intravenous catheters and IV medication administration

advantages to IV therapy

rapid distribution into bloodstream

rapid onset

no drug loss to tissues

less irritation to subcut and muscle tissue

disadvantages to IV therapy

circulatory fluid overload

immediate absorption means no time to correct errors

IV administration can cause irritation to lining of veins

failure to maintain surgical asepsis can lead to local infection and septicemia

reasons for IV replacement of fluids

• physiologically unstable

  • trauma, sevre blood loss, surgery - can't drink for themselves, cancer

• mechanical obstruction of GI tract

  • cant absorb so need stuff through IV to get vitamins absorbed

• severe nausea

  • pregnancy, chemo, food poisoning

• high risk for aspiration

  • pneumonia

  • risk of drinks going to lungs instead of tummy

• impaired swallowing

  • stoke, paralysis, severe cough

  • risk of drinks going to lungs instead of tummy

The two types of vascular acceess devices are

• peripheral IV

• Central line

peripheral IV

• over-the-needle catheter

• short term use

• covers us so we can give you something if things go south fast, will give u no matter what at hospital

• typically in arm/hand

• fluid replacement

• intermittent antibiotics/ medications

central line

• central = location of catheter tip

• can be in neck

• long term use

• pt. can go home w them depending on type

• large volumes of fluid medications that irritate the veins

• TPN

  • total parenteral nutrition

  • food through IV

• still risk for infection

• can tolerate any type of fluid

• can draw labs from this so we don’t have to stick them multiple times

non-tunneled uses

ex: picc line, int/ext jugular or femoral

• percutaneously inserted

• short=term use

• for continuous PICC lines, assess every 4 hours during waking hours f

non-tunneled advantages

• preserves peripheral veins

• multiple lumens

• can be used for all tyoes of U therapies

• can be used for blood sampling

• non tunneled =

  • picc lines (peripherally inserted central canal)

    • 15 inches

    • goes to central veins just outside heart typically SVC

    • can go into right atrium and cause dysrhythmias - this is why they do an x-ray for placement

  • Int/ext jugular and femoral (SVC and IVC)

    • femoral not good bc hygiene, movement, kinks

non-tunnedled disavantages

• highest risk for infection

• greater risk of insertion complications

  • ex: pneumothorax

• not long term

• easily dislodged

• femoral site = greatest risk infection

tunneled uses

• tunneled under skin into vein

• ex: hickman, broviac

• cuff anchors catheter

  • inflates under skin

• long term (months to years)

  • ex: dailysis, TPN

tunneled advantages

• reduces risk of infcetion

• self care by patient

• no dressing needed once healed

tunneled disadvantages

inserted in the OR via fluoroscopy

cost

have to be inserted and removed in OR by a physician not nurse

provider must remove

look up why diff ones are better for diff pt. based on lifestyle

implanted uses

• examples: port-a-cath

• long=term, often intermittent use (months-years)

• can be permanent

  • don’t have to do anything once it heals

  • ex: good for kids in chemo so they can have a lifestyle and swim play etv

• also needs to be inserted by a physician in the OR

implanted advantages

• internal device, no dressing

• unrestricted activity

• decreased risk of infection

implanted disadvantages

• surgical procedure required for implantation

• cost

• requires needle for access (non-coring)

• remember to give heparin right before you remove

infection control - CLABSI

• central-line associated bloodstream infection

• EBP “bundle” used when starting and maintaining central lines

  1. hand hygiene

  2. maximum skin barrier precautions

  3. chlorhexidine skin antisepsis

  4. place under controlled conditions

infection control - ANTT

• aseptic non-touch technique

• makes sure aspetic sites arent touches directly or indirectly

• used when starting PIV (peripheral intravenous) and maintenance

• standard precautions + protect VAD (vascular access device) site and equipment

factors to consider

• choose VAD with least amount i riskreplacements

• minimzie pt/ disconfort morbidity and mortality

• dec, pt/health minimize impat to dfults

gather supplies

• IV catheter

  • choose appropiate size

  • larger # - smaller needle

• IV start kit

  • tegaderm

  • tourniquet

  • chlorhexidine scrub/alcohol

  • gauze

  • tape

• gauze

• extension set (tubing)

• normal saline flush

14g IV gage

• orange

• trauma, rapid infusion

16G

• grey

• trauma, surgery

18G

green

blood transfusions

20G

pink

IV fluids and medications

22G

Blue

Iv fluids, small veins

24G

yellow

fragile veins, pediatrics

26G

purple

neonates

make sure ur looking at nedle part chart in slides

most common puncture site

• foremarm

• more distal first

avoid what when indentifying puncture site

• avoid

• areas of inflammation

  • so bacteria doesn’t go into body

• area of infiltration

  • aka when vein leaks into tissue

  • makes hard to see veins

• area of phlebitis

  • inflammation of vein

  • vein alr irritated, if u inject and make more irritated can inc. chance of blood clot

• arm w dialysis fistula

  • is where artery and vein is sewed together and very turbulent

  • don’t wanna accidentally infect injured area w fistula is bc dialysis is necessary to live

• same side as mesectomy

  • breast removal, avoid that arm

  • bc there’s less lymphatics and circ. system

  • meds wont be distributed well

• area of flexion

• hand if possible

initiating IV therapy

skill 42.1 pg. 1077

• check MD orders

• identify pt. w 2 identifier

• confirm allergies

• perform hand hygiene

• use sterile technique to open packages

• place tourniquet 4-5inches above insertion site

• cleanse sit for 30 sec. and let AIR DRY

• BEVEL UP

• keep all connections to sterile

• occlusive dressing to visualize insertion site

needle stick prevention

• be familiar w IV equipment, needles and syringe equipment

• avoid using needles when needless systems r available

• use protective safety devices

• dispose immediatly in appropiate recepticale s

• dont break, bend, or recap needles

IV infusion

CONTROL RATE

• not too fast

  • pulmonary edema

  • fluid overload

• not too slow

  • dont get therapuedic effects if too slow depending on sit.

REPLACE TUBING

• primary

  • 96hrs

• secondary

  • 24 hrs

• TPN/lipid tubing

  • 24 hrs

• blood tubing

  • high risk of revervior

  • 4 hours

move IV site every

7 days

go back and fill out definitions for key terminology on slides ******

electronic infusion device

• single and multichannel pumps

• tubing is specific to pump and cartidge fits into the door

• attach to rolling pole for mobility/ easy ambulation

• use the drug library embedded in the pump - they are guardrails for safety - USE THEM

• set the rate (ml/hr)

• consider compatibilities between primary and secondary IVF

• KVO/TKO

  • keep vein open

  • low rate

• Bolus?

primary tubing

main line that connects IVF to pt.

administers larger amnts fluid (1L/1000mL)

can be used 96hrs - 7days

remove cap and spike the IVF bag, squeeze chamber to fill w fluid, then open roller clamp to prime tubing

intermittent secondary tubing

• higher bag will be the one that flows bc of gravity

• allows for admin of meds that are stable for a limited tim e

• uses smalm amounts of compatible fluid 50-100mL

• attatched at Y site above pump

the 7 rights of medication admin

• IV IS ORDERED

  1. right person

  2. right medication

  3. right dose

  4. right time

  5. right route

  6. right reason

  7. right documentation

continuous IV infusion example

• D5 ½ NS + 20 mEq @ 125ml/hr

  • will run continuously until ordered to stop

• D5 ½ NS + 20 mEq @ 125ml/hr x 1L

  • stop after liter is done

intermittent IV infusion - IVPB or secondary example

• Ampicillin 250mg in 250ml NS IVPB every 8 hours

  • hang until its done, do again after 8 hours

Direct IV drug injection IVP

• small amount

• administered via syringe push - slowly

  • KNOW RATE OF ADMIN

• know recommened diluent

• ex; morphine sulfate 2mg IVP prn severe pain

add-vantage system

• secondary IV

• nurse prepares IV med

• nurse activates powder medication immediatly before dose

• know eqipment/devices

IV bolus/push IVP

• introduces aa concentrated dose of medication diretly into systemic circulation

• this is most dangerous method

• conform placement of IV line is a healthy site

• determine rate if admin by the amount of medication that can be given each minute, consider diluting small volumes

• FLUSH MED FLUSH

saline lock

• intermittent venous access

• inc. mobility, safety, and comfort for the pt.

• before admin

  • assess the patency and placement of IV site

  • phlebitis or infiltration

  • flush w normal saline to maintain patency Q8h

  • flush w NS before and after meds

direct IVP precautions

• always verify compatibility of solution and drug

• consider length of the injection port on the tubing from the site

  • how much to flush?

• tubing needs to be flushed after direct IV infusion IVP to ensure that part of the drug has not been left in tubing

• drug dosage is not complete until drug has entered patient

circulatory overload complication

IV solution infused too rapidly or too much

assessment findings:

• pulmonary edema - crackles in dependent part of lungs SOB

• FVO fluid volume overload

• dependent edema

• hyponatremia w hypotonic fluid (confusion and seizures)

• hypernatremia w Na+ containing hypertonic fluid (confusion n seizures)

• hyperkalemia form K+ containing fluid ( dysarhythmias, muscle weakness, abdominal distention)

interventions

• reduce IV flow rate and notify HCP

• w ECV excess, raise head of bed; administer oxygen and diuretics if ordered

• monitor vital signs and labs for serum

• hcp may adjust additives in solution or type of IV fluid

infiltration

IV fluid enters subC tissue around puncture site

assessment findings:

• taut, swelling (edematous), cool and pale (blanched), tender

interventions

• stop infusion and discontinue IV

• elevate extremity

• apply warm, moist, or cold compress according to procedure for solution.

• start new IV in other extremities

extravasation

infiltration into tissue, but what infiltrated is damaging to tissues (vesicant drug)

knowing what med leaked is important for proper treatment

assessment findings:

• taut, swelling (edematous), cool and pale (blanched), tender

interventions

• disconnect tubing

• aspirate drug from catheter

• might have to deliver antidote through catheter before removal

• elevate extremity

• DO NOT APPLY PRESSURE BC CAN FORCE SOLUTION INTO MORE TISSUE

• contact provider

• start new IV in other extremity

phlebitis

inflammation and damage to inner layer vein itself

assessment findings:

redness, swelling, heat

severe = streaking of vein

palpable cord along vein

can be mechanical, chemical, or bacterial

• use scale for assessing

• stop infusion and discontinue IV line

• start IV in other extremity or proximal to that one

• apply warm compress or contact hcp if needs more treatment

• elevate extremity

• document phlebitis

local infection

infection at catheter skin entry point during infusion or after removal

assessment findings

• possible purulent damage

• redness

• swelling

• heat

interventions

• culture drainage if ordered

• clean skin w alcohol

• remove catheter and save for culture

• apply STERILE dressing

• notify hcp

• start new IV line in other extremity

• initiate appropriate wound care

air embolsim

• air in syringe

• goes through venous system and could cause stroke, brain damage

assessment findings

• sudden onset of dyspnea, coughing, chest pain, hypotension, tachycardia. dec. LOC, possible stroke signs

interventions

• cover leak to prevent air from entering system

• place pt. on left side w head of bed raised to trap air in lower left ventricle

• call emergency support team and notify hcp

bleeding at venipuncture site

oozing it slow continuous seepage of blood

assessment findings

• fresh blood at site

• sometimes pools under extremities

interventions

• assess whether IV system intact

• if catheter is within vein, apply pressure dressing over site or change dressing

• start new IV line in other extremity or proximal tp previous insertion site if VAD is dislodged, IV is disconnected or bleeding won’t stop

phlebitis scale 0 and 1

0- no signs of phlebitis; no pain erythema, swelling or palpable cord around insertion site

1- possible sign of phlebitis

• pain but no erythema, swelling or palpable cord around insertion site

INTERVENTION = observe intervention site

phlebitis scale 2

early signs of phlebitis

• pain with erythema and or swelling

• no palpable cord around insertion site

INTERVENTION= remove the catheter

phlebitis scale 3

medium stage of phlebitis

• pain, erythema, swelling. hardening or palpable venous cord <6cm around insertion site

INTERVENTION

• remove catheter and asses treatment

phlebitis scale 4

advanced stage if phlebitis

• pain, erythema, swelling, hardening, or venous cord <6cm around the inseertion site and or purulence

INTERVENTION

• remove the catheter and assess treatment

phlebitis stage 5

thrombophlebitis

• frank venous thrombosis with all signs and difficult or halted infusion

• pain, erythema, swelling, hardening, or venous cord <6cm around the insertion site and or purulence

INTERVENTIONS

• remove catheter and start treatment

preventing phlebitis

• asepsis

• avoid manipualtion of canula

• know infusion medication and irritation risks

home IV therapy

typically pt. have central venous catheter

home care nurses assist with monitor

carefully assess pt. and their family to determine their ability to manage therapy at home

teach family and patient:

• to recognize signs of infection and complications

• when to notify the health care provider

• maintenance of equipment

assess VAD site every visit

caregiver or pt. check site w each infusion or at least daily