Week 7 - IV Therapy

What is the minimum height for the IV bag to be placed?

At least 90cm (36 inches) above heart level for the patient.

IV Extension Tubing

- Added to the primary tubing - Used to increase the patient's mobility, decrease manipulation and potential contamination at the insertion site, or facilitate patient changes in position.

Butterfly needle (scalp vein needle) - Uses

- Administration of IV fluids in infants - Community, palliative settings - Preventing dehydration - Pain, sedation

How often should the IV dressing be changed?

- An intact transparent dressing is routinely changed every 72 hours. - A gauze dressing is changed every 48 hours.

IV catheter gauges

- Bigger number = smaller catheter - Lengths: from 3 mm to 0.56 mm

Tourniquets

- Used to reduce venous return and cause distention in the veins where an IV catheter will be inserted. - Type of tourniquet must be determined by assessing the patient for: latex allergies, skin condition, fragility and arm diameter. - Tourniquets can be a source of contamination: single-use products are preferred.

Before changing the dressing of the IV site, what should the nurse assess for?

- When was the last dressing change. - Observe present dressing for moisture and intactness. - Observe IV system for proper functioning or complications. - IV site and signs of potential infection.

COMPLICATIONS - Bleeding

- Can occur around the venipuncture site as a result of local trauma to the vein. - Bleeding also can occur through the catheter if it becomes disconnected from the tubing. - Bleeding from a vein is usually a slow, continuous seepage and is non-life-threatening. - Response: a. Assess site b. Apply a pressure dressing over the site to control the bleeding. c. 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. d. Change dressing e. If bleeding continues, discontinue IV

COMPLICATIONS - Air in the IV tubing

- Causes: container has run dry, tubing lost connection, air not expelled from syringe when flushing. - Symptoms of air embolus: cyanosis, loss of consciousness, weak and rapid pulse, drop in BP, respiratory distress. - Prevention: always prime tubing and expel air bubbles, never let IV system dry up, monitor system continually.

Subcutaneous infusion - Hypodermoclysis

- Common uses: rehydration of elderly and palliative patients, insulin pumps. - Placed at subcutaneous injection sites, using a butterfly needle (23-25 gauge). - Insertion of needle at 30-45 degrees. - Infusion done by gravity, slowly. - Maybe be done intermittently. - Rotate sites every few days or as needed.

Catheter Gauge - 20

- Continuous or intermittent infusions - Blood transfusion

Catheter Gauge - 22

- Continuous or intermittent infusions - Children and older adult patients - Administration of blood or blood products in pediatrics and neonates

Macro Drip Tubing

- Delivers large drops: standard drop size is 10 or 15 drops per mL, depending on the manufacturer. - Used for a solution that needs to be given rapidly.

Catheter Gauge - 24-26

- Fragile veins for intermittent or continuous infusions - Administration of blood or blood products in pediatrics or neonates

COMPLICATIONS - Infiltration

- IV fluids enter the surrounding space around the venipuncture site. - Manifestations: a. Swelling (from increased tissue fluid) b. Pallor and coolness (caused by decreased circulation) - Response: a. Discontinue IV b. Elevate extremity

Sites NOT viable for venipuncture include?

- Infection - Infiltration or thrombosis - Compromised circulation - Site distal to previous venipuncture site - Sclerosed, cord-like, hardened veins - Venous valves or bifurcation - Antecubital fossa - Ventral surface of the wrist

COMPLICATIONS - Phlebitis

- Inflammation of vein related to irritation. - May be chemical: fluid/medications - May be mechanical: IV catheter material, time in place, position. - Manifestations: a. Pain (palpate the catheter site through the intact dressing for complaints of tenderness, pain, or burning, which could indicate phlebitis) b. Edema c. Erythema d. Increased skin temperature over the vein e. In some instances, redness travelling along the path of the vein - Response: a. Discontinue IV b. Apply warm, moist compress c. Monitor for signs of systemic infection such as fever

Fluid volume deficit

- Iv rate isn't enough to supply patient's needs. - Manifestations: a. Dry mucous membranes b. Sunken orbits c. Depressed fontanelles d. Concentrate urine e. Decreased output f. Hypotension g. Tachycardia i. Altered mental status

COMPLICATIONS - Extravasation

- Leakage of irritating fluids into the surrounding tissue causing tissue damage. - Manifestations: a. Pain, redness, irritation at the site. b. Possible tissue necrosis - Response: a. Stop infusion immediately b.Withdraw any fluid from IV cannula if possible then remove c. Notify physician & pharmacy immediately d. Warm or cold compress depending on drug e. Antidote depending on drug

Fluid volume overload

- Occurs when the patient has received a too-rapid administration of IV solutions. - Manifestations: a. Lung crackles b. Weight gain c. Full bounding pulses d. Shortness of breath e. Edema f. Tachycardia

IV Piggyback or secondary IV

- Routinely used for: Antibiotics, Antiemetics, Analgesia. - Medications are usually given via mini-bags - Meds are fluids or powders which require reconstitution. - Always check the MAR for instructions: rate and time of infusion, reconstitution solution, etc.

Saline Lock

- Short term access devices used to: a. Access the site for intermittent infusions. b Maintain access in case of emergency. - Flushing and locking required to maintain patency - usually ordered BID - Turbulent flow (stop/start) technique is used. - Catheter is 'locked' or clamped after flushing.

COMPLICATIONS - Infection

- Signs: a. Erythema of skin around IV site b. Pain at the IV insertion site c. Purulent drainage at the IV insertion site Response: a. Stop IV and remove catheter immediately b. Clean IV site carefully and assess for discharge c. Culture catheter tip and or wound drainage, if requested by MD d. Notify MD - may need topical &/or systemic antibiotic

WHAT TO DO IF: Infiltration as indicated by slowing of infusion, insertion site that is cool to touch, pale and painful.

- Stop infusion and discontinue IV - Elevate affected extremity - Restart new IV if continued therapy is necessary above previous location of infiltrate or opposite extremity - Document degree of infiltration and nursing intervention

WHAT TO DO IF: Phlebitis is indicated by pain and tenderness at IV site with erythema at site or along path of vein. Insertion site is warm to touch and rate of infusion may be altered.

- Stop infusion and discontinue IV - Restart new IV if continued therapy is necessary in area above previous location or opposite extremity - Place moist warm compress over area of phlebitis. - Continue to monitor site for 48 hours after catheter is removed for post-infusion phlebitis. - Document degree of phlebitis and nursing interventions per facility policy and procedure.

Catheter Gauge - 14, 16, 18

- Trauma - Surgery - Blood transfusion

Micro Drip Tubing

- Used to allow precise regulation of IV fluids, even at slow rates. - Delivers small drops: standard drop size is 60 drops/mL - Used for children, infants, and patients requiring close monitoring of IV fluid administration - Example: patients with cardiac or renal disease

IV Dressing change - Supplies (6)

1. Antiseptic swabs (2% chlorhexidine preferred or 70% alcohol, povidone-iodine) 2. Skin protectant swab 3. Adhesive remover (optional) 4. Strips of sterile, precut tape (or roll of sterile tape) 5. Clean gloves 6. Transparent dressing or sterile 5-cm x 5-cm (2-in x 2-in) gauze pads

Safety Checks before starting an IV infusion include?

1. Assess vital signs 2. Assess electrolyte balance 3. Patient's previous experiences with IV Therapy 4. Medical history and chart 5. Patient's dominant hand/side 6. Date of last IV infusion and dressing change. 7. Assess IV site for signs of phlebitis

Discontinuing IV therapy - Supplies (4)

1. Clean gloves 2. Sterile 2 × 2 or 4 × 4 gauze 3. Tape 4. Antiseptic swab

How can you prevent vein damage from administrating irritant solutions such as potassium and diazepam? (3)

1. Dilute medication, if safe for patient (renal, cardiac) 2. Infuse more slowly 3. Use larger blood vessels

Starting IV Therapy - Supplies

1. IV fluids bag 2. IV Administration set: tubing, secondary tubing. 3. IV pump 4. IV pole 5. Additional supplies if performing venipuncture: cannula, tourniquet, alcohol swabs, gloves, dressing supplies, saline lock adapter.

Which allergies are most important to assess regarding IV therapy?

1. Iodine 2. Adhesives 3. Latex Equipment used during VAD insertion may contain such substances to which patient is allergic.

Three categories of IV solutions

1. Isotonic 2. Hypotonic 3. Hypertonic

Flow through the IV system can be occluded by which factors? (4)

1. Kinked tubing 2. The patient lying on the tubing 3. The presence of a restrictive IV dressing 4. A closed roller clamp on the infusion tubing 5. IV fluids are placed lower than vein level.

Information that should be on the minibag label (IV piggyback) (6)

1. Name and room of patient 2. Name and dose of drug 3. Name of IV solution 4. Date & time medication was added 5. Added by whom: nurse signature 6. Sometimes expiry date - (how long med stable after mixed)

Infection prevention strategies for IV sites (7)

1. Perform hand hygiene before and after touching the patient; before handling an invasive device; before donning and after removing gloves; and after contact with inanimate objects near the patient. 2. Cleanse skin site before venipuncture with an appropriate single-use antiseptic solution. 3. Routine site care and dressing changes are not required on short peripheral catheters unless the dressing is soiled or not intact. 4. Chlorhexidine solution is preferred for skin antisepsis. Povidine-iodine, 70% alcohol, or tincture of iodine (1 or 2%) may also be used. Chlorhexidine is not recommended for infants under 2 months of age. 5. Use a catheter stabilization device that allows for visual inspection of the insertion site. 6. Gauze dressings may be placed under a transparent dressing but must be changed every 48 hours. 7. Primary and secondary continuous administration sets used to administer fluids other than lipid, blood, or blood products should be changed at least every 96 hours.

COMPLICATIONS - Infusing incorrect solution - Response

1. Slow rate to a minimum 2. Assess client 3. Verify orders 4. Get correct solution 5. Notify physician, if needed 6. Follow incident reporting procedure for hospital 7. Document

Fluid volume excess - Responses (4)

1. Slow the rate of infusion 2. Notify the health care provider 3. Raise the head of the bed 4. Monitor vital signs

Lactated Ringer's contains? (5)

1. Sodium 2. Potassium 3. Calcium 4. Chloride 5. Lactate

Documentation after discontinuing IV therapy should include?

1. The time the peripheral IV was discontinued 2. Site assessment information 3. Gauge and length of catheter removed 4. Condition of catheter tip to determine that it is intact (because of the risk of an embolus)

Reasons for IV Therapy

1. To replace or correct fluids and electrolytes 2. Maintain or restore fluid volume (Shock/Dehydration) 3. Route for medication administration 4. To transfuse blood or blood components 5. To provide nutritional support (TPN & Lipids) 6. Has a predictable therapeutic effect

What object can substitute a tourniquet when starting IV therapy in an older adult?

Blood pressure cuff. The tourniquet can be damaging to the skin and cause hematoma.

What type of gloves should be used for changing the IV dressing?

Clean gloves.

Which fluid volume imbalance can become a risk factor for phlebitis?

Dehydration may be a contributing factor because of the increase in blood viscosity.

Which venipuncture site is not recommended for elders and young children?

Dorsal surface of the hand. Elders: skin is too thin and sensitive Young children: high risk of bumping this site

How often should the nurse assess the IV site?

Every 1-2 hours

How often should the IV dressing be changed?

Every 48 hours or as needed if becomes soiled or wet.

How often should peripheral venous access sites be replaced to avoid complications?

Every 72 to 96 hours.

The tourniquet should be applied 25 to 30 cm (10 to 12 in) above the proposed insertion site. True or False?

False The tourniquet should be applied 10 to 15 cm (4 to 6 in) above the proposed insertion site.

As a registered nurse you are qualified to try more than two attempts at inserting an IV on any one patient. True or False?

False! A single nurse should not make more than two attempts at inserting an IV on any one patient.

The mini-bag infusion through piggyback should be hung lower than the primary bag. True or False?

False, it should be placed higher - use the hook in the secondary line kit to lower the primary bag.

The nurse should apply extra tape over the transparent dressing for protection against damage. True or False?

False. Tape should never be applied over a transparent dressing.

If the patient's IV site is saline locked, cleanse the port with alcohol, and assess the patency of the IV line by flushing it with 5 - 10 mL of sterile normal saline. True or False?

False. You should flush only 2-3 ml.

Hypertonic Solutions

Have an osmolality greater than that of body fluids and are used most often to increase extracellular fluid volume

Hypotonic Solutions

Have an osmolality less than that of body fluids and are used most often to hydrate cells.

Isotonic Solutions

Have the same osmolality as body fluids and are used most often to replace extracellular (intravascular) volume.

Dextrose 5% in 0.45% NaCl sodium chloride

Hypertonic

Dextrose 5% in 0.9% sodium chloride

Hypertonic

Dextrose 5% in lactated Ringer's

Hypertonic

Tonicity - 3% sodium chloride

Hypertonic

Tonicity - 5% sodium chloride

Hypertonic

Tonicity - Dextrose 10% in water

Hypertonic

Tonicity - Dextrose 50% in water

Hypertonic

Tonicity - 0.33% sodium chloride (one-third normal saline)

Hypotonic

Tonicity - 0.45% sodium chloride (half normal saline)

Hypotonic

Lactated Ringer's (LR)

Isotonic

Tonicity - 0.9% sodium chloride (normal saline)

Isotonic

Tonicity - Dextrose 5% in water

Isotonic

Rate Problems - Ahead or Behind Schedule Formula

Total amount that should infuse (minus) amount already infused/hours remaining in the shift

Formula for calculating infusion rate in drops/minute.

Total volume x Drip factor/ Total time (in minutes) = Rate (DROPS/MIN)

As older adults lose subcutaneous tissue, the veins lose stability and roll away from the needle. To stabilize the vein, pull the skin taut and toward you with your nondominant hand, and anchor the vein with your thumb. True or False?

True.

Phlebitis can lead to thrombophlebitis, when a thrombus forms at the site of irritation. True or False?

True.

Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments. True or False?

True. Nurse must be aware of risk for fluid overload.

Potassium chloride should never be given by IV push or added to a small volume of IV solution. A direct IV infusion of KCl can cause cardiac arrest and may be fatal. True or False?

True. Potassium chloride is administered orally or as a premixed IV additive by the pharmacy or the manufacturer in a larger volume of IV fluids.

What MUST be checked before starting an IV infusion of POTASSIUM chloride?

Verify that the patient has adequate renal perfusion (i.e., at least 30 mL/hr urine output for adults) before administering IV fluids containing potassium chloride.

Which site should the nurse choose? a. The most distal site in the nondominant arm b. An area that is already painful in order to minimize pain locations c. The foot because veins in the foot are easily visible d. The side of paralysis as the patient will be unable to feel the pain of catheter insertion

a. The most distal site in the nondominant arm Place at the most distal site when possible. Using a distal site allows for the use of proximal sites later if the patient needs a venipuncture site change. Using the nondominant arm facilitates mobility.

Your patient has a continuous infusion of 0.45% normal saline at a keep-vein-open rate of 25 mL per hour. The patient is also receiving intermittent IV piggyback infusions of antibiotics. A 1000 mL bag of 0.45% normal saline is opened and hung at 0700 hours. When will a new bag of 0.45% normal saline need to be hung? a. 2300 hours the next day b. 0700 hours the next day c. 0700 hours three days from now d. 1400 hours the next day

b. 0700 hours the next day The Infusion Nurses Society (INS) recommends changing a fluid container within 24 hours after adding a medication or an administration set (INS, 2011). In this case, a secondary set was added for the infusion of antibiotics, and therefore the primary bag should be changed in 24 hours.

A nurse is prioritizing tasks in caring for a group of patients. Who should the nurse see first? a. The patient whose IV has infiltrated and requires IV access for intermittent antibiotics; due in two hours b. The patient whose EID was turned off because it kept alarming when the IV fluid ran dry c. A patient who needs assistance getting up to the bathroom because he has an IV d. A patient with a continuous infusion who has tubing that is dated two days ago

b. The patient whose EID was turned off because it kept alarming when the IV fluid ran dry The priority is to go to the patient whose IV is dry in order to hang a new bag so that it does not occlude due to clot.

A 40-year-old patient will have an IV started preoperatively. Which catheter would be most appropriate for this patient? a. 22-gauge b. Butterfly needle c. 16- to 18-gauge d. 24- to 26-gauge

c. 16- to 18-gauge A patient who requires surgery should be prepared with a catheter large enough (i.e., 16- to 18-gauge) to allow bolus IV fluids at a rapid rate or that can be used if transfusion of blood products becomes necessary.

The UCP comes to you stating that the patient's bag of IV fluids is empty. You checked on it 30 minutes ago, and there was 300 mL left in the bag at that time. The ordered rate of infusion is 100 mL per hour. What action should you take? a. Hang a new bag of fluids and correct the rate to flow at 100 mL per hour. b. Hang a new bag of fluids and keep the rate at a keep-vein-open (KVO) rate for the next 3 hours. c. Assess your patient, hang a new bag of fluids, and keep the rate at a keep-vein-open (KVO) rate and notify the health care provider. d. Instruct the UCP to obtain an electronic infusion pump and set the rate at 100 mL per hour.

c. Assess your patient, hang a new bag of fluids, and keep the rate at a keep-vein-open (KVO) rate and notify the health care provider. The rate of infusion is in error of approximately 250 mL. The patient should be assessed for fluid volume excess (e.g., shortness of breath, tachycardia, confusion) and the health care provider notified.

How often is it recommended that continuous IV infusion tubing be changed? a. Every 24 hours b. Every 48 hours c. Every 96 hours d. Whenever the bag of IV fluids is changed

c. Every 96 hours This will help reduce the risk of infection. Tubing used for intermittent infusion through an injection or access port should be changed every 24 hours because both ends of the tubing are manipulated more frequently than tubing used for continuous infusion.

The order states the IV fluids should infuse at a rate of 50 millilitres per hour. Four hours after hanging a bag of 1000 millilitres, the nurse determines that 600 millilitres are left in the bag. What should the nurse do? a. Nothing, as the fluids are infusing according to the prescribed rate. b. Recalculate the rate of IV fluids for the remaining time of the infusion. c. Slow the IV infusion and notify the health care provider. d. Discontinue the IV infusion.

c. Slow the IV infusion and notify the health care provider. Fifty millilitres per hour should have infused over 4 hours, for a total of 200 mL. In the example, 400 mL had infused (1000 mL minus 600 mL). The nurse should slow the infusion rate to KVO and notify the health care provider immediately.

The nurse is caring for a patient with a diagnosis of heart failure. With which of the following IV solutions should the nurse monitor this patient most closely? a. Normal saline b. D5W c. 0.45% sodium chloride d. D51/2NS e. LR

d. D51/2NS A hypertonic IV solution (e.g. D5 ½ NS) pulls fluid into the vascular space by osmosis, resulting in an increased vascular volume that will possibly result in pulmonary edema. This is common in high-risk patients with cardiac (e.g., heart failure) or renal disease.

Why should the nurse observe the catheter after removing it from the patient? a. To determine if there are signs of infection, such as exudate on the tip b. To note if there is clot formation at the tip c. To identify the gauge of the catheter for documentation purposes d. To ensure that the catheter tip is intact

d. To ensure that the catheter tip is intact The tip of the catheter can break off, causing an embolus, and emergency situation. The health care provider should be notified if the tip is broken.