Infusion Therapy How to tell that a person has a fluid deficit 1. Weight loss 2.

Increased, thread pulse rate 3. Diminished BP 4. Decreased CVP 5. Sunken eyes, dry conjunctiva, decreased tearing 6. Poor skin trugor 7. Lack of moisture in groin and axillae (anhydrosis) 8. Thirst 9. Decreased salivation 10. Dry, cracked lips 11. Furrows in tongue 12. Difficulty forming words 13. Mental status changes 14. Weakness 15. Diminished urine output 16. Increased HCT (hematocrit) 17. Increased serum electrolyte 18. Increased BUN 19. Increased serum osmolarity How to tell that a person has a fluid excess 1. Weight gain 2. Elevated B/P 3. Bounding pulse that isnt easily obliterated 4. Jugular vein dissention 5. Increased respiratory rate 6. Dyspena 7. Moist crackles or rhonchi on auscultation fluids goes from bases and works its way up 8. Edema of dependent body parts, sacral 9. Generalized edema 10. Puffy eyelids 11. Fuller-than-normal cheeks 12. Periorbital edema 13. Slow emptying of hand veins when arm is raised 14. Decreased HCT 15. Decreased serum electrolytes 16. Decreased BUN 17. Reduced serum osmolarity

Understanding Electrolytes

Sodium (Na+) o 135-145 mmol/L o Maintain ECF osmolarity o Influences water distribution o Affects K and Cl o Regulated acid/base o Nerve and muscle fibre impulses  Hyponatremia y Muscle weakness, decreased skin turgor, headache, tremor, seizures  Hypernatremia y Thirst (draws fluid out of the cells), fever, flushed skin, oliguria, dry, sticky membranes o If sodium starts to go out of order, you need to start worrying. If sodium is out of order, it may lead to seizures. Potasium (K+) o 3.5-5 mmol/L o Cell electroneutrality o Cell osmolarity o Nerve conduction o Cardiac muscle o Acid-base balance  Hypokalemia y Decreased muscle function (heart stops= heart attack), decreased reflexes, rapid, weak, irregular pulse, muscle irritability, decreased B/P, muscle irritability, decreased B/P, N/V and paralytic ileus (bowel stops working = constipation)  Hyperkalemia y Muscle weakness, nausea, diarrhea, oliguria Calcium (Ca++) o 2.25-2.75 mmol/L o Bone strength o Cell membrane o Cardiac and skeletal mucles o Neurotransmitter release o Blood coagulation o Immune function  Hypocalcemia y Muscle tremors, cramps, tetany, seizures, parethesias (numbness and tingling), arrhythmia (irregular heart rhythm), decreased BP  Hypo y Lethargy, headache, muscle flaccidity, N/V, anorexia, constipation, polydipsia, hypertension, polyuria Chloride (Cl-) Phosporus (P) Magnesium (Mg++)

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IV solutions Plastic bag Two ports o Primary port where we spike the bag o Injection port where we inject the medication Glass bottles may be something like albumin, or lipids 50-1,000 ml Graduated scale -the numbers along the side of the bag, keep track of how much goes in per hours (put tape beside the graduated scale, and put the time) Labelled with the type of solution it is NS (normal saline), 0.9% or 0.9g sodium chloride per 100mL of fluid (gives you the grams of sodium per 100mL or sodium) 0.45% NS = 0.45g of normal saline D5W, D5NS 2/3 and 1/3

Types of fluids (the additives are included) Isotonic (similar in composition (osmolairty) to the body. Does not do any pulling in either direction (does not pull fluid out of or into cell) D5W (water and dextrose), normal saline (water, sodium and chloride), 5% dextrose and saline (water, dextrose, sodium and chloride), Ringers solution (water, sodium, chloride, potassium and calcium), Ringers Lactate (water, sodium, chloride, potassium, calcium and ), Normosoll R (water, sodium, chloride, potassium and calcium, acetate). Monitor for s&s of fluid overload. Dont give RL to pts with blood pH over 7.5 ***. Avoid in patients at risk for increased ICP (ex; someone with brain trauma). Hypertonic (pulls the fluid out of the cells into the intravascular space, and the cells increase in size) 10% Dextrose and Water (D10W), Dextrose and Water 20% and 50%, Saline 3% and 5%, Normosol M. Monitor for circulatory overload. Not for patients with cellular dehydration (DKA diabetic ketoacidiosis). Not for patient with impaired heart or kidney function. You may admin this for hypoglycaemia, to provide calories (short term), to promote dieresis (ex; if the patient has edema and you want to pull fluids out of the intravascular spaces) Hypotonic (pulls the fluid into the cells (makes the cells larger think hippo) 0.45% Saline (1/2 NS), 3.3$ Dextrose and 0.3% NS (2/3 and 1/3). Typically used for rehydration. Do not use for someone in cardiovascular collapse, increased ICP, not for CVA, head trauma or neurosurgery, third-space risk (burns, trauma, or low serum protein levels) Additives

Other terms you should know Flow rate: expressed in mL/hr Drip rate: drops/minute

Drip factor: # drops/ mL (expressed as #gtts/ ml) o Micro & Macro tubing (ex a package that has 15 15 drops into the drip chamber makes 1 mL of solution) The lower number (the bigger the drip) is macro tubing, for smaller solution (ex; 60 drops per hour), would be used in peads. o You will only use drip factor if you are hanging a gravity line Infusion time: total time (mL/hr, drops/min) Vascular access device (VAD) how we access the body to get the fluid into the system

Types of Infusions Intermittent - Saline lock or heparin lock - Flush - IV bolus, push or IV side arm Continuous - IV bag, change every 8-10 hours, maintain for 3-4 days of their stay - Has a tubing associated with it - Must change tubing every 3 days

Assessment and Device Selection Prescribed therapy toxic medications may cause damage to the vein more easily Duration of therapy 3 days or 1 year? Physical assessment Can you see the veins, are the veins small and not easy to access Client health history TPN history Support system/ resources community care (infusion care at home) Device availability what you have at the moment, getting any time of access that you can Client preference depends on their lifestyle Angiopath is the only IV we can insert

Site Selection

We typically use the back of the hand o Basilica vein by the pinky (b= baby) o Cephalic vein by the thumb

Infusion Pumps Continuous analgesia o Requires less drug to maintain pain control o Control for the client o Small o Mobility and independence Insulin Reservoir: preloaded cassette

Complications of IV Therapy Example 1: Arm swollen, cool to touch, but good blood return Fluid leaking from the site * key fact Tenderness around the site Elderly client

Site near a joint This is called Infiltration o Partial  Tip of cannula remains in the veins, but vessel wall does not seal around it o Complete  Cannuals slips out of the vein  Fluid infuses into surrounding tissues Commonly happens in the elders d/t decreased elasticity of their veins

Example 2: Vein is hard, skin is red, swollen and warm, but good infusion, good blood return Induration (small raised area of erothema, along the area of the vein its red and hard) Hard, red, vein = phlebitis The body creates an area of inflammation and it runs right up the vein o Could be d/t:  Harsh medication  Improper catheters change o Instead  Dilute medication  Slow infusion rate  Rotate sites q 48-72 hours  Use central line

Complications of IV Therapy Infusion is sluggish, IV site looks phlebitic Aspirate before you flush Thrombophlebitis o May accompany phlebitis o Movement within the vein, the catheter is moving around = clot build up (thromboembolitis). If you suspect this, call the MD or NP Remove cannula and call MD Elevated WBC, fever, chills, and increase venous blood cultures o IV antibiotics o Vein excision they may need to cut the vein in order to get rid of the clot

Infusion is sluggish, IV site is hot, red, and painful, but not hard or swollen Chills, rapid pulse, T39.4 Blood, urine and sputum cultures to see how progressive the infection is Heat compress and elevate arm Nosocomial peripheral IV infection with bacteraemia and sepsis

Nosocomial peripheral IV infection with bacteraemia and sepsis Poor aseptic techniques during procedures swab the IV site after disconnecting site

Failure to maintain a clean site or close delivery system change the dressing when/ if it is coming off Failure to change tubing or cannulas at regular intervals Malnourished, immunocompromised, over 60, infection at another site

Complications of IV Therapy Infusion ran too fast Speed shock o Facial flushing, severe headache, chest pain o Irregular pulse, drop in BP, LOC, cardiac arrest o Stop infusion, notify physician, monitor v/s Fluid overload o Gradually o Increased BP, distended jugular veins, tachypnea, SOB, most couch and crackles o Keep the client warm, elevate the head of bed administer oxygen o Monitor for edema o Typical treatment would be a diuretic BP drops quickly and pulse increase after a tubing change Air embolism the intro of air in the dead space of the tubing in the patient Place client on left side, lower head of the bed, clamp IV and check tubing for disconnection or air leak Notify the physician, oxygen monitor the client closely Start some sort of anti-coagulant Unsuccessful insertion, catheter tip gone Arm pain Catheter embolism o Apply tourniquet above the site o Notify the physician o Request x-ray confirmation BP drops, weak/rapid pulse, cyanosis, LOC New IV, red streak over vein, pain at site Allergic reaction the material of the angicath Inform the physical Use catheter of a different material Use Benadryl/ epinephrine IV site suddenly turns red, patient complains of itching and develops a rash SOB Allergic reaction to IV fluid medication Stop the infusion and KVO (keep vein open) with NS (normal saline) Administer O2 and notify physician Document reaction

Care and Maintenance to Reduce Vascular Complications Infection prevention control

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Skin antisepsis Tip placement Dressings Securement Patency/ flushing/ locking Occlusion Blood withdrawal Add-ons take off all the tape Documentation Client education

Going Home with an IV - Is the client medically stable? - Is your client or his support person emotionally stable? - Does your client have the motivation to get involved in his own care? can he look at his IV site? - Will the client be able to learn and remember procedures? competency - Does the client have normal visual acuity and manual dexterity? can they see the IV site? - Does the client have the appropriate home environment? Client education - Alarm - Site monitoring - Mobility ex; teach them not to bend their arm a certain way - Written instructions to help the remember - S&S of allergic reaction on