Med-Surg Nursing I: IV Therapy

Common Indications for IV Therapy

Maintain or restore fluid balance when oral intake is inadequate or impossible
Maintain or replace electrolytes
Administer nutrients (water-soluble vitamins) and provide a source of calories and nutrients (TPN)
Administer medications, specifically designated meds, with the route of most rapid effect (CVAD/peripheral/SC), which can be continuous or intermittent
Replace blood and/or blood products

Types of IV Solutions

Crystalloid: water and dissolved crystals (e.g., salt, sodium chloride, or sugar, glucose, dextrose)
Colloid: water and molecules of suspended substances (not dissolved) (e.g., blood cells and blood products, PRBCs, albumin)

Types of Crystalloid Solutions

Isotonic Solutions (e.g., D5W, LR): fluid has the same concentration of solute as plasma (ECF), maintaining fluid balance when NPO, expanding ECF volume, and using carefully with hypertensive patients and those with heart failure
Hypotonic Solutions (e.g., 0.45% NaCl, 0.33% NaCl): fluid has less solute than plasma (ECF), rehydrating clients in fluid volume deficit, causing fluid shift into cells, and rehydrating them
Hypertonic Solutions (e.g., D10W, D50W, 3-5% NS, 3-5% NaCl): fluid has more solutes than plasma (ECF), drawing water from the cells into the plasma, shrinking them, and useful in treating hypovolemia and hyponatremia

Methods of Infusion

Continuous: regulate the flow of solution over long periods
Intermittent: solution (medication) given over a short period of time, using piggyback (secondary lines)
Direct: IV push, delivering a single dose of medication directly into the vein
Hypodermoclysis: allows IV solutions to infuse into subcutaneous tissue, needs to be fairly slow, and used to treat dehydration at home

Routes of IV Therapy

Peripheral: access to superficial veins, most common sites are the forearm and back of the hand, avoid foot, AC vein, and lower extremities if possible, and infant: scalp veins typically used
Central: access to larger veins, used for long-term IV therapy (chemotherapy, long-term IV antibiotics, TPN, and lipids), or when peripheral IV is not attainable, and can also be used to monitor CVP

Risks and Complications

Vascular access poses risks to the patient, and competency and dexterity are important to keep patients safe
Infection: at IV insertion site or systemically, signs and symptoms include redness, tender, swelling, or purulent drainage, and systemic signs and symptoms may include malaise, fever, hypotension, or tachycardia
Infiltration: IV needle/catheter slips out of the vein or is not inserted into the vein, resulting in fluid build-up in extravascular tissue, signs and symptoms include swelling, pain, redness, decreased infusion rate, and coolness at the site
Phlebitis: inflammation of the vein, signs and symptoms include redness, heat, swelling, and pain along the vein
Thrombophlebitis: inflammation of the vein and blood clot formation, signs and symptoms include pain, tenderness, redness, swelling, and heat along the vein path
Extravasation: similar to infiltration, administration of irritant solutions into surrounding tissue, signs and symptoms include pain, burning, redness, blistering, inflammation, and necrosis
Hematoma: blood leakage into tissue around the insertion site, signs and symptoms include ecchymosis, swelling, and leakage of blood
Occlusions: caused by a clot due to inadequate flushing protocol on locked sites or infusion rates too slow to keep the vein open, signs and symptoms include sluggish flow rate, inability to flush or infuse IV solution or meds, and frequent downstream occlusion alarms on the IV controller/pump
Catheter-related bloodstream infection (CRBSI): caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis, signs and symptoms include elevated temperature, flushed, headache, malaise, tachycardia, decreased BP, and additional signs and symptoms of sepsis
Pulmonary Edema - Fluid Overload: excessive IV fluids cause increased blood pressure and central venous pressure, signs and symptoms include ↓SpO2, ↑respiratory rate, dyspnea, coughing up pink frothy sputum, and auscultation of dependent fine crackles

Regulating IV Flow Rates

Regulate IV flow rates to prevent fluid overload, using electronic infusion devices or manual flow-control devices
Calculate flow rate using the formula: Total Volume in mL / Total hours = mL / hr
Calculate drip rate using the formula: Microdrip – 60 gtt/ml, Macrodrip – 10 or 15 gtt/ml, Calculation: ML / HR X drop factor / 60 min

Monitoring and Evaluation

Monitor the patient's response to therapy, complications of IV therapy, and patency, flow, and insertion site
Perform teach-back – get the patient to repeat what you have taught them
Observe the patient every 1-2 hours, noting volume infused and the rate of the infusion
Monitor patient's vital signs, electrolyte levels, kidney function, urine output, and weight, especially for pediatrics and gerontological considerations