IV Therapy.docx

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IV Therapy

Author: Kristi Hudson RN MSN CCRN

Course Objectives:

Upon completion of this course the student will be able to:

1. State the “7 rights” of safe medicationadministration

2. Describe 2 of the JCAHO safety standards for safe

medication administration

3. Discuss the purpose of IV therapy

4. Understand the difference in Hypertonic vs.

Hypotonic IV solutions

5. Explain 3 signs and symptoms for both fluid

volume overload/deficit

6. List 3 signs and symptoms for an infiltrated IV

7. Discuss the signs and symptoms for air embolism

8. Describe some of the differences in IV access

devices

9. State the steps to accessing a Porta-Cath

Therapy

Understanding the “7 rights” of safe medication

administration:

Most registered nurses learned about the "5 rights" of

medication administration early in their careers. The 5

rights (right drug, right client, right dose, right time and

right route) have been incorporated in their nursing

practice. It is important to remember that hanging a bag of

IV fluid is also considered medication administration, and

must be done using these same safety standards. Inaddition to the “5 rights” of medication administration,

registered nurses also recognize they need to know the

reason the drug is given — the right reason. The

administration of medication is not complete until

documentation has occurred — the right documentation.

Incorporating the right reason and right documentation

into the original “5 rights” of safe medication

administration has turned into the“7 rights” of medication

administration.

1.

RIGHT client (Two Identifiers)2. RIGHT dose

3. RIGHT time

4. RIGHT route

5. RIGHT reason

6. RIGHT documentation

In 2006 the Joint Commission issued National Patient Safety

Goal # 3 (which is still in full force today). This goal is as

follows: PO, IM or Intravenously:

Goal # 3: is to improve the safety of using medication by:

Remove concentrated electrolytes (including but

not limited to potassium chloride, potassium

phosphate and sodium chloride > 0.9 from the

patient care units Standardize and limit the number of drug

concentrations available with in an organization

Identify and at least annually review a list of look

alike/sound alike drugs used in the organization.

Take measures to prevent errors involving these

drugs

Label all medications, medication containers (e.g.,

syringes, medicine cups, basins), or other solutions

on and off the sterile field in perioperative and

other procedural settings

Note: Make sure patient is wearing proper identificationband and allergy band if patient has allergies

The Purpose of IV Therapy:

In addition to having readily available access for

medications, there are five specific purposes for IV therapy

and they include:

1. Providing maintenance requirements for fluids and

electrolytes.

2. Replacing previous losses

3. Replacing concurrent losses

4. Providing nutrition/vitamin replacement

5. Providing a mechanism for the administration of

medications and/or the transfusion of blood and

blood components.

The Three Types of Intravenous Fluids are:

Hypertonic solutions - Any solution that has a

higher osmotic pressure than another solution

(that is, has a higher concentration of solutes than

another solution), which means it draws fluid outof the cell and into the extra-cellular space.

Hypotonic solutions - Any solution that has a lower

osmotic pressure than another solution (that is,

has a lower concentration of solutes than another

solution), which means it pushes fluid into the cell.

Isotonic solutions - Any solution that has the same

osmotic pressure than another solution (that is,

has the same concentration of solutes than



another solution), which means it does not draw

or push fluid into the cell.

Commonly Used Intravenous Solutions:

Normal saline solution (NS, 0.9% NaCl) - Isotonic

solution (contains same amounts of sodium andchloride found in plasma). It contains 9 grams of

sodium chloride per liter of water. It is indicated

for use in conjunction with blood transfusions and

for restoring the loss of body fluids.

Ringer's Solution or Lactated Ringer's (LR) -

Isotonic solution (replaces electrolytes in amounts

similarly found in plasma). It contains sodium

chloride, potassium chloride, calcium chloride, and

sodium lactate. It is indicated for use as the choice

for burn patients, and in most cases of

dehydration. It is also recommended forsupportive treatment of trauma.

Five percent dextrose and water (D5W) - Isotonic

solution (after administration and metabolism of

the glucose; D5W becomes a hypotonic

solution). It contains 5 grams of dextrose per 100

ml of water. It is indicated for use as a calorie

replacement solution and in cases where glucose

is needed for metabolism purposes.

Five percent dextrose and ½ Normal Saline

Solution (D51/2NS) – Hypotonic solution that

draws water out of the cells into the more

concentrated extracellular fluid. Careful usage for

patients with cardiac or renal disease if they are

unable to tolerate the extra fluid watch for

pulmonary edema.

½ Normal Saline Solution – Hypotonic solution that

pushes fluid from the extracellular space into the

cell. Watch if given to patients with increased ICP

i.e. stroke, head trauma or neurosurgery.

TPN (total parenteral nutrition) - TPN contains

water, protein, carbohydrates (CHO), fats,vitamins, and trace elements that are necessary to

the healing process. It is a very strong hypertonic

solution. It must be given through a central venous

catheter to allow rapid mixing and dilution.

Multiple electrolyte solutions are helpful in replacing

previous and concurrent fluid losses. Fluid and electrolyte

losses that occur from diarrhea, vomiting, and/or gastric

suction are an example of concurrent losses.

Nursing assessment for fluid volume deficit and fluid

volume overload during IV therapy include:

FVD (Fluid Volume Deficit)

Dry Skin (Capillary refill > 3 seconds) Elevated or Subnormal Temperature

Thirst

Dry Mucus Membranes

Decreased Urine Output

Soft Sunken Eyeballs ( > then 10% loss of total body fluid

volume decreases intraocular pressure and cause eyes to

appear to be sunken in)

Decrease Tearing and Salivating

Hypotension

FVO (Fluid Volume Overload)

Pitting Edema (1+ - 4+)

Puffy Eyelids

Acute weight gain

Elevated blood pressure

Bounding pulse

Dyspnea and shortness of breath (Usually first

sign)

Ascites or third spacing

Other nursing assessment observations that are important

during IV therapy include:

Close monitoring of weight gain/loss

Accurate I and O (normal urine output is

approximately 1 Ml / Kg of body wt. per hour)

Assessing for signs of edema (skin that is tight and

shiny)

Assessing for skin turgor that when pinched takes

longer then 3 seconds to return to normal. Assessing lung sounds (crackles will be heard with

FVO)

Notification to physician if urine output is < 30cc

for two consecutive hours

Monitor sodium and hematocrit levels

Identifying Common Complications of IV Therapy:

Infiltration – An accumulation of fluid in the tissue

surrounding an IV Catheter site. It is usually caused by



penetration of the vein wall by the catheter itself and later

leads to dislodgement out of the vein and into the tissue.

Signs and systems of infiltration include:

Flow rate may either slow significantly or

completely stop (IV Pump will “beep” occlusion)

Infusion site becomes cool and hard to the touch Infusion site or extremity may become pale and

swollen

Patient may complain of pain, tenderness, burning

or irritation at the IV site

There may be noted fluid leakage around the site

Immediate corrective action to take if IV infiltration is

suspected includes:

Stop IV infusion immediately and remove IV

Catheter Elevate Extremity

If noticed within 30 minutes of onset, apply ice to

the site (this will decrease inflammation)

If noticed later then 30 minutes of onset apply

warm compress (this will encourage absorption)

Notify Supervisor/Physician as per individual

hospital policy

Document findings and actions

Restart IV in an alternative location (opposite

extremity if possible)

Preventive Measures to avoid IV Infiltration include:

Properly securing catheter hub to the limb

Stabilize extremity in use by applying an arm board

if necessary

Frequent assessment of IV site

Keep flow rate at the prescribed rate

Change IV site and tubing per hospital policy

Phlebitis – Inflammation of the wall of the vein, usually

caused by:

Injury to vein during puncture

Later movement of the catheter

Irritation to the vein from long term therapy

Vein overuse

Irritating or incompatible solutions

Large bore IV’s

Lower extremity IV’s (greater risk)

Infection

Signs and Symptoms of Phlebitis include:

Sluggish flow rate

Swelling around infusion site

Patient complaint of pain or discomfort at site

Redness and warmth along vein

Prevention and Treatment for Phlebitis is the same for an

infiltrated IV.

Air embolism - The obstruction of a blood vessel (usually

occurring in the lungs or heart) by air carried via the

bloodstream. The minimum quantity of air that may be

fatal to humans is not known. Animal experimentation

indicates that fatal volumes of air are much larger than the

quantity present in the entire length of IV tubing. Average

IV tubing holds about 5 ml of air, an amount not ordinarily

considered dangerous. Causes of air embolism include:

Failure to remove air from IV tubing

Allowing solution bags to run dry

Disconnecting IV tubing

Signs and Symptoms of Air Embolism include:

Abrupt drop in blood pressure

Weak, rapid pulse

Cyanosis

Chest Pain

Immediate corrective action for suspected Air Embolism

includes:

Notify Supervisor and Physician immediately

Immediately place patient on left side with feet

elevated (this allows pulmonary artery to absorb

small air bubbles)

Administer O2 if necessary

Preventive Measures to avoid Air Embolism

includes:

Clear all air from tubing before attaching it to thepatient

Monitor solution levels carefully and change bag

before it becomes empty

Frequently check to assure that all connections are

secure

IV Therapy Access Devices

Peripheral IV Access:

This is a catheter inserted in a peripheral vein on the hand,



wrist, or arm (rarely the foot in an adult). A peripheral IV is

used for some medications, blood products, and fluid and

electrolyte replacement for short periods of time.

Depending on hospital policy the site is usually changed

every 72 hours. A 2ml - 3ml ml flush of Heparin (100u/cc or

Normal Saline) is required to assure patency. Prior to

inserting a peripheral IV the RN must do the following:

Gather all necessary equipment prior to

attempting to start an IV

Assess veins for size, valves, straightness and ease

of access.

Patient education to include the actual procedure,

purpose of IV Therapy, potential risks involved and

possible discomfort during insertion.

Central Line or Triple Lumen Access

A physician inserts a central line at the bedside, when the

patient either has poor venous access or has the need formultiple different IV therapies. Many times surgeons will

put them in while the patient is in surgery if it is known that

the patient will need IV access for a few weeks. These

catheters can remain inserted for a longer period then a

peripheral IV access (individual hospital policies vary). If

therapy is known to be for longer then a couple of weeks,

then the patient will require a more permanent IV access

port such as a Hickman or Porta-Cath. Triple Lumens are

often the IV access choice for short term TPN

administration. A 2cc to 3cc flush of Heparin (100u/cc or

Normal Saline) can be used to flush the ports and assure

patency. Note an MD order is still required at most facilities

to flush IV access lines.

PICC Line

A PICC line is a peripherally inserted central line. This line is

used when long term IV therapy is needed, and the patient

has poor venous access. It is a less permanent than a port,

Hickman or Porta-Cath. It can be inserted by an RN or

trained individual at the bedside. The catheter is threaded

through the large vein in the arm - brachial - to the superior

vena cava- tip of the right atrium of the heart (Same place

as a port or Hickman). This type of catheter is good for

someone who needs a few weeks of antibiotics at home,

someone who had surgery and needs home IV therapy for

3-4 weeks. This type of catheter can be left in place for up

to 12 months as long as there are no complications.

Hickman Catheter

The Hickman Catheter is a thin, long tube made of flexible,

silicone rubber. It is surgically inserted into the superior

vena cava with the tip resting at the right atrium.

Depending on the therapy needs, the catheter may have

either a single, double or triple lumen (opening) at the tip.

This type of catheter is placed when home or long-term

venous access is required. The ports are flushed with 2cc

to 3cc of Heparin (100u/cc) to maintain port patency and

prevent thrombosis formation.

Porta-Cath

There are several different types of subcutaneous (under

the skin) ports that can be used; the Port-A-Cath is the

most common. The subcutaneous port differs from theexternal catheter in that it is completely under the skin. A

small metal chamber (1 x 1 x 1/2 inches) with a rubber top

is implanted under the skin of the right chest. A catheter

threads from the metal chamber (portal) under the skin to

a large vein (sub-clavian) near the collarbone, then inside

the vein to the right atrium of the heart. Whenever the

catheter is needed for a blood draw or infusion of drugs or

fluid, a needle is inserted by a nurse through the skin and

into the rubber top of the portal.

Accessing a Porta-Cath (10 Steps)

1. Inquire and/or observe whether the patient has

experienced any symptoms that might warn of

catheter fragmentation and/or catheter

embolization since the system was last accessed;

for example, episodes of shortness of breath,

chest pain, or palpitations, If any of these

symptoms are reported, an x-ray is recommended

to determine if there are problems with the

catheter.

2. Examine and palpate the portal pocket and

catheter tract for erythema, swelling, tenderness,

or infection, which might indicate system leakage.If system leakage is suspected, an x-ray is

recommended to determine if there are problems

with the system.

3. Set up the sterile field and supplies.

4. Prepare the site for the injection or infusion.

5. Anesthetize the site for needle puncture, if

desired.

6. Using a 10-ml or larger syringe, prime the porta-

cath access needle and any attached extension set

to remove all air from the fluid path. Do not use

standard hypodermic needles, as these will

damage the septum and may cause leakage.

7. Locate the portal by palpation and immobilize it

using thumb and fingers of the non-dominant

hand.

8. Insert the non-coring needle through the skin and

portal septum at a 90º angle to the septum. To

avoid injection into the subcutaneous tissue,

slowly advance the needle until it touches the

bottom of the portal chamber. Warning - Do not

tilt or rock the needle once the septum is



punctured as this may cause fluid leakage or

damage to the septum.

9. Aspirate for blood return. Difficulty in

withdrawing blood may indicate catheter blockage

or improper needle position.

10. Using a second 10-ml or larger syringe, flush the

system with 10-ml of normal saline, taking care

not to apply excessive force to the syringe.Difficulty in injecting or infusing fluid may indicate

catheter blockage. During this saline flush,

observe the portal pocket and catheter tract for

swelling and inquire or observe whether the

patient is experiencing burning, pain, or

discomfort at the portal site. If any of these

symptoms are noted and/or swelling of the portal

pocket and catheter tract is observed, fluid

extravasations into the portal pocket or catheter

tract should be suspected.

Care of the Subcutaneous Port - The entire port and

catheter are under the skin and therefore require no daily

care. The skin over the port can be washed just like the rest

of the body. Frequent visual inspections are needed to

check for swelling, redness, or drainage.

The subcutaneous port must be accessed and flushed with

Normal Saline (5-10mls) and Heparin (6ml of 100units/ml)

at least once every 30 days, which usually coincides with

the monthly clinic visit and blood checks. A nurse or

technician does this procedure only. The port system

requires no maintenance by the patient or family members.

Contraindicated for patient therapy include:

Presence of infection, bacteremia, or septicemia is

known or suspected.

The patient's anatomy will not permit introduction

of the catheter into a vessel.

The patient has severe chronic obstructive

pulmonary disease (COPD) - chest placement only.

The patient has undergone past irradiation of the

upper chest area - chest placement only.

The patient is known to have, or is suspected to

have, an allergic reaction to materials contained inthe system or has exhibited a prior intolerance to

implanted devices.

Substances are used for patient therapy that is

incompatible with any of the system's

components.

Do not use this product if the package has been

previously opened or damaged.

Use of the system involves potential risks normally

associated with the insertion or use of any implanted

device or indwelling catheter, including but not limited to:

Air embolism

Arteriovenous fistula Artery or vein damage/injury

Brachial plexus injury

Cardiac arrhythmia

Cardiac puncture/Cardiac tamponade

Catheter disconnections, fragmentation, fracture,

or shearing with possible embolization of the

catheter.

Catheter occlusion/ Catheter rupture

Drug extravasations

Erosion of portal/catheter through skin and/or

blood vessel.

Fibrin sheath formation around catheter tip. Hematoma/Thrombosis

Pneumothorax/Hemothorax

Implant rejection

Infection/bacteremia/sepsis

Migration of portal/catheter

Nerve damage

Thoracic duct injury

Thromboembolism/Thrombophlebitis

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