IV Therapy Key Considerations

• The lecture provides an overview of infusion therapies, reasons for IV infusion, characteristics of IV solutions, venous access, equipment, complications, prevention strategies, and teaching plans.
• Key concepts include assessment, fluid and electrolyte balance, medications, nutrition, and skin integrity.

Infusion Therapy in Healthcare

• Infusion therapy is administered across various healthcare settings like hospitals, extended care facilities, outpatient clinics, infusion centers, and homes.
• The Infusion Nurses Society (I.N.S.) establishes evidence-based practice standards for infusion therapy.
• Infusions are needed for fluid/electrolyte replacement, medication and blood product administration, and nutritional support.
• Infusion duration ranges from hours or days to months or even a lifetime.
• The provider's order must specify the solution, additives, infusion rate, and total volume.

Types of IV Solutions

• Crystalloid solutions contain electrolytes dissolved in water: dextrose, sodium chloride, balanced electrolyte, alkalizing, and acidifying solutions.
• Colloid solutions contains larger molecules (protein or starch) suspended in fluid, act as plasma volume expanders, and maintain intravascular volume.
• Osmolarity measures the concentration of a solution, influencing water movement between intracellular and extracellular compartments.
• Blood and body solutions typically have an osmolarity of 270 to 300.
• Isotonic solutions have the same osmolarity as plasma causing no fluid movement into or out of cells; they increase circulating fluid without shifting fluid. Examples are 0.9% sodium chloride (NS) and lactated ringers (LR) with osmolarity between 250-375.
• Hypotonic solutions have lower concentration than plasma, fluid moves into cells, hydrating them but depleting intravascular fluid; an example is 0.45% sodium chloride.
• Hypotonic solutions manage hypernatremia and DKA after initial sodium chloride replacement, used briefly and with caution because of fluid shifts.
• Hypertonic solutions have higher concentration than plasma, fluid moves out of cells, causing them to shrink; an example is 3% sodium chloride.
• Hypertonic solutions are administered in critical situations only and via a central venous access >600 miliosmoles per liter.

Monitoring Fluid Status

• Monitor fluid status through assessment of vital signs, respiratory status, and skin turgor.
• Vigilance is required for older adults and patients with compromised cardiovascular or renal function due to risk of fluid overload.

Intravenous Solution pH

• IV solutions are slightly acidic for stability and shelf life.
• Acidic medications have pH < 7, alkaline medications have pH > 7.
• Solutions or meds with pH < 5 or > 9 require administration via a central line to prevent vein damage.
• An incompatible solution or wrong diluent could alter a medication’s pH.
• Acidic medications and antibiotics can cause chemical phlebitis (vein wall irritation); warmth/tenderness at IV sites may indicate phlebitis.

Medication Incompatibility

• Incompatibility is the undesirable reaction between two medicines or a medication and diluent.
• Physical incompatibility causes visible changes like altered color, cloudiness, turbidity, precipitate formation (most common), or gas formation; calcium increases precipitate risk.
• Chemical incompatibility involves medication breakdown, often being invisible; acid-alkaline reactions are common.
• Therapeutic incompatibility causes increased/decreased therapeutic response, potentially undetected until no clinical response occurs.
• Aminoglycosides are inactivated by penicillin/cephalosporins, requiring separate sites one hour apart.
• Checking compatibility charts and consulting pharmacists is critical when administering IV medications.

Vein Selection

• Vein diameter and blood flow increase closer to the heart; large volumes/extreme osmolarity/pH require larger veins with greater blood flow.
• Selected veins must accommodate the vascular access device allowing for adequate blood flow around it.
• Consider patient condition, solution characteristics including volume and rate, and access device availability.
• Vein walls have three layers, containing valves that prevent backflow.
• Avoid areas with visible valves to ensure catheter passage.
• Infusion therapy categories are based on the access device tip location being peripheral or central.
• Select the device with the least invasive gauge/length to deliver the prescribed therapy.

Peripheral Venous Access

• Peripheral venous access includes short over the needle catheter inserted into a peripheral vein.
• Catheter sizes range from 1-7.5 cm in length, 14-27 gauge with standardized color-coded hubs.
• Smaller needle diameter correlates to bigger the gauge (24-gauge peripheral IV is significantly smaller than 18-gauge).
• Steel wing devices or butterflies are used for short-term or single-dose therapy, more prone to puncture, often used for lab draws.
• Distal sites are preferred for short term peripheral IV access for future insertion sites.
• Selected veins should be soft, non-sclerotic, and non-tender, avoiding areas with previous infiltration or valves.
• Avoid veins in flexion areas (wrist or AC) because they are difficult to stabilize and the lower extremities due to risk of thrombophlebitis.
• Veins on the arm with mastectomy/dialysis access are contraindicated; limit alert bracelets identify these patients.

Midline Catheters

• Midline catheters go into peripheral veins in the upper extremities, its tip terminates distal to the shoulder (basilic, cephalic, or brachial vein).
• It's not a central catheter, and are not used for vesicants, irritating solutions, TPN, solutions with pH < 5 or > 9, or osmolarity > 600; lasts 1-4 weeks.

Central Venous Access

• Central venous access tips terminate in the superior or inferior vena cava.
• Multi-lumen catheters provide separate fluid pathways supporting the delivery of multiple simultaneous solutions.
• Each fluid pathway is totally separate, fluids are infused through different lumen that enters central venous system at different points, proximal, medial, and distal.
• Incompatible solutions can be infused if done with the separate ports; each lumen requires initial flushing to maintain patency.
• Devices may be coated with anti-infective agents, protected by green caps; are able to withstand pressure from imaging studies.

CVAD Types

• CVADs include non-tunneled percutaneous central catheters, tunnel catheters, implanted ports, and peripherally inserted central catheters (PICCs).
• Tips of CVADs are either open or closed; closed CVADs have a valve to prevent backflow and minimize clotting through the catheter.
• Non tunneled percutaneous central catheters are inserted into the jugular or subclavian veins, tip goes into superior vena cava.
• Femoral vein are used cautiously due to risk of infection; often used in emergencies when peripheral access is not available. Placed in emergency situations should be removed within 48 hours.
• Insertion requires full barrier precautions (mask, gown, sterile gloves, sterile drapes and post insertion, a chest X-ray verifies tip location.

Tunnel Catheters

• Tunnel catheters exit the skin from a site distal to the vein entry point, tunneled through subcutaneous tissue.
• The tunneled section contains a cuff promoting tissue adhesion, stabilizing it, forming a barrier against organisms; the exit site is usually placed on the chest.

Implanted Ports

• Implanted ports give long term therapy involving a small reservoir (septum and attached catheter) placed under the skin in upper chest wall.
• It can be placed in upper extremity, abdomen or even back.
• Access requires a specialized non-coring needle using sterile technique, it goes through skin into septum of the reservoir; maintains continuous infusion or periodic flushing per policy.

Peripherally Inserted Central Catheters (PICCs)

• PICC lines are inserted into a peripheral vein and advanced into central vasculature with ultrasound assistance.
• X-ray verifies tip, needs thorough flushing before and after each use, care is needed to flush to not damage the catheter.
• Power PICCs support imaging studies requiring power injection.

Intraosseous Access

• Access to the central venous system occurs via intra osseous access accomplished using handheld driver; IO devices are put into the bone marrow for fluid and medication infusion.
• Any medication given by IV can be administered by IO for patients whom are severely dehydrated and with poor vascular access, which occurs under one minute.
• Pain medication is needed if the patient if experiencing discomfort, more commonly due to infusion of medicine over insertion.
• Sites used in adults commonly include the proximal humerus, proximal tibia, and distal tibia.
• It provides rapid central venous access in emergency situations, recommended during cardiopulmonary resuscitation.

Electronic Infusion Devices

• Electronic infusion devices support accurate infusion, but nurses maintain responsibility for therapy delivery.
• Alarms relate to kinked tubing, increased resistance (suggesting clots or infiltration); feature enforce parameters for safe medication administration.
• Infusion systems use containers, tubing, administration sets with needless systems that reduce needle sticks: disinfect needless systems using a 10-15 second alcohol scrub.
• Primary sets deliver the main IV solution, secondary delivers additional intermittent medications.

Monitoring and Preventing Complications

• Monitor fluid status to ensure therapy targets are fulfilled/maintain euvolemic or normovolemic fluid state.
• Monitor physical assessment, periodic weights, accurate intake/output, and lab values, (serum electrolytes).
• Hypertonic and hypotonic fluids place patients at higher risk for imbalance.

Phlebitis and Infiltration

• Inflammation of vein (phlebitis) presents as pain and erythema along with the standardized scale.
• Remove peripheral sites showing phlebitis, restart elsewhere as it progresses to thrombus formation, cellulitis and sepsis.
• The antecubital fossa has the lowest phlebitis rates, hand veins have the highests.
• Causative factors of phlebitis being chemical (irritating solutions), mechanical (catheter irritation from large catheter or inadequate securement), and bacterial (bacteria introduction).
• Infiltration involves fluid infusion into surrounding tissue, peripherally/centrally presenting as blanched skin, coolness, edema/swelling, pain/burning at insertion site, and fluid leaking.

Tissue Damage Minimization

• Extravasation results when a solution or medication which is a vesicant is introduced to subcutaneous tissue which causes blisters; includes agents that are antineoplastic, antibiotics, and vasoactive.
• Stop infusion immediately and notifying provider, perhaps getting a potential antidote and minimize the tissue damage.

Central Line Complications

• Infection, loss of patency, and air embolism are central line complications.
• CLABSIs involve central line-associated bloodstream infections using maximal sterile barrier precautions.
• Loss of patency or occlusion of CVCs can delay therapies, may require another central line insertion which is caused by thrombotic process.
• Blood or fibrin interferes with the flow which is interfered by blood where proper flushing decreases thrombic occlusions; injection caps prevent thrombotic occlusions by creating positive pressure.
• Occlusions can also be non-thrombotic (medication precipitation) and medication incompatibilities being administered together or without flushing.
• Air inadvertently introduced into venous system causes air embolism where preventive actions include checking connections, clamping sites, using infusion pumps, using priming IV tubing, and expelling air from syringes.
• Ensure intact central line dressing, remove lines with competent personnel and removal/performed with the patient in supine position; use the valsalva maneuver to prevent air entry.

Practices of IV therapy

• Hand hygiene and cleaning injection ports should be used with every entry.
• Proper flushing and using double the volume of the catheter maintains proper placement, and confirms functioning.
• Sterile occlusive dressings must be changed if they are no longer occlusive or moist.
• Peripheral IVs do not require change and must be assessed and documented.

Methods to Administer Solutions

• Methods to administer solutions include continuous infusion, intermittent infusion bullets, and IV push.
• Intermittent infusions need to be stopped when incompatible and tubing must be cleared with a compatible soution.
• The access device needs to be flushed for proper functioning and clearing any potential incompatible solutions.
• The access device needs to be flushed and locked.
• The concentration of the medication for IV push or direct IV needs to be correct with the rate of administration.
• Use lower concentration and and the IV needs to be diluted prior to administration to ensure safe concentration.

Education and Aseptic Techniques

• Educate the patient with expected outcomes if they had any device placed for the rationale, alternatives, learning, the device, and discomforts.
• Explain aseptic technique to patient, family, and significant others.
• Report the type of IV by educating on administration, and administration of the unexpected outcome and complications.

Clinical Case Study

• A 21 year-old motor vehicle accident victim requiring fluid resuscitation gets a 0.9% normal saline solution (an isotonic fluid compatible with blood products and this patient may require them)
• Practitioner inserts a non tunneled percutaneous central catheter (needed for rapid fluid and medication administration)
• Nurse anesthetist then inserts a triple lumen catheter for fluids, antibiotics, and blood products
• Fresh frozen plasma containing clotting factors should be provided along with the packed red blood cells that lack them as separate blood components are often used
• Antibiotics can be given in port where a PCA or saline lock exist, but not in the dedicated port for parenteral nutrition or with blood products
• Untight luer lock puts patient that had some air introduction at risk when it creates air embolism occurring.

Explore critical aspects of IV therapy including patient monitoring, pH levels, and medication compatibility. Learn about the risks and benefits of different IV solutions. Understand the importance of central lines and CVADs in administering IV fluids.