Iv Therapy

IV TherapyC Washington RN, MSNEd

IV TherapyAdministration of fluids, electrolytes, nutrients, or medications by the venous routeClients receiving IV therapy require constant monitoring for complications

Indication for IV TherapyEstablish or maintain a fluid or electrolyte balance Administer continuous or intermittent medication Administer bolus medication Administer fluid to keep vein open (KVO) Administer blood or blood components

Indication for IV TherapyAdminister intravenous anesthetics Maintain or correct a patient's nutritional stateAdminister diagnostic reagents Monitor hemodynamic functions

Major Types of IV Fluids Isotonic Fluids – increases extracellular fluid volumeO.9% NS-expands intravascular volume5% dextrose & water-lowers serum Na+

Isotonic fluids Same osmolarity as serum- 275-295 mOsm/kg

Fluid stays within the intravascular space

Fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance).Isotonic FluidUsed for hypotensive or hypovolemic patients

Risk of fluid overload, esp in patients with CHF & HTN

Contain an approximately equal number of molecules (blue dots nest slide) In this example, there is no fluid flow into or out of the intravascular space.

Hypotonic FluidsLowers the osmotic pressure and causes fluid to move into cellsO.45% NS-maintains level of plasma sodium & chloride

Hypotonic fluids < 275mOsm/kg Dilutes the serum, which decreases serum osmolarity

Used for dehydrated and dialysis patient on diuretic therapy

Used for diabetic ketoacidosis - high serum glucose levels draw fluid out of the cells & into the vascular & interstitial compartmentsHypotonic fluids Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells-cardiovascular collapse and increased intracranial pressure (ICP) in some patients

Example: D5NS.45 (5% dextrose in 1/2 normal saline).Hypotonic fluids Water is pulled from the vascular compartment into the interstitial fluid compartment. As the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells.

Hypotonic fluidsContain a lower number of molecules than serumFluid shifts from the intravascular space to the interstitial space (represented by the green arrows). Decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it) which then causes fluid to move into the cells.

Green arrows represent fluid movement, not molecule movement

Hypertonic FluidsIncreases osmotic pressure, drawing fluid from cellsD5% in 0.45% NS-provides sodium chloride

Hypertonic fluids> 295 mOsm/kg Higher osmolarity than serumStabilize blood pressure, increase urine output, and reduce edema. Rarely used in the prehospital setting Dangerous in the setting of cell dehydrationExamples: 9.0% NS, blood products, and albumin

Hypertonic SolutionPulls fluid & electrolytes from the intracellular & interstitial compartment into the intravascular compartment

Hypertonic fluidsContain a higher number of molecules than serum Increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.

Fluid shifts from the interstitial space to the intravascular space

CrystalloidIdeal for patients who need fluid replacement. Used as a replacement to support blood pressure from blood loss Examples: Lactated Ringer's (LR), NS (normal saline)

ColloidsDraw fluid from the interstitial & intracellular compartments into the vascular compartmentReduce edema (pulmonary or cerebral edema) while expanding the vascular compartment. Examples: albumin and steroids

Initiating Intravenous Therapy

Starting an IV is an art-form which is learned with experience accumulated after performing many IVs. Some patients are easy but many are difficult.

IV Equipment Peripheral IV & Heparin locks – establish a venous route in those clients whose condition may change rapidlyVascular Access Devices – allow long-term IV therapy

Steel Needles: Butterfly catheterDeliver small quantities of medicinesDeliver fluids via the scalp veins in infantsDraw blood samples (although not routinely, since the small diameter may damage blood cells). Small gauge needles

Over the Needle Catheters Example: peripheral IV catheter. This is the kind of catheter you will primarily be using.

A Word About GaugesGauge is the diameter of catheter The smaller the diameter, the larger the gaugeA 22-gauge catheter is smaller than a 14-gauge catheterThe greater the diameter, the more fluid can be delivered

A Word About GaugesTo deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter

A Word About GaugesTo administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

Veins of the HandDigital Dorsal veins (1)Dorsal Metacarpal veins (2)Dorsal venous network (3)Cephalic vein (4)Basilic vein (5)

Veins of the ForearmCephalic vein (1)Median Cubital vein (2)Accessory Cephalic vein (3)Basilic vein (4)Cephalic vein (5)Median antebrachial vein (6)

Points to RememberTry to cannulate the most distal veins first

Failed cannulation attempts of antecubital veins can cause problems in the event of a successful cannulation further down

Any drugs or fluids put through the cannula may extravasate at the failed cannula site.Points to RememberCepahlic veins (1, 3, 5) are the best veins availableLarge and the forearm provides a natural splint

Points to RememberPlacing the cannula too far distally along the vein, you can run into problems with the wrist joint, and are getting close to the radial nerve

The tendons that control the thumb can obscure the vein

These problems can usually be avoided by moving a little further proximally along the veinPoints to RememberBasilic vein (4) is often overlookedHides along the ulnar border of the hand and forearm. It's fairly large It can roll like a tanker in a rough seaCan have more valves than a submarine.

Points to RememberDorsal veins are often quite handyMetacarpals splint cannulae wellThey can be quite small. If the patient is elderly, look elsewhereLack of turgor in the skin & loss of subcutaneous tissue make it quite difficult to cannulate these veins

Points to RememberCannulation of the antecubital veins may occlude the vein as the patient bends their arm

Avoid areas where cannulation or venipuncture has previously taken place

Repeated puncture of the vein wall can result and is painfulPoints to RememberLocate the vein section with the straightest appearance

Choose a vein that has a firm, round appearance or feel when palpated

Avoid areas where the vein crosses over jointsPreparation: Gather SuppliesAbsorbent disposable sheet 1 alcohol prep pad 1 betadine swab Tourniquet IV catheter IV tubing Bag of IV fluid 4 pieces of tape Disposable gloves Gauze (several pieces of 4x4 or 2x2)

Inspect the fluid bag:desired fluidfluid is clearbag is not leakingbag is not expired

Prepare the IVF administration setSelect mini or macro drip administration set

Do not let the ends of the tubing become contaminated.

Close the flow regulator (roll the wheel away from the end you will attach to the fluid bag).

Remove the protective covering from the port of the fluid bag and the protective covering from the spike of the administration set. Prepare the IVF administration setInsert the spike of the administration set into the port of the fluid bag with a quick twist. Do this carefully. Be especially careful to not puncture yourself!

Prepare the IVF administration setIf you overfill the chamber, lower the bag below the level of the drip chamber and squeeze some fluid back into the fluid bag.Hold the fluid bag higher than the drip chamber of the administration setSqueeze the drip chamber once or twice to start the flow. Fill the drip chamber to the marker line (approximately one-third full).

Prepare the IVF administration setOpen the flow regulator & allow the fluid to flush all the air from the tubing

Let it run into a trash can or even the (now empty) wrapper the fluid bag came in.

You may need to loosen or remove the cap at the end of the tubing to get the fluid to flow although most sets now allow flow without removal. Prepare the IVF administration setTake care not to let the tip of the administration set become contaminated.

Turn off the flow & place the sterile cap back on the end of the administration set (if you've had to remove it).

Place this end nearby so you can reach it when you are ready to connect it to the IV catheter in the patient's vein. Perform the venipunctureBe sure you have introduced yourself to your patient & explained the procedure

Apply a tourniquet high on the upper arm

It should be tight enough to visibly indent the skin, but not cause the patient discomfort

Have the patient make a fist several times in order to maximize venous engorgement

Lower the arm to increase vein engorgement

Perform the venipunctureSelect the appropriate vein

If you cannot easily see a suitable vein, you can sometimes feel them by palpating the arm using your fingers (not your thumb)

The vein will feel like an elastic tube that "gives" under pressure

Tapping on the veins, by gently "slapping" them with the pads of two or three fingers may help dilate them. Perform the venipunctureIf you still cannot find any veins, then it might be helpful to cover the arm in a warm, moist compress to help with peripheral vasodilatation

If after a meticulous search no veins are found, then release the tourniquet from above the elbow and place it around the forearm and search in the distal forearm, wrist and hand

If still no suitable veins are found, then you will have to move to the other arm.

Be careful to stay away from arteries, which are pulsatile. Perform the venipunctureDon disposable gloves

Clean the entry site carefully with the alcohol prep pad

Allow it to dry. Then use a betadine swab.

Allow it to dry. Use both in a circular motion starting with the entry site and extending outward about 2 inches.

(Using alcohol after betadine will negate the effect of the betadine) Note that some facilities may require an alcohol prep without betadine. Perform the venipuncture

Perform the venipunctureTo puncture the vein, hold the catheter in your dominant handWith the bevel up, enter the skin at about a 30 to 45 degree angle and in the direction of the veinUse a quick, short, jabbing motionAfter entering the skin, reduce the angle of the catheter until it is nearly parallel to the skin

Perform the venipunctureIf the vein appears to "roll" (move around freely under the skin), begin your venipuncture by apply counter tension against the skin just below the entry site using your nondominant hand.

Many people use their thumb for this. Pull the skin distally toward the wrist in the opposite direction the needle will be advancing.

Be careful not to press too hard which will compress blood flow in the vein and cause the vein to collapse

Then pierce the skin and enter the vein as above. Perform the venipunctureAdvance the catheter to enter the vein until blood is seen in the "flash chamber" of the catheter.

If not successfulSlowly withdraw the catheter, without pulling all the way out

Carefully watch for the flashback to occur

If you are still not within the vein, advance it again in a 2nd attempt to enter the vein

While withdrawing always stop before pulling all the way out to avoid repeating the painful initial skin puncture. If not successfulIf after several manipulations the vein is notenteredrelease the tourniquet

place gauze over the skin puncture site

Try again in the other arm. Inadvertently entering an arteryBright red blood is quickly seen in the IV tubing and the IV bag because of the high pressure that exists. If this occurs, stop the fluid flow, remove the catheter, and put pressure on the site for at least 5 minutes.

If SuccessfulAfter entering the vein, advance the plastic catheter (which is over the needle) on into the vein while leaving the needle stationary.

The hub of the catheter should be all the way to the skin puncture site.

The plastic catheter should slide forward easily.

Do not force it!! If SuccessfulAdvance the plastic catheter

If SuccessfulRelease the tourniquet

If SuccessfulApply gentle pressure over the vein just proximal to the entry site to prevent blood flow.

Remove the needle from within the plastic catheter.

Dispose of the needle in an appropriate sharps container.

NEVER reinsert the needle into the plastic catheter while it is in the patient's arm!

Reinserting the needle can shear off the tip of the plastic catheter causing an embolus. If SuccessfulRemove the protective cap from the end of the administration set and connect it to the plastic catheter.

Adjust the flow rate as desired. If SuccessfulTape the catheter in place using the strips of tape and/or a clear dressing. It is advisable not to use the "chevron" taping technique.

If Successful Label the IV site with the date, time, and your initials. Monitor the infusion for proper flow into the vein (in other words, watch for infiltration).

IV Therapy: Sample IV Orders1 L 5%D/0.45 NaCl with 20 mEq KCL at 125cc/hr1000 ml D5 ½ NS with 20 mEq KCL every eight hours1000 ml D5 ½ NS with 20 mEq KCL to run in 8 hrs

Flow Rates: Microdrip sets Allow 60 drops (gtts) / mL through a small needle into the drip chamberGood for medication administration or pediatric fluid delivery

Flow Rates: Macrodrip setsAllow 10 to 15 drops / mL into the drip chamberGreat for rapid fluid deliveryAlso used for routine fluid delivery and KVO

Flow RatesHow much fluid do you want your patient to receive each hour? “Keep the Vein Open” (KVO), infusing IVF slowly to keep the vein patent, small amount of volume infusedFaster flow rate are expressed in mLs/hr Maintenance“ amount: NS at 125 ml/hr Your patient would receive 125 mL of fluid every hour

Flow RatesUnless you are using an electronic pump to deliver the fluid at precise amounts, you will need to learn how to set a flow rate yourself.

This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute.

To do this, you must know what size administration set you are using (micro or macrodrip).

Plug the numbers into the following formula and you've got it! (See Drug Calculation Handout)Calculating Flow RateTotal Volume = mL/hour infusion rateHours of InfusionFor example:1000 mL = 125 mL/hour infusion rate 8 Hours

IV Therapy: IV LabelAmount & Type of solutionAdditives & their concentrationsRate & duration of IV therapyExpiration dateInitials of pharmacist who preparedPt’s name & room #Date & time startedRN initials

IV Therapy: DocumentationType of fluid & flow rateInsertion site location (L forearm, R hand, L antecubital)State of IV site (swelling, reddness, pain)Patient’s response to therapyIV intake on I & O flow record

Managing IV TherapyIV Therapy requires constant monitoring

Peripheral IV and PICC line Assessment

discoloration: redness, bruise

maceration Managing IV TherapyConcerns may be:Hypervolemia (increased fluid volume)Infiltration (seepage of foreign substances)Phlebitis

IV Therapy: Nursing CareMonitor IV site & infusion every 2 hoursPt age, size, status, c/o discomfort, teachingIntake & OutputNo IV solution hung > 24 hrsMonitor for complications

IV Therapy: Nursing CareChange IV site, dressing, tubing per institution policy (standard q 72-96 hrsNo application of antimicrobial ointment on catheter sitePrevent neddle stick injuryStandard precautions

Complications of IV TherapyPhebitisPain, increased skin temp, erythema, along path of vein

Complications of IV TherapyInfectionIV site red, swollen, warm, tender; purulent foul smelling drainage

Complications of IV TherapyHematomaDiscolored area/bruising around IV site, pain, swelling

Complications of IV TherapyInfiltrationSwelling, possible pitting edema, pallor, coolness pain at site, decrease flow

Complications of IV TherapyExtravasation - inadvertent administration of a vesicant substance into the tissues can have disastrous outcome.

Iv Therapy

More Related Content

What's hot

Similar to Iv Therapy

More from washinca

Recently uploaded

Iv Therapy

Editor's Notes