01 NCM 106 Intravenous Therapy

BASIC FOUNDATIONS OF IV THERAPY

GOALS OF INTRAVENOUS THERAPHY

Primary Goal

The primary goal of intravenous therapy is to provide a positive outcome for the client. Painless and effective therapy is desirable, promoting the client’s comfort, well-being, and often complete recovery from disease or trauma.

The goals of IV therapy are to:

Maintain or place body stores of water, electrolytes, vitamins, proteins, fats and calories in the client who cannot maintain adequate intake by mouth;

Restore acid-base balance; Administer safe and effective infusions of medications by using the appropriate vascular access; Monitor central venous pressure (CVP); Provide nutrition while resting the gastrointestinal tract.

HISTORICAL BACKGROUND OF INTRAVENOUS THERAPY

1942 – The recorded history of IV therapy began in 1942 when a blood transfusion from Romans to the dying Pope Innocent was attempted. The pope and the blood donors all died.

1628 – Almost 400 years had passed since the discovery of blood circulation. William Harvey’s research in 1628 stimulated increase experimentation, and he found out that the heart is both a muscle and a pump.

1656 – Christopher Wren, the famed architect of St. Paul’s Cathedral in London, injected opium intravenously into dogs making them unconscious. Wren, known as the father of modern intravenous therapy, used a quill and bladder syringe.

1662 – John Majors made the first successful injection of unpurified compounds into human beings, although death resulted from injection at the injection site in 1662.

1665 – An animal near death from loos of blood was saved by the infusion of blood from another animal.

1667 – A 15-yearold Parisian boy was the first human to receive a transfusion successfully; lamb’s blood was administered directly into boy’s circulation by Jean Baptiste Denis, physician to Luis XIV 1667.

1668 – The enthusiasm aroused by this success led to promiscuous transfusions of blood from animals to humans with fatal results and by an edict of church and parliament, animal to human transfusion were prohibited in Europe. Nearly 150 years passed before serious attempts were again made to inject blood into people.

1834 – James Blundell, an English obstetrician, revived the idea of blood transfusion. Saving the lives of women threatened by hemorrhage during child birth, he provided that animal blood was unfit to inject into humans and that only human blood was safe. Nevertheless, complications persisted, with infections developing in donor and recipients. With the discovery of the principles of antisepsis by Pasteur and Lister, another obstacle was overcome, although reactions and death continued.

Mid-19th – There was an increase knowledge of bacteriology, pharmacology and pathology that led to new approaches.

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1900 – Karl Landsteiner led the way in identifying and classifying different blood groups.

1914 – It was recognized that Sodium Citrate prevented clotting which opened the gate for extensive use of blood transfusions.

1923 – Discovery and elimination of pyrogens led to safer and more frequent IV administration of parenteral fluids.

1925 – The most frequently used parenteral fluid was Normal Saline Solution (0.9 Sodium Chloride)

1940 – The general responsibilities of an IV nurse include:

Administering IV solutions and blood transfusions Cleaning and sharpening needles for reuse Cleaning the infusion set Maintain the patency of needles Ensuring unobstructed infusion flow

1950 – Administration of parenteral fluids via the IV route has only been used by this time.

The difficulty in accepting this procedure resulted from the lack of safe fluids. The fluids used contained substances called pyrogens (protein that are foreign to the body and not destroyed by sterilization). This caused chills and fever when inserted in the circulation.

IV was being used widely during the World War II, and by the mid 1950’s. It was being used mainly for the purpose of major surgery and rehydration only.

Few medications were given via IV route, with antibiotic more commonly given intramuscularly.

1960-1970 – Intermittent medications, filters, electronic infusion control devices and plastic cannula became available.

Use of multiple electrolyte solutions and medications increased along with blood component or transfusion therapy, and numerous IV drugs and antibiotics were added to IV regimens.

1972 – Ada Plumer and Marguerite Knight are IV nurses, who wrote an organization letter asking individuals to unite to form the American Association of IV Nurses in November, 1972.

The name of the organization was changed to National Intravenous Therapy Association (NITA), now known as the Infusion Nurses Society. The purpose of the organization was to standardize the specialty practice of IV nursing and to ensure the provision of quality, cost-efficient client care.

As knowledge of electrolyte and fluid therapy grew, more parenteral fluid became available, and additional knowledge was then need to monitor the fluid and electrolyte status of a client. The nurse assigned to a client in need of IV therapy is expected to have a working knowledge of fluid and electrolyte balance and to completely assess the client in terms of fluid needs.

The use of IV therapy has expanded dramatically over the last 35 years. This expansion continues to and can be attributed to the following factors:

The understanding of hazards and complications Improvement of IV equipment Increased knowledge of physiological requirements Increased knowledge of pharmacological and therapeutic implications Increased availability of nutrients and drugs in IV solutions

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Changes in traditional roles of doctors and nurses, allowing nurses to develop that were traditionally the task of those in medical profession (e.g., insertion of central venous access devices)

STANDARDS AND COMPETENCIES IN INTRAVENOUS THERAPY

Because infusion practice changes continually, practice standards are updated to reflect those changes.

Each nurse in an organization must be cognizant of the policies and procedures relevant to infusion therapy and familiar with the nurse’s responsibilities to provide a safe level of care for the client. All nurses are responsible for administering IV therapy should be familiar with established Standards of practice.

The Nursing Standards on intravenous Practice was established in 1993 as a guide for those who will be practicing intravenous therapy.

At present, the Association of Nursing Service Administration of the Philippines (ANSAP) conducts IV therapy trainings for BSN graduates who passed the Philippine Licensure Examination for Nurses and has already secured his or her Philippine Regulatory Commission (PRC) license.

RA No. 9173, otherwise known as the “Philippine Nursing Act of 2002”, states that the administration of parenteral injection is included in the scope of nursing practice.

In pursuant to Board of Nursing Resolution No. 08 Series of 1994; "That a registered nurse is prescribed prohibited from administering intravenous injections to a client unless he or she has undergone a special training at least under a nursing administrator who is a member of ANSAP and who is classified under section 28, article V of RA 7164 there on either before or after his registration as a nurse.”

ANSAP believes that nurses who practice IV therapy are only those registered nurses who had been adequately trained and have completed the training requirements of the IV therapy program.

The framework IV Therapy Training (to be a Certified IV Therapy Nurse) is a continuous process in which every nurse shall start as novice nurse in IV therapy, and proceeds to training for the following;

1. ANSAP Standards for IV Therapy2. Implementation of Standards in Infusion Care3. Procedure or Demonstration4. Completion of the requirements under ANSAP standards

Standard requirements for the IV therapy training include the following:

1. Entrance requirement must be a registered nurse with a current license from the PRC or certified Board rating for new nurses.

2. Completion requirement of a 3+3+2 requirements: 3 successful peripheral IV circulation 3 administration of IV medications 2 administrations of blood or blood components

3. Submission of completed requirements within 3 months from the date of IVT training, otherwise, the 3-day Basic IV Therapy Program will be repeated.

Grounds for the cancelation of the IV Therapy card include grave offenses such as dishonesty, grave misconduct, falsification of documents, disgraceful or unpleasant conduct, and or gross violation for Nursing Law and ANSAP IVT Standards.

The following grave offenses shall incur the penalty of six months suspension and fine or cancelation accreditation, upon discretion of the ANSAP Board.

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INFUSION or INTRAVENOUS THERAPY NURSE SPECIALIST

An infusion/intravenous therapy nurse is a highly-trained nurse knowledgeable and skilled in initiating and monitoring IVs and in the assessment of infusion products for use.

He or she works independently and is held accountable from knowing what to do and how to do it. The practice of IV nursing is a specialization.

The infusion nurses practice is based on the following:

Knowledge of anatomy and physiologySpecific knowledge and understanding with other body systems and infusion therapy modalitiesParticipation in the establishments of the client’s ongoing plan of carePossession of skills necessary for the administration of infusion therapiesKnowledge of state-of-the-art technologies associated with infusion therapiesKnowledge of psychosocial aspects, including sensitivity to the client’s wholeness, uniqueness, and

significant social relationships, and knowledge of community and economic resourcesInteraction and collaboration with members of the health care team and participation in the clinical

decision-making process

The following are roles and scope of practice of an infusion nurse:

Infusion administration of parenteral fluids, blood and blood components, total parenteral nutrition, antineoplastic therapy, intra-arterial therapy, and pain management

IV access and monitoring of peripheral lines, pediatric IV lines, administration set and dressing changes, therapeutic phlebotomy, venous sampling, peripherally inserted central catheters, Ommaya reservoirs, and other alternative access devices

Client and family education about self-care and home therapy Preparation of drugs in a solution

Collaborative practice may include being part of the safety committee, quality improvement, code team, product evaluation, and development of policies and procedures.

REVIEW OF ANATOMY AND PHYSIOLOGY

Integumentary System

The integumentary or skin is the first organ affected in IV access. It protects the body from the environment a natural barrier to external forces. The skin is made up of two layers, the epidermis and the dermis.

The epidermis is the uppermost layer, which form a protective covering for the dermis. Its thickness varies in different parts of the body.

It is the thickest on the palms of the hands and the soles of the feet and thinnest on the inner surface of the limbs.

Its thickness also varies with age. In an elderly client, for example, the skin on the dorsum of the hand may be so thin that it doesn’t

adequately support the vein for venipuncture when parenteral infusions are required.

The dermis or under layer, is highly sensitive and vascular. It contains many capillaries and thousands of nerve fibers.

The superficial fascia, or subcutaneous areolar connective tissue, lies below the two layers of the skin and is itself another covering.

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The superficial veins are located in this fascia, which varies in thickness. When a catheter is inserted into this fascia, there is free movement of the skin above Great care and meticulous aseptic technique must be observed because an infection in this loose

tissue spreads easily.

Peripheral Vascular System

The veins, because of their abundance and location, provide the most readily accessible route for infusion therapies.

The arteries and bone marrow are also used.

Arteries provide the route for using radiopaque material for diagnostic purposes, such as in arteriograms to detect cerebral disorders, blood pressure monitoring, determinations of arterial blood gas levels, and administration of chemotherapy.

The dangers of arterial spasm and subsequent gangrene present problems that make this route of therapy hazardous for therapeutic use.

The bone marrow, because of this venous plexus is used for infusion therapy by intraosseous route.

The superficial or cutaneous veins are used in venipuncture. They are located just beneath the skin in the superficial fascia. When located in the located in the lower extremities, cutaneous vein unite with the deep veins.

The superficial veins of the upper extremities consist of the digital, metacarpal, cephalic, basilica and median veins

Difference between Arteries and Veins

The most important difference between arteries and veins is that arteries pulsate and veins do not. Both the artery and vein comprise three layers of tissue- tunica intima, tunica media and tunica adventitia.

The first vascular layer is known as the tunica intima.

It consists of an inner elastic endothelial lining, which also forms the valves in veins. Although these valves are absent in arteries, the endothelial lining is identical in the arteries and the veins, consisting of a smooth layer of flat cells. This smooth surface allows the cells and platelets to flow through the blood vessels without interruption under normal conditions.

Many veins contain valves, which are semilunar folds of the endothelium. Found in the larger veins of the extremities, these valves function to keep the blood flowing toward the heart. They are located at points of branching and often cause a noticeable bulge in the veins.

Care must be taken to avoid roughening this surface when performing a venipuncture or removing a needle from a vein. Any trauma that roughens the endothelial lining encourages thrombin formation, a result of cells and platelets adhering or aggregating to the vessel wall.

Factors which may result in damage to endothelial cells Rapid advancement of cannula Poor technique Using a cannula which is too large for the lumen of the vein Using a cannula which remains relatively rigid after insertion Placing a cannula near to areas of flexion such as over joints Unsecured cannula, which may result in movement Poor skin preparation and incorrect use of dressing which can lead to contamination of the site Infusion of any of the following irritant solutions: hypertonic and hypotonic, very low or very high pH Infusion of particulate matter Rapid infusions of any particulate matter

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Rapid infusions of large quantities of fluid which may be too great for the vessel to accommodate.

The second layer, the tunica media, consist of muscular and elastic tissue.

The nerve fibers, both vasoconstrictors and vasodilators, are located in this mid layer. These fibers which constantly receive impulses from the vasoconstrictor center in the medulla, keep the vessels in a state of tonus. They also stimulate both arteries and veins to contract and relax.

The middle layer is not as strong as stiff in the veins as it is in the arteries. Therefore, the veins tend to collapse or distend as the pressure within falls or rises.

Arteries do not collapse. Stimulation by a change in temperature or by mechanical or chemical irritation may produce spasm in the vein or arteries. Application of heat to the vein promotes vasodilation, which relieves the spasm, improves the flow

of blood, and relieves the pain. Spasm produce by a chemical irritation in an artery may have dire consequences. A single artery

supplies circulation to a particular area. if this artery is damaged, the related area experiences impaired circulation, with the possible development of necrosis and gangrene.

If a chemical agent is introduced into the artery, the result maybe spasm- a contraction that could shut off the blood supply completely. This problem is not that serious when vein are used because many veins supply a particular area; if one is injured, others maintain the circulation.

The third layer is the tunica adventitia.

It consists of areolar connective tissue, which surrounds and supports the vessel. In arteries, this layer is thicker than in veins because it is subjected to greater pressure from the force of blood. Arteries require more protection than veins and are placed where injury is less likely to occur. Whereas vein are superficially located, most arteries lie deep in the tissues and are protected by the muscle.

INTRAVENOUS INFUSION

Parenteral Fluids

Parenteral fluids are classified according to the tonicity of the fluid in relation to blood plasma which is 290mOsm per liter.

Isotonic fluid – approximately 290mOsm/L Hypertonic fluid – serum osmolality is greater than 290mOsm Hypotonic fluid – serum osmolality is less than 290mOsm

The results of infusion of fluids with different tonicities are:

Isotonic fluid increases extracellular volume Hypertonic fluid increases osmotic pressure of plasma; draws fluid from the cells Hypotonic fluid lowers the osmotic pressure of plasma causes fluid to invade the cell.

Infusions and Medications

Infusion is an amount of fluid greater than 100mL designated to be infused parentally because the volume must be administered over a long period.

Medications are administered as piggyback secondary to and delivered with the initial infusion.

Small-volume (50 to 100ml) parenteral infusion may require 30-60 minutes. Larger volume of 150 to 200 ml may require more than an hour of infusion.

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Kinds and Compositions of Fluid

The following are the metabolic effects of dextrose:

Provides energy for essential energy Improves hepatic function because glucose is converted into glycogen by the liver Spares body protein (prevents unnecessary breakdown of protein tissue) Prevents ketosis or excretion of the organic acid, which may occur when fat is burned by the body

without an adequate supply of glucose Stored intracellularly in the liver as glycogen, causes shift of potassium from extracellular to the

intracellular fluid compartment (this effect is the desired treatment for hyperkalemia achieved by infusing dextrose and insulin)

Isotonic sodium chloride infusions (PNSS/ 0.9NaCl)

The term normal or physiologic is misleading because the chloride in normal saline s 154 mEq/L, compared with the normal plasma chloride value of 103 mEq/L, whereas the sodium is 154 mEq/L or approximately higher than normal plasma value 140 mEq/L.

The tonicity of the fluid depends on the sodium and chloride ions because normal saline lacks the other electrolytes present in plasma. This results to a higher concentration of sodium and chloride ions.

Marked electrolyte imbalances have resulted from the almost exclusive use of normal saline. Hypernatremia acidosis and circulatory overload may result when normal saline is administered in excess of the client’s tolerance.

Dextrose 5% in 0.9% Sodium Chloride

When normal saline is infused, the addition of 100 grams dextrose prevents both the formation of ketone bodies and the increase demand of water the ketone bodies imposed for renal excretion.

The dextrose prevents catabolism and, consequently, loss of potassium and intracellular water. The hazards of using this fluid type are the same as those for normal saline injection.

Dextrose 10% in 0.9% sodium chloride

Must be administered IV, preferably through a wide vein to dilute the fluid and reduce the risk of trauma to the vessel (this is due to the fluid’s hypertonicity)

Close observation and precaution are necessary to prevent infiltration and damage to the tissue.

Hypertonic Sodium Chloride Infusions

These infusions include 3% Sodium Chloride and as well as in 5%

Hypotonic Sodium Chloride in water

0.45% Sodium Chloride solution with 1,000 mL containing 77mEq of sodium and 77mEq of chloride. It provides sodium, chloride, and free water and is used primarily as a hydrating solution.

Hypotonic multiple-electrolyte solutions

Contains 5% dextrose, once the dextrose is metabolized, these solutions disperse as hypotonic fluids.

Isotonic multiple-electrolyte solutions

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These are commercial replacement fluids; balanced fluids of isotonic electrolytes with an ionic composition similar to plasma.

Rapid initial replacements of this fluid type are seldom necessary. When using this solution, fluid overload must be monitored and prevented. Central venous pressure

monitoring is especially helpful in elderly clients and with those in renal and cardiovascular disorders. Extracellular replacement can usually be assumed to be complete after 48 hours of replacement

therapy unless proved otherwise by clinical or laboratory evidence. To continue replacement fluids after deficits have been corrected may result in sodium excess, leading to pulmonary edema or hear failure.

Gastric replacement fluids are contraindicated in clients with hepatic insufficiency or renal failure, and should also be avoided in clients with renal damage or Addison’s disease. Also the low pH of these fluids causes incompatibilities with many additives.

Lactated Ringer’s injection is contraindicated in severe metabolic acidosis or alkalosis and in lover disease or anoxic states that influences lactate metabolism.

Alkalizing fluids

One-sixth molar sodium lactate – the lactate ion must be oxidized in the body to carbon dioxide before it can affect acid-base balance; the complete conversion of sodium lactate to bicarbonate requires approximately 1 to 2 hours.- Sodium lactate is not used for clients experiencing oxygen deficiency, as in shock or congenital

heart disease with persistent cyanosis, because oxidation is necessary to increase the bicarbonate concentration in the body.

- Also contraindicated in liver disease because the lactate ions are improperly metabolized.

Sodium bicarbonate injection

An isotonic fluid that provides bicarbonate ions for conditions with excess depletion. The fluid should be infused slowly IV. Rapid infusion may induce cellular acidity and death. The client should be monitored for signs of hypokalemia tetany, and calcium supplement should be

administered if required; calcium does not ionize well in an alkaline medium. Extravasations of hypertonic sodium bicarbonate injections must be avoided. Bicarbonate therapy should cease when the pH reaches 7.2.

Acidifying solutions

Normal saline is not usually listed among the acidifying infusions. However because metabolic alkalosis is a condition association with excess bicarbonate and loss of chloride, isotonic saline provides conservative treatment and the alkalosis is relieved.

Ammonium chloride is used as a usual acidifying agent.- Ammonium chloride must be infused at a very slow rate to enable the liver to metabolize the

ammonium ions not to exceed 5mL per minute in adults.- Rapid injection can result in toxic effects, causing irregular breathing bradycardia, and twitching.- This solution must not be administered to clients with severe hepatic disease or renal failure due to

its acidifying effect that depends on the liver for conversion.- It is also contraindicated in any condition which the client has a high ammonium level.

NUSING MANAGEMENT FOR THE CLIENT RECEIVING IV THERAPY

Physical Preparation

Safety

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The following are nursing assessments and interventions that promote and contribute to the client’s safety prior to the initiation of peripheral infusion therapy.

1. Verification of the physician’s order2. Correct client or patient identification3. Validation that the ordered infusion is appropriate for the client4. Confirmation that the client is not allergic to anything that is to be administered5. Confirmation that all supplies and equipment for venipuncture are sterile and handled

aseptically, and that they have not exceeded their expiration dates.6. Documentation of significant laboratory and diagnostic reports7. Strict asepsis in the preparation of all products to be used for venipuncture and IV infusions.8. The provision of safe environment for the client during infusion therapy in terms of bed rails,

restraints, movement and ambulation.9. Assessment and selection of the peripheral vessel that is appropriate for the type of infusion

ordered10. Teaching measures that will instruct the client about what he needs to report in terms of

activity, discomfort, or signs and symptoms associated with any untoward reactionComfort

The ambulatory client may still get up and move around during IV therapy however, measures must be employed to prevent dislodgement of the cannula or disconnections of any proportions of the setup.

Prior to initiation of IV therapy, there are several nursing assessments and interventions that need to be employed in the interest of client’s physical comfort, including:

1. Determine the client whether he is right handed or left handed (For the IV not to affect client’s ADL)

2. The nurse should also avoid using veins in areas of flexion or in the antecubital fossa unless such areas are immobilized in a safe manner.

3. The IV site is being inserted to provide access during surgery; the access site should present minimal interference with the surgical procedure or positioning during the intraoperative and postoperative periods.

4. Allowing the client to carry out ADL’s prior to the initiation of therapy, if time permits.5. Securing IV tubing that is of the length appropriate for minimally restricted movement by the

client during the infusion.6. Providing loose-fitting bed clothes that will not restrict movement or fluid flow, and allow for

easy removal when they need to be changed, without interfering with the IV7. Providing privacy

Position

Prior to the initiation if the IV therapy, the client should be positioned in a manner that allows the optimum conditions for venous access.

The preferred position is the Fowler’s position.

The knees maybe flexed and supported by pillows The arms should be positioned at the client’s side, with the intended site of venipuncture at a lower level than the heart, to promote venous filling.

An arm board maybe unnecessary if the nurse appropriately selects and cannulates the vein, allowing for natural anatomic splinting by the bones.

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If immobilization of the extremity is required the nurse must follow agency policy and procedural guidelines regarding the use of arm boards, restrains, or any stabilization devices. When an arm board is applied, the nurse must protect circulatory status and flow, and be able to monitor the infusion site. Remove any device frequent intervals in order to adequately assess circulatory status.

Selecting an IV Site

The following are factors to consider when selecting a site for venipuncture

Condition of the vein Type of the fluid medication to be infused Duration of the therapy Client’s age and size Whether the client is right or left-handed Client’s medication history and current health status Skill of the person performing venipuncture

When choosing to cannulate a particular vein for any infusion, the nurse must assess the client and his condition, the indication for therapy, the product/s to be infused, and the projected time the therapy will be employed.

The following are the dos and don’ts of IV site selection:

Use the distal veins of the upper extremities first, with subsequent venipunctures proximal to the previous sites. Palpate the veins prior to venipuncture to determine the condition of the client’s veins. Use appropriate for the prescribed infusate. Larger veins should be used for irritating or hypertonic preparations. Use the veins that will most likely sustain the infusion for most likely 48-72 hours. With prolonged infusion therapy, all measures must be taken to preserve peripheral veins. Use the smallest cannula that will deliver the prescribed infusate. Do not use the veins of the lower extremities in adults and children who are walking. Do not use veins that are irritated or scierosed from previous use. Avoid areas of flexion, unless the joints are immobilized. Avoid veins in the antecubital fossa. Do not use tourniquet on fragile veins. Do not use veins in an extremity:

- On the side of the body where radical mastectomy has been performed with lymph node dissecting/stripping.- That is impaired that is a result of CVA- That is partially amputated, or has undergone reconstructive or orthopedic surgery- That has sustained third-degree burnsCirculation in these areas is impaired, with altered venous and lymphatic flow which can cause or exacerbate edema.

Do not use an anteriovenous fistula, shunt or graft for peripheral infusion therapy. These routes are preserved for hemodialysis access.

Equipment and Supplies

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The nurse must be familiar with the numerous equipment items and supplies needed to safely carry out intravenous therapy. This includes the:

- Types of infusate containers available;- Categories of administration set tubing’s and the devices that can be added to them;- Various types of peripheral venous access cannulas available and their indications for use;- Materials needed to prepare and maintain a percutaneous venous access site;- Categories of infusion devices available and the manner in which they operate;

The following are equipment and supplies used in IV therapy:

Infusate containers

- Used for the delivery of IV infusions, usually made of flexible plastic materials; however, glass containers are also used due to the chemical makeup of some infusates.- The following are some actions necessary prior to setting up and administering the infusate

o Read the label of ascertain that the infusate is the correct one ordered for his client and check for the expiration rate.

o Evaluate the container, make sure that all seals are intact and that there are no breaks no breaks in its integrity.

o Check the fluid for clarity and absence of particulate matter.o Affix additive labels to containers in an inverted position so they can

easily be read when the container is hanging upside down on an IV pole.

o Never write directly on a flexible plastic IV bag with a ballpoint pen or any point of indelible marker.

Infusate administration sets

- IV administration set; the tubing that delivers fluid or medication from the infusate container to the client. The tubing on all sets has a screw, roller and slide clamp that provides a means for the nurse to regulate using one hand.

Peripheral venous access device

- Range in variety from straight steel and winged needles to catheters made of Teflon, polyurethane, PVC, polyethylene, silicone, or other materials. They vary in length and gauge to meet the needs of a wide variety of clients.

o Over – the – needle cannula For long term use of an active or agitated client. More comfortable for the client when it is in place. Contains radiopaque thread for easy location, some units come with a syringe that permits easy check of blood return, some units include wings; actively-restricting devices such as arm board rarely needed. More difficult to insert than other devices.

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o Winged infusion set Short-term therapy for cooperative adult client; therapy for any duration for a neonate or child or for an elderly client with fragile of sclerotic veins. Less painful to insert, ideal for non-irritating IV push drugs. May easily cause infiltration if a rigid-needle winged infusion device is used.

The following maybe considered when selecting a catheter gauge:

o 16-gauge – major surgery, trauma, obstetric surgeryo 18-gauge – blood and blood products, administration of viscous

medicationso 20-gauge – most client or patient applicationso 22-gauge – most client or patient applications, especially children and

adult clientso 24-gauge – pediatric clients, neonates and older adult clients

Maintenance materialsInclude antiseptic for skin preparation, dressing (sterile gauze or sterile transparent,

semipermeable dressing) tourniquet, ad tape.

Preparing the IV site Before the preparation, ask the client about allergies to latex or iodine. Remove excessive hair at the selected site by clipping to facilitate insertion of the cannula and adherence of dressing to the IV insertion site Ensure that the IV device, fluid, the container, and the tubing are sterile Perform hand hygiene and put on gloves. Gloves must be worn during the venipuncture procedure because of the likelihood of coming into contact with blood borne pathogens. Prepare the insertion site according to the institutional policy

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Performing Venipuncture There are four methods that can be used for advancing an over-the-needle cannula into the vein. With any method, insert the cannula with a smooth, aggressive but not jerky motion as the needle is advanced through the skin and into the vein. o Floating technique

With the floating method, remove the stylet before fully advancing the cannula. This is a good technique for inexperienced nurse because it will be less likely that the vein’s opposite wall will be punctured.

1. Perform a venipuncture and advance the cannula about one-third to one0half its length into the vein or until a backflow of blood is seen.

2. Place a protective pad under a catheter hub to catch any blood that escapes when the stylet is removed.

3. Release the tourniquet and remove the stylet.4. Attach the tubing and start the IV infusion at a slow rate(or attach an injection cap)5. Use one hand to maintain a vein stretch while advancing the cannula with a one

hand.6. When the cannula is fully advanced, adjust the IV rate.o Two-handed technique

This method is usually used by nurses because the stylet partially obstructs the cannula as it is advanced, this method reduces blood spillage.

1. Insert the cannula into the vein approximately half the length of the cannula or until backflow of blood is visible.

2. With one hand, hold the hub of the cannula while retracting the stylet about half way with the other hand.

3. While maintaining vein stretch, advance the cannula until it is inserted completely. Remove the tourniquet.

4. Remove the stylet and attach the IV tubing (or instill 1-2 mL of normal saline solution and attach an injection cap).With practice, the inexperienced nurse can learn to advance the catheter of the stylet with one hand, while the other maintains vein stretch. If the vein is small, leave the tourniquet tied to increase vein size during cannula advancement.

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o One-step techniqueThis method is done by experienced nurses at venipuncture. This is also used if the vein is straight, even and superficial.An experienced, skillful nurse can place the cannula in the vein lumen with one deft motion without injuring the vein.

1. In one step, enter the sin and advance the cannula in the vein completely up to the hub.2. Remove the stylet and attach the IV tubing or injection cap.

o Pushing technique

Pushing the cannula off the stylet is recommended for catheters with a raised lip on the hub.1. Advance the cannula halfway into the vein.2 Using the forefinger or thumb, press against the hub’s lip: slide the cannula forward so that it moves off the stylet into the vein.3. Discard the stylet, remove the tourniquet, and attach the IV tubing or injection cap.

Complications of IV Therapy1. Infiltration

Caused by the dislodgement of IV cannula from the vein resulting in infusion of fluid into the surrounding tissues

Signs and SymptomsSwelling, blanching, and coolness of surrounding skin and tissuesDiscomfort, depending on nature of solutionFluid flowing more slowly or ceasingAbsence of blood backflow in IV catheter and tubing.

Preventive MeasuresMake sure that the IV and distal tubing are secured sufficiently with tape to prevent movement.Splint the client’s arm or hand as necessary.Check the IV site frequently for complications

Nursing InterventionsStop infusion immediately and remove the IV needle or catheter.Restart the IV in other arm.If infiltration moderate to severe, apply warm, moist compress and elevate the limb.If a vasoconstrictor agent has infiltrated, initiate emergency local treatment as directed; serious tissue injury, necrosis, and sloughing may result if actions are not taken.Document interventions and assessment.

2. ThrombophlebitisPossible Causes

Injury to vein during venipuncture, large-bore needle or catheter use, or prolonged needle or catheter use.Irritation to vein due to rapid infusion or irritating solutions.Clot formation at the end of the needle or catheter due to slow infusion ratesMore commonly seen in synthetic catheters than steel needles

Signs and SymptomsTenderness at first, then pain along the vein;Swelling, warmth, and redness at infusion site; the vein may appear as a red streak above the insertion site.

Preventive MeasuresAnchor the needle or catheter securely at the insertion site.

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Change the insertion site at least every 72 hours. If the facility phlebitis rate goes above 5%, insertion sites should be changed every 48 hours.Use large veins for irritating fluid because of higher blood flow, which rapidly dilutes the irritant.Sufficiently dilute irritating agents before infusion.

Nursing InterventionApply cold compress immediately to relieve pain and inflammation.Follow with moist, warm compress to stimulate circulation and promote absorption.Document interventions and assessment.

3. BacteremiaPossible Causes

Underlying phlebitis increase risk 18-foldContaminated equipment or infused solutionsProlonged placement of an IV deviceNon-sterile IV insertion or dressing changeCross-contamination by the client with other infected areas of the bodyA critically ill or immunosuppressed client is at greatest risk of bacteremia

Signs and SymptomsElevated temperature, chillsNausea, vomitingElevated white blood cells (WBC) countMalaise, increased pulseBackache, headacheMay progress to septic shock with profound hypertensionPossible signs of local infection at IV insertion (e.g., redness, pain, foul drainage)

Preventive MeasuresFollow the same preventions listed in thrombophlebitis.Use strict sterile technique when inserting the IV or changing dressing.Solutions should never hang longer than 24 hours.Change the insertion site at least every 48-72 hours and intermittent IV administration every 24 hours.Change IV dressing every 48-72 hours.Maintain integrity of the infusion system.

Nursing InterventionsDiscontinue infusion and IV cannulaIV device should be removed and the tip cut off with sterile scissors, placed in a dry sterile container, and immediately sent to the laboratory for analysis.Check VS; reassure the client.Obtain WBC count, as directed, and assess for other sites of infection (urine, sputum, wound). Start appropriate antibiotic therapy immediately after receiving orders.Document interventions and assessments.

4. Circulatory OverloadPossible CausesDelivery of excessive amounts of IV fluid (at risk are elderly clients, infants and children with cardiac or renal insufficiency)

Signs and SymptomsIncreased blood pressure and pulse;Increased central venous pressure (CVP), venous distension (engorged jugular veins);Headache, anxietyShortness of breath, tachypnea, coughing;Pulmonary crackles

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Chest pain if (+) history of CADPreventive Measures

Know whether the client has existing heart or kidney condition; be particularly vigilant with high-risk clients.Closely monitor the infusion flow rate; keep accurate intake and output records.Splint the arm or hand if the IV flow fluctuates too widely with movement

Nursing InterventionsSlow infusion to keep vein open (KVO) rate and notify the healthcare provider;Monitor closely for worsening condition;Raise the client’s head to facilitate breathing;Document interventions and assessment.

5. Air EmbolismPossible Causes

A greater risk exists in central venous lines, when air enters the catheter during tubing changes (air sucked in during inspiration due to negative intrathoracic pressure.Air in tubing delivered by IV push or infused by infusion pump.

Signs and SymptomsDrop in blood pressure, elevated heart rateCyanosis, tachypneaRise CVPChanges in mental status, loos of consciousness

Preventive MeasuresClear all air from tubing before infusing to client.Change solution containers before they run dry.Ensure that all connections are secure; always use leur-lock connections on central lines.Use precipitate and air eliminating filters unless contraindicated.Change IV tubing during expiration.

Nursing InterventionsImmediately turn the client on his left side and lower the head of the bed, in this position, air will rise on the right atrium.Notify the healthcare provider immediately.Administer oxygen as neededReassure the clientDocument interventions and assessment.

Mechanical FailurePossible Causes

Needle lying against the side of the vein, cutting off fluid flowClot at the end of the catheter needleInfiltration of IV cannulaKinking the tubing or the catheter

Signs and SymptomsSluggish IV flowAlarm on flow regulatory surrounding(+) signs of local irritation; swelling, coolness of skin

Preventive MeasuresCheck IV often for patency of kinkingSecure the IV well with tape and an arm board if necessary

Nursing InterventionsRemove tape and check for kinking of tubing or catheterPull back of the cannula because it may be lying against wall or vein, vein valve, or vein bifurcation

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Elevate or lower needle to prevent occlusion of bevelMove client’s arm to new positionLower solution container below level of client’s heart and observe for blood backflowIf an electric flow-rate regulator is in use, check its integrityIf none of the preceding steps produces the desired flow, remove the needle or catheter and restart infusion.

6. HemorrhagePossible Causes

Loose connection of tubing or connection port.Inadvertent removal or peripheral or central catheter.Anticoagulant therapy

Signs and SymptomsOozing or trickling of blood from IV site or catheterHematoma

Preventive MeasuresCap all central lines with luer-lock as0needed adapters and connect luer-lock tubing to the cap, not directly to the line.Tape all catheters securely; use transparent dressing when possible for peripheral and central line catheters. Tape the remaining catheter lumens and tubing in a loop so tension is not directly in the catheter.Keep pressure on sites where catheters have been remove; a minimum of 10 minutes for a client taking anticoagulants.

7. Venous ThrombosisThe vein in which the peripheral or central catheter lies becomes fully or partially occluded by a thrombosis. This may be due to: Infusion or irritating solutions Infection along catheter Fibrin sheath formation with evaluation clot formation around the catheter (this clot will eventually occlude the vein).

Signs and SymptomsSlowing of IV infusions or inability to draw blood from the central lineSwelling and pain in the area of catheter or in the extremity proximal to the IV line]

Preventive MeasuresEnsure proper dilutions of irritating substancesEnsure superior vena cava catheter tip placement for irritating solutions

Nursing InterventionsStop fluids immediately and notify the health care providerReassure the client and institute appropriate therapy (application of heat, elevated of affected extremity, and administration of anti coagulant)

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