iv therapy

IV Therapy, Blood Products & Volume Expanders

NUR 113 - Pharmacology
Bishop State Community College
Lashawndree Brown-Johnson, RN, MSN, CCRN, CNE

Learning Objectives

1. Management and Monitoring of IV Therapy

   • Understanding how to administer and observe patients during IV therapy.

2. Select Appropriate Catheter Gauge for Specific Infusion Needs

   • Importance of selecting the correct gauge for flow and type of solution administered.

3. Explain Alternative Infusion Routes

   • Include Intraosseous (IO), subcutaneous, and intraspinal routes.

4. Identify Types of Blood Products and Their Indications

   • Knowing the different blood products available and their proper use cases.

5. Explain the Purpose and Types of Volume Expanders

   • Types of solutions used when blood products are not available.

6. Recognize Signs of Transfusion Reactions and Nursing Interventions

   • Identifying complications that may arise during blood transfusions and the emergency responses required.

7. Differentiate Scope of Practice between RN and LPN

   • Understanding the roles and limitations of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) regarding IV therapy.

IV Therapy Basics

Types of Access

Peripheral IV (PIV)

• Most common method, inserted into veins of hand, forearm, or antecubital for short-term use (72-96 hours).

• Gauge: 14-24 (note: smaller number means larger bore, facilitating higher flow rates).

• LPNs can insert and manage PIVs within state regulations.

Central Venous Access

• PICC (Peripherally Inserted Central Catheter) and central lines (subclavian, jugular, femoral) for longer therapy durations or administering TPN.

• Managed by RNs, with insertion done by RNs (PICC) or physicians.

• Midline Catheters: inserted in the upper arm and used for 1-4 weeks (not suitable for TPN or vesicants).

• Inserted by specially trained RNs or MDs.

Vein Selection Considerations

• Start distally on the extremities; avoid the wrist (median nerve proximity).

• Avoid joints, previous sites, and areas with medical history (mastectomy, AV fistula).

• Check for vein adequacy against the selected catheter gauge.

Peripheral Catheter Gauge Selection

Reminder

• Smaller gauge number means larger catheter bore and faster flow rate.

Patient Safety: IV Insertion

Site Safety Considerations

• Avoid the palmar side of the wrist to prevent nerve damage and painful stabilization.

• Signs of nerve puncture during insertion: tingling, “pins and needles”, numbness.

  • If these occur, stop insertion, remove catheter, and choose a new site.

Winged Needles (Butterfly)

• Best for single-dose injections but high risk of infiltration; must have design for safety.

Infection Prevention

• Follow CDC guidelines to prevent catheter-related bloodstream infections (CRBSI) through aseptic techniques.

• Limit unsuccessful IV attempts to two per clinician; consult IV therapy team after two attempts.

Intraosseous (IO) Therapy

Indications & Uses

• Rapid access into the rich vascular network in red marrow, especially in emergencies when IV access fails.

• Suitable for adults and pediatrics in situations like trauma, cardiac arrest, burns, ketoacidosis, and prehospital emergencies.

Common Sites for IO Access

• Proximal tibia (most common), distal femur, medial malleolus, proximal humerus, iliac crest.

• Preferred needle gauge: 15-16.

Contraindications

Absolute

• Fracture at target bone site.

Relative

• Severe osteoporosis, skin infections, previous unsuccessful attempts on same site.

Complications of IO

• Improper placement (infiltration), osteomyelitis, compartment syndrome, needle obstruction.

• Use lidocaine for comfort during infusions; infusion pumps recommended for rapid rates.

Subcutaneous Infusion Therapy

Hypodermoclysis

• Gradual infusion of isotonic fluids into the subcutaneous tissue, often used for palliative or geriatric care when IV access isn't feasible.

Applications

• Mild to moderate dehydration, palliative care, medication administration, and insulin therapy.

  • Not suitable for high-quantity or emergency needs.

Nursing Care Instructions

• Clean site, insert needle correctly, and rotate infusion sites regularly.

Specialized Infusion Routes

Intraarterial Infusion

• Placing a catheter into arteries used for blood sampling and localized therapies.

• Complications: Requires specific equipment (Luer-Lok connections) to prevent disconnections causing hemorrhaging.

Intraperitoneal (IP) Infusion

• Delivery of medication into the abdominal cavity, mostly for chemotherapy treatments.

  • Risks: Nausea, respiratory distress, infections, peritonitis.

Intraspinal Infusion

• Administering drugs via epidural or intrathecal routes.

• Requires preservative-free medications to avoid toxicity; monitoring for infection crucial.

IV Solutions Review

Classification of Solutions

Isotonic

• Solutions: 0.9% NaCl, Lactated Ringer’s, D5W (in bag).

• Use: Hypotension, hypovolemia.

Hypotonic

• Solutions: 0.45% NaCl, 0.33% NaCl, D5W (in body).

• Use: Cellular dehydration, DKA (after initial isotonic fluid).

• Contraindication: Increased ICP.

Hypertonic

• Solutions: D5NS, D5 ½ NS, 3% NaCl (critical use).

• Use: Cerebral edema, hyponatremia.

• Note: Only 0.9% Normal Saline allowed for blood transfusions to prevent hemolysis.

Important Precaution

• Never use dextrose or Lactated Ringer’s with blood products due to hemolysis risk and clotting factor interference.

IV Therapy Management

Complications and Monitoring

Key Complications

• Infiltration: Cool, pale, swollen; actions include D/C IV and warm compress application.

• Extravasation: Vesicant leakage causing tissue damage; follow specific protocols for management.

• Phlebitis: Inflammation indicating need for D/C and warm compress.

Infection Indicators

• Fever, chills, and purulent drainage; follow protocols by D/C IV, culture, and notify the provider.

Emergency Situations

1. Air Embolism: Clamp tubing immediately and position patient on left side, Trendelenburg.

2. Fluid Overload: Recognize dyspnea, JVD, and hypertension; act by slowing/stopping IV and notifying provider.

Blood Types & Compatibility

Understanding ABO and Rh Factors

Blood Type Overview

• Types: A, B, AB, O categorized by the presence or absence of antigens and their compatibilities.

• Rh Factor: Positive indicates the presence of the Rh antigen.

Universal Blood Types

• Universal Donor: Type O negative; no antigens.

• Universal Recipient: Type AB positive; contains all antigens but no antibodies.

Blood Products Overview

Types of Blood Products

• Packed RBCs (PRBCs): Increases oxygen carrying capacity; use for anemia and hemorrhage.

• Fresh Frozen Plasma (FFP): Contains clotting factors; administer for coagulopathy, requires ABO compatibility.

• Platelets: For thrombocytopenia; rapid infusion recommended.

Additional Blood Products

• Cryoprecipitate: Contains fibrinogen; indicates when levels critically low.

• Albumin: Plasma protein; no crossmatch required. Used for oncotic pressure maintenance.

Volume Expanders

Definition and Types

• Used to increase intravascular volume; classified as crystalloids (0.9% Normal Saline, Lactated Ringer’s) and colloids (Albumin).

• Crystalloids: inexpensive and first-line for resuscitation (3:1 replacement ratio).

• Colloids: Stay in vessels longer but are expensive.

Monitoring

• Monitor for fluid overload across all expanders; significant signs include crackles and JVD.

Patient Safety in IV Therapy

National Patient Safety Goals: IV Therapy

Key Considerations

• Infection Risk Reduction: Educate patients about catheter details, hygiene, and signs to report.

• Ensure no BP is taken from the arm with catheter and blood draws are from the opposite extremity.

• Perform systematic assessments from insertion site upward.

Securing and Dressing IV Catheters

• Use securement methods to avoid complications.

• Adhere to dressing schedules and proper technique to prevent insertion site contamination.

Massive Transfusion Protocol (MTP)

Definition

• Initiation occurs when ≥10 units PRBCs are needed in 24 hours.

• Common in trauma and significant hemorrhage events.

Complications of MTP

• Triad of Hypothermia, Acidosis, and Coagulopathy; monitor for indicators of these complications and follow protocols for correction.

Blood Transfusion Procedure

BEFORE Transfusion

• Verify consent, obtain baseline vitals, and ensure tubing and patient ID verification (two-RN confirmation).

DURING Transfusion

• Employ safety measures; start slowly and monitor for adverse reactions, notably within the first 15 minutes.

Transfusion Reactions

Types of Reactions

Acute Hemolytic

• Serious reaction from incompatible blood types; signs include fever, chills, low back pain, chest tightness, notifying medical team immediately.

Febrile Non-Hemolytic

• Most common; typically mild, may allow the transfusion to resume post-management with antipyretics.

Allergic and Anaphylactic

• Manage mild allergies with antihistamines; severe require epinephrine.

TACO and TRALI

• Differentiate between overload symptoms (TACO) and TRALI’s respiratory distress indications; manage accordingly.

Scope of Practice

RN vs LPN

RN Scope of Practice for IV Therapy

• RNs can administer all IV meds, oversee all IV therapy including blood, assess patients, educate, and help facilitate and delegate tasks.

LPN Scope of Practice

• LPNs may insert peripheral IVs and monitor infusions but cannot administer IV push meds, blood products, or manage central lines.

Test Yourself: NCLEX-Style Questions

• Apply knowledge with practice questions covering various topics related to IV therapy, blood products, and transfusion reactions.

NCLEX Key Points

• Understand gauge sizes, transfusion protocols, solutions for IV usage, and recognize the severe medical situations to help guide patient care decisions.

Questions?

• Feel free to reach out for further clarification and discussion on vital topics regarding IV therapy and blood product management!

Learning Objectives 1. Management and Monitoring of IV Therapy - Understanding how to administer and observe patients during IV therapy, focusing on maintaining patient comfort and safety while ensuring effective fluid and medication delivery. 2. Select Appropriate Catheter Gauge for Specific Infusion Needs - Importance of selecting the correct gauge for flow and type of solution administered, taking into account the viscosity of the fluid and patient characteristics. 3. Explain Alternative Infusion Routes - Include Intraosseous (IO), subcutaneous, and intraspinal routes, discussing the specific indications, advantages, and limitations of each route. 4. Identify Types of Blood Products and Their Indications - Knowing the different blood products available and their proper use cases, including therapeutic effects and potential complications associated with each product. 5. Explain the Purpose and Types of Volume Expanders - Types of solutions used when blood products are not available, explaining their mechanism of action and clinical situations for use. 6. Recognize Signs of Transfusion Reactions and Nursing Interventions - Identifying complications that may arise during blood transfusions and the emergency responses required, emphasizing the importance of monitoring and rapid intervention. 7. Differentiate Scope of Practice between RN and LPN - Understanding the roles and limitations of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) regarding IV therapy, specifically related to legal and ethical considerations.

IV Therapy Basics ### Types of Access #### Peripheral IV (PIV) - Most common method, inserted into veins of hand, forearm, or antecubital for short-term use (72-96 hours), suitable for various therapies including hydration and medication administration. - Gauge: 14-24 (note: smaller number means larger bore, facilitating higher flow rates). - LPNs can insert and manage PIVs within state regulations, including recognition of complications. #### Central Venous Access - PICC (Peripherally Inserted Central Catheter) and central lines (subclavian, jugular, femoral) for longer therapy durations or administering TPN, allowing for reliable access to the central circulation. - Managed by RNs, with insertion done by RNs (PICC) or physicians, requiring specific training and skill. - Midline Catheters: inserted in the upper arm and used for 1-4 weeks (not suitable for TPN or vesicants), offering an alternative for patients with difficult venous access. - Inserted by specially trained RNs or MDs, emphasizing the need for adherence to sterile techniques.

Vein Selection Considerations - Start distally on the extremities; avoid the wrist (median nerve proximity) to minimize complications. - Avoid joints, previous sites, and areas with medical history (mastectomy, AV fistula) to ensure optimal success. - Check for vein adequacy against the selected catheter gauge, utilizing ultrasound if necessary for challenging access candidates.

Peripheral Catheter Gauge Selection

Reminder - Smaller gauge number means larger catheter bore and faster flow rate, important during critical care situations.