ATI Module (IV Therapy)

At the distal end of the tubing is the male adapter that is connected to the hub of the IV catheter. To keep the connection intact, most IV tubing has a

"locking collar" that slips over the connection and screws into place.

Usually referred to as the primary tubing, this long piece of tubing has several components attached:

-the spike, -the drip chamber, -the roller clamp, -the syringe tip & locking collar -medication ports

Infiltration Scale

0 = No symptoms 1 = Skin blanched; 2 = Edema < 1" in any direction; cool to touch; with or without pain 3 = Skin blanched, translucent; gross edema >6 inches in any direction; cool to touch; mild to moderate pain; possible numbness 4 = Skin blanched, translucent; skin tight, leaking; skin discolored, bruised, swollen; gross edema >6 inches in any direction; deep pitting tissue edema; circulatory impairment; moderate to severe pain; infiltration of any amount of blood product, irritant, or vesicant

Phlebitis Scale

0: no symptoms; 1: Access site w/ erythema, possible pain; 2: pain at access site w/erythema and/or edma; 3: pain at access site with erythema and/or edema; streak formation, palpable venous cord; 4: pain at access site w/erythema and/or edema, streak formation, palpable cord more than 1 inch long, purulent drainage

When initiating IV therapy in pediatric patients, use the smallest catheter available, usually a

22- to 26-gauge.

For most adults, a 20- to 22-gauge catheter is adequate for infusing fluids and medication.

A 22- to 24-gauge catheter is best for children, older adults, and anyone who has small or fragile veins.

If your patient will not have a continuous infusion, initiate a saline lock.

A saline lock consists of an IV catheter and a short piece of extension tubing.

The product most often used to clean the site prior to initiating IV access is chlorhexidine 2%. Allow it to air-dry completely to reduce the microbial count effectively at the insertion site.

After the site is dry, avoid touching it with your finger because you could transfer micro-organisms from your glove to the clean area. If you touch the site after you clean it, clean it again.

Avoid using veins in an extremity with compromised circulation and those that are distal to previous IV sites.

Also avoid sclerosed or hardened veins, bruised areas, and areas where there are valves or bifurcations.

Over-the-needle catheters (ONCs) with built-in safety devices are the type of catheter most often used for initiating IV therapy.

An ONC consists of a metal stylet, or needle, that pierces the skin and a flexible catheter, usually made of silicone or Teflon, that is threaded into the vein.

Because hypertonic solutions can be extremely irritating to the patient's veins, some must only be infused through a central line.

Before initiating a hypertonic solution, be sure to check your facility's policy to determine the appropriate intravenous route.

If your patient will receive a continuous infusion, you'll also need the prescribed bag of fluid and an infusion set (tubing).

Before starting the infusion, spike the bag of fluid and prime the tubing

Solutions with a greater osmolarity than body fluids are considered hypertonic. Hypertonic solutions are infused to treat patients who have severe hyponatremia.

Depending on the type of hypertonic fluid infused, it can provide patients with calories, free water, and some electrolytes. Examples of hypertonic solutions are dextrose 10% in water (D10W), dextrose 5% in 0.9% sodium chloride (D5NS), and 3% sodium chloride.

When securing the catheter, place the tape only over the hub and not over the insertion site. For easy assessment, keep the insertion site visible

Do not wrap the tape around the patient's arm either, since this can impair circulation if the arm swells.

Patients receiving intravenous (IV) therapy require frequent assessment of the IV site.

Each time you inspect the site, check the solution, tubing, and flow rate as well.

Specially designed securement devices produced by a variety of manufacturers are designed to create a bridge or compartment over the catheter hub.

Evidence indicates that this type of device has significant advantages over traditional practices.

Extension tubing is a short piece of IV tubing that has a male adapter at one end and a female adapter at the other.

Extension tubing is typically added to the primary tubing to lengthen it, thus allowing the patient greater mobility.

Glass bottles are used primarily for infusing substances that are unstable in plastic bags.

For fluids to flow out of a glass bottle, there must be a mechanism that allows air to enter the bottle. This is usually accomplished by incorporating a vent into the drip chamber of the tubing.

These solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can result in pulmonary edema, particularly in patients who have cardiac or renal disease.

Hypertonic solutions

Additives such as vitamins and electrolytes are often infused along with an IV solution. Most IV fluids are manufactured with the additives already included to avoid contamination of the fluid and to prevent errors.

If an IV solution is not available with the prescribed additives already included, they should be added in the pharmacy department under a laminar flow hood.

In addition to inspecting the intravenous catheter, assess the IV site for signs of infection, which include pain, redness, swelling, and drainage. If the site appears to be infected, notify the provider immediately.

If cultures are ordered, obtain a specimen for culture from the insertion site. Also, with sterile scissors, cut off the tip of the IV catheter and place it in a sterile container. Send both to the laboratory for culture.

A peripherally inserted venous catheter is usually replaced every 72 to 96 hours or per your agency's policy.

If the IV was initiated outside of the hospital setting or in an emergency situation and there is any question about sterility during the initiation, it is best to remove the catheter and start a new IV line.

When the secondary infusion is complete, the primary infusion resumes.

If the primary infusion's rate differs from that of the secondary infusion, remember to adjust the rate as soon as possible after the secondary infusion is complete.

Because the names of IV solutions are often abbreviated or shortened, it is important to become familiar with the names of the different solutions.

If you are uncertain about a solution, consult an intravenous therapy drug guide or a pharmacist before initiating the infusion.

If your patient will receive subsequent doses of the secondary infusion, leave the bag and tubing hanging.

It can be used for 72 to 96 hours, depending on your facility's policy.

Infiltration is leakage of intravenous solution or medication (non-vesicant) into the extravascular tissue. Infiltration results when the IV catheter is dislodged and fluid infuses into the tissue.

It is characterized by edema, pallor, decreased skin temperature around the site, and pain.

Circulatory overload is a systemic complication of IV therapy that causes excess fluid in the circulatory system. The characteristics of circulatory overload include dyspnea, elevated blood pressure, edema in dependent areas, and moist breath sounds when auscultating the lungs.

It is imperative to complete a baseline assessment prior to initiating IV fluids and to monitor for fluid excess throughout administration of IV fluids.

Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area.

It is important to monitor the IV site every hour for redness and tenderness to prevent this from occurring.

A vein illumination device may be available to assist with locating veins.

It provides a pattern of light on the patient's skin to reveal the position of underlying veins on the skin's surface.

To minimize pain during the IV therapy procedure for pediatric patients, use a topical anesthetic such as

LMX (lidocaine) or EMLA (eutectic mixture of lidocaine and prilocaine) cream to numb the site.

Isotonic solutions have the same effective osmolality as body fluids. This type of solution is infused to replace fluid losses, usually extracellular losses, and to expand the intravascular volume.

Most isotonic solutions do not provide calories or free water. Examples of isotonic solutions are 0.9% sodium chloride, commonly called normal saline (NS), and lactated Ringer's (LR).

When you begin your assessment of an IV site, start by inspecting it for any redness, swelling, streaking, or drainage.

Next, palpate the area around the site and along the vein for any pain, firmness, swelling, or blanching. While palpating, be sure to note the skin temperature near the site and along the vein, especially if you note any redness.

To help keep your pediatric patient properly positioned and the extremity immobilized, ask another nurse to help you

Or, if the parents are available and willing, ask them to help with positioning and immobilizing the extremity.

If the patient has fragile skin or a tourniquet is not available, blood-pressure cuff instead.

Place the cuff on the patient's upper arm and inflate it to just below the patient's normal diastolic pressure. Once you inflate it, keep it inflated until after you have inserted the IV catheter.

To initiate IV access, place the patient's extremity in a dependent position and apply a tourniquet around the arm to distend the veins.

Place the tourniquet above the antecubital fossa or approximately 4 to 6 inches (10 to 15 centimeters) above the anticipated site.

Apply a transparent dressing to protect the IV site from contamination while still allowing visibility.

Position the dressing over the vein so that it extends to the lip of the hub of the catheter. Leave the connection between the catheter hub and the IV tubing uncovered to facilitate changing the tubing.

Infection at the site is characterized by redness, swelling, and warmth to touch. There could also be purulent drainage.

Protocol requires discontinuing the IV line, expressing drainage if present, and sending the catheter tip for culture. It is imperative to use aseptic technique when initiating and managing an IV line to help prevent infection at the site.

All IV fluids must be administered carefully, but hypertonic solutions are particularly

RISKY

________________________are also administered with an IV pump.

Secondary infusions

In addition to the IV catheter, you will also need: -a tourniquet or a blood-pressure cuff, -an antimicrobial wipe, -several small gauze pads, -tape, -a transparent dressing, -gloves.

Some facilities provide all the necessary supplies in an "IV start kit." If your facility does not use these kits, gather all these supplies before initiating IV access

Basic IV extension tubing is available in various lengths and from a variety of manufacturers.

Specialized extension sets might include filters, access ports, and control devices such as stopcocks, roller clamps, and slide clamps

When removing an intravenous catheter, first move the roller clamp on the tubing to the closed position to avoid spilling IV fluid. If you anticipate excessive bleeding, you may want to place a bed protector or linen saver under the site to protest the bedding.

Then, stabilizing the catheter at all times, pull the transparent dressing and tape toward the insertion site to avoid injuring the vein. Do not apply pressure over the intravenous catheter when removing it, as this can be painful for the patient.

Since most IV fluids are available in plastic bags that collapse as the fluid infuses, vented tubing is unnecessary.

Therefore, some primary tubing is designed without a vent.

Intravenous (IV) fluids are infused to maintain fluid balance, replace fluid losses, and treat electrolyte imbalances.

They are commonly available in volumes ranging from 25 mL to 1,000 mL and are dispensed in either plastic bags or glass bottles.

If you are using a glass bottle, be sure to use tubing with an air vent above the drip chamber.

This allows air to enter the bottle and the fluid to infuse.

Another complication of IV therapy is extravasation.

This term is sometimes used interchangeably with infiltration but more accurately describes a situation when an IV catheter becomes dislodged and medication infuses into the tissues.

An example of a hypotonic solution is 0.45% sodium chloride (0.45% NS), commonly called half normal saline.

This type of solution provides free water, sodium, and chloride but does not provide calories or other electrolytes

All patients with IV access are at risk for developing IV-related complications, such as -skin infection, -phlebitis, -infiltration, -and circulatory overload.

Those receiving hypertonic, acidic, or irritating fluids or medications; patients with fragile veins; and pediatric patients, however, are at higher risk and require especially frequent assessment.

Once you have removed the catheter, inspect the catheter tip to be sure that it is intact. If it is not intact, notify the provider immediately. A catheter that broke off in the vein has the potential to cause an embolus.

To limit the movement of the embolus, apply a tourniquet high on the extremity where the IV line was located and follow your facility's policy for further intervention.

When using the piggyback setup, leave both the primary and the secondary lines open.

To regulate the flow rate of the secondary infusion, open the roller clamp on the secondary tubing completely and use the roller clamp on the primary tubing to adjust the flow rate.

When selecting an IV site for older adults, try to avoid the veins in the hand and the dominant arm since these sites can make it difficult for an older patient to perform activities of daily living. Use a smaller catheter, such as a 22-gauge.

To secure the catheter, use minimal tape to avoid irritating or traumatizing the skin. If possible, use a mesh dressing instead. If your patient is restless or confused, use an arm board or a commercially available protective device to protect the IV site.

Again, the degree of infiltration is often documented using a scale that ranges from 0 for no symptoms to 4, the most severe.

Use the most severe presenting symptom to determine the degree of infiltration.

The degree of phlebitis is often documented using a scale that ranges from 0 for no symptoms to 4, the most severe.

When determining the degree of phlebitis, use the most severe symptom.

Older patients' skin tends to be thinner and their veins more fragile and superficial with a tendency to roll. To avoid bruising or tearing the skin, use a tourniquet sparingly.

When inserting the catheter, be sure to pull the skin below the insertion site taut to stabilize the vein. Also, use a lower angle of insertion to avoid puncturing the posterior wall of the vein.

It is a good practice to assess and document the condition of the IV site, solution, tubing, and flow rate at the beginning of your shift, to establish a baseline at that point in time.

You can then compare your ongoing assessments throughout your shift and at the end of your shift to what you assessed at that initial point.

After connecting the secondary tubing to the primary tubing, using aseptic technique,

allow the primary fluid to prime the secondary tubing by opening the primary and secondary tubing and allowing the fluid in the primary bag to flush the secondary tubing. This helps to decrease loss of medication in the secondary infusion.

One way of priming secondary tubing is to use a

backflow method.

Once intravenous (IV) therapy is initiated, it is important to secure the IV catheter to keep it from

becoming dislodged or moving around in the vein and causing trauma.

The product most often used to clean the site prior to initiating IV access is

chlorhexidine 2%.

If the patient has excessive body hair, do not shave the area; instead,

clip the hair with scissors. Shaving can cause microabrasions that increase the risk for infection.

Extravasation is characterized by pain, stinging, burning, swelling, or redness at the site. This complication can be quite serious since vesicants can cause severe tissue damage. Follow your agency's policy for treatment, which will likely include

discontinuing the IV line and applying a cool compress to the area. If the medication has an antidote, it should be prescribed and administered immediately. The degree of extravasation is usually documented using the same scale that is used for determining the degree of infiltration.

Consult your agency's policy for treatment of infiltration, which involves

discontinuing the IV line and elevating the extremity. --It may also recommend applying a warm compress at the site to help absorb the fluid.

Discontinuing a peripheral intravenous (IV) line is a relatively quick and simple procedure. Before you remove an intravenous catheter, however, be sure to

double-check the order to make sure that the IV infusion is to be discontinued. When you remove the catheter, follow infection-control guidelines to reduce the risk of infection at the site.

Distributed by a variety of manufacturers, primary IV infusion sets are available with

either micro- or macrodrip tubing and may also have inline filters, stopcocks, access ports, and shutoff clamps.

Hypotonic solutions have an effective osmolality less than body fluids and are administered to

expand the intracellular space. --They are commonly infused to dilute extracellular fluid and rehydrate the cells of patients who have hypertonic fluid imbalances and to treat gastric fluid loss and dehydration from excessive diuresis.

Since fluids do not infuse continuously through a saline lock to maintain patency of the IV line, you must

flush the lock usually with normal saline, 1 to 3 mL, before and after you administer each medication or at regular intervals.

If you are having problems finding a well-dilated vein, you can try

gently stroking the extremity below the intended IV site from distal to proximal or place a warm blanket or towel on the extremity for a couple of minutes. Avoid rubbing the extremity vigorously or flicking the vein as this can cause the vein to constrict or a hematoma to form.

To keep air from entering the tubing and being infused, be sure the drip chamber is at least

half full.... Gently squeezing the chamber two or three times helps accomplish this.

When inspecting the patient's hand and arm for an IV site, begin by

looking at the most distal part and move proximally.

When setting the flow rate, it is often helpful to

move the roller clamp closer to the drip chamber, as this makes it easier to reach the roller clamp and adjust the flow rate while counting the drops in the drip chamber.

If the patient is critically ill or requires long-term IV therapy, the provider typically considers a

peripherally inserted central catheter (PICC).

To protect the patient's skin,

place a small gauze pad under the hub of the IV catheter to elevate it and keep it from exerting pressure on the patient's skin. Replace the gauze pad if it becomes wet or soiled.

If the patient has fragile skin or excessive hair,

place the tourniquet over the sleeve of the gown to protect the skin and avoid pulling the hair.

Once you have found a vein, make sure that

placing the IV catheter in that location will not interfere with any planned procedures or with the patient's ability to perform activities of daily living.

In many situations, a pharmacist will add any prescribed medications, vitamins, or electrolytes to the IV fluid, but if you are adding any of these, be sure to

put a label on the bag indicating: -what you added -amount added, -date, and time, -your initials or signature -any other information your facility's policy requires. Also, put a piece of time tape on the bag to help you monitor the flow rate.

Educate the patient to report changes at the site such as,

redness, swelling, pain, tightness of skin, coolness of skin, burning, fluid leaking, or drainage.

In addition to the usual sites you'd use for initiating IV therapy in adults, you can also use infants'

scalp and foot veins.

Along the tubing are several access ports to use for administering medications. Since most facilities use needleless systems, you'll most likely use

secondary tubing or syringes that screw into the port to access the tubing.

With a piggyback setup, you'll hang the smaller bag of fluid, the secondary infusion, higher than

the larger bag of fluid, the primary infusion. To do this, use the plastic hook, or extension hanger, that is packaged with the secondary tubing

When the roller is at the wider top end of the device, it is open,

thus allowing fluid to move freely through the tubing.

If the patient will receive large quantities of fluids at a rapid rate or blood or blood products,

use a larger catheter, such as an 18-gauge.

If an infusion device is not available,

use a piggyback setup to infuse the secondary bag of fluid or medication.

Only use medications in the secondary infusion that are compatible with

with the primary fluids