Peggy D. Johndrow (edited by Dr. C. Scudmore) IV Therapy Peggy D. Johndrow (edited by Dr. C. Scudmore)

IV Administration Administer into circulatory system Large volume infusions: 250mL to 1000 mL Bolus injection: IV push Volume-controlled infusions: 50 mL to 250 mL Piggyback Tandem Volume-control set Mini-infuser pump

IV Solutions Isotonic: concentration most like blood Used to expand blood volume Normal saline or 0.9% NaCl Lactated Ringers Hypotonic: concentration less than blood Used for dehydration 0.45% NaCl 0.33% NaCl Hypertonic : concentration greater than blood Draws fluid into vascular compartment; not for clients with kidney or heart problems D5 NS D5 1/2 NS D5LR Many Isotonic (most like blood): used to expand blood volume; same concentration of solutes as blood. Assess for signs of hypervolemia such as bounding pulse, & SOB. Normal saline or 0.9% NaCl Lactated Ringers (sodium, chloride, potassium, calcium & lactate) Hypotonic: provide free water and treat cellular dehydration; promote elimination via kidneys; less concentration of solutes than blood 0.45% NaCl 0.33% NaCl Hypertonic: draws fluid out of intracellular & interstitial compartment and into vascular compartment, due to higher concentration of solutes than blood; caution for clients with kidney or heart problems. D5 NS Osmosis = water moves from less to greater concentration to equalize D5 1/2 NS D5LR Acidifying solutions used to treat metabolic alkalosis; include D5W in ½ NS (½ NS is the same as 0.45% sodium chloride) Other fluids used to increase blood volume are Volume expanders; include: Dextran & Serum albumin

Overview: IV Insertion Use needle with catheter sheath 20-22 gauge typical for adult If blood transfusion anticipated , use 18 or 20 gauge Most IV solution sets deliver 10 drops per mL, or 60 drops per mL (microdrop) IV solution should be clear; cloudy solutions may indicate contamination Safety shield type of catheter required by OSHA; also called over the needle (ONC) Review packaging label for exact drop per ml

IV sites Peripheral Central Metacarpal: top of the hand Basilic & Cephalic typically used on forearm Use most distal part first Consider type of solution to be infused Central IVs inserted into subclavian or jugular vein Groshong Triple lumen Implanted ports PICC lines Site varies depending on the client age, the type of solution, the length of time the infusion is to run, the type of solution used & the condition of the veins. Peripheral sites Metacarpal - in the top of the hand Basilic - In the forearm - arm is natural splint and armboards may not needed. Use cathelons/catheters that cover the needle; catheter left in, not needle Cephalic - Also in forearm

Precautions for IV Sites Avoid Bony prominences Legs & feet Mastectomy arm Operative arm Injured arm Dialysis catheter or shunt

Documentation IV Start Number of attempts Type of fluid/saline lock Insertion site Type and size of catheter or needle Flow rate Response to IV Record response to IV fluid, amount infused integrity and patency of system every 1-2 hours

Procedure for Hanging IV Fluid Remove IV bag from protective cover Check expiration date & assess for cloudiness or leaks Hang the IV bag on a pole Remove IV tubing from its bag Close roller clamp Spike the bag Fill drip chamber 3/4 full Open the roller clamp & prime tubing Close roller clamp & replace protective cap Label the tubing with date to be changed Adjust roller clamp to appropriate drip rate or place into IV pump and set rate Remove tubing from bag and straighten it Close roller clamp Hang IV bag on the IV pole Spike the bag by pulling off blue protective cover (keep sterile) and inserting tubing into bag Fill drip chamber 3/4 full by squeezing it gently Openroller clamp & prime tubing: fill entire tubing with IV solution avoiding any air bubbles; small air bubble less than 0.5 mL usually not harmful unless infusing into a central line Label the tubing with times for solution to be infused, especially if no pump and with tubing change date (usually q 72 hours) Adjust roller clamp to appropriate drip rate or place tubing into an IV pump; set the primary rate and volume in the pump

Procedure Hanging IVPB Open tubing same as IV Close roller clamp Hang IVPB bag on pole Spike bag same as IV Prime tubing Connect IVPB tubing to IV tubing Place wire hanger on pole Lower IV bag on to hanger Set correct drip rate Label the tubing with date to be changed Open tubing same as IV Close roller clamp Hang IVPB on pole Spike bag same as IV Prime tubing Connect IVPB tubing to IV tubing Place wire hanger on pole Lower IV bag on to hanger Adjust roller clamp to appropriate drip rate: check order, check bag correct rate. If using IV pump, set secondary volume & rate; primary IV will start to run when IVPB is infused Label the tubing with date to be changed

Preparation for IV Check physician order Check fluid, electrolyte, and nutritional status for baseline information to make comparison of IV effectiveness Know agency policies Assess client understanding of reasons for procedure Assess veins

IV Equipment Obtain equipment Safety catheter needle Tourniquet Chlorhexidine prep Alcohol swabs Gloves Towel Transparent dressing Tape IV tubing & solution bag IV pole and/or pump

CHAIN OF INFECTION Microorganism Carrier Person Susceptible A way out Travel Method A way out Skin puncture Susceptible

Prevention of IV site infection CDC guidelines Wash Hands Use sterile technique Change IV solution q 24 hrs Change IV site every 48 to 72 hours Change IV tubing every 48 hours Use gloves & sharps containers Check agency policy

Client Education Teach S&S of infection or problems When to call for help How to prevent IV from clotting or being pulled out Arm positioning Walking with IV pole

Starting IV Check client’s ID bracelet Wash hands Organize equipment at bedside within reach Set bed height for ease of nurse Put towel under arm Place tourniquet around upper arm Palpate dilated veins Hang arm down to dilate vein Select site low on arm first Release tourniquet (if anticipate a lot of time passing)

Prepare Site & Insert IV Put on gloves Clean the site Alcohol, then betadine (let dry) Re-apply the tourniquet 1-2 inches above site Secure vein by placing thumb 2-3 in below site and gently stretching skin Stick vein (15 to 30 degree angle) with bevel of needle up Watch for flashback in chamber

Insert Catheter Stabilize stylet and advance catheter Loosen stylet from catheter Release tourniquet Hold thumb over vein above catheter tip Remove stylet and attach IV tubing; put stylet in sharps container Connect tubing

Start Fluid Start IV fluid at slow rate Secure catheter Transparent dressing over insertion site Tape over hub of catheter No tape near site of insertion Label site with date, time & initials Label tubing with date to be changed Chart Date, time, type & gauge of catheter, dressing type Fluid attached as IV Clients reaction to procedure

IV Flow Rate Nurse responsible for flow rate maintenance Can result in fluid overload leading to cardiovascular, renal or neurological impairment Controlled by roller clamp, controller device or IV pump, & affected by client position Controller device & roller clamp work with gravity (must be 36 inches above site)

Controller Device & Roller Clamp Determine hourly rate Determine drops/minute rate Set rate by counting drips per 15 seconds & multiply by 4 to get drops per minute Mark time in hours on IV bag tape help keep the rate accurate Readjust rate as needed

IV Pump/Controller IV pumps deliver IV fluids by exerting positive pressure on fluid tubing Most pumps alarm with an occlusion, but many times they continue to infuse even when infiltrated Insert tubing into pump’s flow control chamber or path Set rate in mLs per hour on the pump Set the volume to be infused (VTBI) Press the start button Monitor a few minutes to be sure the pump is functioning

Intermittent Therapy or Saline Lock Must be flushed at regular intervals with saline or heparin to maintain patency (usually q shift) Flushes prevent clotting of catheter & maintain patency of IV site For intermittent access (meds) For potential access (telemetry) For tests (stress test, etc) Use push-pause technique When client takes shower, cover IV site with plastic Heparin generally only used for dialysis catheters and in cath lab. Check hospital policy and MD orders.

Converting IV to Intermittent Therapy Check the order Obtain equipment & take to bedside Syringe with saline/heparin INT device & extension tubing Check ID bracelet Instruct client Wash hands Don gloves Prime INT device Remove IV tubing & replace with INT device Tape securely Flush with saline (3 mls)/heparin (as ordered)

IV Site Complications Assess IV site for: Infection: redness, warmth, swelling & pain; possible fever, & site discharge Infiltration: redness, edema at the site, burning pain, coldness, fluid will not flow by gravity Blood backflow does not always mean IV not infiltrated

Other IV Complications Allergic reaction : rash, redness, itching, anaphylaxis Circulatory overload: dyspnea, cyanosis, JVD, edema, wt gain, ascites Air embolism: decreased blood pressure, cyanosis, tachycardia, JVD, dyspnea Small amounts of air do not produce symptoms because air is removed from the circulation. Large boluses of air (3-8 mL/kg) can cause acute right ventricular outflow obstruction and result in cardiogenic shock and circulatory arrest. Subclinical air embolism in hospitalized clients may be common. Procedures that most commonly result in VAE are CV (internal jugular or subclavian) catheterization and pressure infusion of fluids and blood. Symptoms, which develop immediately following embolization, are similar to pulmonary thromboembolism. Severity of symptoms related to degree of air entry and include the following: Dyspnea, Chest pain, Tachycardia, Hypotension, Altered sensorium Circulatory shock or sudden death (clients with severe VAE) Physical: Acute respiratory distress, Tachypnea, Agitation, Disorientation Classic finding - Mill wheel murmur upon auscultation of the heart Cyanosis and hypotension - Accompany severe VAE Actions Once VAE suspected, immediately stop infusion and clamp line. Do not withdraw the catheter at this time unless it cannot be clamped. Promptly place client in Trendelenburg position and rotate toward the left lateral decubitus position. This maneuver helps trap air in the apex of the ventricle, prevents its ejection into the pulmonary arterial system, and maintains right ventricular output. Administer 100% oxygen and intubate for significant respiratory distress or refractory hypoxemia. If CV catheter is present, aspirate from the distal port and attempt to remove air. Catheter may have to be advanced for this to be successful. CPR helps expel air from the pulmonary outflow tract and disperse it into the peripheral pulmonary venous system. Admit client to ICU.

Macrodrops and Microdrops

IV Tubing Label

IV Tubing Label

Math problems

Calculating Rate in Drops per Minute Formula Volume x drop factor = gtts/min Time in minutes =60 x hours

Calculating Rate in mL per Hour Formula: Volume = mL/hr Hours

Infusion Time Formula: Volume x drop factor (gtts/mL) = hours to infuse Flow rate (gtts/min) x 60

Calculation of Medication Use ratio and proportion Medication amount available = Amount to give Amount of mL X mL

Intermittent Therapy Special adapter: flush with NS every shift; use push-pause technique to flush (push fluid in, pause, push fluid in, pause…), if needle-less system clamp tubing while still pushing fluid; usually use 2-3 cc of NS to flush SAS : saline, additive (medication), saline Pediatric clients: often use heparin solution to lock; SASH Push pause method creates turbulence inside the tubing and prevents debris from sticking to inside of tubing. Ensures longer patency.

IV Intake Example: John's primary IV is running at 34 mL/hr while NPO. When the nurse runs the Vancomycin (250 mg IV q 8 hr) in over 90 minutes [volume is 100 ml], the primary IV is stopped. The ampicillin (395 mg IV q 6 hr) is given concurrently in 10 ml of fluid over 30 minutes. He received 2 boluses of aminophylline (20 ml each over 20 minutes). The IV fluids were stopped while the aminophylline infused. Since microtubing was used for the medications, total flush is negligible (approximately 3 ml). What is John’s total IV intake for 24 hours?

Calculate using the critical information: Vancomycin runs 1.5 hrs x 3 doses = 4.5 hrs IV is stopped Primary IV flds 24 (hr) minus 4.5 = 19.5 hrs. Primary fld stopped as aminophylline is infusing: 20 min x 2 = 40 minutes Primary fld 19 hr 30 min. - 40 minutes = 18 hr 50min (18.83 hrs) x 34 mL = 640.22 mL

Calculation Vancomycin: 100 cc x 3 = 300 mL Ampicillin 20 cc x 2 = 40 mL Aminophylline 20 cc x 2 = 40 mL Normal saline flush (approx.) = 3 mL 640.22 + 300 + 40 + 40 + 3 =1023.22 mL/24hrs John's daily IV intake, based on all therapeutic modalities, is 1023.5 mL

Calculate Total Intake and Output Example: Crystal has an IV infusing at KVO (10 mL/hr). She receives an antibiotic in 22.5 mL q 8° concurrently. One mL flush is given after each antibiotic. She is given 30 mL of formula q 3°. She had diaper weights of 17 mL, 33 mL, 55 mL, 45 mL, 52 mL, 50 mL, 15 mL, and 36 mL. Calculate her I & O for the past 24 hours.

Intake: IV @ 10 mL/hr x 24 hr = 240 mL Med of 22.5 mL x 3 (q8°) = 67.5 mL Flush of 1 mL x 3 = 3 mL Formula of 30 mL x 8 (q 3°) = 240 mL 240 mL + 67.5 mL + 3 mL + 240 mL = 550.5 mL Crystal's intake is 550.5 mL for the past 24 hours