Invasive I - IV Therapy

A slogan that was developed to emphasize the importance of using a sterile alcohol pad to scrub the injection port with friction for at least 15 seconds when accessing a central line injection port or IV connection. Exceed the standard of care by scrubbing the hub when accessing a peripheral IV line.

"Scrub the hub"

IV Flow Rates Manual IV tubing - gravity

(gtt/min) Always a whole number (Can't have 1/2 drop)

IV Flow Rates Using Electronic Infusion Pump

(mL/hr) Always a whole number (Can't have 1/2 drop)

Cellulitis

-Pain; warmth; edema; induration; red streaking; fever, chills, and malaise. treatment, stop IV, elevate the extremity, warm compresses 3-4, culture if drainage is present

A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40 mg/mL. How many mL should the nurse administer? Round the answer to the nearest tenth. Do not use a trailing zero

0.3 mL

A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30 mg/mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero

0.5 mL

Trouble Shooting - Intravenous Flow 1 - Height of infusion container 2 - System Vent 3 - Position of tubing 4 - Position of the extremity where the site is located 5 - Any possible obstruction to the flow 6 - When the filter was changed 7 - Position of the catheter within the vein 8 - If other measures are unsuccessful, try to aspirate blood from the catheter 9 - NEVER FORCE FLUSH AN IV CATHETER

1 - Height of infusion container (infusion pumps may be somewhat less sensitive to the height of the container) - The patient may have changed position. The container should be at least 36 inches above the heart. 2 - System vent - Air vent occlusion will prevent the flow. 3 - Position of tubing - Tubing may be kinked, obstructing the flow. Tubing hanging below the bed interferes with gravity flow. 4 - Position of the extremity where the site is located - Flexion of the extremity may compress the vein, slowing the flow. 5 - Any possible obstruction to the flow - A protective device on the limb may be too tight. Tape may be compressing the extremity. 6 - When the filter was changed - The filter may be occluded. 7 - Position of the catheter within the vein - The catheter may be lying against the vein wall. Turning the catheter slightly may reposition the tip. 8 - If other measures are unsuccessful, try to aspirate blood from the catheter - A small clot may be obstructing the catheter. Aspiration may withdraw the clot. 9 - Never force flush an IV catheter - Forcefully flushing a catheter SEND THE CLOT INTO THE BLOODSTREAM. This creates an embolus that could lodge anywhere, including the brain, heart, or lungs.

What are the potentially serious complications of IV therapy? Select all that apply. 1 - Infiltration 2 - Infection 3 - Catheter embolus 4 - Site irritation resulting from tape

1 - Infiltration 2 - Infection 3 - Catheter embolus Rational Infiltration, infection, and catheter embolus are potentially serious complications of IV therapy. Site irritation is most likely not a serious, but a localized, reaction caused by tape. REF: Page 709, Table 36 2

The nurse must assess for complications of IV therapy. Signs of common complications include (Select all) 1 - Swelling and coolness at the site 2 - Redness along the vein 3 - Pale skin at the insertion site 4 - Immobility of the extremity 5 - Erythema and tenderness 6 - Vomiting and diarrhea

1 - Swelling and coolness at the site 2 - Redness along the vein 3 - Pale skin at the insertion site 5 - Erythema and tenderness Rationale: Swelling, coolness, or pale skin at the insertion site is a sign of an infiltration of a nonirritating IV fluid. Erythema and tenderness are signs of infiltration of an irritating medication or fluid. Redness along the vein can occur with a very irritating medication. Redness and tenderness could also signal a localized infection. (4) Use of an armboard could decrease the patient's mobility, but armboards are generally not necessary if the IV is properly secured and if the antecubital site is avoided. (6) Vomiting and diarrhea are not usually directly associated with IV fluid therapy or catheter insertion.

Principles that affect the rate of flow for IV infusions NOT administered by a pump are

1 - The higher the container is placed above the level of the patient's heart, the faster the rate of flow 2 - Fuller containers, the faster the rate 3 - The more viscous (thicker) the fluid, the slower the flow - ex - red blood cells will flow more slowly than 5% dextrose in water 4 - The larger the diameter of the needle and tubing the faster the flow 5 - The higher the pressure within the vein, the slower the flow. As an infusion progresses and the veins become fuller, the IV solution may drop more slowly. 6 - Fluid will pass through a straight tube faster than thought one that is coiled or hanging below the level of the cannula. *No attempt should be made to "Catch up" (circulatory overload/volume excess = edema)

A nursing is adding a secondary piggyback to the patient's existing IV. To use gravity system, the nurse should hang: 1 - The piggyback bag higher than the maintenance IV bag 2 - The maintenance IV bag at the same height as the piggyback bag 3 - The piggyback bag and the maintenance IV bag using Y tubing 4 - The maintenance IV bag after the piggyback bag is completed.

1 - The piggyback bag higher than the maintenance IV bag Rationale: If the piggyback bag is higher than the maintenance bag, the fluid from the piggyback will flow in first. As soon as the piggyback is empty, fluid from the maintenance bag will begin. Recall that the fluid level in the piggyback bag must be higher throughout the entire infusion. (2) If the maintenance bag and the piggyback bag are at the same height, the fluid from the maintenance bag can flow up into the piggyback (if there is no backflow valve within the tubing). The bag that has the greater volume will flow first. As the volume of the greater bag depletes, the less the bag will begin to flow. Eventually both would infuse, but the two bags of fluid would be competing for flow. (3) Y-tubing is generally reserved for blood product infusion. It would be an inappropriate waste of a more expensive tubing (which has a special filter). (4) You can manually hang or restart the maintenance IV after the piggyback is completed. In fact, if fluid overload is an issue and you do not have an infusion pump, you may choose to do this; however, this completely eliminates the advantage of having a piggyback setup.

The primary IV tubing set, used in gravity delivery, is sized by the number of drops per milliliter (gtt/mL) to be delivered into the drip chamber. There are three major sizes: 1. Regular drops ________________ gtt/mL 2. Macrodrops _______________ gtt/mL 3. Microdrops __________________ gtt/mL

1. Regular drops (10 to 20 gtt/mL of fluid as specified by the manufacturer), used for administering IV therapy to most adult patients. 2. Macrodrops (10 to 15 gtt/mL), used for viscous (sticky or thick) fluids, such as blood; may be used for regular fluids. 3. Microdrops (60 gtt/mL), used when small amounts of fluid are required or when extreme care must be used to measure the exact amount; most often used for giving IV fluids to infants and children; recommended for older adults with fragile veins.

A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The amount available is acetaminophen liquid 160 mg/5mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trialing zero

10 mL

A nurse is preparing to administer dextrose 5 % in water (D5W) 1,000 mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number. Do not use a trailing zero

100 mL/hr

Correct size catheter

16 gauge for client who have trauma, rapid fluid volume 18 - 20 gauge for clients who are having surgery, rapid blood administration 22-24 gauge for other clients (children and adults) PowerPoint •16-18 for multiple traumas, surgery, or blood administration •20 gauge is used for adults, minor surgery/trauma and sometimes blood (18 is preferred) •22 gauge is used to peds or adults with small veins •24 peds

A patient is receiving heparin intravenously. What signs and symptoms would alert you to the patient having adverse effects of heparin? Select all 1 - Sleeplessness 2 - Bleeding gums 3 - Blood in urine 4 - Coughing 5 - Bruising

2 - Bleeding gums 4 - Coughing 5 - Bruising Rationale: All are signs of bleeding, which is a complication of heparin.

What is the nurse's primary responsibility in the daily care of a patient with a central line? 1 - Use sterile technique during insertion 2 - Flush the line according to agency policy 3 - Verify catheter placement with an x-ray examination 4 - Rotate the insertion site every 72 hours

2 - Flush the line according to agency policy Rationale: Nurses are responsible for the maintenance of central lines, which would include flushing to ensure patency. (1) Sterile technique is used during the insertion; however, central lines are usually inserted by physicians or advanced practice nurses who have undergone specialized training. (3) The catheter placement should be verified with a radiograph; however, this is the responsibility of the person doing the insertion. The nurse should not use the catheter for infusion until after placement has been verified. (4) The site is not usually changed so frequently. One of the advantages of central line placement over peripheral sites is longevity.

You respond to a patient complaining of pain, burning, and wetness over the peripheral IV site. On assessment, you find that the IV insertion site is tender and cool to touch. These are signs and symptoms of 1 - Phlebitis 2 - Infiltration 3 - Infection 4 - Venous spasm

2 - Infiltration Pain, burning, coolness, and wetness over the IV site are signs of infiltration of IV fluid into the tissue. (1) Phlebitis is inflammation of a vein. (3) Infection will cause the area to be hot to the touch. (4) The first sign of a venous spasm is sharp pain extending up the arm.

Which would be the most accurate way to assess for dehydration in an elderly patient? 1 - Skin turgor 2 - Urine output 3 - Respirations 4 - Thirst levels

2 - Urine output Inadequate urine outflow is an indication that dehydration is occurring. A decrease in weight would be a secondary finding and would occur later. (1) Skin turgor is not a good indicator of dehydration in older adults. (3) Respirations are not a good indicator of dehydration in older adults. (4) Dehydration in older adults is often not accompanied by thirst.

A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? Round the answer to the nearest whole number. Do not use a trailing zero

2 tablets

Because of a communication error, the pharmacy says that there is a long delay for a replacement bag of TPN to be mixed and delivered to the unit for the patient. While awaiting the replacement bag of TPN, the nurse recognizes that a medical order is needed for which type of IV fluid? 1 - 0.45% Saline 2 - 5% Dextrose in water 3 - 10% Dextrose in water 4 - Lactated Ringer

3 - 10% Dextrose in water Rationale: If TPN is suddenly discontinued, a patient can experience hypoglycemia. (1) 0.45% saline is a common solution ordered for maintenance replacement of fluids. (2) 5% dextrose is most commonly used as a vehicle for piggyback medications. (4) Lactated Ringer is an isotonic solution that is used for cases of excessive fluid loss, such as trauma or major burns.

In which circumstance would the use of a burette be advised as a safety device 1 - A trauma patient needs several units of packed red blood cells 2 - The patient needs IV fluids, but no infusion pump is available 3 - An infant is at risk for IV fluid overload 4 - A confused patient keeps trying to unplug the infusion pump

3 - An infant is at risk for IV fluid overload Rationale: The burette provides a way to measure the exact amount of IV fluid that could flow into the infant. (1) The burette would not be used in the case of a trauma patient. (2) You could use a burette for a patient who needs IV fluids, but remember that the burette will hold a limited amount of fluid and you will have to refill the burette frequently, so it may cause more work. (4) If a patient unplugs an infusion pump, the pump is likely to continue on a battery. When the battery runs low, an alarm will begin to sound. If the battery depletes, the IV will not infuse. Use of a burette in this case serves no purpose.

A patient returns from physical therapy, and her IV has a very sluggish flow, but it was functioning well before going to physical therapy. What is the priority nursing action? 1 - Call the physical therapist and ask if anything happened to the IV during the treatment session 2 - Discontinue the IV and restart the IV at a new site 3 - Assess the IV insertion site and tubing and try repositioning the extremity 4 - Use a heparin flush to clear the line

3 - Assess the IV insertion site and tubing and try repositioning the extremity Rationale: Assess the site and try to troubleshoot; repositioning the extremity is one solution. Also, try to aspirate for a small blood clot. (See Table 36-3 for other troubleshooting tips.) (1) PT should have called you if something happened to the patient that created a potential danger. It is unlikely that you will gain any useful information by calling, but you could if you suspect an unusual circumstance. (2) Discontinue and restart, if you have tried to reestablish flow without success. (4) Use of a heparin flush requires a medical order.

The patient is receiving a blood transfusion and develops a fever, shortness of breath, and a diffuse rash within 10 minutes after the start of the transfusion. What is the priority action? 1 - Take vital signs and call the primary care provider 2 - Place the patient in a supine position and start oxygen 3 - Stop the blood and change the IV tubing 4 - Slow the blood and check the vital signs

3 - Stop the blood and change the IV tubing Rationale: First stop the blood and change the IV tubing so that the patient does not receive the blood that is within the tubing. (1, 2, 3) Taking the vital signs, starting oxygen, and calling the primary care provider are appropriate actions. The high Fowler position is better initially for oxygenation; if the patient's vital signs suggest shock, the supine position is used. Slowing the blood is not an adequate measure if a transfusion reaction is in progress.

At the beginning of the shift, there is 410 mL of fluid in the IV bag. A piggyback medication containing 150 mL is hung at 12:00 noon to run over 30 minutes. You hang a new bag of 1,000 mL at 1:00 p.m. to run at 125 mL/hr. At the end of shift there is 250 mL left in the bag. The count for the total amount of fluid infused during your shift ending at 7:00 p. m. is: 1 - 1260 mL 2 - 1285 mL 3 - 1560 mL 4 - 1310 mL

4 - 1310 mL Intake is 150 mL from the Piggyback medication, 410 mL from the old IV fluid infusion, and 750 mL infused from the bag hung at 1300. 150 + 410 + 750 = 1310 mL.

A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number. Do not use a trailing zero.

400 mL/hr

A nurse is preparing to administer dextrose 5% in lactated Ringer's (D5LR) 1,000 mL to infuse over 6 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Do not use a trailing zero.

42 gtt/min

A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Do not use a trailing zero

83 gtt/min

A __________________________ is a long-term peripheral venous access device (VAD), a device that keeps a vein open for long-term intermittent medication administration.

A SALINE LOCK is a long-term peripheral venous access device (VAD), a device that keeps a vein open for long-term intermittent medication administration. ~children are freed from IV tubing, repeated "sticks" ~remains in place and periodically flushed with sterile saline to prevent clotting and documented

Controlled-Volume Intravenous Set

A dose of diluted medication can also be given through a controlled-volume administration set. In most cases, an infusion pump (a machine that delivers IV fluids at a rate that is set by the nurse) is used to administer fluid or medication. However, the controlled-volume system is sometimes used as a safety backup between the primary IV bag and the entry to the infusion pump to prevent free flow of fluid. It can be used for administration of fluids to infants, children, and older adults. Using a controlled-volume set decreases likelihood of fluid overload because only a specified amount of fluid is available to be infused at any one time.

The provider prescribes the type of IV fluid, the volume to infuse, and either the rate at which to infuse the IV fluid or the total amount of time it should take to infuse the fluid. The nurse regulates the IV infusion, either with an IV pump or manually, to be sure to deliver the right amount.

A fluid bolus is a large amount of IV fluid to give in a short time, usually less than 1 hr. A fluid bolus rapidly replaces fluid loss from dehydration, shock, hemorrhage, burns, or trauma. (example pain medication) 18- gauge or larger is essential for maintaining the rapid rate necessary to give medications as an IV bolus. Use extreme caution and observing for adverse reactions or complications such as redness, burning, or increasing pain

Central venous access devices (CVAD)

A peripherally inserted central catheter (PICC) is a type of central venous access device that is inserted for moderate-length therapy. The tip of the catheter usually terminates in the SUPERIOR VENA CAVA. Specially trained RNs may insert the PICC line.

An intravenous (IV) route is the primary method of supplying the patient with fluids and medications via the veins when the patient cannot take them orally. Advantage - Disadvantage -

Advantage of making drugs or fluid instantly available for circulation in to all tissues. Disadvantage - if an error is made adverse effects will occur more rapidly.

Edema in extremities

Apply digital pressure over the selected vein Apply pressure with a swab Cannulate the vein quickly

Equipment for IV administration 1 - Primary IV set 2 - Seconday, or piggyback 3 - Parallel or Y 4 - Controlled-volume IV set

As long as the patient is not receiving blood, blood products, fat emulsions, or propofol infusion, change IV tubing no more frequently than every 96 hours but at least every 7 days for infection control purposes. Check agency policy for frequency of tubing change ~Check agency policy

Nursing Intervention - IV therapy

Assess the lungs for signs of crackles indicating fluid overload. Crackles in lungs may indicate fluid overload from IV infusions.

Older adults clients, clients taking anticoagulants, or client's who have fragile veins

Avoid tourniquets Use a blood pressure cuff instead Do not slap the extremity to visualize vein Avoid rigorous friction while cleaning the site

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A - "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood? B - "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C - "I will apply pressure approximately 1-2 inches below the insertion site prior to removing the needle." D - "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."

B - "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." Rational A - After seeing a flashback of blood, the nurse should lower the hub close to the skin to prepare for threading the needle into the vein, then loosen the needle from the catheter and pull back slightly on the needle so that it no longer extends past the tip of the catheter. The nurse should use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site, Inserting the needle all the way into the vein could puncture the vein. B - The nurse should use a smooth, steady motion to insert the catheter through the skin at an angle of 10 to 30 degrees with the bevel up. This is the optimal angle for preventing the puncture of the posterior wall of the vein C - The nurse should apply pressure approximately 3 cm above the insertion site to reduce the backflow of blood into the vein prior to removing the needle. D - The nurse should not use a vein in the antecubital fossa for IV insertion, except for emergency access, because it will limit the mobility of the client's arm.

Select the vein by using visualization, gravity, fist clenching, friction with the cleaning solution, or heat

Chose Distal veins on the NONDOMINANT hand A site that is not painful or bruised and will not interfere with activity A vein that is resilient with a soft, bouncy sensation on palpation Avoid Varicose veins Veins in the inner wrist with bifurcations, in flexion areas, near valves (appearing as bumps), in the lower extremities, and in the antecubital fossa (except for emergency access) Veins in the back of the hand Veins that are sclerosed or hard Veins in an extremity with impaired sensitivity Veins that had previous venipuncture

IV Therapy Disadvantages

Circulatory fluid overload Leaves little time to correct errors Can irritate the lining of the vein Failure to maintain surgical asepsis can lead to local and systemic infection

Hypotonic solutions

Contain less solute than extravascular fluid and may cause fluid to shift out of the vascular compartment and into the cells. This can cause a dangerous situation, as cells can rupture. Hypotonic solutions are generally considered unsafe to administer to children. ~ 0.45% Saline - Supplies normal daily salt and water requirements

Postprocedure Maintaining the patency of IV access

Do not stop a continuous infusion or allow blood to back up into the catheter for any length of time Instruct client not to manipulate the flow rate Make sure the IV insertion site's dressing is not too tight Flush intermittent IV catheters after every medication administration or every 8 hr to 12 hr when not in use. Monitor the site and infusion rate at least every hour

Hematoma

Ecchymosis at the site (bruise)

Phlebitis or thrombophlebitis

Edema; throbbing, burning, or pain at the site; increased skin temperature; erythema; a red line up the arm with a palpable band at the vein site; slowed rate of infusion

Filters trap small particles such as undissolved medication or salts that have precipitated from solution

For solutions containing lipids or albumin, a 1.2-micron filter is used. A special filter is needed for blood components.

Hypertonic solutions

Have a greater tonicity compared with blood. They are used to replace electrolytes and, when given as concentrated dextrose solutions, produce a shift in fluid from the intracellular compartment to the extracellular compartment, causing shrinkage of cells. Concentrated solutions of glucose, mannitol, or sucrose are given to reduce cerebral edema in patients with head injury because the osmotic pressure draws water out of the cells, whereas hypotonic solutions would not be given because the potential fluid shifting could exacerbate cerebral edema ~ 10% Dextrose in water - if TPN is abruptly discontinued ~ 5% Dextrose in 0.9% saline - Early treatment of burns ~ 5% Dextrose in 0.45% saline - Postoperative, common maintenance fluid ~ 5% Dextrose in Ringer lactate - Burns, dehydration from severe diarrhea or vomiting

Isotonic solutions

Have the same concentration, or osmolality, as blood and are used to expand the body's fluid volume. When exposed to isotonic solutions body cells stay approximately the same size. ~ 0.9% Saline - Trauma, diabetic ketoacidosis, blood transfusions, and hyponatremia ~5% Dextrose in water - Vehicle for some IV piggyback medications and hyperkalemia 5% Dextrose in 0.2225% saline - Postoperative, common maintenance fluid Ringer lactate - Trauma, dehydration from severe diarrhea or vomiting

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Toddler (Age 1-3 Years )

IV Placement (Ideal site) - Hand, arm, foot Preparation of child - Prepare child immediately before procedure (limited attention span), Give very simple explanation, Show equipment, Do not offer choices, Restraining toddler for an IV usually requires more than one person

Nursing guidelines for Peds Intravenous Lines (Table 22.2) School-Age Child (Age 7-11 Years)

IV Placement (Ideal site) - Hand, forearm (less dominant) Preparation of child - Prepare child ahead of time but on same day of insertion. Carefully explain and demonstrate equipment and reasons for IV therapy, letting patient watch or help set up equipment. Ask child if they have any questions, give child choices and let child help in procedure whenever possible. Tell child crying is ok because needles hurt.

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Preschool (Age 4-6 Years)

IV Placement (Ideal site) - Hand, forearm (less dominant) Preparation of child - Prepare child just before procedure. Using small bottle, tubing, and doll or stuffed animal, explain in literal terms the need for IV and insertion procedure. Allow child to see and touch equipment. Explain how child can help with procedure, by cleaning site, opening packages, and tape

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Adolescent (Age 12-18 Years)

IV Placement (Ideal site) - Hand, forearm (less dominant) Preparation of child - Prepare patient several hours to a day before procedure, if possible. Needs time between preparation and insertion to absorb explanations and ask questions. For most adolescents, approach discussion on an adult level. Explain need for IV therapy and expected duration and show equipment. May need much support for acceptance of therapy.

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Infant (First year)

IV Placement (Ideal site) - Scalp vein, foot, hand, forearm Preparation of child - It is best not to feed infant immediately before IV insertion (vomiting and aspiration are possible)

Administering Intravenous Medications The medication is also absorbed more rapidly, which is of value. The nurse monitors the IV site carefully for patency, infiltration, and inflammation. ~Because the medication reaches the heart and brain within seconds, adverse reactions can occur quickly. A rapid rate of flow of IV solution can cause fluid overload (manifested by an increased pulse rate or blood pressure, distended neck veins, and puffy eyes), or a slow rate of infusion can result in clot formation that obstructs the patency of the IV line

IV medications can cause phlebitis, and the nurse must observe the child's IV site hourly for reddened areas or signs of inflammation. Infiltration is a risk for children who are active, and the site should be observed hourly, because infants cannot communicate the burning or pain that may accompany infiltration. Leakage at the IV site, a tense tissue turgor, and cool, blanched skin around the IV site may indicate infiltration; the registered nurse (RN) should be notified. ~A pacifier should be provided for infants who are given nothing by mouth status (NPO) to fulfill their developmental need for sucking.

Check your state's nurse practice act to determine whether an IV certification is necessary to administer IV medications.

In some states, LPN/LVNs are not allowed to perform IV therapy. All nurses must monitor IV therapy.

Parallel, or Y, Intravenous Set

Is used to infuse certain blood product The blood product is placed on one side, and a bag of normal saline is placed on the other side. The saline is started first, and then the blood administration is begun. The saline is stopped while the blood is running. Blood products are never infused into the same IV line as medications or other fluids. When the transfusion (introduction of blood components into the bloodstream) is complete, the tubing is flushed with the normal saline solution.

It is _____________________ to be able to feel or see the vein

It is NECESSARY to be able to feel or see the vein venoscope can be used to illuminate the tissue and outline the vein

Intravenous (IV) therapy involves infusing fluids via an IV catheter to administer ____________

Medications, supplement fluid intake, or provide fluid replacement, electrolytes, or nutrients. Never administer IV medication through tubing that is infusing blood, blood products, or parenteral nutrition solutions. Verify the compatibility of medications with IV solutions before infusing a medication through tubing that is infusing another medication or IV fluid.

catheter embolism

Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration. A shaving or piece of catheter breaks off and floats freely in the vessel

IV Therapy in older adults Life span consideration

Monitor electrolyte levels closely; fluid therapy can rapidly change the fluid and electrolyte balance.

When your patient has an IV, you are responsible for ensuring that the correct solution is infusing at the prescribed rate

Movement of the patient can alter the rate. Check the flow rate after the patient has been ambulating, returns from a test or treatment, has been turned in bed, or has been up to the bathroom. Keeping the intravenous solution running ~Each state sets the scope of practice for the LPN/LVN, but each organization can narrow the scope. It is important, therefore, for you to know what your specific organization does and does not allow the LPN/LVN to do.

Infiltration or extravastion

Pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed rate of infusion

Patient-controlled analgesia (PCA) pumps

Patient-controlled analgesia (PCA) pumps are commonly used in both hospitals and home settings. This pump is used for pain control, and it has a remote-control button by which the patient can administer a controlled bolus of pain medication. The pump is programmed to allow a set amount at specified intervals.

Potassium is always diluted in fluid and given as a carefully controlled infusion. Potassium is ______________ given as a bolus because it can cause cardiac arrest.

Potassium is NEVER given as a bolus because it can cause cardiac arrest.

Intermittent Intravenous Device (Saline or PRN Lock)

Preferred for patients who receive intermittent antibiotics, heparin, corticosteroids, antimetabolites, and other IV push drugs. Advantage - Freedom of movement ~Because no solution is continuously infusing through the lock, saline or dilute heparin is used to flush the device to maintain patency by keeping a clot from forming at the tip of the catheter ~The device is established by applying a Luer-Lok cap or an extension set, which is a short piece of tubing, to the IV cannula. ~Most locks are flushed with saline ~It is critically important to be sure you are using the correct concentration of heparin, because a mistake can result in patient death.

IV Therapy Advantages

Rapid absorption and onset of action Constant therapeutic blood levels Less irritation to subcutaneous and muscle tissue

Whenever a patient who is receiving an IV infusion is out of bed, _____________________ once he is back in bed

Recheck the drop rate. The fluid drop rate often changes when the patient is up and moving around

The average adult needs 1500 to 2000 mL of fluids in a 24-hour period to replace fluids eliminated by the body.

Some patients have decreased fluid intake. Others experience fluid loss through hemorrhage, severe or prolonged vomiting or diarrhea, profuse perspiration, and moderate to excessive drainage from wounds, especially from burn wounds. Fluid balance is also affected by increased metabolic processes, for example, during a fever. Accurate recording of the patient's intake and output (I & O) is needed to determine the amount of fluids necessary for daily replacement. The primary care provider considers laboratory tests related to electrolytes when ordering replacements such as sodium, potassium, and chloride. Patients who require fluids by the IV method are place on I & O recording to monitor for fluid overload.

A nurse is preparing to administer lactated ringer's (LR) 1,500 mL IV infuse over 10 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Using a leading zero if it applies. Do not use a trailing zero.

Step 1 - What is the unit of measurement gtt/mion Step 2 - What is the quantity of the drop factor 15 gtt/mL Step 3 - What is the volume to be infused 1,500 mL Step 4 - What is the total infusion time 10 hr Step 5 - Should the nurse convert the units of measurement? No - (mL = mL) Yes - (hr-min) 1 hr/60 min = 10 hr/X min X = 600 min Step 6 - Set up equation Volume (mL) / Time (min) x Drop factor (gtt/mL) = X 1,500 mL/600 min X 15 gtt / mL = 37.5 = 38 gtt/min

A nurse is preparing to administer dextrose 5% in water (D5W) 500 mL IV to infuse over 4 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Using a leading zero if applies. Do not use trailing zeros.)

Step 1 - What is the unit of measurement mL/hr Step 2 - What is the volume the nurse should infuse 500 mL Step 3 - What is the total infusion time? 4 hr Step 4 - Should the nurse convert the units of measurement No Step 5 - Set up the equation and solve for X Volume (mL)/Time (hr) = X mL/hr 500 mL/4 hr = X mL/hr 125 = X 125 mL / hr Reassess to determine whether the IV flow rate makes sense.

A nurse is preparing to administer ranitidine 150 mg by intermittent IV bolus. Available is ranitidine 150 mg by intermittent IV bolus. Available is ranitidine 150 mg in 100 mL of 0.9% sodium chloride (0.9% NaCl) to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

Step 1 - What is the unit of measurement the nurse should calculate gtt/min Step 2 - Should the nurse convert the units of measurement Yes - (mg - mL) 150 mg/100 mL = 150 mg = X mL X - 100 Step 3 - What is the total infusion time 30 min Step 4 - What is the quantity of the drop factor that is available 10 gtt/mL Step 5 - What is the volume the nurse should infuse? 100 mL Step 6 - Set up an equation Volume (mL) / Time (min) x Drop factor (gtt/mL) = X 100 mL/ 30 min x 10 gtt/mL = 33.33 = 33 gtt/min

A nurse is preparing to administer cefotaxime 1 g intermittent IV bolus over 45 min, Available is cefotaxime 1 g in 100 mL 0.9% sodium chloride (0.9% NaCl). The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number

Step 1 - What is the unit of measurement the nurse should calculate? ml/hr Step 2 - Should the nurse convert the units os measurement Yes (min - hr) & (g = mL) 60 min/45 min = 1 hr/X hr - X=0.75 100 mL/1 g = X mL/1g = X = 100 Step 3 - What is the total infusion time Step 4 - What is the volume the nurse should infuse? 100 mL Step 5 - Set up an equation and solve Volume (mL)/Time (hr) = X mL/hr 100 mL/0.75 hr = 133.333 Step 6 - round - 133 mL/hr Step 7 - reassess to determine whether the IV flow rate makes sense

Solutions that are given intravenously must be ____________________

Sterile Check the expiration date and inspect the container for clarity of solution, the solution should be clear.

Sings of fluid overload

Such as sudden weight gain, crackles in lungs on auscultation, and peripheral edema. The LPN/LVN must accurately record I & O and report changes, observe for subtle changes in urinary patterns, and monitor laboratory results, including: electrolytes, BUN, and serum creatinine. ~Patients who receive IV fluids must be observed

A primary responsibility is to check the IV at least every 60 minutes and observe each of these points

The IV flow—for the gravity method, the solution should drip into the chamber at regular intervals. • The rate of the infusion—count the rate if you are using the gravity method. If it is too fast or too slow, adjust it to the correct infusion rate per minute. • The infusion pump—if a pump is used, check the programmed rate and volume; the dripping in the chamber will occur intermittently. • The insertion site—are there any signs of infiltration, extravasation, or phlebitis? • Patient complaints—an established IV should not cause any pain or discomfort, and there should be no leaking at the site. • The level of the fluid remaining in the bag—when 50 mL are left, a new bag may be added before the current solution is completely infused . Check to see whether the tubing needs to be changed (no more frequently than 96-hour intervals, but at least once every 7 days), and change the tubing when a new bag is hung. Check your facility's policy for frequency of tubing changes.

Primary IV Set

The primary IV infusion setup consists of a bag of solution, a regular tubing set, a needleless connector, and an IV stand. A filter may be added. The IV tubing set consists of the spike end, which is inserted into the bag; the drip chamber; the tubing; a flow regulator or clamp; and a Luer-Lok connector. The primary IV infusion setup is used for any type of IV therapy except the administration of blood products, which requires a special set with a filter in the drip chamber.

Secondary, or Piggyback, Intravenous Set

The primary infusion is interrupted to infuse medications such as antibiotics and antineoplastic drugs at regularly scheduled times The secondary bag containing the medication, also known as the piggyback, is hung higher than the level of fluid in the primary IV so that gravity forces it to empty first. Do not clamp or alter the flow of the primary bag. If the secondary bag is positioned correctly, the primary IV will begin to flow as soon as the secondary bag is finished. ~Use of needleless devices for attaching secondary tubing for the infusion of medication is highly recommended to prevent injury and exposure to these diseases

Client who are obese

Use anatomical landmarks to find veins

Which route of administration results in a drug instantly being available for circulation to all tissues? a - Intravenous (IV) b - Subcutaneous (SC) c - Intradermal (ID) d - Vaginal application

a - Intravenous (IV) Rational IV route is the main method of supplying the patient with fluids and medications when the patient is unable to take them orally. The IV route has the advantage of making drugs or fluid instantly available for circulation to all tissues. SC injection does not supply substances as rapidly as the IV route. ID injection does not supply substances as rapidly as the IV route. Vaginal application delivers different types of medications and is not as rapid as the IV route.REF: Page 699

An infusion pump is mandatory when patients receive: a - lactated Ringer's. b - chemotherapy drugs. c - proton pump inhibitors (PPIs). d - normal saline IV fluid.

b - chemotherapy drugs. Rational Chemotherapy drugs require critical accuracy and an infusion pump is necessary. Infusion pumps are not mandatory with lactated ringer's, PPIs, or normal saline IV fluid.REF: Page 704

Blood should be infused with an IV tubing set selected for: a - regular drops. b - macrodrops. c - microdrops. d - large drops.

b - macrodrops. Rational Macrodrops are used for viscous fluids, such as blood. Regular drops are used to administer IV therapy to most adult patients. Microdrops are most often used for infants and children. a - This is not one of the three major drop sizes.REF: Page 702

A patient requires an intravenous antibiotic for 6 weeks. The appropriate type catheter would be: a - Broviac. b - midline catheter (ML). c - Hickman. d - Groshong.

b - midline catheter (ML) Rational Midline catheter is used in home care for IV therapy of 6 to 8 weeks. Broviac, Hickman, and Groshong are long-term catheters used for more than 6 to 8 weeks.REF: Page 706

Mannitol is given to reduce cerebral edema in patients with a head injury because the osmotic pressure draws water out of the cells. What type of solution is mannitol? a - Isotonic b - Hypotonic c - Hypertonic d - Eutonic

c - Hypertonic Rational Hypertonic solutions have a greater tonicity than blood. They are used to replace electrolytes and, when given as concentrated dextrose solutions, produce a shift in fluid from the intracellular compartment to the extracellular compartment. Isotonic solutions have the same concentration as blood. Hypotonic solutions contain less solute than extravascular fluid. Eutonic does not refer to solutions. REF: Page 699

An appropriate diagnosis for a patient on total parenteral nutrition (TPN) is: a - Deficient fluid volume related to inability to take fluids by mouth. b - Risk for dehydration related to poor fluid intake. c - Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. d - Ineffective tissue perfusion related to loss of red blood cells/fluid volume.

c - Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. Rational Nutritional status of patients who are NPO and on IV therapy must be assessed every day because the amount of calories supplied by the IV solution is below the total daily requirement. Supplemental calories can be provided through TPN; therefore the most appropriate nursing diagnosis would be Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. Deficient fluid volume and Risk for dehydration are nursing diagnoses for fluid replacement. Ineffective tissue perfusion is a nursing diagnosis for blood product transfusion.REF: Page 727

An elderly patient has a rapid pulse, shortness of breath, and distended neck veins. An IV of 0.9 NS at 150 mL/hr is infusing. What should the nurse be concerned about? a - Catheter embolus b - Speed shock c - Septicemia d - Fluid overload

d - Fluid overload Rational Elderly patients who have IV fluid infusing are at risk for potential fluid overload. Rapid pulse, shortness of breath, and distended neck veins are possible signs of fluid overload. Catheter embolus may cause loss of consciousness. Speed shock may result in cardiac arrest. Signs of septicemia are fever, chills, and general malaise.REF: Page 709, Table 36 2

A nurse initiating peripheral IV therapy should use: a - the antecubital site. b - sterile technique. c - three attempts before asking another nurse to perform the venipuncture. d - a catheter stabilization device to secure the catheter.

d - a catheter stabilization device to secure the catheter. Rational The catheter stabilization device is used after insertion of a peripheral IV and has a see-through area to view the IV site. The antecubital site is not used extensively as a result of increased risk of damage to the vein and potential muscle or nerve damage. Asepsis must be maintained when performing a venipuncture. If an IV cannot be initiated in two attempts, another nurse should be asked to complete the task. REF: Page 714

fluid overload

distended neck veins, increased BP, tachycardia, shortness of breath, crackles in the lungs, edema. additional findings varying with the IV solution Treatment: stop IV, raise the head of the bed, assess vital signs and oxygen saturation, adjust the rate as prescribed, administer diuretics if prescribed.

Intravenous setups should be checked once every _________________

hour (must be checked at 30 - 60 minute intervals)

IV Pump Troubleshooting

~ Check the medication, calculate the correct dosage, and determine the pump setting before entering the patient's room ~ For adult usage, most pumps measure delivery rate in milliliters per hour. Set the pump for the correct rate in milliliters per hour. ~ Pumps usually allow you to set a total volume; the machine will alarm when it reaches that volume ~Before you leave the room, check to ensure that the patient is comfortable, there is no swelling at the insertion site, appropriate clamps are open, and intermittent dripping (not continuous) is occurring in the drip chamber. ~ If the IV pump is continually alarming: Check the IV site for infiltration, pain, and other signs of infiltration. Check tubing for kinks or air in the line. Check clamps and flow regulators. Check IV bag to see whether there is fluid for infusion. Make certain the pump is plugged into an electrical source. Recheck settings on the pump. Change the position of the patient's extremity. Try turning the pump off and resetting it. Try another pump.

Using a blood pressure cuff rather than a tourniquet is sometimes better for the fragile veins of older adults. Place the cuff about _______________ above the selected site.

~ Place the cuff about ***** 6 INCHES****** above the selected site. Inflate the cuff to about 10 mm Hg above the diastolic pressure to dilate the vein. If the patient is fluid depleted, inflate to 20 mm Hg over the diastolic pressure. ~For pediatric patients (or confused older adults) who are pulling at the tubing and catheter, a sleeve or roller gauze can be used to cover the site and equipment

Factors that influence the rate of flow of an IV solution

~Are catheter size, height of the solution container, and viscosity of the fluid. Fluids flow less rapidly through a catheter with a small bore (internal diameter) than through a catheter with a larger bore. In the gravity method, the higher the container, the faster the fluid will flow. ~The device may do the math, but you are responsible for correct use of the equipment and correct entry of the required parameters. ~To calculate the flow rate using the gravity method, you must know how many drops are contained in each milliliter (drop factor) as it passes through the drip chamber of the tubing. The standard set produces 10 to 20 gtt/mL, and the pediatric or microdrop chamber produces 60 gtt/mL.

Selection of the intravenous site

~Depends on several factors, including the vein's accessibility and general condition, the type of fluid or medication to be given, and the duration of IV therapy. The veins preferred for infusions and intermittent doses of medications are those distal to the antecubital area; a new site cannot be placed distal to an old site.

IVs are given to supply the body with fluids, electrolytes, nutritional components, or drugs. List Examples

~Fluids & electrolytes that the patient is unable to take orally in sufficient amounts ~Medications that are more effective when given by this route or cannot be given any other way ~Blood, plasma, or other blood components ~ Nutritional formulas containing glucose, amino acids, and lipids.

Disadvantage of pumps

~Include expense and special administration sets. ~ Incidents of pump failure ~ Should purchase infusion pumps that have administration sets with set-based anti-free-flow mechanisms that prevent gravity free flow by closing off the tubing when the administration set is removed from the pump ~Other pumps must have a free-flow safety device attached to the tubing before it enters the pump.

Total parenteral nutrition (TPN), also known as hyperalimentation

~Provides the total nutritional needs for infants and children who cannot use the gastrointestinal tract for nourishment for a prolonged period. It allows highly concentrated solutions of proteins, glucose, and other nutrients to infuse directly into a large vessel (e.g., the superior vena cava) via a CVAD. ~Hypoglycemia, hyperglycemia, and electrolyte imbalances can occur. ~The rate is gradually reduced,

Nursing care of a child receiving "parenteral fluids" - given by some route other than the digestive tract

~The IV pump allows the administration of microdrops of IV solution so that a slow rate of infusion can be maintained. ~IV sets administer 15 drops per 1 mL. Pediatric IV sets administer 60 drops per 1 mL. ~The nurse observes the child hourly for: • Low volume in the bag • The rate of flow of the solution • Pain, redness, or swelling at the catheter insertion site • Moisture at or around the catheter insertion site

Many facilities require use of pumps to regulate the flow of routine IV fluids, especially those containing potassium.

~Use of pumps is mandatory when patients are receiving total parenteral nutrition (TPN), or for medications that require critical accuracy, such as heparin, insulin, cardiovascular medications, chemotherapy drugs, or medications that are used to induce labor ~They have alarms that warn when the IV container is empty, when air is present in the tubing, or when there is an occlusion. They also alarm when the site is infiltrated (solution is deposited in tissue outside the vein); however, the infiltration can be extensive before the machine detects an obstruction of flow ~Remember a pump is never a substitute for good nursing observation.

Starting the Primary Intravenous Infusion

~Use strict aseptic technique when handling IV fluids and tubing because an IV site provides access for bacteria to enter the bloodstream. ~Gloves ~Choose the most distal site possible ~Patient education ~6 rights ~Remove cover and check bag ~Open set and clamp, remove tab, maintain sterility ~Contaminated equipment myst be discarded. ~Remove hair by clipping (do not shave) - Hair harbors microorganisms that contribute to infection ~Stabilize the skin below the IV site by placing your thumb about 2 inches directly below the insertion site. ~indirect method, first insert the cannula into the subcutaneous space directly parallel to the side of the vein. Then move the tip toward the vein, and gently ease the cannula into the vein. Using the direct method, hold the cannula with the bevel upright and at a 15- to 25-degree angle to pierce the skin ~Advancing the cannula when it is not in the vein causes pain and tissue damage. If you continue to push the stylet after the flashback, you will go through vein wall, and fluid will infiltrate into the surrounding tissues. Special Considerations • If you cannot initiate a patent IV in two attempts, ask another nurse to perform the task. • A peripheral IV site is changed every 72 to 96 hours or according to agency policy. • Never perform venipuncture in an extremity where there is a hemodialysis access shunt or on the side of a mastectomy or paralysis.

Preventing Infection

~hand hygiene ~standard precautions ~change IV site according to the facility's police (Usually 72 hr ~Replacement of the admin set is dependent upon the tube of infusion. A continuous infusion of fluids with or without secondary fluids should be changed every 96 hr. Intermittent infusion should be changed every 24 hr ~Remove catheters as soon as there is no clinical need ~Replace if suspected break in surgical aseptic ~Use a sterile needle for each insertion attempt ~Avoid writing on bags with pens or markers, because ink can contaminate the solution. ~Do not allow fluids to hand for more than 24 hr unless it is a closed system (Pressure bag for hemodynamic) ~ Wipe all ports with alcohol or an antiseptic swab before connecting IV lines or inserting a syringe ~Never disconnect tubing for convenience or to reposition the client

Intravenous Therapy Guidelines 1 - Keep IV Fluids sterile 2 - Protect the catheter site 3 - Hang fluids at the correct height 4 - Carefully regulate the rate of flow 5 - Monitor I & O when a patient is receiving IV fluids or blood 6 - Hang the solution that should run in first in a higher position 7 - Assess the site frequently for signs of complications Students must have supervision when performing a venipuncture. Whenever an IV site is initiated or changed or an IV solution is hung, document this on the parenteral infusion record

• Keep IV fluid sterile. Everything coming into contact with the solution must be sterile, including the inside surface of the catheter hub and all connecting points between the bag and drip chamber and between the tubing and the needleless connector. • Protect the catheter site from contamination to avoid possible infection. An airtight, transparent dressing is used over the catheter site. Keep tubing free of air. Clear tubing of air before connecting to the catheter. Do not allow the current bag to run dry before changing to the next one. • Hang fluids at the correct height. Keep the bag of fluid sufficiently above the level of the catheter site to maintain flow; avoid having it too high because this significantly increases the effect of gravity. • Carefully regulate the rate of flow. If the IV is behind schedule, do not run in a large amount of fluid to catch up. Rather, recalculate either (1) the span of time for the infusion or (2) the rate of drops per minute for the fluid to run at the ordered rate. (For an infusion pump, access the function of the pump.) • Monitor intake and output when a patient is receiving IV fluids or blood. Keep accurate intake and output records and compare intake with output over 24 hours. • Hang the solution that should run in first in a higher position. Attach the piggyback tubing to a port beneath the roller clamp on the primary tubing. Lower the primary bag without clamping the tubing so it will begin to flow when the piggyback has run in. • Assess the site frequently for signs of complications. Monitor for infiltration, extravasation, swelling at the IV site, irritation of the vein, formation of a clot stopping the flow, or systemic reaction. Take vital signs several times a day to detect early signs of infection or adverse reaction.

Reduce Risk of pump failure • Plan • Label • Check • Use • Report

• Plan: have a backup plan in the event of pump failure; participate in educational opportunities relating to the facility's smart pump; use a secondary device to check the expected volume infused. • Label: clearly label tubing and pump channels with the name of the medication infusing, especially if multiple lines are running. • Check: verify pump settings; have another nurse double-check your settings when infusing high-risk medications. Monitor: carefully watch patients for signs of over infusion or under infusion. • Use: consult with super-users for additional assistance and training, use available resources to prevent and respond to pump problems, and follow the Six Rights for medication administration. • Report: promptly report adverse events to the FDA; remove any equipment that is not working properly.