IV Therapy Notes Chapter 42 Purposes of IV Therapy Fluids correct or prevent fluid disturbances Electrolytes correct or prevent electrolyte (and salt) imbalances Medications treat medication conditions (chronic, acute or life threatening) Blood and Blood components replace blood loss, treat anemia, treat bleeding disorders. Provide a lifeline cardiac arrest, hemorrhage, burns, shock, etc. Replace fluids and electrolytes dehydration, electrolyte imbalances, preoperatively for surgery Nutrition TPN and PPN Provides replacement of water, electrolytes and nutrients more rapidly than the GI route. Physician Order for IV Therapy Type of solution to be infused Route of administration Exact amount (dose) of any medications to be added to a compatible solution Rate of infusion Duration of infusion or the time over which the infusion is to be completed Physician’s signature Components of an IV IV Fluids o Isotonic expands only the ECF and fluid DOES NOT move into cells; ideal for fluid replacement for patients with ECF volume deficits 0.9% Normal Saline Used for patients with fluid and sodium loss (diarrhea/vomiting) To expand intravascular volume or replace ECF losses Slightly higher concentration of sodium than plasma too much isotonic saline can lead to increase in sodium/chloride levels Can lead to circulatory overload Only solution compatible with blood Lactated Ringers Has sodium, potassium, chloride, calcium, lactate Same concentration as the ECF and used to treat burns and GI fluid loss Contraindicated in patients with liver dysfunction, hyperkalemia, severe hypovolemia (already have high levels of potassium in body) o Hypotonic dilutes ECF lowering serum osmolality Easy to remember, only one plus a faker Water moves from the ECF to interstitial space and cells (cell swells) Useful in treating patients with hypernatremia Good maintenance fluid as most normal daily loses are hypotonic Monitor for cerebral edema s/s and changes in mentation (infuse slowly to prevent) Not good for replacement because they deplete ECF and lower BP Examples: 0.45% Saline used for hypernatremia and uncontrolled hyperglycemia, can be used as a maintenance solution D5W isotonic in container but becomes hypotonic in the body; used to replace water losses and prevent ketosis o Hypertonic higher osmolality than plasma Draws water out of cells into the ECF (cell shrinks) Useful in treatment of hyponatremia and trauma with head injury Requires frequent monitoring of BP, lung sounds, serum sodium Risk for intravascular fluid volume excess Examples: 3% saline, 5% saline D ½ Normal Saline common maintenance fluid, replace fluid loss (seen a lot with sickle cell patient) D5 Normal Saline D10W (10% Dextrose in water) 5% Dextrose in Ringers Lactate Solution o Colloids stay in vascular space and increase oncotic pressure Used for volume expansion Human plasma products: albumin, fresh frozen plasma, blood Semisynthetic: Dextran o TPN highly concentrated solution containing nutrients and electrolytes to specifically meet patient needs Total parenteral nutrition that is administered through a central venous catheter for high osmolality solutions There must be meticulous management of the central venous catheter or IV to prevent infection Careful monitoring to prevent metabolic complications Catheters o Vascular Access Devices (VADs) catheter or infusion ports designed for repeated access to vascular system Peripheral Catheter Short term Used for fluid restoration of short-term medication administration Over the needle, small plastic tube is introduced & needle (stylet) removed Insert the stylet into the vein and advance the catheter, withdraw stylet and catheter remains (safety to prevent sticks) Gather equipment organization is key assess site for edema, erythema, warmth, bleeding, drainage venipuncture is contradicted in areas of infection, infiltration thrombosis avoid using arm that has a vascular graft or fistula or same Tubing side mastectomy avoid areas of flexion choose most distal appropriate site cephalic, basilic, and median cubital veins are best for placement in adults flush Q8h monitor every 1-2 hours with infusion rate Older Adults o Use smallest catheter possible and avoid hand/places that is easily bumped o Avoid vigorous friction when cleaning o If veins are fragile use torniquet over clothing, gown, or blood pressure cuff o Veins lay more superficially due to Subq loss and roll away easily o Stabilize vein by applying traction below the projected site and avoid excessive use of tape Central Line Long term use include catheters and implanted ports which empty into a central vein Central refers to location of catheter tip NOT insertion site More effective than peripheral IV for administering large volume fluid, parenteral nutrition or meds that can irritate the veins Can be used for hemodynamic monitoring and blood draws Clabsi prevention (Box 42.6) Nurses need specialized education for care of CVC and implanted infusion ports Nurses must monitor the access site carefully, flush line to keep patent, perform dressing changes (ALWAYS USE STABILIZATION DEVICES TO PREVENT DISLODGEMENT) Regulation of IV Infusion Site Locations and Assessment Changing IV Fluid Containers, Tubing, Dressings o Continuous every 96 hours or if compromised/contaminated o Intermittent every 24 hours or if compromised/contaminated o Blood Tubing every 4 hours for blood and blood components o Continuous IV Lipids every 24 hours o Transparent Dressings leave in place until tubing is replaced o Gauze change every 48 hours Both types of dressings must be changed when the IV is removed or replaced or when dressing becomes damp, loosened, or soiled Regulating IV Flow Rate o Too slow further physiological compromise in patient that is dehydrated, in circulatory shock, or critically ill o Too rapid fluid overload causing fluid/electrolyte imbalance and cardiac complications in vulnerable patients (older adults or with preexisting heart disease) o Electronic Infusion Devices (EIDs) deliver accurate hourly infusion rate Alarm responds to air in line, occlusion, completion of infusion, high/low pressure, low battery Maintaining the System o Once you have established patient IV access (peripheral or central) infusions may begin o Ensure you have documented confirmation of placement or central line and “ok to use/draw” order o To maintain the system keep the system sterile and intact, change IV fluid containers, tubing, and contaminated site dressings, help a patient with ADL care so that IV line is not disrupted, monitor for complications of IV therapy, keep the use of extension tubing to a minimum as it decreases risk of contamination, do NOT let tubing touch the floor, clean injection port with 2% chlorohexidine or 70% alcohol, assess insertion site frequently Site Care o Identify using 2 identifiers o Peripheral IV keep transparent dressing in place until IV site is changed unless wet, soiled, or loose at least every 5-7 days o Observe for patency of line and assess for pain, erythema, edema, or burning o Hand hygiene and clean gloves o Stabilize catheter with non-dominant hand o Use alcohol swab to loosen dressing and remove by pulling up one corner straight out and parallel to skin o Use adhesive remover to remove residue o Use antiseptic wipe in back-and-forth motion for 30 seconds, allow to dry o Apply skin protectant, then new sterile dressing, anchor extension tubing, label per protocol and document Discontinuing an IV o Make sure there is an order for discontinuation o If phlebitis, infiltration or local infection occurs o If the IV slows or stops (thrombus) o Perform hand hygiene/apply gloves o Observe site for pain, tenderness, swelling, bleeding, draining, leaking, erythema o Assess if patient is on anticoagulant therapy (if so hold for 5 minutes) o Turn off and close roller clamp o Remove site dressing and stabilization device o Place sterile gauze above insertion site and using dominate hand withdraw the catheter in a slow steady motion o Keep hub parallel to skin without lifting until completely out of vein and inspect tip o Apply gauze and apply pressure 30 seconds or longer until hemostasis achieved; apply dressing Complications o Circulatory Overload infused too rapidly or in too large amount Assessment: ECV, hyponatremia with hypotonic fluid, hypernatremia with hypertonic fluid, hyperkalemia Nursing: if symptoms appear reduce flow rate and notify MD Raise HOB with ECV and administer oxygen and diuretics if ordered Monitor lab and serum levels o Infiltration IV fluid entering subcutaneous tissue around venipuncture site Assessment: Skin around catheter site taut, blanched, cool to touch, edematous; may be painful as infiltration increases; Infusion may slow or stop on its own Nursing: Stop infusion Discontinue IV infusion if no vesicant drug elevate affected extremity avoid applying pressure over site; can force solution into contact with more tissue contact health care provider if solution contained KCl, a vasoconstrictor, or other potential vesicant apply warm, moist or cold compress according to procedure for type of solution infiltrated start new IV line in other extremity use standard scale for assessing and documenting infiltration Extravasation is term used when a vesicant (tissue damaging) drug (chemotherapy) enters the tissues Grade 0 1 2 3 4 Grade 0 1 2 3 4 Clinical Scale No Symptoms Skin blanched Edema (1 inch) any direction Cool to touch With or without pain Skin blanched Edema (1-6 inch) any direction Cool to touch With or without pain Skin blanched, translucent Gross edema (6 inches) any direction Cool to touch Mild-moderate pain Possible numbness Skin blanched, translucent Skintight, leaking Skin discolored, bruised, swollen Gross edema (6 inches) any direction Deep pitting tissue edema Circulatory impairment Moderate-to-severe pain Infiltration of any amount of blood product, irritant, or vesicant o Phlebitis inflammation of inner layer of a vein Is dangerous because inflammation of the vein wall can lead to associated blood clots (thrombophlebitis). Clots form along vein and in some cases cause emboli, which can break off and enter circulation Assessment: redness, tenderness, pain, warmth along course of vein starting at access site; possible red streak and/or palpable cord along vein Nursing: stop infusion and discontinue IV start new IV line in other extremity or proximal to previous insertion if continuation is necessary apply warm, moist compress or contact IV therapy team or health care provider if area needs additional treatment elevate affected extremity document phlebitis using standardized scale, including nursing interventions per agency policy/procedure Clinical Scale No Symptoms Erythema at access site with or without pain Pain at access site with erythema and/or edema Pain at access site with erythema and/or edema; streak formation; palpable venous cord Pain at access site with erythema and/or edema; streak formation; palpable venous cord >2.54 cm (1 inch) in length; purulent drainage o Local Infection infection at catheter-skin entry point during infusion or after removal of IV catheter Assessment: redness, heat, swelling at catheter-akin entry point, possible purulent drainage Nursing: culture any drainage (if ordered), clean skin with alcohol; remove catheter and save for culture; apply sterile dressing, notify hcp, start new IV line in other extremity, initiate appropriate wound care if needed o Air Embolism air in the vein from unpurged syringe or tubing Assessment: sudden onset dyspnea, coughing, chest pain, hypotension, tachycardia, decreased LOC, stroke symptoms possible Nursing: prevent further air from leaking in by clamping/covering leak Place patient on left side with HOB raised to trap air in the lower portion of the left ventricle; call MET team or emergency support team and notify provider o Bleeding at Puncture Site oozing or continuous seepage of blood Assessment: fresh blood at venipuncture site or pooling of blood under extremity Nursing: assess if IV system is intact, apply pressure dressing over site or change dressing, start new line in other extremity or proximal to the previous insertion site
