IV Therapy: Indications and Standards

• IV therapy involves administering fluids or medications directly into the bloodstream via a needle or catheter (cannula).
• Nurse Practice Acts regulate IV therapy; scope of practice varies by state for LPNs/LVNs.
• The Infusion Nurses Society (INS) provides standards of practice for infusion therapy.
• The Institute for Healthcare Improvement (IHI) provides information on central line care.
• The National Institute for Occupational Safety and Health (NIOSH) oversees workplace safety related to IV therapy.
• The American Society for Parenteral and Enteral Nutrition (ASPEN) offers resources for IV nutrition.

Indications for IV Therapy

• IV therapy administers fluids, electrolytes, nutrients, blood products, and medications.
• IV medications act faster, important in emergencies.
• Continuous IV administration maintains therapeutic blood levels of medications.
• IV blood transfusions can be lifesaving for patients with blood loss.
• IV fluids and electrolytes provide sustenance for those unable to eat or drink adequately.
• Parenteral nutrition meets nutritional needs when a patient cannot eat for an extended period.
• Parenteral refers to any medication route other than the digestive tract.

Types of IV Infusions

• Four primary modes of IV medication administration: continuous, intermittent, direct injection/IV push, and patient-controlled analgesia.

Continuous Infusion

• A large volume (250–1,000 mL) of solution or medications given over 2 to 24 hours.
• The health-care provider orders the infusion in mL to be delivered over a specific amount of time, such as 100 mL per hour or 1,000 mL over 8 hours.
• Used when a medication must be highly diluted or when a constant plasma concentration of a drug must be maintained.
• Requires rate control using an electronic infusion device (EID), mechanical controller, or roller clamp.

Intermittent Infusion

• Some IV medications, like antibiotics, must be infused over a short time.
• An antibiotic can be mixed with 50 to 100 mL of 5% dextrose or 0.9% sodium chloride solution and infused over 30 to 60 minutes.
• Health-care provider orders must specify route, drug, dose, and amount to be infused over a specified time.

Primary Intermittent Infusion

• Delivered using primary intermittent administration tubing connected and disconnected with each use.
• A short peripheral vascular access device, sometimes called a saline lock, provides access to the bloodstream.
• An IV cannula is inserted and covered with a sterile needleless cap or valve that seals after each use.
• Peripheral intravenous (PIV) cannulas should be flushed with saline to remain patent while not in use.
• Central venous access devices (CVADs) should be flushed with heparin (10 units/mL or 100 units/mL based on agency policy).
• Each time a primary intermittent set is disconnected, the tip of the tubing must be kept sterile using a sterile end cap.

Piggyback (Secondary) Intermittent Infusion

• Secondary infusion "piggybacked" into the primary IV line if the patient already has a primary continuous IV infusing.
• Tubing remains attached to the primary administration set.
• The intermittent infusion must hang higher than the primary infusion to work.
• Deliver using an EID, mechanical controller, or roller clamp.
• Intermittent infusion medication must be compatible with the primary IV tubing solution.

Needleless Connectors

• Provide connection to IV catheters (piggybacking into a primary IV line), administration sets, and syringes without a needle.
• Injection cap, port, or injection valve are other terms.
• Help avoid needle stick injuries in nurses.
• Hub or extension set of a peripheral cannula that is “capped off” with a needleless connector (saline lock) is available for intermittent or emergency access.
• Maintains a sterile closed infusion system because the needleless connector does not have to be removed to allow access.
• Patency (unobstructed flow) of an intermittent cannula must be maintained by flushing, based on institution policy.
• Check for patency of an intermittent device before administering a medication by scrubbing the hub, attaching a syringe, and checking for backflow of blood.
• If blood is seen in the syringe, the catheter is patent.
• Once patency is confirmed, flush with normal saline (0.9% sodium chloride).
• Flush the cannula after each use or at least every 12 hours if not in use or according to institution policy to maintain patency.
• Flushing with saline prevents mixing of incompatible medications and solutions.
• The INS recommends sodium chloride for maintaining peripheral intermittent devices.
• Heparin, an anticoagulant, is recommended for flushing CVADs.
• Positive pressure must be maintained in the lumen of the cannula during the administration of the flush solution to prevent a backflow of blood or solution into the cannula lumen, which could lead to an occlusion.
• Positive pressure maintains a closed infusion system within the needleless connector.
• Do not exert pressure on the syringe plunger to restore patency if resistance is met while a cannula is being flushed.

Direct Injection/Intravenous Push

• Injected over 1 to 10 minutes via a syringe into an IV site or port.
• Provides a rapid effect, delivered directly into the patient’s bloodstream.
• Always check a drug reference to determine the safe amount of time over which the drug can be injected.

Patient-Controlled Analgesia

• An EID or pump delivers the analgesic drug when the patient presses a button.
• The EID is programmed to administer the prescribed amount.
• Remember to consider the PCA medication in the tubing when researching for incompatibilities when administering medications through an IV line on a patient receiving PCA.

Methods of Infusion

Gravity Drip

• A solution is positioned about 3 feet above the infusion site.
• If too high, the infusion may run too fast; if too low, it may run too slowly.
• Flow is controlled with a roller or screw clamp.
• A mechanical flow device can be added to achieve more accurate delivery of fluid.

Calculating Administration Rates

• Sets deliver 10, 15, 20, or 60 drops per milliliter of fluid.
• Sets delivering 10, 15, or 20 drops per milliliter are called macrodrop sets, used for fluids that need to be infused more quickly.
• Sets delivering 60 drops per milliliter are called microdrop or minidrop sets, used for solutions that need to be infused more slowly.

Factors Affecting Flow Rates of Gravity Infusions

• A change in the cannula's tip position affects the infusion flow rate; if the bevel is against the wall of the vein, the flow rate decreases.
• Placement of a PIV in a joint area (wrist or elbow) can cause a kink in the cannula or change the tip position.
• A change in the height of the infusion bag or bottle or a change in the level of the bed can increase or decrease the flow rate.
• As the distance between the solution and the patient increases, the flow rate increases.
• A small clot or fibrin sheath can occlude the cannula lumen and decrease the flow rate or stop the flow completely.
• A fibrin sheath begins developing within the first 24 hours of the cannula insertion.
• Avoid use of a blood pressure cuff on the affected limb because of the resulting transient increase in venous pressure.

Mechanical and Electronic Infusion Devices

• Flow control devices, such as EIDs and mechanical controllers, regulate the rate of infusion and are used in all health care settings.
• Mechanical controllers measure the amount of solution delivered and depend on gravity.
• EIDs, sometimes called pumps, use positive pressure to deliver the solution.
• Pumps and controllers are used for infusing precise volumes and rates of solution.
• Institution policy often dictates use of controllers for very fast or slow rates and infusion of potent medications, such as heparin, concentrated morphine, and chemotherapy solutions.
• Some EIDs are portable and worn on the body, called ambulatory infusion devices.

Filters

• Filters can either be added to administration sets or built into the set during manufacturing.
• In-line filters can remove bacteria, fungi, particulate matter, air, and some endotoxins from IV fluids.
• In-line filters can significantly reduce phlebitis in hospitalized patients.

Types of Fluids

• Three basic types of IV solutions: isotonic, hypotonic, and hypertonic.
• Fluids and electrolytes administered via the IV route pass directly into the plasma space of the extracellular fluid compartment.
• Dextrose and sodium solutions are the most commonly infused fluids and are called crystalloid solutions.

Crystalloid Solutions

Dextrose Solutions

• Dextrose in water is available in concentrations of 2.5%, 5%, and 10%.
• Concentrations above 10% must be infused via a central line.
• Advantages include the provision of carbohydrates for energy, treatment of dehydration, and a means for medication administration.
• Disadvantages include vein irritation, damage, and thrombosis.

Sodium Chloride Solutions

• Sodium chloride solutions are available in concentrations of 0.25%, 0.33%, 0.45%, 0.9% (normal saline), 3%, and 5%.
• Advantages include fluid replacement, treatment of shock, hyponatremia, and metabolic alkalosis, as a primer for blood transfusions, and during resuscitation after trauma.
• Disadvantages include circulatory overload, hypernatremia, and acidosis.

Balanced Electrolyte Solutions

• Replace lost fluids and electrolytes.
• Maintenance electrolyte solutions, such as lactated Ringer solution, supply normal body electrolyte needs.
• Often contain lactate or acetate (yielding bicarbonate), which helps combat acidosis and provides a truly balanced solution.
• Potassium is an electrolyte commonly added to balanced solutions to replace potassium deficits.

Osmolarity of Intravenous Solutions

• IV fluids are classified as isotonic, hypotonic, or hypertonic.
• Isotonic fluids have the same ratio of solutes to water as body fluids.
• Hypertonic solutions have more solutes.
• Hypotonic solutions have fewer solutes.
• Water moves from areas of lesser concentration to areas of greater concentration.
• Hypotonic solutions send water into areas of greater concentration (cells).
• Hypertonic solutions pull water from cells.

Isotonic Solutions

• Normal saline (0.9% sodium chloride) solution is an isotonic solution that has the same tonicity as body fluid.
• Expands the extracellular fluid volume because it neither enters cells nor pulls water from cells.
• A solution of 5% dextrose in water (D5W) is also isotonic when infused.
• Lactated Ringer solution and 5% albumin are other examples of isotonic solutions.
• Isotonic solutions commonly treat dehydration, fluid loss, and hyponatremia.
• Be vigilant for signs of fluid overload when infusing isotonic solutions.

Hypotonic Solutions

• Used when fluid is needed to enter the cells, as in the patient with cellular dehydration.
• Also used as fluid maintenance therapy.
• Examples are dextrose 2.5% water and 0.33% or 0.45% sodium chloride solution.
• Can worsen hypotension, cause cardiovascular collapse, and increase intracranial pressure because they leave the intravascular space and enter cells.

Hypertonic Solutions

• Examples include 5% dextrose in 0.9% sodium chloride, 3% sodium chloride, calcium chloride 10%, 5% dextrose in lactated Ringer solution, 10% dextrose in water, and albumin 25%.
• Used to expand the plasma volume and to replace electrolytes.
• Monitor for circulatory overload and elevation in blood pressure.

Intravenous Access

• IV therapy can be administered into the systemic circulation via the peripheral or central veins.
• Peripheral veins lie beneath the epidermis, dermis, and subcutaneous tissue and usually provide easy access.
• Central veins are deeper and located closer to the heart.
• A CVAD is a special catheter with a tip that ends in a large vessel (i.e., superior vena cava) near the heart.

Nursing Process for the Patient Receiving Intravenous Therapy

• The nurse is responsible for appropriate assessment, monitoring, documentation, and reporting related to the therapeutic goals.
• Some institutions require assessment of patients receiving IV therapy as often as every hour.

Data Collection

• Assess at least every 4 hours for patients not getting an irritant or vesicant who are alert and oriented.
• Assess every 1–2 hours for critically ill patients and adult patients who have cognitive sensory deficits, are receiving sedative medications or unable to notify the nurse of any problems, or have an IV placed in a joint area or external jugular vein.
• Assess every hour for pediatric or neonatal patients.
• Assess more frequently for any patient receiving vesicant medication.
• Assessment should be systematic and thorough and include physiological and psychosocial data, critical laboratory values, allergies and environmental issues, and presence of adverse reactions or complications related to infusion therapy.
• Daily weights and measurement of intake and output help determine whether the patient is retaining too much fluid.
• Skin turgor, mucous membrane moisture, vital signs, and level of consciousness also indicate hydration status.
• New onset of fine crackles in the lungs can indicate fluid retention.
• Inspect the insertion site for redness or swelling, evaluate the integrity of the dressing, and document your findings.
• Inspect the tubing to ensure tight connections and the absence of kinks or defects.
• Inspect the solution container and compare it with the HCP’s order for type, amount, and rate.
• Report abnormal findings to the RN or HCP.

Gerontological Issues

• Regularly monitor older adults receiving IV fluids for potential fluid volume excess.
• Symptoms include elevated blood pressure, increasing weight (a weight gain of 1 kg [2.2 lb] is equal to the retention of 1 L of body water), peripheral edema, full bounding pulse, shallow, rapid respirations, jugular venous distention, increased urine output, development of moist crackles in the lungs, or cyanosis.

Nursing Diagnoses, Planning, and Implementation

• Priority nursing diagnoses for IV-related issues may include: Risk for Fluid Volume Excess related to IV fluid administration, Impaired Physical Mobility related to placement and maintenance of IV cannula, and Risk for Infection related to broken skin or traumatized tissue.

Complications of IV Therapy

• Complications fall into two categories: local and systemic.
• Any complication or unusual incident should be reported to the RN or HCP, and a quality improvement report should be prepared according to institution policy.
• The most common peripheral local complications are hematoma, phlebitis, or thrombophlebitis, infiltration, extravasation, and nerve injury.
• Systemic complications can be serious.
• They include circulatory overload, septicemia, venous air embolism, and speed shock (a sudden reaction due to medication that is delivered too quickly).
• The nurse delivering infusion therapy must be knowledgeable in preventing, recognizing, and treating all complications of IV therapy.

Central Venous Access Devices

• CVAD care often involves assisting the RN with assessments.

Central Catheter Types

• Nontunneled Central Catheter: Short-term, inserted into jugular, subclavian, or femoral vein.
• Tunneled Catheters: Long-term, placed under the skin from insertion site to vein.
• Peripherally Inserted Central Catheter: PICC, inserted in the arm and terminates in the central vasculature.
• Ports: Surgically implanted reservoir connected to a catheter in a central vein.

Other Therapies

Parenteral Nutrition

• PN is complete IV nutrition for patients unable to take adequate nutrients enterally.
• Solutions contain carbohydrates, amino acids, lipid emulsions, electrolytes, trace elements, and vitamins.
• Requires filtration and an EID for administration, with a 0.22-micron filter for lipid-free PN and a 1.2-micron filter for PN solutions with lipids.
• The rate is increased gradually to the prescribed rate to prevent hyperglycemia when starting PN therapy.
• High glucose concentration of PN puts the patient at risk for infection and blood glucose disturbances.

Home Intravenous Therapy

• Allows patients early discharge and health care at home.
• Requires assessing the home environment and the patient's ability to manage the therapy.

Subcutaneous Infusion (Hypodermoclysis)

• It is being used more commonly in pediatrics, palliative care, home care, and hospice settings as well as for the elderly.
• A needle or catheter is placed below the dermis and epidermis in the fatty tissue, after which fluids may be administered by gravity or infusion pump.
• Locations include the abdomen, thighs, upper arms, chest, and scapular areas.
• Patient education should include reporting pain, redness, swelling, or leaking at the site.
• Monitor for edema at the infusion site, as it could indicate that the infusion is exceeding the rate of absorption.