31 August 2011 perform venipuncture, insert stylet and cannula,

IV Therapy except TPN and cut down (extremity edema, pitting =

Nancel Dumlao
INTRAVENOUS THERAPY
INTRODUCTION
Intravenous Therapy insertion of a needle/catheter/
cannula into a vein, based on the physicians written
prescription
those who are allowed to give: trained registered nurses
lead by ANSAP (Association of Nursing Service
Administration of the Philippines)
PHILOSOPHY:
to maintain fluid volume and electrolyte homeostasis
GOALS:
replace/maintain body stores of water, protein,
vitamins, electrolytes
restore acid-base balance
restore blood volume components
avenue for drug administration
monitor central venous pressure
provide nutrition while resting the GI tract
LEGAL ASPECTS:
protocols governing special training
administration of IVT for RNs
1991 RA 7164(old)/9173(new) Sec 27 (a)
defines scope of nursing practice
nursing care includes but not limited to
traditional innovative approaches in
nursing IM/IVT injections
IV injection shall include administration of
drugs, fluid and electrolytes, blood and
blood products. It shall include insertion of
needles/butterfly in IV infusions.
guidelines to be formulated by:
BON
PNA
ANSAP
PRC BON Resolution No. 08
IVT Training to be prescribed by ANSAP
Civil Code of the Philippines (Article 3)
Acts and omission punished by law are
felonies. These are committed by means of
deceit (DOCO) and fault (CULPA)
deceit performed with deliberate
intent
fault wrongful acts resulting from
negligence lack of foresight/ lack of skill
requisites of felony are:
act of omission
punishable by law
REQUIRED COMPETENCIES:
hand washing
VS assessment
standard precautions
principles of aseptic technique
medication calculations
medication administration
ROLES AND RESPONSIBILITIES OF A NURSE IN
ADMINISTRATION OF IVT:
validate doctors order for IVT
cut portion of vein then insert IV)
prepare, monitor, terminate IVF solution
incorporation of IV meds (collaborative)
administer blood products as ordered by physician
recognize solution and med incompatibilities (ex.
Phenytoin do not administer to dextrose with sugar
because it will crystallize)
maintain and replace sites, tubings, and dressings in
accordance with established procedures
regulate flow rates of solution, medicines, blood and
blood components
utilize knowledge and proficient techniques in the
use/care/maintenance and evaluation of IV
equipment
nursing management of TPN (most common:
NUTRIPACK contains lipids, CHO, and milk solution
protein) discuss basic concepts out-patient, home
IV care
implement infection control protocols related to IVT
accurate and complete documentation (cardex,
chart, IV sheet)
PRINCIPLES OF PHYSIOLOGICAL ASSIMILATION OF
on INFUSION SOLUTIONS
Tissue cells (erythrocytes, neurons, etc.) are
surrounded by a semi-permeable membrane =
cytoplasm, cell wall, cell membrane
Osmotic pressure: water moves through semi-
permeable membrane from weaker to storage
concentration of solute; the end result is equilibrium
Extracellular components fluids primarily include
plasma and interstitial fluid
if there is an in hydrostatic pressure = edema
(hypertonic)
principle: hydrostatic pressure should be =
oncotic pressure
TYPES OF IVF FLUIDS
ISOTONIC SOLUTIONS:
PNSS (0.9%)
replenish bodily fluid losses
treat shock: NS + blood (hypovolemic)
diluent for IV meds
for hemorrhage
Lactated Ringers (aka Plasma expander)
replace electrolyte losses
replenish isotonic bodily fluid losses
correct metabolic acidosis
Blood Component
Albumin 5%
Plasma
all blood components are hyperkalemic in
nature
D5W (an isotonic solution like NS)
replenish water and isotonic bodily fluid losses
provide calories (d/t exercise)
diluents for IV meds
HYPOTONIC SOLUTIONS: (to expand shrink cells)
Normal Saline/Sodium Chloride
0.45% or 1 1/2
0.33% (Pedia)

1
//carengreyes
 exert less osmotic pressure than that of blood For patient who cannot take drugs orally (coma)
plasma or IM (coagulation disorders)
causes dilution of plasma solute concentration cost effective
forces water movement into cells Precautions/Recommendations:
HYPERTONIC SOLUTIONS: Before administration
PNSS (0.3%/0.5%) MDs drug order
D5 0.9% PNSS dilute drug
D5 0.45% NaCl determine the correct (safest)
D5LR administration
D10W check drug-drug compatibility
D50W assess IV line
Hyperalimentation solutions (TPN) assess patient condition and ability to
Albumin tolerate drugs
Vamin assess patency of IV line by the presence of
hyperglycemic blood return
exerts high osmotic pressure than of blood lower running IV bottle
plasma withdraw with syringe before injecting
increase the solute concentration of plasma meds
(form cell to vascular space) pinch IV tubing gently
cells will then shrink watch patient reaction to drug
be careful: may result to pulmonary edema watch for major and minor adverse effects
(especially cardiac/renal cases) vesicants are given through the side part of a
running IV infusion
know hospital policies on how, when, by whom
TOTAL PARENTERAL NUTRITION (TPN) IV push meds
method for providing nutrition IV thus bypassing the GI **The nurse is ultimately accountable for the drug
tract; going directly to venous compartments that she administers. Always confirm unfamiliar
usually use larger veins (central vein, superior vena cava) drugs or unusual doses
INDICATIONS: 10 Rights of Administration:
GI disorders Drug
malabsorption of the bowel Patient
CA/chemotherapy/radiotherapy Dose
anorexia nervosa Route
burns/draining wounds Time
rest the GIT (fistula, inflammatory bowel disease) Documentation
COMPLICATIONS: Patient education
mechanical (CV catheter insertion) Drug history
air embolism Drug allergies
thrombosis Drug drug/Drug - interaction
pneumothorax CONTINUOUS OF INTERMITTENT INFUSION USING
infection: glucose supports bacterial growth (re- INFUSION CONTROL DEVICES:
insert IV every 15 mins) given through traditionally bags of solution and
hyperglycemia fast administration tubing with or without flow rates regulators
hypoglycemia slow administration IV, intra-arterial, intra-thecal spiral infusion may be
fluid overload accomplished through the external pump
nausea, headache, lethargy General Considerations:
Advantages
TYPES OF IV ADMINISTRATION can infuse large/small volumes of fluid with
IV PUSH (BOLUS): accuracy
administration of a med from a syringe directly into has alarm warning
an ongoing IV infusion less nursing time in readjusting flow
may also be given into a vein by way of an Disadvantages
intermittent access device (saline/heplock) needs special tubing (added cost)
saline administer meds saline heparin infusion pumps will continue in infuse
10% solution (SASH) despite the presence of infiltration
Indications: Nursing Responsibilities:
emergency: rapid remember that machines is only as effective as
quicker response to medication is required the operator
(Furosemide/Digoxin) monitor regularly for complications
limit IM injections follow the manufacturers instruction on tubing
avoid drug incompatibility problems insertion
double check the flow rate
flush all air out of the tubing before insertion
2
//carengreyes
 explain purposes extravasation, poor healing, resulting in impaired
Types: joint movement
Electronic flow rate regulators Methods of distending a vein
Indication manual compression
chemotherapy clench fist
infant and pedia therapies massage
hyperalimentation (protein products) tourniquet
using hypertonic solutions ex. Albumin, BP cuff
Vamin tap the vein site
F&E on patient at risk for the overload dependent arm position
most meds heat to needle site
Battery powered ambulatory infusion pumps Selecting stylet/catheter
Freon-controlled spring pump (implanted) use the smallest gauge cather suitable for the type
Computer-programmable pump (implanted) and location of the infusion
INTERMITTENT INFUSIONS: gauge 16 gray
Intermittent access device (saline lock) gauge 17 white
periodic IV meds gauge 18 green
use Heparin, Saline flush (2ml) gauge 20 pink
Piggyback IV gauge 22 blue
administered med by way of the fluid pathway gauge 24 yellow
of an established primary infusion line parts:
Drug may be given on an intermittent basis flashback chamber
through a primary infusion luer lock plug
Central Venous Access Device (CVAD) luer connector
Peripherally inserted central catheter (PICC) needle grip
inserted into one of the peripheral veins in the injection port ca
upper arm and ends in a large vein of the heart catheter hub and
wings
catheter
NURSING ROLE IN IVT valve
Selecting a vein bushing
check doctors order (except in emergency) IV Flow Rate
explain
select a vein suitable for venipuncture:
back of hand: metacarpal vein
avoid digital veins if possible
Tubing change
this site permits arm movement
check your institutional protocol for the time of
cant use vein higher than the arm if
tubing change
problem occurs in this site
standard is 48-72 hours (every 3 days)
forearm: basilica/cephalic vein
label
inner aspect of elbow, antecubital fossa
Gerontological Alert!
median basilica
veins are prone to collapse
median cephalic
more danger in fluid overload
ankle: great saphenous vein
Pedia Alert!
foot:
neonates and infants do not have as many accessible
venous plexus of dorsum
veins as adults do
dorsal venous arch
veins used are: hands, feet, antecubital, scalp
medical marginal vein
also prone to fluid overload
central veins: jugular, femoral are used
when meds and infusions are:
hypertonic/highly irritating VERNIPUNCTURE USING NEEDLE/CATHETER
requiring rapid EQUIPMENTS:
high volume dilution admin set
when peripheral blood flow: IV fluid
Diminished (shock) IV pole/stand
peripheral vessels are not accessible extension tubing
(obese patients) IV insertion kit
when CVP monitoring is desired tourniquet
when moderate/long-term fluid therapy is tape: 1 inch wide
suspected aseptic swab
**nursing alert! do not use medial/basilic/cephalic arm board
veins for chemotherapy; it will lead to dressing, transparent
clean gloves

3
//carengreyes
 protective equipments (googles, mask large bore needle or catheter use
optional) prolonged needle or catheter use
ASSESSMENT: clot formation
review accuracy and completeness of doctors order Clinical Manifestations
assess for clinical factors that could be affected by tenderness/pain along the vein
the IVF administration swelling, warmth, and redness at the infusion
peripheral edema site
body weight Preventive measures
dry skin and mucous membranes anchor securely
distended neck veins change the insertion
irregular pulse use large veins for irritating fluids
BP changes dilute irritating fluid
auscultation of crackles/ronchi Nursing intervention
poor skin turgor cold compress first 24 hours and warm compress
decrease urine output to succeeding hours
behavioral changes (restlessness, confusion) BACTEREMIA
check arm placement preference Causes
assist risk factors phlebitis
child/elderly contaminated equipment/solutions
cardiac/renal ailment prolonged placement of an IV
skin lesion non sterile IV
infections cross contamination
use of anticoagulants decrease platelets immunosuppressed patient
assess patient understanding/purpose of IVT Preventive Measures
SETTING UP: use strict aseptic technique
wash hands/prepare equipments maintain integrity of solution
check sterility and integrity of the IV solution, IV set Nursing intervention
and other devices stop and remove
place IV label on IVF bottle; signed by RN VS, WBC (as ordered)
patient name culture and sensitivity test of bacteria
room number CIRCULATORY OVERLOAD
solution Cause
drug incorporated delivery of excessive amounts of IV fluid
bottle sequence High Risk
duration, time and date elderly, infants, patient with
explain procedure heart/renal insufficiency
open the seal of the IV infusion aseptically and Clinical Manifestation
disinfect the rubber part BP, PR, CVP
open IV administration engorged jugular veins
fill drip chamber HA
anxiety
COMPLICATIONS OF IVT shortness of breath
coughing
INFILTRATION
tachypnea
Cause
pulmonary crackles
IV cannula is out of vein resulting to infusion of
chest pain (if history of CAD)
fluid into the surrounding tissue
Clinical Manifestation Preventive Measures
monitor I and O, IV flow rate
swelling, blanching, and coolness of surrounding
closely monitor high risk px
skin and tissue
fluid flowing more slowly or ceasing
Nursing Interventions
KVO (10 15gtts/min)
absence of blood backflow in IV catheter and
raise the patients bed for pulmonary
tubing
Nursing Interventions congestion
document
STOP and REMOVE the IV needle/catheter
closely monitor for worsening congestion
restart IV in the other arm
apply warm compress to promote venous return
AIR EMBOLISM
elevate
Causes
air enters catheter and travels to the heart
document
air in tubing by IV push or infused by infusion
THROMBOPHLEBITIS
Causes pump
injury to vein during:
Clinical Manifestation
drop in BP, PR
venipuncture

4
//carengreyes
 cyanosis, tachypnea insert needle and syringe into rubber port distal to
rise in CVP air and aspirate to remove air
changes in mental status, loss of consciousness BACKFLOW OF BLOOD
Preventive Measures fluid above the level of catheter site and the level of
clear all air fluid before infusion to px the heart
change solution container before they run dry check security of tubing connection
secure all connections check that infusing fluid has not run out and that
change IV tubing during expiration catheter is in a vein, not an artery (note pulsation of
Nursing Interventions blood in tubing)
put on left side and lower head of bed IV IS POSITIONAL (runs well only when arm/hand is in a
notify physician certain position)
oxygen stabilize IV site
reassure the patient FLUID LEAKING AROUND PUNCTURE SITE
document discontinue IV and restart in another site
HEMORRHAGE place warm soak over infected site
Cause reassess frequently
loose connection of tubing
inadvertent removal of peripheral or central
catheter
DOCUMENTATION
anticoagulant therapy Provides:
Clinical Manifestation accurate description of care
oozing/tickling of blood from IV site/catheter serve as legal protection
hematoma mechanism to record data
Preventive Measures health insurance
cap all central lines with luer-lock Data recorded:
tape all catheter securely; transparent dressing size, type, length of cannula/needle
put pressure site for 2-5 minutes upon removal name of person who inserted cannula
of cannula (ex. anticoagulant therapy) date/time of insertion
VENOUS THROMBOSIS IVF type, meds, flow rate, duration
vein becomes partially or fully occluded by a location, condition of insertion site
thrombus complications
Cause health teaching
infusion of irritating solutions signature
infection on site
clot formation in vein
Clinical Manifestation
slowing of IV infusion/inability to flow
blood from the central line
swelling and pain on IV site
Preventive Measures
dilute substances
ensure superior vena cava catheter to
placement for irritating solutions
Nursing Interventions
stop and notify
anticoagulants
heat
elevate of affected extremity
antibiotics
reassure patient and institute appropriate
therapy

TROUBLE SHOOTING
DRIP CHAMBER IS OVERFILLED
close regulator clamp
turn fluid container upside down
squeeze fluid from drip chamber until half-full or
slightly below
AIR INSIDE THE TUBING
check inadequacy of fluid level in drip chamber and
security of tubing connections

5
//carengreyes