107 terms

Nursing 105 BSCC IV Therapy

Types of therapy, complications, signs and symptoms of complications, Starting a Peripheral IV, maintaining therapy, patient teaching, Nurse Practice Act
Purpose for Parenteral Fluid Therapy
Provide water, electrolytes & nutrients, replace water, correct electrolyte deficits, administer medications, & blood products
Types of IV Solutions
Isotonic, Hypotonic, & Hypertonic
Has the same osmolality as blood; expand the ECF volume; patients with HTN and Heart failure should be closely monitored for fluid overload
Types of Isotonic Fluid
Dextrose 5% in Water, NS(0.9% NaCL),Dextrose 5% 1/4 NS, & LR or RL (Lactated Ringers- used to correct dehydration, sodium depletion, replace GI losses)
Is < less than the osmolality of blood; Replaces cellular fluid and provides free water for excretion of body wastes; at times used to treat hypernatremia and other hyperosmolar conditions.
Excessive infusions of Hypotonic Solution can lead to:
Intravascular fluid depletion; decreased blood pressure; cellular edema; cell damage
Types of Hypotonic Fluid
0.45% NaCL(1/2 strength saline) frequently used
Is >Greater than the osmolality of blood; Draws fluid from the cell and is irritating when infused
Types of Hypertonic Fluid
Dextrose 5% 1/2 NS, Dextrose 5% NS, Dextrose 5% LR
Safety Alert
Solutions with higher concentrations of DEXTROSE, such as D 50% in Water, are strongly hypertonic and must be administered into Central Veins so they may be diluted by rapid blood flow
Other IV Therapies
Protein, vitamin, fats, colloids, plasma expanders, and blood products such as( Whole RBC's, Packed RBC's, Albumin, and cryoprecipitate)
Medication Infusions
IV medications delivered the IV route can be either by Continuous, Intermittent through hep lock, or Direct Bolus(IV Push); monitor for potential adverse reactions immediately within seconds to minutes of administration because they are delivered directly into the bloodstream.
Safety Nursing Alert
Assess the patient for a hx of allergic reactions to medications
Choosing the IV Site
Condition of the vein
Type of fluid or medication to be infused
Duration of therapy
Patient's age, size, and activity level
Whether pt is right or left handed
Pt's medical hx and current health status
Setting in which the therapy will take place
Choosing a vein
Vein should feel firm, elastic, engorged and round----Not hard, flat, or bumpy. Pay close attention that the vein Does NOT have a pulse otherwise this is an artery
Needle Gauge and Color Code
14GA-Orange; 16GA-Grey; 18GA-Green; 20GA-Pink; 22GA-Blue; 24GA-Yellow
14 to 18 Gauge used for:
Trauma, Surgery, and Blood Transfusions
20 to 22 Gauge used for
Most IV fluids (except caustic or viscous solutions where larger bore needles are used)
22 to 24 Gauge used for
Older patients, children, Toddlers
IV sites to avoid
Antecubital Fossa used as last resort flexion of the arm may hinder flow if IV solution; leg veins in adults, veins distal to previous IV infiltration or phlebitis area, sclerosed or thrombosed veins, arms with shunts or fistula, arm affected by edema, infection, blood clot, deformity, severe scarring, skin breakdown, arm on same side as mastectomy, veins with bifurcation go above or below.
Educate the patient
Patient should be prepared in advance for an IV infusion:
Venipuncture, expected length of infusion, activity restriction, understand the procedure, give the patient opportunity to ask questions and express concerns. (Except in Emergency situations) always tell the patient what your doing no matter what their health status!!
Preparing the IV Site
Ask pt if they are allergic to latex or iodine, Excessive hair at site may be removed by clipping to increase visibility and adherence of dressing, IV equipment and fluid must be sterile to prevent infection, Hand hygiene, gloves, site prep antiseptic, tourniquet.
2 attempts should only be made by one nurse, if unsuccessful get someone else
Factors Affecting Flow
Flow is directly proportional to the height of the liquid column(if flow is slow raise the bag), flow is also proportional to the size of tubing and cannulas(flow is faster in larger gauges slower in smaller gauges), consider the length of tubing, the viscosity of the fluid such as blood require larger cannulas.
Monitoring Flow
IV container should be marked to indicate time and whether the correct amount has infused. Flow rate is calculated when the solution is originally started then monitored hourly.
Electronic Infusion Devices (EID) pump
Calculated the volume delivered by measuring the volume in a reservoir that is part of the set and is calibrated in mL/hr. A controller that relies on gravity for infusion is calibrated in gtt/min
Discontinuing an Infusion
*Prescribed by an appropriate health care provider or on assessment of the nurse(contamination, phlebitis, or infiltration)
Complications in DCing an Infusion/Intervention
*Bleeding- pressure applied over a sterile dressing
*Catheter Embolism-severed and loose fragment can travel to RVentricle and block bloodflow(apply tourniquet and call Health care provider)
Prevention of Catheter Embolism
*Avoid using scissors near the catheter
*Avoid withdrawing the catheter through the insertion needle.
*Follow manufacturer's guidelines carefully(cover the needle point with the bevel shield to prevent severing the catheter)
System Complications
Circulatory Overload-Air Embolism-Febrile Reaction-Infection
Signs and Symptoms of Fluid Over Load
Moist crackles on auscultation of the lungs, cough, restlessness, distended neck veins, edema, weight gain, dyspnea, and rapid, shallow respirations
Treatment for Fluid Over Load
Decreasing IV rate, monitoring VS frequently, assessing breath sounds, and placing patient in a High Fowler's position. Contact physician immediately.
Prevention of fluid overload
Use of an infusion pump, also by carefully monitoring all infusions
Complications Resulting from Fluid Over Load
Heart Failure
Pulmonary Edema
Signs and Symptoms of Air Embolism
Palpitations, dyspnea, continued coughing, jugular venous distention, wheezing and cyanosis, HTN, weak but rapid pulse, altered mental status, chest, shoulder and lower back pain
Treatment of Air Embolism
Immediately clamping the cannula, replacing a leaking or open infusion system, placing patient on left sided Trendelenburg position, assessing VS and breath sounds, administering O2,
Prevention of Air Embolism
Use locking adapters on all lines, correctly priming tubing completely with solution, using air detection alarms
Complications of Air Embolism
Pyrogenic substances in either the infusion solution or the IV administration set can cause bloodstream infections
Signs and Symptoms of Infection
Abrupt Temperature elevated shortly after infusion is started, backache, headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and shaking, and general malaise(fatigue) additionally erythema, edema, induration or drainage at the sited of insertion
Prevention of Infection
Perform proper standard precautions, Examine IV solution for cracks, leaks, or cloudiness, Use Aseptic technique, firmly anchoring IV cannula to prevent to and fro motion, Inspect IV site daily(replacing soiled or wet dressings), Disinfect injection access ports before administering or adding medications or fluid, Remove IV cannula at the first sign of local inflammation, contamination, or complication, Replacing an IV cannula that was inserted in an emergency situation, Replacing solution or administration set in accordance with agency policy, Infusing or discarding medication or solution w/in 24hrs of its addition to an administration set, Changing primary and secondary continuous administration sets with policy or if contamination occurs, Using administration sets with a twist lock design
Local Complications at IV Site
Infiltration and Extravasation
Clotting and Obstruction
the unintentional leakage of medication or fluid into surrounding tissue.
Cause of Infiltration
IV cannula dislodges or perforates the wall of the vein
Signs and Symptoms of Infiltration
Edema around insertion site, leakage at the insertion site, discomfort, coolness around site, decrease in flow rate, if solution is irritating sloughing of tissue may result
Confirmation of Infiltration
Place a tourniquet above the site of insertion if fluids continue to flow infiltration is present.
Treatment of Infiltration
DC IV infusion, apply warm compress, apply dressing, elevate the extremity ...If indicated restart IV in new site proximal to the infiltration.
similar to infiltration with inadvertent administration of vesicant or irritant solution or medication into the surrounding tissue. Such as: vasopressors, potassium, calcium preparations, and chemotherapeutic agents can cause pain, burning, and redness at the site.
Indication of Extravasation
Blistering, inflammation, and necrosis of tissue... palpable cording of veins, fluid leakage
Treatment of Extravasation
Infusion Stopped, provider notified, facility policy followed such as specific treatments like antidotes whether IV line should remain in place for treatment
inflammation of a vein can be categorized as chemical, mechanical, or bacterial...2 or more of these types occur simultaneously.
Phlebitis results from
Rapid infusion rates, medication incompatibility, long periods of cannulation, catheters in flexed areas, catheter gauges larger than the vein, poorly secured catheters, poor hand hygiene, lack of aseptic technique, failure to check all equipment before use, failure to recognize early s/s of phlebitis, poor venipuncture technique,
Signs and Symptoms of Phlebitis
Reddened, warm area around the insertion site or along the vein, and swelling.
Treatment of Phlebitis
Discontinuing IV, restarting in another site, applying warm, moist compress
Prevention of Phlebitis
Using proper Aseptic Technique, proper sized cannula, considering the composition of fluids and medications, observing the site hourly, anchoring the cannula or needle well, and changing the IV site according to policy
Grading Scale for Infiltration
0-No symptoms
1-skin blanched, edema <1 in. in any direction from site, cool to touch, with or w/out pain
2-skin blanched, edema 1-6 in., cool to touch, with or w/out pain
3-skin blanched, translucent, gross edema > 6 in., cool to touch, mild or moderate pain, possible numbness
4-skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross edema > 6 in., deep pitting tissue edema, circulatory impairment, moderate to severe pain, infiltration of any amount of blood products, vesicant, or irritant.
Grading Scale for Phlebitis
0-No symptoms
1-Erythema at access site with or w/out pain
2-Pain at access site, erythema, edema, or both
3-Pain at access site, erythema, edema or both, streak formation, palpable venous cord(1 inch or shorter)
4-Pain at access site with erythema, streak formation, palpable venous cord(longer than 1 inch) purulent drainage
the presence of a clot plus inflammation in the vein
Thrombophlebitis Signs and Symptoms
localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein, immobility of the extremity due to discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis
Treatment of Thrombophlebitis
DC'ing IV, applying a cold compress first to decrease flow of blood, followed by warm compress, elevating the extremity, restarting the line in opposite extremity.... DO NOT flushed...
Prevention of Thromboplebitis
Avoid trauma to the vein during insertion, observe site every hour, check medication additives for compatibility.
When blood leaks into the tissue surrounding IV insertion site. Resulting from perforated vein during venipuncture, needle slips out of the vein, cannula is too large for vessel, insufficient pressure applied after removal of cannula or needle.
Signs and Symptoms of Hematoma
Ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site.
Treatment of Hematoma
Removing of needle or cannula, applying light pressure with sterile dressing, applying ice inadvertently for 24 hrs to avoid extension of the hematoma, elevate to max venous return, assess for circulatory, neurological or motor dysfunction, restart line in other extremity.
Clotting and Obstruction
Clots may form in the line from kinked IV tubing, very slow infusion rates, an empty IV bag, failure to flush the IV line after intermittent medication or solution administration
Signs of Clotting or Obstruction
Decreased flow rate and blood back flow into tubing
Treatment of Clot
DC infusion, and restart in another site with new cannula and administration set, do not irrigate tubing or milk, Do not raise container, clot should not be aspirated from the tubing.
Clot Prevention
Do not allow IV bag to run dry, tape tubing to prevent kinking, maintain patency, maintaining adequate flow rate, flushing line after intermittent medication or other solutions.
Educating Patients about Self Care
It is important to ensure the patient and family can manage IV fluid and infusions correctly and avoid complications in the home setting. Written instructions as well as demonstration and return demonstration help reinforce key points for all functions.
280-300 mOsm?kgH2O
135-145 mEq/L
3.5-5.5 mEq/L
98-106 mEq/L
Total CO2
22-30 mEq/L
Arterial 22-26 mEq/L
Venous 24-30 mEq/L
Ca 2+
8.4-10.5 mg/dL
ionized Ca 2+
4.5-5.3 mg/dL
Mg 2+
1.5-2.5 mEq/L
Phosphate PO4
2.7-4.5 mg/dL
Anion Gap
5-11 mEq/L
Blood Gases pH
35-45 mm Hg
80-100 mm Hg
O2 Saturation
Base Excess
-2 to +2 mmol/L
Blood Transfusion Objectives
1-increasing circulating blood volume after surgery, trauma, or hemorrhage 2-increasing the number of RBC's and maintaining Hgb levels in patients with severe anemia 3-providing selected cellular components as replacement therapy(clotting factors, platelets, albumin)
Autologous transfusion
is the collection and reinfusion of a patient's own blood, commonly obtained preoperative donation up to 6 weeks before surgery.
Normovolemic hemodilution
Blood salvage
ABO compatibilities for Transfusion Therapy
PRBC's O can give to O,A,B,AB
A can give to A, AB B can give to B, AB AB can give to AB
FFP O can give to O A can give to A, O B can give to B, O AB can give to AB, B, A, O
Platelets RBC: ABO and Rh Compatible Preferred
O to O,A,B,AB A to A, AB B to B, AB AB to AB
Blood Transfusion Reaction
is an immune system reaction to the transfusion that ranges from a mild response to severe anaphylactic shock or acute intravascular hemolysis, both of which are life threathening
Interventions to follow when acute intravascular hemolysis is suspected
Stop Transfusion immediately
Keep IV line open by replacing the IV tubing to the catheter hub and running 0.9% NaCl
Do not turn off blood and simply turn on NS this will cause remaining blood in tubing to be infused into patient.
Immediately notify physican or emergency response team
Remain with the patient, observing signs and symptoms and monitoring VS as often as every 5 minutes
Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids and corticosteroids per physician order or protocol
Save blood container, tubing, attached labels, and transfusion record for return to the blood bank
Obtain blood and urine samples per protocol or physician order
Acute Intravascular Hemolytic Reaction Cause
Infusion of ABO-incompatible whole blood, RBC's or components containing 10 mL or more of RBC's Antibodies in recipients plasma attach to antigens on transfused RBC's, causing RBC destruction
Acute Intravascular Hemolytic Reaction Signs and Symptoms
Chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinuria, hemoglobinemia, sudden olguria(acute kidney injury) circulatory shock, cardiac arrest, death
Acute Intravascular Hemolytic Reaction Prevention
Meticulously verify and document patient identification from sample collection to component infusion
Febrile nonhemolytic (most common) Cause
Antibodies against donor white blood cells
Febrile nonhemolytic reaction Signs and symptoms
Sudden shaking chills(rigors), fever(rise in temp 1 degree F, headache, flushing, anxiety, muscle pain
Interventions for Febrile Reaction
Stop Transfusion
Give antipyrectics as prescribed, avoid asprin in thrombocytopenic patients
Do NOT restart infusion
Prevention of Febrile Reaction
Consider leukocyte poor blood products(filtered,washed, or frozen) Pretreat with antipyrectics if prior history
Mild Allergic Reaction Cause
Antibodies against donor plasma proteins
Mild Allergic Reaction Signs and Symptoms
Flushing, itching, urticarial(hives)
Mild Allergic Reaction Interventions
Stop Transfusion Temporarily
Give antihistamine as directed
If symptoms are mild and transient, restart transfusion slowly
WARNING! Do not restart transfusion if fever, pulmonary symptoms, or hypotension develop
Mild Allergic Reaction Prevention
Treat prophylactically with antihistamine
Anaphylactic Reaction Cause
Antibodies to donor plasma, especially anti-IgA
Anaphylactic Reaction Signs and Symptoms
Anxiety, urticarial, dyspnea, wheezing, progressing to cyanosis, severe hypotension, circulatory shock, possible cardiac arrest
Anaphylactic Reaction Intervention
Stop Infusion
Have epinephrine ready for injection
Provide BP support as ordered
Initiate CPR if indicated
WARNING Do Not restart transfusion
Anaphylactic Reaction Prevention
Transfuse extensively washed RBC products from which all plasma has been removed. Alternatedly use blood from IgA-deficient donor
Keep Vein Open, keeps vein patent
Facility Policy example 25mL/hr