Presentation on theme: "Indications for Intravenous Therapy. Purpose of IV Therapy To provide maintenance and replacement of – acid-base balance or – fluid and electrolyte balance."— Presentation transcript:
Indications for Intravenous Therapy
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)
Purpose of IV Therapy Chemotherapy Avenue for continuous or intermittent medications e.g. antibiotics, vasopressors, analgesics, electrolytes, vitamins and diuretics
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 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
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
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
The Skin Resident Flora – Permanent residents – Not readily removed by handwashing – Can be inhibited with use of antimicrobial soaps
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
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 – second hand wash vigorously with soap and running water Don’t forget to clean your pen!
Skin Cleansing and Disinfecting Disinfectant Types
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
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
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
Layers of the Vein
Tunica Intima Characteristics – Innermost layer – Smooth elastic lining – Recognizes foreign material – Prostaglandin & heparin mast cells...mediators for inflammatory process – Stage for phlebitis
Tunica Media Characteristics – Middle layer – Smooth muscle & elastic tissue – Nerve fibers dilation/constriction muscle tone Clinical indications – Affects efforts of vasodilation
Those Pesky Venous Valves Damage may lead to thrombus formation Incomplete catheter insertion can lead to leaking, variable IV rate and/or early removal
Comparison of Arteries and Veins
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
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
Associated Nerve Structures
Radial nerve 1.Posterior cutaneous nerve of forearm arises in spiral grove 2.Branches to brachoradialis and exteral radial 3.Deep branch perforates supinator to form posterior interosseous nerve which supplies extensor compartment 4.Superficial branch supplies skin on dorsum of hand and digits proximal to nail beds
Assessing Patient for IV Therapy
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.
‘Informed’ Consent Requires – 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.
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.
Disease States/Conditions Renal Dialysis – Hemodialysis grafts Obesity – Veins deep or pushed to surface Sclerotic Veins – Tendency to roll
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.
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. Osmolarity of Fluid
Allergy Assessment Medication history First dose considerations – Risk analysis Iodine allergy (note shellfish allergy) – Use alcohol or chlorhexidine Latex allergy Local anesthetics
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
Veins: So many to pick from!
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?
Infants only (Up to 2 years old)
Dangers Associated with Lower Extremities Thrombosis Varicosity Immobility Increase risk of Pulmonary Embolism a travelling clot
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. 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) Distending Techniques
Intravenous Supplies and Equipment
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
Short-term Peripheral Catheters Most commonly inserted catheter Any appropriate peripheral vein Usual dwell time (P&P) – hours – Heparin lock - 96 hours Peripheral solutions only “Clean” vs. sterile technique
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
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
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 *
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
Advantages of PICC In addition…... – Can be inserted by qualified RNs – Provides a reliable means for collecting blood samples – Safe alternative to central access
Midline & PICC may be indicated Coagulopathy Immunosuppression Less risk of arterial puncture / bleeding compared to multiple “pokes” Lower infection rates Caution
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
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
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.
Implanted VADs- Vasc. Assist Devices
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.
Umbilical Artery Catheter (UAC)
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
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
Plastic Containers Disadvantage – 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
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
Glass Bottles Disadvantages – 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
How can I infuse thee? Let me count the ways. IV Administration Sets 1.Nonvented vs. Vented 2.Piggyback 3.Pump Administration Sets 4.Filters
Standard Straight Gravity Flow IV IV with Piggyback (IV PB)
Infusion sets Injection sites for piggy back medication Notice airway that can be open or closed as needed
Blood Infusion Set Large filter to catch clumps No injection ports Airway
Volume Control Set Clamp Injection port Drug and fluid administration chamber Drip chamber Check valve Drip Regulating Clamp
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
IV Filters Remove pathogens and particles – 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
IV Filters Types – 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
IV Filters: Indications Hyperalimentation (nutrition/TPN) Using additives comprising of many particles such as antibiotics Solutions requiring reconstitution or when administering several additives
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
Needle-less Systems Interlink System Clave System Saf-T-prn
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
IV Pumps Controllers Mechanical Mini Infusers Syringe Pumps Computerized – Cadd Prism – Cadd Plus – Sabratek 6060 – Sabratek 3030
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
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.
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)
IV Push or Bolus Remember to use a 10 cc syringe, usually Give slowly over 3-5 minutes, usually Flush afterwards with appropriate solution
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