IV Therapy for Nurses

Objectives

• Student nurses should be able to describe IV therapy indications, including blood products.
• Student nurses should be able to discuss appropriate IV access devices, placement and rationale for selection.
• Student nurses should be able to recognize signs/symptoms of potential IV therapy complications.
• Student nurses should be able to prioritize nursing interventions for managing patients before, during, and after IV therapies.
• Student nurses should be able to explain the procedure for safely administering blood products.

Provision 3 of ANA Code of Ethics

• The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Why IV Therapy?

• Used in all care settings, including hospitals, extended care facilities, outpatient centers, infusion centers, and homes.
• Reasons include fluid and electrolyte replacement, medication and blood product administration, and nutritional support.

IV Fluids - Purposes

• Maintenance of fluids when oral intake is inadequate.
• Replacement of fluids when losses have occurred.

Solutions used in Infusion Therapy

• Crystalloid solutions can be isotonic, hypotonic, or hypertonic.
• Colloid solutions include plasma expanders.

Tonicity

• Hypotonic solutions move fluid out of the vascular space and into intracellular and interstitial spaces.
• Isotonic solutions increase fluid in the vascular system without causing fluid shifts.
• Hypertonic solutions move fluid from cells into the intravascular space.

Proper IV Order

• The route given intravenously(IV)
• The type of fluid/solution, additives, infusion rate, or volume.
• Example: D5 0.45%NS IV at 100 mL/hr, or D5 0.45% 500 mL over 1 hr

Choosing a Vein for IV Therapy

• Consider vein size, patient condition, characteristics and rate of the solution, and the available intravenous access device.

Types of IV Access Devices

• Peripheral IVs
• Central IVs

Peripheral Venous Access

• Short over-the-needle catheters.
• Steel-winged devices.
• Midline catheters.

IV Catheter Gauge Sizes

• Smaller gauge number equates to a bigger diameter or hole.
• 14G: Trauma, rapid infusions
• 16G: Trauma, surgery
• 18G: Blood transfusions
• 20G: IV fluids and or medications
• 22G: IV fluids, small veins
• 24G: Fragile veins, pediatrics
• 26G: Neonates

Central Venous Access

• Non-tunneled percutaneous central catheters.
• Tunneled catheters.
• Implanted ports.
• Peripherally inserted central catheters (PICC).
• Intraosseous (IO).

PICC Line

• A central venous catheter inserted into an arm vein.
• Can be single or multilumen and non-tunneled.
• Used for patients needing vascular access for 1 week to 6 months.
• Blood pressure readings or blood draws should not be taken from the arm with a PICC line.

Intraosseous (IO) Access

Nursing Management of Infusion Therapy - Styles

• Continuous infusion.
• Intermittent infusion.
• Bolus.
• IV push.

Routine IV Care

• Follow facility policy.
• Scheduled saline flushing is required if no continuous fluids are being infused
• Care and cleaning of the hub.
• Dressings.
• Documentation

Monitoring and Preventing Complications - Fluid Volume Overload

• Assess fluid status
• Perform physical assessments.
• Monitor intake (I) and output (O).
• Take daily weights.
• Monitor serum electrolytes.
• Physical findings include increased blood pressure, dyspnea, wet cough with crackles/rails, increased heart rate, and distended neck veins.

Monitoring and Preventing Complications - Infiltration

• The solution is inadvertently infused into the tissue surrounding the vein.
• Signs include blanched skin, cool skin, edema, unexpected pain/burning, and fluid leakage at the insertion site.
• Extravasation is infiltration caused by a vesicant solution/medication; stop the infusion immediately.

Monitoring and Preventing Complications - Phlebitis

• Inflammation of the vein.
• Causes include chemical, mechanical, and bacterial factors.
• Symptoms include pain and erythema along the vein.
• Graded using the 0-4 Phlebitis Scale.
• May progress to cellulitis, thrombus, or sepsis; remove and replace the IV.

Phlebitis Scale

• Grade 0: No clinical symptoms
• Grade 1: Erythema at access site with or without pain
• Grade 2: Pain at access site with erythema and/or edema
• Grade 3: Pain at access site with erythema, streak formation, and/or palpable cord
• Grade 4: Pain at access site with erythema, streak formation, palpable 1-inch or more venous cord and/or purulent drainage

Monitoring and Preventing Complications - Central Line

• Infection.
• Loss of patency that may be due to thrombotic occlusion or medication precipitation.
• Air embolism.

Special Considerations: Blood Transfusions

• Whole blood.
• Packed Red Blood Cells (PRBCs).
  • Most common; improves oxygen-carrying capacity in trauma, surgeries, and anemia.
• Fresh Frozen Plasma (FFP).
  • Second most common; improves blood clotting.
• Platelets.
  • Given for thrombocytopenia or pre-surgery patients on platelet inhibitors; do not use an IV pump.
• Albumin.
  • Volume expander; improves protein levels and does not require type & cross.

Blood Compatibility

• Type O is the universal donor.
• Type AB is the universal recipient.
• Rh-positive individuals can receive either Rh +/- blood.
• Rh-negative individuals can only receive Rh-negative blood.

Administering Blood Products- Pre-Checks

• Verify the blood order
• Verify that consent has been obtained and signed by the provider and patient.
• Type and cross-match has been completed.
• Patent and appropriately sized IV.
• Gather supplies and equipment
• Determine whether the patient requires pre-medication
• At the bedside, two nurses must verify the blood products
• Two nurse verifications includes blood to order, the patient to blood, ABO & Rh, and that the expirations date are correct
• Patient assessment including vital sounds, along with lung sounds, and a discussion concerning the blood transfusion should be discussed
• Patient Education, along with signs and symptoms of concern such as fever, chills and shortness of breath

Administering Blood Products - Start of Infusion

• Start the infusion slowly at 2mL/min or 120 mL/hr for the first 15 minutes.
• The nurse should remain at the patient's side for the first 15 minutes
• Take the first set of vital signs at 5 minutes.
• Monitor for concerns of reaction such as fever, itching, or dyspnea.
• Set the infusion rate per order but should be no greater than 4 hours, or per hospital policy.

Potential Transfusion Reactions

• Acute hemolytic reaction.
• Febrile nonhemolytic reaction.
• Allergic reaction.
• Circulatory overload.