Transcript IV THERAPY - wbpracnsg.com

IV THERAPY
PART I
Catherine Luksic BSN,RN
WHAT IS IV THERAPY ?



Intravenous – into the vein
Administration of substances (fluids) directly into
the vein
Parenteral route
PN SCOPE OF PRACTICE:

IV THERAPY
State of Pennsylvania – requirements
Satisfactory completion of Board approved IV therapy
course
 LPN complies w/ policies/procedures of institution
 Review of policies/procedures q 12 mos.


Functions of PN
Perform venipuncture
 Administer IV fluids
 May NOT administer:





Antineoplastic agents
Blood products
Titrated medications
IV push medications
**As of 7/2012 – LPN may
administer & maintain
TPN, lipids
PN SCOPE OF PRACTICE: RULES AND
REGULATIONS

Refer to Handout
LEGAL ISSUES

Informed Consent
Pt. has right to refuse treatment
 If pt. is incompetent or unable to give consent, legally
authorized rep. may consent


Coercion of rational adult patient to place an IV
catheter constitutes assault & battery


Nurse must comply w/ acceptable nursing
standards established by facility, as well as
state/federal guidelines


Manual of IV Therapeutics, Phillips, 2010
Infusion equipment, administration of meds,
monitoring of pt., documentation, etc.
If an act of malpractice causes harm, legal action
can be initiated
INDICATIONS FOR IV THERAPY

Fluid & Electrolytes
Maintenance
 Replacement – fluid or electrolyte deficit
 Restoration - ongoing losses. (i.e. drains, NGT’s,
severe diarrhea, vomiting, burns)


Medications


Nutrients


antibiotics, potassium, insulin, heparin, etc.
TPN, PPN
Blood Products

PRBC’s, FFP, Platelets
ADVANTAGES OF IV THERAPY

1. Bioavailability is immediate

Drug enters circulation immediately, permits access to
site of action
2. Absorption into bloodstream is complete and
reliable
 3. Large doses can be delivered at a continuous
rate
 4. No “first pass” effect in the liver

DISADVANTAGES OF IV THERAPY

1. Adverse reactions may occur – can be life
threatening
If medication administered too quickly
 Allergic reaction
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2. Increased risk of complications
Extravasation
 Vein irritation (phlebitis)
 Systemic infection
 Air embolism

THE HEART
BLOOD VESSELS

Arteries - carry blood away from heart. Branch
off into smaller arteries eventually into
capillaries.

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OXYGENATED BLOOD
Veins - blood from capillaries flow into veins,
carry blood back to the heart

UNOXYGENATED BLOOD
BLOOD VESSEL WALLS
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
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Tunica intima - innermost layer. Continuous with
the endocardium.
Tunica media - middle layer. Smooth muscle and
elastic tissue.
Tunica adventicia (externa) - tough outer layer.
BLOOD VESSEL WALLS
BLOOD VESSEL WALLS
ARTERIES VS. VEINS
Middle layer (tunica media) much thicker in
artery
 Arteries contract & relax


Due to high pressure and thicker muscle layer
Pressure much less within veins.
 Veins have one-way valves to direct blood flow
toward the heart.
 Veins store blood (70% of blood volume).

ARTERIES:
Thick wall (tunica
media)
 Lacks valves
 Pulsates
 Bright red blood
 High pressure

VEINS:
Thin wall
 valves present approx.
every 3 in.
 No pulsation
 Dark red blood
 Lower pressure


*pulsation may be
seen in jugular vein
VEINS
VEINS

Used for IV therapy

Peripheral (arms/hands):
Cephalic (upper and lower)
 Basilic
 Median (antecubital)
 Metacarpal *First choice for site selection
*allows for increased mobility

*less risk of phlebitis
(Burton textbook recommends forearm veins – to avoid
nerve/tendon damage in hands ???)
PERIPHERAL VEINS – UPPER EXTREMITY
FACTORS TO CONSIDER
 Adipose
 Edema
tissue
 Color

? Adequate tissue perfusion

? Dehydration, volume overload, normovolemic

Avoid these areas

? Lack of, can pt. feel “pain”
 Hydration
 Tissue
elasticity
 Bruising, rashes, breaks in skin
 Sensation
VEINS
Refer to handout: Veins
 Practice identification of peripheral veins in
classroom
 Learn to properly apply tourniquet to upper
extremities

VENOSCOPE: VEIN FINDER
IV ACCESS

Peripheral - Located in peripheral veins of
upper (and sometimes lower) extremities
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
Can be placed by nursing (qualified LPN’s & RN’s)
Central - Located in large vessels near heart (ie,
subclavian, internal jugular, femoral)

Can only be placed by physician or specially trained
practitioners
PERIPHERAL IV
Smaller vessels
 Slower blood flow
 Easy access
 Veins of hands, arms most commonly used
 Metacarpal, cephalic, basilic, accessory cephalic,
median, upper cephalic
 Needs to be changed regularly



Every 48-72 hours, according
to policy
2011 Infusion Nursing Standards of Practice –
rotate peripheral IV catheters based on clinical
condition vs. set time frame
CENTRAL IV ACCESS
Higher risk of life-threatening complications
 Larger vessels
 More turbulent blood flow
 Care includes sterile dressing changes and
flushes
 Used if peripheral access not possible, or for
long-term use.
 Percutaneous, tunneled, or implanted.
 Includes PICC lines (peripherally inserted
central catheter)
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CENTRAL IV LINES
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Usually located in subclavian vein, jugular vein
Can also have access through cephalic, basilic,
antecubital and axillary veins
 PICC lines
PICC LINE
CENTRAL IV LINE
CENTRAL IV LINE
IV SOLUTIONS

Bottle vs. Bag
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Types of Solutions

Tonicity
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Electrolyte Solutions
SOLUTION CONTAINERS
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Bottle - Not commonly used

Meds that cannot be in plastic
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Advantages: Very easy to visualize solution and to
see calibrations
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Disadvantages: BREAKS. Easier to contaminate.
Takes more storage space.

Examples: Nitroglycerin, Albumin, Lipids


Lipids are also stable in special plastic
Requires tubing w/ vent
IV BOTTLE
SOLUTION CONTAINERS

Plastic - Most common container

Atmospheric pressure collapses bag , forces fluid out.

Advantages: Easy to store. Not greatly affected by
temp fluctuations.

Disadvantages: Can be punctured. Some meds can
adhere to plastic.

**ALWAYS inspect bag/bottle before
use
TYPES OF SOLUTIONS

Colloids - Pulls fluid into intravascular space, volume
expanders
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Albumin – treat low BP/shock, provides protein
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Dextran – to prevent venous thrombosis during OR
Hespan (hetastarch)
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Considered to be a blood product
Similar to albumin
Crystalloids - Used for hydration, most common **
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Saline, Dextrose
TYPES OF SOLUTIONS
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Blood and blood products
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Restore blood volume or components
PRBC’s – acute blood loss, anemia Hg <8.0
FFP – replace coag factors, will reverse effect of
coumadin (PT/INR elevated)
Platelets – thrombocytopenia, control bleeding
Whole blood – rarely used, restores blood volume

LPN cannot admin. but can monitor pt. during
infusion

Beware of transfusion reaction
TYPES OF SOLUTIONS:
BLOOD PRODUCTS
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Physician order & consent required
Type and crossmatch required (ABO type, Rh
group)
Only compatible with 0.9% NS **
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Dextrose can cause hemolysis
Frequent VS, monitor pt. continuously for first
15 min.
2 RN’s must check blood product before
initiating infusion
TYPES OF SOLUTIONS
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Transfusion Reactions
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1. Hemolytic: DANGEROUS, RBC’s attacked by
immune system – cells burst
Bleeding (urine), chest pain, back pain, low BP, chills
 May be a delayed reaction, usually immediate
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2. Febrile:
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3. Allergic
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Itching, SOB, wheezing, possible rash
4. Anaphylaxis: DANGEROUS
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N/V, fever, chills, headache, chest pain
Wheezing/stridor, SOB, low BP, cyanosis, anxiety
5. Circulatory Overload
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Low SP02, tachycardia, high BP, dyspnea
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ALWAYS STOP THE TRANSFUSION IMMEDIATELY
IV NUTRITIONAL SUPPORT
 TPN – Total Parenteral Nutrition: IV infusion of
amino acids, vitamins, electrolytes, and minerals
Usually high dextrose concentration
 Used when GI system cannot be used for feeding
 LPN can administer **
 High dextrose concentration (>10%) can damage veins,
usually given via central vein

 Intralipids - intravenous infusion of fat (fatty
acids)
essential fatty acid is linoleic acid, needed for proper
metabolism.
 IV lipids are “white”
 Lipids can be “piggybacked” with TPN

IV NUTRITIONAL SUPPORT
 Increased
dextrose level of TPN can lead
to increased microbial growth
TPN & LIPIDS
FLUID COMPARTMENTS IN THE BODY

Intracellular :
fluid inside cells of the body
 High concentrations of potassium(K+), phosphate,
and magnesium ions
 2/3 of body water
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
Extracellular:
fluids outside cells
 Includes interstitial & intravascular compartments
 Contains high concentrations of sodium, chloride, and
bicarbonate ions
 1/3 of body water

ELECTROLYTES
Sodium (Na+)
 Major extracellular cation
 Normal 135-145 meq/L
 Calcium (Ca+) – extracellular cation
 Chloride (Cl-)
 Major extracellular anion
 Bicarbonate (HCO3) – extracellular
 Magnesium (Mg+) – intracellular cation
 Potassium (K+)
 Major intracellular cation
 Normal 3.5-5.0
 Hyperkalemia = serious danger !

IV SOLUTIONS

Osmosis: regulates fluid & electrolyte balance =
movement of water through SPM from area of
lower concentration (solutes) to higher
concentration
SPM’s = tunica intima, capillary walls, and cell
membranes of RBC’s

Rate of osmosis – depends on osmotic pressure within
tissues/cells
Draws water through SPM to more concentrated area
 IN or OUT of cell
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IV SOLUTIONS
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Tonicity = osmolarity or concentration of IV
solution
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Amount of solute in a fluid (dextrose, sodium, etc.)
ISOTONIC: concentration same as blood
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No osmosis
No change in solute or water in blood, no shrink or swell
Increases amount of ECF
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Caution w/ fluid volume overload (CHF, renal patients)
Uses: replace fluid loss, dehydration, to administer
IVPB
0.9% NS, LR, D5%W
ISOTONIC SOLUTIONS
IV SOLUTIONS
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HYPERTONIC: Higher concentration of
solutes
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Osmosis pulls water out of cells
Fluid shifts from intracellular > intravascular
Increased fluid volume in vascular space
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CAUTION with CHF patients
May raise BP
May irritate the vein walls
Cells shrink
Can cause “cellular dehydration”, cellular death
Uses: dehydration, electrolyte replacement
(severe), expand blood volume
D5LR, D5 0.9% NS, D5 0.45% NS, D10%, albumin,
dextran
HYPERTONIC SOLUTIONS
IV SOLUTIONS
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HYPOTONIC: Lower concentration of solutes
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Osmosis pushes water into cell
Fluid shifts from intravascular > interstitial >
intracellular
Cell is re-hydrated
Cells swell, can possibly “burst” – hemolysis
Uses: DKA
Can cause intravascular fluid depletion – caution !
 May cause hypotension
Can increase ICP from quick fluid shift
 Cerebral edema
0.45% NS, 0.3% NS, 0.25% NS
HYPOTONIC SOLUTIONS
IV SOLUTIONS
ISOTONIC
HYPERTONIC
HYPOTONIC
No osmosis; no shift
Osmosis pulls water
out of cell; “raisin”
Osmosis pushes
water into cell;
“grape”
Uses: dehydration,
fluid loss, commonly
used for IVPB
Uses: dehydration,
electrolyte
replacement (severe)
Uses: DKA, cellular
re-hydration, can
replace daily NaCl
requirement
Caution: fluid
volume overload
(cardiac, renal)
Cautions: fluid
volume overload,
hypertension, vein
irritiation
Caution: hemolysis
of cells, intravascular
volume depletion,
hypotension, cerebral
edema
0.9% NS, LR, D5%W
D5 0.9% NS,
D5 045% NS, D5 LR,
D 10%, Albumin
0.45% NS, 0.3% NS,
0.25 % NS
NORMAL SALINE
0.9% NS
 Isotonic – osmo same as blood
 NaCl = sodium chloride
 Non-caloric
 Standard “flush” solution
 Standard hydrating solution
 0.45% NS (1/2) is hypotonic


Lower osmo, less concentrated
SALINE
 Saline
- “NS” or “NaCl”

.9% (is isotonic)

.45% is ½

(is hypotonic)
When mixed with D5 may become
hypertonic - MUST WATCH FOR
FLUID OVERLOAD

More fluid in intravascular space
DEXTROSE
 Contains
dextrose and free water
 Available in a variety of concentrations, 5%
most common.
 5% (D5W) is isotonic.
 Usually in mixture with NS; D5W alone can
cause severe hyponatremia, hypokalemia, and
water intoxication.
Dilutes body’s normal level of electrolytes
 NOT 1st choice for hydration

 Cannot

be administered w/ blood
hemolysis
DEXTROSE
Dextrose
 usually
- “D”
5%
Also 10%, 20% (usually TPN only –
hypertonic)

 provides

calories
D5 = 170 cal/liter
 cannot
D10 = 340 cal/liter
be used with blood, certain
meds

Check compatibility
 can
affect blood glucose
monitor DM

ELECTROLYTE SOLUTIONS
 Usually
isotonic solutions that contain
electrolytes in concentrations similar to
plasma
 Lactated Ringer’s most common


contains potassium, sodium, chloride, and
calcium. Lactate added as buffer
Ringers solution = no lactate added
 short-term
use (48 hours)
 used for fluid loss (vomiting, diarrhea)

Electrolyte replacement
ELECTROLYTE SOLUTIONS
 Electrolyte






solutions
Ringer’s or Lactated Ringer’s (LR)
provides electrolytes and hydration
short-term
monitor ELECTROLYTES
no calories
cannot use lactate if liver disease
present – cannot metabolize
ELECTROLYTE SOLUTIONS
 Plasmalyte

Multiple combination
Dextrose
 Sodium chloride
 Sodium acetate
 Sodium gluconate
 Potassium chloride
 Magnesium Chloride

IV THERAPY: ABBREVIATIONS
D5W
0.9% NS
NS = 0.9%
½ NS = 0.45%
(5% dextrose solution
¼ NS = 0.225%
D5
w/ 0.9% normal saline)
D5
0.45% NS
(referred to as D5 ½ NS)
D5 0.45% NS @ 50 cc/hr
D5 ½ NS @ 50 ml/hr
IV THERAPY: ABBREVIATIONS
PICC
POC
TLC
HL
SL
KCL (meq)
CaGluc
MgSO4
TYPES OF IV INFUSIONS
 Continuous
rate
– not interrupted, ordered
 Intermittent
- access for infusions that
are only given at specific times

IV antibiotics
 IV
push - meds that are given all at
once. Not given by LPN’s

with exception of saline flush.
IV PUSH

Meds NOT administered by LPN’s


Must be given by RN
Delivery is immediate
 Saline
flush (non-med) – 3-10 mL given
directly into IV to maintain patency.
 CAN
 IVP
be given by LPN
INTERMITTENT INFUSIONS
 Not
continuous
 “Piggy-back” meds (IVPB) - intermittent
infusions given through continuous
primary IV line.


ie; IV antibiotics, IV potassium
Check compatability between “piggyback”
and continuous IV solution
Call Pharmacy re: drug-drug interactions
 Use on-line resources
 Use IV compatibility chart
 Incompatible drugs can cause a precipitate

CONTINUOUS IV INFUSION

Can be large volume (250 to 1000cc) of solution
administered continuously


correct or maintain fluid and electrolyte balance.
Can be a medication being delivered on a
continuous basis
to maintain a constant serum level – ie; heparin,
insulin
 Needs to be infused with IV pump to avoid error


Continuous IV medications cannot be titrated
(regulated) by LPN’s – must be done by RN