Transcript Chapter_018_LO

Chapter 18
Intravenous Therapy
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Learning Objectives
• List the indications for intravenous fluid therapy.
• Describe the types of fluids used for intravenous fluid
therapy.
• Describe the types of venous access devices and other
equipment used for intravenous therapy.
• Given the prescribed hourly flow rate, calculate the
correct drop rate for an intravenous fluid.
• Explain the causes, signs and symptoms, and nursing
implications of the complications of intravenous fluid or
drug therapy.
• Explain the nursing responsibilities when a patient is
receiving intravenous therapy.
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Types of Intravenous Fluids
• Tonicity
• A measure of the concentration of electrolytes in the
fluid
• The normal concentration of electrolytes in body
fluids is about 285 mEq/L
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Types of Intravenous Fluids
• Isotonic solutions
• The concentration is the same as body fluids
• Hypertonic solutions
• The concentration is greater than 300 mEq/L
• Draws and retains water in the circulation,
increasing the blood volume
• Hypotonic solutions
• The concentration is less than 280 mEq/L
• Allows water to shift out of the capillaries into body
tissues, resulting in decreased blood volume
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Types of Intravenous Fluids
• Components
• Commonly used IV solutions: specific combinations of water,
sugar (dextrose), sodium chloride, and other electrolytes
• Sodium chloride solutions
• An isotonic solution is 0.9% sodium chloride
• A hypotonic solution is 0.45% sodium chloride
• Dextrose, sodium chloride, and other electrolytes are available
in numerous combinations
• Plasma-Lyte and lactated Ringer’s solution; dextrose 5% in
Ringer’s solution is a combined dextrose and electrolyte
solution
• Total parenteral nutrition: for long-term or aggressive
intravenous therapy for nutrition
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Venous Access Devices
• Intravenous fluid is delivered by various types
of venous access devices
• Needles, over-the-needle catheters, inside-needle
catheters (rarely used), subcutaneous infusion
ports, subcutaneous pumps
• Cannula size is based on the inside diameter and is
expressed as a gauge
• The smaller the gauge, the larger the inside diameter of the
cannula
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Venous Access Devices
• IV fluid administration requires placement of the
venous access device into a peripheral or central vein
• Peripheral veins
• Located in the extremities (and in the scalp of an infant)
• For short-term therapy, when a patient has healthy veins, and
when relatively nonirritating fluids are given
• Central veins
• Large vessels located nearer the heart
• For long-term therapy, when patient has poor peripheral veins,
and when irritating fluids are to be administered
• Central lines are inserted into the subclavian or jugular vein or
into the superior vena cava
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Figure 18-1
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Port
• A device with a central catheter that is surgically
implanted in the subcutaneous tissue
• A venous catheter and a port through which fluids can
be injected, but it has no external parts
• Catheter inserted into a central vein; port, which has a
rubber septum, can be felt under the skin
• A specialized needle that does not damage the septum
is used to puncture the skin and deliver fluid and
medications through the port and into the catheter
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Figure 18-2
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Figure 18-3
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Needles
• Winged (“butterfly”) infusion needle
• A short needle with two plastic wings that are held
during insertion
• Self-sheathing stylet
• Retracts into a rigid chamber at the catheter hub
after insertion
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Catheters
• A small plastic tube that fits over or inside a needle
• After insertion into vein, needle is withdrawn, leaving
the catheter in the vein
• Peripherally inserted central catheter (PICC)
• Inserted into vein in antecubital space; advanced into axillary,
subclavian, or brachiocephalic vein or the superior vena cava
• Tunneled catheters
• An incision is made at the entrance site, a tunnel created in the
subcutaneous tissues, and the catheter threaded through the
tunnel and into the subclavian vein
• Subclavian catheters
• Can have from 1-4 lumens
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Figure 18-5
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Figure 18-6
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Implanted Devices
• Some devices can be implanted to allow immediate
access to a vein without repeated, painful
venipunctures
• Include infusion ports, pumps that are implanted under
the skin, and external infusion pumps
• Infusion ports consist of a catheter and a chamber into
which fluids can be injected directly into vein or artery
• The chamber is easily felt directly under the skin
• Infusion pumps are filled with a special needle that is
inserted through the skin into the port
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Intermittent Infusion Devices
• Intravenous medications are given at specific
intervals
• Drugs are often “piggybacked”
• Given through an injection port in the tubing of a
continuous infusion
• Heparin lock
• Patient who does not need continuous IV therapy
may have a latex resealable lock
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Initiation of Intravenous Therapy
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Equipment
• Cannula (needle or catheter), tourniquet, alcohol
swabs, skin cleansing solution, tape, dressing supplies,
gloves, tubing, solution container, a pole to suspend
the container, and infusion pump
• Prescribed solution or drug
• Use the “five rights”: right solution or drug, right dose or
strength, right patient, right route, and right time
• Attach tubing to solution container, fill drip chamber
halfway, allow some fluid to run through the tubing until
completely filled with fluid and there are no air bubbles
in the tubing
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Site Selection
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Should be the least restrictive
A large vein that is in good condition
A soft, straight vein is best
Avoid veins that are hard and bumpy, bruised, swollen,
near previously infected areas, or close to a recently
discontinued site
Transilluminator or ultrasound can facilitate locating a
vein
Preferred site is usually patient’s nondominant arm
Begin with most distal veins, then move proximally
Should not be done in an arm that has impaired
circulation or poor lymphatic drainage, as in radical
mastectomy
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Procedure
• Wash hands thoroughly; explain procedure to patient
• Apply tourniquet above venipuncture site to distend
vein
• Locate appropriate vein; temporarily remove the
tourniquet
• Vigorously cleanse venipuncture site in a circular
pattern first with alcohol and then with a recommended
solution
• Allow to air dry after each cleansing step; do not blow
on the site or fan it
• Reapply the tourniquet
• Perform the venipuncture using Standard Precautions
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Procedure
• Carefully insert cannula through the skin and guide it
into the vein in the direction of blood flow
• If first attempt unsuccessful, select another site,
change cannulas, and try again
• When using the catheter over needle, the needle is
threaded only 1/4 inch into the vein
• Then catheter is threaded into vein as needle is
removed
• After threading the cannula into the vein, connect it to
the infusion tubing, and tape it securely but without
restricting circulation
• Dress site with a clear occlusive dressing that allows
inspection of the insertion site or with a sterile gauze
pad
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Procedure
• Pain
• Venipuncture and cannula placement are painful
• Drugs to decrease venipuncture pain include
intradermal lidocaine (Xylocaine), transdermal
lidocaine, and prilocaine (EMLA cream)
• Documentation
• Place a piece of tape on the site dressing with the
date and time that the cannula was inserted as well
as the length and gauge of the cannula and your
initials
• Label every bag of fluid and tubing with the date and
time that it was hung and the fluid’s expiration date
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Maintenance of Intravenous
Therapy
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Factors Affecting Infusion Rate
• Height of fluid container over the patient’s heart
• When container is raised, the fluid flows faster
• Lowering container causes fluid to run more slowly
• Optimal height is 30-36 inches above the patient
• Volume of fluid in the container
• Full container causes the fluid to run faster
• As container empties, rate slows down
• Viscosity of the fluid
• Thin fluids such as normal saline flow more quickly
than thick fluids such as blood
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Factors Affecting Infusion Rate
• Cannula diameter
• Fluid flows more quickly through a large cannula
than through a small cannula
• Venting of the fluid container
• Rigid containers must be vented to allow air to enter
as fluid leaves
• Position of the extremity
• Certain movements or positions may interfere with
the flow of fluid
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Calculating the Infusion Rate
• Determine
• How much fluid to give each hour
• Physician’s order specifies the amount of fluid to be
administered in a specific period of time
• How many drops equal 1 ml in the delivery set used
(called the drop factor)
• Instructions on the delivery set package state how many
drops equal 1 ml using that set
• Standard delivery sets (called macrodrop sets) deliver 10,
12, 15, or 20 drops per ml
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Calculating the Infusion Rate
• When infusion rate is known, use the roller
clamp or screw clamp on a gravity infusion to
adjust the flow rate until the correct number of
drops per minute is infusing
• Recheck the rate hourly
• Common to put a timed tape on the fluid container;
shows hourly levels
• This allows a quick assessment of whether the fluid
is running on schedule
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Infusion Control Devices
• Electronic infusion control devices maintain an
infusion rate set by the nurse
• The most commonly used types also have
alarms that sound when the fluid bag is empty,
when there is air in the line, or when there is
resistance to infusion
• Variety of infusion control devices
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Figure 18-7
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Intravenous Infusion of Medications
• Agency policies dictate what medications nurse may
give by piggyback or by direct injection through
cannula into the vein (intravenous push)
• Many states do not permit LPNs to give medications by
intravenous push
• You must know how to dilute the medication and the
correct rate of infusion
• Improper administration of IV medications is extremely
dangerous
• Some medications and intravenous solutions are
incompatible (they cannot be given together)
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Changing Venous Access Devices
and Administration Sets
• Short peripheral cannulas and the tubing are
usually changed every 48-72 hours
• If complications occur with 72-hour intervals, the
interval should be limited to 48 hours
• Administration sets for continuous peripheral
and central infusions changed every 72 hours
• PICC lines should be changed every 6 weeks
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Changing Venous Access Devices
and Administration Sets
• Tunneled catheters and ports can be left in
place for years
• Tubing used to administer blood, total
parenteral nutrition, or lipids must be changed
every 24 hours
• An intravenous fluid container should not be
used for more than 24 hours
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Termination of Intravenous Therapy
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Put on gloves
Stop the flow of fluid
Loosen or remove the tape and dressing
Gently press a dry gauze pad over the site
Remove cannula, keeping hub parallel to the
skin
• Dispose of needle or catheter according to
Standard Precautions guidelines
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Termination of Intravenous Therapy
• Elevate the extremity and apply pressure to the
puncture site with a sterile gauze pad for 2 or
3 minutes
• Secure the gauze with tape
• Record appearance of the site, condition of
catheter, and how patient tolerated procedure
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Precautions
• Always be aware of the risk of exposure to
bloodborne pathogens
• Most serious: human immunodeficiency virus and
hepatitis B virus
• Numerous products for venipuncture and
intravenous therapy that reduce the risk of
needle punctures or other exposure to blood
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Precautions
• Accidental needlesticks
• Most policies require blood specimens to be drawn
from the nurse and the patient to test for bloodborne
infections
• Drug therapy may be advised if patient has an
infectious disease
• Documentation of the incident and the health status
of the nurse at the time of the exposure is important
if the nurse becomes ill as a result of the exposure
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Complications of Intravenous Therapy
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Tissue trauma
Infiltration
Inflammation
Infection
Fluid volume excess
Bleeding
Embolism
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The Older Patient and
Intravenous Therapy
• Anchor vein with the thumb of your nondominant hand
to hold it in place during venipuncture
• When performing venipuncture, you may be able to
distend the vessel by simply pressing the vein
• Special adhesives/dressings prevent skin damage
• If the hand or arm is secured to an armboard, the
armboard must be padded
• Infiltrated fluid may drain away from the cannula
insertion site
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The Older Patient and
Intravenous Therapy
• If patient confused or restless, protect infusion site and
tubing with a commercial securement device or
conceal the site under long sleeves
• Never apply an immobilizer over an infusion site; the
immobilizer must be below the site
• Reassure the confused patient, use a calm and gentle
approach, and frequently reinforce instructions
• With dementia patients, distraction may take their
attention away from the IV
• Monitoring for excess fluid volume especially
important; older people have less efficient cardiac and
renal function
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Nursing Care During
Intravenous Therapy
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Assessment
• Determine the prescribed rate of flow, and
assess the actual flow rate
• Inspect the infusion site for edema, pallor or
redness, bleeding, and drainage
• Palpate site for edema and warmth or coolness
• Ask the patient if the infusion site is painful
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Assessment
• Take patient’s vital signs and compare the
readings with previous findings to detect
increased pulse and blood pressure
• Measure and record the fluid intake and output,
and auscultate the patient’s lungs for crackles
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Interventions
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Risk for Injury
• Trauma
• The insertion of a cannula is traumatic to the skin
and underlying tissues
• Tape may irritate or tear skin
• Use gentle technique when performing the
venipuncture, and anchor the cannula to reduce
tissue trauma
• Apply a commercial site protector, if available, to
shield the intravenous site
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Risk for Injury
• Infiltration
• Can be caused by leakage where cannula enters
vein or by puncture of a second site in the vein by
the cannula
• Patient may report pain or burning
• Site may be pale and puffy or feel hard and cool
• Stop the infusion and restart it in a different vein
• Elevate the affected arm on a pillow
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Risk for Infection
• Contamination of the site, by the intravenous
fluid, or by the tubing used to deliver the fluid
• Infected site red and warm; purulent drainage
• Use strict aseptic technique when starting and
handling intravenous infusions
• If infusion site inflamed or infected, stop the
infusion and restart it in another site
• If agency policy permits, a warm compress can
be applied to the inflamed site
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Excess Fluid Volume
• Blood volume may increase excessively when fluid is
delivered directly into the bloodstream
• Happens when large volumes of fluid infused, especially in
patients with impaired renal or cardiac function
• Signs and symptoms of fluid volume excess include
rising blood pressure, bounding pulse, and edema
• Controlling the rate of fluid infusion reduces the risk of
excess fluid volume
• Young children and older adults: monitor closely
• If indications of fluid volume excess appear, slow
infusion rate, elevate patient’s head, notify the
physician
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Decreased Cardiac Output
• Bleeding may occur if the cannula is moved
excessively after insertion
• More serious bleeding is possible if the tubing
becomes disconnected from the cannula, allowing
blood to flow freely from the vein
• Make sure all connections in infusion set secure
• Tape tubing so that it cannot be pulled loose easily.
Protect the infusion site and tubing when the patient
moves
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Ineffective Tissue Perfusion
• Risks of emboli from blood clots, air, broken
catheters
• Blood clot can develop in IV needles or
catheters
• Air can enter the bloodstream if the infusion
system is opened
• When the cannula seems to be obstructed,
blood clots may have formed. Irrigation of
cannula is not recommended
• Exercise extra caution to prevent an air
embolism when a patient has a central line
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Self-Care Deficit
• Provide assistance as needed with eating,
dressing, toileting, and hygiene
• Dressing may be easier if patient provided with
a gown or shirt that unfastens at the shoulder
• Explain restrictions needed to protect infusion
• If a commercial intravenous shield is available,
use to reduce the risk of trauma at insertion
site
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