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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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.

23. 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)

24. 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

25. 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.

26. Macrodrops and Microdrops

27. IV Tubing Label

28. IV Tubing Label

29. Math problems

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

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

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

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

34. 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.

35. 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?

36. 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 minutes = 18 hr 50min (18.83 hrs) x 34 mL = mL

37. 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
= mL/24hrs
John's daily IV intake, based on all therapeutic modalities, is mL

38. 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.

39. 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 mL
Formula of 30 mL x 8 (q 3°) = 240 mL
240 mL mL + 3 mL mL = mL
Crystal's intake is mL for the past 24 hours