Intravenous Therapy Notes PDF

Dr.Shimaa Nabil AHN I 1  Outlines   Definition of intravenous therapy.  Goals and indications for I.V. therapy.  Types of I.V. solutions.  Methods of I.V. infusion.  Equipment of I.V. therapy.  Nurse’s role in managing patient receiving I...

Dr.Shimaa Nabil AHN I 1  Outlines   Definition of intravenous therapy.  Goals and indications for I.V. therapy.  Types of I.V. solutions.  Methods of I.V. infusion.  Equipment of I.V. therapy.  Nurse’s role in managing patient receiving I.V. therapy.  Complications of I.V. therapy. 2  Introduction Intravenous therapy (IV) is a way to give fluids, medications, nutrition, or blood components directly into the blood stream  through a vein via a needle, peripheral venous catheter (cannula), or central venous catheter directly into blood stream. 3  Definition of intravenous fluids  Intravenous fluids are chemically prepared solutions that are  administered directly into intravenous fluid compartment producing rapid effect with availability of injecting large volume of fluid more than other method of administration.  Goals and indications for I.V. therapy  Maintaining normal fluid, nutrient, and electrolyte balance when the patient is unable to maintain adequate intake by mouth, e.g. patient during pre- and postoperative period.  Replacing severe fluid loss as in case of server hemorrhage, severe burn, and dehydration.  Treatment through administration of medications intravenously.  Palliation through administration of analgesic medications for pain relief as a result of its rapid action.  Diagnosis of many disorders (e.g. injecting contrast dye intravenously for doing intravenous urogram or pyelogram. 4  Types of I.V. solutions  I.V. solutions can be classified according to their nature to:  crystalloids  colloids  and blood products. 5  A) Crystalloids  Crystalloids are small molecules, contain electrolytes (e.g., sodium,  potassium, calcium, chloride), are classified according to their “tonicity” means their ability move through cell membrane between intravascular and intracellular (body tissues and cells), through osmolarity.  Osmolarity is a measure of the osmotic pressure of a given solution.  A) Types of Crystalloids solutions 1 Isotonic solutions contain the same amount of electrolytes as the plasma so, the osmotic pressure of the solution is equal to intracellular osmotic pressure. The intravascular fluids and intracellular fluids remain as they are. 2 Hypertonic solutions contain more electrolytes than the body plasma so, the osmotic pressure of the solution is higher than intracellular osmotic pressure. The solution shifts the fluids from intracellular (tissues and cells) to intravascular. 3 Hypotonic solutions contain less electrolytes than the body plasma so, the osmotic pressure of the solution is lower than intracellular osmotic pressure. The solution shifts the fluids from intravascular to intracellular (tissues and cells). 6 Table (1): Common intravenous solutions classified by tonicity Solution Solution Uses type examples 1-Isotonic  0.9% normal  Isotonic crystalloids do not crystalloids saline (NS) cause a significant shift of have a  5% Dextrose in water between the blood tonicity equal water (D5W) vessels and the cells. Thus,  to the body  Lactated Ringer there is no (or minimal) plasma (RL) osmosis occurring  Expands intravascular volume  Used for dehydration, shock states 2-  5% dextrose in  High solution osmolarity in Hypertonic 0.45% normal relation to serum crystalloids saline osmolality have a  10 % dextrose  Fluid shifts fro m tonicity in water intracellular to higher than  3% normal extracellular the body saline compartments plasma  Used for treatment of water intoxication, symptomatic hyponatremia 3-Hypotonic  0.45% normal  The administration of a crystalloids saline hypertonic crystalloid have a  0.2% normal causes water shift from the tonicity saline extravascular spaces into lower than  2.5% dextrose the bloodstream, increasing the body the intravascular volume. plasma  Used for fluid deficit (e.g.,7 intracellular dehydration)  8  B) Colloids  large proteins and molecules, cannot pass through the  walls of the capillaries and onto the cells.  Remain in the blood vessels for long periods.  Increase the intravascular volume (volume of blood).  Have specific storage requirements, and have a short shelf life.  Commonly used colloid solutions include: plasma protein fraction, dextran, and hetastarch. 9  C) Blood components  1. Whole blood: Useful in haemorrhage.  2. Packed red blood cells (RBCs): Useful in treatment of anemia.  3. White blood cells (WBCs): Helpful in fighting infection.  4. Platelets: Initiate blood clotting as in thrombocytopenia.  5. Fresh frozen plasma (FFP): Provide clotting factors to  patients with coagulation deficiencies who are bleeding.  6. Albumin. 10  Parenteral nutrition (Hyperalimenation)   Parenteral nutrition (Hyperalimenation)  Parenteral nutrition is a form of nutritional support that supplies protein, carbohydrate, fat, vitamins, and minerals via the IV route to meet the metabolic functioning of the body. Clinical indications of parenteral nutrition - Patient cannot tolerate enternal nutrition as in case of paralytic ileus, intestinal obstruction, persistent vomiting. - Patient with hypermetabolic status as in case of burns and cancer. - Patient at risk of malnutrition because of recent weight loss of > 10%, NPO for > 5 days, and preoperative for 11 severely depleted patients. I.V. infusion methods 1. I.V. Bolus (I.V. push) The term bolus refers to a substance that is  given all at one time. This method is used to achieve as an immediate effect (as in an emergency). 2. Continuous-drip infusion Continuous-drip infusion is the slow instillation (over several hours) of a parenteral fluids and dilutent drugs in large volume (500-1000ml). 3. Intermittent infusion It is one in which I.V. medication is given within a relatively short period of time (minute up to 1 hr) or at specific intervals (e.g. every 12 4 hours).  13  Complications of IV Therapy Local   Infiltration and extravasation  Phlebitis  Thrombophlebitis  Hematoma  Clotting and obstruction Systemic  Fluid overload  Air embolism  Septicemia and other infections  Allergic reaction: may occur due to presence of allergens 14 such as medication.  Nurse’s role in managing patient receiving I.V. therapy A) Solution preparation: the nurse should:   Assess the solution for clarity and not expired.  Time-tape the I.V bottle or bag by securing adhesive tape of fluid indicator tape alongside of fluid container.  Label the I.V container by: patient name, solution name, solution volume, time span, ordered rate, beginning and expected end of infusion, any drug added and nurse initials.  Avoid the use of felt-tip pens or permanent markers on plastic bag, these can contaminate I.V solution.  Hang I.V bag or bottle from I.V pole minimum of 36 inches (90cm) above I.V insertion site. B) Site preparation  If skin is usually soiled, cleanse infusion site thoroughly with a good surgical soap and rinse.  Excessive hair at selected site should be clipped (not shaved) with scissor.  Cleanse I.V site with effective topical antiseptic as (Betadine), or alcohol 70%, in a circular movement from site outward (2-4 inches circle diameter) for 1 minute, then allowing to dry. 15 C) Regulating flow rate The fluids may be delivered via an infusion pump or by gravity. If gravity flow is utilized, the nurse calculates the I.V infusion rate  using the following formula after checking the drop factor. volume to be infused (ml/h)  gtt/ ml (IV set)  gtt/min time in minutes (60 min/1h) E) Monitoring I.V infusion therapy - The nurse should inspect the tubing for kink or blockages and for leakage. - The nurse should inspect the I.V set at routine intervals at least daily. - The nurse should observe for sweating, shivering, rigor, pallor or rash that may indicate an adverse systemic reaction. - Vital signs should be monitored hourly or according to patient condition. 16 - The nurse must monitor intake and output H) Discontinuing an I.V infusion Apply pressure to the site for 2 to 3 minutes  using a dry, sterile gauze pad while elevating the forearm and secured with tape to control leakage of blood and haematoma formation. Inspect the catheter for intactness. The arm or hand may be flexed or extended several times, this help patient to regain sensation and mobility. 17 F) Intermittent flushing of I.V lines  Peripheral intermittent are usually flushed with saline (2-3 ml 0.9% NS) before and after each medication and every 8 hours when medications are not being given.  G) Replacing equipment (I.V container, I.V set, I.V dressing)  I.V container should be changed when it is empty (before the level of fluid drops below the point of the trocar in the neck of container), when there is a change in I.V orders or when the I.V container has been hanging for more than 24 hours.  I.V set should be changed every 24 hours.  The site should be inspected and palpated for tenderness every shift or daily/cannula should be changed every 72 hours and if needs.  I.V dressing should be changed daily and when needed. 18  Nursing consideration for blood transfusion   Large enough access device (usually 18-gauge or larger). Also, frequently assess patient for signs of a transfusion reaction.  The nurse shouldn’t shake or squeeze the container.  Check that the blood has not passed the expiration date.  Reject the blood if it appears dark black or has obvious gas bubbles inside.  Packed RBCs and whole blood should be infused within 4 hours of leaving the blood bank to reduce risk of bacterial contamination.  Platelet should be infused rapidly at rate of 10 minutes a unit with a special platelet administration set with a filter.  Fresh frozen plasma should be infused within 15 to 30 minutes, while cryoprecipitate should be infused within 3 to 15 minutes. 19  Nursing consideration for administration of parenteral nutrition   The nurse should remove the nutrient solution from refrigerator at least 1 hour before administration.  Avoid solution that has cracking or creaming that indicates fluid separation.  Administered through tubing with an in-line filter.  Usually administered at a consistent rate over 24 hours.  The use of an electronic control device ensures accurate rate of administration.  The solution container and tubing must be changed every 24 hours.  Weight the patient daily and monitor blood glucose level.  Monitor intake and especially urine output.  The nurse shouldn’t shake fat emulsion bottle excessively; and fat emulsions are infused over 4 hours, and 20% fats are infused over 6 hours. 20 Fluid, Electrolyte and Acid- Base Balance and Imbalances 21  Outlines   Homeostasis  Functions of Water in the Body  Body Fluid Compartments  Electrolytes  Functions of Electrolytes  Electrolyte Balance  Regulation of Fluid  Fluid Volume Imbalances  Electrolyte Imbalances  Acid - Base Balance  Maintenance of Acid-Base Balance  Disturbances to Acid-Base Balance  Interpreting ABGs 22  Introduction   Water is the chief constituent of human body. Body water is distributed among three types of “compartments”: cells, blood vessels, and tissue spaces between blood vessels and cells. A delicate balance of fluids, electrolytes, and acids and bases is required to maintain good health. This balance is called Homeostasis. 23    Distribution of body fluids (Body Fluid Compartments):  Approximately 60% of the typical adult is fluid that varies with age, body size, and gender 24  1-Intracellular fluid (ICF) found within the cells of the body, constitutes 2/3 of the total body fluid in adult. 2-Extracellular fluid (ECF) found outside the cells accounts about 1/3 of total body fluid.  Extracellular fluid (ECF) outside is divided into:  Interstitial fluid between cell is 80% of ECF  Intravascular (Plasma) in blood is 20% of ECF  Transcellular includes lymph, cerebrospinal fluid, synovial fluid, aqueous humor, vitreous body, endolymph perilymph, pleural, pericardial, and peritoneal fluids 25   Functions of body fluids:  Transporting nutrients and wastes, hormones, enzymes, blood platelets  Facilitating cellular metabolism  Acting as a solvent (A liquid with a substance in solution)  Maintaining normal body temperature  Facilitating digestion and promoting elimination  Acting as a tissue lubricant  26    Regulation of the body fluids It occurs through the following mechanisms  Osmosis Fluid passes from areas of low solute concentration to areas of high solute concentration.  Diffusiontendency of solutes to move freely from areas of high concentration to low concentration.  Filtrationpassage of fluid through a permeable membrane. Movement is from high to low pressure  Active Transport  requires energy to move through a cell membrane from area of lesser 27 concentration to one of greater concentration.  Definition of Electrolytes   Electrolytes are elements or compounds that when dissolved in water or another solvent separates in to charged ions(ions able to conduct an electric current).  -Ions with positive charge are called cations e.g(Na+,K+,Ca 2+,Mg 2+)  -Ions with negative charge are called anions e.g (chloride CI-), (bicarbonate HCO3-) (phosphate HPO4-2) and (sulfate SO4-2)  Electrolytes are measured in milliequivalents per liter of water (mEq/L) or milligrams per 100 milliliters (mg/100ml). 28  Functions of electrolytes:   Maintaining fluid balance  Contributing to acid-base regulation.  Facilitating enzyme reactions.  Transmitting neuromuscular reactions 29  Fluid balance: -   -Fluid intake and fluids loss are balanced.  Fluid intake At moderate activity at moderate temperature the average adult drinks about 1 500 ml/day with 100 ml/ day as added volume form foods and metabolic process of food with total amount 2500 ml/day as total needs.  -Fluid output:1500ml/day 30 There are four routes of fluid output:   1/ Urine  2/ Insensible loss through the skin as perspiration and through the lungs as water vapor in the expired air  3/ Noticeable loss through the skin  4/Loss through the intestines in feces. 31  General Causes of Fluids and Electrolytes Disturbances:   A deficit or excess in the water and /or electrolytes  Inability to ingest or to absorb water and electrolytes  Failure of the kidneys to eliminate wastes  Excessive losses through skin, gastro intestinal tract lungs and kidneys  Lose of fluid caused by surgery trauma, burn, blood loss  Shift of fluid from one space to another as in burn, edema, ascites 32  Fluid Volume Imbalances   Fluid volume deficit (FVD): hypovolemia  Fluid volume excess (FVE): hypervolemia  Fluid Volume Deficit : -Deficit in extracellular fluid volume (dehydration) 33 Causes Clinical Nursing Interventions  Manifestations Decrease  Tachycardia  Assess clinical water intake  Hypotension manifestations of FV e.g.,  Dry skin, deficit & dehydration.  Vomiting oliguria, or  Monitor weight and  Diarrhea anuria, vital signs  intestinal  Acute weight  Monitor fluid intake and obstructio loss output. n  Fatigue  Monitor serum electrolytes.  Encourage fluid intake as indicated.  Encourage dietary sodium as ordered 34 Causes Clinical Nursing Manifestations Interventions  Excess intake  Weight gain *Assess for clinical  Peripheral Manifestations of  of Sodium- containing edema FVE *Monitor weight Intravenous fluids  Increased and vital signs  *Excess blood Pressure *Assess for edema ingestion of and central *Assess breath sodium in diet Venous pressure sounds or medications  Distended neck *Monitor fluid (e.g., sodium intake and output and Peripheral *Monitor serum bicarbonate, veins: electrolytes. antacid)  Slow vein *place in Fowler,s emptying position  Enema solutions *Administer diuretics as ordered  Impaired fluid *Restrict fluid intake as indicated balance *Restrict dietary Regulation sodium as ordered related to: *Implement  Heart failure measures to prevent  Renal failure skin breakdown.  Cirrhosis of the liver 35   Normal Electrolyte Values for Adults  Sodium- 135-145 mEq/L  Potassium- 3.5-5 mEq/L  Chloride- 95-106 mEq/L  Calcium- 4.5-5.5 mEq/L or 8.5-10.5 mg/dl  Magnesium- 1.5-2.5 mEq/L or 1.6-2.5 mg/dl  Phosphate - 1.8-2.6 mEq/L  Serum osmolality 280-300 mOsm/kg water 36  Common electrolyte imbalances   Sodium: hyponatremia and hypernatremia  Potassium: hypokalemia and hyperkalemia  Calcium: hypocalcemia and hypercalcemia  Magnesium: hypomagnesemia and hypermagnesemia  Phosphorus: hypophosphatemia and hyperphosphatemia  Chloride: hypochloremia and hyperchloremia 37  Sodium Deficit Condition Possible Manifestations Causes Hyponatremi a Serum Decreased sodium intake  Muscle weakness Dizziness, headache Hypotension level < Vomiting Tachycardia and shock 135 and Mental confusion mEq/L Stupor and coma Nursing Management: o Monitoring of dietary sodium and fluid intake. o Identification and monitoring of at -risk patients and the effects of medications (e.g. diuretics).  38  Sodium Excess Possible Causes Manifestations  Condition Hypernatremia Dehydration Intense thirst Serum sodium > 145 Water Hypertension mEq/L deprivation Edema Excessive Agitation sodium intake convulsions Nursing Management: o Assess for over-the-counter (OTC) sources of sodium o Offer and encourage fluids to meet patient needs o Provide sufficient water with tube feedings o Monitor U/O & serum sodium level. o Administer fluids carefully o Restrict sodium intake 39 3/ Potassium deficit: (Hypokalemia) Nursing management: Condition Hypokalemia Serum  Possible Causes Excessive loss vomiting in and Manifestations Muscle fatigue Mental potassium < diarrhoea confusion 3.5mEq/L Decreased Increased urine potassium intake output Kidney disease Shallow Hyperaldosteronism respiration - Assess serum potassium (severe hypokalemia is life-threatening). - Monitor electrocardiogram (ECG). - Monitor arterial blood gases (ABGs) - Assess dietary potassium. - Provide nursing care related to IV potassium administration. 40 4/ Potassium Excess: (Hyperkalemia) Nursing management:  Condition Possible Causes Manifestations Hyperkalemia Excessive intake Irritability Serum of potassium Nausea, potassium > 5 Renal failure vomiting mEq/L Aldosterone Diarrhea deficiency Muscular weakness Arrhythmia o Assess serum potassium levels. o Monitor medication effects. o Initiate dietary potassium restriction and dietary teaching for patients at risk. o Administer fluids carefully. 41  Acid-base balance  The  chemical balance of body fluids is regulation of acidity or alkalinity are the key of regulation is the PH.  Acid is the substance that releases hydrogen ions.  Base or alkaline have low hydrogen ions.  pH is the unit of measure used to describe acid base balance  Homeostasis of pH in body fluids is regulated by acid-base buffer systems (primary control), respiratory centers in brain stem, and by kidney tubule secretion of H+.  Acid – Base Balance  Blood - normal pH of 7.35 – 7.45 42  < 7.35 = acidosis > 7.45 = alkalosis Normal Values of Arterial Blood Gases. PH 7.35-7.45 PaO2 80-100 mm Hg PaCO2 HCO3  35-45 Mm Hg 22-26 meq/L O2 saturation 95-98% 43  How to interpret ABG  What is the PaO2 and SaO2:  PaO2 reflects ability to pickup O2 from lung  SaO2 less than 95 is inadequate oxygenation  Low PaO2 indicates hypoxemia Look for evidence of compensation:  - If a change is seen in BOTH PaCO2 and bicarbonate, the body is trying to compensate. 44 How to interpret ABG  45 How to interpret ABG  46  Respiratory acidosis When taking a breath, lungs remove excess carbon dioxide from body. When they cannot do so, blood and other fluids become too acidic. Risk Factors Clinical Nursing Acute lung  Manifestation Increased pulse Intervention Assess respiratory disease: Increased status and lung pneumonia, acute respiratory rate sound. pulmonary Headache Monitor air way edema Confusion and ventilation. Chronic lung Convulsions Administer disease: asthma, Warm flushed inhalation therapy. cystic fibrosis, skin Percussion and emphysema postural drainage. Overdose of Monitor fluid narcotics intake and output. Brain injury Measure vital Airway signs. obstruction Measure arterial blood gases. 47  Respiratory alkalosis Risk Factors Hyperventilation  Manifestation Shortness of Intervention Monitor vital due to: breath signs and ABGs -Extreme anxiety Chest tightness Assist client to -Elevated body Numbness and breath more temp(Fever) tingling of slowly -Over ventilation extremities Help client -Hypoxia Difficulty breath in a paper -Salicylate concentrating bag overdose Blurred vision Brain injury 48  Metabolic acidosis Metabolic acidosis occurs either when body produces too much acid, or when kidneys are unable to remove it properly. Risk Factors  Clinical Manifestation Nursing Intervention -Renal Deep rapid Monitor ABG values impairment respiration Monitor intake and -Diabetic Lethargy, output ketoacidosis confusion Monitor of LOC Decrease in Headache Administer IV sodium bicarbonates: Weakness bicarbonate or apply -Prolonged Nausea and rebreather mask diarrhea vomiting Help Sedation as Excessive prescribed NaCl infusion 49  Metabolic alkalosis Risk Factors Clinical Nursing Intervention Manifestation Excessive acid Increase Monitor intake and base due to: -Vomiting  respiratory rate and output Monitor vital signs -Gastric suction depth especially respiration Excessive use of Dizziness and LOC K-losing Numbness Administer IV fluid diuretics and tingling carefully Excessive of the adrenal corticoid extremities hormones due to: Hypertonic -Cushing’s muscles, syndrome tetany 50  Applying nursing process Assessment: – Nursing history:  Date include fluid and food intake, output. Recent fluid losses. Sign of fluid deficit. Common sign of electrolyte disturbance. Medication. Clinical measurement: – Daily weights, vital sign, fluid intake and output (I&O), serum electrolyte, complete blood count (CBC). Serum osmolality, urine specific gravity. 51  Nursing diagnosis:   Fluid volume deficit related to dehydration. as manifested by dry skin, oliguria, weight loss, fatigue  Fluid volume excess related to heart failure. As manifested by increased BP, weight gain, peripheral edema  Electrolyte imbalance related to (causes of electrolyte imbalance, Na, K, Ca) as manifested by ( clinical manifestation)  Acid- base imbalances related to respiratory/metabolic disturbances as manifested by ( arterial blood gases indicators) 52  Implementation:  Assess clinical manifestation of hypo or Hypervolemia.  Provide fluid and electrolyte orally.    Intravenous therapy can prescribed for those reason Assess vital signs regularly.  Assess consciousness level and report any disturbances.  Assess for edema.  Monitor fluid intake and output chart daily.  Monitor serum electrolytes regularly.  Weight patient daily  Provide frequent oral care.  Place patient in fowler position in case of hypervolemia.  Assess breathing sound, inspiration and expiration (crackles).  Provide safety measures for client  Assess arterial blood gases values regularly or as policy.  Administer IV fluid carefully according to rules of intravenous administration. 53  AHN I 54