1. Intravenous Fluid Administration
B260 Foundations of Nursing

2. IV Fluid Administration: Objectives
Discuss purposes and procedures for initiation, maintenance and discontinuing an infusion.
Explain the importance of infection control in the management of intravenous solutions, tubing, and dressings.
Discuss the complications of intravenous therapy.
Discuss the procedure for initiating a blood transfusion and interventions to manage a transfusion reaction.

3. Intravenous Therapy
Goal: Correct or prevent fluids and electrolyte disturbances
Allow direct access to the vascular system
Requires close monitoring
Knowledge required: solutions, equipment, procedures, regulating flow, maintenance, identifying and correcting problems, and how to discontinue

4. Intravenous Therapy: Types of Solutions
Isotonic: same concentration as body fluids including Blood, most common
use for volume replacement (eg. after prolonged vomiting);
NaCl 0.9% normal saline,
D5W 5% Dextrose in water
Hypotonic: concentration lower than body fluids
 Use to rehydrate the cells;
 0.45% NaCl or ½ normal saline
Hypertonic: concentration higher than body fluids
 Used to increase vascular volume, use with caution due to risk for fluid overload
 D5 0.45% NS
 D10W
 D5LR

5. IV Solution Cheat Sheet

6. Intravenous Therapy: Additives
IV Fluids may contain additives:
Hyperalimentation or Total Parenteral Nutrition
Lactated Ringers, D5LR
Dextrose and saline combinations, with added KCL
KCL is commonly added to IV solutions when patients are NPO; body cannot conserve K
Never give KCL IV push directly as it may be fatal!
KCL: administer slowly over several hours and diluted

7. Intravenous Therapy: Orders
Should contain:
specific solution
additives
time schedule
Example: D5½ NS with 20 meq KCL
Follow 7 rights of medication administration, same as with all medications

8. Review: Seven Rights Right Person Right Drug Right Dose Right Route
Right Time
Right Documentation
Right to refuse

9. IV Therapy: Equipment

10. Intravenous Therapy: Equipment
Butterfly
Angiocath
Saline lock

11. IV Therapy: Peripheral

12. IV Therapy: Peripheral Sites
Feet not recommended for adults

13. IV Therapy: Starting an IV
Review order
Get supplies
Explain to patient
Find best vein
Start distally
Perform venipuncture, secure, start fluids
Document
Dressing should be transparent
Do not select sites on mastectomy side, dialysis, paralyzed. Caution with hard veins, valves, skin bruising or other abnormalities, do not go below previous IV sites.

14. IV Therapy: Angle of Entry

15. IV Therapy: Insertion with Flashback

16. IV Therapy: Dressing

17. Intravenous Therapy: Equipment
Bottles, Bags IVPB Tubing

18. IV Therapy: Administration Sets

19. IV Therapy: Administration Sets

20. Intravenous Therapy: Equipment
Central lines PICC lines Implanted ports

21. IV Therapy: Central Line

22. IV Therapy: Central Line

23. IV Therapy: Central Line Dressing

24. IV Therapy: PICC Line

25. IV Therapy: PICC Line

26. IV Therapy: Implanted Ports
Vascular access devices are designed for repeated access to the vascular system. Peripheral cannulas are for short term use. Central lines, PICCs are for long term use.

27. IV Therapy: Implanted Ports

28. IV Therapy: Implanted Ports

29. IV Therapy: Hyperalimentation

30. IV Therapy: Lipids

31. IV Therapy: Assessment
Important areas to assess:
Daily wt
I&0
Labs=Na+, K+, Cl, glucose, BUN
Skin turgor
Breath sounds
Daily wts are the best way to assess fluid status.
1 kg (2.2 lbs) of fluid = 1 L of fluid
Wts same time of day, same scale, same amt of clothes

32. IV Therapy: Assessment
Psychological responses
Independence
Condition of vein and surrounding tissues
Infiltration
Phlebitis
Infection
Bleeding
Circulatory overload
Severe untoward reactions
Phlebitis: is inflammation of the vein. Sx include pain, edema, erythema, heat, redness may occur along the path of the vein
Infiltration: fluid entering the subcu tissue; sx = swelling, pallor and coolness, pain possible

33. IV Therapy: Complications
Extravasation
Infiltration of drugs into tissues surrounding the infusion site causing local tissue damage.

34. IV Therapy: Complications
Swelling-Edema from Infiltration

35. IV Therapy: Complications
Phlebitis
This child's IV site was completely wrapped, preventing proper assessment.

36. IV Therapy: Complications
Redness and Swelling

37. IV Therapy: Complications
Phlebitis

38. IV Therapy: Complications
This child’s antibiotic infiltrate went untreated for a few days.

39. IV Therapy: Complications
Bruising

40. Intravenous Therapy: Discontinue IV
Review order
Explain to patient
Stop IV fluids, remove dressing
Stabilize the cannula and clean site
Cover with sterile gauze, gentle pressure and remove cannula
Apply pressure 2-3 minutes and secure dressing

41. Collaborative Learning
Jimmy Lewis is brought to the hospital emergency room by some friends. He had been vomiting for several days and was complaining of heart palpitations. Mr. Lewis is a 58-year-old white male who is homeless. He has not had any health care for at least 10 years. He is an alcoholic and drinks a quart of gin or vodka every day. He does not have a job, and his family is all out of state. The emergency physician does an initial assessment and transfers him to a hospitalist, who admits him to a medical-surgical unit for further evaluation and treatment.

42. Collaborative Learning
Mr. Lewis has lab work drawn. His electrolytes are as follows: sodium 138 mEq/L, potassium 3.1 mEq/L (low), chloride 104 mEq/L, and magnesium 1.5 mEq/L (low). His arterial blood gas measurements are as follows: pH 7.48 (high), PaCO2 40 mm Hg, HCO3 29 (high). Jamie Taylor, a 22-year-old nursing student, is assigned to Mr. Lewis. She reviews Mr. Lewis medical record before going in to assess him.

43. Discuss
After reviewing his chart and lab work, what fluid and electrolyte imbalances would Jamie determine?

A. Fluid volume deficit
B. Hypokalemia
C. Hypermagnesemia
D. Hyperkalemia
E. Hypomagnesemia 


44. Discuss
Answer: A, B, E 

Rationale: The results of the lab tests reveal decreased potassium and magnesium. These deficits are related to vomiting and alcoholism. The fluid volume deficit is a result of decreased intake and increased output related to vomiting.

45. Discuss
The hospitalist orders an IV of D5NS to run at 125 ml/hour. What type of fluid is this?

46. Discuss
Answer: B

Rationale: Isotonic fluids replace extracellular volume and will hydrate the cells.


47. Discuss
Two hours after the IV is started, Mr. Lewis complains of pain at the insertion site. Jamie assesses the site and notes that it is cool to the touch around the site and is edematous. She tries to obtain a blood return and does not get any return. This indicates what type of problem, and what action should she take?

48. Discuss
Answer: This indicates infiltration of the IV, and Jamie should discontinue it, raise the extremity, and place a warm, moist towel over the area.

Rationale: An IV is infiltrated when the fluid is entering the subcutaneous tissue around the venipuncture site. This causes swelling of the tissue and pallor and coolness due to decreased circulation around the site. Elevating the extremity promotes venous drainage, and the heat from the warm, moist towel will increase the blood flow.

49. IV Therapy
Blood Administration

50. IV Therapy: Blood Administration
Blood transfusion includes any of the following :
Whole blood
Packed RBC’s
Plasma
Platelets

51. IV Therapy: Blood Products

52. IV Therapy: Whole Blood

53. IV Therapy: Blood Administration
Purpose:
Increase blood volume
Treat anemia
Replace blood components (clotting factors, platelets, albumin)

54. IV Therapy: Blood Administration
Blood Grouping
“O” is universal donor
AB is universal recipient
A blood
B blood
Rh factor
If mismatched, transfusion reaction may occur (mild  severe)

55. IV Therapy: Blood Transfusion
Guidelines for Safe Blood Administration
Blood tubing has an in-line filter
Prime with 0.9% normal saline
Educate patient
Assess patient for history of reaction
Consent signed
Checked by 2 RN’s
Vital signs: baseline, 15 minutes after starting the infusion, when complete, and prn.

56. IV Therapy: Blood Transfusion
Guidelines for Safe Blood Administration
Stay with patient during first 15 minutes
IV gauge: preferred, 20g or less.
Start blood within 30 minutes from blood bank
Administer slowly in first 15 min, then increase rate as ordered or within hours.
Not longer than 4 hours - risk bacterial contamination
Use gloves to prepare and administer

57. IV Therapy: Transfusion Reactions
Acute Hemolytic: Incompatibility to antibodies causing RBC breakdown
Signs & Sx: chills, fever, pain, flushing, tachycardia, tachypnea, etc.
Febrile nonhemolytic:
Sensitization to specific blood components
Signs & Sx: chills, fever, headache, flushing, etc.
Mild allergic: sensitivity to plasma proteins
Signs and Sx: flushing, itching, hives

58. IV Therapy: Transfusion Reactions
Anaphylactic: reaction to blood proteins
Signs & Sx: anxiety, itching, wheezing, cyanosis, shock, etc.
Circulatory Overload: fluid administered faster than the circulation can accommodate
Signs & Sx: cough, dyspnea, pulmonary congestion, headache, hypertension, tachycardia, distended neck veins
Sepsis: contaminated blood
Signs & Sx: chills, high fever, vomiting, diarrhea, hypotension, shock

59. IV Therapy: Transfusion Reactions
Management: stop transfusion! keep IV line open with 0.9% normal saline notify provider stay with patient and monitor (vitals, observe and treat)