Transcript Introduction to IV Therapy

Introduction to IV Therapy
Readings:
Heitz, U., & Horne, M.M. (2005). Pocket Guide to Fluid, Electrolyte, and Acid-Base Balance
(5th ed.). St. Louis: Mosby. Chapter 1. (Available on Mosby’s Nursing Consult –
Books)
Lavery, I, & Ingram, P. (2008). Safe practice in intravenous medicines administration.
Nursing Standard. 22(46).
Scales, K. (2008). Intravenous therapy: A guide to good practice. British Journal of Nursing.
17(19).
IV Therapy – Mosby’s Nursing Skills
Browse by Index: “I”
Intravenous Therapy: Initiation
Intravenous Therapy: dose and Flow Rate Calculations
Intravenous Therapy: Dressing Change
Intravenous Therapy:: Solution Change
Intravenous Therapy: Tubing Change
Intravenous Therapy: Discontinuation
Browse by Index: “M”
Medication Administration: Intravenous Bolus
Medication Administration: Injection Preparation from Ampules and Vials
Medication Administration: Adding Medication to Intravenous Fluid Containers
What is IV therapy?
Administration of liquid substances into the
venous system.
Goals of IV Therapy
The goal of IV fluid administration is correction or
prevention of fluid and electrolyte disturbances in
patients. For example, a patient who is NPO
(nothing by mouth) after surgery routinely receives
IV fluid replacement to prevent fluid and electrolyte
imbalances. Another reason for IV access is to
administer intermittent or emergency medication.
From: Potter, A.G., & Perry, P.A. (2010). Clinical nursing
skills & techniques (7th ed.). St. Louis: Mosby.
Osmolality
• Osmolality reflects the concentration of fluid that affects the
movement of water between fluid compartments by osmosis.
• Osmolality measures the solute concentration per kilogram in
blood and urine.
• Osmotic pressure is the pulling pressure demonstrated when
water moves through the semi permeable membrane of
tissue cells from an area of weaker concentration to stronger
concentration of solute .
• The number of dissolved particles contained in a unit of fluid
determines the osmolality of a solution, which influences the
movement of fluid between the fluid compartments.
• There are two fluid compartments: extracellular &
intracellular.
Intracellular Fluid
•
Intracellular fluid is the fluid contained within the cells. In adults, approximately two thirds of the body's
fluid is intracellular; this is approximately 27 L in the average (70-kilogram [kg]) adult male. In contrast,
only half of an infant's body fluid is intracellular.
Extracellular Fluid
•
Extracellular fluid is the fluid outside the cells. The relative size of ECF decreases with advancing age. In
the newborn, approximately half the body fluid is contained within ECF. After 1 year of age, the relative
volume of ECF decreases to approximately one third of the total volume. This equals approximately 15 L in
the average (70-kg) adult male. ECF is further divided into the following:
•
1. Interstitial fluid: Fluid surrounding the cells, equal to approximately 11 to 12 L in adults. Lymph fluid is
included in the interstitial volume. Relative to body size, the volume of ISF is approximately twice as great
in the newborn as in the adult.
•
2. Intravascular fluid: Fluid contained within the blood vessels (i.e., the plasma volume). The relative
volume of IVF is similar in adults and children. Average adult blood volume is approximately 5 to 6 L, of
which about 3 L is plasma. The remaining 2 to 3 L consist of red blood cells (RBCs, or erythrocytes), which
transport oxygen and act as important body buffers; white blood cells (WBCs, or leukocytes); and
platelets. Functions of the blood include: ▪ Delivery of nutrients (e.g., glucose, oxygen) to the
tissues ▪ Transport of waste products to the kidneys and lungs ▪ Delivery of antibodies and WBCs to
sites of infection ▪ Transport of hormones to their sites of action ▪ Circulation of body heat
•
3. Transcellular fluid (TCF): Fluid contained within specialized cavities of the body. Examples of TCF
include cerebrospinal, pericardial, pleural, synovial, and intraocular fluids, and digestive secretions. At any
given time, TCF is approximately 1 L. However, large amounts of fluid may move into and out of the
transcellular space each day. For example, the gastrointestinal (GI) tract normally secretes and reabsorbs
up to 3 to 6 L per day.
Heitz, U., & Horne, M.M. (2005). Pocket Guide to Fluid, Electrolyte, and Acid-Base Balance (5th ed.). St. Louis:
Mosby.
Available on Mosby’s Nursing Consult - Books
Commonly Prescribed Intravenous Fluids
• Intravenous fluids are divided into two major categories: crystalloids and colloids.
Crystalloid solutions contain only electrolytes and glucose, substances that are not restricted to
the intravascular space. Therefore these solutions expand the entire extracellular space.
Depending on their sodium content, crystalloids also may expand the ICF volume. Isotonic
NaCl (0.9%) and Ringer's solution expand only the ECF, whereas hypotonic NaCl solutions and
dextrose and water solutions expand all fluid compartments. Crystalloids are typically
classified according to the osmolarity (tonicity) of the solution. Isotonic solutions have an
osmolarity similar to plasma, hypotonic solutions have an osmolarity significantly less than
plasma, and hypertonic solutions have an osmolarity significantly greater than plasma.
Because of the risk of RBC hemolysis, there is a limit to how hypotonic a fluid may be and still
be safely administered IV. Pure water and hypotonic saline solutions such as 0.225% NaCl
require the addition of 5% dextrose to allow safe administration. For the clinician
administering IV fluids, it is important to consider the “true” tonicity of the solution.
Although both normal saline (0.9% NaCl) and 5% dextrose in water (D5W) are considered
isotonic (osmolarity similar to plasma) before administration, D5W is in fact a hypotonic fluid
once it has been administered and the dextrose has been metabolized. Advantages of
crystalloids are that they are relatively inexpensive and non-allergenic.
Colloid solutions contain cells, proteins, or synthetic macromolecules that do not readily cross the
capillary membrane. These solutions remain within the vascular space and, depending on
their concentration, may cause an osmotic shift of fluids from the interstitium into the
intravascular space. Disadvantages of colloids can include increased cost, risk of allergic
reactions, and clotting abnormalities. Blood is the most commonly administered colloid.
From: Heitz & Horne (2005). Chapter 6.
Types of IV Fluids
ISOTONIC
• Has similar osmolality close to
ECF & don’t cause RBC’s to swell.
• Stays where you put it - expands
intravascular compartment only.
• Isotonic fluids expand the ECF
volume
• One L of isotonic fluid expands
the ECF by 1L therefore, but 3L is
req’d to replace 1L of blood loss.
• Pt’s are at risk for fluid overload
as isotonic fluids expand the
intravascular space.
 Normal Saline 0.9%
 Lactated Ringers
 Hartman’s Solution
 Albumin
 Plasmalyte
 Plasma
 D5W (Dextrose 5% in
water)
Types of IV Fluids
HYPOTONIC
• Replaces cellular fluid
• Shifts fluid and electrolytes out of
intravascular hydrating
intracellular and interstitial.
• Provides free water
• Used to treat hyponatremia
• Excessive infusions of hypotonic
solutions can lead to intravascular
fluid depletion, decreased blood
pressure, cellular edema, and cell
damage.
 0.45% sodium chloride
Types of IV Fluids
HYPERTONIC
• These solutions are very strong as
they exert a strong pull from ICF
to the ECF making cells shrink
• Draws fluid into the intravascular
dehydrating intracellular and
interstitial
• Can be corrosive to veins
therefore must be given slowly
and into a large vein
• If given rapidly, they can cause
extracellular volume excess and
precipitate circulatory overload
and dehydration
 Dextrose 5% in normal
saline 0.9%
 Dextrose 5% in half –
strength normal saline
 Dextrose 10% in water
 Dextrose 20% in water
 Saline -3% and 5%
 Dextrose 5% in Lactated
Ringer`s
 Haemaccel 3.5%
 Gelofusine
 Albumin 25%
How can we deliver IVF?
1. Continuous Infusion
By peripheral access
2. Intermittent Infusion
By central access
3. IV Push (IVP)
Central (Venous) Catheters (lines)
• Long term therapy:
days, weeks, months
• Specialized training
required for caring for
CVL
Peripherally Inserted Central
Catheter
• Can remain in for weeks
to months
• Used for patients with
limited peripheral
access
• Specialized IV training
to insert them
Peripheral Catheters
• Most common
• Training required for
insertion
• Nurses are trained for
peripheral cannulation
• Some substances CANNOT
be given by the peripheral
route
Peripheral IV Cannulas
N.B. the different colours
of the cannulas
correspond to the different
sizes (gauges)
IV (fluid)Bags
• 50mL, 100mL, 250mL, 500mL, 1L sized bags
Solution type
Expiry date
Bag intactness
Clarity/colour
IV Bag Time
Strips
To keep
track of
how
much
fluid has
been
infused
IV Tubing
(+piggyback)
IV Tubing
• Drip chambers can be:
• A micro drip system delivers 60 drops\ml.
• A macro drip system delivers 10,15,20
drops\ml.
• Drops/ml is also known as gtt(s)/ml.
• Drop factor can be found on the packaging of
the IV tubing.
• Usually looks like:
20
IVF Orders: Look at this order…
The Dr has asked for 1L of 0.9% of Normal Saline to be
infused over 8 hours, but did not write down the mL/hr…we
have to figure that out ourselves!!
Calculating mLs/hr.
EASY PEASY!!
Using the IVF order on the previous slide, take
the amount of fluid ordered and divide it by
the time the Dr has stated.
Ex: 1000 (mL) ÷ 8 (hrs) = 125 mL/hour.
Calculating drops/min (gtt/min)
First you have to find out the drop factor on
your IV tubing, remember this can be micro or
macro.
Let’s say the IV tubing on your ward has a 20gtt
factor.
Ex: 125mL/hr
20 (gtt factor)
60 (time)
= 41.6 gtts/minute or 42 gtts/min !!
Counting gtt/min
Now if you are using a gravity system, you don’t
want to stand there for ages adjusting the
roller clamp and counting 42 drops in the drip
chamber every minute..you could be there for
AGES!!
• Simply, divide 42 gtt/min by 2 to count drops
for 30 seconds. (answer=21gtt/30 seconds)
• Or, divide 42 gtt/min by 4 to count drops for
15 seconds. (answer=10.5 or 11gtt/15
seconds)
IV Pumps
What is your role in IV
administration/therapy?
• To prevent adverse effects of IV therapy
WATCH FOR:
• Signs of infiltration or sluggish flow
• Signs of phlebitis, thrombophlebitis or infection.
• Cellulitis or sepsis.
• Air embolism, hematoma, clotting, mechanical obstruction.
• Correct solution , medication, volume, and rate (I & O!!)
• Dwell time of catheter.
• Condition of catheter dressing and changing same.
• Fluid and electrolyte balance (lab tests).
• Signs of fluid overload or dehydration.
• Patient satisfaction with therapy.
Complications
Hematoma
Extravasation
Infiltration
Infection
Extravasation
Complications
• Hematoma: can occur when the luer leaves the vein or when
the luer is taken out and bleeding occurs into the tissues.
• Infiltration: can occur when the luer leaves the vein and nonvesicant fluid continues to infuse into the tissue.
• Infection: can occur when a luer or previous luer site becomes
infected because it’s been insitu >72 hrs or the previous luer
site has been contaminated.
• Extravasation: occurs when a vesicant fluid leaks out of the
vein and damages the tissues and leads to tissue necrosis.
• Speed shock: can occur at anytime a medication is introduced
too quickly into a vein. This is especially evident and risky
when giving IV Push (IVP) medications. To prevent this, read
manufacturers instructions and push medication over
allocated time – NO FASTER!!
YouTube: Introduction to IV Therapy
(Spiking & Priming an IV line)
• http://www.youtube.com/watch?v=7QpX6Np
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