1 RN Skills RN Skills Laboratory Laboratory Intravenous Therapy Intravenous Therapy West Coast University West Coast University Week 7 Week 7
Mar 26, 2015
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RN Skills LaboratoryRN Skills LaboratoryIntravenous TherapyIntravenous Therapy
West Coast UniversityWest Coast University
Week 7Week 7
ObjectivesObjectives
IV therapy overviewIV therapy overview Type of fluidsType of fluids IV drop factors & calculationsIV drop factors & calculations IVPBsIVPBs IVPsIVPs Central LinesCentral Lines Blood and Blood ProductsBlood and Blood Products TPNTPN
IV TherapyIV Therapy
IV therapy – peripheralIV therapy – peripheral Admission criteria in hospitalAdmission criteria in hospital Surgical, transfusion patientsSurgical, transfusion patients Hydration, restoring fluids/electrolyte imbalanceHydration, restoring fluids/electrolyte imbalance Administration of drugsAdministration of drugs
Side affectsSide affects Bleeding, infiltration, infection, hearing loss, bone Bleeding, infiltration, infection, hearing loss, bone
marrow suppression, kidney and heart damagemarrow suppression, kidney and heart damage Is not long-term therapy and more expensive than Is not long-term therapy and more expensive than
other routesother routes
Fluid ManagementFluid Management
Thin people 50-70% waterThin people 50-70% water Obese people 50% waterObese people 50% water Elder 46-52% waterElder 46-52% water Two main compartmentsTwo main compartments
Intracellular (64%)Intracellular (64%) Extracellular (36%)Extracellular (36%)
¾ interstitial¾ interstitial ¼ plasma¼ plasma
Fluid ManagementFluid Management
Physiological homeostasisPhysiological homeostasis Fluid movement done by osmotic pressure Fluid movement done by osmotic pressure
(holding on)(holding on) Hydrostatic pressure (letting go)Hydrostatic pressure (letting go)
Plasma uses osmotic pressure (why?)Plasma uses osmotic pressure (why?)
Kidneys are the primary regulator of fluidsKidneys are the primary regulator of fluids Usually produces 1-2L/24hUsually produces 1-2L/24h Must produce a minimum of 500-600mL/24hMust produce a minimum of 500-600mL/24h
Fluid ManagementFluid Management Homeostatic MechanismsHomeostatic Mechanisms
Thirst to CNSThirst to CNS Illness, LOC, age changes thirst mechanismIllness, LOC, age changes thirst mechanism
Antidiuretic hormone (ADH) – hypothalamusAntidiuretic hormone (ADH) – hypothalamus Extracellular volume is concentratedExtracellular volume is concentrated Fluid retention by hemorrhage, cardiac output, trauma, pain, Fluid retention by hemorrhage, cardiac output, trauma, pain,
fear, surgery, dehydrationfear, surgery, dehydration
Aldosterone – adrenal cortexAldosterone – adrenal cortex Reabsorbs Na & HReabsorbs Na & H22O = changes electrolytesO = changes electrolytes Na exchanges for K or HNa exchanges for K or H Kidneys and the angiotensin systemKidneys and the angiotensin system
Renin – angiotensin I – angiotensin IIRenin – angiotensin I – angiotensin II
Fluid Management - TonicityFluid Management - Tonicity
HypertonicHypertonic
Increased Increased solutes in solutes in relationship to relationship to plasmaplasma
D5.9%NSD5.9%NS
D5LRD5LR
D5.45%NSD5.45%NS
HypotonicHypotonic
Decreased Decreased solutes in solutes in relationship to relationship to plasmaplasma
.25%NS.25%NS
.45%NS.45%NS
2.5%Dextrose2.5%Dextrose
IsotonicIsotonic
Same tonicity as Same tonicity as plasmaplasma
.9%NS.9%NS
D5WD5W
LRLR
VenipunctureVenipuncture
Site selectionSite selection Gauge needleGauge needle SuppliesSupplies ProcedureProcedure Charting – location and identify vein Charting – location and identify vein
usedused
SuppliesSupplies The pumpThe pump The drip factor (varies by The drip factor (varies by
manufacturer)manufacturer) MicrodropMicrodrop
60gtt/mL60gtt/mL MacrodropMacrodrop
20gtt/mL20gtt/mL 15gtt/mL15gtt/mL 10gtt/mL10gtt/mL
The volume control setThe volume control set The filterThe filter
FormulasFormulas
FlowFlow raterate
Drops per minuteDrops per minute
Total Solution
# of hours to run
= mL/hr
mL/hr x gtt factor
60 mins
= gtts/min
Secondary InfusionsSecondary Infusions
Piggybacks - IVPBPiggybacks - IVPB Used for mediationsUsed for mediations
Check medicationCheck medication Check capabilityCheck capability
Stop primary, flush, infuse, flush and restart Stop primary, flush, infuse, flush and restart primaryprimary
Bactrim – don’t mix (usually D5W)Bactrim – don’t mix (usually D5W) Dilantin – only in NSDilantin – only in NS
Intravenous Line InjectionIntravenous Line Injection
Pushes - IVPsPushes - IVPs Dilute whenever possibleDilute whenever possible KNOW YOUR DRUGKNOW YOUR DRUG
Digitalis – usually monitoredDigitalis – usually monitored Benzodiazepines (do not mix or dilute)Benzodiazepines (do not mix or dilute)
Clamp, flush, push, flush, unclampClamp, flush, push, flush, unclamp Flush, push, flushFlush, push, flush
SASHSASH
Central Venous Access TypesCentral Venous Access Types
Peripherally PlacedPeripherally Placed PICC PICC
Tunneled Tunneled Groshong (same as PICC only tunneled)Groshong (same as PICC only tunneled) Triple LumensTriple Lumens Hickmans, BoviacsHickmans, Boviacs PortsPorts
Insertion SitesInsertion Sites
NeckNeck JugularJugular
Chest Chest SubclavianSubclavian
ArmArm BacilicBacilic CephalicCephalic AnticubitalAnticubital
SAFETYSAFETY
NO SCISSORS ONCE INSERTEDNO SCISSORS ONCE INSERTED PREVENT INFECTIONPREVENT INFECTION
Site CareSite Care
First 7 days (or if discharge)First 7 days (or if discharge) Use 2x2 gauzeUse 2x2 gauze NO betadine ointmentNO betadine ointment Then q72h or if soiledThen q72h or if soiled Check policyCheck policy
Tubing & Cap changesTubing & Cap changes
Both q72h with fluidsBoth q72h with fluids Blood change bothBlood change both
After 2-3 unitsAfter 2-3 units
TPN (PPN) change bothTPN (PPN) change both q24hq24h
Change caps q blood drawsChange caps q blood draws NO LABEL – change bothNO LABEL – change both
Blood drawingBlood drawing
Access line with prefilled 10cc NSAccess line with prefilled 10cc NS FlushFlush Draw back 10cc blood in same syringe Draw back 10cc blood in same syringe
(discard)(discard) New syringes – draw up sampleNew syringes – draw up sample Change capChange cap Flush with 10cc NS (heparin??)Flush with 10cc NS (heparin??)
CVC Side EffectsCVC Side Effects
Phlebitis Phlebitis mechanical vs bacterialmechanical vs bacterial
InfectionInfection PheumothoraxPheumothorax Superior vena cava syndromeSuperior vena cava syndrome
Flushing Flushing Know the following for allKnow the following for all
Manufactures Manufactures Guidelines Policy/ProtocolGuidelines Policy/Protocol
Peripheral LinesPeripheral Lines 3cc NS3cc NS
Central Lines Central Lines PICC: 10cc NS (No Heparin)PICC: 10cc NS (No Heparin) Central Line: 10cc NS & Heparin 100u/cc (3cc) Central Line: 10cc NS & Heparin 100u/cc (3cc) Tunneled: Same as Central Line (Groshong see PICC)Tunneled: Same as Central Line (Groshong see PICC)
Ports (Should have primary line)Ports (Should have primary line) NeedlesNeedles
-Huber (non-coring)-Huber (non-coring) -Change every Friday-Change every Friday -Flush when needle remove and not reinserted -use Heparin 100u/cc (5cc) -Flush when needle remove and not reinserted -use Heparin 100u/cc (5cc)
Blood AdministrationBlood Administration
Have saline infusing with Y-set upHave saline infusing with Y-set up Use 170 micron filterUse 170 micron filter Double check Double check
At lab/blood bankAt lab/blood bank At bed sideAt bed side
MonitoringMonitoring Prior, 5min after start, 15min after start then q30m Prior, 5min after start, 15min after start then q30m
until completeduntil completed
Should infuse over 1-2 hoursShould infuse over 1-2 hours
The Blood System The Blood System
ABO blood group systemABO blood group system Universal DonorUniversal Donor
O lacks A & B antigenO lacks A & B antigen Universal RecipientsUniversal Recipients
AB lacks anti-A & anti-B antibodiesAB lacks anti-A & anti-B antibodies
Blood ProductsBlood Products
Whole blood Whole blood Packed red cells Packed red cells Granulocyte concentrates Granulocyte concentrates Platelet concentrates Platelet concentrates Fresh frozen plasma Fresh frozen plasma Cryoprecipitate Cryoprecipitate Clotting factors - Factor VIII / IX Clotting factors - Factor VIII / IX
Complications of TransfusionsComplications of Transfusions
Complications of blood transfusionComplications of blood transfusion Haemolytic reactions (immediate or delayed) Haemolytic reactions (immediate or delayed) Bacterial infections from contamination Bacterial infections from contamination Allergic reactions to white cells or platelets Allergic reactions to white cells or platelets Pyogenic reactions Pyogenic reactions Circulatory overload Circulatory overload Air embolism Air embolism Thrombophlebitis Thrombophlebitis
Clotting abnormalities Clotting abnormalities
AnaphylaxisAnaphylaxis
ReactionReaction Usually occurs soon after start of transfusion Usually occurs soon after start of transfusion Presents with circulatory collapse and Presents with circulatory collapse and
bronchospasm bronchospasm
ManagementManagement Discontinue transfusion and remove giving set Discontinue transfusion and remove giving set Maintain airway and give oxygen Maintain airway and give oxygen
Autologous transfusionAutologous transfusion
Is the use of the patients own blood Is the use of the patients own blood Particularly useful in elective surgery Particularly useful in elective surgery Accounts for 5% of transfusions in USA Accounts for 5% of transfusions in USA Reduces the need for allogeneic blood Reduces the need for allogeneic blood
transfusion transfusion Reduces risk of postoperative Reduces risk of postoperative
complications (e.g. infection, tumor complications (e.g. infection, tumor recurrence) recurrence)
Total Parenteral NutritionTotal Parenteral Nutrition
Pharmacist may do formulationPharmacist may do formulation If dextrose >10% - need CVCIf dextrose >10% - need CVC Monitor blood glucose Monitor blood glucose Monitor electrolytesMonitor electrolytes Weigh qdWeigh qd Use filtersUse filters
1.2micron with lipids1.2micron with lipids .2micron without lipids.2micron without lipids
Know who to “ramp up and down”Know who to “ramp up and down”
TPN precautionsTPN precautions
Check compatibility of medicationsCheck compatibility of medications Don’t play “catch-up”Don’t play “catch-up” No bloodNo blood