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IV Therapy Basics This section includes basic knowledge of common IV fluids and IV equipment, detection and care for potential local and systemic complications, and information regarding the variation of IV therapy across the lifespan. The pediatric section of “Lifespan” is optional for this course. I.

IV Fluids 1. General objectives 1. Maintenance  Maintaining daily body fluid requirements  Provides all daily client nutrient needs in the form of dextrose, electrolytes, vitamins and protein.  For a client who is unable to fluid by mouth or has restricted intake 2. Restoration  Aimed at restoring previous body fluid losses and to achieve homeostasis and meet daily needs.  Necessary when maintenance has not been met or when output exceeds intake  Candidates include those suffering from dehydration due to hemorrhage or starvation 3. Replacement  Goal is to replace present body fluid losses plus daily maintenance  Clients who may receive this treatment are those who have ongoing losses from drainage wounds, NG suction and diarrhea.  Fluids ordered depends on the elements being lost. 4. Medication Administration  IV therapy may be established for the sole purpose of providing access for IV medication administration. 2. Key elements a )Water  The most important element usually consumed orally  Humans need about 30 mL of fluid per kg of body weight  Ex. A client weighing 180 lbs unable to take fluid orally would require 2.5 L of IV fluid every 24 hours to meet basic need  Conditions such as tachypnea, fever, and diaphoresis require more fluid intake b)Glucose  Mostly supplied as dextrose and provides calories for energy.  One liter of 5% dextrose provides only 170 calories per liter.  Used in maintenance, restorative, and replacement theory c )Protein  Necessary for tissue growth and repair  Supplied in form of amino acids

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 Can be found in parenteral nutrition solutions d)Vitamins  Important for growth and metabolism  Replacement and restorative therapy  Vitamin B and C are most used in parenteral therapy e )Trace Elements  Essential elements  Zinc, copper, and iron may be included in restorative therapy f ) Electrolytes  Found in replacement and restorative therapy g )pH  Degree of acidity or alkalinity  Many IV fluids are acidic to prolong shelf life which may irritate veins 3. Tonicity a )Isotonic  0.9% sodium chloride  Lactated ringers  5% dextrose in water b)Hypertonic  5% dextrose in 0.45% sodium chloride  5% dextrose in 0.9% sodium chloride  5% dextrose in lactated ringers  10% dextrose c )Hypotonic  0.45% sodium chloride  2.5% dextrose 4. Common IV fluids a )5% Dextrose in water  Vehicle for providing nutrition and treating dehydration  Rapidly becomes hypotonic in the body due to glucose metabolism.  Does not contain any electrolytes, so must monitor Na+, K+, and Clb)0.9% Sodium Chloride (Normal Saline)  Isotonic fluid containing about 9% more sodium and chloride than plasma.  Used to correct fluid and Na loss, tx. for metabolic alkalosis, begin and end blood transfusion  Provides more sodium and chloride and less potassium  Potential complications include hypernatremia, hypokalemia, fluid overload with manifestations such as hypertension and crackles when listening to the lungs  Expands the ECF  If administered continuously may result in metabolic acidosis due to loss of bicarb c )0.45% Sodium Chloride Revised 10/2019 SM

 Used to replace daily losses of sodium and chloride.  Must monitor for hypokalemia due to absence of potassium d)5% Dextrose in 0.45% Sodium Chloride: (D5.45)  Useful for hydrating clients  Must evaluate kidney function prior to infusion and urine output during infusion to prevent fluid overload  Peripheral IV site must be assessed frequently for phlebitis. e )5% Dextrose in 0.9% Sodium Chloride  Used to replace the nutrient, glucose, and the electrolytes, sodium and chloride.  Useful in early burn therapy and occasionally as tx. for shock due to hypovolemia  Potential complications are hypernatremia and acidosis  Assess for phlebitis f ) 5% Dextrose in Lactated Ringers  Used for replacing fluid and electrolytes lost through trauma, burns, vomiting, diarrhea, and dehydration and sometimes mild acidosis.  Consider fluid overload by monitoring the blood pressure, lung sounds and urine output closely.  Assess for phlebitis g )Lactated Ringers  Used for replacing fluid lost as a result of burns, vomiting and diarrhea.  Monitor BP, lung sounds, and urine output II.

IV Equipment 1. Basic set up of equipment 1. Delivery systems (containers) a) Plastic (Advantages)  Closed system  Venting unnecessary  Flexible b) Plastic – Disadvantages  Can be punctured  More difficult to read  May leach plasticizers  Environmentally unfriendly c) Glass-Advantages  Good visualization  Easy to read d) Glass – Disadvantages  Breakable  Rigid  Cumbersome storage and disposal

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e) Sizes  Routine IV therapy: 500ml and 1000ml  Children: 250ml  Medication Administration: 50ml, 100ml, and 150ml 2. Administration sets (tubing) a) basic components of tubing (know all names/pieces) 1. Spike - designed to be inserted into the fluid container. 2. Flange - guard for the fingers to prevent contamination while spiking. 3. Drop orifice - determines the size and shape of the drop. The actual drop factor is found on the flange of the administration set box or in the accompanying literature. Drop factor is necessary to compute the drip ratio 4. Macrodrip - delivers large drops and takes between 10 to 20 drops to make a mL (drop factor) 5. Microdrip - delivers small drops and takes 60 drops to make a mL. Useful in elderly pts 6. Drip chamber - serves as small reservoir, reducing the amount of air that might infuse accidentally into the tubing. 7. Backcheck valve - automatically prevents primary IV solution from flowing while a piggyback solution is infusing. Restarts the primary IV once the piggyback is completely infused. 8. Clamp - controls the rate of the drips The slide clamp should not be used for regulating the drip rate since fine adjustments cannot be made. 9. Injection ports - used as an access into the tubing, usually for medication administration. At least one injection port included with each set. 10. Needleless System - decrease the number of needle stick injuries to health care workers. If using a needle, select a small gauge needle, such as 21 to 25 gauge. 11. Needle Adaptor - plugs into the IV catheter. The adaptor is capped to maintain its sterility until it can be connected to the IV. b) Primary tubing – main tubing that connects the solution to the IV catheter  Vented - has a built in air vent and must be used when a glass bottle does not have a straw  Non-vented - used with a glass bottle that has a straw in it. The straw functions as the vent to overcome the vacuum. Used with bags c) secondary tubing  Piggyback infusion o Administered via a short tubing and is placed into the upper port of the primary set. o Contains a back-check valve o Primary solution will not enter the piggyback because it is hung higher. When the piggyback is completed, the primary infusion will restart.  Simultaneous secondary infusion o Both the primary and secondary IV infuse together and the rate will remain constant if the volumes are approximately equal.  Volume control set o Have chambers that are calibrated in small increments.

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o When used for medication administration, the chamber is first filled with IV fluid, then medication is added through the port in the top of the semi-rigid chamber. d) add-on components  Filters o Eliminate particulate matter, and remove microorganisms from infusion o Are rated by the smallest particle they retain. Solutions o Eliminate air protecting a client from air embolism o Contraindicated for administration of certain medications.  Stopcocks o Used to manually direct the flow of fluid. o Direct flow in 3 or 4 directions. o Useful in certain situations especially in critical care. o Widespread use of stopcocks is discouraged because they have been cited as a source of contamination.  Extensions o Lengthens the administration set o Should not be used routinely since they have been identified as a potential source of contamination. o Must be connected to the tubing and catheter with a luer lock connector. o Change extension tubing on the same schedule as the administration set.  Rate regulators o They are added on to the administration set near the client connection. o The roller clamp is no longer used to control the rate. o The main problem with these devices is that once the dial or indicator is set to a certain number, it may not deliver that rate. I o A change in client position, room temperature, or solution volume may affect the flow of this device. 3. Infusion devices (IV catheter/cannula/needle) a) over the needle catheter-sizes, use  A flexible catheter fits over the metal stylet, used to pierce the skin  22-24 gauge: for pediatric clients or adults with small veins  20-22 gauge: for routine IV therapy  16-18 gauge: for clients with major trauma or surgery b) wing tipped, sizes, use  wings are grasped during insertion and then flattened to anchor in the skin  useful in elderly and pediatric clients and for intermittent infusion  Used for short term only  Length ranges from 3/8 to 1 ½ inches with gauges from 27-13 4.

Intermittent infusion devices a) Heparin/saline locks because its instilled into device to maintain patency

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5. Electronic infusion devices Advantages b)Provides accurate flow  Reduce the risk of runaway IVs c )Reduce the risk of obstructed IVs d)Reduce the risk of empty, or dry IVs e )Useful in-home care settings f ) Clients must be thoroughly oriented to machine g )They must also receive written instructions h)Emergency phone numbers must be provided to the client i ) Controllers regulate the IV by gravity flow through a drop sensor i) Drop sensor verifies the presence of a drop j) Controllers are able to calculate the rate of flow

III.

Lifespan Considerations 1. Geriatric Variations a) Characteristics of the older client  Veins become fragile and easier to blow out  Skin becomes elastic  More prone to complications a) Special techniques  Do NOT use tourniquet  Use blood pressure cuff and pump to 40mmHg

IV.

Complications of IV Therapy Know causes, signs and symptoms, management, and prevention for each 1. Local Complications a )Phlebitis  Causes: administration of hypertonic solutions, repeated use of the same vein for therapy, wiggling of the cannula in the vein, using too large a needle for a particular vein, administering a flow rate that is too rapid for the size of the vein, or placing the IV in a lower extremity where the blood is more sluggish.  Signs and Symptoms: redness, warmth, cordlike vein, and a sluggish flow if a clot is present  Management of this condition: removing the canula, warm soaks for 20 minutes, restarting the IV in the other arm, and documenting the condition  Prevent by: using large veins for hypertonic infusions, changing and monitoring IV site every 72 hrs, maintaining the prescribed rate of flow, anchoring the cannula securely, using the smallest catheter that meets the clients needs, and avoid using the lower extremities.

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b)Site infection  Causes: failure to maintain aseptic technique during IV insertion  Signs and Symptoms: redness, warmth, tenderness, swelling, and exudate  Management of this condition: removing the IV device, culturing the tip of the IV device and site. cleaning the site according to agency policy, notifying the primary healthcare provider for medical orders, restarting the IV in the opposite limb, and documenting the site and measures implement  Prevent by: washing your hands before and after any procedure that involves the IV, rotating the site at least every 48-72 hours, thoroughly cleaning the insertion site with the appropriate antimicrobials, and maintaining aseptic technique when performing IV related procedures.

c )Clotting  Causes: IV rate that is too slow to maintain patency of the device, or cessation of flow like when tubing is kinked.  Signs and symptoms: inability to flush the catheter easily, or at all and tenderness at the site.  Management of this condition: discontinuing the IV and restarting it in the other arm and documenting the site and measures implemented  Prevention: maintaining a constant rate of flow, flushing heparin/saline locks after use per agency policy, making sure all IV connections are tight, and systematically assessing the IV at frequent intervals for kinks, etcetera

d)Hematoma  Causes: may form at the site if the vein is nicked during unsuccessful venipuncture, if the IV is discontinued without holding pressure over the site, or if a tourniquet is applied to the arm too soon after a previously attempted venipuncture.  Signs and symptoms: discoloration, swelling, and discomfort  Management of this condition: removing the IV device and restarting it in the other arm, reassessing the site for continued bleeding, and documenting the condition of the site and the measures implemented  Prevention: applying direct pressure to the site immediately following catheter removal, not attempting to advance the needle if resistance is met on venipuncture, choosing a vein that can accommodate the size of the IV device, rotating the site at least every 48 -72 hours, changing the fluid container every 24 hours, thoroughly cleaning the insertion site with the appropriate antimicrobials, and maintaining aseptic technique when performing IV related procedures

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e )Infiltration  Causes: leakage of a nonvesicant solution or medication into the surrounding tissues from a dislodged needle.  Signs and symptoms: coolness at the site, swelling at the site, and sluggish or stopped flow  Management of this condition: removing the IV device and restarting it in the other limb or well above the previous site, applying warm soaks to help reduce the edema, and elevating the extremity, documenting the condition of the site and measures implemented  Prevent by: frequently assessing the IV site, not obscuring the site with tape or a dressing, restricting the movement of positional IVs with an armboard teaching the client the signs and symptoms to report

f ) Extravasation - infiltration of a vesicant into the surrounding tissues. Extravasation causes tissue injury and possibly necrosis.  Signs and Symptoms - severe pain at the site, redness, ulceration, and swelling  If extravasation is suspected: stop the infusion and follow agency policy guidelines for care of this incident 2. Systemic Complications a )Catheter embolism  Causes: part of an IV catheter breaks off and migrates from the original site. A catheter may be severed either from reinserting a stylet into the catheter or from the back-and-forth motion of a catheter placed over a joint.  Signs and symptoms: Fainting, cyanosis. chest pain, tachycardia, hypotension, and a short, rough, uneven catheter tip or separation of the catheter from the hub may be noted when the IV is removed.  Management of this condition: placing a tourniquet above the site to prevent migration of the broken portion. Be sure to check the circulation of the extremity while the tourniquet is in place, preparing the client for x-ray, starting a new IV in a different location, and comparing the current catheter length with the inserted length so the size of the embolus will be known.  Prevention: NOT reinserting a stylet into an over-the-needle catheter once it has been removed and NOT placing a catheter over a joint.

b)Circulatory Overload  Causes: too rapid administration of IV solution in a client with cardiopulmonary or renal dysfunction or from failure to monitor an

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infusion. Signs and Symptoms: distended neck veins, shortness of breath, crackles upon auscultation of the lungs, weight gain, fluid intake greater than output. Management of this condition: slowing the IV to a slow rate, raising the head of the bed, administering oxygen, notifying the primary healthcare provider for medical orders, obtaining vital signs, administering diuretics as prescribed. Prevent by: maintaining the prescribed flow rate, NOT playing catch up with the IV if it has been infusing too slowly, monitoring intake and output on all patients with IVs and being aware of the client's cardiovascular and renal history.

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