IV Basics

(Checklist step #5)

Objectives of IV Therapy: Restore and maintain fluid and electrolyte balance Provide medications and chemotherapy Transfuse blood and blood products Deliver parenteral nutrients and nutritional supplements Benefits of IV Therapy: Allows more accurate dosing Medications can act instantaneously Can be used to administer fluids, medications and nutrients when the patient cannot take them orally Risks of IV Therapy: Bleeding Infiltration (when fluids are infused into the surrounding tissue instead of the vein) Infection Overdose (fluid overload, speed shock) Anaphylaxis, Syncope Fluids and Electrolytes The body is made up of mostly liquid. Two-thirds of total body weight in an adult and three-fourths of the body weight in an infant consist of fluid. Body fluids are composed of water and solutes (dissolved substances) which are electrolytes and non-electrolytes. Electrolytes There are six major electrolytes: Sodium Potassium Calcium Chloride Phosphorous Magnesium

These are associated with the electricity (chemical compounds) of the body and are vital to the function of the cells. Too much or too little of any of the electrolytes will cause problems if they are out of balance; fluids and electrolytes go together.

Electrolytes are contained either intracellularly (potassium, magnesium and phosphorous) or extracellularly (sodium and calcium). (Not required for this course, but highly recommended, is further study into the balance of fluids and electrolytes and the fluid movement process). Osmosis is a term for this movement of fluids and electrolytes and the fluid movement gradient. Water flows from higher to lower concentration. When the solute concentration is equal on both sides of a membrane the osmosis stops. It is possible for the osmosis to create an equal concentration if the concentration isnt optimal, then the balance must be corrected. Osmosis is the force which causes water to move when solute (solid) particles draw it toward them. Osmosis only occurs when the concentration of solute on one side of a membrane (like the cell membrane) is different than the concentration of solute on the other side. The side with more solute concentration will draw water to it. As the water moves toward the side with more solute it will eventually cause that side to become the same concentration as the side it is drawn from; at that point, osmosis stops.

Osmotic pressure is based on solute concentration which is referred to as osmolarity (or how much solid is dissolved in the water). The prefixes iso (equal), hyper (higher) and hypo (lower) denote the tonicity or osmolarity of a solution. In the picture above, side A is hypertonic to side B in the left picture, but isotonic to side B in the right picture. IV solutions all have a tonicity; therefore they can have an osmolar effect on the human body. Isotonic IV solutions (iso-osmolar to the blood) will go in to the person without causing any osmotic effect between the plasma, extracellular, or intracellular spaces in the body. Solutions There are three types of IV solutions:

 Isotonic- this has the same osmolarity as serum and other body fluids. It will not cause any osmotic effect on the body. Examples: lactated ringers, ringers, normal saline, dextrose 5% in water and 5% albumin. Hypertonic- this has a higher osmolarity than serum. It will pull fluid from the interstitial and intracellular compartments into the blood vessels. Examples: dextrose 5% in half-normal saline, dextrose 5% in normal saline, dextrose 5% in lactated ringers, 3% sodium chloride, 25% albumin and 7.5% sodium chloride. Hypotonic- this has a lower osmolarity than serum. Fluid moves from the blood vessels and into the cells and interstitial spaces. Examples: Sterile water, half-normal saline, 0.33% sodium chloride and dextrose 2.5% in water. *Since blood products and parenteral nutrition are rarely administered in an office or clinic, they are not addressed here. Delivery Methods There are two types of IV administration: Peripheral Central There are three basic methods to infuse IV fluids and medications via both delivery methods: Continuous infusion- this allows a carefully regulated amount of fluid to be given over a long period of time, helping maintain a constant drug level and is used for fluid therapy and parenteral nutrition. Intermittent infusion- this is the most common and flexible method of IV therapy. Drugs can be administered over a specific period of time at intervals and can be infused through a primary line or a secondary line that has been connected (or piggybacked) to the primary line. Direct injection- the most direct method. This gets the medication or fluid right into the patient right away. It is also called giving a bolus or an IV push. Central Venous Therapy This is IV therapy using major veins instead of those in the limbs and other peripheral veins. It is most useful when a patient needs infusion of a large amount of fluid, requires multiple infusions, and /or requires long-term therapy. A central line may be inserted directly into the superior or inferior vena cava or the 3

right atrium of the heart. In addition, one can be inserted into a peripheral vein and threaded up into the vena cava. There are additional risks to central venous therapy including: Perforation of the vein and adjacent organs Requires more time and skill than peripheral IVs Air embolism or thrombus Sepsis Pneumothorax

Access Devices Types of access devices include: Non-tunneled and tunneled catheters Peripherally inserted central catheters (PICCs) Implanted vascular access ports (VAPs) Supplies and Equipment The tubing for an IV is called an administration set. Which set you choose depends on the type of infusion needed, the infusion container, and whether you are using a volume control device or not. Administration sets can be vented for bottles or un-vented for IV bags. Other items and features include ports for infusion of additional medications, filters for blocking particulates in the fluid, tubing which is designed to enhance devices in regulating flow or for continuous or intermittent infusion or for blood and nutrition. There are also various types of clamps for stopping the flow through the tubing as well as pumps that automatically deliver fluids and medications.

Orders When the physician orders IV administration, it may be a standard or standing order (to be followed for certain illnesses and needs) or it may be an individualized order. They may be limited in the duration of time they are effective for, such as a 24-hour period, when a new order must be given. All orders should include the type and amount of solution to be administered, any additives and their concentration, rate and volume of infusion and the duration of the infusion therapy. Flow Rates Two basic types of flow rates are: Microdrip Macrodrip. Each one delivers a certain amount of drops per milliliter (gtts/mL) and each uses the same calculation formula: Volume of infusion (milliliters) Time of infusion (minutes) X drip factor (gtts/mL) = flow rate (gtts/minute)

When calculating the flow rate, the number of drops needed to deliver 1mL will vary on whether you are using the macrodrip (delivers 10, 15, or 20 gtts/mL) or the microdrip (delivers 60 gtts/mL) administration set. After the flow rate has been calculated, use your watch while checking the drops per minute. Adjust the clamp or roller to slow or speed the flow until the correct number of drops per minute has been achieved. Always count for one full minute. There are also pumps that automatically deliver the medication at the correct rate provided it has been set accurately.

Risks, Complications and Disadvantages There are numerous risks and complications in various aspects of IV therapy. This list is a majority, but is not necessarily all-inclusive: All risks related to phlebotomy Infection Infiltration Irritation at the site or along the vein Incompatibility of drugs Restricted mobility Clotting Too rapid or too slow flow rate can cause many problems for the patient Wrong medication given Using the wrong syringe when multiple syringes are required Allergic response or adverse reaction Hematoma Vasovagal reaction Nerve, tendon or ligament damage Spasm of the vein

Patient Teaching Having an IV is frightening to many patients and it is a little painful. You will need to explain the procedure and try to decrease the patients anxiety. Some things to include are: What intravenous means, and that a plastic catheter will be inserted and left in the vein, not a needle. What fluid or medications they are receiving and why. (Most times the provider will do this). How long the IV will be in. Admit that there may be some discomfort (do not say pain) that should stop once the IV is in place. Explain any sensations the fluid or medication may cause such as coldness, a feeling of it going up the arm, a burning sensation, etc Tell them to report any pain or discomfort once the IV is placed. Explain the restrictions as needed such as ambulating, showering, etc

 Teach them how to help care for the IV such as not pulling on it, not to remove the medication from the pole, not to crimp or kink the tubing and to report any redness or irritation at the site or numbness in the fingers etc Documentation Charting is always required on every task, procedure, instruction, phone conversations, etc with the patient. IV is no exception. There must be an accurate accounting of all care that was given and any problems. There may be several places that it must be charted or recorded. Below is a sample of a pre-printed label that can be completed and stuck to the chart note:

For the insertion of an IV it must include: Size and type of device Name of the person administering (inserting) Date and time Site location Type of solution and any additives Flow rate Whether a pump is used Complications and patient response Patient teaching Number of attempts

If an attempt is unsuccessful, it must be recorded in case problems occur later because of it. Label the dressing as well when inserting the IV and when changing the dressing. Label the fluid container and place a strip of tape down the side to monitor amount of time that fluid is infused. Maintenance of an IV is also charted and should include: Condition of the site Site care provided

 Dressing changes Site changes Tubing and solution changes Additional patient teaching There may also be flow sheets, medication sheet and/or intake/output records to document as ell. All of these are vital. Discontinuing an IV is charted as well as insertion and maintenance. When you discontinue an IV, include in your documentation: Date and time Reason for stopping the therapy Assessment of the site before and after removal Complications Patient reaction Integrity of the device upon removal Any follow-up tasks such as a dressing or insertion in another site

Legal Issues Administering fluids and medications by IV therapy is one of the most legally risky tasks performed in the medical setting. There are numerous lawsuits against those who have made errors involving IV solution administration. It is especially risky for the medical assistant who works under the physicianemployers license, whereas nurses have their own license. Errors in medication dosage, incorrect placement of an IV line, and failure to monitor adverse reactions, infiltration, and dislodgement of IV equipment are the common problems. The medical assistant CANNOT place, start, monitor or remove an IV unless they are fully trained to the full extent of their State laws and only when your physician-employer has allowed you to do so. (**See the State laws of Washington called the Healthcare Assistant Law in another assignment of the checklist in your packet for more information on this). The medical assistant must be fully knowledgeable about the laws that govern their right to practice within their scope of training. Be fully aware of the policies in your office/clinic and follow all Federal and State laws for infection control when performing tasks that involve body fluids (OSHA, WISHA, CDC, Bloodborne Pathogen Standard, Standard Precautions).

Answer the following questions and submit with completed packet:

Questions 1. How much of the body weight of an infant is fluid? 2. Name four of the six electrolytes. 3. What are the two types of IV therapy? 4. Name the three types of IV solutions. 5. According to this handout of IV basics, which of the three delivery methods is the most common and flexible? 6. Is it Federal or State laws that govern whether an MA can do IVs? 7. Name three risks or complications of IV therapy. 8. How many drops per minute can a microdrip system deliver? 9. Are electrolytes only contained within the cells (intracellularly)? 10. Name the two vessels that central venous therapy uses. 11. Of the IV solutions named here, which has a higher osmolarity than serum? 12. What is the type of delivery method also know as an IV push? 13. Name two additional risks in central venous that are not in peripheral IV therapy. 14. What are the five major risks of peripheral IV therapy? 15. Name two of the four objectives of IV therapy. 16. What type of IV solution is lactated ringers? 17. What are the three types of IV administration sets? 18. What does the acronym PICC stand for?

19. How long should you compare your watch to the drop count to ensure the flow rate is being delivered accurately? 20. How long do you count on your watch to ensure the flow rate of drops is running at the correct speed of administration?

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IV Therapy: Nearly 85% of all patients admitted to the hospital will receive IV therapy during their stay. Patients may also receive infusion therapy in clinics, medical offices, nursing homes, and in their own homes. General IV Policies: Prior to initiating IV therapy for any patient, you must receive an order from the physician. The order must include the date, route, volume of solution, named solution, and any additives, rate of flow and the physicians signature. Before performing an IV venipuncture it is imperative that the agency has IV policies and procedures in place and that the administrator is aware of all that is included in the manual. Remember, the licensed professional performing this procedure is legally accountable for all the actions performed. Other resources to consult are the infection control manual and the OSHA standards on bloodborne pathogens, which describe the employer and employee responsibilities to prevent the transmission of bloodborne infections. Preparing for Venipuncture: Once an order is obtained, gather all the equipment needed. This includes an IV pole, the ordered IV solution, appropriate IV administration set, IV catheter, sharps container, alcohol prep pad, gloves, tourniquet, gauze, tape and transparent dressing , or if your agency provides, a prepackaged IV start pack. An integral part of all nursing procedures is good hand washing to remove surface dirt and bacteria from the skin. Properly identify the patient before proceeding any further and explain the procedure to the patient fully in terminology they can understand. It is illegal to perform a venipuncture on a patient who refuses. Perform a preliminary assessment of both upper extremities, assessing for scars, bone deformities, areas of infiltration or phlebitis. Affected CVA and post-mastectomy arms should be avoided due to their impaired abilities to reabsorb infiltrated IV fluids. When choosing the intended IV venipuncture site, the non-dominant arm is usually preferred. Apply the tourniquet to the selected upper extremity about three to four inches above the antecubital fossa. The most appropriate tourniquet is made of a latex material since it is inexpensive and can be readily discarded. A properly applied tourniquet will stop

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venous blood return to the heart causing the veins below the tourniquet to engorge. Some additional methods that can be sued to distend veins include: - Gently tapping the vein over the intended insertion site, this will cause irritation of the middle or muscular layer of the vein wall. - Having the patient open and close the fist, ,which will cause the muscles of the forearm to externally massage the vein wall, thus facilitating venous blood return to the heart and causing the occluded veins to distend. Location of Veins: Hand and Wrist For a successful venipuncture, the person performing it must have a working knowledge of the location of all the major superficial veins of the upper extremities. The digital veins flow along the lateral portions of the fingers. The metacarpal veins are formed by the union of the digital veins at the knuckles and flow on the back of the hand. The dorsal venous arch is formed by the union of the metacarpal veins on the dorsal side of the wrist. The dorsal venous arch flows upward along the dorsal surface of the forearm and turns at a right angle to join other veins. The digital veins are located in areas of multiple joint flexures. These veins can easily infiltrate and therefore should only be used as a last resort. If digital veins have to be used, stabilization of the joint with a padded tongue blade or finger splint is necessary. The metacarpal vein is the site of choice for pre-op patients due to easy accessibility by the anesthesiologist. When choosing a metacarpal vein, the clinician must be sure that the fully inserted catheter lies on the flat of the hand. Avoid placing the IV catheter over areas of joint flexure, such as the wrist. An additional location to avoid is the knuckles. Venipuncture at this site can easily lead to mechanical phlebitis due to the catheter moving in the vein. The dorsal venous arch is a comfortable venipuncture site. The dorsal surface of the forearm is callused as opposed to the less exposed, more tender ventral surface. The cephalic vein originates at the wrist and flows along the radial portion of the forearm. This is often called the nurses vein. The basilica vein originates at the wrist and flows upward along the ulnar portion of the forearm. The median antebrachial vein arises from the palm of the hand and extends upward, located on the ventral portion of the forearm. The cephalic vein is one of the most prominent veins of the forearm and is frequently used because it is easy to see. It can accommodate a large gauge IV catheter. Avoid catheter placement over the wrist joint or in the antecubital fossa. Catheter movement in these areas can puncture the vein wall and lead to infiltration. The basilic vein is visualized by having the patient flex the arm. It is located on the posterior aspect of the forearm. To assure correct catheter placement, lower and gently rotate the arm and access the vein with the catheter tip pointed towards the heart. The median

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antebrachial vein is extremely superficial but has a narrow lumen casing it to be difficult to access. Small gauge IV catheters should be used. Avoid using veins of the antecubital fossa. Antecubital veins are not appropriate for routine IV therapy. These larger lumen veins should be used for peripherally inserted central catheters and routine phlebotomy. The cephalic and basilic veins extend above the antecubital fossa and merge at the shoulder to become the subclavian vein which in turn becomes the superior vena cava. The median antebrachial vein arises from the palm of the hand, crosses over the antecubital fossa and usually merges with the basilic vein. Palpating and Prepping the Venipuncture Site: When choosing the appropriate venipuncture site on your patient, the cephalic and basilic veins of the upper arm should not be overlooked. Locating the vein is not the only determining factor in IV site selection. The vein must also be palpated to assess its condition. Palpation is achieved by gently rolling two fingers over the intended insertion site from left to right. These fingers will develop a sensitivity in picking up bifurcations and abnormalities in the veins, for example, sclerosed veins or valves. Avoid palpating the vein using an up and down motion. This will flatten the vein, and therefore decrease vein visibility. Once the intended insertion site is selected, prep the area vigorously with alcohol and allow to air dry. The best prepping technique is to use an upward motion. This will cause the vein to distend. Avoid prepping with a circular motion or an up and down motion. This will cause the vein to flatten out and become difficult to see. Alcohols antiseptic properties will kill staph on the epidermis which is the major organism responsible for peripheral IV site infections. The site is adequately prepped when the prep pad is clean. Selecting the IV Catheter: An important step prior to the venipuncture is choosing the appropriate IV catheter gauge. The correct gauge selection depends on several factors, such as the ordered flow rate, the type of fluid, the patients vein status and the viscosity of the IV fluid. A 22 gauge catheter is the standard gauge for infusing routine IV fluids and antibiotics. This catheter can deliver up to 500 cc of IV fluid per hour in a good vein. A smaller 24 gauge catheter is considered standard size for pediatric and geriatric populations and is appropriate in small lumen veins such as the median antebrachial vein. This gauge catheter can deliver up to 250 cc per hour in a good vein. A larger 20 gauge catheter is used for infusion of blood and blood products, since these infusions tend to be viscous and a larger lumen catheter will allow for a quicker infusion time. When you are selecting the gauge for your patient, remember the golden rule of IV therapy: use the smallest gauge possible in the largest vein possible.

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The IV catheter is made up of several parts. These include the air vent, a plastic or styrofoam plug which prevents blood from shooting out of the back of he catheter; the flashback chamber, where blood return is visible when the lumen of he vein has been accessed; the color-coded hub, colors will vary among the manufacturers; the catheter, a radiopaque plastic type tube which remains in the patients vein; the stylet, a stainless steel needle located inside the catheter that is longer than the catheter and extends beyond the catheter tip. The stylet pierces the skin and vein wall and it is removed once the vein is accessed. The bevel is the sloped, exposed opening at the tip of the stylet. Holding the Catheter Properly: In keeping with universal precautions and OSHA standards for bloodborne pathogens, proper fitting gloves should be worn for venipuncture. With properly gloved hands, remove the selected IV catheter from the package and discard the protective cover. When holding the IV catheter, the index finger, middle finger and thumb are placed on either side of the flashback chamber level with the catheter. The clinicians hand should be on top of the device. This holding technique will afford good control over the catheter, thus allowing for smooth entry into the vein. The IV catheter should not be held from the back nor with the clinicians hand placed under the device. This would cause a dart-like insertion and afford less control of the IV catheter entering the skin and vein. The correct position is always with the hand on top of the IV catheter and fingers on either side of the flashback chamber. Using the non-sticking hand, retract the skin at the site tightly with a downward motion. Press to anchor the vein approximately three inches below where you intend to pierce the skin. One of the most important steps in the IV insertion procedure is the entry angle of the IV catheter. If the vein is superficial and easily visualized, the entry level should range from 0 degrees to 5 degrees maximum. If the vein is deeper, not easily visualized and can only be palpated, the entry angle should range from 5 degrees to 15 degrees maximum. IV Insertion: The IV catheter should be inserted directly over the vein. Holding the flashback chamber at the correct angle, with the bevel up, push the IV catheter through the skin and into the vein with one smooth, quick motion. The IV catheter will go through two layers of skin: the epidermis, the outer calloused layer; and the dermis which contains capillaries and thousands of nerve fibers. Any pain the patient experiences during venipuncture is directly related to the IV catheter passing through the dermis where the nerves are located. The IV catheter then penetrates the three layers of the vein. The outermost layer, which is punctured first, is the tunica adventitia. This layer supports and protects the vessel. The tunica media, or middle layer, consists of nerve and muscle fibers which can cause the vein to constrict or dilate. The innermost layer is the tunica intima

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which consists of endothelial cells and semilunar valves. These valves move the blood back to the heart. When the catheter enters the lumen of the vein, blood return will be seen in the flashback chamber. Retract the skin with your non-sticking hand. To level off the entry level of the catheter, lower the flashback chamber. Advance the catheter until one third of the catheter is in the vein. This will ensure that the bevel and the catheter have entered the lumen of the vein. In a correctly inserted catheter, the bevel of the stylet and the tip of the catheter are definitely within the lumen of the vein. Avoid removing the stylet prematurely. If you were to remove the stylet immediately after the initial puncture of the vein, only the bevel of the stylet and not the catheter would have penetrated the vein wall. Remember, the stylet is longer than the catheter. Also, if you continue to advance the catheter farther at the same angle used for the initial penetration, the stylet would pierce the far wall of the vein, exit the vein and lead to the formation of a hematoma. The correct procedure is to level off the angle after the initial penetration and continue insertion until one third of the catheter is in the vein. Completing and Dressing the Venipuncture: Once the catheter has been properly placed, remove the tourniquet. Hold the hub of the IV catheter. With the sticking hand, grasp the flashback chamber and gently remove the stylet from the IV catheter Attach the primed IV tubing and open the IV flow clamp. Retract the skin, and with the sticking hand holding the catheter hub, gently advance the catheter completely into the vein. The IV fluid will cause the vein to dilate and will also lubricate the catheter. Regulate the rate of flow and apply the dressing. A simple tool to remember the major steps for completing a venipuncture properly is the acronym BLATS. B L A T S Blood return enters the flashback chamber. Level the catheter. Advance the catheter. Tourniquet is removed. Stylet is removed.

Applying a gauze and tape dressing: gently lift the catheter. Place one strip of tape under the catheter hub with the adhesive side up. Chevron or cross the tape over the junction of the hub and IV tubing. At this time the clinician should remove the gloves to prevent the tape from sticking to the gloves. Place two three-inch strips of tape below the catheter hub and work upward. Do not place tape over the insertion site. Fold a two-by-two gauze pad in half and place it over the insertion site. Use tape to anchor the gauze in place. The IV tubing should be taped in a looped fashion and placed on the patients arm. The site can now be inspected, if needed, by simply lifting the tape covering the gauze and reapplying

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it once the site inspection is complete. The venipuncture site could also be dressed using a transparent dressing. Documenting the Procedure: The IV insertion procedure must be documented on the patients record. The notes for IV insertion must include the following: the insertion date and time, the gauge of catheter, the length of catheter, the style and brand of IV catheter, the specific vein name, the type of infusion and the number of attempts required for a successful venipuncture. 7/7/08 10:30am a 22 gauge, 1 Deseret Insyte catheter inserted into right mid cephalic. 1000cc D5 NS with 20 MEQ KCl infusing at 125cc/hr by gravity. Patient states IV site feels good. M. Allen, CMA Catheter Removal: IV catheter removal should be performed on a routine basis every 48 hours or at the first suspected sign of contamination or complication. The following equipment is needed for IV catheter removal: tape, gloves, gauze and a sharps container. Gloves should be worn in keeping with universal precautions. Stop the IV infusion by clamping the tubing. Carefully remove either the gauze or the transparent dressing, pulling the tape in the direction of the hair growth. Place a two-by-two gauze pad over the insertion site with the non-dominant hand and gently remove the IV catheter. Once the tip of the catheter is out of the skin, apply pressure over the site with the gauze. Once the bleeding has stopped, tape a clean gauze in place over the insertion site. Discard the removed catheter properly in a sharps container and document the IV catheter removal in the patients record. Review of Main Steps: Obtain and check the IV order Gather the appropriate equipment Wash your hands Identify the patient and assess the condition of the patients arm Apply the tourniquet Select appropriate vein Prep with alcohol in an upward manner Put on gloves Hold the catheter bevel up, at the appropriate angle Retract the skin Insert until the blood return is visible in the flashback chamber Level off the angle of entry 17

Advance the catheter slightly Remove the tourniquet Remove the stylet Attach the IV tubing Open the flow control clamp Retract the skin Advance the catheter to the hub Regulate the flow rate Remove gloves Center the transparent dressing over the site to anchor the catheter in place Loop the IV tubing and tape in place Document the procedure in the patient chart The insertion of a peripheral IV catheter is a complex procedure, but skill and dexterity come with practice. A review of the insertion steps, especially the critical points, will help to enhance the clinicians skills.

IV catheters

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IV cannulas

Hand positioning

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Looping and dressing style

Hand IV placement

Arm IV placement

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