NUR 1021 Marion technical College Spring Semester 2016 Intravenous therapy

I. Introduction to IV Therapy Indications for IV therapy To provide water, electrolytes, and nutrients to meet daily requirements To replace water and correct electrolyte deficits To administer medications and blood products

What Do IV solutions consist of? IV solutions contain dextrose or electrolytes mixed in various proportions with water Can electrolyte-free water can be administered by IV? NOO! it rapidly enters red blood cells and causes them to rupture

IV Solutions There are several types of IV fluids type of fluid used selected according to the client and the reason for its use IV solutions are clearly labeled with the exact components and amount of solution IV solutions orders – often written with abbreviations

Remember the Abbreviations! “D” is for dextrose “W” is for water “S” is for saline “NS” is for normal saline Ringer lactate (lactated Ringer)- commonly used electrolyte solution abbreviated “RL” or “LR”

Solution Strength IV’s often identified with abbreviation letters These indicate the components in the IV solution the numbers indicate the solution strength or concentration of components in the IV fluid numbers written as subscripts for example, D5W (dextrose 5% in water).

Let’s Practice: What is the full name of the IV’S from these abbreviations? NS = Sodium Chloride 0.9% D5W = Dextrose 5% in water RL = Lactated Ringer solution (electrolytes) D5 and ½ NS (0.45%) = Dextrose 5% in 0.45% sodium chloride

Components of IV Solutions D5W/0.45NS - solution contains 5 g of dextrose & 0.45 g (or 450 mg) of NaCl per 100 mL solution D5W- each 100 mL of solution contains 5 g dextrose D5W/0.9NS - solution contains 5 g of dextrose & 0.9 g (or 900 mg) of NaCl per 100 mL solution

IV Solution Additives- Potassium Potassium chloride (KCl) – common additive to IV fluids Potassium chloride- measured in milliequivalents (mEq) order usually written to indicate the amount of milliequivalents per liter IV solutions are often available with Potassium premixed in them

SAFETY ALERT! Remember the following when adding potassium to an IV: It should be compatible with the solution and well-diluted Monitor client during infusion, rapid infusion of potassium can cause death due to cardiac depression, arrhythmias, and arrest. Check IV site frequently, medication is extremely irritating. Administer IV using an infusion control device. Never administer potassium concentrate IV push. DO NOT add potassium to an IV bag that is already infusing this would cause the medication to concentrate in the lower portion of IV bag results in client receiving a concentrated medication solution- can be harmful.

IV Fluid 3 main types: Isotonic Hypotonic provides more water than electrolytes- diluting the ECF Hypertonic

Types of IV Solutions Isotonic Hypotonic Hypertonic 0.9% Sodium Chloride = Normal Saline 0.45% NaCl D5/LR Lactated Ringer’s (LR) 0.33% NaCl D5/0.9%NS (D5/NS) D5W D5W- Glucose rapidly metabolized = hypotonic TPN D5/0.45 %NS Solutions containing meds

Isotonic fluids Close to the same osmolarity as serum Isotonic fluids expand the ECF volume expand the intravascular space What implications does this have for a patient with Hypertension or Heart failure if they receive isotonic IV’s? Risk of fluid overload

Isotonic Solutions Provides Benefits OF: Hydration maintain electrolytes Used during and after surgery

D5/W -Helpful for: Provides free water necessary for renal excretion of solutes Used to replace water losses and treat hypernatremia Provides 170 calories/L

3. 5% dextrose in normal saline 4. 5% dextrose in lactated Ringer’s NCLEX Practice: The nurse recognizes requires fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is: 1. 0.45% saline 2. Lactated Ringer’s 3. 5% dextrose in normal saline 4. 5% dextrose in lactated Ringer’s ANS: 2 Lactated Ringer’s is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringer’s are both hypertonic solutions.

Hypotonic Fluids – Purpose Replace cellular fluid Provides free water for excretion of wastes Often use 0.45% NS – Rx hypernatremia or other hyperosmolar conditions Less osmolarity than serum Dilutes the serum

Excessive Use of hypotonic Solutions Leads to intravascular fluid depletion Decreased blood pressure Cellular edema

0.45% NS - Hypotonic Provides free water in addition to Na+ and Cl– • Used to replace hypotonic fluid losses • Used as maintenance solution does not replace daily losses of other electrolytes • Provides no calories A hypotonic solution that provides Na+, Cl−, & free water Used as a basic fluid for maintenance needs

Helpful for: Cellular dehydration: Fluid shifts out of blood vessel (less concentrated) to the tissue cells (more concentrated) Ex: dry mucous membranes Hyperglycemic conditions: Diabetic ketoacidosis

Can be harmful: Sudden shift of fluid from blood vessel to the cells – cardiovascular collapse Hypotonic solutions - potential to cause cellular swelling Monitor for changes in mentation →indicate cerebral edema Examples- Hypotonic IV solutions D5NS.45 (5% dextrose in ½ normal saline) 5% Dextrose and water (D5W)- Provides calories and water

3. 5% dextrose in lactated Ringer’s 4. Dextrose 5% in NS NCLEX PRACTICE: A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is: 1. 0.45% normal saline (NS) 2. 10% dextrose 3. 5% dextrose in lactated Ringer’s 4. Dextrose 5% in NS ANS: 1 The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringer’s are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.

Hypertonic (hyper-osmolar) Higher osmolarity than serum Pulls fluids and electrolytes from the intracellular & interstitial compartments into the intravascular compartment Examples D5/0.9NS and D5/0.45NS Use Postop when some sodium is needed D5LR

Helps to: ↓ edema  urine output Stabilize BP Used to maintain fluid intake Can temporarily be used to treat hypovolemia if plasma expander is not available Solutions with concentrations greater than 10% must be administered through a central line Allows adequate dilution to prevent shrinkage of RBCs

1. Expand the volume of fluid in the vascular system A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells ANS: 1 Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the body’s fluid volume without causing a fluid shift from one compartment to another. The remaining options describe the function of other types of fluids.

1. Expand the volume of fluid in the vascular system A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells ANS: 2 A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink. The remaining options describe the function of other types of fluids.

1. Expand the volume of fluid in the vascular system A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: 1. Expand the volume of fluid in the vascular system 2. Pull fluid from the cells 3. Keep protein levels normal 4. Move fluid into the cells ANS: 4 Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge. The remaining options describe the function of other types of fluids.

IV sites Peripheral Superficial veins of forearm, hand, and scalp of children arm veins - commonly used relatively safe and easy to enter Chose site - does not interfere with mobility Use most distal site of the arm or hand first This permits subsequent IV access sites to be moved progressively upward IS the antecubital fossa a preferred IV site? NO - Limits mobility

Other IV sites to be Cautious OF: Leg veins should rarely be used high risk of thromboembolism avoid vein access distal to a previous IV infiltration Avoid sclerosed or thrombosed veins Avoid an arm with an arteriovenous shunt or fistula Avoid arm affected by edema, infection or blood clot Avoid arm on the side of a mastectomy - impaired lymphatic flow.

PICC line (peripherally inserted catheter) Can be inserted by nurses who have had special training Long catheter inserted into antecubital vein with tip positioned in superior vena cava Use for IV antibiotics for several weeks or TPN Less risk of complications

Central Line IV Therapy Centrally inserted catheters - special catheter inserted into a large vein in the neck or chest (subclavian or jugular) threaded through into the right atrium tip rests in distal end of superior vena cava

Use of CVC’s (Central Venous Catheters) Medication administration • Cancer • Chemotherapy- infuse irritating or vesicant medications • Infection • Long-term administration of antibiotics Nutritional replacement • Infusion of parenteral nutrition (PN) • Able to infuse higher dextrose solutions through central line than peripheral line

Administration of IV Fluids Use an IV infusion set A drip chamber is connected to the IV bottle or bag flow rate is adjusted to drops per minute (gtt/min) with roller clamp Injection ports - located on the IV tubing & on most IV solution bags allow for injection of medications directly into IV bag or IV line injection ports also allow for attachment of secondary IV lines for IVPB medications

Common Complications of Peripheral IV Therapy

Phlebitis : inflammation of a vein Signs & symptoms of phlebitis redness, swelling, pain, and edema at the insertion site and/or along the vein Treatment - removal of catheter & application of warm soaks

Infiltration : venipuncture device is dislodged from the vein S & S: local edema skin blanching skin coolness leakage at the puncture site Pain & feelings of Tightness blanching at the site absent backflow of blood Treatment: DISCONTINUE THE iv & MONITOR SITE

Which is it? Infiltration redness Swelling pain and edema at the insertion site and/or along the vein Phlebitis edema skin blanching skin coolness leakage at the puncture site absent backflow of blood Infiltration

Variety of ways for Implementing IV Therapy