1. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Administering Intravenous Solutions and Medications

2. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lesson 36.1

3. Theory 1) List four purposes for administering intravenous (IV) therapy. 2) Evaluate the advantages and potential problems of using an infusion pump to deliver fluids or medications. 3) Summarize the possible complications that can arise from the use of the IV route and the corrective actions you should take for each one. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 3

4. Clinical Practice 1) Prepare to give medications using each of the following methods: a. Using an infusion pump b. Using a second IV line as a piggyback c. Using a controlled-volume device d. Using an intermittent IV or a PRN (as-needed) lock e. Giving the medication as a bolus Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 4

5.  IVs are given to supply the body with:  Drugs or substances that cannot be supplied by other means (orally/rectally)  Fluids and electrolytes—for patients who do not have adequate oral intake  Blood, plasma, and other blood components  Nutritional formulas containing glucose, amino acids, and lipids Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 5

6. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 6

7.  The average adult needs 1500 to 2000 mL of fluids in each 24-hour period to replace those eliminated by the body  Fluids are lost by:  Hemorrhage  Severe or prolonged vomiting or diarrhea  Excessive wound drainage  Wounds (especially burn wounds)  Profuse perspiration Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 7

8.  Solutions most frequently used contain:  Glucose  Saline  Electrolytes  Vitamins  Amino acids  Blood and blood products Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 8

9.  Isotonic solutions  Have the same concentration, or osmolality, as blood  Used to expand the fluid volume of the body  Hypotonic solutions  Contain less solute than extravascular fluid  May cause fluid to shift out of vascular compartment  Hypertonic solutions  Have a greater tonicity than blood  Replace electrolytes; when given as concentrated dextrose solutions, produce shift in fluid from intracellular to the extracellular compartment Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 9

10.  0.9% salineIsotonic  0.45% salineHypotonic  5% dextrose in water Isotonic  10% dextrose in water Hypertonic  5% dextrose in 0.9% salineHypertonic  5% dextrose in 0.45% salineHypertonic  5% dextrose in 0.225% salineIsotonic  Ringer’s lactateIsotonic  5% dextrose in Ringer’s lactateHypertonic Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 10

11.  Primary intravenous set  Consists of bag of solution, regular tubing set, needleless connector, and IV stand  Secondary or piggyback intravenous set  Medications to be given intravenously often added to an existing IV line by using the piggyback method  Parallel intravenous set  A Y-type administration set used to infuse certain blood products Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 11

12. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 12

13. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 13

14. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 14

15.  Controlled-volume set  Infusion pump administers small volumes of fluid or medication  Intermittent intravenous device (saline or PRN lock)  Established by applying Luer-lock cap or an extension set to the IV cannula  Filters  Trap small particles such as undissolved medication or salts that have precipitated from solution Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 15

16. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 16

17. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 17

18.  An added safety measure used in many agencies to regulate the flow of routine IV fluids  Use is mandatory when patients receive total parenteral nutrition or for medications that require critical accuracy  Programmed infusion pumps more accurate and provide better control over the amount of solution being infused  Controllers reduce risk of infusing fluid too quickly  Patient-controlled analgesia pumps used in most hospitals and in the home setting Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 18

19. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 19

20.  Used in home IV therapy to administer pain medication  Portable pumps: used at home to regulate TPN  PCA pumps: used in hospitals to allow patient to regulate administration of IV analgesics  Patient receives a preset bolus of medication when the button is pushed and/or a base amount of medication each hour Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 20

21.  Intravenous needles and catheters  Winged-tip or butterfly needle  Meant for short-term therapy  Supplied in odd-numbered gauges (17, 19, 23, and 25)  Over-the-needle catheters  Consist of a needle with a catheter sheath over it  The needle is removed, leaving the flexible catheter in the vein  18-, 19-, 20- to 22-gauge needles  Through-the-needle catheter  Used for midline catheter insertion for long-term peripheral use Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 21

22. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 22

23. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 23

24.  May be left in place for 6 to 8 weeks  Positioned in right atrium or superior vena cava  Some are tunneled long-term catheters such as a Hickman or Broviac catheter  PICC lines are the first choice in home IV therapy  Correct placement is verified by x-ray Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 24

25.  When giving IV medications:  Review the drug’s action before administration and know possible side effects and nursing implications  Assess for allergies and check for possible drug solution incompatibilities  Ensure that IV line is patent before attempting to administer medication, and verify flow rate IV solution Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 25

26. The average adult needs how many mL of fluids in a 24-hour period to replace those eliminated by the body? 1) 500 to 750 2) 750 to 1000 3) 1000 to 1500 4) 1500 to 2000 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 26

27. Different types of tonicity are found in intravenous therapy solutions. Ringer’s lactate and 5% dextrose are what type of solution? 1) Hypotonic 2) Isotonic 3) Hypertonic 4) None of the above Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 27

28. Richard is getting supplies ready to administer blood to his patient. Which type of administration set does he need? 1) Primary 2) Secondary 3) Y-type 4) Controlled-volume Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 28

29. One difference between the peripherally inserted central catheter (PICC) and a midline (ML) catheter is: 1) you can take a blood pressure on the arm that has a midline. 2) only a PICC line can be used in children. 3) only a midline is placed in the patient under sterile technique. 4) the ML sits inside the subclavian vessel; the PICC may be advanced to the subclavian vessel. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 29

30. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lesson 36.2

31. Theory 3) Summarize the possible complications that can arise from the use of the IV route and the corrective actions you should take for each one. (Continued) 4) State at least seven guidelines related to IV therapy of fluids or medications. 5) Summarize special considerations for elderly patients who need IV therapy. 6) Recognize the signs and symptoms of a blood transfusion reaction and describe the steps you should take if one occurs. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 31

32. Clinical Practice 2) Devise a care plan with patient-specific data for a patient who needs IV fluid therapy. 3) Calculate the rate of flow of IV fluids from various IV orders. 4) Initiate IV therapy by performing venipuncture with an IV cannula (catheter over the stylet) using aseptic technique, and starting the ordered infusion. 5) Add a new bag of fluid to replace one from which the solution has infused. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 32

33. Clinical Practice 6) Discontinue an IV infusion and evaluate the site and surrounding tissue. 7) Safely monitor a patient receiving a blood transfusion; document your actions and the patient’s response to therapy. 8) Collect data on a patient who is receiving total parenteral nutrition; document your findings and the patient’s response to therapy. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 33

34.  Occurs when fluid or medication leaks out of the vein into the tissue  Often there will be edema around the site and the tissue will feel cool  Infusion is discontinued and another site is initiated to continue therapy  Fluid that is in the tissue will usually reabsorb within 24 hours Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 34

35.  Caused by irritation of the vein by the needle, catheter, medications, or additives in the IV solution  Signs: erythema, warmth, swelling, tenderness  IV must be discontinued and another site found  Warm compresses to the inflamed site will decrease discomfort Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 35

36.  Occurs when infectious pathogens introduced into the bloodstream  May occur from breaks in sterile technique during cannula insertion or any time the system is opened to change the bag or tubing  Signs and symptoms: fever, chills, pain, headache, nausea, vomiting, extreme fatigue  Blood cultures ordered and aggressive antibiotic therapy is started  IV site is immediately discontinued Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 36

37.  Catheter embolus  Occurs when a piece of the catheter breaks off and travels in the vein until it lodges  Air embolus  Can occur when changing bags, or when opening the line of a subclavian catheter  Speed shock  Occurs when fluids or medications given by bolus are administered too rapidly Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 37

38.  Risk for deficient fluid volume  Imbalanced Nutrition: Less than body requirements, related to decreased oral intake  Ineffective tissue perfusion, related to loss of red blood cells or volume Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 38

39.  Selection of the IV site  Consider:  Accessibility of the vein, its general condition  Type of fluid to be given  Duration of IV therapy  Veins preferred for infusions and intermittent doses of medications are those distal to the antecubital area  Cephalic, basilic, and antebrachial veins of the lower arm and the veins on the back of the hand are the sites of choice for most adult patients Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 39

40.  All medications are administered using the Six Rights, with the addition of the right rate  Movement of the patient can affect the flow rate  Potassium is ALWAYS diluted and never given as a bolus  Sterile technique is used when medications are added to IV fluids  Most facilities require certification to administer chemotherapy drugs Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 40

41.  To calculate drops/minute:  Amount of solution in mL x number of drops/mL / time (in minutes) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 41

42. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 42

43.  Keeping the IV solution running  Assess:  The IV flow: the solution should drip into the chamber at regular intervals  The rate of the infusion  If a pump is used, check the programmed rate and volume; the dripping in the chamber will occur intermittently  The insertion site  Complaints from the patient  The level of the fluid remaining in the bag Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 43

44.  Administering IV medications  Methods  Adding medications to the primary bag of fluids  Adding a secondary line or piggyback to the primary line  Using controlled-volume burettes  Directly injecting the medication into the vein  All medications are administered following the Six Rights and are documented on the medication administration record (MAR) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 44

45.  Administering antineoplastic medications  Many are very irritating to tissue  Special precautions are used in preparing and administering these drugs  Discontinuing an IV infusion  When an infusion is to be discontinued, the flow is stopped and the catheter is removed  Discontinuation is documented on the IV flow sheet Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 45

46.  Administering blood and blood products  A consent to receive blood must be signed by the patient  If a reaction to the blood occurs with the Y administration system, the blood should be instantly shut off  Start the saline (with fresh tubing) to keep the IV access open, in case emergency drugs are needed Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 46

47.  Total parenteral nutrition  Mainly given through a central line  The nutritional status of patients who are NPO and on IV therapy must be assessed every day  IV solution contains dextrose but amount of calories supplied is below the total daily requirement  Lacks other essential nutrients and bulk  Supplemental calories may be provided by the use of amino acids and fat emulsions Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 47

48.  Constant assessment of the patient  Evaluation of the effect of IV therapy relates to the reason it was given  If fluids are given to hydrate the patient, check for good skin turgor, adequate urine output, and moist mucous membranes  If TPN is given, assess patient’s weight gain and monitor blood glucose level  When a blood product is administered, monitor the blood count to see if values improve  Monitor for signs/symptoms of transfusion reaction Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 48

49.  Documentation  Documentation of IV medication is done on the MAR  IV site is accessed every 1 to 2 hours according to agency policy and observations are entered on a flow sheet or in nurses’ notes  IV fluid counted as intake and recorded on I&O sheet Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 49

50. Which action by the nurse is incorrect when hanging intravenous therapy? 1) Hang the solution to run first at the lowest point. 2) Observe closely for transfusion reactions. 3) Keep the tubing free from air. 4) Keep IV fluids sterile. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 50