IV Therapy by GC.

RN
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Vein A&P 

Veins are unlike arteries in that they are 
 

superficial, display dark red blood at skin surface have no pulsation 

VEIN ANATOMY

- Tunica Adventitia
- Tunica Media - Tunica Intima - Valves

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Tunica Adventitia outer layer 

Connective tissue Contains the arteries & veins supplying blood to vessel wall 

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Tunica Media 

middle layer

Contains nerve endings & muscle fibers Vasoconstrictive response occurs at this layer 

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Tunica Intima inner layer 

One layer of endothelial No nerve endings 

Surface for PLT aggregation w/trauma and recognition of foreign object at this level 


PHLEBITIS begins here

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VALVES present in MOST veins 

Prevent backflow & pooling More in lower extremities and longer vessels Vein dilates at valve attachment  

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UPPER EXTREMITIES VEINS 

DIGITAL Vessels
- Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize & should be your LAST RESORT 

METACARPAL Vessels
- Located between joints & metacarpal
bones (act as natural splint) - Formed by union of digital veins - Geriatric pts often lack enough connective / adipose tissue & skin turgor to use this area successfully
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Digital

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UPPER EXTREMITIES Veins 

CEPHALIC Intern s Vein - Starts at radial aspect of wrist - Access anywhere along entire length * BEWARE of radial artery/nerve MEDIAL CEPHALIC On ramp to Cephalic Vein - Joins the Cephalic below the elbow bend -Accepts larger gauge catheters, but may be a difficult angle to hit & maintain MEDIAN CUBITAL usually saved for PICC line insertion; inconvenient in children as it limits motility
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UPPER EXTREMITIES Veins 

BASILIC Originates from the ulnar side of the metacarpal veins & runs along the medial aspect of the arm. It is often overlooked b/c of its location on the back of the arm, but flexing the elbow/bending the arm brings this vein into view MEDIAL BASILIC Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters. * BEWARE of Brachial Artery/Nerve 

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Anatomical sites in Infants

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INITIAL IV ACCESS SITES

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INITIAL IV SITES

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Fluid Intake

Water from metabolism: 200 ml (8%)

Water from beverages: 1600 ml (64%)

Water from food: 700 ml (28%)
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Fluid Output

Water from feces: 150 ml (5%)

Water from lungs: 300 ml (11%)

Water from skin: 550 ml (25%)
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Water from urine: 1500 ml (59%)
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IV therapy is the aseptic instillation of fld, lytes, nutrients or fld, lytes, meds through a needle into a vein. PURPOSES To administer flds & chemical substances when circumstances prevent the pt from consuming normal diet & oral liquids. To replace flds & chemical substances when the pt has experienced their loss through vomiting, diarrhea, bleeding, etc To provide access to the circulatory system if it becomes necessary to administer emergency meds To maintain an access to the circulatory system for the intermittent administration of scheduled meds. meds.
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NSG CONSIDERATIONS 


Venipuncture site will remain nontender throughout the infusion. Solns will infuse safely at the prescribed rate.

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TYPES OF IV FLUIDS Isotonic fluids  Hypotonic fluids  Hypertonic Fluids 

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ISOTONIC
have the same osmolarity as body fluids.  Remain intravascularly mommentarily, thus mommentarily, ECF volume  do not enter the cells b/c no osmotic force exists to shift the fluids.  Used for pts w/hypotension/ hypovolemia. hypovolemia.  HR FVE.  Caution: pts w/left ventricular dysfx, CHF HTN. dysfx,  Avoid: volume hyperexpansion in pts w/ intracranial pathology or space occupying lesions. 

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HYPOTONIC 
  

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more dilute have a lower osmolarity than body flds. flds. These flds DILUTE serum thus Osmolarity Used w/dehydration dt dialysis, diuretics, DKA (high serum glucose causes fluid to move out of the cells into the vascular and interstitial compartments). Caution: b/c sudden fluid shifts from the intravascular space to cells can cause CV collapse & ICP
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Affects of HYPOTONIC Soln on Cell 

solute outside the cell is lower than inside. H20 moves from Low high [solute] cell swells & bursts! 

Swollen RUPTURED Swelling Cell Cell CELL Cell

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HYPERTONIC 
   



more concentrated have higher osmolarity than body fluids. Concentrate ECF & cause mvmt of H20 from cells into ECF by osmosis. They pull fluid and sometimes electrolytes from the intracellular/interstitial compartments into the IV compartments. Use: for stabilizing BP, urine output, correcting hypotonic hyponatremia & edema. edema. HR for dehydration.
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Affects of HYPERTONIC Soln on Cell 

solute outside the cell is higher than inside. H20 moves from low [solute] high [solute]. cell shrinks!
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Shrinking SHRUNKEN Cell Cell CELL 

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ISOTONIC 

0.9% NS = 308 mOsm LR = 275 mOsm remember that lactate is converted to bicarb by the liver. D5W = 260 mOsm isotonic in the bag, once infused the glucose is utilized leaving just water. D5 ¼ NS
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Hypotonic
0.45% NS (1/2 NS)
= 154 mOsm

Third 0.33% NS = 103 mOsm D2.5W = 126 mOsm CAUTION:  Hypotonic fluids can cause sudden fluid shifts to intracellular & interstitial spaces.

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HYPERTONIC
D5 ½ NS (0.45%) 406 mOsm (0.45%)  D5NS (0.9%) 560 mOsm  D5LR 575 mOsm  D10W 


CAUTION: Hypertonic fluids greatly expand the intravascular compartment.

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TWO MAIN GROUPS OF FLUIDS 

Crystalloids 

Colloids

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CRYSTALLOIDS
Clear solns contain lytes + H20 = small molecules.  Used for fld volume replacement. y However, both H20 & lytes will cross a semi-permeable semimembrane into the interstitial space and achieve equilibrium in 2-3 hrs. 2y ** Remember: 3 mL of isotonic crystalloid soln are needed to replace 1 mL of pt blood. blood. y B/c 2/3rd of the soln will leave the vascular space in approx. 1 B/c hr. y In the mgmt of hemorrhage, initial replacement should not exceed 3L before you start using whole blood b/c of risk of edema, especially pulmonary edema. 

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CRYSTALLOIDS Cont
Advantage:  inexpensive, easy to store with long shelf life, readily available with a very low incidence of ADR, and there are a variety of formulations that are available that are effective for use as replacement fluids or maintenance fluids. Disadvantage:  it takes approximately 2-3 x volume of a 2crystalloid to cause the same intravascular expansion as a single volume of colloid.
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COLLOIDS Plasma expanders
Pull fld from the interstitial compartment into the vascular  used to vascular volume rapidly (hemorrhage/severe Hypovolemia) (hemorrhage/severe Hypovolemia)  Large molecular wt solns. These solutes are macormolecular substances solns. made of gelatinous solns which have particles suspended in soln and do NOT readily cross semi-permeable membranes or form sediments semi

B/c of their high osmolarities, these are important in capillary fluid B/c osmolarities, dynamics b/c they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries 

These work well in edema b/c they draw fld from the interstitial and intracellular compartments into the vascular compartments. 
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Initially these flds stay almost entirely in the IV space for a prolonged period of time compared to crystalloids.  These will leak out of the intravascular space when the capillary permeability is deranged or leaky.  Plasma Substitutes (Hypertonic)  Dextran & Hetastarch

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COLLOIDS Cont
ALBUMIN - available for use as colloids for volume expansion in the setting of CHF however albumin is in short supply right now.  There are other solns containing artificial colloids available. 

The general problems with colloid solns are:  Much higher cost than crystalloids  Small but significant incidence of adverse reactions  B/c of gelatinous properties, these can cause platelet B/c dysfunction & interfere with fibrinolysis and coagulation factors thus possibly causing coagulopathy in large volumes.  HR dramatic fluid shifts which can be dangerous if they are not administered in a controlled setting.

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CRYSTALOIDS SALINE 
        

0.9% NORMAL SALINE Think of it as Salt + water Principal fld used for IV resuscitation and replacement of salt lose, D/ V Distribution: Stays almost entirely in the Extracellular space Of 1 litre 750ml ECF; 250ml ICF So for 100 ml blood loss need to give 400 ml NSS [only 25% remains intravascular] 0.45% NORMAL SALINE = Half NSS = HYPO-tonic saline HYPOReserved for severe hyperosmolar states E.g. severe dehydration Leads to HYPOnatraemia if plasma sodium is normal May cause rapid reduction in serum Na+ if used in excess or infused too rapidly.

1.8, 3.0, 7.0, 7.5, 10% Saline = HYPER tonic saline Reserved for plasma expansion with colloids Rarely used in general wards; Reserved for high dependency, specialist areas Distributed almost entirely in the ECF & intravascular space. This leads to an osmotic gradient between the ECF & ICF, causing passage of fld into the EC space. This fld distributes itself evenly across the ECF & intravascular space, in turn leading to intravascular repletion.  Large volumes will cause HYPERnatraemia & IC dehydration. Previous Next 
  

CRYSTALLOIDS

DEXTROSE SOLN S

5% DEXTROSE (D5W) Sugar + Water  Used to maintain H20 balance in pts who are not able to take NPO - post-op in conjuction with salt retaining fluids ie saline; post- Often prescribed as 2L D5W: 1L N.Saline [ Physiological replacement of H20 + Na+ losses]  Provides some calories [ approximately 10% of daily requirements]  Regarded as electrolyte free contains NO Na, K, Chl or Ca  Distribution: <10% Intravascular; > 66% intracelluar  Is rapidly redistributed into the intracellular space; >10% stays in the intravascular space therefore it is of limited use in fluid resuscitation.  For every 100 ml blood loss need 1000 ml dextrose replacement - 10% retained in intravascular space  Common cause of iatrogenic hyponatraemia in surgical Pt DEXTROSE SALINE Think of it as a bit of salt + sugar  Similar indications to D5W; Provides Na+ 30mmol/l + Cl- 30mmol/l - sprinkling of salt + sugar  Used to replace H20 losses post-op post Limited indications outside of post-op replacement post Neither really saline or dextrose  Advantage doesn t commonly cause water or salt overload Previous

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Infusion of isotonic soln into veins Infusion of hypertonic soln into veins Infusion of hypotonic soln into veins 

No fluid mvmt  

Fluid mvmt into veins  

Fluid mvmt out of veins
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Determining Appropriate IVF
Step 1: Assess volume status  What is the volume status of my patient?  Do they have ongoing losses?  Can my patient take PO safely?  Are the NPO for a reason? Step 2: Determine Access  Peripheral IV  Central line  IO line

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Step 3: Select Type of Fluid

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Determining

Con t

HYPOVOLEMIC Patient  ** Always use Normal Saline for goal of volume resuscitation  Normal saline is almost isotonic with blood so it is the best choice!  On surgery or if going to adm more than 3-4 L often use LR. (Addition of lactate that is 3metabolized to bicarbonate to help buffer acidosis) HYPERVOLEMIC Patient  Avoid additional IVF  Maintain access IV access with HepLock NPO Patient now euvolemic  Adm maintenance fluids. Goal: to maintain input of flds to keep up with ongoing losses and normal fld needs  For average adult NPO for >6-12 hrs, consider D51/2NS at 75-100cc/hr >675 Consider pt co-morbidities co Constantly reassess, at least 2x day or with any change  Don t give fluids blindly ie: if the pt is pre-procedure but is old (predisposed to fluid ie: preoverload b/c of stiff LV) or has history of CHF, be CAREFUL!  Pearl: the reason for giving dextrose (D5) is to prevent catabolism.  Daily I/O s, watch lytes Normal PO Intake  No need for fluids if they are taking PO without problems!  Avoid IVF

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Determining

Cont

Step 4: Determine Rate  In medical patients, the rate is always a ballpark and you have to use your clinical judgement. judgement. (Not applicable for PEDS!)  To fluid resuscitate that pt, you might be giving fluids wide open or 500 cc/hr.  Hypovolemic pt may need multiple 1L bolus to reestablish intravascular volume  If you are just giving fluids to the average pt, give fluids at 75-100 cc/hr. Adjust for individual patient 75-

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FLUID RESUSCITATION
Dehydration & Volume Loss  Replace Lost Fluid or Blood  Often requires 2-3 times the amt lost 2 2:1 rule  Shock Management  Controversial  Definitive therapy = Surgery & blood replacement  EMS p judicious replacement  Improve end organ perfusion (BP at 90 - 100 mm Hg) 

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A peds method that can be helpful:

y Ex: y For a 55 kg pt, the maintenance IV fluid rate would be y 4*10 + 2*10 + 35*1 = 95 mL/hour. mL/hour.

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Good Formulas to Remember
For The Hypernatremic Pt: STOP THE ONGOING LOSS! To Calculate H20 Deficit:  Estimate TBW: 50-60% body wt (KG) depending on body composition 50(W vs M)  Calculate Free-Water deficit: [(Na+ - 140)/140] x TBW Free Administer deficit over 48-72 hrs 48Ongoing H20 Losses:  Calculate Free-H20 clearance from urinary flow rate (V) and urine (U) Free(V (U Na + & K + concentrations V V x (UNa + UK)/140 Insensible Losses:  Approximately 10mL/kg per day: less if ventilated, more if febrile. Total:  Add above components to determine fluid administration rate  (typically approximately 50-250 mL/h) 50mL/h)
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Correcting the Hyponatremic Patient y Need raise plasma Na+ by restricting H20 intake & promoting H20 loss y And to correct the underlying disorder! Rate of Correction: y Rate should be slow (approximately 0.5 mmol/L/ hr of Na+) mmol/L/ y Rule of Thumb: limit change in mmol/L of Na+ to ½ the total Thumb: mmol/L difference within the first 24 hours. y More rapid correction is associated with central pontine myelinolysis! myelinolysis! y Reserve hypertonic solns for pts with SEVERE hyponatremia and ongoing neurologic compromise (ie: with Na+ <105 mmol/L in status epilepticus) ie: mmol/L epilepticus)
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Then you can raise it at a rate of 1-2 mmol/L / hr for the 1ST 3-4 hrs 1- mmol/L or until the seizures stop but really no more than 12 mmol/L for the mmol/L st 24 hrs. 1

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Hyponatremia Pearls Cont

Normal TBW is 50-60% 50 So for a 70kg male, if we wanted to raise the Na+ concentration from 105 to 115 mmol/L: mmol/L: [(115 105) x 70 X 0.6] 

which means we require 420 mmol for this patient

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Theory of Fluid Flow 

Flow = diameter4 / length 


Larger catheters = higher flow Short catheters = somewhat higher flow Tubing length Size of Vein Temperature and viscocity of fluid  

Other factors affecting flow 
 

Warm fluids flow better than cold

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Tips on Increasing Flow 

Use a large vein 

Large AC preferred for cardiac arrest, trauma, adenosine & D50 administration 11/4 14 g 

 

Use a short, large bore catheter 

Use short tubing with large drip set 

Macrodrip (10 gtts/ml) and NO extension set gtts/ml)

Use warm fluid with pressure infuser
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Factors Affecting the Flow Rate:

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COMMON VENIPUNCTURE SITE

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Veins in the hand, forearm & antecubital fossa are suitable sites.

Veins in the lower extremities are not suitable b/c of the risk of thrombus formation & possible pooling of meds in areas of VR

Veins in the scalp & feet may be suitable sites for infants.
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The most frequently used sites are the veins of the forearm b/c the bones of the forearm act as natural support and splint.

Assess the veins of both arms closely before selecting a site.

Start the IV infusion distally to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs.
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SELECTION OF PERIPHERAL IV SITE
NO BP on the arm receiving the IV infusion if possible. Do not place restraints over the venipuncture site.
Use an arm board as needed when the venipuncture site is located in an area of flexion.
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Infection

Electrolyte overload

Tissue Damage

Hematoma

Phlebitis

Air Embolism

Thrombophl ebitis

Circulatory overload

Infiltration
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Catheter Embolism
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On an IV tray: IV soln, as ordered IV tubing Needle:, as case may be Tourniquet Antiseptic swabs Plaster & masking tape Arm board, if needed Scissors IVF label
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IV DEVICES

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IV CANULAS 

STEEL NEEDLE / BUTTERFLY SETS  Wing tip needle with a metal cannula  Needle is 0.5 1.5 inches in length G 16 -26  Use in small and fragile bones  Infiltration is more common PLASTIC NEEDLE  Use in short term therapy  Use for rapid infusion and more comfortable for the pt  In-needle catheter can cause catheter embolism In- 

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Types of IV Needles
STEEL NEEDLES: Butterfly catheters, named for the plastic NEEDLES: tabs that look like wings. Used for small quantities of medicine, infants, and to draw blood although the small size of the catheter can damage blood cells. Usually small ga needles. OVER-THEOVER-THE-NEEDLE CATHETERS: Peripheral-IV catheters Peripheralare usually made of various types of Teflon or silicone materials which determines how long the catheter can remain in your vein. Need to be replaced about Q 1 - 3 days. INSIDE-THEINSIDE-THE-NEEDLE CATHETERS: Larger than Over-theOver-theneedle catheters, typically used for central lines.
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Needle GAUGE
smaller the gauge the larger the outside diameter

Violet = Newborn = 26 G  Yellow = Pedia = 24 G (Introcath) (Introcath)  Blue = Adult = 22 G  Green = OB/OR (Adult) = 20 G  Pink = BT/OR = 18 G 

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25 Ga 14 -19 G for rapid fld administration (blood products /anesthetics) 20 21 G for peripheral fat infusion 22 24 G STD IV fluid + clear liquid meds 24 25 G for very small veins
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22 G catheter is smaller than a 14 G  Larger diameter = more fluid able to be delivered  If you need to deliver a large amount of fluid, typically 14- or 16-G catheters are used. 1416

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IV CONTAINERS  Glass or plastic 

Do not write the plastic IV bag with marker pen

IV TUBING 
 

Contains the spike end, drop chamber, roller clamp, Y site and adapter end Use of vented or non vented tubing Shorter 2-ry tubing use for piggyback solns, 2solns, connecting them to the injection site
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DRIP CHAMBER
MICRODRIP 60 gtt/ ml gtt/  Are used if fluid will be infused at 50 ml/ hr  Used if soln contains potent meds that needs to be titrated

MACRODRIP 10 

20 gtt/ ml gtt/

Use if soln is thick or need to infuse rapidly

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FILTERS 
 

Filters provide protection by preventing particles from entering the pt s veins Filters are used in IV lines to trap small particles such as undissolved ABT or salt or meds that have precipitated in solution agency policy regarding the use of filters 0.22 um filter - used for most solutions 1.2 um - solns containing lipids or albumin Special filter for blood components
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NEEDLELESS SYSTEMS  Include recessed needles, plastic cannulas, cannulas, and one-way valves; these onesystems exposure to contaminated needles 

** Do not administer TPN or blood products through a one-way valve one-

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INTERMITTENT INFUSION SETS
Intermittent sets are used when IV accessibility is desired for intermittent adm of meds by IV push or IVPB  An IV lock is attached for intermittent infusion devices  Patency is maintained by periodic flushing with NSS soln (sodium chloride & NSS are interchangeable names)  When adm meds, flush with 1 - 2 mL ( agency policy) of NSS to confirm placement of the IV cannula; adm the cannula; prescribed meds, and then flush the cannula again with 1 -2 mL ( agency policy) of NSS to maintain patency 

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PARTS OF IV TUBING
Protector cap  Spike Connector  Connector to IV cath  Drip chamber  Clamp  2-ry Port 

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ACTION
IV soln type amt, % of soln, rate of flow & meds additives with the MD order (compare medicine ticket with medical order sheet). Wash your hands.

RATIONALE
Ensures that the pt receives the correct IV soln & meds, as ordered by the MD. Prevents the spread of microorganisms.

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ACTION
RATIONALE
Having all equipment available saves time. Prevents the contamination of IV soln and set which can infect the pt rapidly. This punctures the seal in the IV bag or bottle.
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Gather all materials & prepare the IV soln & tubing. Maintain aseptic technique when opening sterile packages and IV soln. Clamp tubing, uncap the spike and insert it into the entry site on the bag or bottle as manufacturer directs. If an additive is ordered, incorporate it before inserting the spike into the entry site.

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PROCEDURE. . . ACTION Gather all materials . . . Suspend the IV soln on a hook in the prep n area and press the drip chamber and allow it to fill at least halfway. Remove cap at end of tubing, release clamp & prime the tube Remove air from the system Close clamp and recap tubing end. Maintain set-up sterility. Id pt & explain the procedure. supine or low Fowler s

RATIONALE
Suction effect causes fluids to move into the drip chamber and also prevents air from moving down the tubing. This removes air from the tubing; in large amounts, this air can act as an air embolus.

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PROCEDURE . . .

ACTION

Suspend the soln bag or bottle on the IV stand. Release the tourniquet when when a return flow of blood to adapter is observed (optional up to doctor).

Fld height should be 1824 in. above the level of the vein, to overcome the venous pressure. Tourniquet venous pressure resulting in automatic backflow, an indication of positive needle insertion into vein.

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Venipuncture Procedure: Tips
Stabilize extremity  Stabilize adjacent skin  Remove restricting band  before removing needle  after drawing blood  Remove needle & place in sharps  Check for adequate flow  RECHECK drip rate 

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Venipuncture Procedure: Tips

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PROCEDURE . .

ACTION Connect the tubing to the needle. Start the flow of soln promptly by releasing the clamp on the tubing. Assess the site for signs of infiltration.
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Rationale

Blood will clot readily if IV flow is not maintained. If the needle accidentally slips out of the vein, the solution will accumulate and infiltrate into surrounding tissue.

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PROCEDURE . . .

Rationale
ACTION
If necessary, support the needle with a small piece of gauze or tissue paper under the hub, to keep it in place.

The pressure of the wall of the vein against the bevel of the needle will interrupt the rate of flow of the solution. The vein walls can be easily punctured by the needle.
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PROCEDURE. . .

Action
Loop the tubing near the site of entry and anchor it with plaster to prevent the pulling out of the needle.

Rationale
The smooth structure of the vein does not offer resistance to the (slipping) movement of the needle. The weight of the tubing is sufficient to pull the needle out of the vein if it is not well-anchored.
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IV Infusion . . .

Action
Anchor the arm to an arm board with liberal lengths of plaster for support, if necessary. Adjust the rate of flow according to the doctor s order. Complete the label and tape it to the IVF bag/bottle.

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Action
Do the after care of equipment, and wash your hands. Document the procedure & pt s response. Chart the time, site, device used, soln, rate of flow and the inserting doctor/nurse.
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IV Infusion . . .

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The Fluid chart

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The Fluid Chart
You need to fill in all the areas of the chart, just like a drug chart.  Useful to record the pt s weight if known; Guestimate and record it if not.  You will note there is a drop rate advised at the bottom of the chart shown in the previous slide 

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INFILTRATION/EXTRAVASATION INFILTRATION/EXTRAVASATION
The most common cause is damage to the wall during insertion or angle of placement. S/S Edema, pain & coolness at the site

STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book.

Notify MD & document

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PHLEBITIS
PHLEBITIS

THROMBOPHLEBITIS

heat, redness, tenderness, not hard, swollen THROMBOPHLEBITIS heat, redness, tenderness, hard & cordlike vein CHEMICAL
- Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. -Anti-inflammatory & analgesic meds

MECHANICAL

BACTERIAL

-bacteria into the vein. Caused by irritation to internal lumen -S/S arm will be painful, red & warm; of vein during insertion of vascular edema may accompany access device and usually appears shortly after insertion. - Remove the device immediately & tx - Remove device & warm compresses ABT.
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CELLULITIS 
Inflammation of loose connective tissue around insertion site. - Caused by poor insertion technique - Red swollen area spreads from insertion site outwardly in a diffuse circular pattern - Treated w/ABT INFECTION redness, swelling & drainage at site; chills, fever, malaise, HA

SEPTICEMIA Severe infection that occurs to a system or entire body Most often caused by poor insertion technique or poor site care D/C device immediately, C&S site & treat appropriately

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Bruising

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CX
PULMONARY EDEMA dt rapid infusion BP, JVD, rapid breathing, dyspnea, moist s/s depend on the specific electrolyte imbalance CIRCULATORY OVERLOAD cough & crackles ELECTROLYTE OVERLOAD

PULMONARY EMBOLISM - Caused by any free floating substances that require thrombolytic therapy for several months. Increased risk w/lower ext. CATHETER EMBOLISM BP, pain along vein, weak, rapid pulse, cyanosis of nail beds, loss of consciousness AIR EMBOLISM obstruction caused by a bolus of air that enters the vein through an inadequately primed IV line, from a loose connection, or during tubing change or removal of IV line S/S tachycardia, dyspnea, hypotension, cyanosis, LOC NI: Keep insertion site below level of heart HEMATOMA ecchymosis, immediate swelling and leakage of blood at the site, and hard painful lumps at the site
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TROUBLESHOOTING GUIDELINES:

1. IF AN INCOMPLETE COLLECTION
OR NO BLOOD IS OBTAINED: needle should form a 15 -30O angle with the surface of the arm Adjust the angle (bevel may be against the vein wall). ‡ Loosen the tourniquet. It may be obstructing blood flow. or move it backward (it may have penetrated too far).
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Change the position of the needle. Move it forward (it may not be in the lumen).

‡ Try another tube. There may be no vacuum in the one being used. ‡ Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site.

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TROUBLESHOOTING GUIDELINES: 3. OTHER PROBLEMS 2. IF BLOOD STOPS FLOWING INTO THE TUBE:

The vein may have collapsed; resecure the tourniquet to venous filling; if not effective REMOVE ! ALSO, the needle may have pulled of the vein when switching tubes. Hold equipment firmly when changing tubes!

A hematoma forms under the skin adjacent to the puncture site - release the tourniquet immediately & withdraw the needle. Apply firm pressure.

Blood is bright red &/or pulsating (arterial) rather than venous. Apply firm pressure X >5 min.
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DOCUMENTATION OF IV THERAPY
DOCUMENT on IV TAPE  Size, type & length of cannula & ga of catheter / needle  Site of insertion (be specific to name of vein, area of arm).  Type of cleansing agent used.  Date & time of insertion & name of person who inserted LABEL THE IV SOLUTION SPECIFYING  Type & amount of IV fluid or meds additives to be infused  Flow rate of infusion  Use of any electronic infusion device  Duration of therapy & nurse s name & signature  Condition of the IV site.  Resident s response to procedure.

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ADMINISTRATION OF IV SOLN 
   

Change - IV site q 48 72 hrs Change - IV dressing q 72 hrs especially when wet and contaminated Change - IV tubing q 24 - 72 hrs Label the tubing, dsg & soln bags indicating the date & time when changed Before adding med or solns, swab access solns, ports with 70% ETOH

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10 GOLDEN RULES FOR ADMINISTERING DRUG SAFELY  

       

Assess complete pt drug history. (There is a risk of ADR when a number of drugs are taken or when pt is taking ETOH drinks) Assess drug allergies Assess potential drug to drug / drug to food interactions. Right drug Right patient. Right dose Right route Right time Document each drug you administer ED patient about the drugs he is receiving
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NI BLOOD TRANSFUSION  

    

A large volume of blood transfused rapidly through a central catheter into the ventricle of the heart will cause cardiac dysrhythmias No solns other than NS should be added on blood components Infusion should not exceed more than 4 hrs Medication are never added to blood components Blood administration set - changed q 4 - 6 hr 2 RN need to check the physicians order, pts identity, pts identification band Check the blood bag tag, label and blood requisition form

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NI con t 
   
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Check the date of expiration Inspect he blood for abnormal color, leaks, clots, bubbles Blood must be administered 20-30 min from 20its being received from the blood bank Never refrigerate blood in refrigerator other than blood bank Monitor vs and assess lung sounds
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CALCULATION OF INFUSION OF UNIT DOSAGE PER HOUR   

Two Steps 1. determine the amount of medication/ ml 2. determine the infusion rate or ml/ hr Amount of medication/ ml  med/ ml = known amount of medication  total volume of diluent Infusion rate  ml/ hr = dose per hour desired  concentration per ml

Order: continuous heparin Na by IV at 1000 units per hour  Available: IV bag 500 ml D5W with 20,000 unit of heparin Na  How Many ml/hr are required to administer the correct dose  Conc/ ml = 20, 000 units Conc/ = 40 units/ ml 500 ml  ml/ hr = 1000 unit =25 ml/ hr 40 unit Previous

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gtts/min gtts/min = volume in cc x DF nos. of hrs x 60 min nos. of hrs = volume in cc x DF gtts/ gtts/ min x 60 min cc/ hr = volume in cc number of hrs Infusion time = total volume to infuse ml/ hr being infused   

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Types of BLOOD COMPONENTS

RBC

to replace erythrocytes in acute & chronic anemia HgB by 1 g/dL & HCT by 2-3% 2-

250 ml PRBC will

WHOLE BLOOD - to resolve hypovolemic shock resulting from excessive bleeding  500 ml  Rarely use

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ALBUMIN 


Tx hypovolemic shock or hypoalbuminemia Prepared from plasma & can be stored for 5 yrs 25g/100ml of albumin = 500ml of plasma 

CRYOPRECIPITATES 
 

To replace factor VIII & fibrinogen Prepared from FFP Can be stored for 1 yr but once thawed, the product must be used
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PLATELET 
   

Tx thrombocytopenia & PLT dysfxn X matching is not required 50 70ml /unit or 200 400ml/ unit Adm immediately & given for 5 30min Evaluate after 1 hr and 24 hrs after transfusion
Use to provide clotting factors or volume expansion Infused within 6 hours of thawing Infused as rapidly as possible X- matching is needed PT & aPTT
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FFP 
   

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TYPES OF BLOOD DONATION
AUTOLOGOUS  Pt own blood before the scheduled procedure  risk of disease transmission & potential transmission cx  q 3 days as long as Hgb remains with in a safe range  Donation should be made within 5 wks of the transfusion date & end at least 3 d before the date of transfusion BLOOD SALVAGE  An autologous donation  Suctioning of blood from body cavities, joint spaces  Blood may need to be washed by a special process that removes tissue debris before reinfusion
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DESIGNATED DONOR

When recipients select their own compatible donors  Does not reduce the risk of contracting infection but they feel comfortable

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COMPATIBILITY 
 

Rh type + ABO type are identified Use to prevent transfusion Rx CrossCross-matching testing of donors blood and the recipients for compatibility

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