W2 IV THERAPY

RATIONALE FOR IV THERAPY

  • Replace/correct fluid and electrolyte balance: Essential for normal bodily functions.

  • Maintain or restore fluid volume: Significant in conditions like shock and dehydration.

  • Route for medication administration: Allows for precise and rapid delivery of medications.

  • Transfusion of blood or blood components: Vital in managing blood loss or anemia.

  • Provision of nutritional support (Total Parenteral Nutrition - TPN & Lipids): For patients unable to ingest nutrients orally.

TYPES OF IV ADMINISTRATION SETS

  • Macro-Drip Set

    • Comes in drop factors of 10 or 15 gtts/mL.

    • Used for large volumes of fluid or quick infusions.

  • Micro-Drip Set

    • Comes only with a drop factor of 60 gtts/mL.

    • Used for small or precise fluid amounts, critical for patient safety.

    • Primarily utilized for neonates or pediatric patients.

PRIMING IV TUBING IN A GRAVITY SYSTEM

Steps to Prime:

  1. Inspect IV solution and tubing for expiry and any issues.

  2. Hang the IV bag approximately 90 cm above client’s insertion site.

  3. Close roller clamp and slider clamp just below the first port.

  4. Ensure proximal and distal ends of tubing remain sterile.

  5. Insert spike into IV bag.

  6. Fill drip chamber 1/2 - 1/3 full and invert injection ports.

  7. Open slider clamp and slowly release roller clamp to start priming; close roller clamp once primed.

  8. Check for bubbles.


Refer to skills checklist for detailed information.

SALINE LOCK (INTERMITTENT VENOUS ACCESS)

  • Definition: Short-term access devices used for intermittent infusions and to maintain access in emergencies.

  • Advantages:

    • Decreased risk of fluid volume excess.

    • Increased comfort, safety, and mobility for the patient.

  • Flushing and Locking: Typically ordered BID to maintain patency – involves turbulent flow technique.

    • Final fluid flush is locked to create negative pressure.

  • Usage: Must be supervised by clinical instructor or staff nurse when flushing.

ASSESSING YOUR PATIENT WITH AN IV

  • Considerations:

    • Verify doctor’s order for the correct solution and infusion rate.

    • Assess IV site, tubing, and bag every 1-2 hours.

      • Primary line = 24h

      • Intermittent = 72h

    • Document intake and output at the start and end of shifts or as ordered.

    • Document amount infused from the bag and amount to be absorbed (TBA).

    • Identify issues or complications and intervene as needed.

NURSING ASSESSMENT OF FLUID & ELECTROLYTE STATUS

  • Measurements:

    • Daily weights.

    • Intake and output.

    • Lab values including urine specific gravity, hematocrit, electrolytes, BUN, creatinine (eGFR).

  • Assessment:

    • Signs of Overload: Altered LOC, periorbital & peripheral edema, ascites, anasarca, crackles in lungs, polyuria, diuresis, hypertension, tachycardia, tachypnea, altered mental status.

    • Signs of Deficit: Dry mucous membranes, sunken orbits, depressed fontanelle, concentrated urine, decreased output, hypotension, tachycardia, altered mental status.

COMPLICATIONS ASSOCIATED WITH IV ADMINISTRATION

  • Possible Complications:

    • Fluid overload

    • Fluid deficit

    • Electrolyte abnormalities

    • Irritant or vesicant IV solution

    • Local complications at insertion site:

    • Pain

    • Phlebitis

    • Infiltration

    • Tissue damage

    • Septicemia (most common with PICCs)

IV THERAPY IRRITANTS

  • Risk Factors: Greater deviation from normal serum pH increases potential for vein irritation, pain, and inflammation.

  • Medications That Irritate:

    • Penicillin

    • Acyclovir

    • Cephalosporins

    • Diazepam

    • Amphotericin

    • Potassium

    • Vancomycin

IV THERAPY VESICANTS

  • Definition: Medications that cause severe tissue damage if they infiltrate subcutaneous tissue.

  • Examples:

    • KCL intravenous additives

    • Contrast medium

    • Antineoplastics

    • Calcium solutions

    • Nitroprusside

    • Vinblastine

    • Doxorubicin

  • Prevention of Damage:

    • Dilute medication when safe for patient.

    • Infuse slowly.

    • Use larger blood vessels like Central Venous Line or PICC Line.

TROUBLESHOOTING COMPLICATIONS

  • Common Issues:

    • Bleeding/Bruising

    • Phlebitis

    • Infection

    • Infiltration

    • Extravasation

    • Pain

    • Accidental dislodgement of catheter

    • Broken catheter

    • Rate or drug-related errors.

BRUISING

  • Definition: Occurs when the punctured vein wall allows blood to enter the skin and pool.

  • Causes: Can arise during IV therapy or cannula insertion.

  • Symptoms: Discoloration as the skin absorbs blood.

NURSING INTERVENTIONS FOR BRUISING

  • Stop IV and remove cannula.

  • Apply ice or cold pack to the site for 10-20 minutes per application.

  • Patient can continue with usual bathing but avoid vigorous activity around the affected area.

PHLEBITIS

  • Definition: Inflammation of the vein related to irritation from IV fluid/medications or mechanical irritation from catheter placement.

  • Symptoms:

    • Swelling and redness along vein course (streaking).

    • Pain, erythema, warmth, and a palpable venous cord.

  • Complications: May lead to thrombus (thrombophlebitis) and embolus; can cause permanent vein damage and extended hospitalization.

  • Assessment: Use a standardized phlebitis scale to document severity (0-5 scale).

NURSING INTERVENTIONS FOR PHLEBITIS

  • Conduct frequent assessments and intervene early to prevent phlebitis.

  • Discontinue IV and remove cannula if necessary.

  • Elevate the affected arm to minimize swelling.

  • Apply warm, moist compress:

    • Document using phlebitis scale.

    • Document site accurately for future comparisons.

    • Continue assessments for increasing pain.

    • Notify physician regarding the site and treatment.

    • Set up new IV system, away from the irritated site.

LOCALIZED INFECTION OF IV SITE

  • Risks: Can spread systemically; monitor for hyperthermia or hypothermia.

  • Symptoms: Redness, pain at the IV site, and potential drainage (serous or purulent).

NURSING INTERVENTIONS FOR LOCALIZED INFECTION

  • Discontinue IV and notify physician.

  • Potential need for topical/systemic antibiotics.

  • Culture catheter tip or wound drainage if requested.

  • Clean IV site and assess for discharge.

  • Restart IV on opposite arm/location from infected site.

  • Document findings and interventions thoroughly.

INFILTRATION

  • Definition: Leakage of non-irritating fluids into surrounding tissues.

  • Symptoms: Limb appears swollen, cool, pale, tender, leaking clear or serous fluid, and increasing pain.

NURSING INTERVENTIONS FOR INFILTRATION

  • Stop infusion and discontinue IV.

  • Restart IV in a new location away from the infiltration site.

  • Remove any items restricting blood flow.

  • Elevate the affected limb and apply a warm compress for 20 minutes.

  • Notify the physician (not urgent unless circulation is compromised).

  • Complete documentation in line with policy.

EXTRAVASATION

  • Definition: Infiltration of irritants/vesicants into surrounding tissue, causing potential tissue damage.

  • Common Causes: Chemotherapy drugs, nitroglycerin, adrenalin, dopamine, TPN, KCL, antibiotics.

  • Potential Outcomes: Pain, redness, irritation, tissue necrosis, or loss of limb.

NURSING INTERVENTIONS FOR EXTRAVASATION

  • Stop infusion immediately!

  • Withdraw any fluid from IV cannula if possible, but do not remove it (antidote may be administered).

  • Notify physician and pharmacy urgently.

  • Apply warm or cold compress based on medication type.

  • Document all findings, skin condition, and any interventions; notify the family.

  • Set up a new IV system in a different limb.