N370: IV hydration

6 rights

Right drug/solution Right dose/concentration Right patient Right route Right date/time Right documentation

saline lock

maintains patent IV access. Flushed after direct IV infusion via bolus (at same rate as med admin was)

hemodilution

occurs in hypervolemia, when there is too much fluid in the intravascular space, it causes serum solutes to be artificially low.

hemoconcentration

occurs in hypovolemic episodes, where water is lost and the solutes remain become artificially high

miniinfuser

prevents air embolus; ensures proper medication admin and route of entry

albumin

range: 3.5 - 5

volutrol

reduces risk of rapid infusion, rotate for equal distribution

premixed infusions

solutions in which medications or electrolytes have been added by the manufacturer. Must know complete pt hx to prevent adverse reaction PROS: stability of solution, correct med + diluents CONS: potential dosage med errors

extracellular

the "third space", outside the cell

Intravenous lock

vial of normal saline flush solution (saline recommended); if facility continues to use heparin flush, the most common concentration is 10 units/mL

insensible loss

water loss from skin, lungs, stool • accounts for 500-1000mL/day • increases w/ rapid respiration, ventilation, GI suctioning, severe diarrhea, drainage

minimal rate KVO

10 - 15 mL/hr; use micro drip set

pounds to mL

2.2 lbs = 1000mLs, or 1kg = 1000mLs

Hematoma formation

• Apply a pressure dressing to the site. • Apply ice to slow or stop bleeding. • Monitor for additional bleeding. • Assess circulatory, motor, and neurological function of the extremity.

20

Continuous or intermittent infusions, blood transfusion • do not use smaller than this for surgery

roller clamp

Failure to open the roller clamp is one preventable error to administering a piggyback over the desired timeframe

Is it necessary to dilute if less than 1mL?

If less than 1 mL of medication is given, it should be diluted in 5 to 10 mL of normal saline or sterile water so that the medication passes through the "dead spaces" of the IV delivery system

blood administration set

Infusion of blood products requires this, which contains an in-line filter

IV infusion is slower than ordered.

Intervention: • Check vascular access device (VAD) site for complications. • Check for positional change that affects rate, height of IV container, or kinking of tubing or obstruction. • recalculate new mL/hr flow rate • NEVER try to "catch up" an IV that is behind schedule by positioning the roller clamp wide open and rapidly infusing fluids

IV site show signs of infiltration

Intervention: • Stop IV infusion and discontinue access device. • Elevate affected extremity. • warm or cool compress depending on policy. • Treat IV site as indicated by facility policy (e.g. sterile dressing if weeping) • Insert new IV catheter if therapy continues. • determine how harmful the IV medication is to subcutaneous tissue. Provide extravasation care (e.g., injecting phentolamine [Regitine] around the IV infiltration site)

IV bolus medication is incompatible with IV fluids (e.g., IV fluid becomes cloudy).

Intervention: • Stop IV infusion immediately and clamp the IV line. • Flush the IV with 10 mL of 0.9% sodium chloride or sterile water. • Give the IV bolus over the appropriate amount of time. • Flush with another 10 mL of 0.9% sodium chloride or sterile water at the same rate as the medication was administered. • Restart the IV fluids at the prescribed rate.

Patient develops adverse or allergic reaction to medication

Intervention: • Stop medication infusion immediately. • Follow guidelines for appropriate response to allergic reaction (e.g., administration of antihistamine) • Notify the patient's health care provider immediately. • Add allergy to records

Catheter tip is broken off resulting in an embolus.

Monitor patient. Notify health care provider immediately.

14, 16, 18

Trauma, surgery, blood transfusion • needs to be in a vein that can accommodate it • allows for faster rates but risk for phlebitis

cardiac output

heart rate x stroke volume - total CO = 5L/min - when volume decreases, HR will increase to keep cardiac output at baseline levels

Mini-Infusion Pump

battery operated and delivers medication in very small amounts of fluid (5 to 60 mL) within controlled infusion times using standard syringes.

intracellular

fluid within the cells. Most of body potassium is inside the cell = 3.5 - 5

Patient Factors of IV flow rates

• Change in patient position • Flexion of involved extremity • Partial or complete occlusion of IV device, such as lying on tubing • Venous spasm • Vein trauma (phlebitis, infiltration) • Manipulation of IV catheter by patient or visitor

IV fluid container empties with subsequent loss of IV line patency.

• Discontinue present IV and restart new short peripheral catheter at proximal site.

infection

• Elevated temperature • Drainage at the insertion site • Erythema (redness) at the insertion site • Complaints of pain at the insertion site. • Retain the IV catheter for possible culture, discontinue IV and notify physician.

24-26

• Fragile veins for intermittent or continuous infusions • administration of blood or blood products in pediatrics or neonates and geriatrics • not ideal for viscous fluids

Mechanical Factors of IV flow rates

• Height of parenteral container (should be higher than 90 cm above the heart) • Access device coming in contact with intraluminal valve • Viscosity or temperature of IV solution • Occluded air vent • Occluded inline filter • Improperly placed restraints • Crimped administration set tubing • Tubing dangling below bed • Low battery of an electronic IV infusion device

IV Controller

• IV flow control devices deliver fluid with the aid of gravity. • The IV container must be placed approximately 90 cm above the IV site to operate properly. • The nurse must monitor the volume delivered each hour to ensure that the calculated drops per minute deliver the actual volume desired. • Because IV flow control devices cannot overcome increased resistance in the IV system, if infiltration develops the drip rate will slow, allowing the nurse to identify the problem more quickly than with an EID

flushing

• If resistance is met, first assess mechanical causes • Never forcefully attempt to flush. • If unable to observe a blood return and unable to flush, discontinue the IV and insert a new IV catheter in a different location. • Given to inject "spacer" between incompatible medications given by IVP or IVPB • After delivery of blood products • after blood sampling • converting from continuous to intermittent therapy • After intermittent medication delivery

IV benefits

• In emergencies when a fast-acting medication must be delivered quickly • When it is necessary to establish constant therapeutic blood levels • When the oral route is contraindicated • For administering medications that are highly alkaline and irritating to muscle and subcutaneous tissue.

IV considerations

• Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions. • Assess patency of the pt's existing IV infusion line or saline lock. Do not administer medication if site is edematous or inflamed. • If the pt's IV site is saline locked, cleanse the port with alcohol, and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile sodium chloride. • Assess pt's symptoms/knowledge before initiating medication therapy

risk reduction

• Only add medications to new IV fluid containers. • Verify any medications added to IV fluids with another nurse.

Standards to Decrease Intravascular Infection

• Palpate catheter site for tenderness daily • inspect a catheter site if patient develops adverse symptoms • perform hand hygiene before and after palpating, inserting, replacing, or dressing • Cleanse skin before venipuncture • Allow site to air-dry before proceeding • Do not palpate insertion site after skin has been cleansed • Gauze dressings that cover a catheter site must be changed every 48 hours • Change IV tubing every 96 hours • Clean injection ports with single-use antiseptic solution before use • Replace short, peripheral venous catheters and rotate sites

delegation to NAP

• Potential medication actions and side effects and to report their occurrence to the nurse. • Reporting any patient complaints of moisture or discomfort around IV insertion site. • Reporting any change in the patient's condition or vital signs to the nurse.

fluid volume excess

• SX: distended neck veins, crackles/ronchi, edema, increased BP, HR, increase in daily weight (best indicator) • HR, BP will be up • decreased O2 saturation • hemodilution • Reduce IV flow rate if symptoms appear, and notify health care provider. Raise head of bed and monitor vitals. • Volume-control devices can prevent sudden excessive increases in the volume of IV solution infused

fluid volume deficit

• SX: postural hypotension, skin turgor, thirst mechanism, behavioral changes, dry skin and mucous membranes, decreased urine output, weak/rapid/thready pulse • HR up, BP down • delayed cap refill time • urine output <30ml/hr • narrowed pulse pressure • hemoconcentration • confirm orthostasis • Notify health care provider. Requires readjustment of infusion rate.

Phlebitis is indicated by pain and tenderness at IV site with erythema at site or along path of vein

• 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. • Continue to monitor site for 48 hours after catheter is removed for post-infusion phlebitis

changing infusion

• You will change a container when there is an order for a new solution or when it becomes time to add a sequential container to avoid exceeding hang time. • change the fluid container within 24 hours after adding a medication or an administration set • 96 hours for tubing changes of IVs with continuous infusion of IV fluids • tubing used for intermittent infusion, should be changed every 24 hours because both ends of the tubing are manipulated more frequently spike is contaminated, a new IV tubing set is required. • blood products = no more than 4 hours

manifold

• a device used for complex IV therapy controlled by snap clamps • has multiple ports for running compatible meds along the same IV line • ensures a closed system to keep from contamination

orthostasis

• a positive finding when 20% of circulating blood volume is lost • may cause syncope • HR will increase as compensation • measure BP and HR together to interpret data • test in supine --> sitting up --> standing up • if systolic drops 20+ and HR goes up 20+, confirms hypovolemia

piggyback

• a small (25 to 250 mL) IV bag or bottle connected to a short tubing line that connects to the upper Y-port of a primary infusion line. • It is a drop system. • the small bag or bottle is set higher than the primary infusion bag or bottle. • In the PGYB set-up the main line does not infuse when a compatible PGYB medication is infusing. • The back-check valve opens and the primary infusion starts to flow again after PGYB done infusing.

volume controlled device

• a small container, holding 50 to 150 mL of fluid, is attached below the primary infusion bag. • The priming filling of the set is different, depending on the type of filter (floating valve or membrane) within the set. • beneficial when administering fluids to neonates, very young children, and older adults. PROS: reduces rapid-dose infusion by IV push; admin of meds that are stable for a limited time; control of IV fluid intake

extravasation

• administration of vesicant solution into surrounding tissue • medication that causes blisers, necrosis, and tissue sloughing • same causes as infiltration • response: stop infusion but do NOT remove catheter; consult the physician for next move (administer antidote); then take out IV, start a new line

catheter embolism

• anything that damages the catheter leading to break off that floats freely in the vessel • SX: depends on location • TX: emergency notify the physician; remove the catheter; apply a high tourniquet; determine how much of cath is left; surgery

thrombosis

• blood clot inside the vein • Causes: multiple puncture attempts; use of too large catheters; hypercoagulable state • SX: slowed IV rates; swollen, tender, redness, engorged veins • TX: stop infusion, discontinue catheter; apply cold compress to decrease blood flow; elevate extremity; surgical intervention • Prevention: make only two attempts at venipuncture; choose small gauge; low dose warfarin

smart pumps

• built-in software programmed from health care pharmacy databases with unit-specific profiles • audible and visual alert when the pump setting does not match the medication administration guidelines • Each pump has the potential to use add-on syringe pumps, permit multiple infusions, and administer patient-controlled analgesia.

ONC

• catheter is over the needle, needle is removed after • advantages: easy to insert, long term therapy, radiopaque detection, infiltration is rare • disadvantages: stylet is inflexible, risk for accidental puncture • sizes: 14 - 22 gauges for adults; larger sizes for viscous fluids and fast delivery rates

maintenance IV

• common rate is 125mL/hr • provisions for pts who cannot meet their needs thru oral routes, yet are otherwise well, i.e. euvolemic w/o electrolyte deficiencies • preop patients who are NPO • the aim is to give enough fluids and electrolytes to meet insensible losses, enable renal excretion of wastes • e.g. saline, glucose 5%, crystalloids

hypovolemia

• decreased circulating fluid volume. • Commonly found when dehydrated, as a result, plasma becomes concentrated as water is lost, the body will begin to pull water from cells to compensate leading to cell shrinkage. • the main defense is vasoconstriction • CVS: ↑HR, ↓BP, ↓ pulse pressure, orthostasis; hemoconcentration • RR: ↑RR, • neuro: ↑confusion (esp. in older adults) • Skin: dryness, turgor

EID

• delivers a measured amount of fluid over a period of time (e.g., 100 mL/hr), using positive pressure. • use an electronic sensor and an alarm that signals if the pressure in the system changes and the desired flow rate alters. • An infiltration is sometimes extensive before a positive-pressure EID alarm responds.

IV site contraindications

• dorsal surface of the hand in the very young and older adult • An infected site • compromised circulation— e.g. vascular (dialysis) graft/fistula, mastectomy, or paralysis • infiltration or thrombosis • Sites distal to previous venipuncture site • Sclerosed or hardened cordlike veins • Areas of venous valves or bifurcation • Veins in the antecubital fossa and wrist *** hair of the IV site may be clipped, but shaving should be avoided

Lactated ringers

• electrolyte replacement solution • prescribed after burns, surgery, trauma • a replacement solution, does not go on as maintenance

hypervolemia

• excessive fluid in extracellular space • r/t excessive intake or inadequate excretion of fluid • can lead to HF, pulmonary edema in cardiac/renal disfunction • leads to hemodilution • CVS: ↓pulse pressure, ↑BP, ↑HR • RR: ↑RR, shallow respirations, crackles • skin: pitting edema, pale or cool, rapid weight gain • Neuro: ALOC, headache, parasthesia

macrodrip

• has a drop factor of 10, 15, 20 gtt/mL. • Should be used when large quantities or fast intravenous infusion rates are necessary. • A solution given rapidly needs to be infused with macro drip tubing, which delivers large drops

microdrip

• has a drop factor of 60 gtt/mL. • If an IV is ordered at a KVO, micro drip tubing is preferred. • also preferred for pediatric applications and may be referred to as pediatric tubing. • often preferred when infusion rates are less than 100 mL per hour • should be used when small or very precise volumes are to be infused. • allow precise regulation of IV fluids even at slow rates for: young children, neonates, severe head trauma, older adults, cardiac/renal dz

hypertonic

• has an osmolality greater than body fluids (300mosm) and are used most often to increase extracellular fluid volume. • pulls fluid into the vascular space resulting in an increased vascular volume (e.g., replace electrolytes, treat shock) • irritating to the vein as well as have the potential to cause phlebitis, HF and pulmonary edema • Examples: D10W, 3% NS, 5% NaCl, D5 0.9% NaCl, D5 0.45% NaCl, D5LR

hypotonic

• has an osmolality less than body fluids and are used most often to hydrate cells (e.g., hypertonic dehydration, required water replacement) • could exacerbate a hypotensive state in a patient with low blood pressure • Examples: 0.45% NS, ⅓ NS

isotonic

• has the same osmolality as body fluids and are used most often to replace extracellular (intravascular) volume (e.g., simple dehydration after prolonged vomiting) • could cause increased fluid overload • Examples: D5W, 0.9% NS, LR

phlebitis

• inflammation of the vein (may be infected) • Risk factors include: chemical and additive irritation, dehydration, position and time catheter has been in place, bacterial cause; • SX: edema, erythema, warmth, pain, cordlike vein • prevention: Rotate IV sites regularly; avoid sites of flexion; avoid osmols >500, pH <5 or >9;

colloids

• large molecules like protein, sugar, starch • attracts water, pulling from interstitium • does not flow freely between compartments • e.g. blood products, sugars, starches

removing catheter

• lift opposite sides of tegaderm and pull laterally to remove the dressing from the side while stabilizing the catheter • withdraw the catheter and apply pressure with gauze • assess cath tip for intactness • assess site for complications

IV patency

• means that the tip of the needle or catheter is without clots and that the catheter or needle tip is positioned away from the vein wall. Allows IV fluids to run freely. • Can be affected by: kink in tubing; restrictive IV dressing, position of pts extremity & control clamp, height of solution bag • If mechanical factors are absent, assess for patency by checking for a blood return.

Premixed solutions

• medications or electrolytes have been added by the manufacturer PROS: increased stability of the solution, selection of the correct medication, and diluents CONS: come in more than one dosage, leading to potential medication errors

crystalloids

• non-protein containing fluids • flows easily through the membranes • can migrate into tissues over time, causing edema • e.g. NS, LR

bleeding

• occurs as a result of local trauma to the vein. • can occur through the catheter if it becomes disconnected from the tubing. The backflow of blood will result in soiling of the IV dressing. • Intervention: apply a pressure dressing over the site to control the bleeding. • If d/t disconnection of tubing, immediately cleanse the ends of the connectors with an antiseptic swab and reconnect.

infiltration

• occurs when IV fluids enter the surrounding space around the venipuncture site. • Cause: obstruction causing backflow; puncture vein wall; leakage at capillary level; • SX: IV rates slowed; edema; skin tightness, pallor, coolness, burning; fluid leaking from puncture site • Prevention: catheter stabilization; make punctures proximal to last puncture; monitor frequently

Ambulatory Pumps

• promote independence and improved quality of life. • Most pumps weigh less than 6 lbs & range from palm size to fitting in a backpack. • Programming capabilities range from rate adjustments, remote site adjustments and therapy specific settings such as pt controlled analgesia.

colloid oncotic pressure

• protein content will attract water • pulls water from tissues into vascular space • e.g. albumin

speed shock

• reaction to rapid infusion of a substance into the system • SX: lightheaded, dizzy, chest tightness, irregular pulse • TX: immediately d/c the drug and hang isotonic solution to KVO; monitor vital signs; notify physician

three additional rights to bolus admin:

• right speed • right monitoring • right flushing

dressing change

• should be changed when loose or soiled • gauze and tape every 48 hours • tegaderm every 5 to 7 days • remove by pulling laterally from side to side

Potassium chloride

• should never be given by IV push or added to a small volume of IV solution. • A direct IV infusion can cause cardiac arrest and may be fatal. • is administered orally or as a premixed IV additive by pharmacy or the manufacturer in a larger volume of IV fluids.

bolus

• small volume of medication through an existing IV infusion line or intermittent IV access site directly into the vein. • Common in emergencies when you need to deliver a fast-acting medication quickly. • CONS: no time to correct errors; too quick = death; irritation to vessels • PROS = good when fluid restricted

pulse pressure

• the difference between systolic and diastolic pressure • when these numbers get closer, to <30-40 apart • a sign of fluid deficit

butterfly IVs

• the needle will stay in the patient • good for one time IV med administration • used for small veins, elderly or infants • immobilize the arm to keep patient from bending with needle • have a high frequency of infiltration

nurse activated piggyback

• times when the pharmacy dispenses an IV piggyback with an unreconstituted medication vial attached to the mini-bag. • It is up to the nurse to break the seal between the vial and the mini-bag and mix the solution at the time of delivery. • Must remember to activate the piggyback.

venous distention

• use of tourniquet • rubbing pts arm from distal to proximal below the proposed site • apply a warm pack to arm for 30 mins • Have patient clench fist • Lightly "tap" skin to bring up vein

restoration IV

• used as needed • e.g. bolus, wide open • solutions given per med and patient status • given for restoration of fluids, electrolytes, blood volume

tourniquet

• used to reduce venous return and cause distention in the veins where an IV catheter will be inserted. • The veins of older patients are more fragile, and therefore a blood pressure cuff may be used instead. • Tourniquet is released after a "flashback" of blood is observed in the catheter's flashback chamber

hydrostatic pressure

• water pressure • with more water = more pressure • water will leak out of vessels due to pressure