PARENTERAL FLUIDTHERAPYMaria Carmela L. Domocmat, RN, MSNAssistant ProfessorSchool of NursingNorthern Luzon Adventist College
Outline• Definition of IV therapy• Indication of IV therapy• Type of IV solution• Nursing role in managing patient receiving IV therapy
DEFINITION OF IVTHERAPY
Definition of IV therapyIt is an effective and efficient method of supplying fluiddirectly into intravenous fluid compartment producingrapid effect with availability of injecting large volumeof fluid more than other method of administration.
INDICATION OF IV THERAPY
PURPOSE• The choice of an IV solution depends on the purpose ofits administration.• Restore or maintain F & E• Administer meds• Provide nutrition• Transfusion• Route for blood samples
Types of Solutions• Hypertonic• Draw fluid from cells• D5 in 0.45 Saline• D5 in NS• D5 LR• 3% NaCl• D10W• Hypotonic• Shift fluid into cells• 0.33% Saline• 0.45% Saline• 2.5 Dextrose
EQUIPMENT OF I.V. THERAPY
Equipment• Containers• Glass bottles• Plastic bags• Administration Sets• IV set• Macro drips• Microdrips• Y ports• Buretrols• In line filters• Timing strips• Electronic InfusionDevices
IV Infusion MethodIVInfusionMethodI.V. Bolus(I.V. push)Continuous-drip infusionIntermittentinfusion
Equipment of I.V. therapySolution containers administration sets
VENIPUNCTURE DEVICES• Equipment used to gain access to the vasculatureincludes• Cannulas• needleless IV delivery systems• peripherally inserted central catheter or midline catheter accesslines.
Venipuncture Devices: CANNULAS• Most common peripheral access devices• have an obturator inside a tube that is later removed.“Catheter” and “cannula” : used interchangeably.• main types of cannula devices available are thosereferred to• winged infusion sets (butterfly) with a steel needle or as over-the-needle catheter with wings• indwelling plastic cannulas inserted over a steel needle• indwelling plastic cannulas inserted through a steel needle.
• Scalp vein or butterfly needles• short steel needles with plastic wing handles• Easy to insert• but infiltration occurs easily• because they are small and nonpliable,• use should be limited to obtaining blood specimens oradministering bolus injections or infusions lasting only a few hours• increase the risk for vein injury and infiltration.
• over-the-needle catheter• less likely to cause infiltration• available in long lengths• well suited for placement in central locations.• Parts:• Intracatheters: Plastic cannulas inserted through a hollow needle• Stylet
Venipuncture Devices: NEEDLELESS IVDELIVERY SYSTEMS• an effort to decrease needlestick injuries and exposure toHIV, hepatitis, and other bloodborne pathogens
Blunt cannula syringe
Venipuncture Devices: Peripherally Inserted CentralCatheter or Midline CatheterAccess Lines• Patients who need moderate- to long-term parenteraltherapy• For patients with limited peripheral access• obese or emaciated patients, IV/injection drug users• require IV antibiotics, blood, and parenteral nutrition.• Requires median cephalic, basilic, and cephalic veins• pliable (not sclerosed or hardened)• not subject to repeated puncture.• If these veins are damaged• central venous access via the subclavian or internal jugular vein• surgical placement of an implanted port or a vascular accessdevice
• Also assess the patient for :1- Any allergies and arm placement preference.2- Any planned surgeries.3- Patient’s activities of daily living.4- Type and duration of I.V therapy, amount, and rate.
PREPARING TO ADMINISTER IVTHERAPY• Before performing venipuncture• hand hygiene• applies gloves• informs patient about procedure• Select most appropriate insertion site and type of cannulafor a particular patient.
Factors influencing choices of insertionsite• type of solution to be administered• expected duration of IV therapy• patient’s general condition• availability of veins• skill of the person initiating the infusion
CHOOSING AN IV SITE• Many sites can be used for IV therapy, but ease of accessand potential hazards vary.• peripheral locations• ordinarily only sites used by nurses• arm veins are most commonly used – coz safe and easy to enter• arm veins• metacarpal, cephalic, basilic, and median veins• More distal sites should be used first, with more proximalsites used subsequently.
CHOOSING AN IV SITE• Avoid the following• Leg veins because of high risk of thromboembolism.• veins distal to a previous IV infiltration or phlebitic area, sclerosedor thrombosed veins,• arm with arteriovenous shunt or fistula• arm affected by edema, infection, blood clot, or skin breakdown.• arm on side of mastectomy because of impaired lymphatic flow.
• Central veins• commonly used by physicians• subclavian and internal jugular veins.• Can gain access to (or cannulate) even when peripheral sites havecollapsed• allow for administration of hyperosmolar solutions.• Hazards are much greater
• Consider mobility• Inspect both arms and hands and choose the site that does notinterfere with mobility.• antecubital fossa is avoided : except as a last resort.• Take note from far to near• most distal site of the arm or hand is generally used first so thatsubsequent IV access sites can be moved progressively upward.
factors to consider when selecting a sitefor venipuncture:• Condition of the vein• Type of fluid or medication to be infused• Duration of therapy• Patient’s age and size• Whether the patient is right- or left-handed• Patient’s medical history and current health status• Skill of the person performing the venipuncture
• After applying a tourniquet, the nurse palpates andinspects the vein.• The vein should feel firm, elastic, engorged, and round,not hard, flat, or bumpy.• Because arteries lie close to veins in the antecubitalfossa, the vessel should be palpated for arterial pulsation(even with a tourniquet on), and cannulation of pulsatingvessels should be avoided.
General guidelines for selecting a cannulainclude:• Length: 3⁄4 to 1.25 inches long• Diameter: narrow diameter of the cannula to occupy minimalspace within the vein• Gauge:• 20 to 22 gauge for most IV fluids; a larger gauge for caustic or viscoussolutions• 14 to 18 gauge for blood administration and for trauma patients andthose undergoing surgery• 22 to 24gauge for elderlyNote: Hand veins are easiest to cannulate.Cannula tips should not rest in a flexion area (eg, the antecubitalfossa) as this could inhibit the IV flow.
PREPARING THE IV SITE• Before preparing the skin, ask patient allergy to latex oriodine• Excessive hair at selected site may be removed byclipping• to increase the visibility of the veins and• to facilitate insertion of the cannula and adherence of dressings tothe IV insertion site.
Nursing diagnosis:• Anxiety (mild, moderate, severe) related to threatregarding therapy.• Fluid volume excess.• Fluid volume deficit.• Risk for infection.• Risk for sleep pattern disturbance.• Knowledge deficit related toI.V therapy.
Planning• Identify expected outcomes which focus on:• preventing complications from I.V therapy.• minimal discomfort to the patient.• restoration of normal fluid and electrolyte balance .• patient’s ability to verbalize complications.
Implementation during initiation phase• Solution preparation• Label the I.V container.• Avoid the use of felt-tip pens or permanent markers on plasticbag.• Hang I.V bag or bottle
• Site preparation1. Cleanse infusion site• The insertion site is scrubbed with a sterile pad soaked in 10%povidone–iodine (Betadine) or chlorhexidine gluconate solution for 2 to3 minutes• from the center of the area to the periphery• Allow the area to air day.• site should not be wiped with 70% alcohol• because the alcohol negates the effect of the disinfecting solution• Alcohol pledgets are used for 30 seconds instead, only if the patient is allergicto iodine2. Excessive hair at selected site should be clipped with scissor .
• Maintain sterility of equipment• IV device, the fluid, the container, and tubing must be sterile• Because infection can be a major complication of IV therapy• perform hand hygiene• put on gloves: nonsterile disposable gloves
PERFORMING VENIPUNCTURE• Venipuncture: the ability to gain access to the venoussystem for administering fluids and medications
Source: Brunner and Suddhart, 2010)
Implementation during maintenancephase• inspect the tubing.• inspect the I.V set at routine intervals at least daily.• Monitor vital signs .• recount the flow rate after 5 and 15 minutes afterinitiation• Site care• Dressings• Tubing and bag changes• Prevent complications
• Intermittent flushing of I.V lines• Peripheral intermittent are usually flushed with saline (2-3 ml0.9% NS.)• Replacing equipments (I.V container, I.V set, I.Vdressing):• I.V container should be changed when it is empty.• I.V set should be changed every 24 hours.• The site should be inspected and palpated for tenderness everyshift or daily/cannula should be changed every 72hours and ifneeds.• I.V dressing should be changed daily and when needed
MONITORING THERAPY• Maintaining an existing IV infusion is a nursingresponsibility that demands knowledge of the solutionsbeing administered and the principles of flow.• patients must be assessed carefully for both local andsystemic complications.
Monitoring Therapy• Flow Rate• Influences• Height of container• Diameter of tubing/cannula• Length of tubing• Viscosity• Cannula position• Position of extremity• Site care• dressings• site change• Tubing and bag changes• Prevent complications
FACTORS AFFECTING FLOW• Height of container• Flow is directly proportional to the height of the liquid column.• Raising the height of the infusion container may improve sluggishflow.• Diameter of tubing and cannula• Flow is directly proportional to the diameter of the tubing.• The clamp on IV tubing regulates the flow by changing the tubingdiameter.• flow is faster through large-gauge rather than small- gaugecannulas.
FACTORS AFFECTING FLOW• Length of tubing• Flow is inversely proportional to the length of the tubing.• Adding extension tubing to an IV line will decrease the flow.• Viscosity• Flow is inversely proportional to the viscosity of a fluid.• viscous IV solutions (ex: blood) require a larger cannula than wateror saline solutions• Cannula position• Position of extremity
IV infusion pumps
Evaluation• Produce therapeutic response to medication, fluid andelectrolyte balance.• Observe functioning and patency of I.V system.• Absence of complications.
DISCONTINUING AN INFUSION• The nurse never use scissors to remove the tape ordressing.• Apply pressure to the site for 2 to 3 minutes using a dry,sterile gauze pad.• Inspect the catheter for intactness.• The arm or hand may be flexed• or extended several times.
DISCONTINUING AN INFUSION• The removal of an IV catheter is associated with twopossible dangers:• bleeding• catheter embolism• To prevent excessive bleeding• dry, sterile pressure dressing should be held over the site as thecatheter is removed.• Firm pressure is applied until hemostasis occurs.
• Catheter embolism• Preventive measures• Avoid using scissors near the catheter.• Avoid withdrawing the catheter through the insertion needle.• Follow the manufacturer’s guidelines carefully (eg, cover the needlepoint with the bevel shield to prevent severance of the catheter).• Management• If the catheter clearly has been severed, the nurse can attempt toocclude the vein above the site by applying a tourniquet to prevent thecatheter from entering the central circulation (until surgical removal ispossible). As always, however, it is better to prevent a potentially fatalproblem than to deal with it after it has occurred
Recording and reporting:• Type of fluid, amount, flow rate, and any drug added.• Insertion site.• Size and type of I.V catheter or needle.• The use of pump.• When infusion was begun and discontinuing.• Expected time to change I.V bag or bottle, tubing,cannula, and dressing.
• Any side effect.• Type and amount of flush solution.• Intake and output every shift, daily weight.• Temperature every 4 hours.• Blood glucose monitoring every 6 hours, and rate ofinfusion.
Documentation• Starting the IV• 10/3/08 – 0900 hours – #22 1-inch Gelco inserted on first attempt toR cephalic vein, NS infusing via pump at 125cc/hr. Pt toleratedprocedure well. S. Wise, RNC• Discontinuing the IV• 10/3/08 – 2000 hours – IV R wrist removed without difficulty, cathlonintact. Pt tolerated well. S. Wise, RNC
Infiltration and Extravasation• Infiltration : unintentional administration of a nonvesicantsolution or medication into surrounding tissue.• occur when IV cannula dislodges or perforates the wall ofthe vein.
Infiltration: S/S• edema around insertion site• leakage of IV fluid from insertion site• discomfort and coolness in area of infiltration• significant decrease in the flow rate• When solution is particularly irritating, sloughing of tissuemay result.
• Closely monitoring the insertion site is necessary to detectinfiltration before it becomes severe.• How to check?• insertion area is larger than same site of the opposite extremity• Backflow of blood into tubing proves that the catheter is properlyplaced within the vein. True or false?• If the catheter tip has pierced the wall of the vessel, however, IV fluidwill seep into tissues as well as flow into the vein.• Although blood return occurs, infiltration has occurred as well.
• Closely monitoring the insertion site is necessary to detectinfiltration before it becomes severe.• How to check?• apply a tourniquet above (or proximal to) infusion site andtighten it enough to restrict venous flow.• If the infusion continues to drip despite the venous obstruction,infiltration is present.
Management• infusion should be stopped• IV discontinued• a sterile dressing applied to the site after carefulinspection to determine the extent of infiltration.• infiltration of any amount of blood product, irritant, or vesicant isconsidered the most severe.• Start another IV infusion at new site or proximal toinfiltration if same extremity is used.
Management• warm compress to the site• if small volumes of noncaustic solutions have infiltrated over a longtime• cold compress• ithe infiltration is recent• Elevate affected extremity to promote the absorption offluid• Use standardized infiltration scale to document theinfiltration (Infusion Nursing Standards of Practice)
Standardized infiltration scale0 = No symptoms1 = Skin blanched, edema less than 1 inch in any direction,cool to touch, with or without pain2 = Skin blanched, edema 1 to 6 inches in any direction, coolto touch, with or without pain3 = Skin blanched, translucent, gross edema greater than6 inches in any direction, cool to touch, mild to moderatepain, possible numbness4 = Skin blanched, translucent, skin tight, leaking, skindiscolored, bruised, swollen, gross edema greater than 6 inchesin any direction, deep pitting tissue edema, circulatoryimpairment, moderate to severe pain, infiltration of anyamount of blood products, irritant, or vesicant
Prevention• Inspect site every hour for• Redness• Pain• Edema• blood return• coolness at the site• IV fluid draining from the IV site.• Use appropriate size and type of cannula for veinprevents this complication
Very Serious Complications Can Occur• Infiltration• Non vesicant solution• Extravasation• Vesicant solution
Extravasation• similar to infiltration with an inadvertent administration ofvesicant or irritant solution or medication into thesurrounding tissue.• Medications such as dopamine• calcium preparations• chemotherapeutic agents• can cause pain, burning, and redness at the site• Blistering, inflammation, and necrosis of tissues canoccur.
• The extent of tissue damage is determined by• concentration of medication• quantity that extravasated• location of the infusion site• tissue response• duration of process of extravasation
Management• Stop infusion• Notify physician promptly.• Initiate agency’s protocol for extravasation• protocol may specify specific treatments, including• Antidotes specific to the medication that extravasated• IV line should remain in place or be removed before treatment.• infusion site be infiltrated with an antidote prescribed afterassessment by the physician and application of warm or coldcompresses, depending on the medication infusing.• extremity should not be used for further cannulaplacement.• Thorough neurovascular assessments of the affectedextremity must be performed frequently
Prevention• Review institution’s IV policy and procedures andincompatibility charts and checking with the pharmacistbefore administering any IV medication, whether givenperipherally or centrally• to determine incompatibilities and vesicant potential.• Careful, frequent monitoring of the IV site• avoid insertion of IV devices in areas of flexion
Prevention• secure the IV line• use smallest catheter possible that accommodates thevein• when vesicant medication is administered by IV push, itshould be given through a side port of an infusing IVsolution to dilute the medication and decrease severity oftissue damage if extravasation occurs
Phlebitis• inflammation of a vein related to a chemical or mechanicalirritation, or both.
S/S• reddened, warm area around the insertion site or alongthe path of the vein• pain or tenderness at the site or along the vein, andswelling.• incidence of phlebitis increases with• Length of time the IV line is in place• composition of the fluid or medication infused (especially its pH andtonicity)• size and site of the cannula inserted• ineffective filtration• improper anchoring of the line• introduction of microorganisms at the time of insertion.
specific standards for assessing phlebitis• Intravenous Nursing Society
Thrombophlebitis• refers to presence of a clot plus inflammation in the vein.
Thrombophlebitis- S/S• Localized pain• redness, warmth, and swelling around the insertion site oralong the path of the vein• immobility of the extremity because of discomfort• swelling, sluggish flow rate• Fever• Malaise• Leukocytosis
Management• D/C IV infusion• 1st: cold compress to decrease the flow of blood andincrease platelet aggregation• followed by a warm compress• Elevate extremity• Restart line in the opposite extremity• If (+) patient has signs and symptoms of thrombophlebitis,the IV line should not be flushed• (although flushing may be indicated in the absence of phlebitis toensure cannula patency and to prevent mixing incompatiblemedications and solutions).
Prevention• Avoid trauma to vein at time the IV is inserted,• Observe site every hour• Check medication additives for compatibility
Local Complication- Hematoma• Hematoma• S & S• Interventions• Prevention
Hematoma• Hematoma results when blood leaks into tissuessurrounding the IV insertion site.• Leakage can result from• perforation of opposite vein wall during venipuncture• Needle slipping out of vein• insufficient pressure applied to the site after removing the needle orcannula.
s/s• Ecchymosis• immediate swelling at site• leakage of blood at site.
Management• Remove needle or cannula and apply pressure with asterile dressing• Apply ice for 24 hours to• site to avoid extension of the hematoma• then warm compress to increase absorption of blood;• assessing the site• Restart the line in the other extremity if indicated.
Prevention• carefully insert needle• use diligent care when a patient has a bleeding disorder,takes anticoagulant medication, or has advanced liverdisease
Clotting and Obstruction• Blood clots may form in the IV line as a result of• kinked IV tubing• very slow infusion rate• Empty IV bag• failure to flush the IV line after intermittent medication or solutionadministrations.• The signs are decreased flow rate and blood backflowinto the IV tubing.
Management• If blood clots in the IV line• DC infusion• Restart another site with a new cannula and administration set.• The tubing should not be irrigated or milked. Neither the infusionrate nor the solution container should be raised, and the clot shouldnot be aspirated from the tubing
Prevention• Do not permit IV solution bag to run dry• Tape the tubing to prevent kinking and maintain patency• Maintain adequate flow rate• Flushing line after intermittent medication or other solutionadministration.• In some cases, a specially trained nurse or physician• may inject a thrombolytic agent into the catheter to clearan occlusion resulting from fibrin or clotted blood.
Local Complication-Site Infection• Site infection• S & S• Interventions• Prevention
Local complication-Tissue Sloughing• Tissue Sloughing• S & S• Interventions• Prevention
Systemic Complication• Circulatory or Fluid Overload• Septicemia/ Systemic Infection• Pulmonary Edema• Catheter Embolism• Air Embolism• Pulmonary Embolus
Fluid Overload• Overloading the circulatory system with excessive IVfluids causes increased blood pressure and centralvenous pressure.
Fluid Overload – S/S• moist crackles on auscultation of the lungs• Edema• weight gain• Dyspnea• respirations : shallow and increased rate.
Fluid Overload – causes• rapid infusion of an IV solution or hepatic, cardiac, orrenal disease.• risk for fluid overload and subsequent pulmonary edemais especially increased in elderly patients with cardiac• disease; this is referred to as circulatory overload.
Management• Decrease IV rate• Monitor VS frequently• Assess breath sounds• Place patient in high Fowler’s position• Contact physician immediately.
Prevention• Use infusion pump for infusions• carefully monitoring all infusions.• Complications of circulatory overload• include heart failure and pulmonary edema.
Air Embolism• risk of air embolism is rare but ever-present.• most often associated with cannulation of central veins.
Air Embolism• dyspnea• Cyanosis• hypotension• weak, rapid pulse• loss of consciousness• chest, shoulder, and low back pain.
Management• Immediately clamp the cannula• Place patient on the left side in Trendelenburg position,• Assess VS and breath sounds• Administer oxygen.
Prevention• Use a Luer-Lock adapter on all lines• filling all tubing completely with solution• Use an air detection alarm on an IV pump.
Septicemia and Other Infection• Pyrogenic substances in either the infusion solution or theIV administration set can induce a febrile reaction andsepticemia.
S/s• abrupt temperature elevation shortly after the infusion isstarted• Backache• Headache• increased pulse and respiratory rate• Nausea and vomiting• Diarrhea• chills and shaking• general malaise.• In severe septicemia:• vascular collapse and septic shock
Causes of septicemia• contamination of the IV product or a break in aseptictechnique• especially in immunocompromised patients.
Management• Treatment is symptomatic• culturing of the IV cannula, tubing, or solution if suspect• establishing a new IV site for medication or fluidadministration.
• Infection ranges in severity from local involvement of theinsertion site to systemic dissemination of organismsthrough the bloodstream, as in septicemia.• Measures to prevent infection are essential at the time theIV line is inserted and throughout the entire infusion.
Prevention• Careful hand hygiene before every contact with any partof the infusion system or patient• Examine the IV containers for cracks, leaks, orcloudiness, which may indicate a contaminated solution• Use strict aseptic technique
Prevention• Firmly anchor the IV cannula to prevent to-and-fromotion• Inspect the IV site daily and replace a soiled or wetdressing with a dry sterile dressing. (Antimicrobial agentsthat should be used for site care include 2% tincture ofiodine, 10% povidone–iodine, alcohol, or chlorhexidine,used alone or in combination.
Prevention• Remove the IV cannula at the first sign of localinflammation, contamination, or complication• Replace the peripheral IV cannula every 48 to 72 hours,or as indicated• Replace the IV cannula inserted during emergencyconditions(with questionable asepsis) as soon as possible
Prevention• Use a 0.2-micron air-eliminating and bacteria/particulateretentive filter with non-lipid-containing solutions thatrequire filtration.• The filter can be added to the proximal or distal end of theadministration set.• If added to the proximal end between the fluid container and thetubing spike, the filter ensures sterility and particulate removal fromthe infusate container and prevents inadvertent infusion of air.• If added to the distal end of the administration set, it filters airparticles and contaminants introduced from add-on devices,secondary administration sets, or interruptions to the primarysystem
Disposable Infusion Set IV Filter
Prevention• Replace solution bag and administration set inaccordance with agency policy and procedure• Infuse or discard medication or solution within 24 hours ofits addition to an administration set• Change primary and secondary continuous administrationsets every 72 hours, or immediately if contamination issuspected• Change primary intermittent administration sets every 24hours, or immediately if contamination is suspected
References• Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O.(2008). Brunner & Suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia: LippincottWilliams & Wilkins.• http://webhome.broward.edu/~gbrickma/Slides/IV%20Therapy%209-12-08.ppt• http://www.mc.vanderbilt.edu/root/sbworddocs/proceed_nursing/Revised_web_IV_therapy.ppt• http://uqu.edu.sa/files2/tiny_mce/plugins/filemanager/files/4300164/Type%20and%20indication%20of%20IV%20therapy%202.ppt• http://faculty.irsc.edu/FACULTY/SWise/IV%20therapy.PPT