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Indications for Intravenous Therapy

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Presentation on theme: "Indications for Intravenous Therapy"— Presentation transcript:

1 Indications for Intravenous Therapy

2 Purpose of IV Therapy To provide maintenance and replacement of
acid-base balance or fluid and electrolyte balance When rapid absorption is necessary (bypasses hepatic system) Access for blood sampling and blood transfusion TPN: Total Parenteral Nutrition (nutritional therapy)

3 Purpose of IV Therapy Chemotherapy
Avenue for continuous or intermittent medications e.g. antibiotics, vasopressors, analgesics, electrolytes, vitamins and diuretics

4 Nursing Responsibilities for IV Therapy
To have a thorough knowledge of fluids and drugs, their effects, dosage, recommended rate, incompatibilities, contraindications, and allergic reactions, prior to administration To have good judgment and assessment skills prior to, during, and post administration LPN

5 Nursing Responsibilities for IV Therapy
To have the ability to interpret physician’s orders To have good documentation and communication skills To know your own scope of practice

6 Nursing Responsibilities for IV Therapy
Choose the most appropriate vascular access device by selecting a device that has the potential for providing access throughout the course of therapy , ensures the best possible outcome, has the least risk to the patient and the health care provider. Collect and document relevant patient data Manage venous access cost-effectively

7 The Skin First line of defense Fertile ground for bacterial growth
Warmth Moisture 10,000 organisms per square centimeter Three layers epidermis dermis subcutaneous tissue

8 The Skin Resident Flora Permanent residents
Not readily removed by handwashing Can be inhibited with use of antimicrobial soaps

9 The Skin Transient Flora Not normally present on the skin
Survive poorly on skin surfaces Noncolonizing flora, vary from day to day Present from touch contamination Can be eradicated by good handwashing Staphylococcus aureus

10 Don’t forget to clean your pen!
Handwashing 50% of nosocomial infections could be eliminated by handwashing alone Hands are only washed 50% of the times indicated Wearing gloves does not eliminate need to wash hands before or after patient contact 15-20 second hand wash vigorously with soap and running water Don’t forget to clean your pen!

11 Skin Cleansing and Disinfecting
Disinfectant Types

12 10% Iodophors Iodine fixed to a carrier molecule reducing the amount of free iodine released on the skin which reduces irritation to the skin Two minutes of contact before effective Must be allowed to air dry Residual activity, if reservoir left on the skin Effectiveness is affected by organic material, wash skin with soap and water if needed or alcohol swabs if available Ensure no allergy to iodine

13 70% Alcohol Recommended agent for iodine allergy
When used alone requires 1 minute scrub Provides immediate kill Has no residual activity Must be allowed to air dry Repeated use is drying to skin

14 Antimicrobial Skin Prep
70% Ethyl Alcohol & 10% Povidone-iodine combination One-step prep 5-7 day efficacy beneath sterile transparent film dressings

15 2% Chlorhexidine vs Iodine options
Chlorhexidine has comparable effectiveness and is safer, cheaper, and preferred by staff, so it is an alternative to iodine tincture. Journal of Clinical Microbiology, May 2004, p , Vol. 42, No. 5 Applied in a scrubbing motion both horizontally and vertically

16 Layers of the Vein

17 Tunica Intima Characteristics Innermost layer Smooth elastic lining
Recognizes foreign material Prostaglandin & heparin mast cells. . .mediators for inflammatory process Stage for phlebitis

18 Tunica Media Characteristics Clinical indications Middle layer
Smooth muscle & elastic tissue Nerve fibers dilation/constriction muscle tone Clinical indications Affects efforts of vasodilation

19 Tunica Adventitia Characteristics Clinical indications Outer layer
Fibrous connective tissue Vein support Vein nourishment Clinical indications “Pop” Sclerosis, scarring

20 Those Pesky Venous Valves
Damage may lead to thrombus formation Incomplete catheter insertion can lead to leaking, variable IV rate and/or early removal

21 Comparison of Arteries and Veins

22 Differentiating Arteries and Veins
Artery Lie deep in tissue Thicker connective tissue: prevents collapsing or distending with pressure Protected by muscles Vein Superficially located Collapses under pressure Muscle layer may spasm with pain More numerous than arteries

23 Differentiating Arteries and Veins
Artery There are some areas where the arteries are superficial Supply single area Pulsate Color bright red Vein Inner layer has one-way valves If spasms, other veins compensate Darker color, bluish

24 Associated Nerve Structures

25 Posterior cutaneous nerve of forearm arises in spiral grove
Branches to brachoradialis and exteral radial Deep branch perforates supinator to form posterior interosseous nerve which supplies extensor compartment Superficial branch supplies skin on dorsum of hand and digits proximal to nail beds Radial nerve




29 Assessing Patient for IV Therapy

30 Patient Preparation/Education
Psychological preparedness Age specific Purpose of therapy Possible duration (peripheral/central) Method of administration Insertion procedure Mobility limitations or restrictions Long-term alternatives to peripheral IV may be nec.

31 ‘Informed’ Consent Requires Refusal of treatment
Sufficient information to make a decision Capacity to make a decision No coercion Refusal of treatment Assault and Battery: Coercion of rational patient into having an IV.

32 Special Considerations

33 Disease States/Conditions
Immunosuppression Increased risk of infection Dehydration Decreased intravascular volume Mastectomy May have compromised circulation, but vascularization has likely been rebuilt. Some pts will be “No IV” “No BP” on affected limb.

34 Disease States/Conditions
Heart disease/edema Obscures veins Irritating cardiac meds Fluid overload Anticoagulation therapy Diabetes Peripheral neuropathy Infection risks, slow to heal Cancer Chemotherapy Decreased cell counts

35 Disease States/Conditions
Renal Dialysis Hemodialysis grafts Obesity Veins deep or pushed to surface Sclerotic Veins Tendency to roll

36 Osmolarity of Fluid Osmolarity = the osmotic concentration of a solution expressed as osmoles of solute per liter of solution Osmole = the molecular weight of a solute Normal osmolarity of blood/serum is about mOsm/L.

37 Osmolarity of Fluid The tonicity of an IV fluid dictates whether the solution should be delivered via the peripheral or central venous route. Hypotonic and hypertonic solutions may be infused in small volumes and into large vessels, where dilution and distribution are rapid. When solutions with extremes of tonicity are infused, fluids shift into or out of cells, including endothelial cells of the tunica intima near the catheter tip and blood cells. The resulting changes in the cell size of the vein wall causes the inflammatory and clotting processes to occur, leading to phlebitis and thrombophlebitis.

38 Allergy Assessment Medication history First dose considerations
Risk analysis Iodine allergy (note shellfish allergy) Use alcohol or chlorhexidine Latex allergy Local anesthetics

39 Nursing Assessment Consider the following
Patient condition, age, diagnosis & activity level Vein condition, size & location Associated structures Skin integrity Type & duration of therapy Drugs that affect skin integrity Corticosteroids Heparin/Coumadin Chemotherapy Prednisone

40 Veins: So many to pick from!

41 Antecubital Fossa Large veins Tendency to “roll”
Because the veins in this area are visible and easily accessed, the antecubtial is ideal for blood samples and bolus drugs Unless joint is immobilized, cannula could kink or move in and out of the vein damaging the vein. Discuss cannula, what, why, rigid?

42 Infants only (Up to 2 years old)

43 Dangers Associated with Lower Extremities
Thrombosis Varicosity Immobility Increase risk of Pulmonary Embolism a travelling clot 

44 Distending Techniques
By understanding the physiology of veins, the IV therapist can use vasoconstriction and vasodilation to increase the vein size, increase visibility and decrease venous spasm. Distending Techniques Tourniquet (just enough to restrict venous return but not impede arterial flow) Dependent Position, (works well for elderly with tortuous veins instead of tourniquet) Warm moist heat compress Blood pressure cuff (40-50 mm HG below systolic—check for pulse) Clenching fist (muscles pump veins up)

45 Intravenous Supplies and Equipment

46 The Right Device to Start
Greatest likelihood of surviving anticipated length of therapy Accommodates therapy requirements Is the least invasive Utilizes the fewest number of catheters Meets a benefit vs. risk assessment

47 Short-term Peripheral Catheters
Most commonly inserted catheter Any appropriate peripheral vein Usual dwell time (P&P) 48-72 hours Heparin lock - 96 hours Peripheral solutions only “Clean” vs. sterile technique

48 Short-term Acute Catheters
Tip located in the SVC or IVC Dwell time varies 7-14 days Used for all types of solutions X-ray required (why?) Sterile technique Inserted subclavicular region by specialty nurse or physician, with imaging assistance- ultrasound

49 Midline Tip Tip placement in proximal portion of the upper extremity
Lower extremity may be used in the neonate and infant Dwell time 2-4 weeks avg Peripheral solutions only Sterile technique No X-ray required

50 Peripherally Inserted Central Catheters (PICC)
Tip located in the SVC (superior vena cava) or IVC Dwell time indeterminate Consider in patients requiring therapy up to one year Used for all types of solutions X-ray required Maximum sterile barrier precautions *

51 Advantages of PICCs & Midlines
Eliminates need for multiple venipunctures Reliable venous access Increased hemodilution Less traumatic to insert Insertion at bedside Cost & time efficient Easily removed Increased patient comfort and satisfaction

52 Advantages of PICC In addition…... Can be inserted by qualified RNs
Provides a reliable means for collecting blood samples Safe alternative to central access

53 Midline & PICC may be indicated
Less risk of arterial puncture / bleeding compared to multiple “pokes” Lower infection rates Coagulopathy Immunosuppression Caution

54 Non-Tunneled Central Venous Access
Tip SVC (superior vena cava) or IVC Used for all types of solutions Dwell time < 1 year X-ray required Sterile technique

55 Tunneled Catheters & Implanted Ports
Tip in SVC or IVC Dwell time not established Used for all types of solutions Surgical placement X-ray required Sterile technique

56 Port A port is a completely implanted device that consists of: Reservoir - a hollow titanium disk that has a rubber septum. The reservoir is implanted in a pocket just below the skin on the chest wall. Catheter - a tube that is connected to the reservoir and placed into one of the large veins of the chest.

57 Implanted VADs- Vasc. Assist Devices

58 Mediport Access

59 After the port is placed, it can be used for both infusion of medication and blood draws. The port is accessed using a special needle called a Huber needle.

60 Umbilical Artery Catheter (UAC)

61 Infusing Blood & Blood Products
Fluid viscosity Doubling the viscosity of a fluid will decrease flow rate by half Temperature of the fluid LENGTH + GAUGE + WALL THICKNESS+ VISCOSITY = SLOW FLOW RATE

62 Plastic Containers Advantages Flexible, collapse as fluid flows out
Not evacuated (no vacuum) Air venting is not required decreasing risk of airborne contamination Easily transported Easily stored Easily disposed

63 Plastic Containers Disadvantage Inspection before using
Some medications are absorbed by plastic, e.g. insulin or diazepam Inspection before using Squeeze and visually inspect Check lot number and expiration date Assess label with physician order Lot # jkl675 Expiration date: 6/5/08

64 Glass Bottles Sterile bottle with a vacuum inside
Any additives are pulled in quickly from vacuum Air intake is essential for solution to flow correctly Advantages: For medications that are absorbed by plastic

65 Glass Bottles Disadvantages Inspection Difficult to store
More likely to break Increased chance of air-borne contamination Inspection Look for cracks or chips in glass bottle Check lot number and expiration date Assess label with physician’s order When puncturing rubber seal, make sure vacuum is present

66 How can I infuse thee? Let me count the ways.
IV Administration Sets Nonvented vs. Vented Piggyback Pump Administration Sets Filters How can I infuse thee? Let me count the ways.

67 Standard Straight Gravity Flow IV
IV with Piggyback (IV PB)

68 Infusion sets Injection sites for piggy back medication
Notice airway that can be open or closed as needed

69 Blood Infusion Set Airway No injection ports
Large filter to catch clumps No injection ports

70 Volume Control Set Clamp Injection port Drip Regulating Clamp
Drug and fluid administration chamber Drip chamber Check valve

71 Drip Factor Some of these supplies are becoming obsolete, with pumps taking over Is indicated on the top of the cover A macrodrip delivers solution at rapid rates A microdrip, always 60 gtts/cc, is more controlled

72 IV Filters Remove pathogens and particles To minimize phlebitis
to reduce infection To reduce chance of infection To minimize phlebitis To reduce introduction of bacteria , foreign particles and air into the blood stream Filter needle- when using a glass vial that must have tip snapped off

73 IV Filters Types Sizes Inline
Others need to be added, always using aseptic technique Sizes 5 to 1 micron filters; Removes particle matter but not most fungi or bacteria .45 micron filters: Removes bacteria not fungi .22 micron(absolute filter): Removes all fungi and bacteria

74 IV Filters: Indications
Hyperalimentation (nutrition/TPN) Using additives comprising of many particles such as antibiotics Solutions requiring reconstitution or when administering several additives

75 IV Filters have Idiosyncrasies too!
INS Standards recommend routine usage of 0.22 in-line filter but CDC states it is not necessary if the tubing is being changed every 24 hours Filters used with infusion pumps must be able to withstand the pressures generated by the pumps In-line filters must be primed when you set up the system

76 Needle-less Systems Interlink System Clave System Saf-T-prn

77 Infusion Methods

78 Continuous Infusion Used to maintain a constant rate of infusion Uses
TPN Post and Peri operative Hydration Pain Control Pump is useful in maintaining a constant rate

79 IV Pumps Controllers Mechanical Mini Infusers Syringe Pumps
Computerized Cadd Prism Cadd Plus Sabratek 6060 Sabratek 3030

80 IV PUMP Clinician should have complete working knowledge:
How to turn it on How to prime administration set (what is priming?) How to calculate and set rate of flow How to correct alarms How to program the programmable pumps

81 IVPB “Piggyback” A secondary line that is connected to the injection port of a primary IV line Check for incompatibility with primary IV Allergies If pump is unavailable, hang primary with extension hook to position primary IV container BELOW the piggyback container.

82 Intermittent Heparin Lock /Reflux Valve
Use an administration set to infuse solution directly into a capped system Flush with normal saline before and after administration to reduce irritation to vein (per MD order) Prevent clotting by flushing with dilute heparin solution, usually 10U/cc (per MD order)

83 IV Push or Bolus Remember to use a 10 cc syringe, usually
Give slowly over 3-5 minutes, usually Flush afterwards with appropriate solution

84 Important ! ! ! Never assume ALL drugs are compatible with Sterile Normal Saline, but incompatibility is very rare Check with your institution’s Policy and Procedure Book or your dispensing pharmacists for information, or your online aide for nurses often by subscription with your employer

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