Intravenous Fluid Management: Mrs. McGill
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.
2.
3.
4.
5.
Providing maintenance requirements for fluids and electrolytes.
Replacing previous losses
Replacing concurrent losses
Providing nutrition/vitamin replacement
Providing a mechanism for the administration of medications and/or the
transfusion of blood and blood components.
The Three Types of Intravenous Fluids are:
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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 out of 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:
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Normal saline solution (NS, 0.9% NaCl) - Isotonic solution (contains same amounts
of sodium and chloride 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.
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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 for
supportive treatment of trauma.
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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.
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Intravenous Fluid Management: Mrs. McGill
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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.
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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.
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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)
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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)
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Decrease Tearing and Salivating
Hypotension
FVO (Fluid Volume Overload)
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Pitting Edema (1+ - 4+)
Puffy Eyelids
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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:
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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:
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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:
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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:
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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:
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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:
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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:
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Failure to remove air from IV tubing
Allowing solution bags to run dry
Disconnecting IV tubing
Signs and Symptoms of Air Embolism include:
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Abrupt drop in blood pressure
Weak, rapid pulse
Cyanosis
Chest Pain
Immediate corrective action for suspected Air Embolism includes:
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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 the patient
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:
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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 for multiple 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.
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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 the external
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 nondominant 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.
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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:
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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 in the 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:
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Air embolism
Arteriovenous fistula
Artery or vein damage/injury
Brachial plexus injury
Cardiac arrhythmia
Cardiac puncture/Cardiac tamponade
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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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