Test 1- WALDEN 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 Intermittent IV is used primarily for IV medication administration Bolus increase in medication immediately IV medications bypass the enzymatic process of the liver Nursing Responsibilities Knowing IV sets and their functions Calculating IV drip rates Mixing and diluting medications in IV fluids Knowing the medications, purposes, and side effects Nursing Responsibilities continued 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 route could provide a direct route for contamination with pathogens Closely monitor the client for adverse reactions IV Considerations Is fluid loss severe or life-threatening?
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Test 1- WALDEN
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
Intermittent IV is used primarily for IV medication administration
Bolus increase in medication immediately
IV medications bypass the enzymatic process of the liver
Nursing Responsibilities
Knowing IV sets and their functions
Calculating IV drip rates
Mixing and diluting medications in IV fluids
Knowing the medications, purposes, and side effects
Nursing Responsibilities continued
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 route could provide a direct route for contamination with pathogens
Closely monitor the client for adverse reactions
IV Considerations
Is fluid loss severe or life-threatening?
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
*Two kilograms of weight gain is equivalent to 2 liters of fluid gain
5 pounds = 2.5 liters fluid
Restoring fluids by IV
Why: fluid/ blood loss, precautionary
Large IV ideal but…. Difficult to find a vein
Small bore initially- large (18-20GA) once fluids reestablished
IV pump to regulate infusion and decrease risk of too rapid an infusion
Monitor sites, solution, and outcomes frequently
Restoring fluid risks
Renal, cardiac, pulmonary overload
Overflow diuresis without cellular replacement
Hypernatremia with diuresis
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 catheterbutterfly
Potter page 446- 447
Read regarding flow rate, sites, large gtt
Flow factor and micro drip factor for slow IV infusions as PEDs.
EID (Electronic infusion device)
Gather supplies
Assess patient for safe site
Common sites in adult veins in hands and arms
See & Know figure 15 – 5 pg446 PP Basic.
approach
Sites to avoid
Areas of inflammation
Infiltration
Thrombosis
Mastectomy sides
IV grafts sites
Avoid adult foot
Use most distal when possible, allowing proximal sites for subsequent venipuncture
Elderly Perry Potter Basic 447 box 15 – 3
Use of tourniquet
Site to avoid
Gauge to use
Insertion angle
Flow rate for IV medication
Skin barrier recommendation
Use of netting to secure
Avoid restraints precaution
Mental status assessment
EID
Gauge and Fluid Rate
24 gauge (yellow) = 15-25ml/min
22 gauge (blue) = 26-36 ml/min
20 gauge (pink) = 50-65 ml/min (maintenance rate)
18 gauge (green) = 85-105 ml/min
(when large bolus rapid infusion needed)
Geriatrics
22 – 24 gauge
Tourniquet may not be necessary
Position hand dependent
No slapping see box 15- 3 page 447 Techniques.
Remember geriatric care.
Central venous catheters
“central lines”
Multilumen or single lumen non-tunneled
Lumens (“pigtail”) different length and color (1,3,4)
MD or NP to insert
Sutured to skin
Longer term catheters as compared to peripheral
Non-tunneled catheter
Sterile dressing changes by RN / LPN q 3-7 days or PRN
Maintenance (flushing Q shift)- RN
Central lines cont.
Uses
Blood sampling
CVP monitoring
Continuous/ intermittent drug infusions
Diagnostic testing
Simultaneous infusion of several medications
Viscous or high-volume fluids / blood
TPN (total parenteral nutrition)
PICC IV access (alternate access)
Peripherally inserted central catheters (arm)
Longer catheter, terminates at subclavian vein
Longer term than peripheral IV caths (7days to 3 months)
Must be specially trained RN
Sterile technique
Function and maintenance is same
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.
Central hemodialysis catheters
Subclavian, jugular, or femoral catheter
Temporary vascular access
Two ports - blue and red
Used for acute hemodialysis
MD to insert
Sutured to skin
Special training to access
Accountability and Infusion Therapy
The RN is accountable for knowing
What is ordered
Why it is intended
Impact on the patient
Any possible side effects
How to administer the infusion
How to maintain the infusion
How to discontinue properly
How to document appropriately
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
Delegate certain nursing tasks to licensed and unlicensed personnel
Still responsible for tasks delegated
Must evaluate others competency, instruct them, and verify proper training
Responsibilities may vary among states and employers
Compatibility
Nurse is responsible to verify compatibility of fluids with medication administered via IV
Or if a Medication is in the IV fluid and a drug is given intermittently
Nurse must make certain fluids and drugs are compatible.
IV Therapy
RN vs. LPN
“…..responsibilities include administering medications and treatments prescribed by a
licensed or otherwise legally authorized physician.”
“…..responsibilities include administering medications and treatments, under the direction of
a licensed registered nurse or a licensed or otherwise legally authorized physician.”
No IV medications
Nurse responsible to
Observe clinet
Report any reactions
Take measures necessary to avoid complications
Assess IV site on adult every 2 hours
Pediatric and High alert medication more often)
Check point
A client has a continuously running peripheral infusion.
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
2. start a new IV site to prevent fluid volume overload
3. Increase the IV fluid rate to dilute the antibiotic infusing piggyback
4. Check to see if the antibiotic is compatible with the soluitions infusing.
CONSIDER AGENCY IV THERAPY POLICY
RBCs in isotonic solution
IV THERAPY
Review
Adding medications to bag- labeling
Spiking bag, filling drip chamber
Priming (bleeding) line
Accessing ports on line
Running piggyback (secondary) with primary line
Fluid compatibility
Connecting tubing and priming lines
Open transfusion set
Insert IV tubing spike into opening of bag of fluids
Remember to keep ends sterile!!
Compress drip chamber to 1/3 full
Prime by opening roller clamp- all air bubble should be removed- then close roller clamp
Tap to remove small air bubbles
All lines must be primed including PRN loops
Flushing a saline lovk
Use approximately 1 ½ times the amount of fluid that the tubing will hold in order to flush the
tubing.
USE sterile (aseptic ) technique to prevent complications as infection.
Intermittent IV Therapy
IV Therapy that is ordered frequently for short periods of time.
EX:
Rocephin 1gm IVPB Q 12 hours x 6 doses.
Demerol 25mg IVP Q 4-6 hours PRN pain.
IV push (IVP) or IV piggyback (IVPB, secondary)
Requires tubing and site change q 48-72 hours
Frequent site monitoring
Fluid infused recorded on chart q shift
IVP (IV push medications)
Check order
Prepare medications and check compatibility with fluids
Assess site
Select port proximal to patient
Clean port with alcohol swab
Flush with 10ml of NS before medication
Insert/attach medication syringe
Occlude IV tubing above port (pinch)
Pull back gently to aspirate blood return (may not get)
Inject medication in designated time frame (look up in drug book)
Release tubing if fluids running - if saline lock, flush with 10ml of NS and lock
Small volume needs to hang higher
IV PUSH
Draw up correct dose into a 10mL syringe.
Verify dose with second nurse
Then add additional saline to syringe to equal 10 mL
Pause.
Lets think
1 mL/ over 1 minute
Let’s see that is ¼ mL/ in 15 seconds
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.
How long will it take to give
2 mL over one minute?
1 mL over two minutes.
OK: Tell me how would you divide this to deliver the push in a controlled slow process????
Continuous IV Therapy
IV therapy that continues over a long period of time.
EX: D51/2 NS @ 75ml/hr
Requires frequent site monitoring
Fluid infused documentation (q 8 hours)
IV Tubing change q 72 hours
Site change q 48-72 hours
* Tubing and site change may vary depending on agency policy.
KVO or TKO
“KVO” or “TKO” = flow at rate to Keep Vein Open or To Keep Open
Often will see this order:
IV NS @ KVO rate
IV RL TKO rate
What do you do? There is no established minimal flow for KVO/TKO
*****Clarify MD’s order*****
May be anywhere from 30-100ml/hr but this must be specified by MD.
Bolus
Introducing a concentrated dose directly into systemic circulation quickly
Into tubing port or saline lock
Rate of administration (bolus) varies from drug to drug
May be fluids or medications
Rate for fluids should be included in MD’s order
IV solutions 101
Two basic categories:
First category:
Crystalloids: contain water, dextrose, and or electrolytes
Used to treat fluid and electrolyte imbalances
IV solutions
Second basic categories:
Colloids: referred to as:
plasma expanders or volume expanders
Increased osmotic pressure in comparison with crystalloids
Colloids remain in vascular space longer and are used for volume expansion
Volume expanders
Include: Colloids, dextran, and hetastarch.
Colloids are protein solutions as albumin, plasma, and Plasmanate ( prepared by
pharmaceutical company).
Volume Expanders
Albumin is the most abundant plasma protein in humans
USES: Albumin 5% rapid volume expansion and mobilize interstitial edema
25%
Hypoproteinemia
Volume Expansion
Others are Dextran, synthetic colloid made of glucose-
Mobilizes interstitial edema
Hetastarch (Hespan) Made from corn.
Mobilizes interstitial edema
Volume expanders
Plasma plasmanate (Plasma protein fraction
Contains human plasma proteins in Normal Saline (NS).
Increases serum colloid osmotic pressure
Types of intravenous solutions
Isotonic
Normal Saline (NS) & Ringers Lactate(RL)
Dextrose in water (D5W)
Hypotonic
0.45% Normal Saline
0.33% Saline
2.5% Dextrose
Hypertonic
Total Parenteral Nutrition (TPN)
Dextrose in Normal Saline (D5NS)
Dextrose in .45 Normal Saline (D5 ½ NS)
Isotonic “Same as blood”
Isotonic Solutions
Liver converts lactate to bicarbonate- watch pH, liver function
Has same osmolality as body fluids
Hydrates all cells without affecting movement of fluid- NO SHIFT
Expand IV compartment
Watch for overload
Used most commonly for ECF volume replacement
Isotonic solutions
Expand only ECF (IVC) no net loss or gain.
L/R contains Na KCl Cl Ca and Lactate
Same concentration as blood.
Uses
NaCl used to replace both fluid and sodium losses or
Vascular replacement in hypovolemic shock.
HYPOTONIC SOLUTIONS
OUT OF VASCULAR COMPARTMENT
Hydrates cells
Can cause sudden shift
Cardiovascular collapse
Increased ICP
Not for treatment of head injury, trauma, neurosurgery, burns
Hypotonic
Hypotonic fluid pushes fluid into cell
.
Contains more water than electrolytes
So, are there concerns with HYPOTONIC Solutions?
Push fluid into cells : Why might we see mental status change?
Why is D5 W isotonic in the bag
AND HYPOTONIC in the vein
Glucose enters the vascular compartment
Is then rapidly metabolized by the LIVER thus
Leaves water in vascular compartment.
HYPERTONIC SOLUTIONS
PULLS INTO VEIN FROM CELL
Dehydrates cells and interstitial compartments
Watch for venous overload
Not for patients with kidney failure, heart disease
Hypertonic soulutions
Expand ECF (IVC) (Draws fluid into vein)
Used to treat:
Hypovolemia
(low volume)
Hypo natremia
(low sodium)
D 50 W
Very hypertonic.
Push slowly
Let’s recall Assessment
How do we watch for FVO (Fluid volume overload)?
B/P
Lung sounds
Serum Sodium Level
Edema
JVD
What else??
Other hypertonic solutions
D 10 W or greater
Central lines should be used. To avoid shrinkage of RBCs.
IV SALINE solutions
NS (0.9 % Na CL)
Saline
3% NaCl
5% NaCl
Contains sodium and chloride in water
Uses:
Alkalosis
Fluid loss
Sodium depletion
Dextrose (dextrose in water)
D 5 W
D10 W
Uses:
Replace calories as carbohydrates
Prevent dehydration
Maintain water balance
Promote sodium diuresis
Dextrose in Saline
D5NS
D51/2 NS
D10 NS
Promotes diuresis
Correct moderate fluid loss
Prevent alkalosis
Provides calories and sodium chloride
Electrolytes
Lactated Ringers
Ringers Lactate
Contains Na, Cl, K, Ca, and lactate
Replaces fluid lost in vomiting, or GI suction,
Treat dehydration
Restore normal fluid balance
IV Additives
Vitamins & KCL are frequently added to IV Solutions
Verify adequate urine output before administering KCL
K*Under no circumstances can potassium chloride (KCL) be given IV push. A direct IV
infusion of KCL is fatal.
So Ms Verhoff if KCL is an electrolyte in the body
Why verify KCL doses?
Why are there no KCL push?
Why is an EID used for concentrated bolus administered.
What is a concentrated bolus.
TPN
Nutritional adequate hypertonic solution consisting of glucose and other nutrients and
electrolytes given through an indwelling peripheral or central line
Used as intervention in severe cases of malnutrition.
TPN ??????
Why should we monitor Glucose every 6 hours?
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
Equipment and Supplies
IV catheter (24GA, 22GA, 20GA, 18GA, 16GA)
IV start kit (drape, cleaning and antiseptic preps, dressings, tape, label, tourniquet,
transparent dressing)
GLOVES
Tubing if fluids ordered, fluids ordered
Injection cap (PRN adapter) or IV loop (pigtail)
Sharps container
Flush
Volume regulator
Purpose and Selection of IV supplies
IV Catheter
Size
Conventional or safety
Fluids vs. PRN lock (saline or heparin)
Tubing and extension
Medication/ Blood administration
Pumps, dial-a-flow, volume control device (gravity)
Children
Allergy to iodine, latex, or tape
Arm board
Transparent dressing/ tape
Practice correctly
Assessment for initiating IV therapy
Assemble correct supplies
Review MD’s order
5 rights
Assess for clinical factors/ conditions
Assess previous experience/ expectations
Consider future treatments
Allergies/ lab data (betadine tape)
Planning for initiating IV therapy (goals)
F & E Balance and VS will return to normal
IV line will be patent
Site will be benign
Client will understand purpose
IV site selection
Age and status of patient
Purpose of the infusion
Duration of therapy
Condition of patient’s veins
Location of previous site(s)
Most common in lower arm and hand. If possible use the non-dominant hand/arm
Hand and arm
IV site location
Most distal in nondominiant arm
Clip hair – do not shave
Avoid bruises, scars
Large vein
Consider activity
Medical history
Children, adults
Other options as above
Implementation of IV therapy
Comfortable position, change gown
Wash hands
Open sterile packages using sterile aseptic technique
Prepare IV solution, open infusion set, spike bag, and prime line, cap, or pigtail