IV Therapy Study Guide

• Study notes on IV therapy

Common IV Solutions

• Hypotonic solutions hydrate cells, e.g., 0.45% Sodium Chloride (NaCl) and 5% Dextrose water (D5W).
• Isotonic solutions do not cause fluid shifts, e.g., 0.9% Normal Saline, Lactated Ringers, and 5% Dextrose water (D5W).
• Hypertonic solutions replace electrolytes, e.g., 3% Sodium Chloride (NaCl) and 5% Dextrose 0.45% Sodium Chloride (D5 0.45%NaCl).
• Colloid solutions act as plasma volume expanders, e.g., Albumin, Dextran, and Mannitol.

IV Pump Troubleshooting

• Check tubing for kinks, twists, and disconnects.
• Check roller clamps.
• Check for air bubbles in the tubing.
• Assess the IV site for proper catheter placement and ensure the joint is not bent.

Infection Prevention

• Priority nursing actions for complications include performing and maintaining hand hygiene.
• Avoid touching or manipulating the line or port without proper hand hygiene.
• Use aseptic technique.
• Disinfect the catheter hub and injection port for at least 15 seconds with an alcohol swab.
• If assisting or supervising line insertion, uphold sterile technique and field, and report any breaks in sterility.
• Complete a line insertion checklist.
• Educate the patient and family about preventing central line infections before insertion.
• Educate all staff managing central lines about preventing central line-associated bloodstream infections and monitor compliance.
• Routinely evaluate and remove nonessential catheters.

Complications

• Occlusions result in loss of patency ~Prevention: Flush the catheter and avoid mixing incompatible solutions. ~Intervention: Reposition the patient, raise the patient's arm overhead, assist the patient to stand up and sit down, ask the patient to cough and deep breathe, administer thrombolytics, and consider removal if needed.
• Catheter Damage or Breakage ~Prevention: Use a 10 mL syringe to avoid excessive pressure, never flush against resistance, use needless system devices, and ensure proper clamping with a closed catheter system. ~Intervention: Clamp the catheter, apply sterile gauze over the break or hole until repaired, use a repair kit based on manufacturer guidelines, and consider removal if needed.
• Infection (CLASBI) ~Prevention: Use aseptic technique, follow agency guidelines and policies, and adhere to the CLASBI precaution bundle. ~Intervention: Notify the provider, obtain a blood culture, and consider removal, obtain culture from CVAD tip using sterile scissors and sterile cup.
• Life-threatening measures include initiating antibiotics, implementing infection prevention measures, consulting vascular access specialists, doctors, and nurses for case review.
• Dislodgement ~Prevention: Ensure the catheter is secure at all times. ~Intervention: Avoid pulling or manipulating the catheter, apply pressure to the site, respond quickly, and monitor for air embolus.

Phlebitis

• Phlebitis is the inflammation of a vein, marked by pain and erythema. ~Causes
• Chemical: Results from infusing irritating solutions or medications.
• Mechanical: Caused by catheter irritation of the vein wall.
• Bacterial: Results from bacteria entering through improper IV technique.
• Prevention: Involves assessing the site regularly, even after removal of the catheter and educating the patient on signs and symptoms.
• Education the patient that indicates they need to seek medical attention.

Infiltration

• Infiltration is the inadvertent infusion of a solution or medication into the tissue surrounding the vein.
• Vesicant solutions or medications can cause blisters if infiltrated.

Extravasation

• Extravasation is the leakage of IV fluid into the subcutaneous tissue, leading to skin blanching.
• Prevention includes using compatible medications and routinely assessing the infusion site for infiltration.
• Clinical Manifestations: Blanched skin, cool to touch, edema, unexpected pain, swelling, burning, leaking fluid, pain, erythema, hardening, palpable venous cord, and fever.
• Actions include stopping the transfusion, starting another arm, and applying warm or cool compress.
• For redness or pain at the IV site, or alarm with reported pain, always check the patient/IV site first then remove the IV.

IV Therapy Considerations

• Nurses can remove and restart peripheral IV access if undesirable symptoms are reported.
• Body regulates fluid via renal, endocrine, and respiratory systems.
• Need to know clinical manifestations for Fluid Volume Overload/ Deficit for proper treatment scenario.

Fluid Balance Regulation

• It occurs through osmosis ICF and ECF through fluid shifts from lower concentration to higher concentration
• Shift of water occurs to create balance of solute concentration
• Controlled by regulatory mechanisms to maintain homeostasis.
  • Renal (kidneys), Endocrine (RAAS), and Respiratory (vaporization).

Fluid Overload (FVO)

• It results from increased water and sodium retention, leading to increased intravascular and interstitial fluid volume.
• Causes are Cirrhosis, Heart Failure, Stress, Adrenal Gland Disorder, and Ingestion of excess salt.
• Lab Values: Increased serum electrolytes, Decreased hematocrit/BUN, Increased serum osmolality/albumin.
• Clinical Manifestations: Weight gain, ascites, edema, increased urinary output, Cardiac manifestations (tachycardia, S3 heart sound). It also includes JVD, Hypertension, elevated venous pressure, increased circulatory volume, left-side heart failure, cough, tachypnea, adventitious breath sounds, and orthopnea.

Allergic Reaction- Priority Nursing Intervention

• Allergies to medications(antibiotics and pain medication)
• Stop infusion
• Administer Diphenhydramine
• Monitor vitals (if any acute symptoms administer antidote)

Blood Transfusions

• Acute Hemolytic Reaction:
  • Stop transfusion, notify provider, and maintain BP.
• Febrile Nonhemolytic Reaction:
  -Stop transfusion, monitor vitals, administer antipyretics, and restart transfusion slowly.
• Allergic Reaction:
  • Stop transfusion, monitor vital signs, and administer antihistamines.
• Circulatory Overload:
  • Stop transfusion, monitor vitals, elevate HOB, administer diuretics and oxygen, and restart transfusion slowly.
• Normal Electrolyte Values: Sodium (135-145), Potassium (3.5-5.0), Calcium (8.2-10.2), Magnesium (1.6-2.2), Phosphorus (2.5-4.5), and Chloride (97-107).
• Sodium: monitors neuro status
• Potassium: monitors cardiac status

Hyponatremia (Low Sodium)

• Interventions: Fluid restriction, 3% NaCl, oral sodium supplements, loop diuretics.

Hypernatremia (High Sodium)

• Interventions: Fluid Replacement consisting of .45% NaCl or D5W, and treat underlying causes.

Hypocalcemia (Low Calcium)

• Causes: Muscle Spasms, Chvostek’s and Trousseau sign/laryngospasm.
• Nursing action: IV Calcium, Oral supplement, Monitor at risk patients, possible intubation/tracheostomy and ensure crash cart is available.

Hypercalcemia (Increased Calcium)

• Causes: Muscle Spasms, Chvostek’s and Trousseau sign/laryngospasm.
• Treatment: IV fluids, Loop Diuretics Bisphosphates.
• Nursing Actions: monitor at-risk patients, cardiac status, neuro status, make patient ambulate, Increase hydration and monitor FVE from the rehydration.

Hypermagnesemia (High Magnesium)

• Treatment: Increased fluids and Loop Diuretics.
• Nursing action: Monitor at risk patients, Cardiac monitoring, Respiratory assessment, neuro assessment and patient education.

Hypomagnesemia (Low Magnesium)

• Treatment: PO or IV replacement.
• Nursing action: Monitor at risk patients, Cardiac monitoring, Seizure and fall precautions and patient education.

Hypophosphatemia (Low Phosphate)

• Treatment: PO or IV replacement.
• Nursing action: Monitor at risk patients and provide patient education.

Hyperphosphatemia (High Phosphate)

• Treatment: Oral Phosphate binding medications or IF normal renal function IV NS and Loop Diuretics.
• Nursing action: Monitor at risk patients and provide family education.

Hypochloremia (Low Chlorine)

• Treatment: Consists of .45% or .9% NaCl, correct underlying condition, encourage an early recognition phase and implement actions to correct levels.
• Nursing action: Monitor neuro and cardiac function, respiratory status and encourage patient education to allow the ability to recognize signs of underlying condition.

Hyperchloremia (High Chlorine)

• Treatment: 0.45% NaCl and correct the underlying problems.
• Nursing actions: Monitor neuro, cardiac and respiratory function and encourage patient education.

Hypokalemia (Low Potassium)

• Nursing Action: Increase dietary intake, Increase Potassium Supplementation, and IV Replacements.
• Nursing Actions: ECG monitoring and providing patient education.

Hyperkalemia (Increased Potassium)

• Treatment: Kayexalate, 50% Dextrose/Regular Insulin, Calcium Gluconate, Sodium Bicarb, Neb, or Loop Diuretics.
• Nursing Actions: Monitor ECG, Administer medications and encourage patient education.

ABG's Normal Values

• pH 7.35-7.45, PaO2 80-95, PaCO2 35-45, HCO3-22-26.
• Fully Compensated: normal pH, abnormal PaCO3, abnormal HCO3.
• Partially Compensated: normal pH, abnormal PaCO3, abnormal HCO3.
• Uncompensated: abnormal pH, normal PaCO3, normal HCO3.

Lasix (Crackles in Lungs)

• Administration of Lasix allows rapid diuresis decreasing the circulating blood volume
• Closely monitor I&O and labs. If potassium is low Lasix encourages K+ wasting (inducing hypokalemia).
• Normal Potassium Values 3.5-5.0 Lasix and Nitro must be titrated in any indication of Acute Renal Failure.
• Infuse Blood Transfusions over 1.5-2hrs, DO NOT EXCEED 4 HOURS*
• Nurse must obtain informed consent, and confirm order (blood type, number of units, and desired volume).
• Patient identification, and blood blank are crucial during blood sample
• The nurse must assess IV access and confirm patency for infusion
• For set-up gather biohazard bag, blood tubing, alcohol swaps, 500 cc bag of NS, 10mL syringe, and 18-20 gauge needle
• Once the correct equipment is collected, check with matching blood product to order and matching order to patient
• Before transfusion:
  • Confirm patient's name band- require two patient identifiers Ensure ABO and RH are compatible with donor and recipient Confirm time/ date/ expiration for blood release date
• Patient Assessment
• Provide explanation of procedure
• Allow patient to verbalize understanding of procedure
• Encourage patient to report on any complications that may arise during set-up procedure

Equipment Set-Up

• Always assess patient before equipment set-up
• Assessment of patient during treatment/ procedure
• Hang and spike the appropriate IV; .9% saline bag
• Close the roller clamp
• When ready spike the blood
• Ensure the prime set-up is fully executed to encourage accurate readings
• Connect IV tubing to IV line/hub to allow connection
• The first initial set set-up should be 2mL/min for the first 15 minutes
• Monitor patient during this time frame to ensure correct compatibility Measure vitals every 15 minutes during set-up
• Continue the blood transfusion with consistent monitoring
• Every hour monitor the vitals: After 4 hours stop infusion and disconnect
• Return any remaining blood to be returned back to lab
• Throw away tubing used in biohazard bag
• Check vital signs and continue to monitor patient
• Blood Compatability chart*
• Ethics*
• Nurses encourage autonomy in their field through professional environments based on responsibilities
• This is determined through clinical judgment and their advocacy/ support for patients' rights
• American Nurses Association Code of Ethics provides a framework of ethics for understanding proper work ethic
• Prevent harm
• Justice: Fair treatment for all

Circulatory Overload

• Circulatory issues pertaining to issues include Hypertonic solutions
• Administer through CVA and ensure correct blood flow for accurate dilution of the solution
• Stop the transfusion
• Elevate patient
• Give 02
• Monitor Vitals
• Give diuretics if necessary
• Restart Transfusion if necessary

Indications of Central IV's

• Severe Dehydration
• Long Term/ frequent IV access
• Cancer Treatment
• Rapid Fluid Resuscitation
• Hemodialysis

Patient Teaching

• Assess underlying conditions to explain the indications of access devices for patient
• Explain what type of infusion therapy will be given through admin
• What is the expected outcome for infusion therapy?
• Mention any complications
• What alternative are suitable for infusion therapy/ access devices
• Mention proper expectations during insertion of the devices used
• Level of Discomfort for process
• Provide instructions for decreasing discomfort during device usage
• Provide instructions on aseptic process

Nursing Implications

• Patient is accountable and responsible for using proper technique during assessment of port- accessing for usage
• Understanding the indications of accessing access and ensure reporting of signs and symptoms are completed in proper protocol/ guidelines
• Proper protocol for complications such as

1. Discomfort
2. Redness
3. Swelling
4. Temperature 5.Chills

TPN Usage

• Pt education for indicating when dressing for devices no longer remain occlusive/ or indication of becoming loose.
• Encourage proper patient monitoring of the patient to promote aseptic cleansing of the ports/ devices while using alcohol swabs for 15 seconds or greater.

Indication of increased Osmolality

• TPN provides increase and can be used for indication of increased osmolality for patients
• Composition use Macronutrients, Protein, Carbohydrates and Lipids during intervention
• Micronutrients- electrolytes, vitamins and trace minerals all are determined by providers
• Indication to encourage usage when patient does not obtain required need through oral intake only
• Protien and Amino acids promote growth during intervention
• Carbohydrates/ Dextrose- assist and generate energy for usage
• Lipids- assist with generating energy for patient as well

Monitoring TPN

• Start gradual
• check blood glucose Q6hrs
• Monitor fluid tolerance
• Monitor I and O
• Discontinue Infusion rates gradually
• Encourage no usage of medications through devices
• Change infusion set every 24hrs to decrease infection

Fluid Volume Deficit

• Increase in concentration of urine osmolality
• Increase value of urine specific gravity
• Decrease hemoglobin levels
• decrease hematocrit
• Increase BUN and increase level of sodium in bodily levels

Treatment- Consist of fluid replacement, and increase volume

• Monitor input/ and output levels Monitor lab's Encourage to address the underlying causes for issue

Common symptoms

• Dehydration as stated through Vomiting, Perianal Failure, Renal Function, Hemorrhage
• Diarrhea - leading cause of dehydration, which can lead to electrolyte imbalances Encourage a level amount of electrolytes
• Increase volume and intake

Symptoms included but not limited to:

• Weight loss quickly , hypotension, skin tenting issues
• Thirst increase and decline
• Peripheral pulses may indicate weak presence of blood
• Hypotension - indication of blood level imbalance
• Anxiety of patient
• Decreasing and restlessness
• Cool- clammy - and pale indications in terms of skin issue causes
• therapeutic indications consist of maintaining consistent level of fluid

Therapeutic responses may included, but not limited to:

• Intaking water with consistent fluids
• Pulmonary function with regular fluid levels The following is the therapeutic responses for patient, be mindful:
• Isotonic Solutions

1. NS/ normal saline (.9%)
2. LR administration ( Ringer Solution)
3. D5 .45%

• Encourage constant fluid levels and assessing proper vitals for patient
• Monitor Neuro and indication of decreasing fluid levels Treatment involves promoting fluid therapy and encouraging adequate blood levels
• **The nursing implication is the patient may have low blood levels and that if you administer an IV solution,monitor patients to assist with Hypotension. These can be dangerous.

IV Potassium

• Very high risk, dangerous medication
• Ensure you do not give a lot
• Make sure the dose you are using matches the order from Doctor
• The rate and fluid is 10 in 1hr...20 is 2 IV PUMP
• Best to give potassium through a central line access
• Check and check access for patient to ensure correct volume usage
• In concentrated forms
• Give potassium with concentration of 100s and give 10 MEQ - which is over 1- 2 IV pump
• Most accurate form is giving through central access

IV Push - IVP - intravenous medication

• Fluid to be administered must come with medical clarification from the Doctor
• Nurse must ensure patients are accurately tolerating indication level the infusion

How is it done? How to assess?

• Does iv still work? Do we still have IV flow? If patient reporting PAIN- then you always stop infusion
• If patients pain is alarming and concerning, this must be the initial indicator always
• Do no use IV access for patient

What to do with patient that has continuous issues pain??

• Always access patients first and then remove IV Always access by checking patients level with constant fluid for toleration

Fluid placement of the veins. What do we want to do?

• Use the largest gauge we can

• Diameter of veins: large veins

• Must consider rate and volume for medication administration

• Must not be sclerotic/ hard vein

• Must not be tender to the touch

• Must be above the infusion

• Delegate Tasks- this is ok for the Tech

• Proper level of tasking assigned to patients and in appropriate situations

• Proper level of knowledge is needed to accomplish task

• Patient is responsible to possess those skills

• Indications for different insertion of IVs*

• Peripheral IV- 1-3 days

• Midline- 1-4 days

• Port - can be permanent/often for cancer treatment.

• Veins*

• medial Cephalic and Basilic veins Indication of veins ( low extremities is a indication of blood issues) If any mastectomy issues has been seen in patient, do not use affected side

• Check concentrations of meds to ensure proper usage during flow

• Check levels to see if meds cause irritation Right of Delegation to tech:

• Patients must know of tasks in order to create task

• Nurse that ensure proper actions

• What needs to be accounted for

• Right Delegation is proper if proper communication has been completed