IV Therapy Author: Kristi Hudson RN MSN CCRN Course Objectives: Upon completion of this course the student will

be able to:

Goal # 3: is to improve the safety of using medication by:

1. 2. 3. 4. 5. 6. 7. 8. 9.

State the 7 rights of safe medication administration Describe 2 of the JCAHO safety standards for safe medication administration Discuss the purpose of IV therapy Understand the difference in Hypertonic vs. Hypotonic IV solutions Explain 3 signs and symptoms for both fluid volume overload/deficit List 3 signs and symptoms for an infiltrated IV Discuss the signs and symptoms for air embolism Describe some of the differences in IV access devices State the steps to accessing a Porta-Cath

Remove concentrated electrolytes (including but not limited to potassium chloride, potassium phosphate and sodium chloride > 0.9 from the patient care units Standardize and limit the number of drug concentrations available with in an organization Identify and at least annually review a list of look alike/sound alike drugs used in the organization. Take measures to prevent errors involving these drugs Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings

Note: Make sure patient is wearing proper identification band and allergy band if patient has allergies The Purpose of IV Therapy: In addition to having readily available access for medications, there are five specific purposes for IV therapy and they include:

Therapy Understanding the 7 rights of safe medication administration: Most registered nurses learned about the "5 rights" of medication administration early in their careers. The 5 rights (right drug, right client, right dose, right time and right route) have been incorporated in their nursing practice. It is important to remember that hanging a bag of IV fluid is also considered medication administration, and must be done using these same safety standards. In addition to the 5 rights of medication administration, registered nurses also recognize they need to know the reason the drug is given the right reason. The administration of medication is not complete until documentation has occurred the right documentation. Incorporating the right reason and right documentation into the original 5 rights of safe medication administration has turned into the7 rights of medication administration.

1. 2. 3. 4. 5.

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.

The Three Types of Intravenous Fluids are:

1. 2. 3. 4. 5. 6.

RIGHT client (Two Identifiers) RIGHT dose RIGHT time RIGHT route RIGHT reason RIGHT documentation

In 2006 the Joint Commission issued National Patient Safety Goal # 3 (which is still in full force today). This goal is as follows: PO, IM or Intravenously:

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:

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)

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 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. 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.

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

Multiple electrolyte solutions are helpful in replacing previous and concurrent fluid losses. Fluid and electrolyte losses that occur from diarrhea, vomiting, and/or gastric

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:

Signs and Symptoms of Phlebitis 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

Sluggish flow rate Swelling around infusion site Patient complaint of pain or discomfort at site Redness and warmth along vein

Immediate corrective action to take if IV infiltration is suspected includes:

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:

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)

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

Preventive Measures to avoid IV Infiltration include: Immediate corrective action for suspected Air Embolism includes: 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 IVs Lower extremity IVs (greater risk) Infection

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:

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)

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

1.

2.

3. 4. 5. 6.

7.

8.

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 portacath 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 90 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. 9. Aspirate for blood return. Difficulty in withdrawing blood may indicate catheter blockage or improper needle position. 10. 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.

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:

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:

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

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.