Chapter 18

1. Chapter 18 Intravenous Therapy

2. Learning Objectives • List the indications for intravenous fluid therapy. • Describe the types of fluids used for intravenous fluid therapy. • Describe the types of venous access devices and other equipment used for intravenous therapy. • Given the prescribed hourly flow rate, calculate the correct drop rate for an intravenous fluid. • Explain the causes, signs and symptoms, and nursing implications of the complications of intravenous fluid or drug therapy. • Explain the nursing responsibilities when a patient is receiving intravenous therapy.

3. Types of Intravenous Fluids Tonicity A measure of the concentration of electrolytes in the fluid The normal concentration of electrolytes in body fluids is about 285 mEq/L

4. Types of Intravenous Fluids Isotonic solutions The concentration is the same as body fluids Hypertonic solutions The concentration is greater than 300 mEq/L Draws and retains water in the circulation, increasing the blood volume Hypotonic solutions The concentration is less than 280 mEq/L Allows water to shift out of the capillaries into body tissues, resulting in decreased blood volume

5. Types of Intravenous Fluids Components Commonly used IV solutions: specific combinations of water, sugar (dextrose), sodium chloride, and other electrolytes Sodium chloride solutions An isotonic solution is 0.9% sodium chloride A hypotonic solution is 0.45% sodium chloride Dextrose, sodium chloride, and other electrolytes are available in numerous combinations Plasma-Lyte and lactated Ringer’s solution; dextrose 5% in Ringer’s solution is a combined dextrose and electrolyte solution Total parenteral nutrition: for long-term or aggressive intravenous therapy for nutrition

6. Venous Access Devices Intravenous fluid is delivered by various types of venous access devices Needles, over-the-needle catheters, inside-needle catheters (rarely used), subcutaneous infusion ports, subcutaneous pumps Cannula size is based on the inside diameter and is expressed as a gauge The smaller the gauge, the larger the inside diameter of the cannula

7. Venous Access Devices IV fluid administration requires placement of the venous access device into a peripheral or central vein Peripheral veins Located in the extremities (and in the scalp of an infant) For short-term therapy, when a patient has healthy veins, and when relatively nonirritating fluids are given Central veins Large vessels located nearer the heart For long-term therapy, when patient has poor peripheral veins, and when irritating fluids are to be administered Central lines are inserted into the subclavian or jugular vein or into the superior vena cava

8. Figure 18-1

9. Port A device with a central catheter that is surgically implanted in the subcutaneous tissue A venous catheter and a port through which fluids can be injected, but it has no external parts Catheter inserted into a central vein; port, which has a rubber septum, can be felt under the skin A specialized needle that does not damage the septum is used to puncture the skin and deliver fluid and medications through the port and into the catheter

10. Figure 18-2

11. Figure 18-3

12. Needles Winged (“butterfly”) infusion needle A short needle with two plastic wings that are held during insertion Self-sheathing stylet Retracts into a rigid chamber at the catheter hub after insertion

13. Catheters A small plastic tube that fits over or inside a needle After insertion into vein, needle is withdrawn, leaving the catheter in the vein Peripherally inserted central catheter (PICC) Inserted into vein in antecubital space; advanced into axillary, subclavian, or brachiocephalic vein or the superior vena cava Tunneled catheters An incision is made at the entrance site, a tunnel created in the subcutaneous tissues, and the catheter threaded through the tunnel and into the subclavian vein Subclavian catheters Can have from 1-4 lumens

14. Figure 18-5

15. Figure 18-6

16. Implanted Devices Some devices can be implanted to allow immediate access to a vein without repeated, painful venipunctures Include infusion ports, pumps that are implanted under the skin, and external infusion pumps Infusion ports consist of a catheter and a chamber into which fluids can be injected directly into vein or artery The chamber is easily felt directly under the skin Infusion pumps are filled with a special needle that is inserted through the skin into the port

17. Intermittent Infusion Devices Intravenous medications are given at specific intervals Drugs are often “piggybacked” Given through an injection port in the tubing of a continuous infusion Heparin lock Patient who does not need continuous IV therapy may have a latex resealable lock

18. Initiation of Intravenous Therapy

19. Equipment Cannula (needle or catheter), tourniquet, alcohol swabs, skin cleansing solution, tape, dressing supplies, gloves, tubing, solution container, a pole to suspend the container, and infusion pump Prescribed solution or drug Use the “five rights”: right solution or drug, right dose or strength, right patient, right route, and right time Attach tubing to solution container, fill drip chamber halfway, allow some fluid to run through the tubing until completely filled with fluid and there are no air bubbles in the tubing

20. Site Selection Should be the least restrictive A large vein that is in good condition A soft, straight vein is best Avoid veins that are hard and bumpy, bruised, swollen, near previously infected areas, or close to a recently discontinued site Transilluminator or ultrasound can facilitate locating a vein Preferred site is usually patient’s nondominant arm Begin with most distal veins, then move proximally Should not be done in an arm that has impaired circulation or poor lymphatic drainage, as in radical mastectomy

21. Procedure Wash hands thoroughly; explain procedure to patient Apply tourniquet above venipuncture site to distend vein Locate appropriate vein; temporarily remove the tourniquet Vigorously cleanse venipuncture site in a circular pattern first with alcohol and then with a recommended solution Allow to air dry after each cleansing step; do not blow on the site or fan it Reapply the tourniquet Perform the venipuncture using Standard Precautions

22. Procedure Carefully insert cannula through the skin and guide it into the vein in the direction of blood flow If first attempt unsuccessful, select another site, change cannulas, and try again When using the catheter over needle, the needle is threaded only 1/4 inch into the vein Then catheter is threaded into vein as needle is removed After threading the cannula into the vein, connect it to the infusion tubing, and tape it securely but without restricting circulation Dress site with a clear occlusive dressing that allows inspection of the insertion site or with a sterile gauze pad

23. Procedure Pain Venipuncture and cannula placement are painful Drugs to decrease venipuncture pain include intradermal lidocaine (Xylocaine), transdermal lidocaine, and prilocaine (EMLA cream) Documentation Place a piece of tape on the site dressing with the date and time that the cannula was inserted as well as the length and gauge of the cannula and your initials Label every bag of fluid and tubing with the date and time that it was hung and the fluid’s expiration date

24. Maintenance of Intravenous Therapy

25. Factors Affecting Infusion Rate Height of fluid container over the patient’s heart When container is raised, the fluid flows faster Lowering container causes fluid to run more slowly Optimal height is 30-36 inches above the patient Volume of fluid in the container Full container causes the fluid to run faster As container empties, rate slows down Viscosity of the fluid Thin fluids such as normal saline flow more quickly than thick fluids such as blood

26. Factors Affecting Infusion Rate Cannula diameter Fluid flows more quickly through a large cannula than through a small cannula Venting of the fluid container Rigid containers must be vented to allow air to enter as fluid leaves Position of the extremity Certain movements or positions may interfere with the flow of fluid

27. Calculating the Infusion Rate Determine How much fluid to give each hour Physician’s order specifies the amount of fluid to be administered in a specific period of time How many drops equal 1 ml in the delivery set used (called the drop factor) Instructions on the delivery set package state how many drops equal 1 ml using that set Standard delivery sets (called macrodrop sets) deliver 10, 12, 15, or 20 drops per ml

28. Calculating the Infusion Rate When infusion rate is known, use the roller clamp or screw clamp on a gravity infusion to adjust the flow rate until the correct number of drops per minute is infusing Recheck the rate hourly Common to put a timed tape on the fluid container; shows hourly levels This allows a quick assessment of whether the fluid is running on schedule

29. Infusion Control Devices Electronic infusion control devices maintain an infusion rate set by the nurse The most commonly used types also have alarms that sound when the fluid bag is empty, when there is air in the line, or when there is resistance to infusion Variety of infusion control devices

30. Figure 18-7

31. Intravenous Infusion of Medications Agency policies dictate what medications nurse may give by piggyback or by direct injection through cannula into the vein (intravenous push) Many states do not permit LPNs to give medications by intravenous push You must know how to dilute the medication and the correct rate of infusion Improper administration of IV medications is extremely dangerous Some medications and intravenous solutions are incompatible (they cannot be given together)

32. Changing Venous Access Devices and Administration Sets Short peripheral cannulas and the tubing are usually changed every 48-72 hours If complications occur with 72-hour intervals, the interval should be limited to 48 hours Administration sets for continuous peripheral and central infusions changed every 72 hours PICC lines should be changed every 6 weeks

33. Changing Venous Access Devices and Administration Sets Tunneled catheters and ports can be left in place for years Tubing used to administer blood, total parenteral nutrition, or lipids must be changed every 24 hours An intravenous fluid container should not be used for more than 24 hours

34. Termination of Intravenous Therapy Put on gloves Stop the flow of fluid Loosen or remove the tape and dressing Gently press a dry gauze pad over the site Remove cannula, keeping hub parallel to the skin Dispose of needle or catheter according to Standard Precautions guidelines

35. Termination of Intravenous Therapy Elevate the extremity and apply pressure to the puncture site with a sterile gauze pad for 2 or 3 minutes Secure the gauze with tape Record appearance of the site, condition of catheter, and how patient tolerated procedure

36. Precautions Always be aware of the risk of exposure to bloodborne pathogens Most serious: human immunodeficiency virus and hepatitis B virus Numerous products for venipuncture and intravenous therapy that reduce the risk of needle punctures or other exposure to blood

37. Precautions Accidental needlesticks Most policies require blood specimens to be drawn from the nurse and the patient to test for bloodborne infections Drug therapy may be advised if patient has an infectious disease Documentation of the incident and the health status of the nurse at the time of the exposure is important if the nurse becomes ill as a result of the exposure

38. Complications of Intravenous Therapy Tissue trauma Infiltration Inflammation Infection Fluid volume excess Bleeding Embolism

39. The Older Patient and Intravenous Therapy Anchor vein with the thumb of your nondominant hand to hold it in place during venipuncture When performing venipuncture, you may be able to distend the vessel by simply pressing the vein Special adhesives/dressings prevent skin damage If the hand or arm is secured to an armboard, the armboard must be padded Infiltrated fluid may drain away from the cannula insertion site

40. The Older Patient and Intravenous Therapy If patient confused or restless, protect infusion site and tubing with a commercial securement device or conceal the site under long sleeves Never apply an immobilizer over an infusion site; the immobilizer must be below the site Reassure the confused patient, use a calm and gentle approach, and frequently reinforce instructions With dementia patients, distraction may take their attention away from the IV Monitoring for excess fluid volume especially important; older people have less efficient cardiac and renal function

41. Nursing Care During Intravenous Therapy

42. Assessment Determine the prescribed rate of flow, and assess the actual flow rate Inspect the infusion site for edema, pallor or redness, bleeding, and drainage Palpate site for edema and warmth or coolness Ask the patient if the infusion site is painful

43. Assessment Take patient’s vital signs and compare the readings with previous findings to detect increased pulse and blood pressure Measure and record the fluid intake and output, and auscultate the patient’s lungs for crackles

44. Interventions

45. Risk for Injury Trauma The insertion of a cannula is traumatic to the skin and underlying tissues Tape may irritate or tear skin Use gentle technique when performing the venipuncture, and anchor the cannula to reduce tissue trauma Apply a commercial site protector, if available, to shield the intravenous site

46. Risk for Injury Infiltration Can be caused by leakage where cannula enters vein or by puncture of a second site in the vein by the cannula Patient may report pain or burning Site may be pale and puffy or feel hard and cool Stop the infusion and restart it in a different vein Elevate the affected arm on a pillow

47. Risk for Infection Contamination of the site, by the intravenous fluid, or by the tubing used to deliver the fluid Infected site red and warm; purulent drainage Use strict aseptic technique when starting and handling intravenous infusions If infusion site inflamed or infected, stop the infusion and restart it in another site If agency policy permits, a warm compress can be applied to the inflamed site

48. Excess Fluid Volume Blood volume may increase excessively when fluid is delivered directly into the bloodstream Happens when large volumes of fluid infused, especially in patients with impaired renal or cardiac function Signs and symptoms of fluid volume excess include rising blood pressure, bounding pulse, and edema Controlling the rate of fluid infusion reduces the risk of excess fluid volume Young children and older adults: monitor closely If indications of fluid volume excess appear, slow infusion rate, elevate patient’s head, notify the physician

49. Decreased Cardiac Output Bleeding may occur if the cannula is moved excessively after insertion More serious bleeding is possible if the tubing becomes disconnected from the cannula, allowing blood to flow freely from the vein Make sure all connections in infusion set secure Tape tubing so that it cannot be pulled loose easily. Protect the infusion site and tubing when the patient moves

50. Ineffective Tissue Perfusion Risks of emboli from blood clots, air, broken catheters Blood clot can develop in IV needles or catheters Air can enter the bloodstream if the infusion system is opened When the cannula seems to be obstructed, blood clots may have formed. Irrigation of cannula is not recommended Exercise extra caution to prevent an air embolism when a patient has a central line