NUR105 Module B: IV Therapy Lecture Notes PDF

5/17/2023 MODULE B: IV THERAPY Learning Objectives Define terms associated with iv therapy Describe key points of the nurse practice act concerning iv therapy Explain...

5/17/2023 MODULE B: IV THERAPY Learning Objectives Define terms associated with iv therapy Describe key points of the nurse practice act concerning iv therapy Explain cdc guidelines and agency policies for iv therapy Explain selected concepts of ethics and patients rights related to iv therapy Differentiate between the registered and practical nurse’s responsibilities for iv therapy Explain the registered and practical nurse’s responsibilities in administration of blood, blood products, and volume expanders Interpret doctor’s orders for iv therapy Explain the anatomical and physiological considerations associated with iv therapy Explain rationale for the selection of iv solutions Describe the purpose of equipment and supplies for iv therapy Select appropriate equipment and supplies for specified iv therapy Describe the process of preparing a patient for iv therapy Describe the process of preparing the equipment for performing iv therapy 1  5/17/2023 Learning Objectives (continued) Calculate iv flow rates Describe the process of starting iv therapy Describe the process of managing iv therapy including iv piggyback and saline flush Identify expected outcomes of treatments for iv therapy Use critical thinking to prioritize management of care for clients receiving selected iv therapy Identify equipment and techniques for collecting blood specimens Select the appropriate color collection tube for an ordered diagnostic test based on organizational protocol Describe the process of preparing a patient for collecting blood specimens Explain the process for obtaining blood specimens Explain cdc guidelines and/or agency policies for handling blood specimens Explain the procedures for handling and disposing of specimen gathering materials Clinical and Lab skills Use relevant technology care and documentation Perform venipunctures Manage iv therapy including ivpbS AND FLUSH Document Obtain Blood Specimen Handle and dispose of IV therapy and blood specimen materials 2  5/17/2023 What is Infusion Therapy? Provides immediate access to the vascular system for the rapid delivery of specific solutions without the time required for gastrointestinal tract absorption Medications Fluids Blood Products Nutrition May also be referred to as a type of parenteral therapy. Parental Therapy – Medical treatments administered by injection The most common invasive therapy procedure performed in hospitalized patients. Who Can Perform Infusion Therapy? Nurse Practice Acts (NPAs) Defines Scope of practice Licensure requirements Guidelines for educational programs Grounds for disciplinary actions Monitored and enforced by the state board of nursing Depending on the state’s nurse practice act, licensed practical nurses (LPNs) may be trained and credentialed to insert IV catheters and assist with infusions Vary by state and facility 3  5/17/2023 Who Can Perform Infusion Therapy? If ever in doubt of IV medications and/or initiation of IV therapy, ALWAYS refer to your state’s nurse practice act and the facility policy and procedure manuals. Peripheral Circulation vs Central Circulation Peripheral Circulation Smaller veins of the venous system located in the upper and lower extremities Central Circulation Larger veins of the venous system located in the central portions of the body Subclavian veins Femoral Veins Depending on the concentration (osmolarity) of the solution, some solutions have to be given in the central circulation of the body versus the peripheral circulation Central circulation provides greater blood flow and hemodilution Damage to blood vessels and the vein can occur if this precaution is not taken If the osmolarity of the solution is greater than 600 mosm/l, central circulation should be used TPN Osmolarity - >1400 mosm/l 4  5/17/2023 Vascular Access Devices (VADs) Plastic tube placed in blood vessel to deliver fluids, medications, blood products, and nutrition. (We will cover the most commonly seen devices.) Peripheral VADs Central VADs Also known as Central Lines Short Peripheral IV Devices Most Common Peripherally Inserted Central Catheters (PICC) Midline Catheters Nontunneled Percutaneous Central Venous Catheters Tunneled Catheters Implanted Ports Hemodialysis Catheters Peripheral Vascular Access Devices (VADs) 5  5/17/2023 Intravenous (IV) Devices Peripheral IV Devices Plastic Cannula Used for short-term therapy Most commonly placed in the veins of the forearm and hand. The bones in this area act as a natural support and splint for the catheter Lower extremity veins should be avoided due to the increased risk for clot formation Intravenous (IV) Devices Length ¾ inch to 1¼ inch Gauge Refers to the diameter of the needle or cannula The smaller the number, the larger the diameter of the cannula or needle is The gauge size used depends on the solution to be administered and the size of the available vein. 14-, 16-, 18-, 19-Gauge Rapid emergency fluid administration, blood products, or anesthetics 20- or 22-Gauge Standard IV fluid infusion 23- thru 27-Gauge Used in clients with very small veins Pediatrics Older Adults Choose the smallest gauge catheter capable of delivering the prescribed therapy Depending on brand purchased by facility, gauges will be color- coded 6  5/17/2023 Intravenous (IV) Devices and Precautions Allergies Ensure patient is not allergic to latex products or certain types of adhesive Assessment Once a shift if saline locked Every 4 hours if infusing Infection Control Hand hygiene Clip hair...do not shave Aseptic technique Clean gloves Prepare skin with 70% alcohol or chlorhexidine for 30 seconds Clean ports with 70% alcohol before each connection Change dressing if wet or contaminated Dwell Time Catheter should be removed and/or rotated to a different site based on clinical indications Phlebitis Infection Malfunction Always check facility policy as well Peripheral IV Device Precautions Technology Advancements Sites to Avoid Vascular visualization technology Areas of joint flexion Ultrasound guided IV placement The wrist area Median nerve Dominant arm Arm on the side of a mastectomy, lymph node dissection, AV shunt or fistula, or paralysis Veins that feel hard or cordlike Areas of cellulitis, dermatitis, or complications from previous catheter sites 7  5/17/2023 Midline Catheter 3 to 8 inches long Double or single lumen Used for 1-4 Weeks Inserted using sterile technique Dressing changes done using sterile technique Do not administer vesicants or TPN through midline catheters Vesicant – Medication with chemicals that damage body tissues upon contact. Do not draw blood through these catheters If patient has a double lumen catheter, ensure that the drugs being administered are compatible Peripherally Inserted Central Catheter (PICC) Length of 18 to 29 inches Chest X-Ray Determines Placement SUPERIOR VENA CAVA Sterile technique is used for insertion and dressing changes Available in single, double, and triple lumen Solutions of all types can be used in the PICC line regardless of the osmolarity Dwell time for picc lines can be for months or even years Blood can be drawn from the picc line Strict aseptic technique should be used to prevent bloodborne infections 8  5/17/2023 Implanted Ports Used in patients who are expected to receive IV therapy for more than 1 year Inserted surgically by a physician usually in the upper chest area Available in single or double lumen The access port for the device is housed in the subcutaneous tissue with a center made of self- sealing silicone No portion of the catheter can be seen externally Solutions of all types can be used in the PICC line regardless of the osmolarity Implanted Ports Implanted ports must be accessed using a non-coring needle or Huber needle Implanted ports should be flushed after each use and at least once a month between the courses of therapy Prevents the formation of clots in the access device A dressing is not required when the port is not accessed Before administering any medication through a port always check for blood return Hold medication until the proper measures can be taken to assure patency Extravasation with vesicant drugs can occur causing serious damage to vein and surrounding tissues 9  5/17/2023 Hemodialysis Catheter Very large lumen catheters to accommodate the hemodialysis procedure or apheresis procedure that is used to harvest specific blood cells Critical to the management of renal failure Surgically placed for long term use Common complications Catheter related bloodstream infections Vein thrombosis Catheter should never be used for the administration of fluids or medications except in an emergency situation Alternative Sites for Infusion Intraosseous (IO) infusion Allows access to vascular network in the marrow of the bones Used in pediatrics and life-threatening situations for adults. Contraindications Fracture in the bone Complications Infiltration Osteomyelitis – Infection of the bone Compartment syndrome – increased tissue pressure in a confined space causes decreased blood flow to the area EMERGENCY – ALERT PHYSICIAN PROMPTLY 10  5/17/2023 Complications of IV Therapy – Infection Catheter-Related Bloodstream Infection (CRBSI) Causes up to 28,000 deaths per year Can occur in any vascular device The skin is the bodies first line of defense against infection IV insertion compromises that defense by breaking the skin The longer the IV is in place, the more at risk the patient is for infection Can occur just at the insertion site or can occur within the body (systemically) Complications of IV Therapy – Infection - Prevention HANDS Hygiene - Wash your hands; use gloves; ensure patient skin is clean Antisepsis – Clean and prepare skin with an antiseptic with a back and forth motion for 30 seconds and allow the solution to dry before catheter insertion. Chlorhexidine Alcohol Povidone-Iodine No-Touch Technique – Once the area has been prepped, do not touch the site. Documentation – Document assessment of the site, dressing, and tubing. Scrub the Hub – Scrub the hub of the catheter site with an alcohol pad for at least 30 seconds each time you access the infusion site. 11  5/17/2023 Complications of IV Therapy – Infection Prevention Methods Use appropriate infection control measures Aseptic/Sterile technique Changing IV tubing no more than every 96 hours per CDC Changing IV dressing only when soiled/contaminated IV solutions should not hang for more than 24 hours Assessment Local Redness, swelling, and drainage Systemic Chills, fever, malaise, headache, nausea, vomiting, tachycardia Interventions Discontinue IV immediately and notify physician Obtain blood cultures Restart the IV in the opposite arm Document any and all prevention methods and interventions performed Complications of IV Therapy - Phlebitis Inflammation of the vein Assessment Pain at site with erythema and warmth Red streak along the vein Phlebitis Scale from INS Standards of Practice Grade Clinical Criteria 0 No symptoms 1 Erythema with or without pain 2 Pain at access site with erythema and/or edema Pain at access site with erythema and/or edema 3 Steak formation Palpable cord Pain at access site with erythema and/or edema Steak formation 4 Palpable cord Purulent drainage 12  5/17/2023 Complications of IV Therapy - Phlebitis Treatment Remove catheter immediately Apply a warm compress Insert new catheter in opposite extremity Document assessment and interventions Prevention Use the smallest gauge cannula when inserting Avoid sites of frequent flexion Change IV sites per CDC/facility policies Make sure IV catheter is secure and stable Monitor site frequently Complications of IV Therapy - Infiltration Leakage of non-vesicant IV solution Infiltration Scale from INS Standards of Practice into the tissues surrounding the vein Grade Clinical Criteria Assessment 0 No symptoms Most common finding is increased edema Skin blanched around the site Edema 6 inches in any direction 3 Cool to touch Mid-to-moderate pain Possible numbness Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction 4 Deep pitting tissue edema Circulatory impairment Moderate-to-severe pain Infiltration of any amount of blood product, irritant, or vesicant 13  5/17/2023 Complications of IV Therapy - Infiltration Treatment Stop infusion Remove iv catheter and apply dressing to site Elevate extremity Insert new catheter into opposite extremity Prevention Make sure iv catheter is secure and stable Monitor site frequently Complications of IV Therapy - Extravasation Leakage of a vesicant iv solution or medication into the tissue surround the vein Assessment Increased edema around the infusion site with blistering and tissue sloughing Treatment Stop infusion immediately Disconnect IV tubing Aspirate remaining medication from catheter Administer antidote if available Apply cold compress Photograph site and monitor for further complications Surgical intervention may be required Prevention Make sure IV catheter is secure and stable Monitor site frequently 14  5/17/2023 Complications of IV Therapy - Thrombophlebitis Blood clot in the vein Assessment Slowed or occluded transfusion Hard, cord-like vein Swollen, tender, and red extremity Treatment Stop infusion and remove IV catheter immediately Apply cold compress Elevate extremity Ultrasound to identify and locate clot Thrombolytic agents may be given to break-up or dissolve clot Prevention Make sure IV catheter is secure and stable Monitor site frequently Choose the smallest appropriate gauge for insertion Ensure adequate hydration to decrease thickness of blood Avoid areas of frequent flexion for insertion Complications of IV Therapy – Ecchymosis and Hematoma Blood leaks into the surrounding tissues of the insertion site Causes Multiple IV insertion attempts Factors that increase bleeding Factors that make veins fragile Older adults Chronic corticosteroids Assessment Swelling Bruising Pain or tenderness Treatment Do not apply excessive pressure when removing Prevention Avoid veins that cannot be seen or palpated Do not stick patient an excessive amount of times for IV unless an emergent situation Sometimes unavoidable but all precautions should be taken to prevent formation 15  5/17/2023 Complications of IV Therapy Circulatory Overload Excessive amount of fluid in the circulatory system Monitor patient intake and output to ensure they stay within close range of one another Speed Shock Reaction to the rapid infusion of a medication/solution unfamiliar to the patient’s circulatory system Always double check infusion rate of medication Ensure all infusions are set up on an infusion control device Air or Catheter Embolism Excessive air or a piece of the catheter breaks off and floats freely into the circulatory system Always remove all air from syringes an IV tubing prior to administration of medications Never use scissors to cut a dressing off near an IV Notify physician if any of these complication occur immediately IV Therapy and the Older Adult Skin Care Skin becomes thin and fragile with age Increased risk for skin tears Use alcohol to remove dressing and securing devices Apply skin protectant when applicable Clip hair Apply wash cloth or gown between skin and tourniquet Decreased ability to feel pain May not notice infiltration or extravasation as quickly Monitor frequently. Heart and Kidneys Assure accuracy of infusion rate and volume Confusion Keep IV and administration set (tubing) out of reach of the patient who is confused. Use flexible dressings to cover the IV site that will still allow the insertion point to be visualized Out of sight, out of mind Ensure dressing is not tight enough to occlude blood flow the extremity 16  5/17/2023 Types of Infusion Therapy Fluids IV Solutions Blood and Blood Components Drug Therapy Intravenous Solutions Osmolarity Concentration of a solution Based on the comparison to a normal patient’s blood concentration Normal Blood Osmolarity 270 TO 300 mOsm/L Each infusion solution available is classified according to it osmolarity Three Types ISOTONIC 270 - 300 mOsm/L HYPERTONIC >300 mOsm/L HYPOTONIC 300 mOsm/L The total # of particles per liter is greater than that of a patient's blood Best used as source of energy than volume Types of Hypertonic Solutions Total Parenteral nutrition TPN - 1400 mOsm/L 3% normal saline 3% NS – 513 mOsm/L 5% dextrose in lactated ringers D5LR – 525 mOsm/L 5% dextrose in 0.45% saline D5 ½ NS - 406 mOsm/L 5% dextrose in 0.9% saline D5NS - 560 mOsm/L 10% dextrose in water D10W - 500 mOsm/L 18  5/17/2023 Hypotonic Solutions Osmolarity