2Learning ObjectivesList 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.
3Types of Intravenous Fluids TonicityA measure of the concentration of electrolytes in the fluidThe normal concentration of electrolytes in body fluids is about 285 mEq/LWhy is the tonicity of fluids important?
4Types of Intravenous Fluids Isotonic solutionsThe concentration is the same as body fluidsHypertonic solutionsThe concentration is greater than 300 mEq/LDraws and retains water in the circulation, increasing the blood volumeHypotonic solutionsThe concentration is less than 280 mEq/LAllows water to shift out of the capillaries into body tissues, resulting in decreased blood volume
5Types of Intravenous Fluids ComponentsCommonly used IV solutions: specific combinations of water, sugar (dextrose), sodium chloride, and other electrolytesSodium chloride solutionsAn isotonic solution is 0.9% sodium chlorideA hypotonic solution is 0.45% sodium chlorideDextrose, sodium chloride, and other electrolytes are available in numerous combinationsPlasma-Lyte and lactated Ringer’s solution; dextrose 5% in Ringer’s solution is a combined dextrose and electrolyte solutionTotal parenteral nutrition: for long-term or aggressive intravenous therapy for nutritionWhat is the only source of calories in most intravenous solutions?Total parenteral nutrition provides dextrose, water, amino acids, electrolytes, vitamins, and minerals.Fat emulsions can also be given intravenously.
6Venous Access DevicesIntravenous fluid is delivered by various types of venous access devicesNeedles, over-the-needle catheters, inside-needle catheters (rarely used), subcutaneous infusion ports, subcutaneous pumpsCannula size is based on the inside diameter and is expressed as a gaugeThe smaller the gauge, the larger the inside diameter of the cannula
7Venous Access DevicesIV fluid administration requires placement of the venous access device into a peripheral or central veinPeripheral veinsLocated 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 givenCentral veinsLarge vessels located nearer the heartFor long-term therapy, when patient has poor peripheral veins, and when irritating fluids are to be administeredCentral lines are inserted into the subclavian or jugular vein or into the superior vena cavaThe central line may be placed in the subclavian vein through a surgical incision, inserted into a peripheral vein and advanced to the desired location, or inserted through a skin incision and tunneled under the skin and into the large vessel.The central line threaded through a peripheral vein is called a peripherally inserted central catheter (PICC).What are some examples of central venous tunneled catheters?
9PortA device with a central catheter that is surgically implanted in the subcutaneous tissueA venous catheter and a port through which fluids can be injected, but it has no external partsCatheter inserted into a central vein; port, which has a rubber septum, can be felt under the skinA 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 catheterA port requires less care and is less restrictive than other access devices, but it does require a needle puncture for each infusion.What types of catheters are more appropriate for long-term use?
12Needles Winged (“butterfly”) infusion needle Self-sheathing stylet A short needle with two plastic wings that are held during insertionSelf-sheathing styletRetracts into a rigid chamber at the catheter hub after insertionA winged infusion needle is useful in infants when a scalp vein is used for intravenous therapy; it is also used at times in adults who have very poor or small veins, for one-time therapy, to draw blood samples, and for therapy of short duration.What is the purpose of a self-sheathing stylet?
13Catheters A small plastic tube that fits over or inside a needle After insertion into vein, needle is withdrawn, leaving the catheter in the veinPeripherally inserted central catheter (PICC)Inserted into vein in antecubital space; advanced into axillary, subclavian, or brachiocephalic vein or the superior vena cavaTunneled cathetersAn 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 veinSubclavian cathetersCan have from 1-4 lumensCatheters are less likely than needles to puncture the vein once they are in place.What length catheters do nurses usually insert?Advantages of the PICC over other central catheters include easier insertion, cost savings, and less risk of pneumothorax, hemothorax, infection, or air embolism.Tunneled catheters are inserted only by the physician.
16Implanted DevicesSome devices can be implanted to allow immediate access to a vein without repeated, painful venipuncturesInclude infusion ports, pumps that are implanted under the skin, and external infusion pumpsInfusion ports consist of a catheter and a chamber into which fluids can be injected directly into vein or arteryThe chamber is easily felt directly under the skinInfusion pumps are filled with a special needle that is inserted through the skin into the port
17Intermittent Infusion Devices Intravenous medications are given at specific intervalsDrugs are often “piggybacked”Given through an injection port in the tubing of a continuous infusionHeparin lockPatient who does not need continuous IV therapy may have a latex resealable lockThe Heparin lock was so named because it may be flushed with a dilute heparin solution after each use to keep clots from forming and blocking the catheter.Although research suggests that flushing with normal saline may be just as effective as, and less expensive than, using heparin, the use of heparin persists in some settings.Any intravenous cannula (needle or catheter) can be converted to intermittent administration by attaching a resealable cap or an extension with a cap.
19EquipmentCannula (needle or catheter), tourniquet, alcohol swabs, skin cleansing solution, tape, dressing supplies, gloves, tubing, solution container, a pole to suspend the container, and infusion pumpPrescribed solution or drugUse the “five rights”: right solution or drug, right dose or strength, right patient, right route, and right timeAttach 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 tubingHow do you determine what size cannula is needed?
20Site Selection Should be the least restrictive A large vein that is in good conditionA soft, straight vein is bestAvoid veins that are hard and bumpy, bruised, swollen, near previously infected areas, or close to a recently discontinued siteTransilluminator or ultrasound can facilitate locating a veinPreferred site is usually patient’s nondominant armBegin with most distal veins, then move proximallyShould not be done in an arm that has impaired circulation or poor lymphatic drainage, as in radical mastectomy
21Procedure Wash hands thoroughly; explain procedure to patient Apply tourniquet above venipuncture site to distend veinLocate appropriate vein; temporarily remove the tourniquetVigorously cleanse venipuncture site in a circular pattern first with alcohol and then with a recommended solutionAllow to air dry after each cleansing step; do not blow on the site or fan itReapply the tourniquetPerform the venipuncture using Standard PrecautionsWhat cleansing solutions are recommended?
22ProcedureCarefully insert cannula through the skin and guide it into the vein in the direction of blood flowIf first attempt unsuccessful, select another site, change cannulas, and try againWhen using the catheter over needle, the needle is threaded only 1/4 inch into the veinThen catheter is threaded into vein as needle is removedAfter threading the cannula into the vein, connect it to the infusion tubing, and tape it securely but without restricting circulationDress site with a clear occlusive dressing that allows inspection of the insertion site or with a sterile gauze padHow often should IV site dressings be changed?
23Procedure Pain Documentation Venipuncture and cannula placement are painfulDrugs to decrease venipuncture pain include intradermal lidocaine (Xylocaine), transdermal lidocaine, and prilocaine (EMLA cream)DocumentationPlace 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 initialsLabel every bag of fluid and tubing with the date and time that it was hung and the fluid’s expiration dateIntradermal lidocaine may cause vasospasm, allergic reactions, and anaphylaxis.Both lidocaine and EMLA cream must be applied and covered with an occlusive dressing for 60 minutes to be effective.What is an iontophoresis of lidocaine?
25Factors Affecting Infusion Rate Height of fluid container over the patient’s heartWhen container is raised, the fluid flows fasterLowering container causes fluid to run more slowlyOptimal height is inches above the patientVolume of fluid in the containerFull container causes the fluid to run fasterAs container empties, rate slows downViscosity of the fluidThin fluids such as normal saline flow more quickly than thick fluids such as blood
26Factors Affecting Infusion Rate Cannula diameterFluid flows more quickly through a large cannula than through a small cannulaVenting of the fluid containerRigid containers must be vented to allow air to enter as fluid leavesPosition of the extremityCertain movements or positions may interfere with the flow of fluid
27Calculating the Infusion Rate DetermineHow much fluid to give each hourPhysician’s order specifies the amount of fluid to be administered in a specific period of timeHow 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 setStandard delivery sets (called macrodrop sets) deliver 10, 12, 15, or 20 drops per mlThe physician’s order specifies the amount of fluid to be administered in a specific period of time.The instructions on the delivery set package state how many drops equal 1 mL using that set.How many drops per milliliter do microdrop sets deliver?
28Calculating 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 infusingRecheck the rate hourlyCommon to put a timed tape on the fluid container; shows hourly levelsThis allows a quick assessment of whether the fluid is running on schedule
29Infusion Control Devices Electronic infusion control devices maintain an infusion rate set by the nurseThe 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 infusionVariety of infusion control devicesYou must become familiar with the type of infusion control devices used in your work setting.Do IV flow rates need to be monitored when using an electronic infusion device?
31Intravenous 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 pushYou must know how to dilute the medication and the correct rate of infusionImproper administration of IV medications is extremely dangerousSome medications and intravenous solutions are incompatible (they cannot be given together)
32Changing Venous Access Devices and Administration Sets Short peripheral cannulas and the tubing are usually changed every hoursIf complications occur with 72-hour intervals, the interval should be limited to 48 hoursAdministration sets for continuous peripheral and central infusions changed every 72 hoursPICC lines should be changed every 6 weeks
33Changing Venous Access Devices and Administration Sets Tunneled catheters and ports can be left in place for yearsTubing used to administer blood, total parenteral nutrition, or lipids must be changed every 24 hoursAn intravenous fluid container should not be used for more than 24 hours
34Termination of Intravenous Therapy Put on glovesStop the flow of fluidLoosen or remove the tape and dressingGently press a dry gauze pad over the siteRemove cannula, keeping hub parallel to the skinDispose of needle or catheter according to Standard Precautions guidelines
35Termination of Intravenous Therapy Elevate the extremity and apply pressure to the puncture site with a sterile gauze pad for 2 or3 minutesSecure the gauze with tapeRecord appearance of the site, condition of catheter, and how patient tolerated procedure
36PrecautionsAlways be aware of the risk of exposure to bloodborne pathogensMost serious: human immunodeficiency virus and hepatitis B virusNumerous products for venipuncture and intravenous therapy that reduce the risk of needle punctures or other exposure to bloodEvery nurse should be familiar with the agency needle puncture and body fluid exposure guidelines.
37Precautions Accidental needlesticks Most policies require blood specimens to be drawn from the nurse and the patient to test for bloodborne infectionsDrug therapy may be advised if patient has an infectious diseaseDocumentation 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
38Complications of Intravenous Therapy Tissue traumaInfiltrationInflammationInfectionFluid volume excessBleedingEmbolism
39The Older Patient and Intravenous Therapy Anchor vein with the thumb of your nondominant hand to hold it in place during venipunctureWhen performing venipuncture, you may be able to distend the vessel by simply pressing the veinSpecial adhesives/dressings prevent skin damageIf the hand or arm is secured to an armboard, the armboard must be paddedInfiltrated fluid may drain away from the cannula insertion siteIf a tourniquet is needed, protect fragile skin by wrapping a washcloth under the tourniquet or by using a blood pressure cuff inflated just above the patient’s diastolic pressure.What can be applied to the skin to protect it from adhesives?
40The 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 sleevesNever apply an immobilizer over an infusion site; the immobilizer must be below the siteReassure the confused patient, use a calm and gentle approach, and frequently reinforce instructionsWith dementia patients, distraction may take their attention away from the IVMonitoring for excess fluid volume especially important; older people have less efficient cardiac and renal function
42AssessmentDetermine the prescribed rate of flow, and assess the actual flow rateInspect the infusion site for edema, pallor or redness, bleeding, and drainagePalpate site for edema and warmth or coolnessAsk the patient if the infusion site is painfulIf blood flows into the tubing when the fluid container is lowered, can the infusion be infiltrated?
43AssessmentTake patient’s vital signs and compare the readings with previous findings to detect increased pulse and blood pressureMeasure and record the fluid intake and output, and auscultate the patient’s lungs for crackles
45Risk for InjuryTraumaThe insertion of a cannula is traumatic to the skin and underlying tissuesTape may irritate or tear skinUse gentle technique when performing the venipuncture, and anchor the cannula to reduce tissue traumaApply a commercial site protector, if available, to shield the intravenous site
46Risk for Injury Infiltration Can be caused by leakage where cannula enters vein or by puncture of a second site in the vein by the cannulaPatient may report pain or burningSite may be pale and puffy or feel hard and coolStop the infusion and restart it in a different veinElevate the affected arm on a pillowInfiltration is the collection of infused ﬂuid in tissue surrounding the cannula.The term extravasation is often used interchangeably with infiltration, but extravasation specifically refers to leakage of fluid from a blood vessel.What are vesicants?
47Risk for InfectionContamination of the site, by the intravenous fluid, or by the tubing used to deliver the fluidInfected site red and warm; purulent drainageUse strict aseptic technique when starting and handling intravenous infusionsIf infusion site inflamed or infected, stop the infusion and restart it in another siteIf agency policy permits, a warm compress can be applied to the inflamed sitePhlebitis may be due to irritation by the cannula or by medications.What symptoms may suggest phlebitis?
48Excess Fluid VolumeBlood volume may increase excessively when fluid is delivered directly into the bloodstreamHappens when large volumes of fluid infused, especially in patients with impaired renal or cardiac functionSigns and symptoms of fluid volume excess include rising blood pressure, bounding pulse, and edemaControlling the rate of fluid infusion reduces the risk of excess fluid volumeYoung children and older adults: monitor closelyIf indications of fluid volume excess appear, slow infusion rate, elevate patient’s head, notify the physician
49Decreased Cardiac Output Bleeding may occur if the cannula is moved excessively after insertionMore serious bleeding is possible if the tubing becomes disconnected from the cannula, allowing blood to flow freely from the veinMake sure all connections in infusion set secureTape tubing so that it cannot be pulled loose easily. Protect the infusion site and tubing when the patient movesWhat measures should be taken if a large amount of blood is lost from the IV site?
50Ineffective Tissue Perfusion Risks of emboli from blood clots, air, broken cathetersBlood clot can develop in IV needles or cathetersAir can enter the bloodstream if the infusion system is openedWhen the cannula seems to be obstructed, blood clots may have formed. Irrigation of cannula is not recommendedExercise extra caution to prevent an air embolism when a patient has a central lineAn embolus can have serious and even life-threatening effects if it lodges and obstructs blood flow in a critical blood vessel.The risk of air embolism with peripheral lines has been greatly reduced by the use of plastic rather than glass fluid containers.Which type of IV line is at greatest risk for an air embolism?A rare occurrence is a catheter embolus.
51Self-Care DeficitProvide assistance as needed with eating, dressing, toileting, and hygieneDressing may be easier if patient provided with a gown or shirt that unfastens at the shoulderExplain restrictions needed to protect infusionIf a commercial intravenous shield is available, use to reduce the risk of trauma at insertion site