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• Introduction to Intravenous Infusion • Spike

Administering IV Therapy
- 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
Drip Chamber
• 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
Roller Clamp
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
Checking Drip Chamber and Time Drops
a vent for air to enter to
replace fluid flowing from
the container
– glass bottles
• required for certain
medications
• require a vent to allow air to
enter the bottle as the fluid
leaves the bottle
• Basic Administration Set
• Guidelines for Nursing Care: Regulating IV
for IV Therapy
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
• ensure comfort and safety • Infusion Pump
• macrodrip (10, 15, 20 drops per mL)
– used for rates greater than 75 mL per
hour
• 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
Selected IV Solutions
nurse to monitor the rate at which the solution
is entering the patient Isotonic Solution
• factors: height of the container, BP, patient’s 5% dextrose in water (D5W)
position, patency of the IV catheter, Supplies about 170 cal/L and contains 50 g of glucose
infiltration, knot or kink Should not be used in excessive volumes because it does
• check the infusion every hour or more not contain any sodium; thus the fluid dilutes the
frequently, if indicated amount of sodium in the serum. Brain swelling, or
hyponatremic encephalopathy, can develop rapidly and
• Calculate the flow rate:
cause death unless it is promptly recognized and treated.
EXAMPLE—Administer 1000 mL D5W over
0.9% NaCl (normal saline)
8 hours (set delivers 60 gtt/1 mL).
Not desirable as routine maintenance solution because it
provides only Na+ and Cl-, which are provided in
a. Standard formula excessive amounts.
gtt/min = volume (mL) x drop factor (gtt/mL) May be used to expand temporarily the extracellular
time (minutes) compartment if circulatory insufficiency is a problem;
also used to treat diabetic ketoacidosis.
gtt/min = ?
Lactated Ringer’s Solution
b. Short formula using milliliters per hour
A roughly isotonic solution that contains multiple
gtt/min = mL per hour x drop factor (gtt/mL)
electrolytes in about the same concentrations as found in
time (60 min) plasma (note that this solution is lacking in Mg2+ and
Find milliliters per hour by dividing 1000mL by 8 PO43-)
hours: 1000mL / 8 = 125 mL/hr Used in the treatment of hypovolemia, burns, and fluid
gtt/min = 125 mL/hr x 60 gtt/mL lost as bile or diarrhea
Useful in treating mild metabolic acidosis
60 min/hr
Hypotonic Solution
c. Dimensional Analysis
0.33% NaCl 1/3-strength saline)
gtt/min = gtt x mL x hr
A hypotonic solution that provides Na+, Cl-, and free
mL hr min
water Na+ and Cl- allows kidneys to select and retain
gtt/min = 60gtt x 1000mL x 1 hr needed amounts
1mL 8 hr 60 min Free water desirable as aid to kidneys in elimination of
gtt/min = 125gtt/min solutes
• Count drops per minute in drip chamber 0.45% NaCl ½-strength saline)
(number of gtt/15 sec interval x 4). Hold watch A hypotonic solution that provides Na+, Cl- and free
beside drip chamber. water
• Adjust IV clamp as needed and recount drops Often used to treat hypernatremia (because this solution
per minute contains a small amount of Na+, it dilutes the plasma
• Mark IV container according to agency policy sodium while not allowing it to drop too rapidly)
and manufacturer’s recommendations. Use a Hypertonic Solution
time tape or label if indicated to measure 5% dextrose in 0.45% NaCl
amount to be infused at timed intervals. A common hypertonic solution used to treat
• Monitor IV flow rate at frequent intervals. hypovolemia; used to maintain fluid intake
Document patient’s response to infusion at 10% dextrose in water (D10W)
prescribed rate.
Supplies 340 cal/L • usually introduced into the subclavian or
Used for peripheral parenteral nutrition (PPN) internal jugular vein and passed to the superior
5% dextrose in 0.9% NaCl (normal saline) vena cava just above the right atrium
Replaces nutrients and electrolytes • require radiographic confirmation of position
Can temporarily be used to treat hypovolemia if plasma Types of CVADS
expander is not available • Peripherally Inserted Central Catheters
Vascular Access Devices (PICCs)
• Factors • Nontunneled percutaneous central venous
• length of time the infusion therapy is needed catheters
• type of medication or product that will be • Tunneled central venous catheters
delivered intravenously • Implanted ports
• patient's health status and needs determine • PICCs
which option is used • >20 cm depending on patient size, that can be
• what will pose the least risk for IV introduced into a peripheral vein
complications – basilic, brachial, or cephalic veins
• Peripheral Venous Catheters • advanced as far as the superior vena cava
• Over-the-needle catheters - the most common • specially trained registered nurse or physician
type of peripheral vascular catheter used. can insert this type of catheter
• infusion therapy will be brief, a short (<3 • radiographic verification
inches) peripheral catheter
• single or multiple lumens
• insertion site should be rotated at least every
• PICCs
72 to 96 hours for an adult
• for long-term IV therapy, from 6 weeks to 6
• child - the site can remain in place until the IV
months
intervention is completed unless a
complication develops • normally replaced as needed

• smallest-gauge device is usually selected to – catheter is no longer patent


minimize trauma to the vein – site looks infected.
• Midline Peripheral Catheter • Indications for PICCs
• inserted peripherally, normally through the • administration of IV antibiotics for an
antecubital fossa into the proximal basilica or extended period (2–6 weeks)
cephalic veins • infusion of parenteral nutrition
• longer (>3 inches) than peripheral venous • chemotherapy
catheters
• continuous narcotic infusions
• not considered to be central lines
• vesicants, hyperosmolar solutions
• should not be used to infuse vesicants or
• blood components
hyperosmolar or irritating solutions
• other specific medications (eg, vasopressors,
• length of time - median of 7 days, but possibly
anticoagulants)
as long as 49 days. Follow agency policy for
rotation of midline catheter insertion site. • long-term rehydration

• Central Venous Access Devices • Advantages of PICC

• (CVADs) are now an integral component of • less risk of complications because the catheter
patient care in acute, ambulatory, and subacute is inserted peripherally
care settings, as well as in the home and long- – infection
term care facilities. – pneumothorax
• provide access for a variety of IV fluids, • cost effective
medications, blood products, and TPN
• provide adequate hemodilution for medications
solutions
• Nontunneled Percutaneous Central Venous
• allow a means for hemodynamic monitoring
Catheters
and blood sampling
• have a shorter dwell time (3–10 days)
• CVAD
• introduced through the skin into the internal the upper chest wall, and no external parts of
jugular, subclavian, or femoral veins and the system are visible
sutured into place • placed in the antecubital area of the arm
• can have double, triple, or quadruple lumens (peripheral access system ports)
• >8 cm, depending on patient size • initially used for chemotherapy
• Nontunneled Percutaneous Central Venous • Implanted Port
Catheters • now used for any patient requiring long-term
• tip rests in the superior vena cava intermittent infusions
• may be inserted at the bedside or in outpatient • a special angled noncoring needle is inserted
settings through the skin and rubber septum and into
• associated with a high risk for complications , the port reservoir
accounting for most catheter-related • require minimal care, but the discomfort of
bloodstream infections accessing the port may be a disadvantage for
– infection some patients
– pneumothorax the catheter is placed • Implanted Port

– in the subclavian vein. • numbing cream can be applied to the site


before needle insertion (ensure that all of the
triple-lumen nontunneled percutaneous central venous cream is removed and the skin adequately
catheter cleaned before accessing the port)
• associated with the lowest risk for catheter-
related bloodstream infections
• patients report improved self-image
• surgery is required for catheter removal.

• Tunneled Central Venous Catheter


• intended for long-term use
• implanted into the internal jugular subclavian,
or femoral vein
• length of this catheter is >8 cm, 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, but after 7 to 14
days, the sutures are removed.
• subcutaneous tissue attaches to a Dacron •
polyester cuff around the catheter, helping to • STARTING AN
stabilize the catheter and minimize the risk for INTRAVENOUS INFUSION
infection
• Equipment
• associated with a lower incidence of infection
• IV solution
than is the nontunneled central venous catheter
Towel or disposable pad
• Tunneled Central Venous Catheter Nonallergenic tape
• Implanted Port IV infusion set
• >8 cm, depending on patient size Gauze or transparent dressing (according to
agency policy)
• tip is placed in the subclavian or internal
Electronic infusion device (if ordered)
jugular vein, but the proximal end or port is
usually implanted in a subcutaneous pocket of
IV tubing Tourniquet for allergies. Check for color, clarity, expiration
Time tape or label (for IV container) date, etc.
• Equipment Rationale
• Armboard (if needed) This ensures that the correct IV solution and rate of
Cleansing swabs (chlorhexidine preferred, infusion, and/or medication will be administered.
alcohol, povidone-iodine) 2. Know the techniques for IV insertion, precautions,
Site protector or tube-shaped elastic netting purpose of the IV administration and medications if
(optional) Clean gloves ordered.
IV pole
This knowledge and skill is essential for safe and
Anesthetic (numbing) cream (if ordered)
accurate IV and medication administration.
Lidocaine 1% injection (if ordered)
1-mL syringe (for lidocaine) 3. Gather all equipment and bring to the bedside.
IV catheter (over the needle, Angiocath) or Having equipment available saves time and facilitates
butterfly needle accomplishment of the task.
• Butterfly 4. Identify the patient. Ask the patient if he/she is
allergic to any medication, iodine, or tape, as
appropriate. If considering using an anesthetic
(numbing) cream or 1% lidocaine injection, check
for allergies for these substances as well.
Identi fication of the patient ensures that the right
patient receives the correct IV administration and
medication as ordered.
Possible allergies may exist related to medications,
• Angiocath iodine, tape, anesthetic cream or lidocaine injection.
Injectable anesthetic can result in allergic reactions,
tissue damage, and inadvertent injection into the
vascular system.
5. Explain the need for the IV and procedure to the
patient
• Neoflon Explanation allays anxiety.
6. Perform hand hygiene. If using an anesthetic cream,
apply the anesthetic cream to a few potential insertion
sites.
Hand hygiene deters the spread of microorganisms.
Anesthetic (numbing) cream decreases the amount of
pain felt at the insertion site. Some of the numbing
creams take as long as an hour to become effective.
7. Prepare IV solution and tubing:
Venflon
a. Maintain strict aseptic technique when opening
sterile packages and IV solution.
Asepsis is essential for preventing the spread of
microorganisms
b. Clamp IV tubing, uncap spike on the administration
set, and insert into the entry site on the IV bag or bottle
as the manufacturer directs.
This punctures the seal in the IV bag or bottle.
Clamping the IV tubing prevents air and fluid from
entering the IV tubing at this time
c. Squeeze the drip chamber and allow it to fill at least
halfway

Actions
1. Verify the IV order against the physician order.
Clarify any inconsistencies. Check the patient's chart
Suction causes fluid to move into the drip chamber and The use of an appropriate vein decreases discomfort for
prevents air from moving down the tubing. the patient and reduces the risk for damage to body
tissues.
11. If the site is hairy and agency policy permits, clip a
2-inch area around the intended site of entry.
Hair can harbor microorganisms.
12. Apply a tourniquet 3 to 4 inches above the
venipuncture site to obstruct venous blood flow and
distend the vein. Direct the ends of the tourniquet away
from the site of entry. Make sure the radial pulse is still
present.
d. Remove the cap at end of the IV tubing and while Interrupting the blood flow to the heart causes the vein
maintaining its sterility, open the IV tubing clamp, and to distend. Distended veins are easy to see, palpate, and
allow fluid to move through tubing. Allow fluid to flow enter. The end of the tourniquet could contaminate the
until all air bubbles have disappeared and the entire area of injection if directed toward the site of entry.
length of the tubing is primed (filled) with IV The tourniquet may be applied too tightly, so
solution. Close the clamp and recap the end of tubing, assessment for the radial pulse is important.
maintaining sterility of the setup.
This technique prepares for IV fluid administration and
removes air from tubing. In large amounts, air in the
tubing can act as an embolus.
e. If an electronic device is to be used, follow the
manufacturer's instructions for inserting the tubing and
setting the infusion rate.
This ensures correct flow rate and proper use of
equipment.
13. Instruct the patient to hold the arm lower than the
f. Apply the label if medication was added to container heart.
(pharmacy may have added medication and applied the
Lowering the arm below the heart level helps distend
label). Label the tubing with the date and time that
the veins by filling them.
tubing was hung.
14. Ask the patient to open and close the fist. Observe
This provides for administration of correct solution with
and palpate for a suitable vein. Try the following
prescribed medication or additive. Labeling the tubing
techniques if a vein cannot be felt:
alerts nursing staff of the need for IV tube changes.
Consult hospital policy. In general, IV tubing is changed Contracting the muscles of the forearm forces blood into
every 72 hours. the veins, thereby distending them further.
g. Place time-tape on the container and hang the IV on a. Massage the patient's arm from proximal to distal
the pole. end and gently tap over the intended vein.
This permits immediate evaluation of the IV according Massaging and tapping the vein help distend veins by
to the time-tape schedule. filling them with blood.
8. Place the patient in low Fowler's position in bed. b. Remove the tourniquet and place warm moist
Place protective towel or pad under the patient's arm. compresses over the intended vein for 10 to 15 minutes.
Close the door to the room or pull the bedside curtain. Warm moist compresses help dilate veins.
The supine position permits either arm to be used and 15. Put on clean gloves.
allows for good body alignment. Gloves protect against transmission of HIV, hepatitis,
Closing the door provides for patient privacy. and other blood-borne infections.
9. Provide emotional support as needed. 16. If using intradermal lidocaine, cleanse the insertion
The patient may experience anxiety because he/she may site with alcohol using a circular motion. Inject a small
fear needle stick or IV infusion in general. amount (0.2 to 0.3 mL) of lidocaine into the area. If
10. Select and palpate for an appropriate vein. Avoid numbing cream was used, wipe cream off the insertion
an arm that has been compromised, such as with the site. Cleanse the site with an antiseptic solution such
presence of arteriovenous fistula. as chlorhexidine or according to agency policy. Use a
circular motion to move from the center outward for
several inches.
The lidocaine numbs the skin and makes the insertion 22. Secure the catheter with narrow nonallergenic tape
less painful. Cleansing that begins at the site of entry (½ inch) placed with the sticky side up under the hub
and moves outward in a circular motion carries and crossed over the top of the hub.
organisms away from the site of entry. Organisms on the The weight of the tubing is sufficient to pull it out of the
skin can be introduced into the tissues or the vein if it is not well anchored. Nonallergenic tape is less
bloodstream with the needle. Chlorhexidine is the likely to tear fragile skin.
preferred antiseptic solution but iodine, iodophor, and
23. Place sterile dressing over the venipuncture site.
70% alcohol are considered acceptable alternatives. If
Agency policy may direct nurse to use gauze dressing or
there is difficulty visualizing or palpating the intended
transparent dressing. Apply tape to dressing if
vein for IV insertion, a tourniquet may be left in place.
necessary. Loop the tubing near the site of entry, and
17. Use the nondominant hand, placed about 1 or 2 anchor to dressing.
inches below the entry site, to hold the skin taut against
Transparent dressing allows easy visualization. Gauze
the vein. Avoid touching the prepared site. Ask the
dressings are capable of absorbing drainage.
patient to remain still while the venipuncture is
performed. Securing the Catheter

Pressure on the vein and surrounding tissues helps


prevent movement of the vein as the needle or catheter
is being inserted. The needle entry site and catheter must
remain free of contamination from unsterile hands.
Patient movement may prevent proper technique for IV
insertion.
18. Enter the skin gently, holding the catheter by the hub
in your dominant hand, bevel side up, at a 10- to 15-
degree angle. The catheter may be inserted from directly
over the vein or the side of the vein. While following the
course of the vein, advance the needle or catheter into 24. Label the IV dressing with the date, time, site, and
the vein. A sensation of “give” can be felt when the type and size of catheter used for the infusion on the
needle enters the vein. tape anchoring the tubing.
This allows the needle or catheter to enter the vein with Other personnel working with the infusion will know
minimal trauma and deters passage of the needle what type of device is being used, the site, and when it
through the vein. was inserted. IV insertion sites are changed every 48 to
19. When blood returns through the lumen of the needle 72 hours or according to agency policy (Lavery, 2005).
or the flashback chamber of the catheter, advance either 25. Remove all equipment and dispose of properly.
device 1/8 to ¼ inch farther into the vein. A catheter Remove gloves and perform hand hygiene.
needs to be advanced until the hub is at the venipuncture Hand hygiene deters the spread of microorganisms.
site, but the exact technique depends on the type of
26. Anchor arm to an armboard for support if necessary,
device used.
or apply a site protector or tube-shaped mesh netting
The tourniquet causes increased venous pressure, over the insertion site. Explain to the patient the purpose
resulting in automatic backflow. Placing the catheter of the armboard and the importance of safeguarding the
well into the vein helps to prevent dislodgement. site when using the extremity.
20. Release the tourniquet as soon as possible. Quickly An armboard or site protector helps to prevent the
remove the protective cap from the IV tubing and attach position of the catheter in the vein from changing.
the tubing to the catheter or needle. Stabilize the
27. Adjust the rate of solution flow according to the
catheter or needle with your nondominant hand
amount prescribed, or follow manufacturer's directions
Bleeding is minimized and the patency of the vein is for adjusting flow rate on infusion pump.
maintained if the connection is made smoothly between
The physician prescribes the rate of flow.
the catheter and tubing
28. Document the procedure and the patient's response.
21. Start the flow of solution promptly by releasing the
Chart the time, site, device used, and solution.
clamp on the tubing. Examine the tissue around the
entry site for signs of infiltration This provides accurate documentation and ensures
continuity of care.
Blood clots form readily if IV flow is not maintained. If
the catheter accidentally slips out of the vein, the 29. Return to check the flow rate and observe the IV site
solution will accumulate (infiltrate) into the surrounding for infiltration 30 minutes after starting the infusion.
tissue. Ask the patient if he/she is experiencing any pain or
discomfort related to the IV infusion.
This documents the patient's response to infusion. Avoid further use of the vein.
Pain is a symptom often associated with IV Restart the infusion in another vein.
complications such as infiltration and phlebitis. * Thrombus: a blood clot Tissue trauma from
• Sources of Catheter Contamination needle or catheter
• Hands of the caregiver > Symptoms similar to phlebitis IV fluid flow may
• Skin bacteria that contaminate the catheter cease if clot obstructs needle
during insertion ^ Stop the infusion immediately.
• Disconnection of the tubing or injection cap Apply warm compresses as ordered by the
from the catheter hub, allowing bacteria to physician.
enter the closed system or multiple-lumen Restart the IV at another site.
catheters Do not rub or massage the affected area.
• Poor insertion technique * Speed shock: the body's reaction to a substance
that is injected into the circulatory system too
• An IV solution that becomes contaminated
rapidly
when solutions are changed, a medication is
Too rapid a rate of fluid infusion into circulation
added, or the solution is allowed to infuse for
too long a period > Pounding headache, fainting, rapid pulse rate,
apprehension, chills, back pains, and dyspnea
• Complications Associated With Intravenous
Infusions ^ If symptoms develop, discontinue the infusion
immediately.
*Complication/Cause
Report symptoms of speed shock to the physician
Infiltration: the escape of fluid into the immediately.
subcutaneous tissue Dislodged needle Penetrated Monitor vital signs if symptoms develop.
vessel wall Use the proper IV tubing.
>Sign and Symptoms Carefully monitor the rate of fluid flow.
Swelling, pallor, coldness, or pain around the Check the rate frequently for accuracy. A time tape
infusion site; significant decrease in the flow rate is useful for this purpose.
^Nursing Considerations * Fluid overload: the condition caused when too
large a volume of fluid infuses into the circulatory
Check the infusion site several times per shift for
system
symptoms.
Too large a volume of fluid infused into circulation
Discontinue the infusion if symptoms occur.
Restart the infusion at a different site. > Engorged neck veins, increased blood pressure,
Limit the movement of the extremity with the IV. and difficulty in breathing (dyspnea)
* Sepsis: microorganisms invade the bloodstream ^ If symptoms develop, slow the rate of infusion.
through the catheter insertion site Notify the physician immediately.
Poor insertion technique Multilumen catheters Monitor vital signs.
Long-term catheter insertion Carefully monitor the rate of fluid flow.
Frequent dressing changes Check the rate frequently for accuracy.
> Red and tender insertion site Fever, malaise, * Air embolus: air in the circulatory system
other vital sign changes Break in the IV system above the heart level
allowing air in the circulatory system as a bolus
^ Assess catheter site daily.
Notify physician immediately if any signs of > Respiratory distress
infection. Increased heart rate
Follow agency protocol for culture of drainage. Cyanosis
Use scrupulous aseptic technique when starting an Decreased blood pressure
infusion. Change in level of consciousness
* Phlebitis: an inflammation of a vein ^ Pinch off catheter or secure system to prevent
Mechanical trauma from needle or catheter entry of air.
Chemical trauma from solution Place patient on left side in Trendelenburg position.
Septic (due to contamination) Call for immediate assistance.
Monitor vital signs and pulse oximetry.
> Local, acute tenderness; redness, warmth, and
slight edema of the vein above the insertion site
^ Discontinue the infusion immediately.
Apply warm, moist compresses to the affected site.