skills iv therapy fluid

Maintaining Fluid and Electrolyte Balance:  Fluid is internal and surrounds all the cells in the body. Cellular fluids contain electrolytes such as sodium and potassium and also have a degree of acidity. Fluid, electrolyte, and acid-base balance within the body maintain the health and function of all body systems. The characteristics of body fluids influence body system function because of their effects on cell function. HOMEOSTASIS is the balance of fluid, electrolytes, acids and bases.

How Does This Relate? -Your body is always working to maintain equilibrium through the following regulation mechanisms:

The kidneys - The lungs- The skin- and the pituitary gland. If any of these regulating systems are interrupted, part of the treatment will require IV electrolyte therapy.

-The characteristics of body fluids influence the body system functioning because of the effects on cell functioning.

-It is important to understand how the body normally maintains fluids, electrolytes, and acid-base balance.

Fluid Balance:Fluid homeostasis is the dynamic interplay of three processes: (1) fluid intake and absorption, (2) fluid distribution, and (3) fluid output. To maintain fluid balance, fluid intake must equal the output. Fluid intake occurs oral through drinking but also through eating because most foods contain some water.

The term fluid distribution means the movement of fluid among various compartments.

Fluid distribution between the extracellular and intracellular compartments occurs by osmosis.

Fluid distribution between the vascular and interstitial parts of the ECF occurs by filtration.

Fluid output occurs through 4 organs: the skin, lungs, GI tract, and kidneys. Examples of abnormal fluid output include vomiting, wound drainage, or hemorrhage. Insensible loss (not visible; Invisible = Insensible the “in’s” go together) water loss through the skin and lungs is continuous. It increases when a person has a fever or a burn to the skin. Sensible fluid loss is by urine and defecation. The average adult normally excretes only 100 mL of fluid each day through feces.

Healthy Adult’s  average Fluid INTAKE - Fluid Intake occurs orally through drinking but also through eating because most foods contain some water. Food metabolism creates additional water. Average fluid intake from these routes for healthy adults is about 2300 mL, although this amount can vary widely depending on exercise habits preferences and the environment. Other routes of fluid intake include IV , rectal (for examples enemas) and irrigation of body cavities that can absorb fluid.

Healthy Adult’s Average Fluid OUTPUT -Fluid output normally occurs through four organs: the skin, lungs, GI tract and kidneys. Examples of abnormal fluid loss include vomiting, wound drainage or hemorrhage.   urine output varies widely, depending on fluid intake.

 Insensible loss IS NOT VISIBLE water loss as through the skin and lungs and it is continuous. The GI tract plays a vital role in fluid balance. Approximately 3 to 6 Liters of fluid moves into the GI tract daily and returns to the ECF or extracellular fluid.

Key Terms:  Fluid that contains a large number of dissolved particles is more concentrated than the same amount of fluid that contains only a few particles.

Osmolality of a fluid is a measure of the number of particles per kilogram of water. Some particles pass easily through cell membranes; others such as sodium can not cross easily. The particles that cannot cross cell membranes easily determine the  effective concentration of a fluid. A fluid with the same tonicity as normal blood is called isotonic. A hypotonic solution is more dilute than the blood, and a hypertonic solution is more concentrated than normal blood.

Fluid Imbalances:  If disease process, medications, or other factors disrupt fluid intake or output, imbalances sometimes occur. For example, with diarrhea there is an increase in fluid output, and a fluid imbalance (or dehydration) occurs if fluid intake does not increase appropriately. There are two major types of fluid imbalances: volume imbalances and osmolality imbalances. (1) Volume imbalances are disturbances of the amount of fluid in the extracellular compartment. (2) Osmolality imbalances are disturbances of the concentration of body fluids. Volume and osmolality imbalances can occur separately or in combination.

In an Extracellular Volume or ECV imbalance, there is either too little or too much isotonic fluid. Extracellular volume deficit is present when there is insufficient isotonic fluid in the extracellular compartment. Remember that there is a lot of sodium in normal ECF. With ECV deficit, output of isotonic fluid exceeds intake of sodium -containing fluid. Because Extracellular Fluid (ECF) is both vascular and interstitial, signs and symptoms arise from lack of volume in both of these compartments.

Extracellular Fluid Volume Excess occurs when there is too much isotonic fluid in the extracellular compartment. Intake of sodium-containing isotonic fluid has exceeded fluid output. For example, when you eat more salty food than usual and drink water, you may notice that your ankles swell or rings on your fingers feel tight and you gain 1 kg (2 lbs) over night. These are manifestations of mild ECV excess.

In an osmolality imbalance, body fluids become hypertonic or hypotonic, which causes osmotic shifts of water across cell membranes. The osmolality imbalances are called hypernatremia and hyponatremia.

Hypernatremia, also called a water deficit, is a hypertonic condition. Two general cause make body fluids too concentrated: loss of relatively more water than salt, or gain of relatively more salt than water. When the interstitial fluid becomes hypertonic, water leaves cells by osmosis, and they shrivel. Signs and symptoms of hypernatremia are those of cerebral dysfunction, which arise when brain cells shrivel.
Hyponatremia, also called water excess or water intoxication, is a hypotonic condition. It arises from gain of relatively more water than salt or loss of relatively more salt than water. The excessively dilute condition of interstitial fluid causes water to enter cells by osmosis, causing the cells to swell.

ECV deficit and hypernatremia often occur at the same time; this combination is called clinical dehydration. The ECV is too low and the body fluids are too concentrated. Clinical dehydration is common with gastroenteritis or other causes of severe vomiting and diarrhea when people are unable to replace their fluid output with enough intake to dilute sodium-containing fluids.

Potassium Imbalances: Hypokalemia is abnormally low potassium concentration in the blood. Common causes of hypokalemia from increased potassium output include diarrhea, repeated vomiting, and use of potassium-wasting diuretics.

Hyperkalemia is abnormally high potassium concentration in the blood. People that have decreased urine output are at high risk of hyperkalemia. It is important to check a patient’s potassium level before administering IV solutions containing potassium. Hyperkalemia can cause muscle weakness, potentially life-threatening cardiac dysrhythmias, and cardiac arrest.

Hypocalcemia is abnormally low calcium concentration in the blood. People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. Hypocalcemia increases neuromuscular activity.

Hypercalcemia is abnormally high calcium in the blood. Patients with some types of cancers such as lung and breast cancers often develop hypercalcemia because some  cancer cells secrete chemicals into the blood that are related to parathyroid hormone. These chemicals can weaken the bones by shifting the calcium inside the bones to the extracellular fluid causing the patient to experience pathological fractures ( bone breakage caused by forces that would not break a healthy bone). Hypercalcemia decreases neuromuscular activity, the most common sign is lethargy.

Hypomagnesemia is abnormally low magnesium concentration in the blood. Signs and symptoms are similar to those of hypocalcemia because hypomagnesemia also increases neuromuscular activity.
Hypermagnesemia is abnormally high magnesium concentration in the blood. End-stage renal disease causes hypermagnesemia unless the person decreases magnesium intake to match the decreased output. Signs and symptoms are decreased neuromuscular activity, lethargy, and decreased deep tendon reflexes being the most common.

Clinical assessment begins with a patient history designed to reveal risk factors that cause or contribute to fluid, electrolyte or acid base imbalance. Ask specific, focused questions to identify factors that contribute to a patient’s potential imbalances. AGE: An Infant’s portion of total body water (70-80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. Older adults experience a number of age-related changes that potentially affect fluid, electrolyte, and acid-base balances.

-Environment:  Hot environments increase fluid output thought sweating. Excessive sweating without adequate replacement of salt and water can lead to ECV deficit, hypernatremia, or clinical dehydration.

-Dietary Intake: Assess dietary intake of fluids; salt; and foods high in potassium, calcium, and magnesium. Starvation diets or those with high fat and no carb content often lead to metabolic acidosis ( see table 42.7 in your book).

- LIFESTYLE: Assess alcohol intake. How many days does a person have an alcoholic drink each week and how many drinks does a person have at one time? Chronic alcohol abuse commonly causes hypomagnesemia, in part because it increases renal magnesium excretion.

- Medications- obtain a complete list of your patient’s current medications, including OTC and herbal preparations, to assess the risk for fluid, electrolyte  imbalance

Surgery causes a physiological stress response which increases with extensive surgery and blood loss. Increased output of fluid through the GI tract is a common and important cause of fluid, electrolyte and acid-base imbalance and requires accurate measurement and assessment. Always note the volume and appearance of any output. Vomiting and diarrhea can cause ECV deficit, hypernatremia, clinical dehydration and hypokalemia. Acute illness or trauma place patients at high risk for fluid, electrolyte and acid-base imbalances. Alterations include respiratory diseases, burns, trauma, and acute renal disease. Many chronic illnesses create ongoing risk of fluid, electrolyte and acid-base imbalances. For example, chronic obstructive pulmonary disease or COPD often causes chronic respiratory acidosis. In addition, treatments for chronic diseases often cause imbalances. The specific fluid and electrolyte imbalances that occur with cancer depend on the type and progression of the disease. Many patients with cancer develop hypercalcemia when the cancer cells secrete chemicals that circulate to bones and cause calcium to enter the blood. Patients with chronic heart failure have diminished cardiac output which reduces kidney perfusion (blood flow through the renal tissue)  and activates the RAAS ( or renin-angiotensin-aldosterone system) which is a critical regulator of blood volume and electrolyte balance. Oliguria occurs when the kidneys have a reduced capacity to make urine. Oliguric renal disease prevents normal excretion of fluid, electrolytes and metabolic acids, resulting in ECV excess, hyperkalemia, hypermagnesemia and metabolic acidosis. The severity of these imbalances is proportional to the degree of renal failure.

Daily weights are an important indicator of fluid status. Fluid gains or losses indicate changes in the amount of total body fluid, usually the ECF,(extracellular fluid)  but do not indicate shift between body compartments. It is important to have the patient void and weigh at the same time each day on the same scale. Measuring and recording all liquid input and output during a 24 hour period is an important part of fluid balance assessment. Compare a patient’’s 24 hour fluid intake to output. The two measures should be approximately equal if the person has normal fluid balance. Review the patient’s laboratory test results and compare them with normal ranges . The frequency of electrolyte level measurements depends on the severity of a patient’s illness. Analyzing a patient’s lab results requires thorough and extensive scientific nursing knowledge, especially if a person develops an acute imbalance while also having a chronic disease.

Possible nursing diagnoses for patients with fluid, electrolyte, and acid-base imbalance include the following 4 things: Fluid imbalance, Dehydration, Electrolyte imbalance, and Lack of knowledge of fluid regimen. When caring for patients with suspected fluid, electrolyte and acid-base imbalances it is particularly important to use critical thinking to formulate nursing diagnosis. The assessment data that establish the risk for or the actual presence of a nursing diagnosis may be subtle and patterns and trends only emerge when there has been good assessment. - Multiple body systems often are involved. Careful clustering of assessment findings leads to selection of the appropriate diagnoses.

Health Promotion activities focus primarily on patient education, which nurses provide based on a patient’s and family’s health literacy. Use plain language to teach patients and caregivers to recognize risk factors for developing fluid and electrolyte imbalances and implement appropriate preventive measures.

 For example, How would you teach the parents of an infant about fluid imbalance?

 parents of infants need to understand that GI losses quickly lead to serious imbalances; therefore when vomiting or diarrhea occurs in an infant, parents need to promptly rehydrate with sodium-containing fluid and/or seek health care to restore normal balance. People of all ages need to learn to replace body fluid losses with sodium-containing fluid and water, especially during exercise or while spending time outside in hot weather.

Although fluid, electrolyte and acid-base imbalances occur in all settings, they are common in acute care. Acute care nurses administer medications and oral and IV fluids to replace fluid and electrolyte deficits or maintain normal homeostasis: they also help with restricting intake as part of therapy for fluid excesses. Patients with hyponatremia usually require restricted water intake. (p. 1063) Patients who have very severe ECV excess sometimes have both sodium and fluid restrictions. Fluid restriction is often difficult for patients, particularly if they take medications that dry out the oral mucous membranes or if they are mouth breathers. Nurses educate patients and family members to know the amount of fluid permitted orally and understand that ice chips, gelatin and ice cream are fluids. Nurses can help the patient decide the amount of fluid to drink with each meal, between meals, before bedtime and with medications. Parenteral Replacement of Fluids - Fluids and electrolytes may be replaced through infusion of fluids directly into the veins (intravenously) rather than the digestive system. Parenteral replacement includes parenteral nutrition (PN),  IV fluids, and electrolyte therapy (crystalloids), and blood and blood component (colloids) administration.

Fluid balance or fluid homeostasis is composed of three process: fluid intake and absorption, fluid distribution, and fluid output. To aid in promotion fluid and electrolyte balance - patients should:

-consume adequate fluid intake

•Avoid foods with excess salt, sugar, caffeine

•Eat a well-balanced diet

•Limit alcohol intake

•Increase fluid intake before, during, after strenuous exercise

•Replace lost electrolytes

Promoting Fluid and electrolyte balance:  

-Patients’ should also try to maintain normal body weight

-Learn about, monitor and manage side effects of medications

-Recognize risk factors

-Seek professional health care for signs of fluid imbalances

Recognize that fluid imbalances are especially vital in the very young, in older adults and in the critically ill.

Guideline for facilitating fluid intake of pt to help maintain fluid balance •Explain reason for required intake and amount needed

•Establish 24-hour plan for ingesting fluids

•Set short term goals

•Identify fluids client likes and use those

•Help clients select foods that become liquid at room temperature

•Offer ice chips and mouth care

•Supply cups, glasses, straws

•Serve fluids at proper temperature

•Encourage participation in recording intake

•Be alert to cultural implications

Correcting Fluid Imbalances in Patients : Oral replacement to increase fluids may be considered if:

○If client is not vomiting

○If client has not experienced excessive fluid loss

○Has intact GI tract and gag and swallow reflexes

●Restricted fluids may be necessary for Patients with fluid retention. This may:

○Vary widely  from having nothing by mouth to having precise amounts of fluids ordered

○Dietary changes may be required

Enteral and Parenteral Nutrition:   ENTERAL  tube feedings are used with patients who are unable to ingest food, but DO still maintain the ability to digest and absorb nutrients. EXAMPLES: some dementia, Parkinson Disease or stroke patients. PARENTERAL NUTRITION: is used with patients who are unable to digest or absorb Enteral Nutrition. EXAMPLES: Some patients having GI surgery, chemotherapy, or trauma to abdomen.

•Parenteral nutrition- is a form of nutritional support that supplies protein, carbohydrate, fat, electrolytes , vitamins, minerals, and fluids via the IV route to meet the metabolic functioning of the body. PN is IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a patient’s specific needs. Depending on the osmolality, PN solutions are administered through a CVC in cases of high osmolality or  through a peripheral IV line for solutions with Lower osmolality.

• Safe administration depends on appropriate assessment of a patient’s nutritional needs, management of the CVC or IV line to prevent infection, and careful monitoring to prevent any metabolic complications such as glucose monitoring to assess for hyperglycemia.  IV devices are called peripheral IVs when the catheter tip lies in a vein in one of the extremities. They are called central venous catheters (CVCs) or IVs when the catheter tip lies in the central circulatory system. For example: in the vena cava close to the right atrium of the heart.

Clinical Indications of Parenteral Nutrition:  textbook further reviews principles and guidelines for PN administration which is used when patients are unable to receive enough nutrition orally or through enteral feeding. Patients in highly stressed physiological states, such as sepsis, head  injury, or burns are candidates for PN therapy. Please see textbook for further Indications for Enteral and Parenteral Nutrition.•Client cannot tolerate enteral nutrition as in case of paralytic ileus, intestinal obstruction, persistent vomiting.

•Client with hyper-metabolic status as in case of burns and cancer.

•Client at risk of malnutrition because of recent weight loss of > 10%, NPO for > 5 days, and preoperative for severely depleted clients.

The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system., IV therapy requires a health care provider’s order for type, amount and speed of administration of a solution. Three types of solutions are ISOTONIC, HYPOTONIC, and HYPERTONIC. Many prepared IV solutions are available for use.  ISOTONIC solutions have the same effective osmolality as body fluids. Sodium containing isotonic solutions such as normal saline (NS) are indicated for ECV replacement to prevent or treat ECV deficit. HYPOTONIC solutions have an effective osmolality less than body fluids, thus decreasing osmolality by diluting body fluids and moving water into cells. HYPERTONIC solutions have an effective osmolality greater than body fluids. If they are hypertonic sodium containing fluids they increase osmolality rapidly and pull water out of cells causing them to shrivel. The decision to use a hypotonic or hypertonic solution is made by the health care provider on the basis of a patient’s fluid and electrolyte imbalance. Note of caution: When IV fluids are too rapidly or excessively infused there is a potential for serious side effects.  Vascular Access Devices or (VADs) are catheters or infusion ports designed for repeated access to the vascular system.

The purpose of IV therapy is to (1) maintain fluid and electrolyte balance (2) Administer medications (3) transfuse blood and blood products and to (4) Provide parenteral nutrition

⮚Isotonic = Have same effective osmolality as body fluids

⮚Hypertonic = Have an effective osmolality greater than body fluids

⮚Hypotonic = Have an effective osmolality less than body fluids

⮚

 Isotonic solutions have the same effective osmolality as body fluids. Sodium-containing isotonic solutions such as normal saline are indicated for Extracellular (ECV) replacement or ECV deficit

Expand intravascular volume

❖0.9% NaCl (normal saline)

❖Lactated Ringers (LR)

❖Dextrose 5% in Water (D5W)

Draw fluid from cells

❖3% or 5% Sodium Chloride (NaCl)

❖Dextrose 5% in 0.45% NaCl

❖Dextrose 5% in 0.9% NaCl

❖Dextrose 5% in LRHypertonic solutions have an effective osmolality greater than body fluids. If they are hypertonic, sodium-containing solutions, they increase osmolality rapidly and pull water out of cells.  Hypertonic solutions are sometimes used to reduce intracranial pressure.

Hypotonic Solutions which shift fluid into the cells. Hypotonic solutions have a lower osmolality.  Some hypotonic solutions are used to treat cellular dehydration.

Shift fluid into cells

❖0.225% sodium chloride

❖0.45% sodium chloride

This figure presents potential sites for contamination of vascular access devices. An important component of patient care is maintaining the  integrity of an IV line to prevent infection or contamination. Some potential sites for contamination of IV sites are shown here.  Inserting an IV line under appropriate aseptic technique reduces the chances of contamination from a patient’s skin.

 ALWAYS maintain the integrity of an IV system. NEVER disconnect tubing because it becomes tangled or it might seem more convenient for positioning or moving a patient or applying a patient gown. If a patient needs more room to maneuver, use aseptic technique to add extension tubing to an IV line. NEVER LET IV TUBING TOUCH THE FLOOR.

Venipuncture is a technique in which the vein is punctured through the skin by a sharp rigid stylet (for example a metal stylet). The stylet is partially covered either with a plastic catheter or a needle attached to a syringe. General purposes of venipuncture are to collect a blood specimen, start an IV infusion, provide vascular access for later use, instill a medication, or inject a tracer for special diagnostic examine.

. EIDs or Electronic Infusion Devices are also called IV pumps or infusion pumps. Many EIDs have operating and programming capabilities that allow for infusions of single or multiple solutions at different rates. We will be able to use IV pumps in your lab this coming Monday.

After placing an IV line and regulating the flow rate, it is necessary to maintain the system. Line maintenance involves: (1) Using standard ANTT (Aseptic Non Touch Technique) to keep the system sterile and intact (2) Using standard aseptic technique to change IV fluid containers, tubing, and contaminated site dressings (3) helping a patient with site care (4) monitoring for complications of IV therapy. (5) When required it is also necessary to discontinue the peripheral IV access. A very important component of patient care is maintaining the integrity of an IV line to prevent infection.

Patients receiving IV therapy over several days require periodic changes of IV fluid containers. It is important to organize tasks so that you can change containers rapidly before a thrombus forms in a catheter. The changing of IV tubing requires the use of standard ANTT practices. (Aseptic Non Touch Technique. The frequency of a change is based on a patient’s condition and the type, rate, and frequency of solution administered.

 REPLACE primary and secondary CONTINUOUS administration sets used for crystalloid solutions and medications NOT more frequently than every 96 hours BUT at least every 7 days (unless otherwise stated in the manufacturer’s instructions).  In contrast change tubing for INTERMITTENT INFUSIONS every 24 hours because of the increased risk of contamination from opening the IV system. Blood, blood components and lipids are likely to promote bacterial growth in tubing. INS (Infusion Nurse Society) standards suggest tubing changes every 4 hours for blood and blood components and every 24 hours for continuous IV lipids.

Butterfly needles are generally used only for temporary, short term infusions or blood collection and allow venipuncture of thin or fragile veins, as those in the hand or scalp.

A sterile dressing over an IV site reduces the entrance of bacteria into the insertion site. Transparent dressings, the most common type, help secure the VAD, allow continuous visual inspection of the IV site, and are less easily soiled or moistened than gauze dressings.

 A peripheral VAD (Vascular Access Device)  is called an OVER THE NEEDLE CATHETER.  It consists of a small plastic tube or catheter threaded over a sharp stylet (or needle). Once you insert a stylet and advance the catheter into the vein, you withdraw the stylet leaving the catheter in place. These devices have a safety mechanism that covers the sharp stylet when withdrawing it to reduce the risk of needlestick injury.

Starting an Intravenous Infusion: To provide safe and appropriate therapy to patients needing IV fluid apply knowledge of the correct ordered solution, the reason the solution was ordered, the equipment needed, the procedures required to initiate an infusion, how to regulate the infusion rate and maintain the system, how to identify and correct problems, and how to discontinue the infusion•The type and amount of solution to be infused

•The exact amount (dose) to be added to a compatible solution (usually pharmacist prepares)

•The rate of flow or the time over which the infusion is to be completed

Starting a Peripheral IV
Finding a vein can be challenging

•Go by “feel”, not by sight.  Good veins are bouncy to the touch but are not always visible.

•Use warm compresses and allow the arm to hang dependently to fill veins.

•A BP cuff inflated to 10 mm Hg below the known systolic pressure can create a tourniquet. 

•If the patient is NOT allergic to latex, using a tourniquet may provide better venous congestion

•Avoid areas of joint flexion

•Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy

Although veins are found in the same location in most people with only minor variations, certain situations might make it more difficult to find potential venipuncture sites. It takes practice to become proficient in venipuncture. Only experienced practitioners should perform it for patients whose veins are fragile or easily collapse.

IV Start Pain Management
Topical anesthesia cream may be applied to site.

 It might be a good idea to anesthetize a couple of sites.

Make sure the skin surface cleansing agent

(alcohol/chlorhexidine) is dry prior to stick. Drawing  this into the vein may stimulate the vasoconstrictive action of the tunica media layer.

Correct selection and preparation of IV equipment helps in safe and quick placement of an IV line. Because fluids infuse directly into the bloodstream, aseptic technique is necessary. Organize all equipment at the bedside for an efficient insertion. IV equipment  includes: VADs, tourniquet, clean gloves, dressings, IV fluid containers, various types of tubing and EIDs also called electronic infusion pumps.

See Catheter Gauge Sizes.
Use the smallest gauge catheter (with safety mechanism) for short peripheral IV.

Adults: 20 to 24 gauge catheter

Neonantes, children, older adults, adult patients (limited venous options) to minimize insertion related trauma: 22 to 26 gauge catheter

Select a large gauge catheter (for example 20 gauge) for adult and pediatric patients when rapid fluid replacement is required.

As you assess a patient for potential venipuncture sites, consider conditions that exclude certain sites. Venipuncture is contraindicated in a site that has signs of infection, infiltration, or thrombosis. Do not use an infected site because of the danger of introducing bacteria from the skin surface into the bloodstream. Avoid using an extremity with a vascular (dialysis) graft/fistula or on the same side as a mastectomy. Do not use visible veins of the chest, breast, abdomen or other locations on the trunk of the body as there is no evidence supporting their safe outcomes. AVOID AREAS OF FLEXION IF POSSIBLE AND VEINS THAT ARE COMPROMISED. Use the most distal side in the non-dominant arm if possible. Patients with VAD in their dominant hand/arm have decreased ability to perform self-care.

The most common IV sites are on the inner arm.  If possible do not use hand veins on older adults or patients who are ambulatory. IV insertion in a foot vein is common in children, but avoid these sites in adults because of the increased risk of thrombophlebitis (inflammation in a vein by a blood clot). As you assess a patient for potential venipuncture sites, consider conditions that exclude certain sites. Venipuncture is contraindicated in a site that has signs of infection or inflammation.

Older adults may often have more fragile skin. Use the smallest gauge catheter or needle possible for Older Adults ( for example, a 22-24 gauge). Their veins may be very fragile, and a smaller gauge allows better blood flow to provide increased hemodilution of the IV fluids or medications.

 For OLDER ADULTS also Avoid the back of the hand, which may compromise a patient’s need for independence and mobility, Avoid placement of an IV line in veins that are easily bumped because older adults have less subcutaneous support tissue. Avoid rigorous friction while cleaning a site to prevent tearing fragile skin. If an older patient has fragile skin and veins use minimal or no tourniquet pressure.

Veins rolls away from the needle easily because of loss of subcutaneous tissue. To stabilize a vein, apply traction to the skin below the projected insertion site. Secure IV site with a catheter stabilization device, avoiding excessive use of tape on fragile skin, consider covering the site additionally with surgical stretch mesh. Numerous medications and supplements such as anticoagulants increase the likelihood of bruising and bleeding.

Tourniquets frequently used are disposable elastic tourniquets (ETs) or blood pressure type cuffs

Blood is noted in the flashback chamber. Observe for blood return in catheter or flashback chamber of catheter, indicating that bevel of needle has entered the vein.

 Anchor vein: Occlude the vein with one finger while removing the stylet.

TSM dressings are Transparent- Semi-Permeable. The use of transparent film dressings for insertion of peripheral intravenous catheters increase the dwell time of the catheter and reduces the incidence of complications.  Change transparent semipermeable membrane dressings at least every 7 days (except neonatal patients) or immediately if dressing integrity is disrupted

Label dressing per agency policy. Include date and time of IV insertion, IV gauge size and length, and your initials. This allows for recognition of type of device and length of time that the device has been in place.

illustration is an I.V. House Protection Device. These protective devices are used if a patient may pick at or bump their dressing. Site protection devices also include vented plastic or stretch netting coverings and mitts for hands. They are designed to reduce risk of  phlebitis, infiltration or catheter displacement from mechanical motion.

Good to know for your test

This is a picture of an adhesive securement device (ASD) which is an adhesive-backed device that adheres to the skin with a mechanism to hold the VAD or IV in place. This helps to prevent the accidental dislodgement of the IV catheter.

 (The StatLock Catheter Stabilization Device is shown here). Adhesive securement devices (ASDs) must be removed and replaced at specific intervals.

If an ASD is used, carefully monitor the patient for development of a medical device-related pressure injury or (MDRPI) or skin breakdown.

Per institution guidelines label IV tubing as required.  DO NOT write directly on IV bags with pens/markers because ink could contaminate solution.

Assessment   When performing an IV assessment: (1) Proceed from IV bag to the IV site (2) Check Bag (3) Check Pump/Gravity Drip (3) Check Tubing (4) Check IV site (5) Document findings•Proceed from IV bag to the IV site

•Bag: Clear? Particles? Correct/expired IVF?

•Pump/Gravity Drip: Set correctly?

•Tubing: Kinks? Air? Precipitate? Tangled? Catheter secure at site? Piggyback secure?

•IV Site: c/o swelling? redness? pain? tenderness? patent? catheter size? infusing or to HL/SL? leaking?

•Document

Electronic Infusions Devices (EIDs) also called IV pumps or infusion pumps - deliver an accurate hourly IV infusion rate. An IV Pump uses positive pressure to maintain correct flow rates and catheter patency to deliver a measure amount of fluid over a prescribed period of time. IV Pumps are needed for patients who require low hourly rates, are at risk for volume overload, have impaired renal function, or are receiving solutions or medications that require a specific hourly volume. IV Pumps have various detectors and alarms to alert of air in IV lines, completion of infusion, occlusion, high and low pressure and low battery power.

 Ensure that IV container ia at least 30 inches above IV site for adults, and increase height more for viscous fluids. (2) slowly open roller clamp on tubing until you can see drops in drop chamber. Hold a watch with second hand at same level as drop chamber and count drip rate for one minute. See page 1091, Step 2B. Adjust roller clamp to increase or decrease rate of infusion. (3) monitor drip rate at least hourly.

An IV Bolus introduces a single dose of medication directly into the circulatory system. The fluids enter the body at a much faster rate than with a regular IV drip.

IV Push medications are given through either an existing continuous IV infusion or an intermittent venous access (commonly called a saline lock).

The IV Bolus or Push is the most dangerous method for administering medications because there is no time to correct errors. It is vital to verify the rate of administration of IV push medication by using agency guidelines or a medication reference manual.

A saline lock is an IV catheter with a small “well” or chamber covered by a rubber cap.  The Use of a lock saves time by eliminating constant monitoring of an IV line. It also offers better mobility, safety and a comfort for patients by eliminating the need for a continuous IV line. After you administer an IV BOLUS through an intermittent venous access, flush with a normal saline solution to keep it patent.

After initiating a  peripheral IV infusion and checking it for patency, it is time to regulate the rate of infusion. Patency of an IV catheter means that IV fluid flows easily through it. For patient safety avoid the uncontrolled flow of IV fluid into a patient. Nurses are responsible for calculating the flow rate (mL/hr) that delivers the IV fluid in the prescribed time frame.

 The correct IV infusion rate ensures patient safety by preventing too-slow or too-rapid administration of IV fluids.

An infusion rate that is too slow often leads to further physiological compromise in a patient who is dehydrated, in circulatory shock, or critically ill.

An infusion rate that is too rapid overloads the patient with IV fluids, causing fluid and electrolyte imbalances and cardiac complications in vulnerable patients, for example those older adults or patients with pre-existing heart disease.

Calculating Milliliters Per Hour is a vital skill. To calculate milliliters per hour-Check medical order to see how long each liter of fluid should infuse. If hourly rate (mL/hr) is not provided in order, calculate it by dividing volume by hours. For example. If 3 L is ordered for 24 hours, 3000 mL divided by 24 hours = 125 mL per hour. Calculating hourly flow rates ensures that the prescribed amount of fluid to be infused over the prescribed time frame is correct.

PLEASE Review textbook and calculations for Milliliters Per Hour.

Calculating drops per minute is another vital calculation.
Drip factor is the number of drops (gtts) in one milliliter (mL) of solution delivered by gravity.

Drops per minutes is used to calculate the IV flow rate of a given volume. When administering intravenous via a gravity line, the rate of flow is determined using drops per minute. To calculate Drops Per Minute: take total volume in mL - Divided by the time in minutes - Multiplied by the drop factor. So for example 1000 mL over 8 hours with a gtt factor of 20 would equal 42 gtts per minute.

PLEASE Review textbook and calculations for Drops Per Minute.

Carefully assess and monitor a patient’s response to IV therapy.

 Some common complications are listed here including: phlebitis and infiltration.

Phlebitis such as inflammation of a vein,  results from chemical, transient mechanical infections or postinfusion causes. Typical symptoms of inflammation are heat, redness, tenderness occurring along the course of a vein. Phlebitis is dangerous because the inflammation of the vein wall can lead to associated blood clots.

 Infiltration occurs when an IV catheter becomes dislodged or a vein ruptures and IV fluids inadvertently enter the subcutaneous tissue around the venipuncture site. Prevention of these complications requires frequent assessment of the peripheral IV site to see if replacement of a IV is clinically indicated.

Another very severe complication of IV therapy is circulatory overload.

Circulatory overload can occur when a patient receives too-rapid administration or an excessive amount of fluid. Assessment findings depend on the type of IV solution that infuses in excess. 

Infiltration and extravasation cause coolness,  paleness and swelling of the area.

 Looking at complications of IV therapy we see that INFILTRATION is IV fluid entering subcutaneous tissue around the venipuncture site.

EXTRAVASATION is the technical term that is used when a vesicant or a TISSUE DAMAGING drug such as chemotherapy enters tissues.

Phlebitis Table 42.13 describes  Phlebitis as inflammation of inner layer of a vein. 

This illustration shows inflammation of a vein that is associated with phlebitis.

As the nurse, you will stop the infusion and discontinue the IV line. Start a new IV line in other extremity or proximal to previous insertion site if continued IV therapy is necessary. Elevate affected extremity. Document phlebitis and nursing interventions per agency policy and procedure.

Other complications of IV therapy include local infection, which is an infection at catheter-skin entry point during infusion or after removal of IV catheter. Symptoms are redness, heat, swelling, possible purulent drainage.

 Bleeding at site is another complication and signs are oozing or slow continuous seepage of blood from venipuncture site.

 Air embolism is a complication that arises from air in the vein. Symptoms of air embolism include sudden onset of dyspnea, coughing, chest pain, hypotension, tachycardia, decreased level of consciousness and possible signs of a stroke.

A central venous catheter or central line is an indwelling device inserted into a large, central vein. These are often needed in critically ill patients or those needing more  prolonged IV therapies.  The term central applies to the location of the catheter tip, not to the insertion site.

Peripherally inserted central catheter or PICCs - are lines that enter a peripheral arm vein and extend through the venous system to the superior vena cava, where they end. Other central lines enter a central vein such as the subclavian or jugular vein or are tunneled through subcutaneous tissue before enteral a central vein. Central lines are often more effective than peripheral catheters for administering large volumes of fluid, PN and mediations or fluids that irritate veins.

PICC or peripherally Inserted Central Catheter- Peripherally Inserted Central Venous Catheter - lines enter a peripheral arm vein and extend through the venous system to the superior vena cava, where they end.

Port a Caths sit under the skin. The plastic catheter part is slender, allowing healthcare providers to thread it into large veins. The catheter makes it possible for people to receive treatment quickly.

Port a caths (or PORTS as they are often called) can be useful when people need frequent IV treatments over a long period of time, such as patients who need chemotherapy treatments for cancer.

Subclavian  Some central lines enter a central vein such as the subclavian

piggyback is a small IV bag or bottle connected to a short tubing line that connects to the upper Y-PORT of a primary infusion line or to an intermittent venous access. This setup is called piggyback because the small bag or bottle is higher than the primary infusion bag or bottle. In the piggyback set-up the main line (lower bag) does not infuse when the piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops flow of the primary infusion once the piggyback infusion flows.

Injectable medications such as antibiotics are usually added to a small IV solution bag and piggybacked as a secondary set into the primary line to be administered over a 30 to 60 minute period.

Internal Jugular - Other central lines enter a central vein such as the  jugular vein

Central Line Site Care

⮚Use sterile technique

⮚Assess site for redness, swelling, tenderness, or drainage.

⮚Measure the length of the external portion of the catheter with its

       documented length to assess for possible displacement. 

   

⮚If, PICC line measure circumference of patient’s arm 3 inches above site to assess for swelling. 

⮚Follow agency protocol for cleaning solutions and types of dressing.

⮚Clean site area starting at the center of the site, moving outwards with

       circular motion, allow site to air dry.

⮚Cover with occlusive dressing.

   

Central Line Site Care
Change cap as per agency protocol, usually every 3-7 days.Change every 3-7 days, depending on site and agency

       policy.  Dressings should be changed when loose or soiled.

•Flush with normal saline 10 mL, a heparin flush (10 units/mL or 100 units/mL) or as agency protocol recommends for the specific type of VAD (vascular access device)  being used.

Flush after infusing medications or solutions, again flush the VAD with normal saline before using heparin flush solution.

Central Line Site Care
The frequency of flushes between uses may vary from every 12 hours to once a week or less, depending on the type of catheter.

•Remember to flush all lumens for multiple lumen catheters. Lumens are the tubes or part of the catheter used to give IV treatments or take blood.

•Implanted venous access device (port a cath) use a Huber needle to access the port.

Flush idle implanted ports with heparinized saline according to agency protocol.

Central Line Site Care
Do not allow anyone to take a blood pressure on the arm a PICC line is inserted.

•Wear a medic-alert bracelet if the device is to be in for a long period of time.

•For a PICC, you do not need to restrict activities.  Showering is allowed if site is kept dry.

Implanted venous device there are no restrictions (port-a-cath). However some agencies (EMORY CANCER CENTER).  do not allowing showering for 24 hours after a port-a-cath is accessed, due to risk of any contamination.

Blood transfusion or blood component therapy is the IV administration of whole blood or a blood component such as  packed red blood cells (RBCs), platelets or plasma. Objectives for administering blood transfusions include
(1) increasing circulating blood volume after surgery, trauma, or hemorrhage (2) increasing the number of RBCs and maintaining hemoglobin levels in patients with severe anemia and (3) providing selected cellular components as replacement therapy (for example clotting factors, platelets or albumin). 

Caring for patients receiving blood or blood-product transfusions is a nursing responsibility. It is vital to be very thorough in patient assessment, checking the blood product against prescriber’s orders, checking it against patient identifiers, and monitoring for any adverse reactions, which could be life threatening.

Blood groups and blood types: Red blood cells have antigens in their membranes; the plasma contains antibodies against specific RBC antigens.  If incompatible blood is transfused (for example if a patient’s RBC differ from those transfused) then the patient’s antibodies trigger RBC destruction in a potentially dangerous transfusion reaction. (For example: an  immune response to the transfused blood components).  The most important grouping for transfusion purposes is the ABO SYSTEM, which identifies A, B, O, and AB blood types.

 Determination of blood type is made on the basis of the presence or absence of A and B Red Blood Cell antigens. People with type O-negative blood are considered UNIVERSAL BLOOD DONORS because they can donate packed RBCs and platelets to people with any ABO blood type. People with type AB positive blood are considered UNIVERSAL RECIPIENTS because they can receive packed RBCs and platelets of any ABO type.

Types of Blood; (Just a quick review of blood types and not on your test)-

There are four types of blood: A, B, O and AB.  The determination of the blood type is made on the presence or the absence of either A and or B antigens.  Individuals that have type A blood have A antigens and B antibodies in the plasma.  People with type B blood have B antigens and A antibodies in the plasma.  AB blood has both A and B antigens and there's no antibodies.  Type O blood has neither A nor B antigens but has both the A and B antibodies that are in the plasma.

People with type O-negative blood are considered UNIVERSAL BLOOD DONORS because they can donate packed RBCs and platelets to people with any ABO blood type. People with type AB positive blood are considered UNIVERSAL RECIPIENTS because they can receive packed RBCs and platelets of any ABO type.

Autologous Transfusion- An autologous transfusion is also know and an autotransfusion.  It is the collection and reinfusion of the patient’s own blood. Preoperative donation may be up to six weeks before surgery. 

Blood Transfusions:

For blood therapy we need as nurses to always verify three things.

Number one, the blood components delivered are the ones that were ordered.

Number two the blood delivered to the patient is compatible with the blood type that is listed for the patient in the medical record, and Number three that the right patient receives the correct blood product.

Together two RNs or one RN and one LPN may check the label on the blood product against the medical record and the patient's medical record number, the blood group, and the patient's complete name. To ensure that this is appropriate where you are working you will need to check the hospital’s policies.  

Blood Transfusion

•Infuse within 2 hours or no longer than 4 hrs if patient at risk for fluid volume overload

•Use 18- or 20-gauge needle

•Y – Set ( contains a filter)

•Normal Saline is the Only fluid hung in combination with blood products.

During Blood Transfusion- Remain near the patient, major reactions usually appear before the first 50 mL have been transfused- Observe patient frequently for any adverse reactions-

⮚Observe site frequently for signs of infiltration

⮚Administer at prescribed rate (No longer than 2 hrs) or 4 hours if the patient is at risk for fluid overload

⮚Monitor vital signs and document as per facility policy usually:

  Within 1 hour before starting infusion

  15 minutes after starting infusion

  Every 30-60 minutes

  Whenever patients condition requires

  At completion of transfusion

Blood Transfusion- Some acute adverse effects of transfusions are:
Acute intravascular hemolytic - or when red blood cells are destroyed faster than they can be replaced.

•Febrile non-hemolytic (most common) - signs are fever and chills

•Mild Allergic

•Anaphylactic shock

•Circulatory Overload

Sepsis

Signs and Symptoms of Blood Transfusion Reactions-  A transfusion reaction is an adverse event that occurs from transfusion of a blood product. Many transfusion reactions involve immune system reaction to the transfusion that ranges from a mild response to severe anaphylactic shock or acute intravascular hemolysis, both of which can be fatal. Table 42.15 presents the causes, manifestations, management and PREVENTION OF THE MOST COMMON ACUTE TRANSFUSION REACTIONS. PROMPT INTERVENTION WHEN A TRANSFUSION REACTION OCCURS MAINTAINS OR RESTORES A PATIENT’S PHYSIOLOGICAL STABILITY.

•Fever

•Chills

• Headache

• Nausea

• Back pain

• Itching

• Hypotension

• Rash

 Transfusion Reactions - Nursing Interventions-

Prompt reaction maintains or restores a patient’s physiological stability.
STOP the Infusion

•KVO (Keep Vein Open) with NS (change tubing)

•Immediately notify MD or emergency response team

•Remain with patient, observe signs and symptoms and monitor vitals every 5 minutes.

•Prepare to administer emergency drugs and CPR

•Return blood container, tubing, labels, etc. to blood bank or lab.

•Obtain blood and urine specimens per MD or protocol

Preventing IV Infections
Always use Standard Precautions

•Change IV sites and tubing as per hospital policy

•Use a new catheter for each insertion attempt

•Change tubing immediately if contaminated

•Fluids should not hang longer than 24 hours

Remove catheter as soon as no longer clinically needed (need MD order)

Preventing IV Infections
Clean ports with alcohol or chlorhexidine (scrub the hub)

•Never disconnect tubing

•Wash hands prior to and after handling IV system

•Do not write directly on IV bags with pens/markers because ink could contaminate solution.

Tips for Easier IV starts
Make sure patient is comfortable

•Dangle arm to encourage dependent vein filling

•Use warm compress – encourages vasodilation

•Hands should be last choice

•Limit attempt to 2 tries.

Display confidence in your own abilities