Chapter 25

INTRAVENOUS THERAPY
Carol Chamley and Michelle Wilson

Introduction
This presentation outlines the principles of caring for a patient receiving intravenous fluid therapy.
Part 1 - Historical Background to Intravenous Therapy Part 2 - Definition and Scope of Intravenous Therapy Part 3 - Physiology: Fluid Compartments, Movement of Body Fluids and Acid: Base Balance and pH Values Part 4 - Classification of Solutions Part 5 - Methods of Cannulation and Fluid Delivery Part 6 - Principles of Caring for the Patient Part 7 - Complications of Intravenous Therapy Part 8 Reflective Practice

PART 1: Historical Background to Intravenous Therapy

Historical Background
Historically, methods for gaining vascular access have been recorded for approximately four centuries. A major landmark came with the discovery of the circulation of blood and the unfolding of anatomical structures within the human body. This discovery was made by William Harvey (pictured).

The idea of circulation probably existed before its discovery in 1628, but it is considered the greatest medical finding due to its enormous effect upon knowledge and clinical practice. Harveys theory has remained untouched and unchanged for centuries.

Medical experimentation and discovery were quite limited during the 18th century, with greater progress being made during the 19th century when knowledge and science sped up the understanding of human physiology.
In 1831 it was reported that cholera victims, who lost vast amounts of salts and water, could have their health restored with injections of water directly into the bloodstream (Dudrick 2006).

Historical events have therefore facilitated a complex and potentially hazardous therapeutic modality to evolve into a commonly applied practice (Dudrick 2006). The field of intravenous therapy has been subject to change over time, with increasing numbers of nurses taking on high profile technological aspects of patient care. The previously medicalised task of cannulation has been welcomed by nurses who are keen to embrace the concept of holistic care.

PART 2: Definition and Scope of Intravenous Therapy

Definition and Scope

Intravenous fluid therapy is an integral part of care for many patients.
The word intravenous literally means within a vein.

Intravenous therapy, also referred to as IV therapy, constitutes the administration of liquid substances directly into a vein and the general circulation through venepuncture (Mosby 1998).

The intravenous route is a fast and efficient method to administer fluids and medication, which can be given continuously or intermittently.

Currently the scope of IV therapy and the evolving range of solutions is immense. Infusion therapy may range from mere measures to hydrate a patient to more complex administration during resuscitation, and the administration of medication including toxic cancer drugs.

The infusion of sterile fluids may be:

Sterile solutions Medication Blood or blood products

According to Brooker (2007) and Martin (2003) intravenous fluid therapy may be used to: Replace fluids and replace imbalances. Maintain fluid, electrolyte and acid-base balance. Administer blood and blood products. Administer medication. Provide parenteral nutrition. Monitor cardiac function. Refer to the RCN (2003) Standards for Intravenous Therapy (www.rcn.org).

PART 3: Physiology: Fluid Compartments, Movement of Body Fluids and Acid Base Balance and pH Values

Physiology

Water is the major constituent of the human body, and body tissue fluids play an important role in maintaining equilibrium in the body. This equilibrium is known as homeostasis.

Fluid Compartments
Functionally, total body water can be divided into two major compartments: Extracellular fluid (ECF) Approximately 80% of extracellular fluid is interstitial, which occupies the microscopic spaces between cells. Approximately 20% of extracellular fluid is plasma, which is the liquid portion of blood Intracellular fluid (ICF). This is also known as cytosol and is the fluid within cells.

Distribution of body fluids

30 25 20 15 10 5 0 Intercellular Fluid Interstitial Fluid Plasma (ICF) Extracellular Fluid (ECF)
16% body weight (9.6l) 4% body weight (2.4l) 40% body weight (24l)

Volume (litres)

 Within the body it is essential that substances move around. Substances will move from areas of high concentration to low concentration and a concentration gradient will exist between the two. No energy is required for these physiological movements as they are described as passive. Movement is facilitated through processes of osmosis or diffusion.

OSMOSIS Osmosis is the movement of water, which goes down the concentration gradient, across a semipermeable membrane when equilibrium cannot be achieved by diffusion of solute molecules.

DIFFUSION Diffusion refers to the movement of a chemical substance from an area of high concentration to an area of low concentration. This process mainly occurs in gases, liquids and solutions.

High concentration

Low concentration

Acid-base Balance and pH Values

Body fluids have pH values that must be maintained within relatively narrow limits for normal cell activities. A pH value of 7 and below indicates an acid solution.

A pH value of 7 and above indicates an alkaline solution.

Acid-base Balance
Bicarbonate 20 parts/carbonic acid 1 part

DEATH

ACIDOSIS S

NORMAL L

ALKALOSIS IS

DEATH

6.80

7.35
pH level

7.45

7.80

pH Values of Body Fluids

Saliva 5.4 7.5

Blood 7.35 7.45

Body Fluids and pH

Gastric Juice 1.5 - 3.5

Urine 4.5 8.0

Bile 6 8.5

PART 4: Classification of Solutions

Classification of Solutions
There are three main types of fluid which include: Isotonic fluids. Hypotonic fluids. Hypertonic fluids.

Intravenous fluids are divided into:

Crystalloids - a clear aqueous solution of mineral salts and other watersoluble molecules, for example 5% Dextrose Solution.
Colloids - contain large insoluble particles which are referred to as solutes, for example blood, or blood products.

PART 5: Methods of Cannulation and Fluid Delivery

Methods of Cannulation and Fluid Delivery

There are a number of veins available for intravenous cannulation. Intravenous cannulation is a clinical procedure which is carried out by the doctor, or nurses who have undergone special training to prepare them for this role.
Several factors will determine the choice of vein, including: Suitability of the vein for the job required Accessibility of alternative sites Duration of catheter use Success rate Complication rate Urgency of cannulation

Internal Jugular Vein (IJV)

External Jugular Vein (EJV) Choice of vein

Antecubital Veins

Femoral Vein

Subclavian Veins

Cannulation is the insertion of a cannula into a blood vessel, using a small flexible tube that is sometimes guided by a pointed instrument known as a trocar. There are a variety of cannulae available for use. Choice will very much depend upon the purpose and urgency of the situation.

From www.hku.hk

Intravenous fluid is normally administered via bags or bottles of fluid.

The fluid is delivered through a sterile, single-use administration set also known as a giving set. See the printed text for more information.

The method of fluid delivery will depend upon the patients condition and the urgency of the situation. Commonly, access is achieved through: Needle and syringe Peripheral Intravenous lines Central Intravenous lines Peripherally Inserted Central Catheter (PICC) Syringe Pumps Central Venous Lines Implantable Ports Epidural Pump Ambulatory Pump Subcutaneous Infusion (Hyperdermolysis)

The potential use of intraosseous (IO) infusions for adults was first explored some 80 years ago (Deboer et al 2005). Until recently the procedure was the preserve of paediatrics, being utilized as a medical rescue technique. It is now recognised as a valuable adjunct to adult and paediatric care. It is an effective, reliable and relatively simple procedure to gain vascular access and administer fluids and medication in emergency care.

Recent technological advances ensure that intraosseous devices are safe and reliable.
Bone marrow functions as a non-collapsable vein, and access can potentially be gained successfully within one minute (Deboer et al 2005). Potential complications associated with intraosseous infusion include: Osteomylitis Micro-fat-emboli Infiltration and subsequent Compartment Syndrome Inhibition of bone growth

PART 6: Principles of Caring for the Patient

Principles of Caring for the Patient

Intravenous therapy is a relatively common clinical procedure, however nurses need to be knowledgeable about the following:
Related anatomy, physiology and pharmacology Procedure and method of delivery Infection control and universal precautions Safe drug/fluid calculations Types of fluids to be used Maintaining accurate fluid balance charts Duty of care and accountability (NMC 2004)(www.nmcuk.org) Monitoring for incompatibilities, contraindications, side effects and complications Maintenance of accurate patient records including fluid balance charts (NMC 2002) Trust policy and procedures and mechanisms for reporting errors

The overriding principles of care for the patient are to ensure the comfort, safety and dignity of the patient. Ideally the non-dominant arm is used to site the infusion.
Practitioners must also be sensitive to cultural issues, for example Muslims use the left hand for personal cleaning and the right hand for feeding (Brooker 2007).

Intravenous infusion bags/bottles are changed using aseptic technique.

All intravenous fluids are prescribed by the doctor, but it is the responsibility of the registered nurse to ensure that the correct fluid is administered to the correct patient.

PART 7: Complications of Intravenous Therapy

Complications of Intravenous Therapy

Possible complications include: Infection Anaphylaxis Speedshock Phlebitis Infiltration Extravasation

PART 8: Reflective Practice

Reflective Practice
Reflective practice is a critical element of health care practice.
Reflection encourages us to examine and think about what we do. Furthermore, it is a process which facilitates better understanding of a situation and questions how we might, or might not, do things differently next time.

Description: what happened?

Action plan: if it arose again, what would you do? Reflective Cycle Feelings: what were you thinking and feeling?

Conclusion: what else could you have done?

Evaluation: what was good and bad about the experience?

Analysis: what sense can you make of the situation?

There are many models available for structured reflection, for example Gibbs (1988) model, which is a reflective cycle beginning with the description and finishing with an action plan for future practice.

1.Description 6.Action Plan Reflective Practice 5.Conclusion 4.Analysis 3.Evaluation

2.Feelings

Q. Reflect upon a situation when nursing a patient with intravenous therapy and, utilizing a model of structured reflection, work through the situation from description to the formulation of an action plan.