Chapter 13 And 15 Iv Therapy


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  • Many Isotonic (most like blood ): used to expand blood volume; same concentration of solutes as blood. Assess for signs of hypervolemia such as bounding pulse, & SOB. Normal saline or 0.9% NaCl Lactated Ringers (sodium, chloride, potassium, calcium & lactate) Hypotonic : provide free water and treat cellular dehydration; promote elimination via kidneys; less concentration of solutes than blood 0.45% NaCl 0.33% NaCl Hypertonic: d raws fluid out of intracellular & interstitial compartment and into vascular compartment, due to higher concentration of solutes than blood; caution for clients with kidney or heart problems. D5 NS Osmosis = water moves from less to greater concentration to equalize D5 1/2 NS D5LR Acidifying solutions used to treat metabolic alkalosis; include D5W in ½ NS (½ NS is the same as 0.45% sodium chloride) Other fluids used to increase blood volume are Volume expanders; include: Dextran & Serum albumin
  • Site varies depending on the client age, the type of solution, the length of time the infusion is to run, the type of solution used & the condition of the veins. Peripheral sites Metacarpal - in the top of the hand Basilic - In the forearm - arm is natural splint and armboards may not needed. Use cathelons/catheters that cover the needle; catheter left in, not needle Cephalic - Also in forearm
  • Remove tubing from bag and straighten it Close roller clamp Hang IV bag on the IV pole Spike the bag by pulling off blue protective cover (keep sterile) and inserting tubing into bag Fill drip chamber ½ full by squeezing it gently Openroller clamp & prime tubing : fill entire tubing with IV solution avoiding any air bubbles; small air bubble less than 0.5 mL usually not harmful unless infusing into a central line Label the tubing with times for solution to be infused, especially if no pump and with tubing change date (usually q 72 hours) Adjust roller clamp to appropriate drip rate or place tubing into an IV pump; set the primary rate and volume in the pump
  • Open tubing same as IV Close roller clamp Hang IVPB on pole Spike bag same as IV Prime tubing Connect IVPB tubing to IV tubing Place wire hanger on pole Lower IV bag on to hanger Adjust roller clamp to appropriate drip rate: check order, check bag correct rate. If using IV pump, set secondary volume & rate; primary IV will start to run when IVPB is infused Label the tubing with date to be changed
  • Small amounts of air do not produce symptoms because air is removed from the circulation. Large boluses of air (3-8 mL/kg) can cause acute right ventricular outflow obstruction and result in cardiogenic shock and circulatory arrest. Subclinical air embolism in hospitalized clients may be common. Procedures that most commonly result in VAE are CV (internal jugular or subclavian) catheterization and pressure infusion of fluids and blood. Symptoms , which develop immediately following embolization, are similar to pulmonary thromboembolism. Severity of symptoms related to degree of air entry and include the following: Dyspnea, Chest pain, Tachycardia, Hypotension, Altered sensorium Circulatory shock or sudden death (clients with severe VAE) Physical: Acute respiratory distress, Tachypnea, Agitation, Disorientation Classic finding - Mill wheel murmur upon auscultation of the heart Cyanosis and hypotension - Accompany severe VAE Actions Once VAE suspected, immediately stop infusion and clamp line. Do not withdraw the catheter at this time unless it cannot be clamped. Promptly place client in Trendelenburg position and rotate toward the left lateral decubitus position. This maneuver helps trap air in the apex of the ventricle, prevents its ejection into the pulmonary arterial system, and maintains right ventricular output. Administer 100% oxygen and intubate for significant respiratory distress or refractory hypoxemia. If CV catheter is present, aspirate from the distal port and attempt to remove air. Catheter may have to be advanced for this to be successful. CPR helps expel air from the pulmonary outflow tract and disperse it into the peripheral pulmonary venous system. Admit client to ICU.
  • Chapter 13 And 15 Iv Therapy

    1. 1. IV Therapy Peggy D. Johndrow
    2. 2. IV Administration <ul><li>Administer into circulatory system </li></ul><ul><li>Large volume infusions: 250mL to 1000 mL </li></ul><ul><li>Bolus injection: IV push </li></ul><ul><li>Volume-controlled infusions: 50 mL to 250 mL </li></ul><ul><ul><li>Piggyback </li></ul></ul><ul><ul><li>Tandem </li></ul></ul><ul><ul><li>Volume-control set </li></ul></ul><ul><ul><li>Mini-infusor pump </li></ul></ul>
    3. 3. IV Solutions <ul><li>Isotonic: concentration most like blood </li></ul><ul><ul><li>Used to expand blood volume </li></ul></ul><ul><ul><ul><li>Normal saline or 0.9% NaCl </li></ul></ul></ul><ul><ul><ul><li>Lactated Ringers </li></ul></ul></ul><ul><li>Hypotonic: concentration less than blood </li></ul><ul><ul><li>Used for dehydration </li></ul></ul><ul><ul><ul><li>0.45% NaCl </li></ul></ul></ul><ul><ul><ul><li>0.33% NaCl </li></ul></ul></ul><ul><li>Hypertonic : concentration greater than blood </li></ul><ul><ul><li>Draws fluid into vascular compartment; not for clients with kidney or heart problems </li></ul></ul><ul><ul><ul><li>D5 NS </li></ul></ul></ul><ul><ul><ul><li>D5 1/2 NS </li></ul></ul></ul><ul><ul><ul><li>D5LR </li></ul></ul></ul>
    4. 4. Overview: IV Insertion <ul><li>Use needle with catheter sheath </li></ul><ul><ul><li>20-22 gauge typical for adult </li></ul></ul><ul><ul><li>If blood transfusion anticipated , use 18 or 20 gauge </li></ul></ul><ul><li>Most IV solution sets deliver 10 drops per mL, or 60 drops per mL(microdrop) </li></ul><ul><li>IV solution should be clear; cloudy solutions may indicate contamination </li></ul><ul><li>Safety shield type of catheter required by OSHA; also called over the needle (ONC) </li></ul>
    5. 5. IV sites <ul><li>Peripheral </li></ul><ul><ul><li>Metacarpal: top of the hand </li></ul></ul><ul><ul><li>Basilic & Cephalic typically used on forearm </li></ul></ul><ul><ul><li>Use most distal part first </li></ul></ul><ul><ul><li>Consider type of solution to be infused </li></ul></ul><ul><li>Central </li></ul><ul><ul><li>IVs inserted into subclavian or jugular vein </li></ul></ul><ul><ul><ul><li>Groshong </li></ul></ul></ul><ul><ul><ul><li>Triple lumen </li></ul></ul></ul><ul><ul><ul><li>Implanted ports </li></ul></ul></ul><ul><ul><li>PICC lines </li></ul></ul>
    6. 6. Precautions for IV Sites <ul><li>Avoid </li></ul><ul><ul><li>Bony prominences </li></ul></ul><ul><ul><li>Legs & feet </li></ul></ul><ul><ul><li>Mastectomy arm </li></ul></ul><ul><ul><li>Operative arm </li></ul></ul><ul><ul><li>Injured arm </li></ul></ul>
    7. 7. Documentation IV Start <ul><li>Number of attempts </li></ul><ul><li>Type of fluid/saline lock </li></ul><ul><li>Insertion site </li></ul><ul><li>Type and size of catheter or needle </li></ul><ul><li>Flow rate </li></ul><ul><li>Response to IV </li></ul><ul><li>Record response to IV fluid, amount infused integrity and patency of system every 1-2 hours </li></ul>
    8. 8. Procedure for Hanging IV Fluid <ul><li>Remove IV bag from protective cover </li></ul><ul><ul><li>Check expiration date & assess for cloudiness or leaks </li></ul></ul><ul><li>Hang the IV bag on a pole </li></ul><ul><li>Remove IV tubing from its bag </li></ul><ul><li>Close roller clamp </li></ul><ul><li>Spike the bag </li></ul><ul><li>Fill drip chamber ½ full </li></ul><ul><li>Open the roller clamp & prime tubing </li></ul><ul><li>Close roller clamp & replace protective cap </li></ul><ul><li>Label the tubing with date to be changed </li></ul><ul><li>Adjust roller clamp to appropriate drip rate or place into IV pump and set rate </li></ul>
    9. 9. Procedure Hanging IVPB <ul><li>Open tubing same as IV </li></ul><ul><li>Close roller clamp </li></ul><ul><li>Hang IVPB bag on pole </li></ul><ul><li>Spike bag same as IV </li></ul><ul><li>Prime tubing </li></ul><ul><li>Connect IVPB tubing to IV tubing </li></ul><ul><li>Place wire hanger on pole </li></ul><ul><li>Lower IV bag on to hanger </li></ul><ul><li>Set correct drip rate </li></ul><ul><li>Label the tubing with date to be changed </li></ul>
    10. 10. Preparation for IV <ul><li>Check physician order </li></ul><ul><li>Check fluid, electrolyte, and nutritional status for baseline information to make comparison of IV effectiveness </li></ul><ul><li>Know agency policies </li></ul><ul><li>Assess client understanding of reasons for procedure </li></ul><ul><li>Assess clothing appropriateness (need wide sleeves) </li></ul><ul><li>Assess veins </li></ul>
    11. 11. IV Equipment <ul><li>Obtain equipment </li></ul><ul><ul><li>Safety catheter needle </li></ul></ul><ul><ul><li>Tourniquet </li></ul></ul><ul><ul><li>Povidone-iodine swabs or chlorhexidine prep </li></ul></ul><ul><ul><li>Alcohol swabs </li></ul></ul><ul><ul><li>Gloves </li></ul></ul><ul><ul><li>Towel </li></ul></ul><ul><ul><li>Transparent dressing </li></ul></ul><ul><ul><li>Tape </li></ul></ul><ul><ul><li>IV tubing & solution bag </li></ul></ul><ul><ul><li>IV pole and/or pump </li></ul></ul>
    12. 12. CHAIN OF INFECTION Microorganism Carrier Person Travel Method A way out Skin puncture Susceptible Person
    13. 13. Prevention of IV site infection <ul><li>CDC guidelines </li></ul><ul><ul><li>Wash Hands </li></ul></ul><ul><ul><li>Use sterile technique </li></ul></ul><ul><ul><li>Change IV solution q 24 hrs </li></ul></ul><ul><ul><li>Change IV site every 48 to 72 hours </li></ul></ul><ul><ul><li>Change IV tubing every 48 hours </li></ul></ul><ul><li>Use gloves & sharps containers </li></ul><ul><li>Check agency policy </li></ul>
    14. 14. Client Education <ul><li>Teach </li></ul><ul><ul><li>S&S of infection or problems </li></ul></ul><ul><ul><li>When to call for help </li></ul></ul><ul><ul><li>How to prevent IV from clotting or being pulled out </li></ul></ul><ul><ul><li>Arm positioning </li></ul></ul><ul><ul><li>Walking with IV pole </li></ul></ul>
    15. 15. Starting IV <ul><li>Check client’s ID bracelet </li></ul><ul><li>Wash hands </li></ul><ul><li>Use eye protection </li></ul><ul><li>Organize equipment at bedside within reach </li></ul><ul><li>Set bed height for ease of nurse </li></ul><ul><li>Put towel under arm </li></ul><ul><li>Place tourniquet around upper arm </li></ul><ul><li>Palpate dilated veins </li></ul><ul><ul><li>Hang arm down to dilate vein </li></ul></ul><ul><ul><li>Select site low on arm first </li></ul></ul><ul><ul><li>Release tourniquet </li></ul></ul>
    16. 16. Prepare Site & Insert IV <ul><li>Put on gloves </li></ul><ul><li>Clean the site </li></ul><ul><ul><li>Alcohol, then betadine (let dry) </li></ul></ul><ul><li>Re-apply the tourniquet 1-2 inches above site </li></ul><ul><li>Secure vein by placing thumb 2-3 in below site and gently stretching skin </li></ul><ul><li>Stick vein (15 to 30 degree angle) with bevel of needle up </li></ul><ul><li>Watch for flashback in chamber </li></ul>
    17. 17. Insert Catheter <ul><li>Stabilize stylet and advance catheter </li></ul><ul><li>Loosen stylet from catheter </li></ul><ul><li>Release tourniquet </li></ul><ul><li>Hold thumb over vein above catheter tip </li></ul><ul><li>Remove stylet and attach IV tubing; put stylet in sharps container </li></ul><ul><li>Connect tubing </li></ul>
    18. 18. Start Fluid <ul><li>Start IV fluid at slow rate </li></ul><ul><li>Secure catheter </li></ul><ul><ul><li>Transparent dressing over insertion site </li></ul></ul><ul><ul><li>Tape over hub of catheter </li></ul></ul><ul><ul><ul><li>No tape near site of insertion </li></ul></ul></ul><ul><ul><li>Label site with date, time & initials </li></ul></ul><ul><ul><li>Label tubing with date to be changed </li></ul></ul><ul><ul><li>Chart </li></ul></ul><ul><ul><ul><li>Date, time, type & gauge of catheter, dressing type </li></ul></ul></ul><ul><ul><ul><li>Fluid attached as IV </li></ul></ul></ul><ul><ul><ul><li>Clients reaction to procedure </li></ul></ul></ul>
    19. 19. IV Flow Rate <ul><li>Nurse responsible for flow rate maintenance </li></ul><ul><ul><li>Can result in fluid overload leading to cardiovascular, renal or neurological impairment </li></ul></ul><ul><li>Controlled by roller clamp, controller device or IV pump, & affected by client position </li></ul><ul><li>Controller device & roller clamp work with gravity (must be 36 inches above site) </li></ul>
    20. 20. Controller Device & Roller Clamp <ul><li>Determine hourly rate </li></ul><ul><li>Determine drops/minute rate </li></ul><ul><li>Set rate by counting drips per 15 seconds & multiply by 4 to get drops per minute </li></ul><ul><li>Mark time in hours on IV bag tape help keep the rate accurate </li></ul><ul><li>Readjust rate as needed </li></ul>
    21. 21. IV Pump/Controller <ul><li>IV pumps deliver IV fluids by exerting positive pressure on fluid tubing </li></ul><ul><ul><li>Most pumps alarm with an occlusion, but many times they continue to infuse even when infiltrated </li></ul></ul><ul><li>Insert tubing into pump’s flow control chamber or path </li></ul><ul><li>Set rate in mLs per hour on the pump </li></ul><ul><li>Set the volume to be infused (VTBI) </li></ul><ul><li>Press the start button </li></ul><ul><li>Monitor a few minutes to be sure the pump is functioning </li></ul>
    22. 22. Intermittent Therapy or Saline Lock <ul><li>Must be flushed at regular intervals with saline or heparin to maintain patency (usually q shift) </li></ul><ul><li>Flushes prevent clotting of catheter & maintain patency of IV site </li></ul><ul><ul><li>For intermittent access (meds) </li></ul></ul><ul><ul><li>For potential access (telemetry) </li></ul></ul><ul><ul><li>For tests (stress test, etc) </li></ul></ul><ul><li>Use push-pull technique </li></ul><ul><li>When client takes shower, cover IV site with plastic </li></ul>
    23. 23. Converting IV to Intermittent Therapy <ul><li>Check the order </li></ul><ul><li>Obtain equipment & take to bedside </li></ul><ul><ul><li>Syringe with saline/heparin </li></ul></ul><ul><ul><li>INT device & extension tubing </li></ul></ul><ul><li>Check ID bracelet </li></ul><ul><li>Instruct client </li></ul><ul><li>Wash hands </li></ul><ul><li>Don gloves </li></ul><ul><li>Prime INT device </li></ul><ul><li>Remove IV tubing & replace with INT device </li></ul><ul><li>Tape securely </li></ul><ul><li>Flush with saline (3 ccs)/heparin (as ordered) </li></ul>
    24. 24. IV Site Complications <ul><li>Assess IV site for: </li></ul><ul><ul><li>Infection: redness, warmth, swelling & pain; possible fever, & site discharge </li></ul></ul><ul><ul><li>Infiltration: redness, edema at the site, burning pain, coldness, fluid will not flow by gravity </li></ul></ul><ul><ul><li>Blood backflow does not always mean IV not infiltrated </li></ul></ul>
    25. 25. Other IV Complications <ul><li>Allergic reaction : rash, redness, itching, anaphylaxis </li></ul><ul><li>Circulatory overload: dyspnea, cyanosis, JVD, edema, wt gain, ascites </li></ul><ul><li>Air embolism: decreased blood pressure, cyanosis, tachycardia, JVD, dyspnea </li></ul>
    26. 26. Macrodrops and Microdrops
    27. 27. IV Tubing Label
    28. 28. IV Tubing Label
    29. 29. Math problems
    30. 30. Calculating Rate in Drops per Minute <ul><li>Formula </li></ul><ul><li>Volume x drop factor = gtts/min </li></ul><ul><li>Time in minutes =60 x hours </li></ul>
    31. 31. Calculating Rate in mL per Hour <ul><li>Formula: </li></ul><ul><li>Volume = mL/hr </li></ul><ul><li>Hours </li></ul>
    32. 32. Infusion Time <ul><li>Formula: </li></ul><ul><li>Volume x drop factor (gtts/mL) = hours to infuse </li></ul><ul><li>Flow rate (gtts/min) x 60 </li></ul>
    33. 33. Calculation of Medication <ul><li>Use ratio and proportion </li></ul><ul><li>Medication amount available = Amount to give </li></ul><ul><li>Amount of mL X mL </li></ul>
    34. 34. Intermittent Therapy <ul><li>Special adapter: flush with NS every shift; use push-pull technique to flush (push fluid in & continue to push in as pull syringe out of adapter), if needle-less system clamp tubing while still pushing fluid; usually use 2-3 cc of NS to flush </li></ul><ul><ul><ul><ul><li>SAS : saline, additive (medication), saline </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pediatric clients: often use heparin solution to lock; SASH </li></ul></ul></ul></ul>
    35. 35. IV Intake <ul><li>Example : John's primary IV is running at 34 mL/hr while NPO. When the nurse runs the Vancomycin (250 mg IV q 8 hr) in over 90 minutes [volume is 100 ml], the primary IV is stopped. The ampicillin (395 mg IV q 6 hr) is given concurrently in 10 ml of fluid over 30 minutes. He received 2 boluses of aminophylline (20 ml each over 20 minutes). The IV fluids were stopped while the aminophylline infused. Since microtubing was used for the medications, total flush is negligible (approximately 3 ml). What is John’s total IV intake for 24 hours? </li></ul>
    36. 36. Calculate using the critical information : <ul><li>Vancomycin runs 1.5 hrs x 3 doses = 4.5 hrs IV is stopped </li></ul><ul><li>Primary IV flds 24 (hr) minus 4.5 = 19.5 hrs. </li></ul><ul><li>Primary fld stopped as aminophylline is infusing: 20 min x 2 = 40 minutes </li></ul><ul><li>Primary fld 19 hr 30 min. - 40 minutes = 18 hr 50min (18.83 hrs) x 34 mL = 640.22 mL </li></ul>
    37. 37. Calculation <ul><li>Vancomycin: 100 cc x 3 = 300 mL </li></ul><ul><li>Ampicillin 20 cc x 2 = 40 mL </li></ul><ul><li>Aminophylline 20 cc x 2 = 40 mL </li></ul><ul><li>Normal saline flush (approx.) = 3 mL </li></ul><ul><li>640.22 + 300 + 40 + 40 + 3 =1023.22 mL/24hrs </li></ul><ul><li>John's daily IV intake, based on all therapeutic modalities, is 1023.5 mL </li></ul>
    38. 38. Calculate Total Intake and Output <ul><li>Example : Crystal has an IV infusing at KVO (10 mL/hr). She receives an antibiotic in 22.5 mL q 8° concurrently. One mL flush is given after each antibiotic. She is given 30 mL of formula q 3°. She had diaper weights of 17 mL, 33 mL, 55 mL, 45 mL, 52 mL, 50 mL, 15 mL, and 36 mL. </li></ul><ul><li>Calculate her I & O for the past 24 hours. </li></ul>
    39. 39. Intake: <ul><li>IV @ 10 mL/hr x 24 hr = 240 mL </li></ul><ul><li>Med of 22.5 mL x 3 (q8°) = 67.5 mL </li></ul><ul><li>Flush of 1 mL x 3 = 3 mL </li></ul><ul><li>Formula of 30 mL x 8 (q 3°) = 240 mL </li></ul><ul><li>240 mL + 67.5 mL + 3 mL + 240 mL = 550.5 mL </li></ul><ul><li>Crystal's intake is 550.5 mL for the past 24 hours </li></ul>
    40. 40. Weigh Diaper <ul><li>Gm and mL </li></ul><ul><li>Weight of diapers, measurement is &quot; grams “ </li></ul><ul><li>Volume of urine output is &quot;mL“ </li></ul><ul><li>A 'gram' and a 'mL' are equivalent when measuring water. </li></ul><ul><li>In clinical setting, use grams and mLs as equivalent when measuring urine by diaper weights </li></ul><ul><li>Best noninvasive method currently have and is close enough for clinical decision making </li></ul><ul><li>Process is to weigh diaper on a gram scale and record output in 'mL (must account for weight of dry diaper the same size used) </li></ul>
    41. 41. Output: <ul><li>17 + 33 + 55 + 45 + 52 + 50 + 15 + 36 = 303 mL </li></ul><ul><li>Crystal's output is 303 mL for the past 24 hours. </li></ul>