IV Therapy and IV Push Medications Notes

IV Therapy and IV Push Medications – Comprehensive Notes

• IV therapy definition: placing a catheter into a vein to administer fluids, electrolytes, blood products, pharmacological agents directly into venous circulation via needle or catheter, avoiding the GI tract, and sometimes for nutrition. Provides immediate systemic effects due to rapid absorption and allows precise control of fluid volume, infusion rate, and medication dosage.

• Indications for IV therapy:

  • Hydration (fluid and electrolyte replacement) when intake is deficient or when fluids must be moved through the body.
  • Medication delivery (faster onset, useful when patient cannot take meds orally).
  • Parenteral nutrition (TPN) for patients unable to use the GI tract.
  • Hemodynamic support; advanced lines may be used for hemodynamic monitoring.
  • Blood transfusion (direct venous administration of blood or blood products).
  • Nutritional support (Total Parenteral Nutrition).

• Routes for IV access:

  • Peripheral IV: smaller superficial veins, usually in the extremities, catheter placed here.
  • Central IV: large central veins, closer to the heart; typically requires specialized training to place. PICC lines can be placed by specially trained nurses.

• IV fluids and tonicity:

  • IV fluids may contain additives to make solutions isotonic, hypotonic, or hypertonic.
  • If a solution is anything other than isotonic, you cannot safely give it in a bolus or in excess amounts due to fluid shifts.
  • Tonicity definitions:
  • Isotonic: concentration of dissolved solutes similar to blood. $ext{solute concentration in IV} \,\approx \,\text{solute concentration in plasma}$
  • Hypotonic: lower solute concentration than blood. $C<em>{ ext{IV}} < C</em>{ ext{plasma}}$
  • Hypertonic: higher solute concentration than blood. $C<em>{ ext{IV}} > C</em>{ ext{plasma}}$

• Pharmacology and IV push:

  • Administers medications rapidly with immediate systemic effect; useful when rapid action is needed or patient cannot take meds orally.
  • When IV push conflicts with other infusions, check compatibility and use a buffer if necessary (preflush) to prevent interaction.
  • Post-flush: the post-flush flow rate must match the same rate as the medication infusion to push any residual medication into the bloodstream.

• Blood transfusion considerations:

  • Use the largest gauge catheter available to minimize risk of complications and ensure rapid delivery when needed.

• Parenteral nutrition (TPN):

  • A mixture formulated for venous administration, typically delivered as two bags: TPN (glucose and carbohydrates) and lipids (fats) which are usually separate due to mixing considerations.

• Advantages of IV therapy:

  • Rapid absorption and immediate effect.
  • Precise control of dosage and rate.
  • Ability to deliver large fluid volumes and administer irritating medications diluted in fluid.
  • Continuous delivery via IV drip or PCA pump (for analgesia).
  • Suitable for patients unable to take oral intake; lifesaving in emergencies.

• Disadvantages of IV therapy:

  • Invasive procedure with pain on insertion.
  • Risk of infection.
  • Risk of infiltration or extravasation.
  • Phlebitis, fluid overload, blood exposure risk; not all staff can start IVs (requires training).
  • Higher cost than oral or other routes due to equipment and care requirements.

• Pre-procedure assessment and planning:

  • Always assess allergies (latex, tape, antiseptics) and check the medication orders.
  • Consider what the IV will be used for to determine catheter size and placement.
  • Previous injuries or surgeries can impact placement (e.g., mastectomy on a side; avoid the side with lymph node removal when possible).
  • For patients with mastectomy, fistula, port, or scar tissue, avoid the side with these conditions if feasible; Lindalert bracelets (pink) may be used for marking.
  • If left side is planned for an upper-extremity procedure, avoid placing IV on that side.
  • Pre-assessment also includes checking patient’s dominant hand, anticipated movement, and areas to avoid due to infection or injury.

• Catheter size and gauges (general guidance):

  • Smaller numbers indicate larger diameters; larger numbers indicate smaller diameters. In other words: the gauge is inversely related to diameter. $d \propto \frac{1}{g}$ where d is diameter and g is gauge.
  • Common sizes and uses:
  • $14-16 \text{gauge}$: rapid infusion, major trauma, rapid resuscitation (e.g., cardiac surgery scenarios).
  • $18 \text{gauge}$: suitable for surgery and blood products.
  • $20 \text{gauge}$: general use (most commonly used).
  • $22-24 \text{gauge}$: pediatrics, frail elderly, or small veins.
  • Selection should be based on anticipated therapy, vein suitability, and patient condition.

• Insertion site planning and anatomy:

  • Start with lower extremity veins and work upward if needed to reduce infiltration risk.
  • Common peripheral sites: cephalic vein, basilic vein, dorsal metacarpal veins.
  • When seeking veins, use techniques to improve visibility:
  • Hot compress to promote vasodilation (thermoregulation).
  • Dangling (dependent position) increases venous filling.
  • Avoid valves; anchor the vein to prevent movement.
  • Gentle rubbing after cleansing with alcohol or chlorhexidine to surface the vein.
  • If a vein rolls or is difficult, ensure firm stabilization and consider alternative sites or visualization aids (disillumination device, ultrasound guidance).
  • If a vein collapses, switch to a smaller gauge and/or different site.

• Insertion technique and securing security:

  • Apply aseptic technique: hand hygiene, single-use equipment, proper sharps disposal, site rotation per policy, and infection-control practices.
  • When IV is not in use, keep cap devices on to prevent contamination.
  • Label tubing and ensure securement to prevent dislodgement; use devices like stat locks, chevron tapes, arm boards, or wraps, carefully removing to skin during site assessment.
  • Common sense practice: take down dressings to skin during assessments to check for skin integrity (especially pediatric patients).

• Monitoring and safety checks (in-use and after placement):

  • Perform patient safety checks: ensure tubing is not kinked or pulling, no air in line, pump is plugged in, drip chamber halfway full, and the fluid is infusing at the prescribed rate.
  • Confirm the correct IV fluid is used and the site appears intact and secured.
  • Position the limb comfortably to avoid dislodgement.
  • After initiating IV, monitor the patient’s response for pain, pallor, dizziness, or signs of an adverse reaction.
  • Check IV function (blood return, ability to flush) and ensure extensions or locks are functioning.

• Maintenance and site care:

  • Site assessment frequency: every 4 hours; more frequent (1–2 hours) for critically ill or cognitively impaired patients.
  • Peripheral IV dressing changes:
  • Change dressing every 2 days if gauze; every 7 days if transparent.
  • Change immediately if soiled, loose, dislodged, or if there is moisture, drainage, blood, or compromised skin.
  • Securement devices must be checked and assessed by removing to the skin for inspection.
  • Flushing schedule: flush every $8-12 \ hours$ when not running continuously.

• Troubleshooting and complications:

  • If there is no flashback, adjust the angle, reattempt at a different site.
  • For vein collapse during insertion: use a smaller gauge or another site.
  • Vein rolling: stabilize firmly.
  • Disillumination device (a red-light aid) or ultrasound guidance can help locate veins.
  • Phlebitis: redness, pain, heat, purulent drainage, swelling along the vein. Management includes heat, elevation, analgesics; if infection suspected, send catheter for culture.
  • Infiltration: pain, swelling; cool skin; stop infusion and remove catheter.
  • Extravasation: symptoms mirroring infiltration plus burning, blisters, necrosis. Stop infusion, aspirate any residual medication, follow policy for the drug.
  • Hemorrhage: apply pressure and dressing; reassess site viability for continued use.
  • Local infection: purulent drainage; remove IV, culture, clean site, treat infection.
  • Nerve injury: paresthesia; remove IV and notify provider.

• Lifespan and patient population considerations:

  • Neonates/infants: scalp, dorsal hand, or foot veins; use smallest possible catheter (often $24-\text{to}-!!$ $26\text{ gauge}$); skin is fragile with high infiltration/extravasation risk.
  • Children: preferred sites are hand and forearm veins; catheter size $\text{often }$ $22-!!$ $24\text{ gauge}$; fear/anxiety management with distraction and topical anesthetic (e.g., lidocaine cream);
    securement requires careful attention due to higher risk of dislodgement.
  • Adults: forearm veins are common; gauge $18-22\,$ depending on therapy; consider dominant hand and patient mobility.
  • Older adults: veins fragile, thin-walled; skin thin and less elastic; higher risk of tearing/bruising; use smaller gauges (20-22 gauge) and gentle securement; pad under tourniquet; minimize adhesive trauma; monitor for infiltration, phlebitis, and fluid overload (especially with CHF or renal impairment).
  • Pregnant patients: venous visualization may be harder due to edema; typical catheter size for delivery/trauma $18\,\text{gauge}$; avoid supine hypotension; monitor for fluid overload in preeclampsia.

• Special equipment and documentation:

  • Tools and supplies: standard IV start kit, antiseptics, tourniquet, dressing, securement devices, sterile gloves, sterile catheter, tubing, IV bags, and safety devices.
  • Documentation (post-procedure): date/time, brand of device, gauge and length of the catheter, vein location, whether local anesthetic was used, number of attempts, description of the site, condition of extremity and the IV site, type of dressing, patient tolerance, whether an IV lock was established or IV fluids started, and the patient’s status and patency of the system.

• IV Push documentation and administration:

  • Documentation should include: date/time of administration, medication amount and dose, IV site location (patients may have multiple IVs), administration route and rate, flush solution used, indication for the medication, patient assessments related to the medication, and patient response.
  • Before IV push, follow the eight rights of medication administration and verify doctor orders and patient allergies; ensure IV access is patent and suitable for the medication.
  • Compatibility checks: if incompatible with another infusion, stop the infusion and perform a preflush to buffer between solutions, then administer as normal and perform a postflush at the same rate as the medication.
  • Pre-assessment is essential to determine how the medication will affect heart rate, blood pressure, pain, etc. and to educate the patient about potential reactions.

• Special infusions (PCA and epidurals):

  • PCA (patient-controlled analgesia): patient self-administers opioids to control pain relief; pump limits dosing to prevent overdose. Monitor for respiratory depression. Oxygen tubing attached to the pump to monitor CO2 and respirations.
  • Key PCA components: loading dose, demand dose (dose when patient presses button), lockout interval (maximum doses per hour), and basal infusion (base rate, if any).
  • Safety checks for PCAs require two nurses to verify pump settings to prevent errors; special considerations for patients with sleep apnea, COPD, obesity, etc., who are at higher risk for respiratory complications.
  • Epidurals: analgesics delivered directly into the spinal fluid via a catheter; used for severe pain during surgery or labor. Monitor the insertion site, potential leakage, and side effects such as hypotension, nausea, itching, and urinary retention. Serious risks include respiratory depression, hypotension, and bradycardia; prompt interventions required.
  • Epidural pumps function similarly to PCA pumps for programmed delivery; the injection site (back) and potential site complications are a primary focus of monitoring.
  • Nurses are responsible for safe medication administration, patient safety, and timely communication with the healthcare team; advocate for patient needs (e.g., higher analgesia if pain remains uncontrolled, or turning off a device if not needed).

• Safety, patient education, and advocacy:

  • Nurses must continually assess patient pain and compare subjective reports with objective signs to determine if current analgesia is adequate or excessive.
  • If a patient repeatedly uses the device without relief, reassess pain management plan—consider more medication or alternative strategies; conversely, if overused, assess for potential misuse or adverse outcomes.
  • Emphasize aseptic technique, infection prevention, and prompt reporting of adverse reactions to ensure patient safety.

• Practical summary and takeaways:

  • IV therapy provides rapid, controlled administration of fluids, medications, blood products, and nutrition, with the ability to deliver large volumes and irritant meds safely.
  • Always perform pre-assessment, site selection, and aseptic technique; monitor for complications and maintain thorough documentation.
  • Be mindful of patient-specific factors (anatomy, comorbidities, age, pregnancy) when selecting sites and catheter sizes.
  • For IV push, prioritize compatibility, correct rate, and post-infusion flush; ensure monitoring for adverse reactions.
  • PCA and epidural therapies require rigorous safety checks, patient monitoring, and clear communication among the care team to optimize pain control while minimizing risk.

• This concludes the IV therapy and IV push medications notes. If you have questions, please raise them in class.