Iv Therapy

IV INFUSIONS I.

ADMINISTERING IV THERAPY - physician is responsible for prescribing kind and amount of solution to be used - nurse is responsible for initiating, monitoring, and discontinuing therapy - nurse must understand patient’s need for IV therapy, type of solution being used, desired effects, and untoward reactions that may occur Steps to Remember: maintain strict aseptic technique examine solution for type, amt, expiration date, character of solution, lack of damage to container select and prepare IV infusion pump, as indicated administer IV fluids at room temp monitor for IV patency before administration of IV meds maintain occlusive dressing flush IV lines between administration of incompatible solutions A.

EQUIPMENT - sterile technique must be observed - disposable infusion tubing and needles are used to help eliminate sources of contamination and reduce cost - equipment varies according to manufacturer - most solutions are dispensed in 1-L or 500-mL flexible or rigid plastic containers - because plastic bags collapse under atmospheric pressure as solution enters patient’s vein, they do not require a vent for air to enter to replace fluid flowing from container - some meds bond with plastic in IV bags, glass bottles are then required 1.

Basic Administration Set spike or piercing pin is inserted into container, usually with twisting

motion rate of flow is manually controlled by clamp or constricting device on tubing drip meter or drip chamber connects solution bottle and tubing and permits number of drops per minute of solution to be determined some administration sets have in-line filter - IV catheters are plastic tubes that have been mounted on a needle or are threaded through a needle for insertion - flexible catheter remains in vein - over-the-needle catheter is easy to insert and stable, placement is easily detected w/ x-rays

- single- or double-winged infusion needles (butterflies) are shortbeveled, thin-walled needles with plastic flaps - - used in pediatric settings - not flexible, more likely to infiltrate - devices available that minimize potential for injury and promote safety when connecting, accessing, or disposing of IV equipment - needleless systems & needle-housing systems (recessed & protected needle) are common 2. Vascular – length of time infusion therapy is needed, type of med or product that will be delivered IV, patient’s health, and individualized needs determine which option is used a.

Peripheral Venous Catheters – over-the-needle catheters are most

common - when infusion therapy will be brief, short (< 3 in. ) catheter may be ordered - insertion site should be rotated at least every 72 – 96 hrs. - smallest gauge device is usually selected - dextrose solution 10% or less may be administered this route b. Midline Peripheral Catheter – inserted peripherally, normally through antecubital fossa, but are longer (> 3 ins) - not considered to be central lines and should not be infuse vesicants, hyperosmolar or irritating solutions - no set guidelines for length of time it can remain in place (median of 7 days, possibly as long as 49 days) c. care in acute,

Central Venous Access Devices (CVADs) – integral component of pt. ambulatory, and subacute care settings, as well as home and long-term care facilities - provide access for variety of IV fluids, meds, blood products,

and nutritional solutions - allow a means for hemodynamic monitoring and blood sampling - introduced into subclavian or internal jugular vein and passed to superior vena cava just above right atrium - require x-ray confirmation of position - pt’s diagnosis, type of care that is required and other factors (irritating drugs, limited

venous access, pt. request) determine type of CVAD used i.

Types: Peripherally Inserted Central Catheter (PICC) – can be introduced into peripheral vein and advanced as far as superior vena cava - x-ray verification is always required before use - may have single or dual lumens - normally replaced as needed (no longer patent or site looks infected) - indications include administration of IV antibiotics for extended period (2 – 6 wks), infusion of parenteral nutrition, chemotherapy, continuous narcotic infusions, vesicants, hyperosmolar solutions, blood components, other specific meds (vasopressors, anticoagulants), and long-term rehydration - advantageous because it’s inserted at bedside, risk for pneumothorax is decreased, cost-effective and provides adequate hemodilution for meds - nursing responsibilities include sterile dressing changes, routine heparin or saline flushes, careful observation for any complications DOCUMENT: appearance of site, length of external part of catheter, dates of dressing and cap change, flushing frequency and routine, and any problems Nontunneled Percutaneous Central Venous Catheters – have shorter dwell time (3 – 10 days) and are introduced through skin into jugular, subclavian, or femoral veins, and sutured into place - can have double-, triple- or quadruple-lumens - tip rests in superior vena cava - may be inserted at bedside or in outpatient settings - high risk for complications (infection and pneumothorax) Tunneled Central Venous Catheter – intended for longterm use, placed through small incision into jugular or subclavian vein (where tip lies) and tunneled in

subcutaneous tissue under skin for 3 – 6 ins. to its exit site - initially sutured into place, but after 7 – 14 days, sutures are removed Implanted Port – tip is placed in subclavian or jugular vein, proximal end or port is usually implanted in subcutaneous pocket of upper chest wall, no external parts peripheral access system ports - placed in antercubital area of arm - initially used for chemotherapy - now used for any pt requiring long-term intermittent infusions - special angled noncoring needle is inserted through skin and rubber septum and into port reservoir - require minimal care, but discomfort may be a disadvantage - ensure all numbing cream is removed and skin adequately cleaned before accessing port - nursing responsibilities with central venous catheters include using sterile techniques, changing dressing, carefully assessing for any sign of infection, changing injection caps on lumens, and flushing with prescribed solution (saline, heparin) to prevent clotting and blockage 3.

Starting an IV Infusion prepare IV solution and tubing maintain aseptic technique when opening pkgs./solution clamp tubing, uncap spike, insert into entry site on bag squeeze drip chamber, allow it to fill at least half way remove cap at end of tubing, release clamp, allow fluid to move through tubing until all air bubbles have disappeared close clamp and recap tubing, maintaining sterility if electronic device is to be used, follow mfg.’s instructions for inserting tubing and setting infusion rate label if med was added to container (pharmacy may have added and applied label) place time-tape on container as necessary, hang bag on IV pole apply tourniquet cleanse area with antiseptic solution

with nondominant hand place about 1 or 2 ins below entry site, hold skin taut against vein enter skin gently with catheter held by hub, bevel side up, at 10- to 30-degree angle, directly over or into the side of vein following the course of the vein - sensation of “give” can be felt when needle enters the vein ***Special Considerations: Older Adults - avoid vigorous friction at insertion site and using too much alcohol Infants / Children – hand insertion sites should not be the 1st choice - scalp and feet can be used as alternate sites for infants - do not use feet if child is able to walk - do not replace peripheral catheters in pediatric pts unless clinically indicated - may elect to omit use of tourniquet on pts with prominent but especially fragile veins

B.

SITE SELECTION 1. Accessibility of a Vein - determine most desirable accessible vein (lower cephalic, accessory cephalic, basilic are good sites) - if pt is right-handed and both arms appear equally usable, the left is selected - determine accessibility based on patient’s condition - do not use antecubital veins if another vein is available - because flexion of pt’s arm can displace IV catheter over time - do not use veins in leg, unless other sites are inaccessible - danger of stagnation of peripheral circulation and possible serious complications - do not use veins in surgical areas - select scalp veins for infants because of accessibility and relative ease of preventing dislocation of needle 2. Condition of Vein – thin-walled and scarred veins, especially in some older pts., make continued infusion a problem 3.

Type of Fluid to be Infused – select vein appropriate for solution - hypertonic solutions, irritating meds, rapid rate administration and high viscosity solutions should be given in a large vein to minimize trauma and facilitate rate of flow

- advise pt that some meds administered IV may cause irritation and pain 4. Anticipated Duration of Infusion – select site where restriction in movement is kept to minimum - change peripheral venous catheter sites every 72 to 96 hrs, starting with sites as distal as possible and moving in proximal direction on alternate arms 5. Other Considerations – select catheter with smallest gauge and shortest possible length - insert into largest vein available - select site that is naturally splinted by bone (back of hand, forearm) - if site is not splinted (wrist), use an immobilizer - select site distal to heart and move proximally - select site while moving toward heart and away from damaged vein C.

INITIATION OF IV INFUSION - perform final check of solution to ensure it’s clear and contains no particles - especially important when substances have been added - commercially available in-line filters help reduce risk of contamination - advisable to use product that eases discomfort of venipuncture for those with a fear of needles D.

REGULATION AND MONITORING - nurse is responsible for maintaining proper flow rate while ensuring comfort and safety of patient - physician prescribes amt of solution to be infused within specified period - rate if determined on basis of amt of solution to be infused over 1 hr (drip rate) - drop factor (drops per mL of solution) is determined by size of opening in infusion apparatus - buretrol (volume-control device) is used to reduce risk of fluid-overload or med overdose - common in pediatrics - used to deliver intermittent meds that need to be further diluted and over a specific time - time tape can be placed on container to provide quick reference for nurse to monitor rate - gives hourly indication of where fluid level should be Factors that Affect Flow Rate: height of container in relation to patient infiltration

patient’s blood pressure

knot or

kink in tubing patient’s position

patency of IV

catheter - too slow a flow may result in fluid volume deficit, because input is not balancing fluid lost or it may delay restoration of balance - too rapid a flow can overtax the body’s capacities to adjust to increase in water volume or electrolytes it contains, and lead to fluid volume excess