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Lesson 2

 PHARMACOLOGICAL CONSIDERATIONS
IN INTRAVENOUS THERAPY
Intravenous Therapy
The intravenous route is the fastest way to directly
deliver fluids and medications throughout the body. It can
be used for injections, using a syringe at higher pressures;
as well as for infusions, typically using only the pressure
supplied by gravity.

Fluids are Lost by:

• Hemorrhage
• Elimination
• Severe or prolonged vomiting or diarrhea
• Excessive wound drainage
• Wounds (especially burn wounds)
• Profuse perspiration

Purposes of IV Therapy
• To administer medication and parenteral nutrition
• To provide fluid and electrolyte maintenance,
restoration, and replacement
• To provide avenue for dialysis/apheresis
• To transfuse blood and blood products
• To provide avenue for hemodynamic monitoring
• To provide avenue for diagnostic testing

Figure 7. Phillips 15-Step Venipuncture Method

Characteristics of IV Administration
• Distribution of fluids and/or medications is faster than the oral and parenteral (shot)
routes. Parenteral routes include IV, IM, SC, and ID. IV is the fastest of these. This
takes around 20 seconds.
• IV medications and fluids reach their site of action unchanged from the chemical form
in which they are administered. This is because it does not go through the liver where
it would change it into a different form. This is called liver first pass.
• Must be sterile
• Most dangerous
• Monitor lab values and I & O’s

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Three (3) Types of IV Solutions

• MD orders ---- type of solution, amount to be infused and the rate of the infusion
• Every client on IV fluids should be monitored for intake and output imbalance,
electrolyte panels, daily weights, listening for lungs sounds, measuring abdominal
girth.

1. Isotonic - No shift in fluid; fluid stays the same

a. D5W = 5% dextrose and 95% water
Used for:
Dehydration, hyperkalemia, fluid loss,
vehicle for some IV piggyback
medications
Healthcare Considerations
Never give to clients with head injury,
use cautiously in renal and cardiac
patients can cause fluid overload

b. 0.9% Sodium Chloride or Normal Saline (NS)

Used for: Healthcare Considerations
Trauma, diabetic ketoacidosis, blood Can lead to overload, use with caution in
transfusions, hyponatremia, fluid patients with heart failure or edema
replacement, shock,

c. Lactated Ringers (LR)

Used for: Healthcare Considerations
Trauma, dehydration from severe Cannot be given to people with liver
diarrhea or vomiting, surgery, burns, disease, has potassium don’t use with
acute blood loss renal failure patients

2. Hypotonic - fluid goes into the cells (cells expand) often prescribed for the
dehydrated client
a. 0.45% Sodium Chloride (1/2 NS)
Used for: Healthcare Considerations
to treat fluid loss in dehydrated Don’t use with liver disease, trauma, or
patients, burns may cause cardiovascular collapse
or increased intracranial pressure

3. Hypertonic - fluid escapes and makes the cell shrink often prescribed for the
edematous client
a. D5NS – 5% Dextrose with 0.9% NS
Used for: Healthcare Considerations
over-hydration or edematous clients Don’t use in cardiac or renal patients
Early treatment of burns

b. D5 ½ NS (5% Dextrose in 0.45% Sodium Chloride)

Used for: *Healthcare Considerations
Postoperative; common maintenance
fluid

c. 10% - 50% Dextrose (D10W, D20W, D50W)

Used for: *Healthcare Considerations
IF TPN is abruptly discontinued

d. TPN (Total Parenteral Nutrition)

Used for: *Healthcare Considerations
is an artificial method of feeding, fully
by-passing the GI tract)

*Assignment: In a separate sheet, fill in the healthcare consideration/s.

IV Facts
• All commercially prepared solutions must be sterile, free of particulate matter and
free of pyrogens. Check expiration date.
• Blood is a living substance and contains particulate matter known as blood cells.

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• Blood is only as free of pyrogens, viruses, bacteria, etc., as the person it comes from.
Blood is not sterile.
• Pyrogens are organisms that would cause a fever.

IV Poles
• The height of the IV pole should be adjustable
• The IV pole should have two or more hooks
• Pumps and controllers can be attached to IV poles
• The pump must keep the fluid container at least 24 - 36 inches above the patient’s
heart.

Labels
• Chemical composition of the fluid
• Tonicity, osmolarity, and pH of the fluid
• Date of expiration
• Volume of fluid contained
• Manufacturer
• Always check to make sure you have correct chemical composition (solution)

Bottles
• Glass bottles come from the manufacturer with headspace
• Because a small amount of air enters a glass bottle when the seal is broken, a hiss is
heard when the seal is removed. If you don’t hear the hissing then it was not sealed
correctly and it is not sterile.
• If a glass bottle is not vented, a partial vacuum is created with the fluid leaves the
bottle. Most have an outlet to the outside either in the bottle itself or in the
administration kit. There will be plastic tubing in bottles that are already vented;
otherwise, you will have to use an administration set that is vented.
• There is a little extra fluid so that it can be changed before it empties and the full
amount is still given. This prevents having to run it out and put air in the line.
• The vented bottle has a plastic tub e attached to an opening for air in the stopper. Two
sets of fluid volume calibrations are molded into the glass bottle so that the bottle can
be read in either position.
• The non-vented has no plastic tube in the bottle to vent air

Bags
• As fluid leaves the bag, the bag collapses forcing the fluid to enter the tubing.
• May develop leaks

Semi-rigid
• Has a firm shape when full, but collapses as the fluid runs out
• This makes an air vent unnecessary

Administration Sets
a. Primary (Continuous infusion)
✓ Consists of 5 items:
• A bag of solution, tubing set,
needleless connector, IV stand,
a filter (may be added)
✓ Tubing set consists of:
• Either vented or non-vented
• Spike end inserted into the bag
(has a plastic protector to keep
it sterile)
• Drip chamber
• Tubing
• Flow regulator / clamp
• Needle adapter (has a plastic protector to keep it sterile)
• Has 1 or 2 injection ports
• Used for all types if IV therapy except blood product administration

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The primary IV tubing set is selected according to the size of the drop to be delivered
into the drip chamber. (how many drops does it take equal 1 mL of volume of IV fluid)
Macrodrip deliver 10-20 drops/ml. Used for viscous fluids, such as blood
Microdrip (most pumps) deliver 60 drops/ml. Used for infants, children & the elderly

Parts of an Intravenous Line

b. Secondary / Piggyback
✓ Called the medication port or Y ports (insert adaptor for piggy backs in one closest
to the bag, push meds in the port closest to the patient.)
✓ When this is used the primary infusion is interrupted to infuse medications at
regularly scheduled times. After it has been infused the primary IV begins to flow
again without further adjustments.
✓ Because these drugs are diluted in amounts of 50 to 150 mL of solution, they must
be given by infusion (slow introduction of fluid into the vein) not by bolus (directly
injected into the IV tubing (Ysites - ---IV push)
✓ This bag is hung higher than the primary bag so that gravity forces it to empty first.

c. Parallel or Y intravenous
✓ Used to infuse certain blood products. Saline is the only fluid used in the
conjunction with infusion of a blood product.

d. Controlled-volume
✓ Is a special type of intravenous (I.V.) infusion se t designed to provide a more
accurate delivery of I.V. solutions and to permit the dilution of medication
✓ They are similar to a standard I.V. tubing set-up with the addition of a chamber
(burette) that holds 100–150 cc of fluid immediately above the drip-chamber of the
tubing. The chamber includes a separate medication port and air filter. The volume-
control set can be used with or without pump set tubing.

e. Intermittent (Saline or PRN devices)

✓ Used to maintain venous access in patients without continuous infusion of fluids.
✓ This device is preferred for patients who receive antibiotics, heparin,
corticosteroids antimetabolites and some other drugs.

Tubing is changed every 72 – 96 hrs. (Book indicated 24 – 72 hrs. page 715)

Always label tubing - patient sticker date, time and initials
Use filters with immune suppressed clients, those on prolonged IV therapy and ones
receiving additives in their IV.

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Infusion Pumps and Controllers

Infusion Pumps
• Used to regulate the flow of IV fluids
• Deliver fluids at a set preprogrammed
rate
• Can switch back and forth
automatically for primary and
secondary infusions
• Almost always used for TPN
• Rate controllers operate by gravity but
regulate flow using a drop sensor as an
electronic feedback mechanism
• Pumps are mandatory when using TPN,
Heparin, Insulin, cardiovascular meds,
chemo drugs and medications to induce
labor.
• Protect against accidental infusion of
too much fluid
• KVO = Keep vein open
• VTBI = Volume to be infuse
❖ Types of infusion pumps – CADD PAC, PCA and Insulin Pump

Venous Access Devices

Winged Tip or Butterfly Needles
• Used for short term or intermittent therapy such as a single dose of medication
• Supplied in 15,19, 23, and 25 gauge (the large the number the smaller the needle
diameter)
• May be used in pediatrics or in special procedure room in radiology
• Leaves a needle in the vein

Over the Needle IV Catheter (Used Most Often)

• A needle with a catheter device over it. The needle is used to insert the catheter
into the vein and then withdrawn
• Leaves the catheter in place in the vein (standard IV catheter)
• Sizes 14-27 gauge
• Usually last for 3 days; Replace in 72 hours

Through the Needle Catheter

• Needle inserted first and catheter threaded through the needle
• Usually used for long-term therapy
• Sizes 12-18
• Usually inserted by the doctor only in the subclavian veins

Central Venous Catheters

• May be inserted and left in place 6-8 weeks
• Used when a peripheral vein is difficult to locate or needs long term therapy
• Positioned in the right atrium or superior vena cava
• Some are tunneled long-term catheters such as a Hickman or Broviac catheter
(done in OR)
• Correct placement must be verified by x-ray before fluid is infused through them.

Infusion Port (Infusaports)

• Single or Double lumen catheter
• Medicine is given through a special needle (Huber noncoring Needle). This needle
is inserted through the chest skin into a surgically implanted dome or port
connected to a catheter threaded into a large vein in the upper chest or neck.

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Midwifery Tips:
• Always check: medication, rate, IV site and pump function every 2 hours
• Identify the Client X 2 (right person) ---- Name and Date of Birth
• Change bag at least every 24 hours
• If using a 1000 mL bag set pump to alarm @ 900 mL or 950 mL
• Change tubing every 72 – 96 hrs.
• Change IV site every 72 hours
• Change transparent dressing every 72 hours
• Never take a blood pressure on the arm that has a PICC or ML catheter in place

IV Pump Troubleshooting
• Start at patient and work way up to the IV bag
o Look for kinks
o Make sure clamp is open
o Make sure roller clamp is open
o Is air in the line
o Is the IV bag empty
o Is the IV site ok

Getting Drugs into Person

The intravenous (IV) route, using either central or
peripheral lines, is used for the infusion of fluids and electrolytes,
drug administration and parenteral nutrition. An indwelling iv line
is extremely useful in medical emergencies such as anaphylaxis.
Drugs commonly given intravenously include antimicrobials,
oxytocin, tocolytics, anticonvulsants, heparin and anesthetics.

Administration
Intravenous administration may be by continuous infusion,
intermittent infusion or as bolus doses. The formulations are not interchangeable: a patient
died when a 60-minute intravenous infusion (IVI) of vancomycin was mistakenly administered
as a bolus dose (Cousins, 1995).
Continuous Intravenous Infusions
Continuous IVI aims to establish and maintain a steady concentration of drug in the
circulation, for example oxytocin (Syntocinon ®). The drug is administered as a dilute solution
to reduce irritation of the vein.

Intermittent Infusion
Intermittent infusion may cause the concentration of the drug in plasma to ‘peak and
trough’ and fall above and/or below the therapeutic range. This can cause both toxicity and
therapeutic failure. This could occur, for example, in a woman treated with intravenous
antibiotics or heparin.

Bolus Doses
A relatively large volume of fluid or dose of a drug or test substance given intravenously
and rapidly to hasten or magnify a response. Rapid administration of drugs is likely to cause:
• trauma to the veins
• a severe hypersensitivity response
• serious side effects
• pulmonary edema or embolization if large volumes of fluid are administered.

Complications of Intravenous Therapy

• Thrombosis - development of a clot in a vein
• Phlebitis - local inflammation in a vein
• Thrombophlebitis - local inflammation and a clot in the vein
• Pulmonary embolus - clot in the lung
• Embolus - dislodged floating clot

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Infiltration
• The most common problem
• This occurs when fluid leaks out of the vein into
the surrounding tissues.
• Signs and symptoms: edema around the site, tissue
will feel cool, flow will be slow and sluggish
• If infiltration has occurred, the intervention is to
discontinue the IV and another site is initiated to
continue therapy
• Prevention
o Careful site selection to ensure weak or
damaged veins are not used
o Choose sites above the original site
o Securely stabilize / tape the site
o Tell patient to immediately report pain at the
site
o Instruct patient on avoiding pulling on IV
o Elevate extremity and use warm compress

Extravasation
• Direct injection may exert too much
pressure on fragile veins, causing
thromboembolism or extravasation.
• Leakage (or extravasation) of isotonic fluid
in small amounts is not damaging, but fluid
containing drugs may be extremely
irritant.
• Severe tissue necrosis and skin breakdown,
requiring skin grafting (or even
amputation in neonates) may follow the
extravasation of noradrenaline
(norepinephrine) or adrenaline
(epinephrine).
• Fluids containing potassium or glucose are
also highly irritant.

Thrombosis
• Thrombosis can be caused by
o Traumatic venipuncture, local
inflammation, irritating additives or
solutions, or slow flow rates
• Thrombosis alone is difficult to detect. You may
note a slowed flow rate and localized swelling.
• If suspected, avoid touching the site, gently
remove the infusion device and restart the IV.

Phlebitis
• Caused by irritation of the vein by needle,
catheter, medications or additives in the IV
solution
• Signs and Symptoms: local redness and swelling,
pain or tenderness, hard vein feeling of warmth.
• Interventions
o Remove the IV, notify the physician,
restart IV I the opposite arm and apply a
warm compress.

Catheter Embolus
• Occurs when a piece of the catheter breaks off and travels in the vein until it lodges.
• Signs and Symptoms: Sudden chest pain and SOB, decrea se BP, weak rapid pulse, pain
along vein, cyanosis of nails beds, loss of consciousness

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• Interventions
o Always inspect IV catheter when removing
o Place tourniquet or inflated BP cuff above IV site
o Notify MD
o Obtain an X-ray
o Prepare for surgery

Air Embolism
• Occurs when an air bubble enters a vein, it is
carried quickly to the right ventricle of the
heart
• It can them move to the pulmonary artery
where it occludes the pulmonary capillaries
and prevents the blood from being
oxygenated.
• Signs and Symptoms: Pallor, cyanosis,
decreased blood pressure, coughing,
tachycardia, respiratory distress, increased
venous pressure, loss of consciousness.
• Interventions
o Clamp off the infusion
o Turn the patient on left side with hade and shoulders lowered
o Begin CPR immediately
o Notify the physician

Pulmonary Embolus
• Inert particles may be introduced into the
IV solution during the attachment of the
administration set by the process of coring
or they may form as a result of additives
reacting with a solution

Signs and Symptoms of Pulmonary Embolus

• Sudden chest pain
• Respiratory distress
• Tachycardia
• Hemoptysis
• Coughing

Health Care for Pulmonary Embolus

• Upright position
• Call doctor
• Oxygen administration started
• Possibly Streptokinase or TPa-clot
busting drugs (can cause brain to
hemorrhage immediately)
• Heparin IV – (test for heparin – INR / PTR)

Bloodstream Infection (Septicemia)

• Occurs when infectious pathogens are
introduced into the bloodstream. Occurs when
there is a break in sterile technique.
• Signs and Symptoms: fever, chills, pain,
headache, nausea, vomiting and extreme
fatigue.
• Prevention
o Rigorous adherence to aseptic technique
o Strict hand washing
o Minimizing the time that parts are
exposed to the air

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• Interventions
o Discontinue IV
o Notify MD
o Cultures will be ordered

Speed Shock
• Occurs when fluids / medication is given by bolus (IV push) too rapidly
• Signs and Symptoms: flushed face, headache, chest pain
• Prevention
o When giving bolus medications or fluids, always look them up and deliver over the
time specified

Rapid Delivery
• Too rapid delivery of intravenous fluid has two life-threatening consequences: Fluid
overload which can lead to congestive heart failure and pulmonary edema, and drug or
electrolyte overdose which can lead to speed shock.

Symptoms of Fluid/Circulatory Overload

• Congested lung sounds
• Increased pulse rate/bounding volume
• Increased blood pressure/weight gain
• Orthopnea
• Distended neck veins

Patients at Risk for Overload

• Infants
• Elderly
• Cardiopulmonary
• Neurosurgical
• Renal patients

Prevention of Overload
• Check flow and drip rate hourly
• Check equipment before infusion
• Explain importance of not changing the system

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Health Care for Overload

• If a patient exhibits tachycardia, increased pulse and blood pressure and difficult
respirations and you observe distention of the neck veins, you should perform
the following actions
1. Elevate the head of bed
2. Reduce the flow rate to KVO (keep vein open) 30mL/hr
3. Notify the physician

Pyrogens
• Pyrogens are fever producing substances
• Any intravenous solution that appears cloudy should be discarded
• Pyrogenic reactions occur about 30 minutes after an infusion has been started or a new
container added.

Allergic Reactions
• Allergic or inflammatory reactions to the IV solution, additives or equipment may be
topical, local, or systemic (allergic to tape – solution for skin prep or antiseptic
ointment)
• Prevention of anaphylactic shock and autoimmune reactions include:
o Checking the patient’s history of allergies
o Remaining with the patient for at least 10-15 minutes when infusion has started.

Signs and Symptoms of Anaphylactic Shock

• Respiratory distress
• Hives
• Sudden nasal congestion
• Site reactions
• Skin flushing
• Dizziness

Health Care for Anaphylactic Shock and Topical Reactions

• If any reactions occur, stop the infusion immediately and notify the physician
• Get your epinephrine ready
• Topical reactions are usually caused by allergic reactions to:
o Tape
o Solution for skin prep
o Antiseptic ointment
• To prevent local reactions to iodine asked about allergies to shellfish.
• Signs and symptoms: redness, pain or itching and swelling
• Remove the IV, notify the physician, change the site, type of tape, and cleansing
solution for a new IV.

Flow Rate (Gtts / Min Or Flow Rate Of The IV Per Min)

• To measure drops per min or flow rate we must know: mL, drop factor and time in
minutes
mL X drop factor = gtts / min 1500 X 15
time (minutes) 12 hrs (720) = gtts

Counting Drops by Gravity (Count the # of Drops per Minute)

1. Make sure the bed is at a normal height
2. Check line for kinks, coils, or loops
3. Raise watch to eye level beside drip chamber
4. Count drops in a 15 second period
5. Multiply x 4 then adjust & count again for the 60 seconds

Calculate Infusion Time

1. Divide mL/hour into total number of mL in the bag
2. 1000 mL divided by 100 mL/hr=10 hrs
3. Will divide small number into large number

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EXERCISE
Instruction: On a separate sheet, answer the following questions briefly.

1. As a professional midwife, cite your strategies in preventing and managing the

occurrence of each IV therapy complication.
2. Explain each step enumerated in Figure 7 based on your practice.

J. Milan Jr. Module I