The
Purpose of IV Therapy:
In
addition to having readily
available access for medications, there are eleven specific purposes for
IV therapy and they include:
Providing maintenance
requirements for fluids and electrolytes.
Replacing previous
losses
Replacing concurrent
losses
Providing
nutrition/vitamin
replacement
Providing a mechanism
for the
administration of medications and/or the transfusion of blood and blood
components.
To provide parenteral nutrition
To provide avenue for dialysis/apheresis
To transfuse blood products
To provide avenue for hemodynamic monitoring
To provide avenue for diagnostic testing
To administer fluids and medications with the ability to rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.
Intravenous therapy may be used to correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration. Intravenous therapy can also be used for chemotherapy (The treatment for any kind of cancer.)
The
Three Types of Intravenous
Fluids are:
- Hypertonic solutions -
Any
solution that has a higher osmotic pressure than another solution (that
is, has a higher concentration of solutes than another solution), which
means it draws fluid out of the cell and into the extra-cellular space.
- Hypotonic solutions -
Any
solution that has a lower osmotic pressure than another solution (that
is, has a lower concentration of solutes than another solution), which
means it pushes fluid into the cell.
- Isotonic solutions -
Any
solution that has the same osmotic pressure than another solution (that
is, has the same concentration of solutes than another solution), which
means it does not draw or push fluid into the cell.
Commonly
Used
Intravenous Solutions:
- Normal saline solution
(NS,
0.9% NaCl) - Isotonic solution (contains same amounts of sodium and
chloride found in plasma). It contains 9 grams of sodium chloride per
liter of water. It is indicated for use in conjunction with blood
transfusions and for restoring the loss of body fluids.
-
- Ringer's Solution or
Lactated
Ringer's (LR) - Isotonic solution (replaces electrolytes in amounts
similarly found in plasma). It contains sodium chloride, potassium
chloride, calcium chloride, and sodium lactate. It is indicated for use
as the choice for burn patients, and in most cases of dehydration. It
is also recommended for supportive treatment of trauma.
-
- Five percent
dextrose
and water (D5W) - Isotonic solution (after administration and
metabolism of the glucose; D5W becomes a hypotonic
solution). It
contains 5 grams of dextrose per 100 ml of water. It is indicated for
use as a calorie replacement solution and in cases where glucose is
needed for metabolism purposes.
-
- Five percent dextrose
and
½ Normal Saline Solution (D51/2NS) – Hypotonic
solution
that draws water out of the cells into the more concentrated
extracellular fluid. Careful usage for patients with cardiac or renal
disease if they are unable to tolerate the extra fluid watch for
pulmonary edema.
-
- ½ Normal
Saline
Solution – Hypotonic solution that pushes fluid from the
extracellular space into the cell. Watch if given to patients with
increased ICP i.e. stroke, head trauma or neurosurgery.
-
- TPN (total parenteral
nutrition) - TPN contains water, protein, carbohydrates (CHO), fats,
vitamins, and trace elements that are necessary to the healing process.
It is a very strong hypertonic solution. It must be given through a
central venous catheter to allow rapid mixing and dilution.
Multiple
electrolyte solutions are
helpful in replacing previous and concurrent fluid losses.
Fluid
and electrolyte losses that occur from diarrhea, vomiting, and/or
gastric suction are an example of concurrent losses.
Nursing
assessment for fluid volume deficit and fluid volume overload during IV
therapy include:
FVD
(Fluid Volume Deficit)
- Dry Skin (Capillary
refill
> 3 seconds)
- Elevated or Subnormal
Temperature
- Thirst
- Dry Mucus Membranes
- Decreased Urine Output
Soft
Sunken Eyeballs ( > then
10% loss of total body fluid volume decreases intraocular pressure and
cause eyes to appear to be sunken in)
- Decrease Tearing and
Salivating
- Hypotension
FVO
(Fluid Volume Overload)
- Pitting Edema (1+ - 4+)
- Puffy Eyelids
- Acute weight gain
- Elevated blood pressure
- Bounding pulse
- Dyspnea and shortness
of
breath (Usually first sign)
- Ascites or third spacing
Other
nursing
assessment observations that are important during IV therapy include:
- Close monitoring of
weight
gain/loss
- Accurate I and O
(normal
urine output is approximately 1 Ml / Kg of body wt. per hour)
- Assessing for signs of
edema
(skin that is tight and shiny)
- Assessing for skin
turgor
that when pinched takes longer then 3 seconds to return to normal.
- Assessing lung sounds
(crackles will be heard with FVO)
- Notification to
physician if
urine output is < 30cc for two consecutive hours
- Monitor sodium and
hematocrit
levels
Identifying
Common Complications of IV Therapy:
Infiltration
– An
accumulation of fluid in the tissue surrounding an IV Catheter site. It
is usually caused by penetration of the vein wall by the catheter
itself and later leads to dislodgement out of the vein and into the
tissue. Signs and systems of infiltration include:
- Flow rate may either
slow
significantly or completely stop (IV Pump will
“beep”
occlusion)
- Infusion site becomes
cool
and hard to the touch
- Infusion site or
extremity
may become pale and swollen
- Patient may complain of
pain,
tenderness, burning or irritation at the IV site
- There may be noted
fluid
leakage around the site
Immediate
corrective action to take if IV infiltration is suspected includes:
- Stop IV infusion
immediately
and remove IV Catheter
- Elevate Extremity
- If noticed within 30
minutes
of onset, apply ice to the site (this will decrease inflammation)
- If noticed later then
30
minutes of onset apply warm compress (this will encourage absorption)
- Notify
Supervisor/Physician
as per individual hospital policy
- Document findings and
actions
- Restart IV in an
alternative
location (opposite extremity if possible)
Preventive
Measures to avoid IV Infiltration include:
- Properly securing
catheter
hub to the limb
- Stabilize extremity in
use by
applying an arm board if necessary
- Frequent assessment of
IV site
- Keep flow rate at the
prescribed rate
- Change IV site and
tubing per
hospital policy
Phlebitis
– Inflammation of the wall of the vein, usually caused by:
- Injury to vein during
puncture
- Later movement of the
catheter
- Irritation to the vein
from
long term therapy
- Vein overuse
- Irritating or
incompatible
solutions
- Large bore
IV’s
- Lower extremity
IV’s
(greater risk)
- Infection
Signs
and
Symptoms of Phlebitis include:
- Sluggish flow rate
- Swelling around
infusion site
- Patient complaint of
pain or
discomfort at site
- Redness and warmth
along vein
Prevention
and
Treatment for Phlebitis is the same for an infiltrated IV.
Air
embolism - The obstruction of a
blood vessel (usually occurring in the lungs or heart) by air carried
via the bloodstream. The minimum quantity of air that may be fatal to
humans is not known. Animal experimentation indicates that
fatal
volumes of air are much larger than the quantity present in the entire
length of IV tubing. Average IV tubing holds about 5 ml of
air, an
amount not ordinarily considered dangerous. Causes of air embolism
include:
- Failure to remove air
from IV
tubing
- Allowing solution bags
to run
dry
- Disconnecting IV tubing
Signs
and Symptoms of Air Embolism
include:
- Abrupt drop in blood
pressure
- Weak, rapid pulse
- Cyanosis
- Chest Pain
Immediate
corrective action for
suspected Air Embolism includes:
- Notify Supervisor and
Physician immediately
- Immediately place
patient on
left side with feet elevated (this allows pulmonary artery to absorb
small air bubbles)
- Administer O2 if
necessary
- Preventive Measures to
avoid
Air Embolism includes:
- Clear all air from
tubing
before attaching it to the patient
- Monitor solution levels
carefully and change bag before it becomes empty
- Frequently check to
assure
that all connections are secure
IV
Therapy
Access Devices
Peripheral
IV Access:
This
is a catheter inserted in a
peripheral vein on the hand, wrist, or arm (rarely the foot in an
adult). A peripheral IV is used for some medications, blood products,
and fluid and electrolyte replacement for short periods of time.
Depending on hospital policy the site is usually changed every 72
hours. A 2ml - 3ml ml flush of Heparin (100u/cc or Normal Saline) is
required to assure patency. Prior to inserting a peripheral IV the RN
must do the following:
- Gather all necessary
equipment prior to attempting to start an IV
- Assess veins for size,
valves, straightness and ease of access.
- Patient education to
include
the actual procedure, purpose of IV Therapy, potential risks involved
and possible discomfort during insertion.
Central
Line or Triple Lumen Access
A
physician inserts a central line
at the bedside, when the patient either has poor venous access or has
the need for multiple different IV therapies. Many times surgeons will
put them in while the patient is in surgery if it is known that the
patient will need IV access for a few weeks. These catheters
can
remain inserted for a longer period then a peripheral IV access
(individual hospital policies vary). If therapy is known to be
for
longer then a couple of weeks, then the patient will require a more
permanent IV access port such as a Hickman or Porta-Cath. Triple Lumens
are often the IV access choice for short term TPN administration. A 2cc
to 3cc flush of Heparin (100u/cc or Normal Saline) can be used to flush
the ports and assure patency. Note an MD order is still required at
most facilities to flush IV access lines.
PICC Line
A
PICC line is a peripherally
inserted central line. This line is used when long term IV
therapy
is needed, and the patient has poor venous access. It is a
less
permanent than a port, Hickman or Porta-Cath. It can be
inserted
by an RN or trained individual at the bedside. The catheter
is
threaded through the large vein in the arm - brachial - to the superior
vena cava- tip of the right atrium of the heart (Same place as a port
or Hickman). This type of catheter is good for someone who
needs
a few weeks of antibiotics at home, someone who had surgery and needs
home IV therapy for 3-4 weeks. This type of catheter can be
left
in place for up to 12 months as long as there are no complications.
Hickman Catheter
The
Hickman Catheter is a thin,
long tube made of flexible, silicone rubber. It is surgically
inserted into the superior vena cava with the tip resting at the right
atrium. Depending on the therapy needs, the catheter may have either a
single, double or triple lumen (opening) at the tip. This
type of
catheter is placed when home or long-term venous access is
required. The ports are flushed with 2cc to 3cc of Heparin
(100u/cc) to maintain port patency and prevent thrombosis formation.
Porta-Cath
There
are several different types
of subcutaneous (under the skin) ports that can be used; the
Port-A-Cath is the most common. The subcutaneous port differs from the
external catheter in that it is completely under the skin. A small
metal chamber (1 x 1 x 1/2 inches) with a rubber top is implanted under
the skin of the right chest. A catheter threads from the metal chamber
(portal) under the skin to a large vein (sub-clavian) near the
collarbone, then inside the vein to the right atrium of the heart.
Whenever the catheter is needed for a blood draw or infusion of drugs
or fluid, a needle is inserted by a nurse through the skin and into the
rubber top of the portal.
Accessing
a Porta-Cath (10
Steps)
- Inquire and/or observe
whether the patient has experienced any symptoms that might warn of
catheter fragmentation and/or catheter embolization since the system
was last accessed; for example, episodes of shortness of breath, chest
pain, or palpitations, If any of these symptoms are reported,
an
x-ray is recommended to determine if there are problems with the
catheter.
- Examine and palpate the
portal pocket and catheter tract for erythema, swelling, tenderness, or
infection, which might indicate system leakage. If system
leakage
is suspected, an x-ray is recommended to determine if there are
problems with the system.
- Set up the sterile
field and
supplies.
- Prepare the site for
the
injection or infusion.
- Anesthetize the site
for
needle puncture, if desired.
- Using a 10-ml or larger
syringe, prime the porta-cath access needle and any attached extension
set to remove all air from the fluid path. Do not use
standard
hypodermic needles, as these will damage the septum and may cause
leakage.
- Locate the portal by
palpation and immobilize it using thumb and fingers of the non-dominant
hand.
- Insert the non-coring
needle
through the skin and portal septum at a 90º angle to the
septum. To avoid injection into the subcutaneous tissue,
slowly
advance the needle until it touches the bottom of the portal
chamber. Warning - Do not tilt or rock the needle once the
septum
is punctured as this may cause fluid leakage or damage to the septum.
- Aspirate for blood
return. Difficulty in withdrawing blood may indicate catheter
blockage or improper needle position.
- Using a second 10-ml or
larger syringe, flush the system with 10-ml of normal saline, taking
care not to apply excessive force to the syringe. Difficulty
in
injecting or infusing fluid may indicate catheter
blockage.
During this saline flush, observe the portal pocket and catheter tract
for swelling and inquire or observe whether the patient is experiencing
burning, pain, or discomfort at the portal site. If any of
these
symptoms are noted and/or swelling of the portal pocket and
catheter tract is observed, fluid extravasations into the portal pocket
or catheter tract should be suspected.
Care
of the Subcutaneous Port - The
entire port and catheter are under the skin and therefore require no
daily care. The skin over the port can be washed just like the rest of
the body. Frequent visual inspections are needed to check for swelling,
redness, or drainage.
The
subcutaneous port must be
accessed and flushed with Normal Saline (5-10mls) and Heparin (6ml of
100units/ml) at least once every 30 days, which usually coincides with
the monthly clinic visit and blood checks. A nurse or technician does
this procedure only. The port system requires no maintenance by the
patient or family members.
Contraindicated
for patient
therapy include:
- Presence of infection,
bacteremia, or septicemia is known or suspected.
- The patient's anatomy
will
not permit introduction of the catheter into a vessel.
- The patient has severe
chronic obstructive pulmonary disease (COPD) - chest placement only.
- The patient has
undergone
past irradiation of the upper chest area - chest placement only.
- The patient is known to
have,
or is suspected to have, an allergic reaction to materials contained in
the system or has exhibited a prior intolerance to implanted
devices.
- Substances are used for
patient therapy that is incompatible with any of the system's
components.
- Do not use this product
if
the package has been previously opened or damaged.
Use of the system involves potential risks normally associated with the
insertion or use of any implanted device or indwelling catheter,
including but not limited to:
- Air embolism
- Arteriovenous fistula
- Artery or vein
damage/injury
- Brachial plexus injury
- Cardiac arrhythmia
- Cardiac
puncture/Cardiac
tamponade
- Catheter
disconnections,
fragmentation, fracture, or shearing with possible embolization of the
catheter.
- Catheter occlusion/
Catheter
rupture
- Drug extravasations
- Erosion of
portal/catheter
through skin and/or blood vessel.
- Fibrin sheath formation
around catheter tip.
- Hematoma/Thrombosis
- Pneumothorax/Hemothorax
- Implant rejection
- Infection/bacteremia/sepsis
- Migration of
portal/catheter
- Nerve damage
- Thoracic duct injury
- Thromboembolism/Thrombophlebitis
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