2 Purpose of IV Therapy To provide maintenance and replacement of acid-base balance orfluid and electrolyte balanceWhen rapid absorption is necessary (bypasses hepatic system)Access for blood sampling and blood transfusionTPN: 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 administrationTo have good judgment and assessment skills prior to, during, and post administrationLPN
5 Nursing Responsibilities for IV Therapy To have the ability to interpret physician’s ordersTo have good documentation and communication skillsTo know your own scope of practice
6 Nursing Responsibilities for IV Therapy Choose the most appropriate vascular access device by selecting a device thathas 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 dataManage venous access cost-effectively
7 The Skin First line of defense Fertile ground for bacterial growth WarmthMoisture10,000 organisms per square centimeterThree layersepidermisdermissubcutaneous tissue
8 The Skin Resident Flora Permanent residents Not readily removed by handwashingCan be inhibited with use of antimicrobial soaps
9 The Skin Transient Flora Not normally present on the skin Survive poorly on skin surfacesNoncolonizing flora, vary from day to dayPresent from touch contaminationCan be eradicated by good handwashingStaphylococcus aureus
10 Don’t forget to clean your pen! Handwashing50% of nosocomial infections could be eliminated by handwashing aloneHands are only washed 50% of the times indicatedWearing gloves does not eliminate need to wash hands before or after patient contact15-20 second hand wash vigorously with soap and running waterDon’t forget to clean your pen!
11 Skin Cleansing and Disinfecting Disinfectant Types
12 10% IodophorsIodine fixed to a carrier molecule reducing the amount of free iodine released on the skin which reduces irritation to the skinTwo minutes of contact before effectiveMust be allowed to air dryResidual activity, if reservoir left on the skinEffectiveness is affected by organic material, wash skin with soap and water if needed or alcohol swabs if availableEnsure no allergy to iodine
13 70% Alcohol Recommended agent for iodine allergy When used alone requires 1 minute scrubProvides immediate killHas no residual activityMust be allowed to air dryRepeated use is drying to skin
14 Antimicrobial Skin Prep 70% Ethyl Alcohol & 10% Povidone-iodine combinationOne-step prep5-7 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. 5Applied in a scrubbing motion both horizontally and vertically
22 Differentiating Arteries and Veins ArteryLie deep in tissueThicker connective tissue: prevents collapsing or distending with pressureProtected by musclesVeinSuperficially locatedCollapses under pressureMuscle layer may spasm with painMore numerous than arteries
23 Differentiating Arteries and Veins ArteryThere are some areas where the arteries are superficialSupply single areaPulsateColor bright redVeinInner layer has one-way valvesIf spasms, other veins compensateDarker color, bluish
25 Posterior cutaneous nerve of forearm arises in spiral grove Branches to brachoradialis and exteral radialDeep branch perforates supinator to form posterior interosseous nerve which supplies extensor compartmentSuperficial branch supplies skin on dorsum of hand and digits proximal to nail bedsRadial nerve
30 Patient Preparation/Education Psychological preparednessAge specificPurpose of therapyPossible duration (peripheral/central)Method of administrationInsertion procedureMobility limitations or restrictionsLong-term alternatives to peripheral IV may be nec.
31 ‘Informed’ Consent Requires Refusal of treatment Sufficient information to make a decisionCapacity to make a decisionNo coercionRefusal of treatmentAssault and Battery: Coercion of rational patient into having an IV.
33 Disease States/Conditions ImmunosuppressionIncreased risk of infectionDehydrationDecreased intravascular volumeMastectomyMay have compromised circulation, but vascularization has likely been rebuilt. Some pts will be “No IV” “No BP” on affected limb.
35 Disease States/Conditions Renal DialysisHemodialysis graftsObesityVeins deep or pushed to surfaceSclerotic VeinsTendency to roll
36 Osmolarity of FluidOsmolarity = the osmotic concentration of a solution expressed as osmoles of solute per liter of solutionOsmole = the molecular weight of a soluteNormal osmolarity of blood/serum is about mOsm/L.
37 Osmolarity of FluidThe 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 analysisIodine allergy (note shellfish allergy)Use alcohol or chlorhexidineLatex allergyLocal anesthetics
39 Nursing Assessment Consider the following Patient condition, age, diagnosis & activity levelVein condition, size & locationAssociated structuresSkin integrityType & duration of therapyDrugs that affect skin integrityCorticosteroidsHeparin/CoumadinChemotherapyPrednisone
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 drugsUnless joint is immobilized, cannula could kink or move in and out of the vein damaging the vein. Discuss cannula, what, why, rigid?
43 Dangers Associated with Lower Extremities ThrombosisVaricosityImmobilityIncrease 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 TechniquesTourniquet (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 compressBlood pressure cuff (40-50 mm HG below systolic—check for pulse)Clenching fist (muscles pump veins up)
46 The Right Device to Start Greatest likelihood of surviving anticipated length of therapyAccommodates therapy requirementsIs the least invasiveUtilizes the fewest number of cathetersMeets a benefit vs. risk assessment
47 Short-term Peripheral Catheters Most commonly inserted catheterAny appropriate peripheral veinUsual dwell time (P&P)48-72 hoursHeparin lock - 96 hoursPeripheral solutions only“Clean” vs. sterile technique
48 Short-term Acute Catheters Tip located in the SVC or IVCDwell time varies 7-14 daysUsed for all types of solutionsX-ray required (why?)Sterile techniqueInserted 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 infantDwell time2-4 weeks avgPeripheral solutions onlySterile techniqueNo X-ray required
50 Peripherally Inserted Central Catheters (PICC) Tip located in the SVC (superior vena cava) or IVCDwell time indeterminateConsider in patients requiringtherapy up to one yearUsed for all types of solutionsX-ray requiredMaximum sterile barrierprecautions*
51 Advantages of PICCs & Midlines Eliminates need for multiple venipuncturesReliable venous accessIncreased hemodilutionLess traumatic to insertInsertion at bedsideCost & time efficientEasily removedIncreased patient comfort and satisfaction
52 Advantages of PICC In addition…... Can be inserted by qualified RNs Provides a reliable means for collecting blood samplesSafe alternative to central access
53 Midline & PICC may be indicated Less risk of arterial puncture / bleeding compared to multiple “pokes”Lower infectionratesCoagulopathyImmunosuppressionCaution
54 Non-Tunneled Central Venous Access Tip SVC (superior vena cava) or IVCUsed for all types of solutionsDwell time < 1 yearX-ray requiredSterile technique
55 Tunneled Catheters & Implanted Ports Tip in SVC or IVCDwell time not establishedUsed for all types of solutionsSurgical placementX-ray requiredSterile technique
56 PortA 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.
61 Infusing Blood & Blood Products Fluid viscosityDoubling the viscosity of a fluid will decrease flow rate by halfTemperature of the fluidLENGTH + 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 contaminationEasily transportedEasily storedEasily disposed
63 Plastic Containers Disadvantage Inspection before using Some medications are absorbed by plastic, e.g. insulin or diazepamInspection before usingSqueeze and visually inspectCheck lot number and expiration dateAssess label with physician orderLot # jkl675Expiration date: 6/5/08
64 Glass Bottles Sterile bottle with a vacuum inside Any additives are pulled in quickly from vacuumAir intake is essential for solution to flow correctlyAdvantages:For medications that are absorbed by plastic
65 Glass Bottles Disadvantages Inspection Difficult to store More likely to breakIncreased chance of air-borne contaminationInspectionLook for cracks or chips in glass bottleCheck lot number and expiration dateAssess label with physician’s orderWhen puncturing rubber seal, make sure vacuum is present
66 How can I infuse thee? Let me count the ways. IV Administration SetsNonvented vs. VentedPiggybackPump Administration SetsFiltersHow 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 clumpsNo injection ports
70 Volume Control Set Clamp Injection port Drip Regulating Clamp Drug and fluid administration chamberDrip chamberCheck valve
71 Drip FactorSome of these supplies are becoming obsolete, with pumps taking overIs indicated on the top of the coverA macrodrip delivers solution at rapid ratesA microdrip, always 60 gtts/cc, is more controlled
72 IV Filters Remove pathogens and particles To minimize phlebitis to reduce infectionTo reduce chance of infectionTo minimize phlebitisTo reduce introduction of bacteria , foreign particles and air into the blood streamFilter 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 techniqueSizes5 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 antibioticsSolutions 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 hoursFilters used with infusion pumps must be able to withstand the pressures generated by the pumpsIn-line filters must be primed when you set up the system
78 Continuous Infusion Used to maintain a constant rate of infusion Uses TPNPost and Peri operativeHydrationPain ControlPump is useful in maintaining a constant rate
79 IV Pumps Controllers Mechanical Mini Infusers Syringe Pumps ComputerizedCadd PrismCadd PlusSabratek 6060Sabratek 3030
80 IV PUMP Clinician should have complete working knowledge: How to turn it onHow to prime administration set (what is priming?)How to calculate and set rate of flowHow to correct alarmsHow to program the programmable pumps
81 IVPB “Piggyback”A secondary line that is connected to the injection port of a primary IV lineCheck for incompatibility with primary IVAllergiesIf 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 systemFlush 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, usuallyFlush afterwards with appropriate solution
84 Important ! ! !Never assume ALL drugs are compatible with Sterile Normal Saline, but incompatibility is very rareCheck 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