Obj 5 IV Therapy.pdf

Objective 5 Med-Surg Nursing I IV Therapy 2024 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) Source of calories and nutrients (TPN) Admin...

Objective 5 Med-Surg Nursing I IV Therapy 2024 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) Source of calories and nutrients (TPN) Administer Medications Specifically designated meds Route with most rapid effect (CVAD/peripheral/ SC) Can be continuous or intermittent Replace blood and/or blood products  Common Types of IV Solutions See Table 19-19 Lewis Crystalloid: Water and dissolved crystals. Ex: salt (sodium chloride) or sugar (glucose, dextrose) Colloid: Water and molecules of suspended substances (not dissolved). Ex: blood cells and blood products (PRBCs, albumin)  Types of Crystalloid Solutions Isotonic Solutions (ex: dextrose 5% in water (D5W), LR) Fluid has same concentration of solute (dissolved substance) as plasma (ECF) RBCs will shrink or swell, remain stable. No fluid shift occurs. Purpose: Maintains fluid balance when NPO Expand ECF volume Use carefully with hypertensive patients and those with heart failure Hypotonic Solutions (ex: 0.45% NaCl, 0.33% NaCl) Fluid has less solute than plasma (ECF) Purpose: Rehydrates clients in fluid volume deficit cause fluid shift into cells, rehydrating them and causing cells to swell  Types of Crystalloid Solutions Hypertonic Solutions (ex: D10W, D50W, 3-5% NS, 3-5% NaCl) Fluid has more solutes than plasma (ECF) Draws water from the cells into the plasma, shrinking them Purpose: TPN – useful in treatment of hypovolemia and hyponatremia. Lipid Emulsion: Stabilized mixture of two insoluble liquids Provides essential fatty acids, additional calories  IV Solutions Isotonic 5% Dextrose in Water 0.9% Normal Saline Hypotonic 0.45% Normal Saline 0.33% Normal Saline Hypertonic Dextrose 50% in water **Refer to Table 29.1 in Perry and Potter –Clinical Nursing Skills Other IV Solutions Blood products: Medications: *IV Packed red blood cells, Medications are all fresh frozen plasma, diluted differently* albumin, IVIG, etc  Types of IV tubing 1) Primary: Used to administer large volumes of IV solution over a longer period of time 2) Secondary: Shorter tubing. Used to administer small amounts of solution (usually medicated) through port in primary tubing Primary and Secondary IV Tubing IV Extension Types of IV Tubing 3) Y-tubing: Used for administration of blood products. There are two branches (1 connects to blood bag, 1 connects to a NS bag). There is a filter that connects two lines, that removes clotting/cellular debris. After blood infusion is finished, this design allows flushing of the line with NS to ensure all blood products have been received by patient. Types of Tubing 4) Vented: Air vent located on the drip chamber, to allow air to enter bag/bottle containing solution. Used for medications/solutions packaged in glass bottles (ie nitroglycerin) 5) Filtered: Contains a filter on tubing to help filter any crystallizing medications (ie dilantin)  Basic Components of IV Tubing 1) Spike: site of insertion into product, must remain sterile 2) Drip Chamber: hold small amount of fluid. Where you can count gtt rate 3) Length of Plastic Tubing: Connects solution to catheter 4) Ports: Access site to instill IV medications/additional solutions 5) Roller Clamp: Regulates flow/rate of infusion Methods of Infusion Continuous: Regulate flow of solution over long periods Intermittent: solution (medication) given over short period of time. Given through piggyback (secondary lines) Direct: IV push. Delivers single dose of medication directly into vein Hypodermoclysis: allows IV solutions to infuse into subcutaneous tissue. Needs to be fairly slow (used to treat dehydration at home)  1) Peripheral - Venipuncture site / superficial veins Various Routes of IV Most common sites are forearm and back of hand Therapy Avoid foot, AC vein, and lower extremities if possible (increase risk for clots) Infant: scalp veins typically used  Various Routes of IV Therapy 2) Central: access to larger veins. Used for long term IV therapy (chemotherapy, long term IV antibiotics, TPN & lipids), or when peripheral IV is not attainable. Can also be used to monitor CVP Midline Catheter: Inserted through antecubital area and the tip lies in the axilla region. Needs to be replaced Q2-4 weeks Peripherally inserted central catheter (PICC): Inserted through antecubital region and the tips lie just above the superior vena cava (just above the heart). Can leave in up to a year. Hickman / Brvoviac / Groshung: External tunneled catheters that are surgically implanted. Implanted venous port (Port a cath): Surgically implanted. Reservoir located under skin, need needle to access same. Can stay in long term. Central Venous Access Devices What are the Risks? Vascular access is one of the most common invasive procedure performed by a HCP worldwide Poses risks to the patient Competency and dexterity are important to keep patients safe Asepsis Why is dexterity important? Nursing Management Inspect catheter and insertion site Assess pain Change dressing and clean according to institution policies Change injection caps Flushing is important. 19C-19 Potential IV Therapy Complications Infection: at IV insertion site or systemically Signs and Symptoms Insertion site may become red, tender, swollen, or have purulent drainage. Systemic signs and symptoms may include malaise, fever, hypotension, or tachycardia. Nursing Care Remove immediately. Report to HCP. Clean site aseptically Potential IV Therapy Complications Infiltration: IV needle/catheter slips out of vein or not inserted into vein. results in fluid build- up in extravascular tissue S&S swelling, pain, redness, decreased infusion rate, coolness at site Nursing Care Stop infusion, remove cannula, restart IV at another site Elevate arm (promotes absorption of fluid) Warm compress* Potential IV Therapy Complication Phlebitis inflammation of vein from: prolonged use of vein irritating solution (Potassium especially) S&S Redness, heat, swelling & pain along vein Nsg Care Discontinue IV line Apply warm, moist compresses Potential IV Therapy Complications Thrombophlebitis: inflammation of vein /c blood clot formation results from blood stasis inside vein at catheter/needle tip S&S Pain & tenderness Redness & swelling heat along vein path *Slowed infusion Nursing Care Cold compress followed by warm compress Potential IV Therapy Complications Extravasation Similar to infiltration Administration of irritant solutions into surrounding tissue (ie: chemotherapy) Signs and Symptoms Pain, burning, redness, blistering, inflammation, necrosis Nursing Care - stop infusion, notify physician, apply warm or cold compress depending on solution Potential IV Therapy Complications Hematoma Blood leakage into tissue around insertion site Signs and Symptoms Ecchymosis, swelling, leakage of blood Nursing Care - remove needle/cannula, light pressure , elevate extremity Potential IV Therapy Complications Occlusions: caused by a clot due to inadequate flushing protocol on locked sites or infusion rates too slow to keep vein open. S/S: Sluggish flow rate. Inability to flush or infuse IV solution or meds. Frequent downstream occlusion alarms on the IV controller / pump Nursing Care Follow agency flushing protocols. Assess and resolve any mechanical occlusions (may be a kink in the line). Potential IV Therapy Complications 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 elevated temperature, flushed, headache, malaise, tachycardia, decreased BP, and additional signs and symptoms of sepsis Nursing Care Report concerns to prescriber; monitor bloodwork and vital signs; anticipate blood cultures; IV antibiotic therapy; consider catheter removal, if suspect Potential IV Therapy Complications Pulmonary Edema - Fluid Overload Excessive IV fluids cause increased blood pressure and central venous pressure Signs and Symptoms: ↓SpO2, ↑respiratory rate, dyspnea, coughing up pink frothy sputum, auscultation of dependent fine crackles Nursing Care Prevention: Use IV controller / pump to prevent accidental bolus. Treatment: Must be immediate. ↑HOB, vitals, administer oxygen, notify prescriber. Anticipate diuretics and slowed IV rates. Potential IV Therapy Complications Air Embolism air enters circulatory system via bubbles in tubing/solution running out air travels to lungs S/S Palpitations, dyspnea, cyanosis, hypotension, weak rapid pulse, loss of consciousness, chest pain Nursing care Stop infusion, administer oxygen position client on Lt side, Trendelenburg position Potential IV Therapy Complications Pulmonary Embolus (PE) movement of previously stationary blood clot to lungs Signs and Symptoms Sudden chest pain, Cyanosis, SOB, decreased B/P, Tachycardia, anxiety Nursing care Stay with client, call for help, stop infusion, administer O2, monitor V/S, call physician Nursing Care / Guidelines https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaret rubscn (Anderson 2018) Ordered by a physician / nurse practitioner Must include the type of solution or medication, rate of infusion, duration, date, and time Principles of asepsis / sterile technique must be maintained throughout all IV therapy procedures, including initiation of IV therapy, preparing and maintaining equipment, and discontinuing an IV system Understand the indications (Why you’re doing it) and duration for IV therapy for each patient Nursing Care / Guidelines Practice guidelines recommend that patients receiving IV therapy for more than six days should be assessed for an intermediate or long-term venous access device Patient with an order to keep a vein open, or “TKVO,” or “KVO” the usual rate of infusion is 20 to 50 ml per hour Change continuous infusion tubing Q 96 hours, and intermittent tubing @ 24 hours IV catheter are replaced when clinically indicated IV sites must be assessed regularly. Follow policy guidelines – usually hourly while infusion is running Assess patency, flow, insertion site, patient s/s Evaluation 01 02 03 04 Observe the patient Monitor patient’s Monitor for Perform teach back every 1-2 hours, response to therapy complications of IV – get the patient to noting volume Therapy repeat what you infused and the rate have taught them of the infusion Regulating IV Flow Rates It is important to make sure that fluid is not flowing too fast or too slow into the venous system. Rates will want to be regulated at the prescribed rate (differs for different solutions & medications) There are factors that will affect the infusion flow and rate Changes in patient position (may cause obstruction / kink) Occlusion / infiltration of the IV device Venous trauma Movement / manipulation of the IV itself  Regulating IV Flow Rates 1) Electronic Infusions Devices delivers a measured amount of fluid over a period of time (e.g., 100 mL/h) computer system with a drug library and are associated with reduced risk for infusion-related medication errors This Photo by Unknown Author is licensed under CC BY-ND 2) Manual Flow – Control Devices include flow regulators (i.e., dial or barrel-shaped) volume-control devices deliver small volumes with the aid of gravity height of the IV container, IV tubing size, or fluid viscosity) affect an IV rate with this mechanism This Photo by Unknown Author is licensed under CC BY-SA Calculate Flow Rate ( ML / HOUR) Total Volume in mL / Total hours = mL / hr EX: 1000 mL / 8 hours = 125 ml / hr Calculating Drip Rate delivers standard volume of 60gtts/ml Microdrip delivers small-sized drops drop size varies 10, 15 & 20 gtts / ml Macrodrip 10 is most common - delivers large- sized drops Calculating Drip Rate (DROPS / MIN) Microdrip – 60 gtt/ml Macrodrip – 10 or 15 gtt/ml Calculation : ML / HR X drop factor / 60 min Example: 125 ml/hr X 60 gtt/ml = 7500 gtt/hr 7500 gtt /60 min = 125 gtt/min  Regulating Drip Rate via Gravity Flow IV container must be at least 30 inches above IV site for adults, and this must be increased for vicious fluids (thicker) Slowly open roller tubing until you can see drops in the drip chamber Hold watch with second hand at level of drip chamber and count drip rate for one minute Adjust the roller clamp to increase or decrease the infusion rate Monitor The IV infusion rate and IV site for complications as often as policy guidelines Use watch to verify the rate of infusion, even with Electronic infusion devices (may be faulty) Assess the IV system from container to insertion site when alarm signals or patient c/o any issues Attach labels to the IV administration set, medication tubing, and solutions; follow hospital policies on how often to change tubing  Pediatrics Do not exceed containers greater than 150mL for children under 2 or exceeding 250mL in children younger than 5 or exceeding 500mL in children younger than 10 years old Use of buretrol in pediatrics as a safeguard against fluid overload Gerontological Monitor VS, electrolyte levels, kidney function, urine output and weight At risk for skin breakdown as well Special Considerations Calculation Practice – see Skills book p. 799-802 1. A patient is to receive an IV medication over 3 hrs. The IV solution is 250 mL. The drop factor of the IV set is 15 gtts/mL. What drip rate in gtts/min is needed? 2. The order reads: 488 mL Normal Saline IV to infuse over 11.6 hrs via infusion pump. What is the IV flow rate in mL/hr? 3. Doctor’s Order: 1 ½ L of NS to be infused over 7 hours. The Drop factor of the IV set is 15 gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump? 4. The patient is ordered Lactated Ringers 125 ml/hr via gravity flow using tubing calibrated at 15 gtt/ml. Calculate the flow rate. Review See review questions at the end of each chapter in textbook See online textbook resources for the following sections: Key points Case studies Review questions Review Types of fluids video: https://www.youtube.com/watch?v=51FkahHUBwc Calculating IV rates: (1) https://www.youtube.com/watch?v=rRN3DifaMWo (2) https://www.youtube.com/watch?v=W5VIc6f0fBA Quizzes: https://quizlet.com/291218709/medsurg-intravenous-therapy-flash- cards/