veins A butterfly needle (scalp vein needle used with infants) is a specially designed needle for the administration of intravenous fluids, with a flat flange on each side to facilitate anchoring it after placement in a small vein.

Catheter Embolus

A piece of the IV catheter breaks off and travels through the vascular system Causes: --Reinserting a catheter used in an unsuccessful insertion --Removing and reinserting a stylet, causing shearing of the catheter

Central Lines

Advantages: --Accommodates highly irritating & hyperosmolar solutions --Easily accessible even when severely dehydrated --Medication administration for chemotherapy, antibiotics, or nutrition therapy --Useful for monitoring central venous pressure --Requires radiographic confirmation of placement

OBJECTIVES

After reviewing this, you should be able to: 1. Identify common IV (intravenous) solutions and abbreviations. 2. Calculate the amount of specific components in IV solutions. 3. Define the following terms associated with IV therapy: peripheral line, central line, primary line, secondary line, saline/heparin locks, IV piggyback (IVPB), and IV push. 4. Differentiate among various devices used to administer IV solutions such as PCA (patient-controlled anesthesia) pumps, syringe pumps, and volumetric pumps. 5. Identify best practices that prevent IV administration errors and ensure client safety 6. Identify how technology related to IV therapy can enhance client safety

Continuous Infusion

Check compatibility of IV solution and medication Assess patency of IV site Maintain sterility of IV fluids and medication Affix medication label to bag with name/dose of medication, date and time of administration and your initials or name.

Common IV Sites (NOTES) and look at pic

Common IV sites include (A) inner arm and (B) dorsal surface of the hand. Venipuncture is commonly performed in the hand and arm. Remember that the young, elderly, and frail have fragile veins. You will not insert an IV into an area that has signs of infection, infiltration, or thrombosis. Do not use hand veins on older adults or ambulatory patients. IV insertion in a foot vein is common with children, but avoid these sites in adults because of the increased risk of thrombophlebitis. Venipuncture is contraindicated in a site that has signs of infection, infiltration, or thrombosis. An infected site is red, tender, swollen, and possibly warm to the touch. Exudate may be present. Do not use an infected site because of the danger of introducing bacteria from the skin surface into the bloodstream. Avoid using an extremity with a vascular (dialysis) graft/fistula or on the same side as a mastectomy. Avoid areas of flexion if possible. Choose the most distal appropriate site. Using a distal site first allows for the use of proximal sites later if the patient needs a venipuncture site change. [Review Box 41-6 on text p. 907 Focus on Older Adults: Protection of Skin and Veins During Intravenous Therapy.] [Shown is Figure 41-15 from text p. 906.]

IV Delivery Methods

Continuous IV Infusions --Replace/maintain fluids and electrolytes --Flows continuously until changed Intermittent IV Infusions --Use IV piggy back (IVPB) or IV push (IVP) --Administer medications and supplemental fluids --Intermittent peripheral infusion devices (saline/heparin locks) maintain venous access without the need for continuous infusion

Macro drip tubing

Delivers large drops (standard drop size is 10 or 15 gtt per mL)

Micro drip tubing

Delivers small drops (standard drop size is 60 gtt/mL) For children, infants, and patients requiring close monitoring of IV fluid administration (e.g., patients with cardiac or renal disease). -Usually used with children to prevent fluid overload

Hypertonic

Have an osmolality greater than body fluids

Hypotonic

Have an osmolality less than body fluids

Isotonic

Have the same osmolality as body fluids

Heparin Locks (SAFETY ALERT)

Heparin is a high-alert medication that comes in many dosage strengths. The concentration for a heparin lock flush is 10 units per mL or 100 units per mL. The average heparin flush dosage is 10 units and never exceeds 100 units. Always check the concentration carefully.

Calculating IV Drip Rates for Gravity Flow Infusions

IV flow rates in gtt/min Determined by the type of IV tubing used The drop size is regulated by the size of the tubing The larger the tubing the larger the drops.

Initiating IV Therapy

Maintaining the system --Keeping system sterile and intact Changing intravenous fluid containers, tubing, and dressings Assisting patient with self-care activities Complications --Fluid overload, infiltration, extravasation, phlebitis, local infection, bleeding at the infusion site Discontinuing peripheral IV access

Patency of the IV needle or catheter

Means that the tip of the needle or catheter is without clots and that the catheter or needle tip is positioned away from the vein wall. -Patency allows IV fluids to run freely. -Check Patency by blood return

Intravenous Fluids (SAFETY ALERT)

Nurse is responsible for administering IVF to the correct client at the right rate and monitoring response. Too rapid an infusion or inappropriate infusions can result in reactions that range from mild to fatal!

Catheter Embolus Nursing Response

Nursing Response --Apply a tourniquet above the site --Notify the physician and radiologist --Start a new IV line

Septicemia Nursing Response

Nursing Response --Discontinue the IV infusion immediately --Consult the healthcare provider --Administer Antibiotics

Air Embolus Nursing Response

Nursing Response --Place client in Trendelenburg position on the left side --Administer oxygen --Emergency Equipment and procedures

Hypertonic Solutions

Osmolality of 375 mOsm/L or greater Initially raises the osmolality of ECF Water moves from ICF & interstitial compartments into vascular space Useful in treatment of --Hypotonic Dehydration --Temporary treatment of hypovolemia, hyponatremia and shock

Septicemia

Presence of a microorganism or their toxic by-products in the circulatory system Causes: --Break in aseptic technique --Contaminated fluids Signs/Symptoms: --Fever and chills --Tachycardia and Hypotension --Confusion --Elevated WBC count

IV Sites and Lines

Primary line --Carries main IV solution; is continuous --May have additives such as potassium or vitamins Secondary Line --Usually connected to primary (variety of systems) --Contains solutions of smaller volume with medications --Usually intermittent (IVPB)

Dimensional Analysis

Problem: Infuse D5W at 100 mL per hr What is rate in gtt/min? DF = 10 gtt/mL look at pic

Formula Method

Problem: Infuse NS at 100 mL per hr. The drop factor on tubing is 10 gtt/mL. How many gtt/min? look at formula picture

Plasma Expanders

Stay in vascular space and increase osmotic pressure Colloids (protein solutions) --Packed RBCs --Albumin --Plasma Dextran (complex synthetic sugar) --Pulls additional fluid into the intravascular space Hetastarch (Hespan) --Synthetic colloid works similarly to Dextran to expand plasma volume.

What to do when there is Infection

The patient may display the following signs and symptoms of infection: 1) Erythema of skin around IV site 2) Pain at the IV insertion site 3) Purulent drainage at the IV insertion site If the patient displays any of these signs and symptoms, discontinue the IV and notify the physician. Retain the IV catheter for possible culture to determine the presence of bacteria.

Calculating Flow Rates SAFETY ALERT

The usual rate ranges from 50-200 mL/hr. If the rate exceeds this amount, double check the order and your calculations.

Potential Contamination Sites of VADs (NOTES) and look at pic

These are some potential sites for contamination of a vascular access device. Good IV practice requires periodic updating of procedures based on current research evidence. [Shown is Figure 41-16 from text p. 908.]

Venipuncture

Venipuncture: 1) Collect a blood specimen. 2) Start an IV infusion. 3) Instill a medication. 4) Inject a radiopaque or radioactive tracer for specific diagnostic examinations.

Intravenous Therapy (NOTES)

The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances. IVs allow direct access to the vascular system, permitting continuous infusion of fluids over a period of time. To provide safe and appropriate therapy to patients who require IV fluids, you need knowledge of the correct ordered solution, the reason the solution was ordered, the equipment needed, the procedures required to initiate an infusion, how to regulate the infusion rate and maintain the system, how to identify and correct problems, and how to discontinue the infusion. [Table 41-11 on text p. 905 presents types of IV solutions.] An IV solution may be isotonic, hypotonic, or hypertonic. Isotonic solutions have the same effective osmolality as body fluids. Sodium-containing isotonic solutions such as normal saline are indicated for ECV replacement to prevent or treat ECV deficit. Hypotonic solutions have an effective osmolality less than body fluids, thus decreasing osmolality by diluting body fluids and moving water into cells. Hypertonic solutions have an effective osmolality greater than body fluids. If they are hypertonic sodium-containing solutions, they increase osmolality rapidly and pull water out of cells, causing them to shrivel. The decision to use a hypotonic or hypertonic solution is based on the patient's specific fluid and electrolyte imbalance. Additives such as potassium chloride (KCl) are common in IV solutions. A health care provider's order is necessary if an IV is to have additives added. Administer KCl carefully because hyperkalemia can cause fatal cardiac dysrhythmias. Under no circumstances should it be administered by IV push (directly through a port in IV tubing). Verify that a patient has adequate kidney function and urine output before administering an IV solution containing potassium. Patients with normal renal function who are receiving nothing by mouth should have potassium added to IV solutions. The body cannot conserve potassium, and the kidneys continue to excrete potassium even when the plasma level falls. Without potassium intake, hypokalemia develops quickly. Vascular access devices (VADs) are catheters or infusion ports designed for repeated access to the vascular system. Peripheral catheters are for short-term use (e.g., fluid restoration after surgery and short-term antibiotic administration). Devices for long-term use include central catheters and implanted ports, which empty into a central vein. Remember that the term central applies to the location of the catheter tip, not to the insertion site. Peripherally inserted central catheters (PICC lines) enter a peripheral arm vein and extend through the venous system to the superior vena cava, where they terminate. Other central lines enter a central vein such as the subclavian or jugular vein or are tunneled through subcutaneous tissue before entering a central vein. Central lines are more effective than peripheral catheters for administering large volumes of fluid, parenteral nutrition (PN), and medications or fluids that irritate veins. Proper care of central line insertion sites is critical for the prevention of catheter-related bloodstream infections (CRBSIs). The National Quality Forum (NQF) identified CRBSIs as one of their endorsed patient safety measures that health care institutions are encouraged to report. Beginning in October of 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburses over and above the typical inpatient prospective payment system rate for care required to manage and correct a CRBSI. This means that a hospital is not paid for the added costs and hospital days needed to treat it. Nurses require specialized education regarding care of central venous catheters and implanted infusion ports. Nursing responsibilities for central lines include careful monitoring, flushing to keep the line patent, and site care and dressing changes to prevent CRBSIs.

infiltration

occurs when IV fluids enter the surrounding space around the venipuncture site. This is manifested at the intravenous site as: 1) Swelling (from increased tissue fluid) 2) Pallor and coolness (caused by decreased circulation) Fluid may be flowing through the IV line at a decreased rate or may have stopped flowing. Pain may also be present. It usually results from edema and increases proportionately as the infiltration continues.

Calculating Macrodrip Rate:

Formula X gtt/min = amount of solution(ml) x drop factor time in minutes Order: 100ml D5W /hour. Tubing Available: 10gtt/ml Example: x gtt/min = 100ml x 10gtt 60 min

COMPLICATIONS of IV's: Local

-Infiltration -Extravasation -Phlebitis and post-infusion phlebitis -Thrombosis -Thrombophlebitis -Ecchymosis and hematoma -Local infection

Lactated Ringer's(LR)

-Isotonic -More similar to plasma than NS -----Has less NaCl -----Has K, Ca, lactate (metabolized to HCO3-) -Does not provide calories Clinical Uses: --Fluid and electrolyte replenisher for dehydration from nausea and vomiting, burns, wounds... --Has some incompatibilities with medications

Types of Solutions

-Solutions are classified according to how they compare to the osmolality of blood serum ---Remember that blood serum normal osmolality is 280 - 295 mOsm/kg Classified as: --Isotonic --Hypotonic --Hypertonic (look at abbreviations sheet)

Nursing Response:

-Stop the IV infusion immediately -Administer the antidote if applicable -Elevate the extremity -Apply cold compresses

IV Bolus

-small volume of medication through an existing IV infusion line or intermittent IV access site -involves introducing a concentrated dose of a medication directly into the systemic circulation. -The IV bolus, or "push," is the most dangerous method for administering medications because the medication acts immediately. -bolus may cause direct irritation to the lining of blood vessels

Discontinuing an intravenous infusion is necessary:

1) After the prescribed amount of fluid has been infused 2) When an infiltration occurs 3) If phlebitis is present 4) When an occlusion develops 5) When rotating IV catheter insertion sites (Infusion Nurses Society recommends changing peripheral IV access every 72 hours or per health care provider orders or more frequently if complications occur.) --After IV removal, the nurse may use alcohol or soap and water to remove dried blood or other drainage from around the site.

Ways you can administer medications intravenously

1) As mixtures within large volume of intravenous (IV) fluids 2) By injection of a bolus 3) By "piggyback" infusion of a solution 4) By a volume-control device 5) By electronic infusion devices (i.e., mini-infusion pump)

What to do when there is Fluid Volume Excess

1) Slow the rate of infusion. 2) Notify the physician. 3) Raise the head of the bed. 4) Monitor vital signs.

Electronic Devices

Patient-controlled analgesia ---Allows self-administration of pain medication and/or a continuous "basal" rate of medication "Smart" pumps ---Programmable pumps with safety features to help prevent med errors ---Customized software with reference library of medications ---Safe range of infusion rates

Administration of IV Fluids

Per PUMP or GRAVITY Sterile IV solution ----Injection port on bag Sterile IV administration set ---Drip chamber with specific drop size (varies) and injection spike ---Tubing with injection ports ---Roll clamp or pump adapter ---Needle adapter end for connection to cannulation device

PICC Lines

Peripherally inserted central catheters (PICC)

Order: Administer the following IVs for 24 hours: a. 1,000 mL D5W with 10 mEq KCl (potassium chloride) b. 500 mL D5NS with 1 amp MVI (multivitamin) c. 500 mL D5W

Steps: Calculate mL per hr of total volume Calculate gtt per min Reduce (look at pic)

Administering Intravenous medications Advantages & Disadvantages

Advantages: --Onset of action is quick, within seconds --Good for emergency situations --Only one needle stick even for multiple doses Disadvantages: --If adverse reactions occur, no way to stop its actions. --Risk for sepsis --Limited to highly soluble medications --Patients must have usable veins --Cost of supplies and medications

Central Venous Access

Intravenous line inserted into a major vein --Subclavian or internal jugular most often used --Catheter is advanced from insertion site into the superior vena cava

IV Solution Additives (SAFETY ALERT)

When adding potassium to an IV: --Check compatibility and dilute well --Monitor client during infusion because rapid infusion of potassium can cause DEATH --Check IV site frequently. Medication is irritating --Administer using an infusion control device --NEVER administer via IV push --DO NOT add potassium to an IV bag that is already infusing

Calculating Macrodrip Rate (cont.):

X gtt/min = 100ml x 10gtt 60 minutes 1000ml/gtt = 100/6 = 16.6 or 17 gtt/min 60 minutes

Fluid volume excess

occurs when the patient has received a too-rapid administration of IV solutions. The assessment findings include: 1) Shortness of breath 2)Crackles in the lungs 3)Tachycardia 4) Edema -Neonates, very young children, older adults, patients with severe head trauma, and patients susceptible to volume overload (those with cardiac or renal disease) must be protected from sudden increases in infusion volumes.

Problem: IV of 1,000 mL NS to infuse in 8 hr IV tubing has drop factor of 20 gtt/mL

pic

Piggyback infusion

solution containing the prescribed medication and a small volume of IV fluid through an existing IV line

COMPLICATIONS of IV's: Systemic

-Septicemia -Circulatory Overload -Allergic reaction -Catheter embolism -Air embolus

Normal Saline (NS, 0.9% NS)

--Isotonic --No calories, free water, or other electrolytes --More NaCl than ECF -------excessive administration can result in elevated Na and Cl levels. Clinical Uses --Hyponatremia --Treatment of shock --Use with blood transfusions --Fluid replacement for Diabetic Ketoacidosis --Compatible with most medications

Intermittent Infusion

--Also called "Piggy Back" or "Secondary Line" --Many medications are administered this way especially antibiotics --May be given through the port of a running line or through a saline or heparin lock --Most are supplied in bags containing 50 to 250 mL of D5W or NS --Given over period of time - usually 30-60 minutes and at regular intervals (every 6 hrs) --Small bag is the secondary bag --Attached to primary IV line for administration

Electronic Infusion Devices

--Fluids are pumped in under pressure and don't rely on gravity --Rate of flow is monitored by a sensor --Alarm will sound if rate is disrupted or altered --Alarm will sound if tubing is pinched... --See procedure, Setting up and using IV pumps in your book

Gravity Flow Infusion

--Hang above the level of the client's heart --Height of IV bag will influence the rate of flow -----The higher the IV Bag is hung, the greater the pressure, the greater the rate

Charting IV Therapy and Labeling Bags

--IV administration may be charted on special flow sheets and may include IV site assessment --IV bags must be labeled with contents, rate, and client identifiers --Rate tapes may be applied to visually cue hour and volume correlations

Intravenous Therapy

--IV therapy—fluids, blood, and blood products, nutrients, as well as medications administered via a vein --RAPID acting Replacement fluids: --Vomiting, diarrhea, nutritional imbalances, or hemorrhage Maintenance fluids: --Sustain normal levels of fluids and electrolytes Provide IV medication therapy

Calculating IV Drip Rates for Gravity Flow Infusions (cont.)

--If pumps are not available, the rate is manually regulated with flow regulator in tubing --Drops per minute is determined by the drip factor of the drop chamber below IV bag --Calibration is printed on package; NEVER assume

5% Dextrose in Water (D5W)

--Isotonic but physiologically hypotonic --Provides 50 g/L of glucose or 170 cal/L ----5 grams of Dextrose per 100mL of fluid Indications and Considerations --Provides free water only, no electrolytes --Moves into ICF --Increases renal solute excretion --Used to replace water losses, glucose, and treat hypernatremia

Calculating IV Flow Rates for Several Solutions

--May have different amounts and types ordered over an extended period --Usually for 24-hr period --Usually divided by 3 shifts Steps to calculate: 1. Add up the total amount of fluid 2. Proceed as with other IV calculations

Isotonic Solution

--Osmolality of 250 - 375mOsm/L --Remain inside the intravascular compartments --No fluid shifting occurs ------No net loss or gain from the ICF --Expands only ECF ------Ideal for pts with Hypovolemia or hypotension. --Examples: -------0.9% saline --------Lactated Ringer's solution

Administration of Medications by IV Push (SAFETY ALERT)

--Results are rapid; drugs are potent --Administer or over 1 to 5 minutes, depending on drug guidelines --Medications are diluted in various volumes --Solution compatibility is verified --Tubing is flushed --Calculate rate of push

Circulatory Overload Nursing Response

--Slow the IV flow rate --Place the patient in high fowlers position --Monitor vital signs and oxygen status --Diuretics if ordered

Volume-Control Infusion Sets

--Sometimes called Buretrol, Soluset, Volutrol, or Pediatrol. --Effectively control infusion of smaller amounts of solutions --Used particularly with pediatric patients --Decreased risk of overhydration due to amount of fluid infused in limited to amount placed in smaller container.

What to do when there is Bleeding

-Apply a pressure dressing over the site to control the bleeding. -Bleeding from a vein is usually a slow, continuous seepage and is non-life threatening. -If bleeding is the result of disconnection of the tubing, immediately cleanse the ends of the connectors with an antiseptic swab and reconnect. -Then recheck the infusion rate.

Calculating IV Drip Rates for Gravity Flow Infusions First Step:

-Find the tubing size on the package -It will be listed as drops/ml Two Most Common Used Types of Tubing: -Macrodrop Tubing --Delivers 10, 15 or 20 gtt/ml --Large drops -Microdrip Tubing --Tiny drops --Delivers 60 gtt/ ml --Used when more accurate calculation is necessary (always for Pediatric clients)

D10W

-Hypertonic -Provides 100 g/L of glucose or 340 kcal/L ----10 grams of dextrose in every 100mL -No electrolytes -Limit of dextrose concentration may be infused -peripherally ----Any fluid higher than 10% dextrose must be infused via central line to prevent shrinkage of RBCs.

Extravasation

-Infiltration of potentially necrotizing drug into the surrounding tissue -Can cause blisters, tissue sloughing and necrosis Signs/Symptoms: -Slowed or stopped IV flow -Pain, burning, and swelling at IV site -Coolness of the tissues -Blistering is a late sign

What to do when phlebitis develops

-the IV line must be discontinued and a new line inserted in another vein. -Warm, moist heat on the site of phlebitis can offer some relief to the patient. -Phlebitis can be dangerous because blood clots (thrombophlebitis) can develop in the vein and in some cases may result in emboli. This may result in permanent damage to veins as well as an extended stay in the health care agency. -Phlebitis may be prevented by the routine removal of the IV and rotation of IV sites. -The Infusion Nurses Society recommends replacing peripheral venous catheters and rotating sites at least every 72 hours.

Initiating IV Therapy (NOTES)

After placing an IV line and regulating the flow rate, maintain the IV system. The frequency and options for maintaining the system are identified in agency policies. An important component of patient care is maintaining the integrity of an IV line to prevent infection. Inserting an IV line under appropriate aseptic technique reduces the chances of contamination from the patient's skin microflora. After insertion, the conscientious use of infection control principles, including thorough hand hygiene before and after handling any part of the IV system, and maintaining sterility of the system during tubing and fluid container changes, prevents infection. Always maintain the integrity of an IV system. Never disconnect tubing because it becomes tangled, or it might seem more convenient for positioning or moving a patient or applying a gown. If a patient needs more room to maneuver, use aseptic technique to add extension tubing to an IV line. However, keep the use of extension tubing to a minimum because each connection of tubing provides an opportunity for contamination. Never let IV tubing touch the floor. IV tubing contains needleless injection ports through which syringes or other adaptors can be inserted for medication administration. Patients receiving IV therapy over several days require periodic changes of IV fluid containers. It is important to organize tasks so you can change containers rapidly before a thrombus forms in the catheter. Recommended frequency of IV tubing change depends on whether it is used for continuous or intermittent infusion. To prevent the accidental disruption of an IV system, a patient often needs assistance with hygiene, comfort measures, meals, and ambulation. Nurses monitor vigilantly for complications of IV therapy, which include fluid overload, infiltration, phlebitis, local infection, and bleeding at the infusion site. The signs and symptoms of complications often arise rapidly; this highlights the importance of frequent assessment of patients receiving IV therapy. Infiltration occurs when an IV catheter becomes dislodged, or a vein ruptures, and IV fluids inadvertently enter subcutaneous tissue around the venipuncture site. When the IV fluid contains additives that damage tissue, extravasation occurs. Phlebitis (i.e., inflammation of a vein) results from chemical, mechanical, or bacterial causes. Flood volume excess occurs when the fluid is administered too rapidly. Discontinue IV access after infusion of the prescribed amount of fluid; when infiltration, phlebitis, or local infection occurs; or if the IV catheter develops a thrombus at its tip. [See also Box 41-7 on text p. 908 Evidence-Based Practice: Preventing Complications at Peripheral Intravenous Sites; Table 41-12 on text p. 910 Complications of Intravenous Therapy with Nursing Interventions; Table 41-13 on text p. 911 Infiltration Scale; and Table 41-14 on text p. 911 Phlebitis Scale.]

Shortcut Method

All tubings in facility must have same gtt/mL throughout to prevent errors in macrodrops. Can also be used for microdrop (60 gtt/mL) IV flow rate must be expressed in mL per hr or mL per 60 min Must obtain drop factor constant For 15 gtt/mL: (look at pic)

Calculating Drops per Minute with Large Volumes of Fluid

IV fluid can be ordered in large volumes over several hours (e.g., 1,000 mL over 6 hours) Preliminary step to determine the volume per hour: (look at pic) Dimensional analysis incorporates this preliminary step in one equation

Phlebitis

Inflammation of the vein S/S 1)Pain (palpate the catheter site through the intact dressing for complaints of tenderness, pain, or burning, which could indicate phlebitis) 2) Edema 3) Erythema 4) Increased skin temperature over the vein 5) In some instances, redness travelling along the path of the vein -Dehydration may be a contributing factor because of the increase in blood viscosity.

Practice Problem:

Doctor ordered your patient to have D5W 1000 ml in 12 hours. How many ml will your patient receive per hour? 83 ml/hour How many drops/min will you calculate if using Microdrop tubing? Answer is 83 drops/min

Initiating IV Therapy

Equipment --Vascular access devices (VADs), tourniquets, clean gloves, dressings, IV fluid containers, various types of tubing, and electronic infusion devices (EIDs), also called infusion pumps

IV Push (Bolus) Medications

Injected undiluted or diluted directly into systemic circulation Follow specific guidelines for administration rate and type and amount of dilution if needed No margin for error Rapid administration of some meds can be dangerous Confirm IV catheter is in vein prior to injection Flush line before and after administering medication

Saline and Heparin Locks

Intermittent delivery devices in a vein ---Names: medlock, saline lock, heplocks Saline or heparin is injected into port regularly to prevent clotting Schedule and type are institution specific Flush after infusion of medications in site

Air Embolus

Introduction of air into the vascular system Causes: --Loose connections --Adding a new IV bag to a line that has run dry with out clearing out the tubing of air --Not priming the tubing before connecting to the patient

Hypotonic Solution

Osmolality lower than of 250mOsm/L Water moves out of blood vessel into the cells and interstitial tissue Used for: --Patients with hypertonic dehydration --Patients needing water replacement Examples: --5% dextrose (D5W) --0.45% Saline (1/2NS) --0.33% Saline --0.25% Saline

Local Infections

Related to microbial contamination of the cannula Local infections are related to: --Lack of appropriate hand hygiene --Not swabbing injection port --Catheters left in place > 72 hours --Field sticks not changed after 48 hours --Poor skin prep

Problem: Administer 0.9% NS at 100 mL/hr Drop factor = 20 gtt/mL Constant = 3

Remember: Drop factor constant is obtained by dividing 60 by drop factor of tubing (20) (look at pic)

Hypertonic Solutions require

Require frequent monitoring of BP, lung sounds, & serum Na+ levels Examples: Volume expanders (Dextran, Albumin) D10% W D5% 1/2NS D5%NS D5% LR

Over-the-Needle Catheter (NOTES) and look at pic

Shown is an over-the-needle catheter (or peripheral vascular access device) for venipuncture. VADs that are short, peripheral IV catheters are available in a variety of gauges, such as the commonly used 20 and 22 gauges. A larger gauge indicates a smaller-diameter catheter. A peripheral VAD is called an over-the-needle catheter; it consists of a small plastic tube or catheter threaded over a sharp stylet (needle). Once you have inserted the stylet and advanced the catheter into the vein, you withdraw the stylet, leaving the catheter in place. These devices have a safety mechanism that covers the sharp stylet when withdrawing it to reduce the risk of needlestick injury. Needleless systems allow you to make connections without using needles; this reduces needlestick injuries. [Shown is Figure 41-14 from text p. 906.]

Air Embolus Signs/Symptoms

Signs/Symptoms --Palpitations --Chest pain --Lightheadedness --Dyspnea --Cough --Hypotension --Tachycardia

Catheter Embolus Signs/Symptoms

Signs/Symptoms --Sharp, sudden pain at IV site --Jagged catheter end on removal --Cyanosis --Chest pain --Tachycardia and Hypotension

Infiltration

Signs/Symptoms --Slowed or stopped infusion --Swelling, tenderness, pallor, coolness at site Nursing Response --Stop the infusion --Restart the IV in a different vein --Elevate the affected arm on a pillow

Determining Amount of Medication in Specific Amount of Solution Order: Mix solution of 20 mEq KCl in 1,000 mL of NS. Administer at 2 mEq per hour.

Step 1 - Calculate number of mL needed to deliver 2 mEq of KCl from this solution (look at pic) Step 2 - Calculate rate of flow to deliver 100 mL per hour via pump or by drop factor

Initiating IV Therapy (NOTES)

•Initiation and maintenance of IV therapy require clinical decision making, skill, and organized procedures to maintain the sterility and patency of the system. Correct selection and preparation of IV equipment assist in safe and quick placement of an IV line. Because fluids infuse directly into the bloodstream, sterile technique is necessary. The main IV fluid used in a continuous infusion flows through tubing called the primary line. The primary line connects to the IV catheter. Injectable medications such as antibiotics usually are added to a small IV solution bag and "piggybacked" as a secondary set into the primary line, or as a primary intermittent infusion to be administered over a 30- to 60-minute period. The type and amount of solution are prescribed by the patient's health care provider and depend on the medication added and the patient's physiological status. After you collect the equipment at the patient's bedside, prepare to insert the IV line by assessing the patient for a venipuncture site. Venipuncture is a technique in which a vein is punctured through the skin by a sharp rigid stylet. General purposes of venipuncture are to collect a blood specimen, start an IV infusion, provide vascular access for later use, instill a medication, or inject a radiopaque or other tracer for special diagnostic examinations. Nurses require specialized knowledge and education to place peripherally inserted central catheters (PICCs). Some central lines and implanted ports require insertion by physicians or advanced practice nurses. Both types of central catheters require close monitoring and maintenance. This chapter focuses on peripheral catheters. After initiating a peripheral IV infusion and checking it for patency, regulate the rate of infusion according to the health care provider's orders. Regardless of the method used, nurses are responsible for monitoring fluid flow to prevent overinfusion or underinfusion. Electronic infusion devices (EIDs), also called IV pumps or infusion pumps, deliver an accurate hourly IV infusion rate. Nonelectronic volume control devices are used occasionally with an IV solution infused by gravity to prevent accidental infusion of a large fluid volume.