INTRAVENOUS PARENTERAL THERAPY Definition Intravenous (IV) therapy is the insertion of needle or catheter / cannula into a vein, based on the

physician’s written prescription. The needle or catheter/cannula is attached to sterile tubing and a fluid container to provide medication and fluids. Philosophy Historical background of IV Therapy The record history of i.v. therapy began in 1492 when a blood transfusion from two Romans to the dying Pope Innocent was attempted. All three died. In 1628, Sir William Harvey’s discovery of the blood circulatory system formed the basis for more scientific experimentation. In 1658 Sir Christopher Wren predicted the possibility of introducing medication directly into the bloodstream, although it was Dr. Robert Boyle who used a quill and bladder to inject opium into a dog 1659, with J D Major succeeding with the first injection into human in 1665. A 15 year old Parisian boy successfully received a transfusion of lamb’s blood in 1667. However, subsequent animal to human transfusions proved fatal and eventually, in 1687, the practice was made illegal. In 1834, James Bludell proved that only human blood was suitable for transfusion, and later the century Pastuer and Lister stressed the necessity for sepsis during infusion procedures. In 1900 Karl Landsteiner led the way in identifying and classifying different blood groups, and in 1914 it was recognized that sodium citrate prevented clotting which opened the gate for the extensive use of blood transfusions. Intravenous therapy was being used widely during World War II, and by the mid-1950s was being used mainly for the purposes of major surgery and rehydration only. Few medications were given via i.v. route, with antibiotics more commonly being given intramuscularly. Through the 1960s and 1970s, intermittent medications, filters, electronic infusion control devices and smaller plastic cannulae became available. Use of multiple electrolyte solutions and medications increased along with blood component therapy, and numerous i.v. drugs and antibiotics were being added to i.v. regimens. The use of i.v. therapy has expanded dramatically over the last 35 years. This expansion continues to accelerate and can be attributed to the following factors: • The understanding of hazards and complication

• • • •

Improvement in i.v. equipment Increased knowledge of physiological requirements Increased knowledge of pharmacological and therapeutic implications Increased availability of nutrients and drugs in i.v. solutions Changes in the traditional roles of doctors and nurses, allowing nurses to develop skills that were traditionally the remit of the medical profession (e.g. insertion of central venous access devices).

Here in the Philippines, the Nursing Standards on Intravenous Practice was established in 1993 as a guide for those who are and will be practicing intravenous therapy. During the first months after the promulgation of the professional regulations Commission (PRC), Board of Nursing (BON) Resolution No. 08 series, February 4, 1994, the maiden issues (First Edition) of the Intravenous Standards on Intravenous Therapy was printed and circulated. It was first used in Cagayan de Oro City where the Training for Trainers was conducted last June 9-11, 1994, after the ANSAP Board Members and Advisers had undergone the Training for trainers at Philippine Heart Center on October 1993. Subsequently, another revision was required to incorporate the PRC-BON’s protocol of May 17, 1995. Because of the new concept and evolving technology, more revisions were deemed necessary. Revisions were made by a special committee of the Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP) in collaboration with the PRC-BON, to ensure a safe and quality nursing practice in Intravenous therapy in 2002. The new Nursing Law RA 9173 has stated that the administration of parenteral injection is in the scope of nursing practice. ANSAP believes that the certification of IV Therapist will be continued for several reasons, paramount of which is safe nursing practice.

Standard and competencies of IV therapy Standard Operating Policies and Procedure are established to ensure safe IV therapy practice, to protect the patients by maximizing benefits and minimizing risks associated with IV therapy and to protect the practice of registered professional IV therapy nurses. The IV therapy policies and procedures are written and continuously updated and reviewed as necessary. 1. Key points prior to initiation of IV therapy a. Physician’s prescribed treatment. The initiation of intravenous therapy is upon the written prescription of a licensed physician which is checked for the following:  Patient’s Name  Type and amount of solution  The flow rate  The type, dose and frequency of medication to be incorporated/pushed.  Others affecting the procedure (x-rays, treatment to the extremities, etc) b. Patient Assessment Factors to consider for IV therapy  Clinical status of patient  Patient’s diagnosis  Patient’s age
 Dominant arm ( non)

 Condition of vein/ skin  Cannula size

4. IV set and equipment preparation  Check for expiration date  Check for clarity. August 1988 Cathleen McGovern. Administer the right drug. plastic container (bag) for presence of sediments or insects. 5. Nursing 88 Vol. 8. compatibility of drug with the solution. 2. dose of medication and amount.  Check label against the physician’s written prescription  Label for any medication that are added: date. any presence of holes on plastic cover (packaging). Administer the right drug to the right patient. 6. Type of solution  Duration of therapy c. Administer the right drug by the right route. Be aware of potential drug – drug or drug-food interactions. Document each drug you administer. Teach your patient about the drug he is receiving. 10. 18. drug interaction and possible clinical effects on the vascular system. Medications Nurses administering IV therapy should have knowledge on all medications administered including dosages. 3. time.  Functionality of infusion pump. RN . 10 GOLDEN RULES FOR ADMINISTERING DRUGS SAFELY 1. patient controlled analgesia (PCA) d. Administer the right dose. 9. 7. Take a complete patient drug history. Find out if patient has drug allergies. Administer the right drug at the time.

Cannulation of the lower limbs is associated with an increased risk of venous thromboembolism. The tunica media (the middle layer): a muscular layer containing elastic tissue and smooth muscle fibers. The wall of a vein is composed of three layers (Figure 1): • • • The tunica adventitia (the outer layer): a fibrous layer of connective tissue. Medication administration ANATOMY AND PHYSIOLOGY Superficial veins of the upper limbs are usually selected for peripheral cannulation. Principles of aseptic technique e. Assessing of vital signs c. USA 2. Illinois. Hand washing b. collagen and nerve fibers which surrounds and supports the vessel. The tunica intima (the inner layer): a thin layer of endothelium. Standard precautions d. Trauma to the endothelium encourages platelet adherence and thrombus formation. which facilitates blood flow and prevents adherence of blood cells to the vessel wall. Medication calculation f. Competency a.Quality assuance Coordinator Edge Water Hospital Chicago. .

The dorsum of the hand should be avoided in older people. The veins of older people are often easier to see because of the reduction in subcutaneous tissue. all of these are suitable for cannulation (Figure 2). Ageing alters the structure and appearance of the skin. The metacarpal veins and the dorsal venous arch are easily visualized and palpated. nerves. Skin is composed of two main layers: • Epidermis (skin surface): approximately 1mm thick containing sensory nerve endings. more fragile and often tortuous and thrombosed. . • Dermis (beneath the epidermis): thicker than the epidermis. hair follicles. Vein selection Digital veins of the fingers are small and rarely used. composed of collagenous and elastic connective tissue and containing fat. The dermal layers become thinner and there is less subcutaneous tissue to support the blood vessels. blood and lymph vessels.Figure 1. The radial end of the dorsal venous arch continues to form the cephalic vein while the ulnar end of the dorsal venous arch forms the basilic vein. The vessels are also more mobile. blood vessel structure. sweat glands and sebaceous glands. particularly on the dorsum of the hand.

easily stabilized and accessible (Figure 3). The basilic vein is often overlooked because it is inconspicuous. The cephalic and basilic veins continue into the forearm.Figure 2. the cephalic vein is large. However. . not easy to stabilize and can be difficult to access due to its location.

New cannulae should be sited proximal to any previous sites to prevent drug or fluid infusion through damaged veins. dermatitis. cellulitis. There is great variation in the pattern of veins in this area. arteriovenous fistulae. stroke. fractures. and the cannula prone to failure from kinking or dislodgement. palpated and accessed because of their superficial nature and size. However. The veins of the antecubital fossa are usually easily visualized. An ideal vein is ‘soft and bouncy’ when palpated. which assist blood flow back to the heart. History taking and assessment should alert nursing staff to specific patient issues that should be considered when identifying a site for cannulation. . thrombosed or hard should be avoided. Careful observation may reveal valves (small bulges) within the peripheral veins. Valves may prevent blood withdrawal and cannula advancement and. Discussion with the patient is important. Arteries are pulsatile and should be carefully avoided. The patient may prefer the non-dominant limb to be selected for cannulation to remote independence and comfort. crescent shaped folds of endothelium. planned limb surgery and previous cannulation. therefore. Both upper limbs should be inspected to identify possible veins for cannulation. which should be confirmed by palpation. Veins that are tender. The median cubital vein is absent in 20 percent of the population (Moore and Dalley 1999). Veins contain valves. Potential veins can then be palpated to assess their condition.Figure 3. wounds. skin grafts. their position over the flexor surface of the elbow makes these veins prone to mechanical phlebitis. Valves are most plentiful in the veins of the limbs and occur more frequently at junctions where veins converge. A cannula should not be placed in areas of localized edema. Palpation also allows the practitioner to differentiate between arteries and veins. should be avoided. The median cubital vein runs diagonally across the antecubital fossa connecting the basilic and the cephalic veins.

Do not re-palpate the skin. This will stabilize and anchor the vein before cannulation. 3. including device. • Release the tourniquet. . resulting in catheter embolus. • Slowly advance the cannula into the vein. nurse’s signature and number of insertion attempts. • As the cannula enters the vein blood will be seen in the flashback chamber. • Wash hands and apply non-sterile gloves (Centers for Disease Control and Prevention (CDC) 2002). electrolytes. Replacement therapy Infusions to replace current losses in fluid and electrolytes. resistance or localized swelling. vitamins. • Open the cannula carefully and ensure the stylet within the cannula is positioned with the bevel uppermost. • Hold the patient’s arm or hand and use your thumb to pull the skin taut below the intended puncture site. Lower the cannula slightly to ensure it enters the lumen of the vein and does not puncture the posterior wall of the vessel. • Hold the cannula in line with the vein at a 10-30˚ angle to the skin and insert the cannula through the skin. Maintenance therapy Provides water. This should not obstruct arterial blood flow and the radial pulse should still be palpable. gauge. glucose. The stylet must not be re-inserted as this can damage the cannula. Restoration of deficits In addition to maintenance therapy. location. • Flush the cannula to check patency and to ensure easy administration without pain. 2. fluid and electrolytes are added to replace previous losses. • Apply a tourniquet to the upper limb to improve venous filling. and in some instances protein to meet daily requirements. It may be helpful to support his or her arm on a pillow. • Withdraw the stylet slightly and blood should be seen to enter the cannula: this confirms the position in the vein. • Dispose of the stylet in the sharps’ container at the bedside.Cannulation procedure • Position the patient comfortably. • Clean the skin with a chlorhexidine-based solution and allow to dry. • Ask the patient to open and close the fist to promote venous filling. • Record the cannulation procedure in the patient’s notes. FLUID AND ELECTROLYTE THERAPY Types of therapy 1. • Secure the cannula with a moisture-permeable transparent dressing (Royal College of Nursing (RCN) 2003. The dressing should allow viewing of the entry site while firmly stabilizing the cannula to prevent mechanical phlebitis or cannula dislodgement. ensuring the vein remains anchored throughout the procedure.

Indications: • Dehydration • Hypernatremia • Drug administration Possible side effects: • Hypokalemia • Osmotic diuresis – dehydration • Transient hyperinsulinism • Water intoxication. Five percent dextrose in normal saline (D5NS). • Treatment of matebolic alkalosis. sparring body protein and preventing ketosis resulting from fat breakdown. Isotonic multiple-electrolyte fluids. Provides calories for energy.Normal Saline Indications: • Extracellular fluid replacement when Cl. Fluids that approximate the osmolarity (280-300 mOsm/L) of normal blood plasma. Plasmanate b. • Burns • Acute adrenocortical insufiency. ionic composition approximates blood plasma. • Sodium Chloride (0. Used for replacement therapy. Isotonic solutions a. Types: a.loss is equal to or greater the Na loss. Indications: • Hypovolemic shock – temporary measure. Possible side effects: • Hypernatremia • Acidosis • Hypokalemia • Circulatory overload d. Possible side effects: • Hypernatremia • Acidosis • Hypokalemia • Circulatory overload.9%) . Five percent dextrose in water (D5W). Polysol c. c. • Na depletion • Initiating and terminating blood transfusions. Lactated Ringers . Prevents ketone formation and loss of potassium and intracellular water.Types of intravenous fluids 1. b.

3% and 5% Indications: • Slow administration essential to prevent overload (100 mL/hr) • Water intoxication • Severe sodium depletion 3.Indications: • Vomiting • Diarrhea • Excessive diuresis • Burns Possible side effects: • Circulatory overload.2 % NaCl Common rehydrating solution. Indications: • Nutrition • Replenish Na and Cl. Ten percent dextrose in normal saline Administered in large vein to dilute and prevent venous trauma. • Hypernatremia • Acidosis • Hypokalemia 2. Sodium Chloride solutions. these fluids lower plasma osmotic pressure.45% saline. b. • Lactated Ringers is contraindicated in severe metabolic acidosis and/or alkalosis and liver disease. Indications: • Fluid replacement when some Na replacement is also necessary. a. causing fluid to enter cells.45% sodium chloride Used for replacement when requirement for Na use is questionable. • Evaluate kidney status before instituting electrolyte infusions. Hypotonic solutions Fluids whose osmolarity is significantly less than that of blood plasma (-50 mOsm). a.5% dextrose in 0. b. Possible side effects: • Hypernatremia • Circulatory overload . thereby drawing fluid from cells. • Encourage diuresis in clients who are dehydrated. also 5% in 0. Possible side effects: • Hypernatremia (excess Na) • Acidosis (excess Cl) • Circulatory overload. increase osmotic pressure of blood plasma. Hypertonic solutions Fluids with an osmolarity much higher than 310 mOsm (+ 50 mOsm). 2. 0.

replace None known sodium and chloride. blood transfusions (will not hemolyze blood cells) Type of Solution Hypotonic pH 5.45% Sodium Chloride Shorthand Notation: ½NS 0. renal impairment. alkalosis. continuous infusions 10 grams dextrose (340 calories/liter) may be infused peripherally.3 isotonic hydration. provides some calories water intoxication and dilution of body’s electrolytes with long.• Used with caution in clients who are edematous. Table of Commonly Used IV Solutions Name of Solution 0.0 Shorthand Notation: D5W 10% Dextrose in Water Shorthand Notation: D10W Hypertonic pH 4. appropriate electrolytes should be given to avoid hypokalemia. during transfusions.9% Sodium Chloride Shorthand Notation: NS 3% Sodium Chloride 5% Sodium Chloride Hypertonic pH 5. the cells will pull water hyperosmolar diabetes into them and rupture 5% Dextrose in Isotonic Water pH 5.0 Hypertonic pH 5.7 154 mEq Sodium 154 mEq Chloride isotonic hydration. hyperchloremia and excessive water intake Isotonic pH 5.6 Ingredients in 1-Liter 77 mEq Sodium 77 mEq Chloride Uses Complications hypotonic hydration. provides some calories . hypernatremia or vomiting. hypertonic hydration. replace If too much is mixed with blood cells sodium and chloride.8 513 mEq Sodium 513 mEq Chloride 855 mEq Sodium 855 mEq Chloride 5 grams dextrose (170 calories/liter) symptomatic hyponatremia rapid or continuous infusion can result in due toexcessive sweating.

hydration.S. do not use if lactic acidosis is present . causes agglomeration (clustering) if used with blood transfusions. replace sodium.4 Chloride Shorthand Notation: D5½NS 5% Dextrose in Hypertonic Normal Saline pH 4.45 Sodium pH 4.25%) Saline pH 4. Isotonic pH 5. chloride. hyperglycemia with rapid infusion leading to osmotic diuresis hypertonic fluid replacement.4 Shorthand Notation: D5¼N 5% Dextrose in Hypertonic 0. U.5% Dextrose in Hypertonic 1/4 Strength (or 0. replace sodium. often used to replace extracellular fluid losses rapid administration leads to excessive introduction of electrolytes and leads to fluid overload and congestive conditions. mild to moderate acidosis (the lactate is metabolized into not enough electrolytes for maintenance.8 5 grams Dextrose 34 mEq Sodium 34 mEq Chloride fluid replacement.4 Shorthand Notation: D5NS Ringer’s Injection. chloride and some calories vein irritation because of acidic pH. provides no calories and is not an adequate maintenance solution if abnormal fluid losses are present Lactated Ringer’s Shorthand Notation: LR Isotonic pH 6.6 130 mEq Sodium 4 mEq Potassium 3 mEq Calcium 109 mEq Chloride 28 mEq Sodium Lactate (provides 9 calories/liter) isotonic hydration. replacement of sodium. replace electrolytes and extracellular fluid losses. bicarbonate which patients with hepatic disease have trouble counteracts the acidosis) metabolizing the lactate. and some calories 5 grams Dextrose 77 mEq Sodium 77 mEq Chloride 5 grams Dextrose 154 mEq Sodium 154 mEq Chloride hypertonic fluid replacement.P. chloride and some calories 147 mEq Sodium 4 mEq Potassium 4 mEq Calcium 155 mEq Chloride electrolyte replacement.

The Bevel The bevel up method usually causes fewer traumas to the vein and is less painful for the patient. provides some calories. replace electrolytes and extracellular fluid losses. and bevel position either up or down. Indirect method The first movement. manipulating the needle slight within the vein may relieve the blockage. this position is likely to perforate the opposite wall of the vein on insertion causing a hematoma.5% Dextrose in Hypertonic Lactated pH 4. Use of over the needle cannula requires a different threading technique than a wing tip or scalp vein needle. It is a good idea when entering a small vein with a large bore needle to use the bevel down position. If the needle and vein are approximately the same diameter. sometimes the bevel down position is better. Remember. . penetrate the skin at a 54 degree angle to side of the vein about ½” below the point of the venipuncture. direct. then decrease the needle angle until the is almost parallel to the skin surface. mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis). direct. Remove the needle promptly and reinsert. a needle that is properly placed in the vein can be palpated. the dextrose minimizes glycogen depletion VENIPUNCTURE TECHNIQUE Methods of vein entry There are different methods of vein entry for needles or over needle catheters. This problem is less likely to occur in the bevel down position. probably it has gone through the vein. indirect. In that case.9 Ringer’s Injection Shorthand Notation: D5LR 5 grams Dextrose (170 calories/liter) 130 mEq Sodium 4 mEq Potassium 3 mEq Calcium 109 mEq Chloride 28 mEq Sodium Lactate (provides 9 calories/liter) hypertonic hydration. Entering a vein successfully doesn’t guarantee that the vein won’t collapse and block the bevel when removing the tourniquet. however. With the wing tip usually use the bevel down position. If not. A greater risk of perforating the opposite wall of the vein when the needle’s bevel is facing up.

Gently feel for the tip of the cannula in relation to the vein to give some idea if it is below. Do not spend too much time probing. This method is suitable for securing the wingtip needle. over the needle. U method Using a strip of tape ¼” to ½” wide place with a sticky side up under the hub folding each tape tail over each corresponding wing in the U formation.The second movement . not just the needle. Methods of stabilizing the venipuncture site Chevron method Using a strip of tape ¼” to ½” wide apply sticky side up in a “V” formation. Apply a piece of 1” tape across the two wings of the chevron. Watch for the backflow to confirm proper placement of the needle/catheter. Before insertion. The vein is penetrated in one movement by approaching the vessel from the top or side. H method Place one strip of 1” tape over each wing. Since the needle protrudes further than the catheter. but it is less painful for the patient when done correctly. The loop the tubing and secure it with another piece of 1” tape. This will cause fewer trauma and less pain. penetrate the vessel wall and advance the needle cautiously while lifting the vein with slight upward pressure. This method of venipuncture requires considerable more skill then the indirect method. When trying to penetrate the skin. Use this method with wingtip needle. Never reinsert the needle into the catheter which may cause shearing off of the tip of the catheter leading to catheter embolus. need to be sure that the catheter itself is in the vein. Direct method In the direct method the needle is at 30 degree angle over the vein and is inserted in the direction of the blood flow. to the right. or left of the vein. Then place another piece of 1” tape horizontally over the first two forming the letter H. If cannot stabilize the vein or if it disappears. If using the catheter. Pull down on them slight and hold tension for easier penetration. be sure to hold the skin taught. This method can be used with both plastic cannula/ catheter and wingtip needle. advance the catheter while removing the needle. . Some veins have a tendency to roll or move away. measure the cannula against the vein to be sure the cannula will clear joints and nodules to ease threading. remove the cannula and attempt venipuncture in another vein.

Extravasation c. LOCAL COMPLICATIONS a. Hematoma f. SYSTEMIC COMPLICATIONS a. Thrombosis d. Speedshock h. Pulmonary embolism c. pain at site Feeling of tightness at site . Cause Device dislodged from vein or perforated vein Signs & Symptoms • • • Increasing edema at the site of the infusion Discomfort.INTRAVENOUS THERAPY COMPLICATIONS 1. burning. Embolism b. Circulatory overload i. Allergic reaction INFILTRATION Results when the infusion cannula becomes dislodged from the vein and fluids are infused into the surrounding tissues. Infiltration b. Catheter embolism e. Air embolism d. Phlebitis 2. Thrombophlebitis e. Systemic infection g.

• • • • Decreased skin temperature around site Blanching at site Absent backflow of blood Slower flow rate Nursing intervention Remove the device Apply warm soaks to aid absorption Elevate the limb Notify the doctor if severe Assess circulation Restart the infusion Document the patient's condition and your interventions Prevention Check the I. swelling EXTRAVASATION It occurs when fluids seep out from the lumen of a vessel into the surrounding tissue. Causes Damage to the posterior wall of the vein Occlusion of the vein proximal to the injection site Signs & Symptoms Swelling Discomfort Burning Tightness Coolness in the adjacent skin Slow flow rate Nursing Interventions .V site frequently Don't obscure area above site with tape Teach the patient to report discomfort. pain.

Catheterrelated thrombosis arises as a result of injury to the endothelial cells of the venous wall. Cause .Immediately stop the infusion and remove the device Elevate the affected limb Apply cold compress to decrease edema and pain Apply moist heat to facilitate the absorption of fluid at grossly infiltrated sites DRUGS ASSOCIATED WITH EXTRAVASATION NECROSIS Generic Name • • • • • • • • • • • • • • • • • Brand Name Various Various DTIC Cosmogen Cerubidine Various Adriamycin Idamycin Mustargen Mutamycin Mithracin Zanosar Vumon Various Velban Oncovin Navelbine Calcium chloride Calcium gluconate Dacarbazine Dactinomycin Daunorubicin Dopamine Doxorubicin Idarubicin Mechlorethamine Mitomycin C Plicamycin Streptozocin Teniposide Vancomycin Vinblastine Vincristine Vinorelbine THROMBOSIS Occurs when blood flow through a vein is obstructed by a local thrombus.

2.Injury to endothelial cells of vein wall. Signs & Symptoms Local tenderness Swelling Induration A red line detectable above the IV site.V flow Nursing Interventions Remove the device. Use veins in the upper extremities Avoid placing catheters over joint flexions Select veins with adequate blood volume for solution characteristics Anchor cannulas securely Avoid multiple venipunctures PHLEBITIS inflammation of a vein that may be caused by infection.V therapy – related infection Prevention Use proper venipuncture techniques to reduce injury to the vein THROMBOPHLEBITIS Occurs when thrombosis is accompanied by inflammation. 3. 5. the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. restart the infusion in the opposite limb if possible Apply warm soaks Watch for I. . 4. reddened. Recommendations to Reduce the Risk of Thrombotic Complications 1. indicating progression to an obstructive thrombophlebitis. All thrombotic complications have the associated danger of embolism. Infusions allowed to continue after thrombophlebitis develops will slow and eventually stop. especially in cases where the thrombus is not well attached to the wall of the vein. & swollen vein Sluggish or stopped I. allowing platelets to adhere and thrombus form Signs & Symptoms Painful.

streak present. removal the needle Avoid multiple insertion Application of warm compress Continuously monitor the patient. streak present.Causes: Injury during Venipuncture Prolonged use of the same IV site irritating. hard. erythema and/or edema. purulentdrainage Common Medication that can cause Phlebitis Phenytoin Diazepam Erythromycin Tetracycline Vancomycin Amphothericin B 40 mEq/L or more doses of KCL Nursing Interventions Upon assessment of phlebitis. palpable cord > 1 inch. erythema and/or edema. cord like and warm to touch Red line above the site Signs of infection Phlebitis Rating 0 = No symptoms 1 = Erythema at site with or without pain 2 = pain at site. erythema and/or edema. no streak.vital signs ./incompatible IV additives Use of vein that is too small for the flow rate Use of needle size too large for the vein size Signs & Symptoms Pain Vein that is sore. no palpable cord 3 = pain at site. palpable cord 4 = pain at site.

or when IV lines associated with the catheter are disconnected. Circulatory and cardiac abnormalities are caused by full or partial obstruction of the pulmonary artery. with possible progression to pulmonary hypertension and right-sided heart failure. and rapid loss of consciousness.PULMONARY EMBOLISM It associated with venous access devices is usually the result of a thrombus that has become detached from the wall of the vein. cardiac catheterization may be required to remove the embolus. AIR EMBOLISM Occurs most frequently with the use of central venous access devices. during manipulation of the catheter or catheter site when the device is removed. Administer oxygen Notify the doctor Document the patient's condition and your interventions. Occur with the insertion of an IV catheter. If this happens. It is carried by the venous circulation to the right side of the heart and then into the pulmonary artery. The catheter tip then becomes a free-floating embolus. The tip of the needle used during the placement of the catheter can shear off the tip of the catheter. CATHETER EMBOLISM This can occur during the insertion of a catheter if appropriate placement techniques are not strictly adhered to. Respiratory distress Unequal breath sounds Weak pulse Causes Empty solution container Solution container empties. This can occur with both over-the-needle and through-the-needle catheters. hypotension. . increased venous pressures. next container pushes air down line Tubing disconnected from venous access device or I.V bag Nursing Interventions Discontinue the infusion Place the patient in Trendelenburg position on his left side to allow air to enter the right atrium and disperse through the pulmonary artery. Signs & Symptoms Sudden vascular collapse with the hallmark symptoms of cyanosis.

the infection is called septicemia and can be rapid and life-threatening. chills. Klebsiella.HEMATOMA Blod accumulation resulting from the infiltration of blood into the tissues at the venipuncture site Causes:: Coagulation defects Inappropriate use of tourniquet Unsuccessful insertion attempts Little pressure upon removal of cannula Discoloration of the tissue at the IV site Nursing Interventions Frequent assessment of the site Upon insertion.V site. slowly advance the needle to prevent puncturing both vein walls Discontinue therapy if with edema Apply pressure for at least 5 minutes upon removal SYSTEMIC INFECTION If bacteria do not remain in one area but spread through the bloodstream. as it can deliver bacteria directly into the central circulation. Caused by: Staphylococcuaureus. Pseudomonas Aeruginosa Signs & symptoms Fever. & malaise for no apparent reason Contaminated I. Serratia. An infected central IV poses a higher risk of septicemia. which can set up ideal conditions for organisms growth Poor taping Prolonged indwelling time of device Immunocompromised patient . usually with no visible signs of infection at site Causes Failure to maintain aseptic technique during insertion or site care Severe phlebitis.

Administer medications as prescribed Culture the site and the device Monitor the patient's vital signs Prevention Use scrupulous aseptic technique Secure all connections Change I. Signs & Symptoms • • • • Flushed face Headache Tight feeling in the chest Irregular pulse In extreme cases: • Loss of consciousness . Use maximal sterile-barrier precautions during insertion (sterile technique) Practice good hand hygiene before and after palpating.Nursing Interventions Notify the doctor. If any part of the system is disconnected. tubings and bags per policy example: change set= 72 hours. replacing.V solutions. TPN and single use of antibiotics=24 hrs SPEEDSHOCK Rapid introduction of a foreign substance. tubing and venous access device at recommended times Use I. into the circulation. inserting. don’t rejoin it Remove at first sign of infection Replace site. or dressing any intravascular device.V filters Management and Prevention Tips • • • • • • • • Assess catheter site daily Accurately document visual inspection and palpation data. usually a medication. Refer to physician for any suspected infection.

Nursing Interventions • • rate. Maintain prescribed Know the actions and side effects of the drug being administered Nursing Interventions Use of IV pumps when indicated Begin infusion of 5% dextrose at a KVO rate in emergency cases Evaluate circulatory and neurologic status Notify the physician CIRCULATORY OVERLOAD An excess of fluid disrupting homeostasis caused by infusion at a rate greater than the patient’s system is able to accommodate Signs & Symptoms • • • • • • • Causes Roller clamp loosened to allow run – on infusion Flow rate too rapid Miscalculation of fluid requirements Nursing Interventions Raise the head of the bed Slow the infusion rate Administer oxygen as needed Shortness of breath Elevated blood pressure Bounding pulse Jugular vein distention Increased Respiratory rate Edema Crackles or rhonchi upon auscultation . • STOP the infusion Careful monitoring of IV flow rate and patient response.

anti – inflammatory. Repeat at 3-minute intervals and as needed. solution or intravenous device Signs & Symptoms SYSTEMIC • • • • • Runny nose Tearing Bronchospasm Wheezing Generalized rash LOCAL • • • Wheal Redness Itching at the site Nursing Interventions • If reaction occurs.2 to 0. stop the infusion immediately and infuse normal saline solution. • • Maintain a patent airway. cleansing agent. as ordered FLUID OVERLOAD . Notify the doctor.Notify the doctor Administer medications as ordered ALLERGIC REACTION Maybe a Local or generalized response to tape. as ordered. • Administer antihistaminic steroid. & antipyretic drugs.5ml of aqueous epinephrine subcutaneously. medication. • Give 0.

heart failure. and pulmonary edema. Possible consequences include hypertension. INFECTION CONTROL Infection at the venipuncture site is usually causd by a break in aseptic technique during the procedure. The following measures reduce patient’s risk: • • • Wash hands before starting an IV or before handling any of the IV equipment. . Use a approved antiseptic ( as per hospital’s protocol) to clean the patient’s skin. Cut/ clip the hairs of the venipuncture site if necessary.This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Do not share.

A mechanism for recording and retrieving information. type. and length of cannula/needle Name of person who inserted the IV catheter Date and time of insertion b. A record for health insurers and retrieving information documenting the insertion of a venipuncture devise or the beginning of therapy a. patient’s response and nursing interventions Patient teaching and evidence of patient understanding (for example ability to explain instruction or perform a return demonstration). Label the IV solution specifying: • • • • Type of IV fluid Medication additives and flow rate Use of any electronic infusion devise Duration of therapy and nurse’s signature c. Setting up B. Inserting IV utilizing the dummy arm C. In additional documentation following information is documented in the patient’s chart: • • • • • Location of and condition of insertion site Complications. Changing an IV solution . Signature of nurse Other observations IV THERAPY PROCEDURE A. The following information of acre that can serve as legal protection: • • • Size.Documentation of IV therapy Proper documentation provides: • • • An accurate description of care that can serve as legal protection.

12. Setting up 1. Inserting IV utilizing the dummy arm 1. . splint. 5. tourniquet. alcohol swabs or cotton balls soaked in alcohol with cover (this should be exclusively used for IV). forceps soaked in antiseptic solution.. bottle sequence and duration. 6. size/ condition. Observe ten (10) Rs when preparing and administering IVF. Prepare necessary materials for procedure (IV tray with IV solution. Choose site for IV 5. Verify written prescription and make IV label 2. glove. Check for radial pulse below tourniquet. Explain procedure to reassure patient and/or significant others. Explain procedure to assure the patient and significant others and observed the 10 R’s. 10. IV set and other devices. IV cannula. administration set. B. solution. Apply tourniquet 5 to 122 cm (2-6 inches) above injection site depending on condition of patient. Verify the written prescription for IV therapy. 4. drug incorporation.D. Do hand hygiene before and after the procedure. 7. sterile 2x2 gauze or transparent dressing. Assess patient’s vein. Fill drip chamber to at least half and prime it with IV fluid aseptically. Check the sterility and integrity of the IV solution. 11. plaster. 8. Place IV label on IVF bottle duly signed by RN who prepared it (patient’s name. Do hand hygiene before and after the procedure.Open IV administration set aseptically and close the roller clamp and spike the infusate container aseptically. 2. Discontinuing an IV infusion Steps A. choose appropriate site location. 6. room no. secure consent if necessary. 4. 3. ad IV hook. Open the seal of the IV infusion aseptically and disinfect rubber port with cotton ball with alcohol. 9. time and date).Expel air bubbles if any and put back the cover to the distal end of the IV set (get ready for IV insertion). check prepared IVF and other things needed. 3.

infusate sequence. 12. Tape ( using any appropriate anchoring style) c. advance the catheter and stylet (1/4 inch) into the vein. apply splint ( if needed) 16. 9. Changing an IV solution 1. 21. countercheck IV label. . Band-aid 15. type and gauze of IV catheter and countersign. 8. 10. Document in the patient’s chart and endorse to incoming shift. Verify doctor’s prescription in doctor’s order sheet. and duration of infusion. 2. Transparent tape/ dressing directly on the puncture site. check if tip of catheter can be rotated freely inside the vein. Observe patient and report any untoward effect. reassure patient. 14. C. Anchor needle firmly in place with the use of: a. ( no touch technique) Note: CDC Universal precaution: always wear gloves when doing any venipuncture..Position the IV catheter parallel to the skin. Open the clamp. Label on IV tape near the IV site to indicate date of insertion. Label with plaster on the IV tubing to indicate the date when to change the IV tubing. amount. Tape a small loop of IV tubing for additional anchoring . 18. regulate the flow rate.. remove the stylet while applying digital pressure over the catheter with one finger about 1-2 inches from the tip of the inserted catheter. 17. 13. 11. Observe ten (10) Rs. 19. additives (if any). 20.Discard sharps and waste according to Health Care Waste Management (DOH/ DENR). pierce skin with needle positioned on a 15-30 degree angle. Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry. b. Upon flashback visualization decrease the angle.Slip sterile gauze under the hub. Using the appropriate IV cannula. Release the tourniquet.Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration. Connect the infusion tubing of the prepared IVF aseptically to the IV catheter. Hold stylet stationary and slowly advance the catheter until the hub is 1 mm to the puncture site.7. type. IV card.

Verify written doctor’s order to discontinue IV including IV medicines. Regulate the flow based on the prescribed infusion rate of infusion. 6. 9. 7. 5. Observe ten (10) Rs. Prepare the necessary materials. Open and disinfect rubber port of IV solution to follow. D. 3. 15. Reiterate assurance to patient and significant others. Close the roller clamp of the IV administration set. Explain procedure to reassure the patient and significant other and assess IV site for redness. 4. remove plaster gently. Wash hands before and after the procedure. Calibrate new IV bottle according to duration of infusion as per prescription. Moisten adhesive tapes around the IV catheter with cotton ball with alcohol. 9. Wash hands before and after procedure. 2. 13. Assess and inform the patient of the discontinuation of IV infusion and of any medicine. pick-up forceps in antiseptic solution. 4. Discard all waste materials according to health care waste management. Document and endorse accordingly. swelling. Place IV label on the IV bottle. 10. pain and etc. IV tray or injection tray with sterile cotton balls with alcohol. 8. 8. plaster. Close the roller clamp and spike the container aseptically. Expel air bubbles (if any). 11. 12. Change IV tubing and cannula if 48-72 hrs. Discontinuing an IV infusion 1. Check sterility and integrity of IV solution. Has lapsed after IV infusion. remove needle or IV catheter then immediately apply pressure over the venipuncture site. Prepare necessary materials. . Inspect IV catheter for completeness. 6. kidney basin band aid. 5. Use pick-up forceps to get cotton balls with alcohol and without applying pressure. 14. 7. place on IV tray.3.

.Discard all waste materials including the IV cannula according to health care waste management (DOH/DENR).10. status of insertion site integrity of IV catheter and endorse accordingly. Document time of discontinuance. Reassure patient. 13. Place dressing over the venipuncture site. 12. 11.

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