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IV THERAPY:
1. PURPOSE- To access the venous circulation in order to draw blood for laboratory screens
and diagnostic tests or to administer fluids, electrolytes, medications, blood, blood
products ,and nutritional supplements.
Indicated for situations when oral or other parenteral routes are not
appropriate.
Continuous IV administration
Nursing Responsibilities
Assessment of the client, site, infiltration, rates, adverse reactions, therapeutic actions
IV route is the fastest onset of medication administration, however, once injected, the medication
can not be retrieved
IV Considerations
What is missing?
What is current health status? Co- morbidities: cardiac, renal, liver, pulmonary, I & O
Daily weight – fluids calculated on changes in current weight
Restoring fluids by IV
Dilution of electrolytes
INTRAVENOUS THERAPY
1. Goal: Correct or prevent fluid & electrolyte disturbances
Allows for direct access to the vascular system, permitting the infusion of
continuous fluids over a period of time
Must be continuously regulated because of continuous changes in the client’s fluid
& electrolyte balance.
2. Types of IV catheters:
Peripheral Venous Catheters
Central venous catheters (central lines)
Peripherally inserted central venous catheters (PICC lines)
Central hemodialysis catheters
A. Peripheral Catheters:
-Common type- over the needle catheter
Color coded
Tip should be radiopaque
-Less common- through the needle catheter
butterfly
Potter page 446- 447
Flow factor and micro drip factor for slow IV infusions as PEDs.
Gather supplies
approach
Sites to avoid
Areas of inflammation
Infiltration
Thrombosis
Mastectomy sides
IV grafts sites
Use most distal when possible, allowing proximal sites for subsequent venipuncture
Use of tourniquet
Site to avoid
Gauge to use
Insertion angle
EID
Geriatrics
22 – 24 gauge
MD or NP to insert
Sutured to skin
Non-tunneled catheter
Uses
Blood sampling
CVP monitoring
Diagnostic testing
Sterile technique
TPN
PICC
PICC
The PICC affords a greater hemodilution which decreases the risk of phlebitis and infiltration so
stays in longer.
PICC
May be used to infuse hyper – osmolor fluids as TPN, Blood, chemical irritants and vesicants.
MD to insert
Sutured to skin
What is ordered
Why it is intended
RN Responsibilities
“The RN remains accountable and responsible for all delegated tasks and must have a clear
knowledge of the nursing scope of practice relative to assessment, planning, implementation, and
evaluation of infusion therapy, as well as legal responsibilities associated with delegation of
nursing care activities.” (INS, 2000)
RN’s Responsibilities
Must evaluate others competency, instruct them, and verify proper training
Responsibilities may vary among states and employers
Compatibility
IV Therapy
RN vs. LPN
No IV medications
Nurse responsible to
Observe clinet
Check point
The physician orders a piggyback antibiotic infusion 4 times a day. In order to administer the
antibiotic, the nurse should do which of the following:
Choices:
1 start a new IV access for the piggyback antibiotic so no compatibility issues occur
IV THERAPY
Review
Fluid compatibility
Prime by opening roller clamp- all air bubble should be removed- then close roller clamp
Use approximately 1 ½ times the amount of fluid that the tubing will hold in order to flush the
tubing.
Intermittent IV Therapy
IV Therapy that is ordered frequently for short periods of time.
EX:
Check order
Assess site
Release tubing if fluids running - if saline lock, flush with 10ml of NS and lock
IV PUSH
Lets think
So every 15 second interval push ¼ of a mL. This way we are more controlled and more precise
with a push over one minute.
OK: Tell me how would you divide this to deliver the push in a controlled slow process????
Continuous IV Therapy
KVO or TKO
IV NS @ KVO rate
IV RL TKO rate
Bolus
IV solutions 101
First category:
IV solutions
Colloids remain in vascular space longer and are used for volume expansion
Volume expanders
Colloids are protein solutions as albumin, plasma, and Plasmanate ( prepared by pharmaceutical
company).
Volume Expanders
Volume Expansion
Volume expanders
Isotonic
Hypotonic
0.33% Saline
2.5% Dextrose
Hypertonic
Isotonic Solutions
Liver converts lactate to bicarbonate- watch pH, liver function
Expand IV compartment
Isotonic solutions
Uses
HYPOTONIC SOLUTIONS
Hydrates cells
Cardiovascular collapse
Increased ICP
Hypotonic
HYPERTONIC SOLUTIONS
Hypertonic soulutions
Used to treat:
Hypovolemia
(low volume)
Hypo natremia
(low sodium)
D 50 W
Very hypertonic.
Push slowly
B/P
Lung sounds
Edema
JVD
What else??
D 10 W or greater
IV SALINE solutions
NS (0.9 % Na CL)
Saline
3% NaCl
5% NaCl
Uses:
Alkalosis
Fluid loss
Sodium depletion
D5W
D10 W
Uses:
Prevent dehydration
Maintain water balance
Dextrose in Saline
D5NS
D51/2 NS
D10 NS
Promotes diuresis
Prevent alkalosis
Electrolytes
Lactated Ringers
Ringers Lactate
Treat dehydration
IV Additives
K*Under no circumstances can potassium chloride (KCL) be given IV push. A direct IV infusion
of KCL is fatal.
TPN
Nutritional adequate hypertonic solution consisting of glucose and other nutrients and
electrolytes given through an indwelling peripheral or central line
TPN ??????
Why should we not allow the solution container of TPN run out?
Why should we closely monitor T P R and B/P? WBC? Infusion site? Why is asepsis so vital?
TO START AN IV……
Demonstration in lab
IV start kit (drape, cleaning and antiseptic preps, dressings, tape, label, tourniquet, transparent
dressing)
GLOVES
Sharps container
Flush
Volume regulator
IV Catheter
Size
Conventional or safety
Fluids vs. PRN lock (saline or heparin)
Children
Arm board
Practice correctly
5 rights
IV site selection
Most common in lower arm and hand. If possible use the non-dominant hand/arm
IV site location
Large vein
Consider activity
Medical history
Children, adults
Implementation of IV therapy
Wash hands
Prepare IV solution, open infusion set, spike bag, and prime line, cap, or pigtail
Identify accessible vein and apply tourniquet (4-6 “ above proposed site)
Apply gloves
Warm compress
Chloro-prep
Too slow = vein clots /occlude line or client goes into circulatory /CV collapse
CONT.
Look for blood return “flash” in the chamber. Lower the needle and advance ¼”
Stabilize cath and release tourniquet, apply firm pressure with index finger 1 ¼” above insertion
site.
Secure IV catheter
Discard supplies
Patient teaching
Document procedure
Patient Teaching
IV pump alarm
Documentation
DOCUMENTATION EXAMPLE
22GA IV catheter
2 attempts
L wrist
D5 ½ NS at 100/hr
Blood drawn
“1500 22GA IV to L wrist x 2 attempts, blood drawn and sent to lab, D5 ½ NS @100 ml/hr per
pump. Site clear, no redness or edema. -------------------------------------------------N Nurse RN
*TIP*
Anytime you do anything with a patient’s IV (hang fluids, give medications), always check the IV
site. If the IV is not functional, then you are doing nothing for the patient. OR you may be
damaging tissue!!!!!
IV Management
Check patency
I&O
Weights
VS
IV Management cont.
NORMAL SALINE
Complications of IV therapy
Phlebitis
Infiltration
Hematoma
Pulmonary embolus
Air embolus
Circulatory overload
Phlebitis (thrombophlebitis)
S & SX: Indicated by pain, increased skin temp, erythema along path of vein (cord along vein)
Causes: Drug irritation, trauma to vein, infection, stasis, immobilization, IV catheter in place too
long
Infiltration
S & SX: Indicated by swelling and possible pitting edema, pallor, coolness, pain at insertion site,
possible decrease or absent flow rate
Extravasatinon
Hematoma
Definition: collection of blood in tissue or skin due to trauma, aka: bruise
Bleeding
Pulmonary embolism
Occlusion of the portion of the pulmonary blood vessels by a clot that is carried from the point of
origin. (somewhere else)
May be lethal
S & SX: appear late, tachypnea, dyspnea, anxiety, fretfulness, and CP. Possibly hypoxemia,
diaphoresis, syncope, crackles, fever, murmurs
Pulmonary embolism
Sources: deep calf, tumors, air, fat, heart arrhymias, bone marrow, post-op major operations,
prolonged sitting
Blood flow is obstructed in the lung which leads to decreased profusion of the lung and decreased
cardiac output
THIS IS AN EMERGENCY!!!
S & S: sudden dyspnea, tachycardia, heart murmur, hypotension, decreased LOC, CP,
circulatory shock, sudden death
TX: place in L lateral Trendelenburg position, 100% O2. THIS TOO IS AN EMERGENCY!!!
Circulatory Overload
Circulatory overload occurs when fluid is administered more rapidly than the circulatory system
can adjust. DROWNING IN OWN FLUIDS IS AN EMERGENCY!
Interventions: slow IV to KVO rate, elevate HOB, O2, VS, notify MD, diuretics
Elderly
Outcomes of IV therapy
Administer drugs
Blood Transfusions
Risk: hemolytic transfusion reactions and possibility of contracting infectious diseases (Hep B,
HIV, CMV, EBV, West Nile virus)
When a client is to receive blood, the nurse is largely responsible for its safe administration.
Type A = A antigen
Type B = B antigen
Type AB = both
Type O = none
If have = Rh+
Autologous transfusion
Collect blood from client prior to expected surgical procedure, reinfuse client with blood in
surger
Blood Components
Whole Blood
PRBC
Platelets (PLT’s)
Cryoprecipitate
Granulocyte Concentrations
Plasma
Clotting Factors
Other volume expanders
Whole Blood
Whole Blood
500 ml/unit
Rarely indicated
PRBC’s
PRBCs
Blood loss
Desired over whole blood in cardiovascular & renal compromised, and elderly clients because
PRBCs contain less fluid volume.
Platelets (PLT)
Platelets= Play a role in blood coagulation, hemostasis, and blood thrombus formation.
Platelets
USES: low platelet counts, coagulopathies; 1 unit may increase platelet count by 6000 units
Plasma= liquid part of blood. Medium for transporting substances. Colorless when free of cells.
Used to replace clotinf factors after multiple transfusions ( > 6 units of PRBCs);
Coumadin intoxication
Question
A patient presents to ER after being involved in a MVA, B/P is 70/50, HR 138, R. 44, the patient
has an opened chest wound and has lost a lot of blood. Pt’s Hgb is 6.0. The M.D. orders two units
of blood STAT. Which intervention would be appropriate at this time?
C.) draw blood, band pt with appropriate blood band an send to lab,
5-10ml/unit
Outcomes: correction of factor VIII, vWF, XIII and fibrinogen deficiency, cessation of bleeding
Cryoprecipitate
DIC.
Plasma Derivatives
Rapid infusion may cause hypotension, but 25% albumin can cause a significantly increased
blood pressure because of its ability to draw fluid into the intravascular space
Cannot transmit hepatitis or HIV infection due to the pasteurization process used to prepare
Clotting Factors
Volume expanders
Albumin
ALbumin
Infuse blood
INFORMED CONSENT
Explanation to the client or family member of medical indications for homologous (homologous
vs. autologous) transfusion and its benefits, risks, and alternatives
Assess client history for any previous transfusions and client’s response
VENOUS ACCESS
May use a 22 GA for adults with small veins or children- not best option
Can use a VAD (central line), but a large volume of refrigerated blood infused rapidly into the
ventricle can cause cardiac dysrhythmias
Caution
IF NECESSARY TO use small guage may need to ask lab to split unit into two bags. Smaller
needle can be used for platelets, albumin and clotting factors.
Blood Release
Before going to blood bank, several things must be done: prime blood tubing with NS only and
start NS at KVO, take VS, premedicate if ordered, “banding” the patient
The name and identification number of the recipient must be provided and a permanent record
of this info maintained in blood bank
Record
30 minute window
Blood must be started within thirty minutes of obtaining unit from lab
D5W and LR can cause hemolysis USE NORMAL SALINE. Lewis 731.
Blood is first verified in the blood bank and RN by checking ABO and Rh compatibility. This is
done by checking the bag against the medical record and forms issued by blood bank
Second check is done at bedside by 2 RNs; compare name, number, ABO, Rh compat., blood
band
Check date
The worst reactions to blood are usually due to misidentification of blood or client
TUBING
Empty to full
REACTIONS
90% of hemolytic transfusion reactions are from improper patient to product identification
LEWIS
Usually infuse blood PRBCs over 2 – 4 hours (4 hours if at risk for FVE)
IF patient cannot tolerate volume, specify time frame and have lab split blood unit into two bags
in lab.
If, Rapid infusion, bllod may chill patient, consider blood warmer.
Right to refuse.
INFUSE BLOOD
Blood tubing should be already hanging; usually a Y-type that contains a 170-mm filter designed
to trap fibrin clots, and other debris that accumulates during blood storage
Change tubing every 4-6 hours or per policy, may transfuse 2 units with same tubing
If ABO incompatibility exists or a severe allergic reaction, anaphylaxis, occurs, it is usually w/in
first 50 ml; start transfusion slowly and closely monitor pt; then increase rate to prescribed rate.
Volume
250 – 300 mL of PRBCs over 2 – 4 hours if over 2 hours then 125 mL hour, if over 4 then 63 mL
HR
MONITORING CONT
Take and record VS before transfusion begins then every 5 min for first 15 min, then every hour
until 1 hour after transfusion
To avoid septicemia, infusion should not exceed 4 hours (infuse over 2 hours generally)
Detailed documentation
TRANFUSION REACTIONS
Overview
Other reactions
malaria,
hepatitis,
HIV
Page 475
Question
While receiving a unit of packed red blood cells, the patient develops chills and a temperature of
102.2. The nurse should
D.)Recognize this as a mild allergic transfusion reaction and slows the transfusion.
Reaction is suspected
STOP TRANSFUSION
Infiltration Phlebitis
PREVENT 1st
Before
obtaining blood, be certain patent vein.
Start new IV site and remember blood goes in under 4 hour period, consider: “Is the needle
gauge large enough?”
What if??
What if the rate of infusion slows without signs of infiltration??
What if?
Vital signs
Notify MD
Oxygen
Frequency 1%
Frequency: 0.5-1%
S & SX: fever and/or pulmonary symptoms, sudden chills and fever, HA, flushing, anxiety,
muscle pain
Mgt: If fever and/or pulmonary symptoms- DO NOT resume infusion, treat shock, give
antipyretics
Prevention: Consider leukocyte products which have been filtered, washed or frozen.)
Frequency: 1:25,000
S & SX: chills, fever, <BP, flushing, tachycardia, tachypnea, hypotension, vascular collapse,
ARF, shock, cardiac arrest, DEATH
Mgt: Send blood and UA samples to lab for testing, maintain BP, Foley to measure output,
possible dialysis
Prevention: **Check and double check, then check again.** (MISS Labeled specimens)
Causes cells to agglutinate which obstructs capillaries and blocks blood flow.
Hemoglobin is filtered by Kidney and is found in u/a. Hgb may obstruct renal tubules leads to
acute renal failure > DIC> Death.
Question
Signs and symptoms of a hemolytic transfusion reaction include all of the following: choose all
that apply;
Critical Thinking
Ten minutes after a transfusion of PRBC’s begin infusing your formerly afebrile 26 year old
client has a temperature of 101.6 and feels tightness in the chest. What is the first thing you
should?
First voided urine is collected and sent to lab to check for hemoglobinuria with hemolytic
reactions. Assess for damage to kidney.
If reaction is suspected, should nurse turn saline on and allow saline to flow through tubing?
Frequency: 1:150,000
Mgt: Stop transfusion, CPR if needed, have Epinephrine ready for injection
Delayed hemolytic
Hepatitis B and C
HIV
Iron Overload
Blood Collection
Most commonly used diagnostic aids in the care and evaluation of clients
Yield valuable information about nutritional, hematological, metabolic, immune and biochemical
status
Screen for early signs of disease, plot current treatment course, and monitor response to therapy
Venipuncture- inserting a hollow bore needle into the lumen of a large vein to obtain a specimen.
Capillary puncture- least traumatic, uses sterile lancet to puncture a vascular area a finger, toe,
or heel
Types cont.
Arterial blood gas- diagnosis of respiratory disorder. Arterial puncture (radial or brachial)
Blood cultures- aid in detecting bacteria in the blood. Two cultures from two different sites.
Before antibiotic therapy is started
ABGs
Allen test
Lab value drawn for specific drugs that measure therapeutic levels at the drugs “peak” time and
“trough” time.
EX: Vancomycin
Clean gloves
Tourniquet
Lab requisition
Plastic bag
20-25 GA butterfly
Sterile syringe
Vaccutainer tube
Contraindicated sites?
____________________________________
Wash hands
Apply gloves
Pull skin taut, hold needle at 15-30 degree angle with bevel up
Procedure cont.
When drawing blood for lab, avoid the arm with the IV – it may alter lab results
If have to use same arm, turn off fluids for 10 minutes and use site distal to IV if possible
Needles- sharps
If not saturated with blood may go into regular garbage. If saturated with blood must go into
biohazard receptacle.
IV fluid bags can go into the garbage when drained, tubing must go in biohazard container
Vaccutainer
Butterfly
From IV site
Small world