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INTRAVENOUS THERAPY for Nurses
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Please take note... This educational program is designed to be viewed
as a PowerPoint slide show.
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Learning Objectives Upon completion of this program,
the participant will be able to: Discuss indications for intravenous therapy. Differentiate Crystalloid solutions from Colloid solutions. Define osmosis and its relation to IV therapy. Differentiate local complications from systemic complications of IV therapy.
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What are IV Fluids used for?
IV fluids are used to: restore acid-base balance. provide nutrition while resting the GI tract. maintain or replace body stores of water, electrolytes, vitamins, proteins, fats, and calories in the patient who cannot maintain an adequate intake by mouth. restore the volume of blood components. administer safe and effective infusions of medications by using the appropriate vascular access.
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What’s in that bag… …of fluid?
Saline solutions—water and electrolytes (Na, Cl) Dextrose solutions—water or saline and calories Lactated Ringer's solution—water and electrolytes (Na, K, Cl, Ca, lactate) Balanced Isotonic solution—varies; water, some calories, electrolytes (Na, K, Mg, Cl) HCO3, gluconate Whole blood and blood components Plasma expanders—albumin, mannitol, dextran, hespan Parenteral hyperalimentation—fluid, electrolytes, amino acids, and calories
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IV solutions are either Crystalloid or Colloid…
let’s talk more about this… 1 slide with 2 types of solutions Then next slide
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Crystalloid Solutions…
Crystalloid solutions contain small molecules that pass freely through cell membranes and vascular system walls. These solutions are useful as fluid expanders and are stored at room temperature. Crystalloid solutions are a useful source for electrolytes and a temporary source of fluid volume. Crystalloids flow out of the vascular system rather quickly.
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Types of Crystalloid Solutions
Dextrose in Water Sodium Chloride Balanced Electrolyte Get rid of all the #s
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Did you know about these crystalloid solutions?
Alkalizing Fluids: Two IV fluids are available when there are excessive bicarbonate losses and metabolic acidosis occurs: 1/6 molar isotonic sodium lactate 5% sodium bicarbonate Alkalizing fluids are used in treating vomiting, starvation, uncontrolled diabetes mellitus, acute infections, and renal failure. Acidifying Fluids: Two fluids are available when there is an excess of bicarbonate and metabolic alkalosis occurs: 0.9% NaCl. Ammonium Chloride Acidifing fluids are used for severe metabolic alkalosis caused by a loss of gastric secretions or pyloric stenosis. Ammonium chloride must be used with caution in patients with severe hepatic disease or renal failure and is contraindicated in any condition in which a high ammonium level is present. Rapid infusion can result in toxicity, causing irregular breathing and bradycardia. .
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Crystalloid Solutions….
Act as a vehicle for medication administration. Provide nutrition. Are useful in the treatment of patients with dehydration.
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The pH of Crystalloid Solutions
Crystalloid solutions may cause vein irritation due to their acidic pH. USP standards require that solution pH must be slightly acidic: (between 3.5 and 6.2). Many solutions have a pH of 5. The acidity of a solution allows it to have a longer shelf life.
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True or False Crystalloid solutions are useful as fluid
expanders and can be stored at room temperature. True False
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Moving on to colloid solutions…
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Advantages of Colloid Solutions
have the same effect as hypertonic crystalloids, but require administration of less total volume. have a longer duration of action than crystalloids. are readily available and have a long shelf life. have no special storage or infusion requirements. have no interference with blood grouping or cross matching. are acceptable to all patients, with no religious objections.
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Colloid Solutions… are substances whose particles, when submerged in a solvent, cannot form a true solution because their molecules cannot dissolve. have particles which remain suspended and distributed in the fluid. are also known as plasma volume expanders.
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Colloid Volume Expanders
Dextran Albumin Hetastarch Mannitol
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Dextran IV solutions with Dextran function both as volume expanders and means of parenteral nutrition. Dextran can be used when blood or blood products are not available. When using Dextran, keep in mind: Anaphylactoid reactions can occur. There is an increased risk of bleeding. Dextran is contraindicated in patients with severe bleeding disorders, congestive heart failure, and renal failure. It is important to draw blood for typing and cross-matching before administering dextran. Wikipedia-Dextran
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Albumin Albumin is a natural plasma protein prepared from donor plasma. Albumin maintains electrolyte balance, improves cardiac output & promotes diuresis in the presence of edema.
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Saline versus Albumin Fluid Evaluation (SAFE) Study
may precipitate allergic reactions: (urticaria, flushing, chills, fever, or headache). may cause circulatory overload and/or pulmonary edema. may alter laboratory findings. Evidence-Based Care Saline versus Albumin Fluid Evaluation (SAFE) Study One of the largest prospective multicenter, double blind controlled trial clinical studies, the SAFE trial, randomized a heterogenous group of 7000 critically ill patients requiring fluid resuscitation to receive either iso-oncotic albumin or isotonic saline solution. The study provides evidence that albumin and saline should be considered equivalent treatments for intravascular volume resuscitation. *Finfer, S., Bellomo, R., Boyce, N., et al. (2004). A comparison of albumin and saline for fluid resuscitation in the intensive care unit. New England Journal of Medicine, 350,
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Hetastarch… is a synthetic colloid which expands the plasma and is used in shock precipitated by hemorrhage, trauma, burns and sepsis. is not derived from donor plasma. does not interfere with blood typing and crossmatching. is less toxic, less expensive. may cause anaphylactoid reactions. should be used cautiously in patients whose conditions predispose them to fluid retention. is available under the name Hespan.
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Things to keep in mind when administering Hetastarch…
Use immediately (no preservatives). Monitor for signs of hypervolemia, circulatory overload and pulmonary edema. Assess for adequate tissue perfusion. Observe for S&S of anaphylaxis.
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Mannitol: Osmotic Diuretic
Advantages: Used to promote diuresis in patients with oliguric acute renal failure Promotes excretion of toxic substances in the body Reduces excess cerebrospinal fluid (CSF) Reduces intraocular pressure, intracranial pressure and cerebral edema Administration can reduce excess CSF within 15 minutes Disadvantages: Fluid & Electrolyte imbalances may be severe May induce dehydration Irritating to the vein intima; may cause phlebitis Extravasation of mannitol may lead to skin irritation and tissue necrosis May interfere with laboratory tests
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To Summarize… Can you explain the difference between crystalloids and colloids?
Crystalloids: Solutions that are considered true solutions and whose solutes, when placed in a solvent, mix, dissolve, and cannot be distinguished from the resultant solutions. Crystalloids are able to move through membranes. Examples: Dextrose, Sodium Chloride, and balanced electrolyte solutions. Colloids: Substances whose particles, when submerged in a solvent, cannot form a true solution because their molecules cannot dissolve, they remain suspended and distributed in the fluid. Examples are dextran, albumin, manitol and hetastarch.
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What would you do? You find your patient bleeding profusely
from a surgical site, he has COPD and he has a Blood Management consult. Which of the following fluids would be recommended? Lactated Ringers Albumin 2 Units RBCs
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What does osmosis have to do with IV therapy?
What is OSMOSIS? The movement of solvent molecules through a selectively permeable membrane into a region of higher solute concentration aiming to equalize the solute concentration on the two sides. What does osmosis have to do with IV therapy?
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Osmosis & IV Therapy… Tonicity is the osmotic pressure or tension of a solution, usually relative to that of blood. The tonicity of the IV fluid affects osmotic pressure. Osmosis governs the movement of body fluids between the intracellular and extracellular fluid compartments. Crystalloid solutions are rated according to their comparative tonicity to plasma.
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Administration of IV fluid is guided by the tonicity of the solution and falls into 3 categories:
Isotonic Hypertonic Hypotonic
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Isotonic Solutions A solution is isotonic when the concentration of dissolved particles is similar to that of plasma. These solutions exert the same osmotic pressure as that found in plasma. An infused isotonic solution does not move into cells—no net movement of water. Isotonic solutions do not change cell volume.
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Isotonic Solutions 0.9% Sodium Chloride solution (normal saline)
Lactated Ringer's solution Dextrose 5% in water (D5W)
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0.9% Sodium Chloride: Isotonic
Simply salt water, often called “normal saline solution” Used in fluid volume deficit from hemorrhage, severe vomiting, or diarrhea Conditions commonly treated with 0.9% NaCl include shock, mild hyponatremia, metabolic acidosis and hypercalcemia Good for patients requiring a fluid challenge Fluid of choice for resuscitation Only fluid used with blood transfusion
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Lactated Ringer’s: Isotonic
Also known as Ringer’s Lactate or Hartmann solution. Most physiologically adaptable fluid, its electrolyte content is most closely related to the composition of the body’s blood serum and plasma. Fluid of choice for resuscitation in patients with burn injuries. Lactated Ringer’s is often administered to patients with metabolic acidosis.
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Lactated Ringer’s… Metabolized in the liver, which
converts the lactate to bicarbonate. Not recommended for patients who cannot metabolize lactate. Not recommended for patients with liver disease, renal failure, nor patient’s in lactic acidosis.
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Ringer’s solution: Isotonic
Fluid & electrolyte replenisher Does not contain lactate, nor have the contraindications related to lactate Used instead of Lactated Ringer’s when the patient has liver disease and cannot metabolize lactate. Can be used to treat any type of dehydration Not indicated for patients with metabolic acidosis
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Now You Know… Lactated Ringer’s and Ringer’s Solution are two different fluids.
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Dextrose & Water: Isotonic
Dextrose in water is basically a sugar water solution: 170 calories/liter. Dextrose is absorbed into the cells and used for energy. Free water is left to expand both the extracellular and intracellular compartments simultaneously.
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Don’t Use D5W… for resuscitation, because the solution will not remain in the intravascular space. to treat fluid volume deficit because it dilutes plasma electrolyte concentrations. in the early post-op period, because the body’s reaction to the surgical stress can cause an increase in antidiuretic hormone secretion. Although it supplies some calories, D5W does not provide enough nutrition for prolonged use.
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Nursing Considerations for Isotonic Solutions
Patients being treated for hypovolemia can quickly develop hypervolemia if the infusion is rapid. Document baseline vital signs, edema status, lung sounds, and heart sounds before the start of the infusion. Monitor for signs & symptoms of hypervolemia (fluid overload). Fluid overload will be discussed in detail later in this program under complications of IV therapy. IV Fluids what nurses need to know article
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Hypertonic Solutions Hypertonic solutions exert a higher osmotic pressure than that of blood plasma. Administration of this fluid increases the solute concentration of plasma, drawing water out of the cells and into the extracellular compartment to restore osmotic equilibrium; cells will then shrink. Hypertonic solutions are used as volume expanders.
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The following are Hypertonic Solutions
D5W in 0.45% NaCl D5W in 0.9% NaCl Dextrose 10% in water Dextrose 20% in water Dextrose 50% in water 3% or 5% sodium chloride solution D5W in lactated Ringer's solution
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Hypertonic Dextrose and NaCl Solutions
D5W in 0.45% NaCl and D5W in 0.9% These solutions help replace nutrients and electrolytes. These solutions can be used in place of plasma expanders.
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Hypertonic Dextrose Solutions
10%, 20%, and 50% Dextrose solutions provide nutrition, calories , and free water. 20% dextrose in water is an osmotic diuretic. 50% dextrose in water can be administered rapidly to treat severe hypoglycemia.
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Hypertonic Saline Solutions
Contain a higher concentration of sodium and chloride than that normally contained in plasma. As the sodium level in the bloodstream rises, osmosis occurs, removing fluid from the intracellular space and shifting it into the intravascular and interstitual spaces.
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Nursing Considerations for Hypertonic Solutions
Potential for causing intravascular fluid volume overload and pulmonary edema Monitor serum electrolytes and assess for signs and symptoms of hypervolemia Some hypertonic solutions are contraindicated in patients with cardiac or renal disease because of the increased risk of CHF Can cause irritation, damage, and thrombosis of the blood vessel
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Hypotonic Solutions Hypotonic solutions exert less osmotic pressure than that of blood plasma. Administration of this fluid generally causes dilution of plasma solute concentration and forces water to move into cells to reestablish intracellular and extracellular equilibrium; cells will then expand or swell.
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Hypotonic Solutions Cause fluid to shift from the intravascular space to both the intracellular and interstititial spaces. These solutions will hydrate cells but may also deplete fluid within the circulatory system. Provide free water, sodium, and chloride and replace natural fluid losses.
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The following are Hypotonic Solutions
0.45% NaCL 0.33% NaCl 0.22% NaCl 2.5% dextrose in water
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Uses for Hypotonic Solutions
Hypotonic solutions assist with maintaining daily body fluid requirements Contain no electrolytes (except Na & Cl) Contain no calories Hypotonic saline solutions also help the kidneys excrete excess fluids and electrolytes
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Nursing Considerations for Hypotonic Solutions
Used to treat diabetic ketoacidosis. Use caution, the decrease in vascular bed volume can worsen existing hypovolemia and hypotension and cause cardiovascular collapse. Geriatric patients may become confused, an indicator of a fluid volume deficit. Do not administer hypotonic solutions to patients who are at risk for increased Intra-Cranial Pressure (ICP); because of a potential fluid shift to the brain tissue, this can increase cerebral edema. Do not use on patients with liver disease, trauma, or burns due to potential for depletion of intravascular fluid volume.
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Isotonic, Hypertonic, & Hypotonic
In summary, fluid generally moves toward the area with a higher solute concentration because it has a lower water concentration…
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Choose the Best Solution
Which type of solution would you choose for a patient to help the kidneys excrete excess fluids & electrolytes? a. Hypotonic b. Hypertonic Which isotonic solution is commonly used to treat mild hyponatremia, metabolic acidosis and hypercalcemia? a. D5W b. Lactated Ringer’s c. 0.9% NaCl
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Complications of IV Therapy
Local Complications: At or near the insertion site or as a result of mechanical failure. Air Embolism Hematoma Infiltration Thrombosis Phlebitis Thrombophlebitis Extravasation
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Air Embolism Causes A greater risk exists in central venous lines, when air enters catheter during tubing changes (air sucked in during inspiration due to negative intrathoracic pressure) Air in tubing delivered by IV push or infused by infusion pump Clinical Manifestations Patient complains of palpitations, lightheadedness, weakness Dyspnea, cyanosis, tachypnea, cough, pulmonary edema Weak, thready pulse, tachycardia, substernal chest pain, hypotension Changes in mental status, loss of consciousness, anxiousness
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Air Embolism Preventive Measures Nursing Interventions
Clear all air from tubing before infusion to patient. Change solution containers before they run dry. Ensure that all connections are secure. Always use luer-lock connections on central lines. Use precipitate and air-eliminating filters unless contraindicated. Change IV tubing during expiration. Nursing Interventions Immediately turn the patient on his left side and lower the head of the bed; in this position, air will rise to right atrium. Notify the health care provider immediately. Administer oxygen as needed. Reassure the patient. Document interventions and assessments.
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Hematoma Formations resulting from the infiltration of blood into the tissues at the venipuncture site. Causes: Nicking the vein during an unsuccessful venipuncture attempt Discontinuing the IV cannula or needle without pressure Applying a tourniquet too tightly above a previously attempted venipuncture site Can be a starting point for other complications: thrombophlebitis and infection
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Hematoma - Prevention & Treatment
Apply tourniquet just before venipuncture Use a small needle in the elderly and patients on steriods Use a blood pressure cuff to apply pressure Be gentle Treatment Apply direct, light pressure for 2-3 minutes after needle removed Have patient elevate extremity Apply ice Documentation
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Infiltration Causes: Puncture of the distal vein wall during access
Puncture of the vein wall by mechanical friction Dislodgement of the catheter from the intima of the vein Poor securement High delivery rate
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Second to phlebitis as a cause of IV therapy morbidity!
Infiltration… Signs and Symptoms Coolness of the skin around the site Absence of blood return Taught skin Dependent edema Infusion rate slows Second to phlebitis as a cause of IV therapy morbidity!
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Infiltration…. Preventive Measures
Make sure the IV and distal tubing are secured sufficiently to prevent movement. Splint the patient's arm or hand as necessary. Check the IV site frequently for complications. Nursing Interventions Stop infusion immediately and remove the IV catheter. Restart the IV in the other arm. If infiltration is moderate to severe, apply warm, moist compresses and elevate the limb. Document Interventions and Assessments Lippincott Mynet
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Thrombosis Trauma to the endothelial cells of the venous wall causes red blood cells to adhere to the vein wall and form a clot. This clot is referred to as a thrombosis.
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Thrombosis… Signs and Symptoms Prevention Treatment Document
Infusion site pain Slowed or stopped infusion rate Inability to flush Prevention Use pumps and controllers to manage flow rate Avoid areas of flexion Avoid lower extremities Treatment Never flush a cannula to remove an occlusion Discontinue the cannula Notify the physician and assess the site for circulatory impairment Document
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Phlebitis: Inflammation of a Vein
Mechanical: Catheter size too large for the size of the vein Manipulation of the catheter: improper stabilization Chemical: Vein becomes inflamed by irritating or vessicant solutions or medication The more acidic the IV solution the greater the risk
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Phlebitis… Signs and Symptoms Prevention Redness at the site
Site warm to touch Local swelling Palpable cord along the vein Sluggish infusion rate Elevated temperature Prevention Use larger veins for hypertonic solutions A central line may be considered for long-term infusions.
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Chemical Phlebitis
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thrombosis and inflammation
Thrombophlebitis Thrombophlebitis denotes a twofold injury: thrombosis and inflammation Causes include: Clot formation at the end of the needle or catheter due to slow infusion rates. Irritation to vein due to rapid infusions or irritating solutions (hypertonic glucose solutions, cytotoxic agents, strong acids or alkalis, potassium, and others). Smaller veins are more susceptible.
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Thrombophlebitis Signs and Symptoms: Sluggish flow rate
Edema in the limbs Tender and cord like vein Site warm to the touch Visible red line above venipuncture site Diminished arterial pulses Mottling and cyanosis of the extremities
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Thrombophlebitis Preventive Measures
Anchor the catheter securely at the insertion site. Change the insertion site every 96 hours in adult patients. IV sites started during an emergency situation must be changed as soon as the patient’s condition stabilizes or within 24 hours. This includes IVs initiated prehospital by paramedics “in the field”. Use large veins for irritating fluid because of higher blood flow, which rapidly dilutes the irritant. Sufficiently dilute irritating agents before infusion. Nursing Interventions Apply cold compresses immediately to relieve pain and inflammation. Follow with moist, warm compresses to stimulate circulation and promote absorption. Document Interventions and Assessments
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Extravasation Inadvertent administration of a vesicant solution into surrounding tissue: A vesicant is a fluid or medication that causes the formation of blisters, with subsequent sloughing of tissues occurring from the tissue necrosis Extravasation can be caused by: - Puncture of the distal wall - Mechanical friction - Dislodgement of the catheter
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High concentration of KCL
Examples of Vesicants Fluid/Medication pH Phenergan 4-5.5 Dilantin 12 High concentration of KCL 5-7.8 Calcium Gluconate 6.2 Dopamine 2.5-5 Nipride 3.5-6 10%, 20% or 50% Dextrose Sodium Bicarbonate 7-8.5 Drano 14
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Phenergan Phenergan is a very dangerous medication to be administered peripherally. If it comes in contact with an artery it will cause arterial necrosis. The medication package insert advises that the IM route is best, and gives serious caution to IV administration. Most patients can tolerate this medication rectally. Currently there is a high incidence of litigation related to peripheral IV administration of phenergan and resultant damage to vessels and tissue.
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Dilantin Dilantin has a very high pH, and should be given in a central line through a dedicated port. Administration of ANY other medication or fluid through that port increases the risk of precipitation and line occlusion.
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Extravasation
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Extravasation Signs and Symptoms: Complaints of pain or burning
Swelling proximal to or distal to the IV site Puffiness of the dependent part of the limb Skin tightness at the veinpuncture site Blanching and coolness of the skin Slow or stopped infusion Damp or wet dressing
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Extravasation Prevention: Use of skilled practitioners
Knowledge of vesicants Condition of the patients veins Drug administration technique - Should this medication be administered through a central line?
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Systemic Complications
Septicemia Circulatory Overload and Pulmonary Edema
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Septicemia Risk Factors
Definition: Febrile disease process that results from the presence of microorganisms in the circulatory system. Risk Factors Patient risk factors: Age, underlying illness, presence of other infectious processes Infusion factors: Solution container, stopcocks, catheter material, insertion site, and duration of cannulation Practitioner-related factors: Lack of handwashing, break in sterile technique, inadequately prepared insertion site and repeated manipulation of infusion system
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Septicemia… Signs & Symptoms: Fluctuating fever Profuse, cold sweat
Nausea, vomiting Diarrhea (sudden & explosive) Abdominal pain Tachycardia Change in mental status Hypoxemia-measured by ABGs Urine output less than 30cc/hr Elevated WBC
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Septicemia… Treatment: Consult the physician.
Restart new IV in opposite extremity if a peripheral IV is in place. Obtain cultures from the administration set, container, and catheter tip site as well as patient’s blood. Administer antibiotics, fluid replacement, vasopressors, and oxygen as prescribed. Monitor the patient closely. Transfer to ICU if necessary.
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Fluid Overload and Pulmonary Edema
Circulatory overload is caused by infusing excessive amounts of isotonic or hypertonic crystalloid solutions too rapidly. Fluids infused too rapidly increase venous pressure and lead to pulmonary edema. Patients at risk for pulmonary edema are those with cardiovascular disease, those with renal disease, and elderly patients.
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Signs & Symptoms of Fluid Overload
Restlessness, headache Increased pulse rate Weight gain over a short period of time Cough Presence of edema Hypertension Hypoxia, with severe respiratory distress Oxygen saturation less than 90% on room air Wide variance between intake and output Shortness of breath and crackles in lungs Distended neck veins
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Treatment for Fluid Overload
A Swan-Ganz catheter may be placed to evaluate cause of pulmonary edema Consult Physician for drug therapy: Lasix: to cause vasodilation and decrease pulmonary congestion. Thiazide diuretics: to treat CHF. Nitroprusside or nitroglycerin: to decrease pulmonary vascular pressure. Morphine sulfate: to cause venous dilation Aminophylline: to control wheezing.
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Nursing Interventions for Fluid Overload
Provide oxygen therapy. Position patient in semi-Fowler position. Obtain daily weight to monitor fluid status. Measure I & O. Use microdrip for IV fluid administration. Keep the patient warm to promote peripheral circulation. Monitor vital signs.
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Fluid Overload… Preventive Measures
Know whether patient has existing heart or kidney condition. Be particularly vigilant in the high-risk patient. Closely monitor the infusion flow rate. Keep accurate intake and output records. Monitor closely for worsening condition. Raise the patient's head to facilitate breathing. Document interventions and assessments.
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To summarize Complications of IV Therapy…..
1. Is an air embolism a local or systemic complication? a. Local b. Systemic 2. Signs & symptoms of fluid overload include which of the following? a. SOB, crackles in lungs b. Distended neck veins c. Restlessness d. Hypertension
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Now You Know… The nurse must be knowledgeable about the contents of parenteral fluids, their purposes, actions on the body and the complications that may occur. Each IV fluid has a unique contribution to fluid and electrolyte balance. Understanding the desired effects is important to enable the practitioner to monitor for pertinent side effects. IV fluids are prescribed medications; their potential for complications should not be considered lightly. This has been a review of the many types of Intravenous fluids you may administer and the nursing care involved with doing it safely.
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Reference List Belz, D. (2004). Fluid Therapy. Retrieved August 5, 2011, from Complications of Intravenous Therapy. (2011). Retrieved August 5, 2011 from, Cook, L. (2003). IV fluid resuscitation. Journal of Infusion Nursing, vol26 (5), pp Crawford, A., Harris, H.(2011). I.V.fluids:What nurses need to know.Nursing 2011, vol41, pp30-38. Intravenous Fluid Selection. (2005). Retrieved August 5, 2011 from, Phillips, L. (2010). Manual of I.V. therapeutics. (5th Ed). Philadelphia, PA: Davis Weisbein, J. (2005). Introduction to IV Therapy. Retrieved August 5, 2011 from
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Posttest and Continuing Education Certificate
Once you have completed this PowerPoint program please exit the PowerPoint and complete the associated posttest. You can print a certificate for 1 continuing education hour if you achieve at least an 84% on the posttest. You may take the posttest more than once if needed. Completion of this program will be recorded automatically in the St. Luke’s EduTracker System. A reminder for RNs… Completion of an educational program can only be used one time in a 2 year license renewal cycle.
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Thank you for completing the Intravenous Therapy for Nurses program!
Contact Maryann Kipila, MSN, RNC, at in Educational Services with any questions.
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