IV Cert-Pharm

MBECK.JML, SCHOOL OF PRACTICAL NURSING, IV Certification Class

Class Completion

  • Successfully initiate IV starts in a lab environment.
  • Completion of IV test with a passing grade of 80%.

Objectives

  • Recognize indications, contraindications, and complications of IV access in specific sites.
  • Review fluid and electrolyte distribution in the body and the physiological effect of alterations in fluids and electrolytes in the body.
  • Recognize indications, contraindications, and purposes of commercially prepared IV fluids.
  • Calculate IV flow rates and drip rates.
  • Identify commonly administered IV medications and the key nursing considerations for the administration of each.
  • Explain various aspects of infection control.
  • Initiate and maintain saline locks for adults.
  • Initiate and maintain continuous IV therapy for adults.
  • Identify documentation and guidelines in IV therapy.
  • Explain principles and techniques involved in blood transfusions.
  • Demonstrate ability to discontinue adult peripheral IVs.
  • Administer IV fluids and medications via saline locks.

Illinois LPN Scope

  • The Illinois Department of Financial and Professional Regulation has clarified the scope of the LPN providing IV care:
    • LPNs may initiate IV therapy (start the IV) when ordered by a provider.
    • Administer plain fluids, IV fluids with additives, and antibiotics.
    • The scope is limited; LPNs cannot administer blood, chemotherapy, or IV push medications.

Intravenous Therapy

  • Goal of IV fluid administration:
    • Correct or prevent fluid/electrolyte disturbances.
    • Allows direct access to the vascular system.
    • Must have a provider's order specifying type, amount, rate, and duration.
    • Requires knowledge of correctly ordered solution, reasons for ordering, equipment needed, procedures required to initiate infusion and maintain it, identify/correct issues, and how to discontinue infusion.
    • Cannot initiate infusions in Central lines or Critical medications.

Fluid Balance

  • Human body composition: Approximately 60% water.
  • Distribution:
    • Intracellular (2/3 stored inside cells).
    • Extracellular:
    • Interstitial fluid: Surrounds body cells and includes lymph.
    • Intravascular fluid: Blood/plasma found within blood vessels.
    • Transcellular fluid: Fluids in special compartments (e.g., cerebrospinal fluid).

Types of IV Fluids

  • Isotonic: Equal osmolarity in extracellular and intracellular fluids; no water movement.
  • Hypotonic: Extracellular fluid has fewer solutes, water moves into cells.
  • Hypertonic: Extracellular fluid has more solutes, water moves out of cells.

Intravenous Solutions

  • Types of Solutions:
    • Dextrose in Water Solutions
    • Saline Solutions
    • Dextrose in Saline Solutions
    • Balanced Electrolyte Solutions
    • Remarks:
    • Dextrose is another name for glucose; Saline is Sodium Chloride (Normal Saline).

Dextrose in Water Solutions

  • Solution/Concentration:
    • Dextrose 5% in Water (D5W): Isotonic and hypotonic.
    • Initially hypotonic; dilutes osmolarity after cellular absorption.
    • Should not be the sole treatment for fluid volume deficit.
    • Electrolyte deficits (especially potassium and phosphate) may occur with prolonged use.
    • Blood electrolyte monitoring necessary.
    • Essential vitamins and minerals should be provided as needed.
    • Dextrose 10% in Water (D10W): Hypertonic.

Dextrose in Saline Solutions

  • Solution/Concentration:
    • Dextrose 5% in 0.45% NaCl (D51/2NS; D5 0.45% NaCl): Hypertonic.
    • Dextrose 5% in 0.9% Sodium Chloride (D5NS; D5 0.9% NaCl): Hypertonic.
    • Comments:
    • Little evidence of benefit or harm compared to saline alone.
    • Dextrose added for hypoglycemia, alcohol intoxication, and starvation ketosis.
    • Not to be used in hyperglycemia or hypokalemia conditions.

Saline Solutions

  • Solution/Concentration:
    • 0.9% Sodium Chloride (Normal Saline, 0.9% NaCl): Isotonic.
    • 0.45% Sodium Chloride (Half Normal Saline; ½ NS; 0.45% NaCl): Hypotonic.
    • 3% Sodium Chloride (Hypertonic saline; 3% NaCl): Hypertonic.
    • 0.225% Sodium Chloride (Quarter Normal Saline; ¼ NS; 0.225% NaCl): Hypotonic.
    • Comments:
    • Standard fluid for boluses and maintenance; inexpensive, minimal allergic reaction.
    • Typically combined with potassium or dextrose; used for severe hyponatremia or increased intracranial pressure.

Balanced Electrolyte Solutions

  • Solution/Concentration:
    • Lactated Ringer's (LR): Isotonic.
    • Dextrose 5% in Lactated Ringer's (D5LR): Hypertonic.
    • Comments:
    • LR contains sodium lactate, potassium chloride, and calcium chloride; buffered.
    • May improve renal function in critically ill patients.

Other IV Fluids

  • Components:
    • Potassium Containing Solutions.
    • Parenteral Nutrition/TPN/Lipids.
    • Sedations.
    • Bicarbonate-containing Solutions.
    • Vasopressors.
    • Patient-Controlled Analgesia (PCA).

Types of IV Administration

  • Six Types:
    1. Large-Volume Infusions
    2. Intravenous Bolus
    3. Volume-Controlled Infusion
    4. Piggyback
    5. Volume-Control Administration
    6. Intermittent Venous Access

Types of IV Administration Details

  • Large-Volume Infusion:
    • Used to accurately deliver liquids via IV or epidural, typically rates from 1 to 999 ml/hr or higher.
  • Intravenous Bolus:
    • Administration of vitamins or medications over 1 to 30 minutes in non-emergency situations.
  • Volume-Controlled Infusion:
    • Administers small amounts (50-100 ml) of compatible fluids for IV medication.
  • Piggyback:
    • Involves a small (25-250 ml) IV bag placed higher than the primary infusion.
  • Volume-Control Administration:
    • Sets include 150 ml containers attached just below the primary infusion.
  • Intermittent Venous Access/Saline Lock:
    • Increases patient mobility, safety, and comfort.
    • Requires checking for patency and placement before medications administered, and flushing to maintain patency.

Types of IVs

  • Access Methods:
    • Central Access:
    • Central Line
    • PICC (Peripherally Inserted Central Catheter)
    • Midline Catheter
    • Peripheral Access:
    • Peripheral Venous Catheter (PVC)
    • Subclavian vein insertion
    • Femoral vein catheter insertion
    • Internal jugular vein insertion

IV Access Devices

  • Types:
    • Catheter over needle:
    • Needles needed for insertion covered by a plastic sheath (IV cannula).
    • Sizes range from 24 G (0.6 mm) to 12 G (2.8 mm); lengths from 1/2 inch to 2 inches (1.2 to 5 cm).
    • Butterfly Needle:
    • Scalp-vein needle with two small plastic wings for grasping during insertion.
    • Sizes range 18 to 27 G (1.2 to 0.4 mm) in diameter and lengths from 3/8 to 1 inch (9.5 to 25 mm).
    • Can be used to access scalp veins in neonates and infants up to 18 months.

IV Tubing

  • Administration Sets:
    • Primary IV tubing for gravity and pump infusions.
    • Secondary medication (IVPB) tubing administration set.
    • Blood administration Y-set for blood transfusions.
  • Extenders:
    • Extension tubing for patient mobility and injection ports.
    • Intermittent infusion lock/PRN lock: a small device for either continuous or interval medication administration.

Initiating the Intravenous Line

  • Assessment and Selection:
    • Assess for ideal venipuncture site, avoiding contraindicated areas (e.g., vascular graft/fistula sites).
    • Choose the most distal appropriate site.

Choosing Catheter Size

  • Considerations:
    • Viscosity of fluids, required bolus fluids, pressure injection for imaging tests, and blood administration needs influence catheter size choice.

Common IV Sites

  • Site Characteristics:
    • Common IV sites include the cephalic vein, basilic vein, median cubital vein, and hand veins.
    • Inspect sites for signs of varicosities, peripheral edema, and phlebitis.
    • Varicosities: Dilated superficial veins.
    • Dependent Edema: Sign of venous insufficiency or heart failure.
    • Phlebitis: Inflammation of vein due to trauma or prolonged catheter insertion.

IV Start Kit Components

  • Included Items:
    • Tourniquet.
    • Antiseptic prep pad.
    • Sterile gauze pad.
    • Sterile transparent occlusive dressing.
    • Label tape.

Performing Venipuncture and Cannulation

  • Procedure Steps**:
    • Place tourniquet proximal to the site; keep site clean.
    • Hold skin taut; needle at a 20-30-degree angle.
    • Advance cannula and ensure patency, attach IV tubing, secure with tape, then document.

Confirmation of Catheter Placement

  • First Flash and Second Flash:
    • First Flash indicates needle is in the vessel.
    • Second Flash confirms catheter is also properly placed.

Documentation of IV Insertion

  • Required Information:
    • Number of attempts, catheter type and size.
    • Location of insertion and patient's tolerance.
    • Note if an occlusive dressing was applied.

Maintaining and Regulating IV Infusions

  • Considerations:
    • Monitor for proper IV infusion rates—safety is crucial.
    • Use Electronic Infusion Devices (EIDs) for accurate delivery.
    • Keep system sterile; follow facility protocols for changing fluids and tubing.
    • Assist patient with self-care activities to ensure EID operation is uninterrupted.

Skin and Vein Protection

  • Best Practices:
    • Use the smallest gauge catheter.
    • Avoid back of the hand for insertion; minimize friction while cleaning.
    • Secure IV properly to prevent movement and trauma.

Instructions for Patients to Protect Their IVs

  • Educate patients to report any issues:
    • Blood in tubing, stoppage, swelling, or pain at the site.
    • Ensure IV container height is appropriate; assist in maintaining flow rate.

Possible Complications of IVs

  • Health Risks:
    • Infection: Signs include redness, heat, swelling, and purulent drainage.
    • Phlebitis: Redness, warmth, and tenderness along the vein.
    • Infiltration/Extravasation: Blanching and swelling around the catheter site.
    • Bleeding: Fresh blood at venipuncture site.
    • Speed Shock: Physiologic reaction to rapid IV administration; signs include flushing, headache, chest tightness, and more.
    • Circulatory Overload: Symptoms depend on fluid type administered.
    • Anaphylaxis: Severe allergic reaction.

Discontinuing IV Access

  • Process:
    • Discontinue IV after infusion completion or signs of infiltration, phlebitis, or infection.
    • Document the discontinuation process and site appearance.
    • Educate patients on transitioning from IV to oral fluids.

Drop Factor

  • Definition:
    • The number of drops needed to equal 1 mL of IV fluid.
    • Drop factor numbers found on tubing packages; typically 10, 15, 20, and 60 (with 10 being the largest drop size).

Calculating Hourly Rate

  • Basic formula:
    • Rate (mL/hr)=Total mLTime (Hours)\text{Rate (mL/hr)} = \frac{\text{Total mL}}{\text{Time (Hours)}}
    • Rearranged formula:
    • Volume (mL)=Rate (mL/hr)×Time (hr)\text{Volume (mL)} = \text{Rate (mL/hr)} \times \text{Time (hr)}

Blood and Blood Products

  • Research developments allow isolation of blood components, avoiding whole blood transfusion when unnecessary.
  • Common Components Administered:
    • Albumin: Increase plasma volume.
    • Cryoprecipitate: Replace coagulation factors I, VII, VIII.
    • Fresh-Frozen Plasma: Replace factors V, XI, drug reversal of warfarin.
    • Liquid Plasma: Replace plasma proteins.
    • PRBCs (Packed Red Blood Cells): Used for acute blood loss and symptomatic anemia.
    • Platelets: Manage bleeding in thrombocytopenia.
    • Whole Blood: Rarely used; usually broken down for components.

Additional Learning Resources

  • Online Videos:
    • IV Fluid Types: https://www.youtube.com/watch?v=NmWBzezefCk
    • Spike & Prime: https://www.youtube.com/watch?v=4ntqS_R1r70
    • Starting an IV: https://www.youtube.com/watch?v=PtiHk_ljCUg
    • IV Prep: https://www.youtube.com/watch?v=UahQLJmVAsU
    • Tips & Tricks: https://www.youtube.com/watch?v=dKenI4Q2pWE