NAME: DIZON, DEXIE

CASE ANALYSIS: IV THERAPY

Mr. PEDRO is a 74-year-old male who is brought to the Emergency Department by a family member after falling at
home. He denies hitting his head or losing consciousness. There are no lacerations or open areas noted. He has
severe pain in his left leg and rates it at an "8, with a large hematoma forming. After having x-rays, nothing appears
to be broken. He denies taking any prescription medications, and states he hasn't seen a physician in years because
"they always want to start you on some kind of medication". There is no significant medical history documented in
Mr. PEDRO's medical records. His wife passed away about two years ago, and he has been living alone at home
since this happened. He has children, but they live in the US. They don't visit often, but they do call him every
Sunday. After reviewing the patient's case, the physician decides to admit the patient to the medical/surgical unit
for generalized weakness and pain control. Admission orders are obtained, and the patient is transferred. The
patient weighs 230 lbs other. The physician orders Morphine 1 mg IV every hour PRN for pain.

1. What type of IV access device would be placed in this patient (peripheral or central line)? If you choose
peripheral, note the appropriate gauge. If you choose central line, note the appropriate type (PICC, non-
tunneled, tunneled, or port).

On day three of hospitalization, Mr. PERO does not appear to be making great strides towards recovery. The
pain has improved, but mobility is still limited. He presses his call light telling the nurse that he suddenly has chest
pain, shortness of breath, and just doesn't feel right. Upon further care, CT scan confirms a pulmonary embolism.
The physician writes an order to initiate heparin therapy. The patient’s PTT is 39 seconds. The heparin is bolus
supply is 5000 units/ml, and the heparin infusion supply is 25,000 units/250 ml D5W.

2. What is pulmonary embolism? What causes it to occur?

 PE refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi)
that originates somewhere in the venous system or in the right side of the heart. Deep vein thrombosis
(DVT), a related condition, refers to thrombus formation in the deep veins, usually in the calf or thigh,
but sometimes in the arm, especially in patients with peripherally inserted central catheters. VTE is a
term that includes both DVT and PE. PE can be associated with trauma, surgery (orthopedic, major
abdominal, pelvic, gynecologic), pregnancy, heart failure, age older than 50 years, hypercoagulable
states, and prolonged immobility. It also may occur in apparently healthy people. In the United States,
the precise number of people impacted by VTE is unknown; as many as 900 people could be affected
each year (CDC, 2015e). One-third of people with a VTE will have a recurrence within 10 years.
Estimates range that from 60,000 to 100,000 Americans die of VTE; 10% to 30% of people will die
within the first month of diagnosis, and sudden death is the first clinical sign in about 25% of people
who experience a PE (CDC, 2015e). The outcome in acute PE depends on the presence of pre-existing
comorbidities and the extent of hemodynamic compromise.

Pathophysiology
 Most commonly, PE is due to a blood clot or thrombus. However, there areother types of emboli: air,
fat, amniotic fluid, and septic (from bacterial invasion of the thrombus). When a thrombus completely
or partially obstructs a pulmonary artery or its branches, the alveolar dead space is increased. The area,
although continuing to be ventilated, receives little or no blood flow. Therefore, gas exchange is
impaired or absent in this area. In addition, various substances are released from the clot and
 surrounding area that cause regional blood vessels and bronchioles to constrict. This results in an
increase in pulmonary vascular resistance—a reaction that compounds the V./Q. imbalance.
The hemodynamic consequences are increased pulmonary vascular resistance due to the regional
vasoconstriction and reduced size of the pulmonary vascular bed. This results in an increase in
pulmonary arterial pressure and, in turn, an increase in right ventricular work to maintain pulmonary
blood flow. When the work requirements of the right ventricle exceed its capacity, right ventricular
failure occurs, leading to a decrease in cardiac output followed by a decrease in systemic blood
pressure and the development of shock. Atrial fibrillation can also cause PE. An enlarged right atrium in
fibrillation causes blood to stagnate and form clots in this area. These clots are prone to travel into the
pulmonary circulation. A massive PE is best defined by the degree of hemodynamic instability rather
than the percentage of pulmonary vasculature occlusion. It is described as an occlusion of the outflow
tract of the main pulmonary artery or of the bifurcation of the pulmonary arteries. Multiple small
emboli can lodge in the terminal pulmonary arterioles, producing multiple small infarctions of the
lungs. A pulmonary infarction causes ischemic necrosis of part of the lung.

3. What is the goal of heparin therapy?

 Anticoagulation Therapy
In patients with suspected PE, immediate anticoagulation is indicated to prevent a reoccurrence or
extension of the thrombus and may continue up to 10 days (Tapson, 2016). Long-term anticoagulation is
also indicated from 10 days to 3 months following the PE and is critical in the prevention of recurrence of
VTE. This duration may be extended indefinitely in patients who are at high risk for recurrence (Tapson,
2016).
In patients with proven PE and who are hemodynamically stable, the initial anticoagulant selected may
include a low molecular weight heparin (e.g., enoxaparin [Lovenox]), unfractionated heparin, or one of the
new oral anticoagulants (NOACs), such as a direct thrombin inhibitor (e.g., dabigatran [Pradaxa]), or a
Factor Xa inhibitor (e.g., fondaparinux [Arixtra], rivaroxaban [Xarelto], apixaban [Eliquis], or edoxaban
[Savaysa]) (Kearon et al., 2016). The NOACs are contraindicated in patients who may receive thrombolytic
therapy because their safety and efficacy are unknown in hemodynamically significant PE. Unfractionated
heparin is preferred in patients who are hemodynamically unstable in anticipation of a potential need for
thrombolysis or embolectomy. In very select patients with PE, outpatient therapy can be started by
administering the first dose in the emergency department or urgent care center and the remaining doses
given at home. Although there are not specific selection criteria for outpatient treatment, the patient is
usually at low risk of death, has no respiratory or hemodynamic compromise, does not require narcotics for
pain control, has no risk factors for bleeding, has no serious comorbid conditions, and has normal mental
status with a good understanding of the benefits and risks (Tapson, 2016). The ideal agent for outpatient
administration is unknown, although the NOACs are often used.

One day after the initiation of heparin, Mr. White begins to run a fever with a WBC of 16,000. The physician
decides to initiate antibiotic therapy, and orders Levaquin 500 mg IV every 24- hours. The supply of
Levaquin is 750 mg per 30 ml (25 mg/mL) and will be mixed in a 150 ml bag of normal saline. It must infuse
over 90 minutes. What needs to be considered prior to initiating this infusion?
4. Describe how you will administer this medication.

The things to be considered prior to administration are

• Patient medical condition :if diabetic can lead to hypoglycemia
 • Use of any other antibiotics, NSAIDS,pain killer,OTC, because it strongly interact with most drugs
• Assess for any allergic reactions
• Check for hypersensitivity
• Follow the rights of medication administration
• Patient should not take alcohol
• Gastrointestinal status to be assessed because there are chance of side effects like diarrhoea or
constipation and abdominal pain
The presence of pain, redness along the vein pathway, wariness is a sign of phlebitis
The intervention needed are
• Stop IV and change the peripheral line
• Apply warmth to ensure circulation
• Ice application can soothe the discomfort due to pain
• Anti thrombolytics can be administered superficially

5. How many ml of medication will you prepare?

 The medication can be administered via a peripheral intravenous line slowly .The standard rate is
500mg over 1 hour
Available
750mg=30ml
So 500mg=??
Cross multiply and divide
=20ml (500×30÷750)
Ans:20ml of the medication to be taken for preparation

6. At what rate will you infuse this medication?

 Flow rate=Total volume÷time (min)×60

Here total volume :150ml
Time 90 minutes (1hr 30min)
=150÷90×60
=100drops/minute

Upon assessing the IV site that the heparin is infusing through, you notice that the site is reddened along the
path of the cannula and is warm. Mr. White reports having pain in that area.
7. What complication is occurring at this time?
 The presence of pain, redness along the vein pathway, wariness is a sign of phlebitis.

8. What interventions need to occur at this time?

 The interventions needed are:
• Stop IV and change the peripheral line
• Apply warmth to ensure circulation
• Ice application can soothe the discomfort due to pain
• Anti thrombolytics can be administered superficially