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Intravenous therapy or IV therapy is the giving of liquid substances directly in

to a vein. The word intravenous simply means "within a vein". Therapies administ
ered intravenously are often called specialty pharmaceuticals. It is commonly re
ferred to as a drip because many systems of administration employ a drip chamber
, which prevents air entering the blood stream (air embolism) and allows an esti
mate of flow rate. Compared with other routes of administration, the intravenous
route is the fastest way to deliver fluids and medications throughout the body.
Some medications, as well as blood transfusions and lethal injections, can only
be given intravenously Peripheral Cannula This is the most common intravenous a
ccess method in both hospitals and pre-hospital services. A peripheral IV line c
onsists of a short catheter (a few centimeters long) inserted through the skin i
nto a peripheral vein (any vein that is not inside the chest or abdomen). This i
s usually in the form of a cannulaover-needle device, in which a flexible plasti
c cannula comes mounted on a metal trocar. Once the tip of the needle and cannul
a are located in the vein the trocar is withdrawn and discarded and the cannula
advanced inside the vein to the appropriate position and secured. Blood may be d
rawn at the time of insertion. Any accessible vein can be used although arm and
hand veins are used most commonly, with leg and foot veins used to a much lesser
extent. On infants the scalp veins are sometimes used. The caliber of cannula i
s commonly indicated in gauge, with 14 being a very large cannula (used in resus
citation settings) and 24-26 the smallest. The most common sizes are 16-gauge (m
idsize line used for blood donation and transfusion), 18- and 20-gauge (all-purp
ose line for infusions and blood draws), and 22-gauge (all-purpose pediatric lin
e). 12- and 14-gauge peripheral lines actually deliver equivalent volumes of flu
id faster than central lines, accounting for their popularity in emergency medic
ine. These lines are frequently called "large bores" or "trauma lines". The larg
er the cannula the more discomfort there is for the patient and it is sometimes
kinder to give a small injection of local anaesthetic into the intended site of
insertion of the larger (18G and above) cannula. To make the procedure more tole
rable for children topical local anaesthetic (such as EMLA or Ametop) can be app
lied for about 45 minutes beforehand. The part of the catheter that remains outs
ide the skin is called the connecting hub; it can be connected to a syringe or a
n intravenous infusion line, or capped with a bung between treatments. Ported ca
nnulae have an injection port on the top that is often used to administer medici
ne. Complications
If the cannula is not sited correctly, or the vein is particularly fragile and r
uptures blood may leak into the surrounding tissues, this situation is known as
a "tissuing" or a "blown vein". Using this cannula to administer medications cau
ses extravasation of the drug which can lead to edema, causing pain and tissue d
amage, and even necrosis depending on the medication. The person attempting to o
btain the access must find a new access site proximal to the "blown" area to pre
vent extravasation of medications through the damaged vein. For this reason it i
s advisable to site the first cannula at the most distal appropriate vein. If a
patient needs frequent venous access, the veins may scar and narrow, making any
future access extremely difficult or impossible. A peripheral IV cannot be left
in the vein indefinitely, because of the risk of insertion-site infection leadin
g to phlebitis, cellulitis and sepsis. The US Centers for Disease Control and Pr
evention updated their guidelines and now advise the cannula need to be replaced
every 96 hours.[1] This was based on studies organised to identify causes of Me
thicillin-resistant Staphylococcus aureus MRSA infection in hospitals. In the Un
ited Kingdom, the UK Department of health published their finding about risk fac
tors associated with increased MRSA infection, now include intravenous cannula,
central venous catheters and urinary catheters as the main factors increasing th
e risk of spreading antibiotic resistant strain bacteria. Forms of intravenous t
herapy Intravenous drip An intravenous drip is the continuous infusion of fluids
, with or without medications, through an IV access device. This may be to corre
ct dehydration or an electrolyte imbalance, to deliver medications, or for blood
transfusion. IV fluids Saline solution for IV There are two types of fluids tha
t are used for intravenous drips; crystalloids and colloids. Crystalloids are aq
ueous solutions of mineral salts or other watersoluble molecules. Colloids conta
in larger insoluble molecules, such as gelatin; blood itself is a colloid. Collo
ids preserve a high colloid osmotic pressure in the blood, while, on the other h
and, this parameter is decreased by crystalloids due to hemodilution. [2] Howeve
r, there is still controversy to the actual difference in efficacy by this diffe
rence.[2] Another difference is that crystalloids generally are much cheaper tha
n colloids.[2] The most commonly used crystalloid fluid is normal saline, a solu
tion of sodium chloride at 0.9% concentration, which is close to the concentrati
on in the blood (isotonic). Ringer's lactate or Ringer's acetate is another isot
onic solution often used for
large-volume fluid replacement. A solution of 5% dextrose in water, sometimes ca
lled D5W, is often used instead if the patient is at risk for having low blood s
ugar or high sodium. The choice of fluids may also depend on the chemical proper
ties of the medications being given. Intravenous fluids must always be sterile.
Composition of common crystalloid solutions [Na+] [Cl-] Solut Other [Glucose] [G
lucose] (mmol/L (mmo ion Name (mmol/L) (mg/dl) ) l/L) 5% D5W Dextr 0 0 278 5000
ose 3.3% 2/3D Dextr & ose / 51 51 185 3333 1/3S 0.3% saline Halfnorm 0.45% 77 77
0 0 al NaCl saline Norm 0.9% al 154 154 0 0 NaCl saline Ringe Lactat r's ed 130
109 0 0 lactat Ringer e 5% Dextr ose, D5NS 154 154 278 5000 Norm al Saline Ring
er's lactate also has 28 mmol/L lactate, 4 mmol/L K+ and 3 mmol/L Ca2+. Ringer's
acetate also has 28 mmol/L acetate, 4 mmol/L K+ and 3 mmol/L Ca2+. Effect of ad
ding one litre Change Solution ECF D5W 333 mL 2/3D & 1/3S 556 mL Half-normal 667
mL saline Normal saline 1000 mL Ringer's lactate 900 mL Risks of intravenous th
erapy Infection Any break in the skin carries a risk of infection. Although IV i
nsertion is a aseptic procedure, skindwelling organisms such as Coagulase-negati
ve staphylococcus or Candida albicans may enter through the insertion site aroun
d the catheter, or bacteria may be accidentally introduced inside the catheter f
rom contaminated equipment. Moisture introduced to
unprotected IV sites through washing or bathing substantially increases the infe
ction risks. Infection of IV sites is usually local, causing easily visible swel
ling, redness, and fever. If bacteria do not remain in one area but spread throu
gh the bloodstream, the infection is called septicemia and can be rapid and life
-threatening. An infected central IV poses a higher risk of septicemia, as it ca
n deliver bacteria directly into the central circulation. Phlebitis Phlebitis is
irritation of a vein that may be caused by infection, the mere presence of a fo
reign body (the IV catheter) or the fluids or medication being given. Symptoms a
re warmth, swelling, pain, and redness around the vein. The IV device must be re
moved and if necessary re-inserted into another extremity. Due to frequent injec
tions and recurring phlebitis, scar tissue can build up along the vein. The peri
pheral veins of intravenous drug addicts, and of cancer patients undergoing chem
otherapy, become sclerotic and difficult to access over time, sometimes forming
a hard “venous cord”. Infiltration Infiltration occurs when an IV fluid accident
ally enters the surrounding tissue rather than the vein. It is characterized by
coolness and pallor to the skin as well as localized swelling or edema. It is us
ually not painful. It is treated by removing the intravenous access device and e
levating the affected limb so that the collected fluids can drain away. Infiltra
tion is one of the most common adverse effects of IV therapy and is usually not
serious unless the infiltrated fluid is a medication damaging to the surrounding
tissue, in which case the incident is known as extravasation. Fluid overload Th
is occurs when fluids are given at a higher rate or in a larger volume than the
system can absorb or excrete. Possible consequences include hypertension, heart
failure, and pulmonary edema. Electrolyte imbalance Administering a too-dilute o
r too-concentrated solution can disrupt the patient's balance of sodium, potassi
um, magnesium, and other electrolytes. Hospital patients usually receive blood t
ests to monitor these levels. Embolism A blood clot or other solid mass, as well
as an air bubble, can be delivered into the circulation through an IV and end u
p blocking a vessel; this is called embolism. Peripheral IVs have a low risk of
embolism, since large solid masses cannot travel through a narrow catheter, and
it is nearly impossible to inject air through a peripheral IV at a dangerous rat
e. The risk is greater with a central IV.
in Change ICF 667 mL 444 mL 333 mL 0 mL 100 mL
in
Air bubbles of less than 30 milliliters are thought to dissolve into the circula
tion harmlessly. Small volumes do not result in readily detectable symptoms, but
ongoing studies hypothesize that these "microbubbles" may have some adverse eff
ects. A larger amount of air, if delivered all at once, can cause lifethreatenin
g damage to pulmonary circulation, or, if extremely large (3-8 milliliters per k
ilogram of body weight), can stop the heart. One reason veins are preferred over
arteries for intravascular administration is because the flow will pass through
the lungs before passing through the body. Air bubbles can leave the blood thro
ugh the lungs. A patient with a heart defect causing a right-toleft shunt is vul
nerable to embolism from smaller amounts of air. Fatality by air embolism is van
ishingly rare, in part because it is also difficult to diagnose. Extravasation E
xtravasation is the accidental administration of IV infused medicinal drugs into
the surrounding tissue which are caustic to these tissues, either by leakage (e
.g. because of brittle veins in very elderly patients), or directly (e.g. becaus
e the needle has punctured the vein and the infusion goes directly into the arm
tissue). This occurs more frequently with chemotherapeutic agents and people who
have tuberculosis. IVF INSERTION PROCEDURES
7.
8. 9.
10. 11. 12. 13. 14.
15.
16. 17. 18. 19. 20. 21.
• •
1.
Review physician’s order for type and amount of IV fluid and rate of fluid admin
istration Nurses: follow the six rights of medication administration Assess for
clinical factors/conditions that will respond to or be affected by IV fluid admi
nistration o Peripheral edema o Body weight o Dry skin and mucus membranes o Dis
tended neck veins o Blood pressure changes o Irregular pulse rhythm, increased r
ate o Auscultation of crackles or rhonchi in lungs o Skin turgor o Anorexia, nau
sea and vomiting o Thirst o Decreased urine output o Behavioural change o Decrea
sed capillary refill Assess client’s previous or perceived experience with IV th
erapy and arm placement preference Explain procedure to patient Prepare equipmen
t Universal Precautions: open sterile packages using sterile aseptic technique P
repare IV infusion tubing and solution
22.
23.
Insert infusion set into fluid bag, remove protector cap from tubing insertion s
pike, do not touch spike, and insert spike into opening of IV bag Prime infusion
tubing by filling with IV solution; compress drip chamber and release, allowing
it to fill one-third to one-half full Remove protector cap on end of tubing (so
me tubing can be primed without removal of cap) and slowly open roller clamp to
allow fluid to travel from the drip chamber through the tubing. Close roller cla
mp once the tubing is primed with IV fluid Ensure that the tubing is free of air
and air bubbles. If air and air bubbles are present, tap tubing firmly where ai
r bubbles are located Replace cap on end of infusion tubing Prepare heparin or n
ormal saline lock for infusion Apply disposable gloves Identify accessible vein
for placement of IV cannula. Apply tourniquet around arm above anticubital fossa
or 4 to 6 inches above proposed insertion site. Check for radial pulse (may use
a blood pressure cuff instead of tourniquet) Select well dilated vein. Stroking
the extremity from distal to proximal below the proposed site may foster venous
distension. Vigorous friction and multiple tapping of the veins, especially in
older adults may cause haematoma and/or venous constriction Release tourniquet t
emporarily and carefully Place connection of infusion set or IV plug nearby main
taining sterility Use antiseptic swab agent to cleanse insertion site Reapply to
urniquet 4 to 5 inches above insertion site Perform venipuncture Observe for blo
od return through flashback chamber of catheter or tubing of winged cannula, ind
icating that the bevel of the needle has entered the vein. Lower needle until al
most flush with skin, continue to hold the skin taut, and advance catheter into
vein until the hub rests at venipuncture site Stabilize the cannula with one han
d and release tourniquet with the other. Apply gentle pressure with middle finge
r of nondominant hand 1.25 inches above the insertion. Keep cannula stable with
index finger, slide the catheter off the stylet, remove the stylet, and place di
rectly into sharps container Quickly connect end of the prepared saline lock or
the infusing tubing to end of cannula, secure the connection infusion: Hold the
heparin/saline lock firmly with the nondominant hand and clean with alcohol, ins
ert prefilled syringe containing flush solution into injection cap. Flush inject
ion cap slowly with flush solution by
24. Intermittent
2. 3. 4. 5. 6.
25. Continuous
infusion: Begin infusion slowly opening the clamp of the IV tubing 26. Secure ca
nnula 27. Apply sterile dressing over site
28. Loop tubing alongside the arm and place a second piece of tape directly over
the tape covering the transparent dressing 29. For IV fluid administration, rec
heck flow rate 30. Write date and time of IV placement, cannula gauge size and l
ength and the health care professional s initials (nurse s) on dressing 31. Disp
ose of all sharps in the appropriate sharps container, remove gloves and wash ha
nds 32. Instruct client how to move or turn without pulling on the IV catheter 3
3. Peripheral IV access should be changed every 72-96 hours and more frequently
if complications occur 34. When solution has less than 100ml remaining, next sol
ution should be available at the client’s bedside EQUIPMENTS
• • •
Correct IV solution Proper IV safety access device for venipuncture (will vary w
ith client’s body size and reason for IV fluid administration) A 20 to 22 gauge
flexible catheter is used in most situations for adults whereas a 22 to 24 gauge
catheter may be used for children and older adults or for any client with small
or fragile veins. A large size (20 or 18 gauge) catheter is preferred to allow
rapid infusion of IV fluids or viscous blood product solutions Universal Precaut
ions: gloves, antiseptic swab agent (e.g., alcohol, betadine) to cleanse the sit
e Tourniquet Non-allergenic tape IV pole Sharps container For Heparin or Normal
Saline Lock
• • • • •
For Heparin or Normal Saline Lock
• • • •
Injection cap IV loop or short piece of extension tubing if necessary 1 to 3 ml
of normal saline flush Syringes and 25 gauge needles
Transparent Dressing Only

Transparent dressing
Gauze Dressing Only
• • • • •
2 x 2 or 4 x 4 sterile gauze sponge Sterile tape Collection Needle Vacutainer Bl
ood tubes For Venipuncture for Blood