Intravenous IV

Nursing responsibilities for IV therapy Initiating Monitoring Discontinuing

Initiation and monitoring Patient’s need for IV Type of solution Desired effect Untoward reactions Insert proper catheter and document procedure and patient’s tolerance Systemic complications: Sepsis, embolus, fluid overload

Complications (see ATI book pages 418-420) Infiltration pain, burning, pallor, edema, cool at site, damp dressing, slowed infusion Stop infusion, elevate, ROM, Warm compresses, restart proximal Phlebitis edema, throbbing, burning or pain, warmth, erythema, red line, palpable band, slowed infusion d/c infusion, notify primary care provider(PCP), elevate, warm/moist compress, restart new tubing & fluid, TED hose & anticoagulants culture site/cannula if drainage present

Complications Cellulitis Septicemia Tenderness, warmth, edema, induration, red streaking, fever, chills, malaise Same as phlebitis, antibiotics, analgesics, antipyretics Septicemia Rise in temp, chills, increased HR & RR, HA, N&V, Diarrhea, confusion, Bacteria cultured from blood Monitor vs, notify PCP, blood cultures, antibiotics

Complications Fluid overload Hematoma Distended neck veins, increased B/P, tachycardia, SOB, Crackles in the lungs, edema Elevate HOB, monitor vs, notify PCP, possible readjustment of rate, monitor I&O Hematoma Ecchymosis Pressure dressing, avoiding alcohol, after bleeding stops - using warm compresses and elevation

Complications Catheter embolus If no migration be asymptomatic If migration, sever pain at site(may be same as pulmonary embolus – SOB, chest pain, coughing up blood, decreased B/P, increased HR.) Place tourniquet high & never reinsert stylet into catheter, prepare for removal (OR or x-ray), save catheter to determine cause.

Complication Air embolus If in pulmonary arteries then S&S of pulmonary embolus Rarely occurs with peripheral lines Immediate intervention is key – Trendelenburg position on left side, instruct client to perform Valsalva maneuver (increase pressure to expel feces by contracting abdominal muscles while maintaining closed airway, raises B/P, increased risk for cardiac arrhythmias), notify PCP, perform frequent assessment, ventilator support and IV therapy as ordered

Monitoring Flow rate Correct solution Solution and tubing changes Every 72 hours TPN every 24 hours IV site care Monitor s/s infection, phlebitis , thrombophlebitis and infiltration Pain is first sign Dressing changes every 48 -72 hours Central venous access device(CVAD) every 7 days Soiled, damp or loose

Discontinuation Medical aseptic technique Apply pressure to just above the insertion site with sterile gauze When removing CVAD measure length of catheter and compare it to the documented length at time of insertion. Document findings and patient’s tolerance to procedure.

IV Therapy Maintain strict aseptic technique Examine solution for type, amount, expiration date, character of solution, and container for signs of damage Select and prepare IV infusion pump as indicated Monitor IV for patency Perform site checks according to agency policy Maintain occlusive dressing Flush lines between administration of incompatible solutions

Equipment Sterile technique is used when puncturing a vein. Disposal infusion sets avoid contamination and reduce cost aftercare. Solutions come in 50, 100, 250, 500, and 1000 mL flexible or rigid plastic containers and do not need to be vented Certain medications bond to plastic and must be stored in glass bottles these do need to be vented

Equipment Tubing - spike or pierce the container and come in different flow rates controlled by a clamp (rolling or constricting). The drip chamber or meter permits a number of drops per minute. Some tubing has in-line filters.

Equipment Needles/catheters – variety of sizes - length and gauges Over the needle catheters Plastic tubes over needle, needle is removed and catheter remains in vein Easy to insert and stable Butterflies – single or double winged Short-beveled, thin walled needle with plastic flaps Used in pediatric settings and for short term therapy Not as flexible, infiltrate easily

Equipment Needleless systems promote safety and prevent needle stick injuries when connecting, accessing, and disposing IV equipment. Two piece prepierced septum & blunt cannula device Luer-activated devices Three-way, pressure-activated safety valves

Intravenous Therapy Vascular access devices Peripheral venous catheters – 48-72 hours Midline peripheral catheter – 2 weeks

CVAD Central venous access device Placement confirmed by x-ray Peripherally inserted central catheter (PICC) – 2 weeks Implanted Port - long term placement Tunneled catheters – long term placement Jugular, subclavian, or femoral Double, triple of quadruple lumen Non-tunneled catheters - 3-10 days

Nursing responsibilities of CVAD Change dressings Maintain sterile technique Assess for s/s of infection, infiltration, changing injection caps Flushing tubing with prescribed solution to prevent clotting and blockage

Placement of Peripherally Inserted Central Catheter (PICC)

Peripheral Vein Site Selection Accessibility of a vein Avoid antecubital if another vein is available Not use leg vein without order Not in surgical site Scalp vein for infants Condition of vein Type of fluid to be infused Hypertonic, irritating medications, rapid rate, high viscosity = large vein Advise patient certain medications can cause irritation and pain

Vein Site Selection Anticipated duration of infusion Select smallest catheter, smallest gauge smallest length inserted into largest vein. Site splinted by bone, if not use immobilizer. Site distal to heart and move proximally.

Administering Blood and Blood Products Typing and cross-matching A, B, AB, and O type blood Rh factor Selecting blood donors Initiating transfusion Transfusion reactions

Intravenous medications Most dangerous route because medication is placed directly into the bloodstream. Can not be recalled or slowed Used in most emergency situations when immediate absorption is required.

Solutions Added to IV infusion solution Given slowly and over long period of time Need to check for possible reaction at least every hour

Bolus or push Single injection Slowly over 1 minute or as indicated by manufacturer, pharmacist or physician Most dangerous

Intermittent Mixed with 50-100 mL of solution Given at primary site or at heparin/saline lock Given by: Infusion pump Piggyback – secondary solution must be higher than primary Volume-control administration set

Bibliography Taylor: Fundaments of Nursing Sixth Edition The Art of Science of Nursing Care Sixth Edition