IV-Therapy-and-Insertion-OUTLINE.pdf

INTRAVENOUS THERAPY AND IV INSERTION OF INTRAVENOUS FLUIDS A. Maintenance of Intravenous Infusions LEARNING OBJECTIVES: 1. Factors influencing rate of fluid adm...

INTRAVENOUS THERAPY AND IV INSERTION OF INTRAVENOUS FLUIDS A. Maintenance of Intravenous Infusions LEARNING OBJECTIVES: 1. Factors influencing rate of fluid administration. At the end of the discussion, the learners will be able to: - Type of fluid, age of client, and client’s response to fluids. 1. Identify the indications for IV therapy. - Cardiac and renal status 2. Categorize the different types of IV solutions and - Size of the vein and gauge of catheter or Intravenous devices. needle. 3. Identify the possible complications of Peripheral IV 2. Maintain accurate intake and output records. therapy. 3. Average maintenance fluid rate is 2000 to 3000 4. Describe the nursing management and prevention of mL over 24 hours, depending on body weight and client’s each complication. condition. 5. Demonstrate the procedure for IV insertion and 4. Peripheral IV infusion sites are commonly discontinuation of an IV line. changed every 72 to 96 hours (3 to 4 days, depending on institution policy) unless complications (inflammation, I. INDICATIONS OF INTRAVENOUS THERAPY irritation, or fluid extravasation) occur at the site. 1. Used to sustain clients who are unable to take 5. Carefully monitor the infusion rate: control with substances orally either a roller clamp or an infusion pump. 2. Replaces water, electrolytes, and nutrients more rapidly than oral administration B. Pediatric considerations. 3. Provides immediate access to the vascular system - Children are very susceptible to rapid fluid shifts; for the rapid delivery of specific solutions without the cerebral edema may occur with infusion of D5W. time required for gastrointestinal tract absorption - Most common IV solutions are a combination of 4. Provides a vascular route for the administration of saline (0.9%) and 5% dextrose to decrease the possibility medication or blood components of an untoward fluid shift. - Volume chambers holding no more than a 3-to II. TYPES OF SOLUTIONS 4-hour supply of fluid or controlled infusion devices 1. Isotonic solutions (pumps) should be used for children to prevent the A. Used to expand ECF volume and for intravascular inadvertent rapid infusion of too much fluid. dehydration. - Always make sure infants and young children are B. Solutions. voiding before beginning IV infusion of fluids containing 1. D5W: 5% dextrose in water (physiologically added potassium. hypotonic). 2. 0.9% NaCl (normal saline solution). C. Indications for Use of Infusion Pumps 3. Lactated Ringer’s solution. 1. To deliver a medication that requires a precise rate C. May be used to dilute medications or to keep the of administration (vasopressor agents, patient-controlled vein open. analgesia). 2. To deliver fluids that would precipitate adverse 2. Hypotonic solutions effects if administered too rapidly (total parenteral A. Solutions containing more water and less basic nutrition). electrolytes. 3. To deliver fluids in controlled amounts to clients B. 0.45% or half-strength NaCl (normal saline very sensitive to volume administered (infants, children solution). younger than 10 years of age, older adult clients, clients C. May be used to replenish cellular fluid. with pulmonary edema, cardiac problems, hypertension, D. Monitor closely for intravascular fluid loss, and with decreased renal function hypotension, changes in level of consciousness, and edema IV. INTRAVENOUS DEVICES 3. Hypertonic solutions A. A. Administered slowly; can cause intravascular 1. Butterfly sets volume overload; carefully monitor serum sodium, lung a. The set is a wing-tip needle with a metal cannula, sounds, and blood pressure. plastic or rubber wings, and a plastic catheter or hub. B. Solutions. b. The needle is 0.5 to 1.5 inches in length, with 1. Dextrose 5% in 0.45% or half-strength NaCl needle gauge sizes from 16 to 26. (normal saline). c. Infiltration is more common with these devices. 2. Dextrose 5% in 0.9% NaCl (normal saline). d. The butterfly infusion set is used commonly in 3. Dextrose 5% in lactated Ringer’s. children and older clients, whose veins are likely to be C. Used to treat situations of hyponatremia and small or fragile. hypovolemia 2. Plastic cannulas: Used primarily for short-term therapy. 4. Colloids B. IV gauges a. Also called plasma expanders 1. The gauge refers to the diameter of the lumen of b. Pull fluid from the interstitial compartment into the the needle or cannula. vascular compartment 2. The smaller the gauge number, the larger the c. Used to increase the vascular volume rapidly, such diameter of the lumen; the larger the gauge number, the as in hemorrhage or severe hypovolemia smaller the diameter of the lumen. 3. The size of the gauge used depends on the solution III. NURSING IMPLICATIONS IN ADMINISTRATION to be administered and the diameter of the available vein.  4. Large-diameter lumens (smaller gauge numbers) possible pooling of medication in areas of decreased allow a higher fluid rate than do smaller-diameter lumens venous return and allow the administration of higher concentrations of 2. Infants: Veins in the scalp and feet may be suitable solutions. sites 5. For rapid emergency fluid administration, blood 3. Children: veins on the dorsal surface of the foot products, or anesthetics, preoperative and are frequently used. postoperative clients, large-diameter lumens are used, such as an 18- or 19-gauge lumen. C. IV sites to avoid 6. For peripheral fat emulsion (lipids) infusions, a 20- 1. Areas of flexion, especially the antecubital area. or 21-gauge lumen or cannula is used. -Bending the elbow on the arm with an IV may 7. For standard IV fluid and clear liquid IV easily obstruct the flow of solution, causing medications, a 22- or 24-gauge lumen or cannula is used. infiltration that could lead to thrombophlebitis. 8. If the client has very small veins, a 24- to 25-gauge - Use an armboard as needed when the lumen or cannula is used. venipuncture site is located in an area of flexion. 2. Veins previously injured by infiltration or C. Drip chambers phlebitis. 1. Macrodrip chamber - if infiltration occurs from the antecubital vein, a. The chamber is used if the solution is thick or the lower veins in the same arm usually should not be is to be infused rapidly. used for further puncture sites. b. The drop factor varies from 10 to 20 drops 3. Veins of an affected extremity: mastectomy, (gtt)/mL, depending on the manufacturer. dialysis access. c. Read the tubing package to determine how - Avoid checking the blood pressure on the arm many drops per milliliter are delivered (drop factor). receiving the IV infusion if possible. 4. Veins of an extremity affected by stroke or 2. Microdrip chamber neurologic trauma. a. Normally, the chamber has a short vertical - Do not place restraints over the venipuncture metal piece (stylet) where the drop forms. site. b. The chamber delivers about 60 gtt/mL. 5. Veins in the lower extremities and sclerosed or c. Read the tubing package to determine the drop irritated veins. factor (gtt/mL). 6. Avoid previous venipuncture sites, areas of d. Microdrip chambers are used if fluid will be inflammation or bruising. infused at a slow rate (less than 50 mL/hr) or if the solution contains potent medication that needs to be VI. MANAGEMENT OF PERIPHERAL titrated, such as in a critical care setting or in pediatric INTRAVENOUS LINE clients. A. Precautions for IV lines V. SELECTION OF SITE AND EQUIPMENT 1. On insertion, an IV line can cause initial pain and A. Vein selection discomfort for the client. 1. Distal veins of the upper extremities should be 2. An IV puncture provides a route of entry for used first. Subsequent venipuncture should be proximal to microorganisms into the body. or higher than the previous site. 3. Medications administered by the IV route enter the 2. Veins above or below an area of flexion. blood immediately, and any adverse reactions or allergic 3. Try to select a site on the client’s nondominant responses can occur immediately. extremity. 4. Fluid (circulatory) overload or electrolyte 4. Select a vein large enough to accommodate the imbalances can occur from excessive or too rapid infusion catheter. of IV fluids. B. Client consideration 5. Incompatibilities between certain solutions and 1. Adult: Veins in the lower extremities (legs and feet) medications can occur. should not be used because of the risk for developing thrombophlebitis and thrombus formation due to the B. Local Complications of Peripheral IV Therapy Complication Signs & Symptoms Treatment Prevention Hematoma Ecchymoses Remove catheter Use indirect method of Swelling Apply pressure venipuncture Inability to advance with 2x2 Apply tourniquet just before catheter Elevate extremity venipuncture Resistance during flushing Thrombosis Slowed or stopped Discontinue catheter Use pumps infusion Apply cold compress Choose micro-drip sets with Fever/malaise to site gravity flow if rate is below Inability to flush Assess for circulatory 50 mL/hr catheter impairment Avoid flexion areas Phlebitis Redness at site Discontinue catheter Use larger veins for Site warm to touch Apply cold compresses hypertonic solutions Local swelling initially; then warm Choose smallest catheter Pain appropriate Palpable cord Good hand hygiene Sluggish infusion Dilute medications rate adequately and infuse at prescribed rates. Change solutions containers every 24 hr Rotate infusion sites every 72–96 hr Infiltration Coolness of skin at Discontinue catheter Stabilize catheter (extravasation) site Apply warm, moist heat for Place catheter in appropriate Taut skin 20 minutes to increase fluid site Dependent edema absorption (if not Avoid antecubital fossa Backflow of blood contraindicated); may Check IV flow rate at least absent reapply warm, moist heat 3 every 1 to 2 hours. Infusion rate slowing to 4 times throughout the day; Raise affected extremity to increase venous return and reduce swelling. If infiltrated solution contains an irritating medication (chemotherapy, vasoconstrictive fluids), Call the health care provider for orders to counteract effects of medication in the subcutaneous tissue. Local infection Redness and swelling Discontinue catheter Inspect all solutions at site and culture site Good technique during Possible exudate Apply sterile dressing venipuncture and site Increase WBC count over site maintenance Elevated T Administer antibiotics lymphocytes if ordered Venous spasm Sharp pain at site Apply warm compress Thorough history Slowing of infusion to site Verify allergies Restart infusion only if Proper patient identification spasm continues Warm solutions with appropriate warming device if appropriate C. Systemic Complications of Peripheral IV Therapy Septicemia Fluctuating Restart new IV Good hand hygiene temperature system Careful inspection of fluids Profuse sweating Obtain cultures Use Luer locks Nausea/vomiting Notify physician Cover infusion sites with Diarrhea Initiate appropriate dressings Abdominal pain antimicrobial Follow standards of Tachycardia therapy as practice related to Hypotension ordered rotation of sites/hang  Altered mental status Monitor patient time of infusions closely Use appropriate preparation solutions Fluid Weight gain Decrease IV flow Monitor infusion Maintain overload Puffy eyelids rate flow at prescribed rate Edema Place patient in Monitor I&0 Hypertension high Fowler’s Know patient’s Changes in I&0 position cardiovascular history Rise in CVP Keep patient warm Do not “catch up” Shortness of breath Monitor vital signs infusion—recalibrate Crackles in lungs Administer oxygen Distended neck veins Consider changing to microdrip set Air embolism Lightheadedness Call for help! Remove all air from Dyspnea, cyanosis, Place patient in administration sets tachypnea, expiratory Trendelenburg Use Luer locks wheezes, cough position Attach piggyback to Mill wheel murmur, chest Administer oxygen appropriate port pain, hypotension Monitor vital signs Changes in mental status Notify physician Coma Catheter Sharp sudden pain at IV Apply tourniquet Use radiopaque catheters! embolism site above elbow Do not apply pressure over Rough, uneven catheter Contact physician site. Avoid joint flexions. noted on removal Start new IV Never reinsert stylet that Chest pain Measure remainder has been removed from Tachycardia of catheter sheath. VII. STARTING AND REMOVING A PERIPHERAL IV procedure for documentation of procedure. LINE a. the insertion site, type and size of device, A. Inserting a Peripheral Intravenous Line solution and flow rate, and time; 1. Check the primary health care provider’s (PHCP’s) client’s response. prescription, determine the type and size of infusion device, and prepare intravenous (IV) tubing or extension B. Removing a Peripheral Intravenous Line set and solution 1. Check the primary health care provider’s (PHCP’s) 2. Explain procedure to the client. Select the vein for prescription and explain the procedure to the client; ask insertion the client to hold the extremity still during cannula or 3. Cleanse site thoroughly; re-cleanse the site if area needle removal. was palpated before insertion. 2. Turn off the intravenous (IV) tubing clamp and 4. Wear gloves during insertion of the needle and as remove the dressing and tape covering the site, while long as there is possibility of skin contact with the client’s stabilizing the catheter. blood. 3. Apply light pressure with sterile gauze or other 5. Apply the tourniquet 2 to 6 inches above the site material as specified by agency procedure over the site 6. Stabilize the vein below the insertion site and and withdraw the catheter using a slow, steady movement, puncture the skin/ insert the needle with the bevel up at a keeping the hub parallel to the skin. 15-to 30-degree angle. 4. Apply pressure for 2 to 3 minutes, using dry sterile 7. Observe for blood in the flashback chamber, when gauze (apply pressure for a longer period of time if the observed, lower the catheter so that it is flush with the skin client has a bleeding disorder or is taking anticoagulant 8. Advance the catheter into the vein. After the medication). needle has advanced into the vein and there is good blood 5. Inspect the site for redness, drainage, or swelling; return, release the tourniquet. (if unsuccessful, a new check the catheter for intactness. sterile device is used for the next attempt at insertion). 6. Apply a dressing as needed per agency policy. 9. Always obtain a new catheter or needle if the 7. Document the procedure and the client’s response. insertion attempt was unsuccessful. 10. Tape and secure insertion site with a transparent VIII. REFERENCES dressing as specified by agency procedure (do not place - Silvestri, A., et.al. Saunders Comprehensive Review tape directly over the insertion site.) for the NCLEX RN Examination. 8th ed. 2020. 11. Label the infusion container with: - Zerwekh, J. Illustraded Study Guide for the NCLEX a. Time container was hung; rate of infusion. RN Exam. 10th ed. 2019 b. Any medications that were added. - Perry, A., Potter, P. Mosby's Pocket Guide to 12. Document the specifics about the procedure such Nursing Skills and Procedures. 8th ed. 2015 as number of attempts at insertion; follow agency