W7-IV Therapy notes + Module notes PDF

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W7 PRACTICE: IV THERAPY

Overview of IV Fluid Administration Introduction: Goal of IV therapy  Prevent fluid and electrolyte imbalance  Administer continuous or intermittent solutions or medication  Replenish blood volume  Assist in pain management Assessments of Patient  Anatomy and physiology of circulatory system  Fluid and electrolyte balance  Disease pathophysiology  Type and duration of prescribed therapy  Allergies  Pt response to illness Six Rights of Administering Parenteral Solutions or Medications 1. Right dose or solution 2. Right dose or concentration 3. Right patient 4. Right route 5. Right date and time 6. Right documentation Safety Considerations Safety Guidelines  Know the patient’ sbasel i nevi t al si gnsbef or ei ni t i at i ngI Vt her apy .Fl ui dandel ect r ol yt ei mbal ances affectvi t al si gns. Dehydration sometimes produces hypotension and tachycardia. Fluid overload often results in hypertension and bounding pulses.  Know the patient’ smedi cal hi st or y ,cur r entmedi cat i ons,andt her api es.Somemedi cat i onsaffect flui dandel ect r ol yt ebal ance(e.g., diuretics or steroids). Determine the patient’ spr ev i ousex per i ence wi t hI Vt her apy .  Beware of prolonged environmental conditions that affect the patient’ sflui dst at us( e. g. ,exposur et o hot ,humi dweat her )l eadi ngt oflui dandel ect r ol yt ei mbal ances, particularly in infants, older adults, and people who are chronically ill.  Know if the patient is right- or left-handed. For comfort and mobility, place an IV in the nondominant arm.  Ensure that an IV system is intact and that there is no evidence of phlebitis or infiltration. An intact system ensures that you have maintained sterility and that no fluid or medication has been lost.  Note the date of the last IV administration set and dressing change.  Maintain sterility of a patent IV system using the INS standards.  Know the standard precautions for infection control and the Occupational Safety and Health Administration (OSHA) standards for occupational exposure to bloodborne pathogens. Anatomy and Physiology Common IV puncture sites include the hand and the arm. These sites utilize the cephalic, basilic, and median cubital veins. The use of the foot as an IV site is common with children but is contraindicated in adults because of the danger of thrombophlebitis. When possible, place IVs at the most distal site. Using a distal site first allows for the use of proximal sites later if the patient needs a venipuncture site change. When assessing the patient for potential venipuncture sites for IV infusion, consider conditions and contraindications that exclude certain sites such as the following:

W7 PRACTICE: IV THERAPY  The dorsal surface of the hand in the very young and older adult (these patients have fragile veins and this site may be easily bumped)  An infected site—asi ndi cat edbyr edness ,t ender ness ,swel l i ng,war mt hatt hes i te, and possibly the presence of exudate (danger of introducing bacteria from the skin surface into the bloodstream)  An extremity with compromised circulation— f orex ampl e,v asc ul ar( di al y si s )gr af tor fi st ul a,mas t ect omy ,orpar al y si s( v enous al t er at i onscan increase risk of complications)  A site with signs of infiltration or thrombosis (to prevent further complications of pain and swelling and to allow accurate assessment of the already compromised site)  Sites distal to previous venipuncture site (insertion needs to be proximal to compromised area of vein)  Sclerosed or hardened, cordlike veins that are firm and often tortuous (making it difficult to puncture the vein and increasing the risk of going through the vein when applying force).  Areas of venous valves or bifurcation (increases the risk of damaging the vein with catheter insertion and impedes the flow of IV fluids)  Veins in the antecubital fossa (these veins are used for blood draws, and placement in this area limits mobility of the elbow)  Veins on the ventral surface of the wrist (inner wrist contains numerous tendons and nerves that could be damaged) Prior to a catheter or needle insertion, the hair of the IV site may be clipped, but shaving should be avoided. Hair impedes venipuncture and adherence of dressing. Shaving can cause microabrasions and predispose the patient to infection. Intravenous Solutions Intravenous solutions will fall into the following categories:  Isotonic—hav et hesameosmol al i t yasbodyfl ui dsandar eusedmos tof t ento replace extracellular (intravascular) volume (e.g., simple dehydration after prolonged vomiting)  Hypotonic—hav eanos mol al i t yl esst hant hatofbodyfl ui dsandar eusedmos tof t ent ohydr at e cel l s( e. g. ,hy per t oni cdehy dr at i on,r equi r edwat err epl acement)  Hypertonic—hav eanosmol al i t ygr eat ert hant hatofbodyflui dsandar eusedmostof t ent o i nc r ease extracellular fluid volume (e.g., replace electrolytes, treat shock) The patient’ sspeci ficfl ui dandel ect r ol yt ei mbal anceandser um el ect r ol yt ev al uesguide the need for administration of the appropriate intravenous fluid (Alexander et al., 2010). Administer all IV fluids carefully; isotonic solutions could cause increased fluid overload in patients with renal or cardiac disease; hypotonic solutions could exacerbate a hypotensive state in a patient with low blood pressure; and hypertonic solutions are irritating to the vein and have the potential to cause increased risk of heart failure and pulmonary edema. Premixed solutions in which medications or electrolytes have been added by the manufacturer are available. Advantages of premixed solutions are the increased stability of the solution and selection of the correct medication and diluents. A disadvantage is that admixtures come in more than one dosage, leading to potential medication errors. As the choices of premixed solutions increase so does the risk of related complications. A complete review of the patient's history, physical assessment, and laboratory findings needs to be completed prior to initiation of any solutions or medications. When initiating IV therapy, you must verify that the order is complete. Elements of a complete order include patient identification, type of solution or

W7 PRACTICE: IV THERAPY medication, volume, rate of infusion, frequency of infusion, route, dosage (medication), and any special considerations. The nurse administering IV solutions or medications should be aware of the indications for the prescribed therapy, any adverse reactions, special monitoring (lab values, vital signs, intake and output) and appropriate interventions (INS, 2011). Potassium chloride should never be given by IV push or added to a small volume of IV solution. A direct IV infusion of KCl can cause cardiac arrest and may be fatal. Potassium chloride is administered orally or as a premixed IV additive by the pharmacy or the manufacturer in a larger volume of IV fluids. Verify that the patient has adequate renal perfusion (i.e., at least 30 mL/hr urine output for adults) before administering IV fluids containing potassium chloride. Selecting Appropriate Equipment –IV Catheters Catheter Size (Guage) 14, 16, 18 20 22

24-26

Butterfly needle (Scalp vein needle)

Clinical Indication Trauma, surgery, blood transfusion Continuous or intermittent infusions, blood transfusion Continuous or intermittent infusions, children and older adult patients; administration of blood or blood products in pediatrics and neonates Fragile veins for intermittent or continuous infusions; administration of blood or blood products in pediatrics or neonates Administration of IV fluids in infants

Selecting Appropriate Equipment –Tubing Different types of tubing are used to administer medications or IV fluids. A solution given rapidly needs to be infused with macro drip tubing, which delivers large drops (standard drop size is 10 or 15 gtt per mL, depending on the manufacturer). In contrast, micro drip tubing is used to allow precise regulation of IV fluids, even at slow rates. Micro drip tubing delivers small drops (standard drop size is 60 gtt/mL) for children, infants, and patients requiring close monitoring of IV fluid administration (e.g., patients with cardiac or renal disease). Infusion of blood products requires a blood administration set, which contains an in-line filter. IV extension tubing added to the primary tubing is frequently used to increase the patient's mobility, decrease manipulation and potential contamination at the insertion site, or facilitate patient changes in position.

Commonly Used IV Solutions

W7 PRACTICE: IV THERAPY Solution Dextrose in Water Solutions

Intravenous Solutions Concentration

Dextrose 5% in water*

Isotonic

Dextrose 10% in water

Hypertonic

Dextrose 50% in water Saline Solutions

Hypertonic

0.45% sodium chloride (half normal saline)

Hypotonic

0.33% sodium chloride (one-third normal saline)

Hypotonic

0.9% sodium chloride†( nor mal sal i ne)

Isotonic

3% sodium chloride

Hypertonic

5% sodium chloride Dextrose in Saline Solutions Dextrose 5% in 0.9% sodium chloride

Hypertonic

Dextrose 5% in 0.45% NaCl sodium chloride Multiple Electrolyte Solutions

Hypertonic

Lactated Ringer’ s( LR) ‡

Isotonic

Dextrose 5% in lactated Ringer’ s

Hypertonic

*Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments. †Al t houghi ti si sot oni cbecaus et het ot al concent r at i onofel ect r ol ytes equals plasma concentration, it contains 154 mEq of both sodium and chloride, which is a higher concentration of these electrolytes than is found in the plasma and which can cause fluid volume excess. ‡Cont ai nss odi um,pot as si um, calcium, chloride, and lactate.

W7 PRACTICE: IV THERAPY Selecting Appropriate Equipment –Tourniquet The type of tourniquet to use should be determined based on patient assessment—f orex ampl e,al at ex f r ee t our ni queti fpatient has a latex allergy. Tourniquets are used to reduce venous return and cause distention in the veins where an IV catheter will be inserted. The veins of older adult patients are more fragile, and therefore a blood pressure cuff may be used instead. In infants, rubber bands may be used because they are smaller than tourniquets. Use a latex-free tourniquet if the patient has a latex allergy. Because tourniquets can be a source of contamination, single-use products are preferred.

Insertion of a Peripheral Intravenous Device Introduction Infusion therapy provides access to the venous system to deliver solutions and medications or blood and blood products. Reliable venous access for infusion therapy administration is essential. You need to be able to recognize the appropriate vascular access device needed in order to place a short-term peripheral IV catheter or assist with placement of a midline or central vascular access device. Additionally, skills are needed to prepare the infusion equipment and be familiar with the various infusion systems utilized during an infusion. Some solutions and medications can be administered continuously while others are given intermittently. Various types of administration sets, needleless devices, extension sets, flushes, and pumps are required as well as knowledge and skills for correct and safe use. Know and follow INS standards, your facility policy and procedures, and provincial or government practice guidelines when providing IV therapy. Successful delivery of peripheral IV therapy depends on the following:  Patient preparation  Patient assessment and vein selection  Selection of appropriate equipment including catheter, tubing, solution  Skilled catheter insertion  Knowledge of best practice for continued maintenance It is recommended by the Infusion Nurses Society (INS) that a single nurse should not make more than two attempts at inserting an IV on any one patient. Because the potential for exposure to bloodborne pathogens is high, adhere to principles of asepsis and utilize standard precautions. Delegation and Collaboration The skill of initiating intravenous therapy cannot be delegated to unregulated care providers (UCPs). Delegation to registered practical nurses varies by policy of practice settings. The nurse instructs the UCP to do the following:  Inform the nurse if the patient complains of any IV-related complications such as pain, redness, swelling, bleeding  Inform the nurse if the patient’ sI Vdr ess i ngbec omeswetors oi l ed  Inform the nurse if the solution of fluid in the IV bag is low or the electronic infusion device (EID) alarm is sounding. If the alarm is sounding because of low battery, the UCP should plug the EID into an appropriate electrical outlet Assessing for Signs and Symptoms of Fluid or Electrolyte Imbalances Assess for clinical factors and conditions that respond to or are affected by administration of solutions or medications:

W7 PRACTICE: IV THERAPY  Body weight is one of the initial clinical parameters. Changes in body weight reflect fluid loss or gain. One kilogram or 2.2 pounds of body weight is equivalent to the gain or loss of 1 liter of fluid.  Intake and output. Amounts should be measured accurately. Infusion containers may be overfilled (a 1L container may actually have 1100 L of fluid). Output may be sensible (urine output) or insensible (perspiration).  Vital signs: o Blood pressure, respirations, pulse, temperature. Changes in blood pressure may be associated with fluid volume status (fluid volume deficit [FVD] seen in postural hypotension; increase in blood pressure seen in fluid volume excess [FVE]). Respirations can be altered in the presence of acid– basei mbal ances.Temperature elevations increase the need for fluid requirements (a temperature of 38.3 ° Ct o39. 4° C[ 101° Ft o103° F]r equires at least 500 mL of fluid replacement within a 24-hour period). o Distended neck veins. Suggests fluid volume excess. o Auscultation of crackles or rhonchi in lungs. May signal fluid buildup in the lungs due to fluid volume excess (FVE). o Skin turgor (after pinching, skin fails to return to normal position within three seconds). With FVD, turgor is decreased and the pinched skin stays elevated for several seconds. This is called "tenting" o Edema (pitting or non-pitting) Pitting—af t erpr es si ngt het i ssuewi th the fingers, the indentation remains. Pitting edema seen with a weight gain of 4.5 to 6.8 kg (10 to 15 pounds) of retained fluid. o Thirst mechanism will increase with water loss. Ingestion of sufficient amounts of water is necessary for metabolism. o Behavioral changes (e.g., restlessness, confusion). Occurs with FVD or acid–bas ei mbal anc e. o Dry skin and mucous membranes. Occurs with FVD. Further Assessment In addition to assessing for signs and symptoms of fluid and electrolyte imbalance, the nurse should assess the patient for the following:  Determine if the patient is to undergo any planned surgeries or procedures. Allows anticipation and placement of appropriate vascular access device for infusion and avoiding placement in an area that will interfere with medical procedures.  Assessment of appropriateness for vascular access is based upon the following: o Patient’ scondi t i on,age,anddi agnos i s o Vein integrity, size, and location o Type and duration of prescribed therapy o Patient’ si nf usi onhi st or y o Patient’ spreference for location as appropriate Allows for appropriate placement of vascular access device while minimizing infusion-related complications  Assess patient’ shi s t or yofal l er gi es,especi al l yt oi odi ne,adhesi v e,orl at ex .Equi pmentuseddur i ng VADi ns ertion may contain substances to which patient is allergic. Planning- Expected Outcomes Expected outcomes following completion of procedure are the following:  Fluid and electrolyte balance returns to normal.  Vital signs are stable and within normal limits for patient.  No redness, drainage, swelling, or pain present at venipuncture site.  Infusion of solutions and medications is delivered at ordered rate.

W7 PRACTICE: IV THERAPY  Patient is able to explain purpose and risks of IV therapy. Gerontological Considerations  The veins of older adults are very fragile; there is less subcutaneous support tissue, and there is thinning of the skin (Alexander et al., 2010). Avoid sites that are easily moved or bumped. Use a commercial protective device to protect site and reduce manipulation at the site.  In older adult patients, the use of a 22- or 24-gauge catheter is appropriate for most therapies. Smallergauge catheters are less traumatizing to the vein but still allow blood flow to provide hemodilution of the IV fluids or medications.  Minimize pressure from tourniquets, or avoid them if possible, due to the increased risk of hematoma. Place tourniquet over clothing to avoid bruising or skin tears. Use a blood pressure cuff if possible.  As older adults lose subcutaneous tissue, the veins lose stability and roll away from the needle. To stabilize the vein, pull the skin taut and toward you with your nondominant hand, and anchor the vein with your thumb.  Some older adults do not complain of pain at the insertion site; however, a large amount of fluid may infiltrate before a patient experiences discomfort.  If possible, avoid the back of the older adult's hand or the dominant arm for venipuncture because use of these sites interferes with the person’ si ndependence.  Reduce angle of insertion (e.g., 5 to 15 degrees on insertion) to accommodate more superficial veins. Evaluation Routine site care and dressing changes are not performed on short-term peripheral catheters unless the dressing is soiled or no longer intact. An occlusive transparent dressing is changed at the time of site rotation. Gauze dressings are changed every 48 hours. Observe patient every one to two hours or at established intervals per facility policy and procedure for the following:  Correct type and amount of IV solution or medication has infused by assessing fluid level in IV bag and infusion totals on the electronic infusion device.  Count drip rate (if gravity drip) or check rate on infusion pump.  Check patency of the VAD.  Observe patient during palpation of vessel for signs of discomfort.  Inspect insertion site, note color (e.g., redness or pallor). Inspect site for presence of swelling (which is a sign of infiltration) or pain and tenderness (which is a sign of phlebitis). Palpate temperature of skin above dressing. Observe patient to determine response to therapy (e.g., intake and output [I&O], weights, vital signs, post procedure assessments). Unexpected Outcomes and Interventions Unexpected Outcome Fluid volume deficit (FVD) as manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, shock. Fluid volume excess (FVE) as manifested by crackles in the lungs, shortness of breath, edema. Electrolyte imbalances as indicated by abnormal serum electrolyte levels, changes in mental status, alterations in neuromuscular function, cardiac dysrhythmias, and changes in vital signs. Infiltration as indicated by slowing of infusion,

Intervention Notify health care provider. Requires readjustment of infusion rate.

Reduce IV flow rate if symptoms appear, and notify health care provider. Notify health care provider. Adjust additives in IV or type of IV fluid per order.

Stop infusion and discontinue IV; elevate affected

W7 PRACTICE: IV THERAPY insertion site that is cool to touch, pale and painful.

Phlebitis is indicated by pain and tenderness at IV site with erythema at site or along path of vein. Insertion site is warm to touch and rate of infusion may be altered.

Bleeding occurs at venipuncture site.

IV site infection. Assess site for signs and symptoms of infection, which may include: redness, pain, ...