Introduction to Intravenous Infusion a common form of therapy for handling fluid disturbances ordered by a physician nurse: responsible for initiating, monitoring, and discontinuing the therapy understand the patient’s need for IV therapy, the type of solution being used, its desired effect, and untoward reactions that may occur Examples of NIC: IV Therapy maintain strict aseptic technique examine the solution for type, amount, expiration date, character of the solution, and lack of damage to container select and prepare an IV infusion pump, as indicated administer IV fluids at room temperature Examples of NIC: IV Therapy monitor for IV patency before administration of IV medication maintain occlusive dressing flush IV lines between administration of incompatible solutions Equipment sterile technique disposable infusion tubing and needles varies according to the manufacturer – flexible or rigid plastic containers • collapse and do not require a vent for air to enter to replace fluid flowing from the container required for certain medications require a vent to allow air to enter the bottle as the fluid leaves the bottle
Administering IV Therapy
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Checking Drip Chamber and Time Drops
glass bottles • •
Basic Administration Set for IV Therapy
Guidelines for Nursing Care: Regulating IV Flow Rate Follow agency's guidelines to determine if infusion should be administered by electronic pump or by gravity. Check physician's order for IV solution. Check patency of IV line and needle. Verify drop factor (number of drops in 1 mL) of the equipment in use. Regulation and Monitoring maintain proper flow rate
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which are provided in excessive amounts. Monitor IV flow rate at frequent intervals. Hold watch beside drip chamber. Use a time tape or label if indicated to measure amount to be infused at timed intervals. can develop rapidly and cause death unless it is promptly recognized and treated.allows kidneys to select and retain needed amounts Free water desirable as aid to kidneys in elimination of solutes 0. May be used to expand temporarily the extracellular compartment if circulatory insufficiency is a problem. knot or kink check the infusion every hour or more frequently.45% NaCl ½-strength saline) A hypotonic solution that provides Na+. Brain swelling. patient’s position. Document patient’s response to infusion at prescribed rate. 15. Cl-. and fluid lost as bile or diarrhea Useful in treating mild metabolic acidosis Hypotonic Solution 0.and free water Often used to treat hypernatremia (because this solution contains a small amount of Na+. 0.45% NaCl A common hypertonic solution used to treat hypovolemia. it dilutes the plasma sodium while not allowing it to drop too rapidly) Hypertonic Solution 5% dextrose in 0.33% NaCl 1/3-strength saline) A hypotonic solution that provides Na+. BP.• •
ensure comfort and safety macrodrip (10. infiltration. 8 hr 60 min gtt/min = 60gtt x 1000mL x 1 hr
. Lactated Ringer’s Solution A roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43-) Used in the treatment of hypovolemia. also used to treat diabetic ketoacidosis. a. thus the fluid dilutes the amount of sodium in the serum. Short formula using milliliters per hour gtt/min = mL per hour x drop factor (gtt/mL) time (60 min) Find milliliters per hour by dividing 1000mL by 8 hours: 1000mL / 8 = 125 mL/hr gtt/min = 125 mL/hr x 60 gtt/mL 60 min/hr c. Dimensional Analysis gtt/min = gtt x mL x hr mL hr min 1mL gtt/min = 125gtt/min • Count drops per minute in drip chamber (number of gtt/15 sec interval x 4). used to maintain fluid intake 10% dextrose in water (D10W)
EXAMPLE—Administer 1000 mL D5W over 8 hours (set delivers 60 gtt/1 mL). Cl. 20 drops per mL) – used for rates greater than 75 mL per hour
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microdrip (60 drops per mL) blood adminitration (10 drops per mL) Volume-controlled Set Regulation and Monitoring a time tape can be placed on the container of solution to provide a quick reference for the nurse to monitor the rate at which the solution is entering the patient factors: height of the container. patency of the IV catheter. and free water Na+ and Cl. Adjust IV clamp as needed and recount drops per minute Mark IV container according to agency policy and manufacturer’s recommendations. burns. if indicated Calculate the flow rate:
Selected IV Solutions Isotonic Solution 5% dextrose in water (D5W) Supplies about 170 cal/L and contains 50 g of glucose Should not be used in excessive volumes because it does not contain any sodium. or hyponatremic encephalopathy.9% NaCl (normal saline) Not desirable as routine maintenance solution because it provides only Na+ and Cl-. Standard formula gtt/min = volume (mL) x drop factor (gtt/mL) time (minutes) gtt/min = ? b.
and subacute care settings. provide access for a variety of IV fluids.9% NaCl (normal saline) Replaces nutrients and electrolytes Can temporarily be used to treat hypovolemia if plasma expander is not available Vascular Access Devices • • • • • • • • • • Factors length of time the infusion therapy is needed type of medication or product that will be delivered intravenously patient's health status and needs determine which option is used what will pose the least risk for IV complications Peripheral Venous Catheters Over-the-needle catheters .the most common type of peripheral vascular catheter used. Central Venous Access Devices (CVADs) are now an integral component of patient care in acute. vasopressors. as well as in the home and longterm care facilities.median of 7 days.Supplies 340 cal/L Used for peripheral parenteral nutrition (PPN) 5% dextrose in 0. blood products. ambulatory. or cephalic veins advanced as far as the superior vena cava specially trained registered nurse or physician can insert this type of catheter radiographic verification single or multiple lumens PICCs for long-term IV therapy. brachial. infusion therapy will be brief. hyperosmolar solutions blood components other specific medications (eg. Follow agency policy for rotation of midline catheter insertion site. a short (<3 inches) peripheral catheter insertion site should be rotated at least every 72 to 96 hours for an adult child .the site can remain in place until the IV intervention is completed unless a complication develops smallest-gauge device is usually selected to minimize trauma to the vein Midline Peripheral Catheter inserted peripherally. normally through the antecubital fossa into the proximal basilica or cephalic veins longer (>3 inches) than peripheral venous catheters not considered to be central lines should not be used to infuse vesicants or hyperosmolar or irritating solutions length of time . from 6 weeks to 6 months normally replaced as needed – – catheter is no longer patent site looks infected. that can be introduced into a peripheral vein – basilic. anticoagulants) long-term rehydration Advantages of PICC less risk of complications because the catheter is inserted peripherally – – infection pneumothorax
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cost effective provide adequate hemodilution for medications Nontunneled Percutaneous Central Venous Catheters have a shorter dwell time (3–10 days)
. but possibly as long as 49 days.
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Types of CVADS
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Indications for PICCs administration of IV antibiotics for an extended period (2–6 weeks) infusion of parenteral nutrition chemotherapy continuous narcotic infusions vesicants. and TPN solutions allow a means for hemodynamic monitoring and blood sampling CVAD
usually introduced into the subclavian or internal jugular vein and passed to the superior vena cava just above the right atrium require radiographic confirmation of position Peripherally Inserted Central Catheters (PICCs) Nontunneled percutaneous central venous catheters Tunneled central venous catheters Implanted ports PICCs >20 cm depending on patient size. medications.
but the discomfort of accessing the port may be a disadvantage for some patients Implanted Port numbing cream can be applied to the site before needle insertion (ensure that all of the cream is removed and the skin adequately cleaned before accessing the port) associated with the lowest risk for catheterrelated bloodstream infections patients report improved self-image surgery is required for catheter removal. helping to stabilize the catheter and minimize the risk for infection associated with a lower incidence of infection than is the nontunneled central venous catheter Tunneled Central Venous Catheter Implanted Port >8 cm. the sutures are removed. or femoral veins and sutured into place can have double. or femoral vein length of this catheter is >8 cm. depending on patient size Nontunneled Percutaneous Central Venous Catheters tip rests in the superior vena cava may be inserted at the bedside or in outpatient settings associated with a high risk for complications .
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triple-lumen nontunneled percutaneous central venous catheter • • •
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Tunneled Central Venous Catheter intended for long-term use implanted into the internal jugular subclavian. depending on patient size tip is placed in the subclavian or internal jugular vein. but the proximal end or port is usually implanted in a subcutaneous pocket of • • • • STARTING AN INTRAVENOUS INFUSION Equipment IV solution Towel or disposable pad Nonallergenic tape IV infusion set Gauze or transparent dressing (according to agency policy) Electronic infusion device (if ordered) •
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. subclavian. and no external parts of the system are visible • • • • • placed in the antecubital area of the arm (peripheral access system ports) initially used for chemotherapy Implanted Port now used for any patient requiring long-term intermittent infusions a special angled noncoring needle is inserted through the skin and rubber septum and into the port reservoir require minimal care. triple. subcutaneous tissue attaches to a Dacron polyester cuff around the catheter. accounting for most catheter-related bloodstream infections – – infection pneumothorax the catheter is placed in the subclavian vein.
the upper chest wall.•
introduced through the skin into the internal jugular. or quadruple lumens >8 cm. but after 7 to 14 days. depending on patient size tunneled in subcutaneous tissue under the skin (usually the midchest area) for 3 to 6 inches to its exit site Tunneled central venous catheter initially sutured into place.
Clamp IV tubing. anesthetic cream or lidocaine injection. povidone-iodine) Site protector or tube-shaped elastic netting (optional) Clean gloves IV pole Anesthetic (numbing) cream (if ordered) Lidocaine 1% injection (if ordered) 1-mL syringe (for lidocaine) IV catheter (over the needle. 3. check for allergies for these substances as well. Identify the patient. 2.IV tubing Tourniquet Time tape or label (for IV container) • • Equipment Armboard (if needed) Cleansing swabs (chlorhexidine preferred. If using an anesthetic cream. Check for color. 5. This punctures the seal in the IV bag or bottle. iodine. Injectable anesthetic can result in allergic reactions. Gather all equipment and bring to the bedside. Having equipment available saves time and facilitates accomplishment of the task. purpose of the IV administration and medications if ordered. Clamping the IV tubing prevents air and fluid from entering the IV tubing at this time c. Know the techniques for IV insertion. Hand hygiene deters the spread of microorganisms. tissue damage. Rationale This ensures that the correct IV solution and rate of infusion. Verify the IV order against the physician order. alcohol. Angiocath) or butterfly needle Butterfly
for allergies. uncap spike on the administration set. precautions. as appropriate. Clarify any inconsistencies. iodine. Identi fication of the patient ensures that the right patient receives the correct IV administration and medication as ordered. or tape. Prepare IV solution and tubing: a. Ask the patient if he/she is allergic to any medication. Possible allergies may exist related to medications. etc. Explain the need for the IV and procedure to the patient
Explanation allays anxiety. Anesthetic (numbing) cream decreases the amount of pain felt at the insertion site. If considering using an anesthetic (numbing) cream or 1% lidocaine injection. This knowledge and skill is essential for safe and accurate IV and medication administration. 6. Some of the numbing creams take as long as an hour to become effective.
7. and insert into the entry site on the IV bag or bottle as the manufacturer directs. and/or medication will be administered. Squeeze the drip chamber and allow it to fill at least halfway
Actions 1. apply the anesthetic cream to a few potential insertion sites. Check the patient's chart
. and inadvertent injection into the vascular system. Asepsis is essential for preventing the spread of microorganisms b. expiration date. Maintain strict aseptic technique when opening sterile packages and IV solution. 4. clarity. Perform hand hygiene. tape.
such as with the presence of arteriovenous fistula.
The use of an appropriate vein decreases discomfort for the patient and reduces the risk for damage to body tissues. If numbing cream was used. cleanse the insertion site with alcohol using a circular motion. In general. maintaining sterility of the setup.
13. e. and other blood-borne infections. Closing the door provides for patient privacy. Put on clean gloves. Allow fluid to flow until all air bubbles have disappeared and the entire length of the tubing is primed (filled) with IV solution. Remove the tourniquet and place warm moist compresses over the intended vein for 10 to 15 minutes. Apply a tourniquet 3 to 4 inches above the venipuncture site to obstruct venous blood flow and distend the vein. Massaging and tapping the vein help distend veins by filling them with blood. IV tubing is changed every 72 hours. Apply the label if medication was added to container (pharmacy may have added medication and applied the label).2 to 0. If using intradermal lidocaine. Place protective towel or pad under the patient's arm. Cleanse the site with an antiseptic solution such as chlorhexidine or according to agency policy. Labeling the tubing alerts nursing staff of the need for IV tube changes. 10. Consult hospital policy.
d. This provides for administration of correct solution with prescribed medication or additive. thereby distending them further. f. If an electronic device is to be used. In large amounts. Observe and palpate for a suitable vein. The end of the tourniquet could contaminate the area of injection if directed toward the site of entry. 8. g. Ask the patient to open and close the fist. Avoid an arm that has been compromised. Close the clamp and recap the end of tubing. and allow fluid to move through tubing. Use a circular motion to move from the center outward for several inches. This ensures correct flow rate and proper use of equipment. Warm moist compresses help dilate veins. palpate. clip a 2-inch area around the intended site of entry. wipe cream off the insertion site. 11. This permits immediate evaluation of the IV according to the time-tape schedule. The supine position permits either arm to be used and allows for good body alignment. 12. Distended veins are easy to see. Direct the ends of the tourniquet away from the site of entry. Make sure the radial pulse is still present. This technique prepares for IV fluid administration and removes air from tubing. Hair can harbor microorganisms. The tourniquet may be applied too tightly. Close the door to the room or pull the bedside curtain. Gloves protect against transmission of HIV. follow the manufacturer's instructions for inserting the tubing and setting the infusion rate.
. so assessment for the radial pulse is important. air in the tubing can act as an embolus. Place time-tape on the container and hang the IV on the pole. Lowering the arm below the heart level helps distend the veins by filling them. a. 15. and enter. 14.3 mL) of lidocaine into the area. Try the following techniques if a vein cannot be felt: Contracting the muscles of the forearm forces blood into the veins. open the IV tubing clamp.
Interrupting the blood flow to the heart causes the vein to distend. Place the patient in low Fowler's position in bed. Select and palpate for an appropriate vein. Massage the patient's arm from proximal to distal end and gently tap over the intended vein. 9. Instruct the patient to hold the arm lower than the heart. Label the tubing with the date and time that tubing was hung. If the site is hairy and agency policy permits. Inject a small amount (0. The patient may experience anxiety because he/she may fear needle stick or IV infusion in general. Provide emotional support as needed. hepatitis. b. 16.Suction causes fluid to move into the drip chamber and prevents air from moving down the tubing. Remove the cap at end of the IV tubing and while maintaining its sterility.
and 70% alcohol are considered acceptable alternatives. The needle entry site and catheter must remain free of contamination from unsterile hands. Use the nondominant hand. and type and size of catheter used for the infusion on the tape anchoring the tubing. Cleansing that begins at the site of entry and moves outward in a circular motion carries organisms away from the site of entry. time. Chlorhexidine is the preferred antiseptic solution but iodine. Ask the patient if he/she is experiencing any pain or discomfort related to the IV infusion. Chart the time. and when it was inserted. Securing the Catheter
24. 2005). Apply tape to dressing if necessary. IV insertion sites are changed every 48 to 72 hours or according to agency policy (Lavery. The physician prescribes the rate of flow. Placing the catheter well into the vein helps to prevent dislodgement. 28. Ask the patient to remain still while the venipuncture is performed.
22. Start the flow of solution promptly by releasing the clamp on the tubing. Document the procedure and the patient's response. Hand hygiene deters the spread of microorganisms. Nonallergenic tape is less likely to tear fragile skin. the solution will accumulate (infiltrate) into the surrounding tissue. If there is difficulty visualizing or palpating the intended vein for IV insertion. advance the needle or catheter into the vein. Remove all equipment and dispose of properly. Place sterile dressing over the venipuncture site. Secure the catheter with narrow nonallergenic tape (½ inch) placed with the sticky side up under the hub and crossed over the top of the hub. Patient movement may prevent proper technique for IV insertion. 29.to 15degree angle. a tourniquet may be left in place. 27. site. Anchor arm to an armboard for support if necessary. 19. the site. When blood returns through the lumen of the needle or the flashback chamber of the catheter. Stabilize the catheter or needle with your nondominant hand Bleeding is minimized and the patency of the vein is maintained if the connection is made smoothly between the catheter and tubing 21. While following the course of the vein. placed about 1 or 2 inches below the entry site. Label the IV dressing with the date. The tourniquet causes increased venous pressure. 26. iodophor. If the catheter accidentally slips out of the vein.
. A catheter needs to be advanced until the hub is at the venipuncture site. resulting in automatic backflow. Pressure on the vein and surrounding tissues helps prevent movement of the vein as the needle or catheter is being inserted. 18. This provides accurate documentation and ensures continuity of care. holding the catheter by the hub in your dominant hand. The catheter may be inserted from directly over the vein or the side of the vein. 20. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. A sensation of “give” can be felt when the needle enters the vein. Gauze dressings are capable of absorbing drainage. Remove gloves and perform hand hygiene.The lidocaine numbs the skin and makes the insertion less painful. Examine the tissue around the entry site for signs of infiltration Blood clots form readily if IV flow is not maintained. Return to check the flow rate and observe the IV site for infiltration 30 minutes after starting the infusion. Release the tourniquet as soon as possible. at a 10. device used. to hold the skin taut against the vein. 25. Loop the tubing near the site of entry. This allows the needle or catheter to enter the vein with minimal trauma and deters passage of the needle through the vein. Agency policy may direct nurse to use gauze dressing or transparent dressing. site. or follow manufacturer's directions for adjusting flow rate on infusion pump. 23. Organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Explain to the patient the purpose of the armboard and the importance of safeguarding the site when using the extremity. or apply a site protector or tube-shaped mesh netting over the insertion site. advance either device 1/8 to ¼ inch farther into the vein. bevel side up. Enter the skin gently. and solution. Avoid touching the prepared site. and anchor to dressing. Adjust the rate of solution flow according to the amount prescribed. Transparent dressing allows easy visualization. An armboard or site protector helps to prevent the position of the catheter in the vein from changing. 17. Other personnel working with the infusion will know what type of device is being used. Quickly remove the protective cap from the IV tubing and attach the tubing to the catheter or needle. but the exact technique depends on the type of device used.
back pains. A time tape is useful for this purpose. Restart the infusion in another vein. Check the rate frequently for accuracy. Carefully monitor the rate of fluid flow. Restart the infusion at a different site. coldness. pallor. chills. Apply warm compresses as ordered by the physician. Place patient on left side in Trendelenburg position. * Air embolus: air in the circulatory system Break in the IV system above the heart level allowing air in the circulatory system as a bolus > Respiratory distress Increased heart rate Cyanosis Decreased blood pressure Change in level of consciousness ^ Pinch off catheter or secure system to prevent entry of air. Limit the movement of the extremity with the IV. * Phlebitis: an inflammation of a vein Mechanical trauma from needle or catheter Chemical trauma from solution Septic (due to contamination) > Local. Pain is a symptom often associated with IV complications such as infiltration and phlebitis. or pain around the infusion site. Report symptoms of speed shock to the physician immediately. or the solution is allowed to infuse for too long a period Complications Associated With Intravenous Infusions
Avoid further use of the vein. significant decrease in the flow rate ^Nursing Considerations Check the infusion site several times per shift for symptoms. * Fluid overload: the condition caused when too large a volume of fluid infuses into the circulatory system Too large a volume of fluid infused into circulation > Engorged neck veins. Notify physician immediately if any signs of infection. Check the rate frequently for accuracy. Apply warm. Carefully monitor the rate of fluid flow.
. Discontinue the infusion if symptoms occur. allowing bacteria to enter the closed system or multiple-lumen catheters Poor insertion technique An IV solution that becomes contaminated when solutions are changed. Use the proper IV tubing. Monitor vital signs and pulse oximetry. Call for immediate assistance. Monitor vital signs. other vital sign changes ^ Assess catheter site daily. moist compresses to the affected site. slow the rate of infusion. Do not rub or massage the affected area. * Speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly Too rapid a rate of fluid infusion into circulation > Pounding headache. rapid pulse rate. increased blood pressure. Notify the physician immediately.This documents the patient's response to infusion. apprehension. warmth. a medication is added. Restart the IV at another site.
*Complication/Cause Infiltration: the escape of fluid into the subcutaneous tissue Dislodged needle Penetrated vessel wall >Sign and Symptoms Swelling. • • • • Sources of Catheter Contamination Hands of the caregiver Skin bacteria that contaminate the catheter during insertion Disconnection of the tubing or injection cap from the catheter hub. acute tenderness. and difficulty in breathing (dyspnea) ^ If symptoms develop. and slight edema of the vein above the insertion site ^ Discontinue the infusion immediately. redness. * Thrombus: a blood clot Tissue trauma from needle or catheter > Symptoms similar to phlebitis IV fluid flow may cease if clot obstructs needle ^ Stop the infusion immediately. Use scrupulous aseptic technique when starting an infusion. malaise. fainting. discontinue the infusion immediately. and dyspnea ^ If symptoms develop. * Sepsis: microorganisms invade the bloodstream through the catheter insertion site Poor insertion technique Multilumen catheters Long-term catheter insertion Frequent dressing changes > Red and tender insertion site Fever. Monitor vital signs if symptoms develop. Follow agency protocol for culture of drainage.