IV Therapy and ABGs Review

IV Therapy Week 5

Notes on IV therapy, including backcheck valves, drip tubing, pumps, containers, administration sets, CVADs, ABGs, and medications.

Backcheck Valve

• Prevents retrograde solution flow.

Macro and Micro Drip Tubing

• Macro drip tubing: Delivers 10-20 gtts/ml.
• Micro drip tubing: Delivers 60 gtts/ml.

Elastomeric Pump

• Uses a balloon to create positive pressure.
• Delivers medication when the tubing is unclamped.

Multichannel Pump

• Delivers multiple solutions simultaneously.
• Can use bags, bottles, or syringes.

Syringe Pump

• Fluid held in a syringe chamber.
• A piston controls delivery into the IV tubing.
• Used for small amounts of fluid.

Stylet

• A needle found inside a catheter.
• Used for vein penetration.
• Removed after insertion.

Glass Containers: Pros and Cons

• Pros:
  • Good visualization of contents.
  • Measurements are easy to read.
  • No plasticizers.
• Cons:
  • Easily broken during transport.
  • Potential for particulate matter due to coring.
  • Difficult to dispose of.
  • Needs a vent on tubing.
  • Not commonly used anymore.

Glass Containers

• Must have an open vent.

Plastic Containers: Pros and Cons

• Pros:
  • Closed system.
  • Flexible.
  • Lightweight.
  • Easier storage.
• Cons:
  • Easily punctured.
  • Fluid level is difficult to determine.
  • Made of plasticizers.
  • Potential for leaching.

Administration Sets

• Spike: Inserted into the solution container, must remain STERILE.
• Drip chamber: Pliable, allows visualization of falling drops.
• Primary continuous administration sets: Main sets, tubing changed every 96 hours or upon contamination.
• Secondary administration sets: Used for medication administration, attached to primary set (piggyback). May need an extension hook. Tubing changed every 24 hours.

Primary and Secondary IV bags

Equipment

• Stopcock device: Controls solution flow with manual valve manipulation. Increases infection risk.
• Intermittent infusion device/needleless connector: Allows syringe tip attachment.
• LPNs CAN change needleless connectors on a CVC.
• Stabilization device: Prevents catheter pistoning.

CVADs (Central Venous Access Devices)

• Non-tunneled CVAD
• Peripherally inserted central catheter (PICC)
• Tunneled cuff catheter
• Implanted vascular device

CVAD Types and Characteristics

• Tunneled:
  • IJ entry site with subcutaneous tunnel and cuff.
• Non-tunneled:
  • IJ entry site without subcutaneous tunnel or cuff.

PowerLoc Safety Infusion Set & PowerPort Implantable Port

• Components: Catheter, blood vessel, skin, Palpation Points

CVAD: PICCs

• Most commonly placed CVAD.
• Associated with higher risk of catheter-associated venous thrombosis.
• Often placed at the bedside.
• Tip should be in the superior vena cava.

Comparison of Central Line Placement

• CVC and PICC: Used for rapid infusions, long-term medication administration (antibiotics, chemotherapy), total parenteral nutrition, and frequent blood draws.
• Both can be seen in inpatient and outpatient settings.
• Lines end in the superior vena cava or right atrium.
• PICC lines are commonly placed in: Basilic vein, Brachial vein, Cephalic vein, and/or medial cubital vein
• PICC lines are placed peripherally but terminate centrally.
• Midline catheters are shorter lines also placed peripherally.
• PICC lines are usually recommended for short to medium term use (4 weeks-6 months), indicated for critically ill and oncology patients.

PICCs

• Inserted mainly by PICC nurses; removed by any trained RN.
• Considered short term venous access but may stay in up to a year.
• Inserted through a peripheral vein in the arm, advanced into central circulation, tip in distal 1/3 of the superior vena cava.
• Patients can be sent home with them.
• Risk of thrombus.
• Can be inserted in a patient of any age.
• Can be used for lab draws, but not by the LPN.

Patient Education: PICC

• Keep dressing clean and dry; changed weekly by a nurse.
• Notify nurse if dressing becomes loose.
• Do not submerge the arm in water; showers allowed if arm is completely covered with plastic.
• Do not put anything into the catheter without proper education/orders.

CVAD: Ports

• Non-coring needle is used to access an implantable port.
• LPN can access or de-access an implantable port.
• The preferred cleanser for a CVC dressing change is chlorohexidine (CHG).

Implantable Ports

• Surgically placed.
• Use NON-CORING needle only!
• Can swim/submerge in water after incision has healed.
• Can stay in for years; flush once a month.
• Can withstand up to 5000 sticks.
• Some minimal pain with access.
• LPNs in Ohio may access and de-access these ports (with training).

Review: Expiration Dates & Time

• Primary tubing: 96 hrs.
• Secondary tubing: 24 hrs.
• Blood tubing: 4 hrs.
• Check expiration dates of tubing and solutions.

Hanging an IVPB

• Secondary tubing (intermittent tubing/IVPB tubing) comes with a hook.
• Primary bag is hung on the hook, secondary bag is hung higher.

ABGs (Arterial Blood Gases)

• pH: 7.35-7.45
• CO2: 35-45
• HCO3: 22-26
• PO2: 80-100
• pH measures acidity/alkalinity.
• CO2 relates to the respiratory system (acid).
• HCO3 relates to the metabolic system (base).

ABGs

• Concept maps on Respiratory Acidosis/Alkalosis and Metabolic Acidosis/Alkalosis

ABGs

• Know normal values, including PO2.
• Arterial stick: Direct pressure must be held until bleeding stops (5-20 min).
• Sites: Radial, brachial, femoral.
• Done by physicians, RNs, respiratory therapists.
• Allen test.

Modified Allen's Test

• Radial and ulnar arteries are occluded with firm pressure while fist is clenched until hand blanches.
• Hand is opened and pressure is released from the ulnar artery.
• Color should return within 15 seconds to imply adequate arterial circulation.

ABG Compensation

• Video on ABG compensation (Nurse Sarah ABG with Compensation on YouTube).
• Types of Compensation:
  • Uncompensated
  • Partially Compensated
  • Fully Compensated

Compensation Examples

• pH 7.32 (Acid), pCO2 50 (Acid), HCO3 24 (Norm) = Uncompensated Respiratory Acidosis
• pH 7.32 (Acid), pCO2 50 (Acid), HCO3 28 (Alk) = Partially Compensated Respiratory Acidosis

Compensation Examples

• pH 7.46 (Alk), pCO2 37 (Norm), HCO3 28 (Alk) = Metabolic Alkalosis, Norm – uncompensated; Acid – partial compensation

Compensation Examples

• pH 7.38 (Norm), pCO2 50 (Acid), HCO3 28 (Alk) = FULL Compensation; pH normal = FULL Compensation,

Compensation Examples

• pH 7.44 (Norm), pCO2 50 (Acid), HCO3 28 (Alk) = FULL Compensation; pH normal = FULL Compensation,

Compensation Question

• Patient with COPD, acute exacerbation. ABGs: pH 7.0, pCO2 48, HCO3 26, pO2 65

Compensation?

• No; bicarb is normal (HCO3)
• Respiratory Acidosis

Compensation Question

• Patient with COPD, acute exacerbation. ABGs: pH 7.1 PCO2 50 HCO3 28 PO2 68 (Same person; a little time has passed).

ABG interpretation?

• Still Resp. Acidosis,

Compensation Question

• Patient with COPD, acute exacerbation. ABGs: pH 7.35 PCO2 50 HCO3 28 PO2 70

Same person, more time has passed and the body is compensating so well, that the pH is normal!

Question #1

• Patient with chronic renal disease: creatinine 3.8, BUN 40, Potassium 5.5, ABGs: pH 7.0, PCO2 34, HCO3 19, PO2 88
• Which interventions/orders will the LPN carry out?
  • Monitor intake and output.
  • Encourage the pt. to eat potatoes.
  • Give a dose of kayexalate orally.
  • Check the hemoglobin level.
  • Encourage the pt. to use a salt substitute.

A, C, D

• Question 1 Answer

Question #2

• 60 y.o. patient with new diagnosis of bacterial pneumonia. ABGs: pH 7.2 PCO2 49 HCO3 28 PO2 70
• Which interventions/orders will the LPN carry out?
  • Apply oxygen 3L/min./n.c.
  • Auscultate lungs
  • Hang Levaquin IVPB per PICC
  • Monitor continuous pulse-ox.
  • Administer nebulizer tx. with Duoneb

A,B,C,D,E

• Question #2 Answer

Q#3

• What is the ABG interpretation?
• A 60 y.o. patient has a new diagnosis of bacterial pneumonia. ABGs are drawn pH 7.2 PCO2 49 HCO3 28 PO2 70

Q#3 ANSWER

• RESPIRATORY Acidosis with Partial Compensation

Meds Week 5

• Heparin
• Coumadin
• Lorazepam
• Enoxaparin

Heparin

• Type: anticoagulant, antithrombotic
• Uses: prevent/Tx DVT, MI, PE, embolization with A fib; keep venous devices open and dialysis ports
• Routes: IV flush, IV push, IV drip, and Sub Q
• LPNs can administer flush and SQ in Ohio.

Heparin continued

• Sub Q given in the abdomen
• DO NOT give intramuscularly
• Monitor PTT for labs
• Watch for abnormal bleeding
• HIT- heparin induced thrombocytopenia
• Antidote: Protamine Sulfate
• NPSG

enoxaparin/Lovenox

• Uses: to prevent blood clots in the legs of patients who are on bedrest, orthopedic surgery, or in combination with aspirin to prevent complications from angina.
• SQ
• Side Effects: bruising, bleeding, back pain, headache, melena (bloody stool), blood in urine
• Avoid other drugs that increase the risk of bleeding like nonsteroidal anti- inflammatory drugs (NSAIDs)
• NPSG

Coumadin (Warfarin)

• Type: anticoagulant
• Uses: prevent/Tx DVT, MI, stroke, pulmonary embolism (PE)
• Monitor PT/INR, INR therapeutic range 2-3
• Black box warning: bleeding
• Purple Toe- not bleeding- painful purple lesions on toes and side of feet
• Can cause agranulocytosis
• NPSG

Lorazepam (Benzodiazepine)

• Uses: anxiety, insomnia, sedation, status epilepticus, CIWA (Clinical Institute Withdrawal Assessment )
• Multiple black box warnings: do not give with CNS depressants.
• Routes: po, IM, IV push and infusion
• Common Side Effects: dizziness, drowsiness, orthostatic hypotension, blurred vision
• Serious SE: ECG changes, tachycardia, apnea, and cardiac arrest
• May be habit forming. It is a controlled substance, Schedule IV

Lorazepam overdose(benzo)

• Treatment for lorazepam overdose includes:
  • Administering flumazenil, a benzodiazepine antidote medication, to reverse the effects of lorazepam overdose.
  • IV fluids.
  • Medications to treat overdose symptoms.
  • Breathing support for respiratory depression

MATH: DROPS PER MINUTE

• Order: 1,000 mg of vancomycin in 250 mL of 0.9% sodium chloride to infuse over 50 minutes. What is the mL/hr?

$250/50=x/60$

$250x60=15000$

$15000/50=300 mL/hr$

MATH: mL/hr

• Order: Levofloxacin 500 mg in 100 mL of D5W to infuse over 30 minutes. What will you set the pump on?

$100/30=x/60$

$100x60=6000$

$6000/30=200 mL/hr$

Review practice ABGs on page 51

• Metabolic acidosis no compensation
• Respiratory alkalosis partial compensation
• Respiratory acidosis full compensation
• Metabolic alkalosis full compensation
• Metabolic alkalosis no compensation
• Respiratory acidosis partial compensation
• Metabolic acidosis partial compensation
• Respiratory acidosis no compensation
• Respiratory alkalosis no compensation
• Metabolic acidosis full compensation