Intravenous (IV) Therapy Basics

Intravenous (IV) Therapy

• This involves injecting a solution directly into a vein
• Administration is most effective when a large fluid volume is administered quickly, or when medications need rapid absorption
• A physician's written order is required, including the date, the solution or medication type, dosage, rate, and frequency

Advantages of IV Therapy

• Drugs are administered directly into a vein through syringe injection
• Drugs are administered intermittently or by continuous infusion via peripheral or central line
• It is generally a more comfortable drug administration route compared to intramuscular or subcutaneous routes

Disadvantages of IV Therapy

• IV administration requires more time
• Administration requires a skilled healthcare provider
• Patient mobility is decreased
• Infection risk is increased
• There is an increased risk of severe adverse drug reactions

Intravascular Compartments

• Intravascular compartment includes the blood vessels; arteries, veins, and capillaries
• Intracellular compartment exists inside cells
• Interstitial compartment is the space between cells
• Extracellular compartment includes both intravascular and interstitial aspects
• Extracellular compartment makes up 1/3 of total body water
• Intracellular compartment accounts for the other 2/3 of total body water

Equipment for IV Therapy

• IV administration sets connect a large volume IV bag with the IV access device in a patient's vein
• Sets include spikes, drip chambers, tubing with control clamps, and needle adapters
• Macrodrip chambers deliver 10, 15, or 20 drops per mL
• Microdrip chambers deliver 60 drops per mL

Infusion-Control Pumps

• All devices used for IV fluids and drug administration have safety features
• Safety features include alarm systems, auto-stop capability, and programmability
• Controllers work by gravity
• Some pumps are nonvolumetric while others are volumetric
• Syringe pumps also exist

Intravenous Access Devices

• Peripheral Access Devices: Short-term use in peripheral veins of the hand or forearm
• Midline Catheters: Used for 2-4 weeks; are inserted into intermediate-sized veins and advanced into larger vessels
• Central Devices: Inserted into intermediate-sized vessels
• Implantable Venous Infusion Ports: Surgically placed into central veins for long-term therapy

Peripheral Access Device

• Typical sites are the hand or forearm
• Typical clients are infants or geriatrics
• Extension tubes with injection ports are attached to the catheter when IV therapy is unnecessary but venous access is beneficial (saline or medlock)
• Blood samples should not be drawn from this site

Central Access Devices

• Subclavian, jugular, or femoral veins are potential sites
• Surgically placed tunneled central venous catheters exit on the chest
• Implantable infusion ports into the central vein for long-term therapy are used for fluids, meds, total parenteral nutrition, and chemotherapy, accessed with a 90-degree Huber needle

Types of IV Solutions

• These consist of water-containing solutes
• The concentration of dissolved particles is known as osmolality
• Given to replace body losses of water and electrolytes from a variety of conditions
• Electrolytes include sodium, chloride, and potassium

Isotonic Solution

• Same osmolality as body fluids
• Used to expand intravascular fluid volume and replace fluid loss
• 0.9% sodium chloride is also known as normal saline and is the only solution compatible with blood
• Other examples include 5% dextrose in water (D5W) and Lactated Ringer's (LR)
• Useful for blood loss, dehydration, fluid maintenance, and diabetic ketoacidosis

Hypertonic Solution

• Higher salt and lower water content
• Vessels are more concentrated than cells-- water leaves the cell
• Results in cell shrinkage
• Examples: 5% saline, 3% saline, 5% dextrose in 0.9% saline, and 5% dextrose in LR (D5LR)
• Useful in cases of cerebral edema, hyponatremia, metabolic alkalosis, and hypovolemia

Hypotonic Solution

• Water shifts out of the vessel and into the cell
• Lower salt and higher water content
• Results in cell swell
• Examples: 0.45% saline, 0.33% saline, 0.225% saline, and 5% dextrose in water
• Useful for kidneys to excrete fluids or deal with hypernatremia
• Do not administer to clients with ICP, burns, or trauma

Large-Volume Solution Containers

• Plastic and glass containers are vacuum sealed
• Glass containers are sealed with a hard rubber stopper and metal disk. Remove the cap and disk prior to use
• Volumes range from 100 to 2000 mL

Small-Volume Solution Containers

• These are administered by intermittent infusion through a tandem setup, piggyback, or IV rider
• Most intermittent diluted drug infusions are infused over 20 to 60 minutes

Administration of Medications by the Intravenous Route

• Medications for IV administration come in ampules, vials, prefilled syringes, and large-volume IV solution bags
• Administration is conducted via peripheral or central intravenous access

General Principles of IV Medication Administration

• Know the drug's purpose, using the seven rights
• Determine involved compatibility issues
• Employ aseptic technique
• Use the SASH method (Saline, Administer drug, Saline, Heparin)
• Calculate drip rates properly

Nursing Responsibilities

• Care for sites and implanted ports
• Conduct dressing changes
• Flush catheters
• Discontinue IV infusions as needed
• Know which medications are compatible for IV infusion
• Carefully check drug orders for dose and recommended infusion rate for all IV medications

Monitoring IV Therapy

• Assess site of insertion and equipment use
• Conduct flushing, medication administration, and dressing procedures
• Perform nursing interventions by discontinuing the IV line when appropriate and providing patient teaching

Complications of IV Therapy

• Phlebitis/thrombophlebitis, infection, or septicemia
• Infiltration/extravasation
• Air embolus
• Circulatory overload/pulmonary edema
• Speed shock

Phlebitis and Thrombophlebitis

• Irritation of the vein by the catheter itself
• Chemical irritation from medicines
• Infection from improper aseptic technique
• Thrombophlebitis is caused by clot and inflammation

Infiltration

• IV fluid leaks into the surrounding tissue
• Treatment: Discontinue the IV and insert a new IV line with new equipment checking cap refill and pulse proximal to the site

Extravasation

• Potent and corrosive medications (vesicants) infiltrate the tissues
• Treatment: Discontinue IV but leave catheter in place; a HCP prescribes the aspiration of vesicant and administers phentolamine on the side to minimize tissue damage

Septicemia

• Pathogens invade the bloodstream
• This triggers an inflammatory response
• Suspect if flushing, fever, vomiting, nausea, headache, malaise, hypotension, weak and rapid pulse are present
• Anticipate discontinuation of the IV catheter, blood culture, and antibiotic therapy once the culture is complete.

Air Embolus

• Air bubbles enter the cardiovascular system
• Signs/Symptoms: Palpitations, tachycardia, chest pain, shortness of breath, cyanosis, hypotension, weak pulse
• Action: Position the client on the left side with the head in a dependent position, administer O2, and notify HCP stat
• Anticipate drawing ABG and ventilatory support measures
• Prevention: Clamping the catheters, Valsalva maneuver during tubing and injection, not allowing IV containers to run dry, and removing all air from tubing or syringes before connection

Circulatory Overload and Pulmonary Edema

• Too much fluid infused too rapidly in patients with cardiovascular disease
• Signs/Symptoms: Engorged neck, dyspnea, reduced urine output, edema, bounding pulse, and shallow/rapid respiration
• Pulmonary edema symptoms: dyspnea, crackles, anxiety, potential cardiac dysrhythmias, and irregular blood pressure
• Action: Slow/stop the IV infusion immediately, position the client's head in High Fowler position, start O2, take vitals, and notify HCP stat. Anticipate orders of diuretics, vasodilators, and morphine sulfate. Severe cases may need intubation

Pulmonary Embolism

• Caused by foreign materials being injected into the vein or blood clots that travel to the lungs lodging in the arterioles
• Signs/Symptoms: Apprehension, dyspnea, pleuritic chest pain, sweating, tachycardia, cough, hemoptysis, low-grade fever, cyanosis
• Action: Place the client in semi-Fowler’s position, administer O2, and notify the HCP
• Prevention: Use Inline filters, proper reconstitution diluents, completely dissolve meds, and ensure no visible foreign materials are in the IV solution

Speed Shock

• This is a systemic reaction to a foreign substance being infused rapidly in the bloodstream
• Leads to shock, syncope, or cardiac arrest
• Prevention: carefully timing IV push medications using a clock or keeping direct observation
• Additionally using frequent checking of IV rate infusions, using infusion control devices and resisting speeding up of medications helps
• Asses the patient for lightheadedness, tightness in the chest, hypotension and anaphylaxis before initiating therapy
• Action if suspected: Stop the infusion stat, keep IV patent using a TKO rate, obtain VS, and notify HCP