IV therapy ATI

What is found below the spike?

-Below the spike is the drip chamber, a clear plastic reservoir that allows you to monitor the flow rate by counting the drops dripping into the chamber. -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. 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. 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.

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. -

How to secure IV catheter?

1. Apply a transparent dressing to protect the IV site from contamination while still allowing visibility. 2. 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. 3. 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. 4. 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. 5. Replace the gauze pad if it becomes wet or soiled. 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.

One way of priming secondary tubing is to use a backflow method.

1. Only use medications in the secondary infusion that are compatible with the primary fluids. 2. 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. 3. This helps to decrease loss of medication in the secondary infusion.

Follow your agency's policy for treatment, which will likely include

1. 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.

It is commonly treated by

1. 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. 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

The characteristics of circulatory overload include

1. dyspnea, 2. elevated blood pressure 3. edema in dependent areas, and moist breath sounds when auscultating the lungs.

Apply a transparent dressing to protect the IV site

1. from contamination while still allowing visibility. 2 Position the dressing over the vein so that it extends to the lip of the hub of the catheter. 3. Leave the connection between the catheter hub and the IV tubing uncovered to facilitate changing the tubing. 4.When securing the catheter, place the tape only over the hub and not over the insertion site.

Once you have removed the catheter,

1. inspect the catheter's tip to be sure that it is intact. If it is not intact, notify the provider immediately. 2. 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.

Once intravenous (IV) therapy is initiated,

1. it is important to secure the IV catheter to keep it from becoming dislodged or moving around in the vein and causing trauma. 2. Since techniques for securing an IV catheter can differ, it is important to familiarize yourself with the technique used at your facility and to use it each time you initiate IV therapy.

For easy assessment

1. keep the insertion site visible. 2. Do not wrap the tape around the patient's arm either, since this can impair circulation if the arm swells.

When using the piggyback setup,

1. 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 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.

After you've completed your calculations and before you start the infusion, it is important to

1. mark the bag of fluids with adhesive tape or a commercial time tape next to the volume markings on the bag. 2. Time taping the IV bag helps you check at a glance that the fluids are infusing over the correct period of time. 3. When using an infusion pump the time tape provides an additional check to identify that the correct amount of IV fluid has infused.

Once an intravenous infusion is initiated,

1. monitor the infusion closely to ensure that it is infusing at the correct rate. 2. Check the IV site for signs of infiltration and inflammation. How often you must check varies with the facility, so be sure to become familiar with your facility's policies and follow them consistently each time you are caring for a patient who is receiving an IV infusion.

To protect the patient's skin,

1. 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. 2. Replace the gauze pad if it becomes wet or soiled. 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.

How to initiate IV acess?

1. place the patient's extremity in a dependent position and apply a tourniquet around the arm to distend the veins 2. Place the tourniquet above the antecubital fossa or approximately 4 to 6 inches (10 to 15 centimeters) above the anticipated site. 3. To secure the tourniquet, overlap the ends and then stretch them in opposite direction 4. Next, tuck the top end under the bottom end. The tourniquet should be snug, but not too tight as this can injure or bruise the patient's arm. 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. 5.

All patients with IV access are at risk for developing IV-related complications,

1. skin infection, 2. phlebitis 3. infiltration, and circulatory overload. T hose 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.

When you begin your assessment of an IV site,

1. start by inspecting it for any redness, swelling, streaking, or drainage. 2. Next, palpate the area around the site and along the vein for any pain, firmness, swelling, or blanching. 3. While palpating, be sure to note the skin temperature near the site and along the vein, especially if you note any redness. 4. 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.

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

1. 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. 2. Avoid rubbing the extremity vigorously or flicking the vein as this can cause the vein to constrict or a hematoma to form. 3. Avoid using veins in an extremity with compromised circulation and those that are distal to previous IV sites. 4. Also avoid sclerosed or hardened veins, bruised areas, and areas where there are valves or bifurcations. 5. 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.

How often you assess an IV site often depends on what is being infused

1. your patient's age, and your agency's policy. In addition to inspecting the site as required, it is also 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.

Macrodrip tubing varies with the manufacturer but usually delivers between

10 gtt/mL and 15 gtt/mL. It is used to infuse large volumes or to infuse fluids quickly.

The provider has ordered amiodarone (Cordarone) 300 mg in 100 mL to be infused over 30 min. Determine how many mL/hr to set the IV pump to deliver.

200 ml/hour

The provider has ordered 1,000 mL 0.9% sodium chloride to infuse over 8 hr. You have a macrodrip tubing with a drop factor of 15 gtt/mL available. Calculate how many gtt/min to set as the IV flow rate.

31 gtt/min

The provider has ordered ranitidine (Zantac) 50 mg in 100 mL 0.9% sodium chloride intravenous piggyback to be infused over 20 min. You have a macrodrip tubing with a drop factor of 10 gtt/mL. Calculate how many gtt/min to set as the IV flow rate.

50 gtt/min

Microdrip tubing universally delivers

60 gtt/mL. It is used for infusing small or very precise amounts of fluids.

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.

The provider has ordered 600 mL of 5% dextrose in water to infuse over 8 hr. Determine how many mL/hr to set the IV pump to deliver.

75 ml/hour

Degree of infiltration

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.

IV therapy extension

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. 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.

Circulatory Overload

Circulatory overload is a systemic complication of IV therapy that causes excess fluid in the circulatory system.

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.

Intervention:

Extravasation is an emergent situation, as it can cause serious tissue necrosis. Stop the IV infusion and discontinue the IV line. Consult your agency's policy or a pharmacist for specific care of the extravasated tissue or use a medication manual to determine the appropriate care (for example, injection of phentolamine within the extravasation border). Follow your agency's policy for proper documentation. Establish new IV access in the opposite extremity if IV therapy must continue.

Infection

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

infiltration

Infiltration is leakage of intravenous solution or medication (non-vesicant) into the extravascular tissue.

When does infiltration happens

Infiltration results when the IV catheter is dislodged and fluid infuses into the tissue. Consult your agency's policy for treatment, 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.

IV therapy Primary

Intravenous (IV) fluids are infused through flexible, plastic tubing (often called an infusion set) connected to the bag of fluid at one end and to the hub of the intravenous catheter (or to extension tubing) at the other end.

Infiltration is characterized by

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

Assessment of infiltration:

Leaking from the IV site with slowing or occlusion of fluid flow. The patient reports blanching, burning, tenderness, discomfort, and coolness in the area surrounding the IV insertion site. May also experience fluid leaking from the puncture site.

Prevention:

Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. If central access is available, infuse solutions and medications known to cause tissue necrosis via central venous access. Educate the patient about activities and signs and symptoms of infiltration.

Phlebitis

Phlebitis is characterized by pain, increased skin temperature, and redness along the vein

Prevention

Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. Educate the patient about activities and signs and symptoms of infiltration.

Questionable reconstitution

Problem: Reconstituting a medication results in cloudiness, discoloration, or precipitation of the diluent. Possible cause: The wrong diluent was selected for reconstitution. It is also possible that the visible change is appropriate for that medication. Intervention: Never inject a questionable IV medication. If the medication has been reconstituted improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper diluent for a medication. Review the package insert or consult a pharmacist to verify the expected appearance of the reconstituted medication.

Questionable solutions

Problem: The IV fluid in the bag or a pre-mixed medication solution appears cloudy or discolored or has visible precipitate. Possible cause: The solution may be expired or contaminated or might have been stored improperly (exposed to temperature extremes). Intervention: Never administer questionable IV fluids. Discard or return questionable or expired solutions according to your agency's policy. Prevention: Review the package insert or consult a pharmacist to verify the expected appearance of the medication. Always store IV fluids and pre-mixed medication solutions according to the manufacturer's or the pharmacy's guidelines. Remove from stock and dispose of any IV bags that have expired or are not in their original, sealed packaging.

Drug/fluid incompatibility

Problem: The IV fluid or solution appears cloudy or has visible precipitate after medication has been added. Possible cause: Incompatibility of the drug to the solution or the drug-to-drug mix Intervention: Never administer questionable IV medications or compounded solutions. If the medication has been mixed improperly, discard it or return it to the pharmacy according to your agency's policy. Prevention: Always follow the manufacturer's or the pharmacy's guidelines for selecting the proper solution for piggyback and large-volume medication infusions. Always check and cross-reference medication compatibilities. If your agency's policy permits multiple uses of one secondary line, make sure the current and previous solutions and medications are compatible. Otherwise, set up separate secondary lines and flush between medications.

Interrupted IV infusion

Problem: The line or pump occlusion alarm sounds. Possible causes: The IV line is not patent, the IV is in a location that occludes when the patient changes position, the tubing is kinked, the IV loop or line is clamped, the roller clamp is in the off position, or the pump was loaded improperly. Intervention: Begin at the patient, correcting each problem: Check for IV patency, tubing patency, and position; open all occluding clamps; and check the infusion pump settings and setup. If the location of the IV causes flow occlusion when the patient moves, consider restarting the IV line at another site.

Infiltration

Problem: The tissue surrounding the IV insertion site is swollen, pale, and cool to the touch. Possible cause: Unintentional administration of solution or medication into the surrounding tissue Assessment: Leaking from the IV site with slowing or occlusion of fluid flow. The patient reports blanching, burning, tenderness, discomfort, and coolness in the area surrounding the IV insertion site. May also experience fluid leaking from the puncture site. Intervention: Stop the IV infusion and discontinue the IV line. Elevate the extremity. Warm or cold compresses may be used according to the solution infiltrated and the facility policy. Encourage active range of motion, and follow your agency's policy for site care and documentation of infiltrated IVs. Establish new IV access proximal to the original site or in the opposite extremity if IV therapy must continue. Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Avoid placing restraints at the IV site. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. Educate the patient about activities and signs and symptoms of infiltration.

Medication error potential

Problem: The wrong dose was prepared. Intervention: Discard the prepared dose and prepare a new dose correctly. Check your agency's policy for waste procedures and documentation and for crediting the patient's pharmacy account. Prevention: Adhering to the six rights of medication administration is essential for preventing medication errors.

Precipitation during administration s

Problem: While administering an IV bolus (push) medication, cloudiness or precipitation forms in the tubing. Possible cause: The line was not flushed properly with normal saline prior to injecting an incompatible medication. Intervention: Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. Follow your agency's protocol for wasting and crediting medication and prepare another dose to administer. Observe the site for signs of venous irritation. Prevention: Follow proper technique for flushing the IV line with normal saline before and after injecting IV medications. Questionable solution

Infection protocol

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.

Veins used to initiate IV therapy?

The cephalic, basilic, and median cubital veins in the hand and forearm are the veins most often used for initiating intravenous (IV) therapy. This is because they are larger, easier to puncture, and less likely to rupture than the other veins in the hand and arm are. Cephalic- vein on the thumb side, Basilic - vein on the opposite of thumb

What is the drop or drip factor ?

The drop factor, also called the drip factor, is the calibration or number of drops per mL of solution delivered for a particular drip chamber. Always check the tubing package to be sure.

Assessment:

The pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation and could ultimately become necrosed. Blistering and tissue sloughing may not appear for a few days.

Extravasation Problem:

The tissue around the IV site is pale or discolored and cool to the touch. Possible cause: Inadvertent administration of an irritant solution or medication into the surrounding tissue. Vasoconstrictors, calcium, and chemotherapy drugs are examples of drugs known to cause tissue necrosis with extravasation. The area of tissue damage varies with the concentration of the medication, the quantity of extravasated fluid, and the duration of the extravasation process.

What is the problem with infiltration ?

The tissue surrounding the IV insertion site is swollen, pale, and cool to the touch.

Pediatric Patient -Initiating intravenous therapy for pediatric patients can be challenging. Not only are children's veins much smaller and more fragile than those of adults, but it is sometimes more difficult to keep children still during the procedure.

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. - To minimize pain during the procedure, use a topical anesthetic such as LMX (lidocaine) or EMLA (eutectic mixture of lidocaine and prilocaine) cream to numb the site. -In addition to the usual sites you'd use for initiating IV therapy in adults, you can also use infants' scalp and foot veins. -When initiating IV therapy in pediatric patients, use the smallest catheter available, usually a 22- to 26-gauge. -------Because infants and children are not always able to protect an IV site, be sure to secure the catheter and tubing well and to use an arm board or commercially available protective device to help prevent accidental removal. If the patient is critically ill or requires long-term IV therapy, the provider typically considers a peripherally inserted central catheter (PICC).

Possible cause of infiltration

Unintentional administration of solution or medication into the surrounding tissue

Components of primary tubing

Usually referred to as the primary tubing, this long piece of tubing has several components attached: 1. the spike 2. the drip chamber 3. the roller clamp 4. the syringe tip and locking collar, and medication ports.

Older adult patients 1 Initiating intravenous access in older adult patients can be difficult. 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. When selecting an IV site, 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.

How to do a piggybag set up

With a piggyback setup, 1. 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.

At the top of the tubing is a plastic spike covered with a plastic cap.

You'll keep the cap in place until you insert the spike into the bag of fluid. A short distance from the drip chamber is the roller clamp used to control the flow rate. The roller clamp is in the closed position when it is at the narrow bottom end of the device. When the roller is at the wider top end of the device, it is open, thus allowing fluid to move freely through the tubing.

central venous catheter (sen-truhl vee-nis kah-thi-tur)

a blood-vessel access device usually inserted into the subclavian or jugular vein with the distal tip resting in the superior vena cava just above the right atrium; used for long-term intravenous therapy or parenteral nutrition

peripherally inserted central catheter (PICC) (puh-rih-fih-ruh-lee in-ser-ted sen-truhl kah-thi-tur [pik])

a catheter used for long-term intravenous access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the superior vena cava

heparin lock (hep-uh-rihn lok)

an intravenous catheter inserted into a vein and left in place for the intermittent administration of medication through its port or as an open line for emergency situations and intermittently flushed with a heparin solution to maintain

saline lock (say-leen lok)

an intravenous catheter inserted into a vein and left in place for the intermittent administration of medication through its port or as an open line for emergency situations and intermittently flushed with normal saline solution to maintain patency

If your patient will receive subsequent doses of the secondary infusion, l

eave the bag and tubing hanging. It can be used for 72 to 96 hours, depending on your facility's policy. Of course, discard it immediately if it becomes contaminated.

What to do if you have problem finding well dilated vein?

f 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.

When calculating the flow rate,

first determine whether the intravenous tubing you are using is microdrip or macrodrip, so that you can use the appropriate drop factor in your calculations.

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.

When the roller clamp is in the open position, you can move it along the tubing. 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.

It is imperative to complete a baseline assessment prior to initiating IV fluids and to

monitor for fluid excess throughout administration of IV fluids.

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. Along the tubing are several access ports to use for administering medications. Since most facilities use needless systems, you'll most likely use secondary tubing or syringes that screw into the port to access the tubing.

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.

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.

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.

Secondary tubing is a

short piece of plastic tubing that connects into the primary IV tubing for administering medications.

If an infusion device is not available,

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