OBJECTIVES

• Different routes of Administration

• Fluid Compartments
• Definition of IV fluid
• Anatomy of Veins
• Reasons for IV Infusion/IV therapy
• Advantage /Disadvantage of IV therapy
• AR with IV
• Understand the basics IV therapy
DIFFERENT ROUTES
OF ADMINISTRATION
 BODY FLUIDS
COMPOSITION

Total body water= 60% (male)|50%(female) x body wt

= 0.5 X 70 = 35 liters

ECF=1/3 ICF=2/3
0.33 X 35 = 11.6 liters 0.66 X 35 = 23.3 liters

Blood=1/4 (ECF)
0.25 X 10.5 = 2.625 liters
FLUID COMPARTMENTS

Functionally, total body

water can be divided into two
major compartments:
• Extracellular fluid (ECF)
Approximately 80% of
extracellular fluid is interstitial,
which occupies the microscopic
spaces between cells.
Approximately 20% of
extracellular fluid is plasma,
which is the liquid portion of
blood.
• Intracellular fluid (ICF). Within the body it is essential that substances move
around.
This is also known as cytosol
Substances will move from areas of ‘high’
and is the fluid within cells.
concentration to ‘low’ concentration and a
‘concentration gradient’ will exist between the two.
No energy is required for these physiological
movements as they are described as ‘passive’.
Movement is facilitated through processes of
‘osmosis or diffusion’.
NORMAL PLASMA
ELECTROLYTE COMPOSITION
CATION Concentration ANION Concentration
mEq/L mEq/L
Sodium 135-145 Chloride 95-105
Potassium 3.5-5.0 Phosphate 2.5-30
Calcium 4.0-5.5 Sulfate 1.0
Magnesium 1.5-2.5 Organic 2.0
acids
Osmolarity 285-295 Protein 1.6
THE BALANCING ACT
IN OUT (~1-2L/day )
• Drinking • Urine
• Eating • 12-15mL/kg/day
• Metabolism • Feces
• 3mL/kg
• 3mL/kg
• IV Fluids? • Insensible losses
• 10-13mL/kg/day

With no unusual stresses or losses and normal renal

function intake can be balanced to outputs
PRINCIPLES USED FOR MOVEMENT OF FLUID IN
AND OUT OF CELL ARE (OSMOSIS AND DIFFUSION)

IN OSMOSIS IN DIFFUSION

• fluid moves passively from • solutes(particles) move

areas with more fluid to areas from an area of high
with less fluid concentration to an area
of lesser concentration.
• FLUID MOVES
• This process mainly
occurs in gases, liquids
and solutions
• PARTICLES MOVE
DEFINITION OF IV
FLUIDS
 Intravenous simply means "within vein“
 The word "intravenous" as a noun refers to an
intravenous fluid drip, a solution (usually a balanced
electrolyte solution) administered directly into the
venous circulation.
 Intravenous (iv) therapy is the insertion of a needle or
catheter/cannula into a vein. The needle or catheter
/cannula is attached to a sterile tubing and a fluid
container to provide medication and fluids.
 90-95% of patients in the hospital receive some type of
intravenous therapy.
VEIN ANATOMY AND PHYSIOLOGY

Veins are unlike arteries in that

they are 1)superficial, 2) display
dark red blood at skin surface and
3) have no pulsation

Vein Anatomy
- Tunica Adventitia
- Tunica Media
- Tunica Intima
- Valves
WHY VEIN NOT ARTERY?
• Veins are easier to access due to there superficial locations
compared to arteries which are located deeper under the skin.
• Veins have thinner walls than arteries and have less innervation,
so piercing them with a needle require less force and doesn’t
hurts
• The injection in arteries causes lot of pain because they contains
a lot more pain receptor than the veins
• Venous pressure is also lower than arterial pressure, so there is
less chance of blood seeping back through the puncture point
before it heals.
WHY VEIN NOT ARTERY?
• It is safer if a small embolism( bubble in the blood) is introduce
into a vein rather than an artery. Blood flow in vein always goes
to larger and larger vessel, so there is very little chance of vessel
being blocked by the embolism before the bubbles reaches the
heart/lungs and is hope fully destroyed
• Blood flow in an artery, on the other hand, always moves into
smaller and smaller vessels, eventually ending in capillaries and
there is a chance that a bubble introduced by blood draw or
more commonly an IV line could block a small blood vessel,
potential leading to hypoxia in the affected area
Injecting into veins ensures that the medication is disturbed
through the body quickly, with a lower risk of complication.
WHY VEIN NOT ARTERY?
Points to remember:
• Veins are more superficial
• Easily accessible
• Veins are thin walled than arteries
• Veins are low pressure system when compared to arteries
• Blood loss in case of accidental venepuncture is less than in an
artery
• Veins can easily expand to accommodate large volumes of fluid.
INTRAVENOUS ACCESS DEVICES

These can be used to obtain blood (e.g. for testing), also known
as phlebotomy, as well as for the administration of medication and
fluids
• Hypodermic needle
• Peripheral cannula
• Central lines
• Peripherally inserted central catheter
• Central venous lines
• Tunnelled lines
• Implantable ports
INTRAVENOUS ACCESS DEVICES
IV MODES OF ADMINISTRATION

• Peripheral IV line placed into a peripheral vein

• PICC : Central line that is placed via the peripheral
vasculature. Its tip terminates in the superior vena cava
• Peripheral midline catheters: Shorter version of the PICC,
Its tip terminates in the axilla
• Hickman lines: Skin tunneled cuffed central catheters
REASONS FOR IV
INFUSION/IV THERAPY
According to Brooker (2007) and Martin (2003) intravenous fluid therapy may be used to:
• Replace fluids and replace imbalances.
• Maintain fluid, electrolyte and acid-base balance.
• Administer blood and blood products.
• Administer medication.
• Provide parenteral nutrition.
• Monitor cardiac function.
• Immediate results
• To provide avenue for dialysis/apheresis
• To provide avenue for diagnostic testing
• Predictable therapeutic effects
• Administer chemotherapy to cancer patients
• Administer key-controlled analgesics

To administer fluids and medications with the ability to rapidly/accurately change

blood concentration levels by either continuous, intermittent or IV push method.
ADVANTAGE OF IV ROUTE
• The intravenous route is the fastest way to deliver fluids and
medications throughout the body. The bioavailability of the
medication is 100% in IV therapy.
• Easy access to rapid administration of solutions
• Continuous or intermittent administration of nutrients
• Rapid changes in circulatory system
• Easy to monitor delivery of fluids, electrolytes and nutrients ( for
those with impaired GI tracts.)
• Fast Symptom Relief
ADVANTAGE OF IV ROUTE
• Immediate / Therapeutic effect
• Control over the rate of administration / dilute infusions /
prolonged action
• Patient cannot tolerate drugs / fluids orally
• Some drugs cannot be absorbed by any other route
• Pain and irritation is avoided compared to some
substances when given SC/IM
DISADVANTAGE OF IV ROUTE

• More costly than oral or injectable ( IM, SC )

substances
• One IV site has a limited use/time: usually no
more than 72 hours
• Invasive procedure can cause infection,
bleeding adverse side effects
ADVERSE EFFECT OF
IV ROUTE
• Pain: In injection inherently causes pain and is medically invasive.
• Infection: Any break in the skin carries a risk of infection.
• Phlebitis: Phlebitis is inflammation of a vein that may be caused
by infection, symptoms are warmth, swelling, pain, and redness
around the vein
• Infiltration / extravasation:Infiltration occurs when an IV fluid or
medication accidentally enters the surrounding tissue rather
than the vein. Infiltration is characterized by coolness and pallor
to the skin as well as localized swelling or edema.
ADVERSE EFFECT OF
IV ROUTE
• Fluid overload: This 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.
• Hypothermia: The human body is at risk of accidentally induced
hypothermia when large amounts of cold fluids are infused. Rapid
temperature changes in the heart may precipitate ventricular
fibrillation.
• Electrolyte imbalance: Administering a too-dilute or too-
concentrated solution can disrupt the patient's balance of sodium,
potassium, magnesium, and other electrolytes.
• 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 up
blocking a vessel; this is called embolism
WHAT TO DO IF YOU SUSPECT
TRANSFUSION REACTION

Sings of transfusion reaction may include:

fever, flank pain, vital sign changes, nausea, headache,
urticaria, dyspnea, and broncho spasm.
If you suspect a transfusion reaction, take these immediate
actions:
 Stop the transfusion.
 Keep the I.V. line open with normal saline solution.
 Notify the physician and blood bank.
 Intervene for signs and symptoms as appropriate.
 Monitor the patients vital signs.
TWO KINDS OF IV MEDICATION
ADMINISTRATION TECHNIQUE:

• IV push
An IV “push” or “bolus” is a rapid injection of medication. A syringe is inserted into
your catheter to quickly send a one-time dose of drug into your bloodstream.

• IV infusion
An IV infusion is a controlled administration of medication into your bloodstream
over time. The two main methods of IV infusion use either gravity or a pump to send
medication into your catheter:
Pump infusion: In the United States, a pump infusion is the most common method
used. The pump is attached to your IV line and sends medication and a solution, such
as sterile saline, into your catheter in a slow, steady manner. Pumps may be used
when the medication dosage must be precise and controlled.
Drip infusion: This method uses gravity to deliver a constant amount of medication
over a set period of time. With a drip, the medication and solution drip from a bag
through a tube and into your catheter.
WHAT CAN BE GIVEN
THROUGH IV
Substances that may be infused intravenously include
• Volume expanders,
 COLLOIDS
• Always hypertonic
 CRYSTALLOIDS
• Isotonic
• Hypotonic
• Hypertonic
• Blood-based products,
• Blood substitutes,
• Buffer Solution
• Medications and nutrition.
TYPES OF FLUID
1.Colloid
• Solutions that contain large molecules that don't
pass the cell membranes.
• When infused, they remain in the intravascular
compartment and expand the intravascular volume
and they draw fluid from extravascular spaces via
their higher oncotic pressure
TYPES OF FLUID
2.Crystalloid
• Solutions that contain small molecules that flow easily across
the cell membranes, allowing for transfer from the bloodstream
into the cells and body tissues.
• A clear aqueous solution of mineral salts and other water–
soluble molecules
• This will increase fluid volume in both the interstitial and
intravascular spaces (Extracellular)
It is subdivided into:
* Isotonic
* Hypotonic
* Hypertonic
ISOTONIC SOLUTIONS
• Isotonic solutions have a concentration of dissolved particles
equal to that of intracellular fluid.
• Osmotic pressure is the same both inside and outside the cell.
• Cells neither shrink nor swell with fluid movement.
• Same tonicity as plasma
• Isotonic solution containing electrolytes such as NaCl, KCl, CaCl,
and sodium lactate
ISOTONIC FLUIDS
Types of isotonic solutions include:
0.9% sodium chloride (0.9% NaCl)
lactated Ringer's solution
 5% dextrose in water (D5W)
Ringer's solution
 ISOTONIC FLUIDS
A- 0.9% sodium chloride (Normal Saline)

Solutions Na+ K+ Ca2+ Mg2+ Cl- HCO3- Dextrose mOsm/L

0.9% NaCl 154 154 308

Simply salt water that contains only water, sodium (154 mEq/L),
and chloride (154 mEq/L).
It's called "normal saline solution" because the percentage of
sodium chloride in the solution is similar to the concentration of
sodium and chloride in the intravascular space.
 A- 0.9% SODIUM CHLORIDE (NORMAL SALINE)

When to be given?
1- to treat low extracellular fluid, as in fluid volume deficit from
- Hemorrhage - Severe vomiting or diarrhea - Heavy drainage from
GI suction, fistulas, or wounds
2- Shock
3- Mild hyponatremia
4- Metabolic acidosis (such as diabetic ketoacidosis)
5- It’s the fluid of choice for resuscitation efforts.
6- it's the only fluid used with administration of blood products.
A- 0.9% SODIUM CHLORIDE (NORMAL SALINE)

TAKE CARE:
Because 0.9% sodium chloride replaces extracellular
fluid, it should be used cautiously in certain patients
(those with cardiac or renal disease) for fear of fluid
volume overload.
B- RINGER'S LACTATE OR HARTMANN SOLUTION

+ + 2+ 2+ - -
Solutions Na K Ca Mg Cl HCO3 Dextrose mOsm/L

Lactated
130 4 3 109 28 273
Ringer’s

 Is the most physiologically adaptable fluid because its

electrolyte content is most closely related to the
composition of the body's blood serum and plasma.
 Another choice for first-line fluid resuscitation for certain
patients, such as those with burn injuries.
B- RINGER'S LACTATE OR HARTMANN SOLUTION

When to be used?
To replace GI tract fluid losses ( Diarrhea or vomiting )
Fistula drainage
Fluid losses due to burns and trauma
Patients experiencing acute blood loss or hypovolemia due to
third-space fluid shifts.
 B- RINGER'S LACTATE OR HARTMANN SOLUTION

Notice. Both 0.9% sodium chloride and LR may be used in many clinical situations, but
patients requiring electrolyte replacement (such as surgical or burn patients) will
benefit more from an infusion of LR.

 LR is metabolized in the liver, which converts the lactate to bicarbonate.

LR is often administered to patients who have metabolic acidosis not
patients with lactic acidosis
 Don't give LR to patients with liver disease as they can't metabolize
lactate
 used cautiously in patients with sever renal impairment because it
contains some potassium
 LR shouldn't be given to a patient whose pH is greater than 7.5
C -RINGER'S SOLUTION

Like LR, contains sodium, potassium, calcium, and

chloride in similar. But it doesn't contain lactate.
Ringer's solution is used in a similar fashion as LR,
but doesn't have the contraindications related to
lactate.
 D- DEXTROSE 5%

+ + 2+ 2+ - -
Solutions Na K Ca Mg Cl HCO3 Dextrose mOsm/L

D5W 50gm/l 278

It is considered an isotonic solution, but when the

dextrose is metabolized, the solution actually
becomes hypotonic and causes fluid to shift into
cells.
 D- DEXTROSE 5%
How does it work?
 D5W provides free water that pass through membrane pores to both
intracellular and extracellular spaces. Its smaller size allows the
molecules to pass more freely between compartments, thus
expanding both compartments simultaneously
 It provides 170 calories per liter, but it doesn't replace electrolytes.
 The supplied calories doesn't provide enough nutrition for prolonged
use. But still can be added to provide some calories while the patient is
NPO.
D- DEXTROSE 5%

Take Care !
• D5W is not good for patients with renal failure or cardiac problems since
it could cause fluid overload.
• patients at risk for intracranial pressure should not receive D5W since it
could increase cerebral edema
• D5W shouldn't be used in isolation to treat fluid volume deficit because it
dilutes plasma electrolyte concentrations
• Never mix dextrose with blood as it causes blood to hemolyze.
• Not used for resuscitation, because the solution won't remain in the
intravascular space.
• Not used in the early postoperative period, because the body's reaction
to the surgical stress may cause an increase in antidiuretic hormone
secretion
 PRECAUTIONS IN USAGE OF ISOTONIC SOLUTIONS

• Be aware that patients being treated for hypovolemic can

quickly develop hypervolemia (fluid volume overload)
following rapid or over infusion of isotonic fluids.

• Document baseline vital signs, edema status, lung sounds,

and heart sounds before beginning the infusion, and
continue monitoring during and after the infusion.
PRECAUTIONS IN USAGE OF ISOTONIC SOLUTIONS
 Frequently assess the patient's response to I.V. therapy,
monitoring for signs and symptoms of hypervolemia such as:
hypertension / bounding pulse / pulmonary crackles /
peripheral edema / dyspnea/ shortness of breath /
jugular venous distention (JVD)
 Monitor intake and output
 Elevate the head of bed at 35 to 45 degrees, unless
contraindicated .
 If edema is present, elevate the patient's legs.
 monitor for signs and symptoms of continued hypovolemia,
including:
 urine output of less than 0.5 mL/kg /hour /
 poor skin turgor
 tachycardia
 weak, thready pulse
 hypotension
 Educate patients and their families about signs and symptoms of
volume overload and dehydration
 instruct patients to notify if they have trouble breathing or
notice any swelling.
 Instruct patients and families to keep the head of the bed
elevated (unless contraindicated).
ISOTONIC SOLUTIONS
(250-375 MOSM/L)
EXAMPLES Action: Indications:

■5% dextrose in Will hydrate the Treatment of

water extracellular vascular
■ 0.9% sodium compartment; dehydration;
chloride replaces fluid replaces sodium
Solution (Normal volume without and chloride
Saline) disrupting the
■ Ringer’s intracellular and
injection interstitial
■ Lactated volumes
Ringer’s
Solution
 0.9% Sodium Chloride Normal Saline
Uses Special considerations
• Shock • Use with caution in patients with heart failure, edema, or hypernatremia
• Resuscitation
• Fluid challenges • Can lead to overload
• Blood transfusions
• Metabolic alkalosis
• Hyponatremia
• DKA

Lactated Ringers
Uses Special Considerations
• Dehydration • Contains Potassium, can cause hyperkalemia in renal patients
• Burns • Patients with liver disease cannot metabolize lactate
• GI tract fluid loss • Lactate is converted into bicarbonate by liver
• Acute blood loss
• Hypervolemia

Dextrose 5% in Water (D5W)

Uses Special Considerations
• Fluid loss and dehydration • Solution becomes Hypotonic when dextrose is metabolized
• Hypernatremia • Do not use for resuscitation
• Use cautiously in renal and cardiac patients
HYPOTONIC
SOLUTIONS
• Hypotonic solutions have less particles than does intracellular fluid.
Fluid flows into cells
• Osmotic pressure is greater than that of intracellular fluid.
Hypertonic solutions have a large concentration of solutes
(particles).
• Water is drawn from the cells to equalize the concentration, which
causes the cells to shrink.
• Hypotonic solution containing glucose to provide calories for
metabolism
• Glucose moves into cells rapidly
• Inappropriate use can cause fluid overload and pulmonary edema
TYPES OF HYPOTONIC FLUIDS
• 0.45% sodium chloride (0.45% NaCl), 0.33% sodium
chloride, 0.2% sodium chloride, and 2.5% dextrose in
water
• Hypotonic fluids are used to treat patients with
conditions causing intracellular dehydration, when
fluid needs to be shifted into the cell , such as:
1.Hypernatremia
2. Diabetic ketoacidosis
3. Hyperosmolar hyperglycemic state.
HYPOTONIC FLUIDS
Precautions with hypotonic solutions
 Never give hypotonic solutions to patients who
are at risk for increased ICP because it may
exacerbate cerebral edema
 Don't use hypotonic solutions in patients with
liver disease, trauma, or burns due to the potential
for depletion of intravascular fluid volume
HYPOTONIC FLUIDS
Precautions with hypotonic solutions
The decrease in vascular bed volume can worsen existing
hypovolemia and hypotension and cause cardiovascular
collapse
Monitor patients for signs and symptoms of fluid volume
deficit
 In older adult patients, confusion may be an indicator of a
fluid volume deficit. Instruct patients to inform you if they
feel dizzy or just "don't feel right."
HYPOTONIC SOLUTIONS
(<250 MOSM/L)
EXAMPLES ACTION : Indications:

■2.5% dextrose Will hydrate the Treatment of

in water cells; pulls fluid hypertonic
■0.25% sodium from the vascular dehydration
chloride solution space into the
■0.33% sodium cellular space
chloride solution
■0.45% sodium
chloride Solution
 HYPOTONIC
SOLUTIONS
0.45% Sodium Chloride (1/2 normal saline)

0.45% Sodium Chloride (1/2 normal saline)

Uses
• Gastric fluid loss
• Cellular dehydration
excessive diuresis
• Hypertonic dehydration
• Slow rehydration
Special Considerations
• Do not give to patients at risk for ICP
from • Not for rapid rehydration
• Electrolyte disturbances can occur
HYPERTONIC
SOLUTIONS
• Hypertonic solutions have a greater concentration of dissolved
particles than does intracellular fluid. Fluid is pulled from cells
• Osmotic pressure is less than intracellular fluid
• Water is drawn into the cells from the extracellular fluid causing
them to swell
• Inappropriate use can result in increased ICP and cardiovascular
collapse from volume depletion.
• May cause blood cells to burst
HYPERTONIC SOLUTIONS

• 5% Dextrose in 0.9% Sodium Chloride(D5NS)

• 5% Dextrose in Lactated Ringers (D5LR)
• 5% Dextrose in 0.45% Sodium Chloride (D51/2NS)
HYPERTONIC SOLUTIONS

Precautions with hypertonic fluids:

Hypertonic sodium chloride solutions should be administered only in
high acuity areas with constant nursing surveillance for potential
complications .
Maintain vigilance when administering hypertonic saline solutions
because of their potential for causing intravascular fluid volume overload
and pulmonary edema.
shouldn't be given for an indefinite period of time.
Prescriptions for their use should state the specific hypertonic fluid to
be infused, the total volume to be infused and infusion rate, or the length
of time to continue the infusion .
It is better to store hypertonic sodium chloride solutions apart from
regular floor stock I.V. fluids .
HYPERTONIC
SOLUTIONS (>375
MOSM/L)
EXAMPLES Action: Indications:

■ 5% dextrose in 0.45% Will draw fluid out of Treatment of hypotonic

sodium chloride intracellular space, dehydration; treatment
solution leading to increased of circulatory collapse;
■ 5% dextrose in 0.9% extracellular volume increase fluid shift from
sodium chloride both in vascular and interstitial space to
solution interstitial space vascular space
■ 5% dextrose in
lactated Ringer’s
solution
■ 10% dextrose in water
■ 20% dextrose in water
■ 50% dextrose in water
■ 70% dextrose in water
 5% Dextrose in Lactated Ringers (D5LR)
Uses Special Considerations
• Hypovolemic Shock •
• Hemorrhagic Shock • Do not administer in patients with cardiac or renal dysfunction
• Certain cases of acidosis • Monitor for circulatory overload

5% Dextrose in 0.9% Sodium Chloride(D5NS)

Uses Special Considerations
• Heat related disorders • Should not be given to patients with impaired cardiac or renal function
• Fresh water drowning • Draw blood before administering to diabetics
• Peritonitis

5% Dextrose in 0.45% Sodium Chloride (D51/2NS)

Uses Special Considerations
• Heat exhaustion • Not for rapid fluid replacement
• Diabetic disorders
• TKO solution in patients with renal or cardiac
dysfunction
COLLIDES

• Colloids - contain large insoluble particles which are referred to as solutes, such
as gelatin. Blood is a colloid
• Colloids are made up of much larger solutes than are crystalloids
• Used if crystalloids do not improve blood volume
• Colloids pull fluid into the bloodstream, remember they are always Hypertonic
• Watch for increased BP, Dyspnea, and bounding pulse

For Example:
• Blood, or blood products.
• Albumin
• Plasma Protein fraction
• Dextran
• Hetastarch
COLLOID SOLUTIONS
Examples:

1- 5% albumin (Human albumin solution)

• The most commonly utilized colloid solutions.
• It contains plasma protein fractions obtained from human plasma and works
to rapidly expand the plasma volume used for:
• volume expansion
• moderate protein replacement
• achievement of hemodynamic stability in shock states.
• considered a blood transfusion product and requires all the same nursing
precautions used when administering other blood products.
• -It can be expensive and its availability is limited to the supply of human donors
COLLOID SOLUTIONS
Albumin Contraindications:
a) Severe anemia
b) Heart failure
c ) Known sensitivity to albumin
d ) Angiotensin-converting enzyme inhibitors ( ACEI)
should be withheld for at least 24 hours before
administering albumin because of the risk of atypical
reactions, such as flushing and hypotension
COLLOID SOLUTIONS
2- Hydroxyethalstarches
• Another form of hypertonic synthetic colloids used for
volume expansion
• Contain sodium and chloride and used for hemodynamic
volume replacement following major surgery and to treat
major burns
• Less expensive than albumin and their effects can last 24
to 36 hours
COLLOID SOLUTIONS
Precautions when using Colloid solutions:
1. The patient is at risk for developing fluid volume overload
2. As for blood products, use an 18-gauge or larger needle to
infuse colloids.
3. Monitor the patient for signs and symptoms of
hypervolemia, including:
• Increased BP
• Dyspnea or crackles in the lungs
• edema.
COLLOID SOLUTIONS
Precautions when using Colloid solutions:
4. Closely monitor intake and output.
5. Colloid solutions can interfere with platelet function and
increase bleeding times, so monitor the patient's coagulation
indexes.
6. Elevate the head of bed unless contraindicated.
7. Anaphylactoid reactions are a rare but potentially lethal
adverse reaction to colloids. Take a careful allergy history from
patients receiving colloids (or any other drug or fluid), asking
specifically if they've ever had a reaction to an I.V. infusion
 PLASMA EXPANDERS
EXAMPLES Action: Indications

■ Dextran 70 (isotonic)  Increases volume in the  Emergency treatment

■ Dextran 40 (isotonic) vascular space. of shock due to fluid or
■ 10% mannitol  Will draw fluid out of blood loss.
(hypertonic) intracellular space,  Treatment of hypotonic
■ 20% mannitol leading to increased dehydration.
(hypertonic) extracellular volume  Treatment of circulatory
■ 5% albumin both in vascular and collapse.
■ 25% albumin interstitial space  Increase fluid shift from
■ 6% hetastarch in 0.9% interstitial space to
sodium vascular space
chloride
■10% hetastarch
in 0.9% sodium
chloride
BLOOD-BASED
PRODUCTS

• A blood product (or blood-based product) is any component

of blood which is collected from a donor for use in a blood
transfusion.
• Blood transfusions can be life-saving in some situations, such as
massive blood loss due to trauma, or can be used to replace blood
lost during surgery.
• Blood transfusions may also be used to treat a
severe anemia or thrombocytopenia caused by a blood disease.
People with hemophilia usually need a replacement of clotting
factor, which is a small part of whole blood. People with sickle-cell
disease may require frequent blood transfusions.
• Early blood transfusions consisted of whole blood, but modern
medical practice commonly uses only components of the blood,
such as fresh frozen plasma or cryoprecipitate.
BLOOD SUBSTITUTES

• Blood substitutes (also called artificial blood or blood surrogates)

are artificial substances aiming to provide an alternative to
blood-based products acquired from donors.
• The main blood substitutes used today are volume expanders
such as crystalloids and colloids.
• Also, oxygen-carrying substitutes are emerging.
BUFFER SOLUTIONS

• Buffer solutions are used to correct acidosis or alkalosis.

• Lactated Ringer's solution also has some buffering effect.
• A solution more specifically used for buffering purpose
is intravenous sodium bicarbonate.
MEDICATIONS

Medications may be mixed into

the fluids mentioned above.
Certain types of medications
can only be given
intravenously, such as when
there is insufficient uptake by
other routes of
administration such
as enterally. Examples
include intravenous
immunoglobulin and propofol.
Saline and
5% glucose solution
(Left), levofloxacin 750m
g (Right)
DRUGS TYPICALLY
GIVEN BY IV

Many different types of medications can be given by IV. Some of the

drugs more commonly given by this method include:
• chemotherapy drugs such as doxorubicin, vincristine, cisplatin,
and paclitaxel
• antibiotics such as vancomycin, meropenem, and gentamicin
• antifungal drugs such as micafungin and amphotericin
• pain medications such as hydromorphone and morphine
• drugs for low blood pressure such as dopamine, epinephrine,
norepinephrine, and dobutamine
• immunoglobulin medications (IVIG)
OTHER
• Parenteral nutrition is feeding a person intravenously, bypassing
the usual process of eating and digestion. The person receives
nutritional formulas containing salts, glucose, amino
acids, lipids and added vitamins.
• Drug injection used for recreational substances usually enters by
the intravenous route
FLUIDTHERPY

Importance !
• Can be life-saving in certain conditions
• Loss of body water, whether acute or chronic, can
cause a range of problems from mild headache to
convulsions, coma, and in some cases, death.
COMPONENTS OF FLUID THERAPY

1. Maintenance therapy:
replaces normal ongoing losses
2. Fluid Resuscitation:
corrects any existing water and electrolyte deficits.
COMPONENTS OF FLUID THERAPY

A. Maintenance therapy
Maintenance therapy is usually undertaken
when the individual is not expected to eat or
drink normally for a longer time (e.g.,
preoperatively or patient on a ventilator)
MAINTENANCE THERAPY

How to calculate maintenance fluid flow rates?

The most commonly used formula is (4/2/1) rule a.k.a ( Weight+40),
which is used for both adults and pediatrics.
4/2/1 rule
• 4 ml/kg/hr for first 10 kg (=40ml/hr)
• then 2 ml/kg/hr for next 10 kg (=20ml/hr)
• then 1 ml/kg/hr for any kgs over that
• This always gives 60ml/hr for first 20 kg
• then you add 1 ml/kg/hr for each kg over 20 kg
So: Weight in kg + 40 = Maintenance IV rate/hour
For any person weighing more than 20kg
FLUID RESUSCITATION

B) Fluid Resuscitation :
Correction of existing abnormalities in volume status or
serum electrolytes (as in hypovolemic shock)
What is the Parameters used to assess volume deficit?
1- Blood pressure
2- Urine output
3- Jugular venous pressure
4- Urine sodium concentration
FLUID RESUSCITATION

How to know that the patient has Hypovolemic Shock?

The patient has the following sings and symptoms:
1- Anxiety or agitation 2- Cool, Pale skin
3- Confusion 4- Decreased or no urine output
5- Rapid breathing 6- Disturbed consciousness
7- Low blood pressure 8- Low body temperature
9- Rapid pulse, often weak and
thready
FLUID RESUSCITATION

Rate of Repletion of Fluid deficit:

1- Severe volume depletion or hypovolemic shock:
Rapid infusion of 1-2L of isotonic saline (0.9% NS) as rapidly as
possible to restore tissue perfusion

2- Mild to moderate hypovolemia:

Choose a rate that is 50-100mL/h greater than estimated fluid
losses. calculating fluid loss as follows:
Urine output= 50ml/h
Insensible losses = 30ml/h
Additional loss such as Vomiting or Diarrhea or high fever (additional 100-
150 ml/day for each degree of temp >37 C)
FLUID OVERLOAD (HYPERVOLEMIA)

It is excessive accumulation of fluid in the body,

due to:
1- Excessive parenteral infusion
2- Deficiencies in cardiovascular or renal fluid volume regulation
 FLUID OVERLOAD (HYPERVOLEMIA)
SIGNS AND SYMPTOMS
They are not always typical but most commonly are:
1- Edema (swelling) - particularly feet, and ankles
2- Difficulty breathing while lying down
3- Crackles on auscultation
4- High blood pressure
5- Irritated cough
6- Jugular vein distension
7- Shortness of breath (dyspnea)
8- Strong, rapid pulse
FLUID OVERLOAD (HYPERVOLEMIA)
MANAGEMENT OF HYPERVOLEMIA

1- Prevention is the best way

2- Sodium restriction
3- Fluid restriction
4- Diuretics
5- Dialysis
HOW TO CALCULATE IV FLOW RATES !

Intravenous fluid must be given at a specific rate,

neither too fast nor too slow. The specific rate may
be measured as ml/hour, L/hour or drops/min. To
control or adjust the flow rate only drops per minute
are used.
HOW TO CALCULATE IV FLOW RATES !

What is a drop factor?

Drop factor is the number of drops in one milliliter
used in IV fluid administration (also called drip
factor). A number of different drop factors are
available but the Commonest are:
1- 10 drops/ml (blood set)
2- 15 drops / ml (regular set)
3- 60 drops / ml (micro drop, burette)
HOW TO CALCULATE IV FLOW RATES ?

The formula for working out flow rates is:

volume (ml) X drop factor (gtts / ml)
= gtts / min
---------------------------------------------
time (min)
(flow rate)

Example:
1500 ml IV Saline is ordered over 12 hours. Using a drop factor
of 15 drops / ml, how many drops per minute need to be
delivered?
1500 (ml) X 15 (drop / ml)
--------------------------------------------------- = 31 drop/ minute
12 x 60 (gives us total minutes)
HOW TO CALCULATE DRUG DOSAGE?

Common Conversions:

1 Liter = 1000 Milliliters

1 Gram = 1000 Milligrams
1 Milligram = 1000 Micrograms
1 Kilogram = 2.2 pounds
Remember! Before doing the calculation, convert units of measurement
to one system.
HOW TO CALCULATE DRUG DOSAGE?
Example:

The ordered dose is Ceftriaxone 750 mg IV. the

container contain 1g in a 10 ml vial.
How to calculate?
You should convert first g to mg , then :

(D) 750 mg X (V) 10 ml = 7.5 ml

(H) 1000 mg
HOW TO CALCULATE DRUG DOSAGE?

D
x V = Amount to Give
H
D = dose ordered or desired dose
H = dose on container label or dose on hand
V = form and amount in which drug comes
(tablet, capsule, liquid)
SITE OF IV
ADMINISTRATION
Digital veins on lateral sides of fingers
Advantages:
• None
Disadvantages
• Difficult to stabilize the IV
• Veins are fragile and small with decreased blood flow

Metacarpal veins on dorsal surface of hand

Advantages
• Superficial veins are easier to view and insert IV
• Distal site to place the IV
• Metacarpal bones splint the IV thus providing stability
Disadvantages
• Limits self-care due to placement of IV
• Rolling veins in geriatric clients make it difficult to insert he IV
• More painful site of insertion
• Some IV medications can not be given at this site due to decreased blood flow
SITE OF IV
ADMINISTRATION
Cephalic vein on radial aspect of forearm
Advantages
• Large vein is easy to view, palpate and insert IV
• Radial bone splints the IC
Disadvantage
• IV insertion in cephalic vein near the wrist decreases mobility and self-care
• IV insertion in median cephalic vein near the antecubital fossa (elbow) commonly requires an arm board, which limits mobility
and self-care

Basilica vein on ulnar aspect of forearm

Advantages
• Large vein is easy to palpate
• Ulnar bone splints the IV
Disadvantages
• Location on the inner surface of the arm makes IV insertion difficult
• IV in this location dislodges more easily due to friction against body and bed linens
• IV insertion in median basilica vein near the antecubital fossa limits mobility and self-care
SITE OF IV
ADMINISTRATION
Median vein of forearm and Median cubital vein on
ventral aspect of arm
Advantages
• Large veins are easy to palpate and insert IV
Disadvantages
• IV insertion near the antecubital fossa decreases mobility

Dorsal plexus, Dorsal arch, and Great saphenous vein on

dorsal aspect of foot
Advantages
• Paediatric clients are less likely to dislodge IV
Disadvantages
• Deep location of veins near arteries and nerves
• More painful site of insertion
• Pooling and stasis of blood flow in adult clients increases
the risk for thrombophlebitis (deep vein thrombosis)
CONSIDERATIONS FOR SELECTING
AN IV SITE LOCATION
Purpose and duration of the therapy

• The most common sites for short-term IV therapy are the small veins of the hand and arm. The foot is commonly used in children, but
should be avoided in adults due to the increased risk of thrombophlebitis and infection.
• Large vein-central venous access is used for long-term IV therapy or care of the acutely ill. In central venous access, the tip of the catheter
must be positioned in a high-flow vein such as the superior or inferior vena cava. Access to these high flow veins can be achieved through
the peripheral veins (i.e. basilica or axillary), the jugular vein, the subclavian vein or the femoral vein.
Type of solution to be infused

• The small veins of the hand and arm tolerate saline and Dextrose (5%) solutions
• The larger veins used in central venous access are necessary to infuse high glucose concentrations (i.e. Dextrose 25%) such as total
parenteral nutrition (TPN). In this situation the client requires total nutrition through the vein.
• The larger veins are also used to deliver large volumes of fluid or irritating medications.
Location of site to avoid

• Avoid placing the new IV in the same location as the previous IV. The vein is more fragile due to previous IV placement.
• IV placement is contraindicated in a site that has signs of infection, infiltration or thrombosis. An infected site will show signs of redness,
tenderness, swelling, and warmth to touch. An infected site is not used due to the risk of introducing bacteria into the blood stream.
• Avoid placing the new IV in allocation that would interfere with surgery.
• Do not place IV in an extremity with a vascular (dialysis) graft/fistula due to the risk of damaging the graft or fistula.
• Do not place IV in an extremity on the side of a mastectomy. The extremity on the side of a mastectomy is prone to swelling due to
decreased flow of lymphatic fluid, which can impede venous return.
Client preference

• Position the IV in a comfortable location i.e. non-dominent hand or arm.

• Avoid placing the IV in a site where it would be easily moved or bumped. This is especially important in the young and older adults who
have fragile veins.
Where to start

• Use the most distal site first. This allows the use of more proximal sites later when the IV needs to be changed.
• Refer to assigned readings for additional criteria for selecting a vein.
Classification of parenteral preparations

•Based on types of packaging

1)Single dose units: ampoules, infusions and
prefilled disposable syringes
2)Multiple dose units: multiple dose vials

•Based on the production and control

a)Small volume parenterals: volume < 100 ml
b)Large volume parenterals: volume ≥ 100 ml
Small volume parenteral:
Volume of these parenteral varies from fractions of
Milli liter to several hundred milliliters i.e. 1ml to 500ml
Example: Injections :- Furosemide, Heparin, Cimetidine, Iron
dextran etc.

Large volume parenterals:

Volume of these parenterals varies from 500ml and above.
They are administered as single dose injections at a slow rate.
Example: Infusion Fluids, Total parenteral nutrition solutions,
patient controlled anlgesia, dialysis fluids etc.
 DIFFERENCES BETWEEN SVP & LVP
S.No Small Volume Parenteral (SVP)
1 SVP’s are sterile, pyrogen free
injectable products that are
packaged in vol’s up to 100 ml
2 Some SVP aqueous solutions
can be administered only by IV
route because of local irritation
3 SVP’s are usually packed in
vials, ampoules of small sizes
4 SVP’s include drugs in
suspension, emulsion, freeze
dried product or powder for
reconstitution. The other
products include biological &
diagnostic agents, allergenic
extracts, radiopharmaceuticals,
dental products, liposomes &
lipids etc
Large Volume Parenteral (LVP)
LVP’s are sterile, pyrogen free injectable
products that are packaged in vol’s more
than 100 ml (1litre)
LVP’s are administered by intra or extra
vascular routes depending on
composition.
LVP’s are packed in large containers
(glass/plastic of 1 liter capacity)
LVP’s includes saline solutions, dextrose
solution, ringers solutions, peritoneal
dialysates, irrigating solutions, diagnostic
agents & blood collecting unit with
anticoagulants.
WHAT ARE THE DIFFERENT TYPES OF IV
ADMINISTRATION SETS AND EQUIPMENT'S
IV Infusion can be administered either by:

1) Gravity alone Example:

• Gravity Infusion set.

2)With the use of an electronic infusion device Example:

• Infusion pumps
• Volumetric pumps
WHAT ARE THE DIFFERENT TYPES OF IV
ADMINISTRATION SETS AND EQUIPMENT'S
1) IV infusion administered by gravity:
Gravity Infusion Set:
• The height of the IV solution is of greater importance than the
tubing. Most basic types of IV tubes/tubing can be used in this
type of set. The higher the solution, the faster the solution
infuses. Preferred elevation of the solution from the site of
infusion: 18 to 24 inches (45 to 60 centimeters).
WHAT ARE THE DIFFERENT TYPES OF IV
ADMINISTRATION SETS AND EQUIPMENT'S
2) IV fluids administered with the use of an electronic infusion
device:

Infusion Pump:
• Pressure is used in order to infuse solutions Requires special
tubing that contains a device such as cassette to create a
sufficient pressure to push fluid into the vein.
• Advantage: Programmed to deliver a preset volume per hour.
• Disadvantage: If catheter or needle within vein becomes
misplaced, the pump will still continue on infusing.
WHAT ARE THE DIFFERENT TYPES OF IV
ADMINISTRATION SETS AND EQUIPMENT'S
IV infusion administered with the use of an electronic infusion device:

Volumetric Pump:
• Do not depend upon gravity to force the fluid into the vein.
• All volumetric pumps generally involve the nurse entering the
infusion rate in mL/hr.
• The volumetric pump then automatically maintains that rate.
• Volumetric pumps should still be checked regularly to ensure that
they are infusing the medication correctly.
• Infiltration is possible when using a volumetric pump because it
forces the fluid into the vein, even when it encounters resistance.
IV ADMINISTRATION
EQUIPMENTS

Basic IV Set up consists of the following important parts/equipment:

a) Drip chamber b) Roller clamp
c) Slide clamp d) Injection port
Other IV equipment :
a) IV Tubing b) Hypodermic needle
c) Catheter needle d) Central IV Lines
e)Tunneled Lines/Broviac Line
f)Peripherally inserted central catheter
 IV SETS

• A spike to pierce the rubber

stopper or port on the IV
container
• A drip chamber for trapping air
and adjusting flow rate
• A control clamp for adjusting flow
rate or shutting down the flow
• Flexible tubing to convey the fluid
IV SETS
• A needle adapter for
attaching a needle or a
catheter
• A catheter, or tube,
may be implanted into
the patient and fixed
with tape to avoid
having to repuncture
the patient each time
an infusion is given
THANK YOU