1
Q
What are some disadvantages of IV Therapy?
A
- Invasive therapy
- Higher Cost
- Increased risk of allergy/anaphylaxis
- Scaring
- Infiltration of tissues
- Circulatory overload
2
Q
What information should be on all consent forms created for IV Therapy?
A
- risk and complication review/education for the pt
- explanation of what will happen during tx
- who will be performing the procedure
3
Q
What should be included in the Objective section of IV Therapy SOAP notes?
A
- vitals= pre & post
- size of needle
- how pt tolerated tx
- time= start & end
- drip rate
- pH, total osmolarity
- site of needle insertion
- IV site status
- catheter status
- IV contents (nutrients, fluid carrier, total osmolarity)
4
Q
Know the names of the parts of IV tubing
A
- spike/piercing pin
- vent
- drip chamber
- roller clamp
- Y-port
- Luer Lock/Hub
5
Q
Know all of the “best practice” tips listed in week 2 lecture
A
- ‘Needleless’ dispending devices: use of these devices when mixing solutions. Rationale: reduces contamination and prevents coring of stoppers; also helpful for withdrawing large volumes of Vit C and other viscous fluids
- angiocatheters: safety features preventing needle stick injury, exposure to blood
- UA: perform in office every IV visit to ensure proper kidney function. Will help document safe practices
- Tourniquets: dispose after use with one pt to prevent exposure/contamination
- Transparent semipermeable dressing: best for securing IV catheters. Cover insertion site and hub
6
Q
Isotonic soln
A
- has an osmolarity about equal to that of serum. Because it stays in the intravascular space, it expands the intravascular compartment.
- no effect on the volume of fluid w/in the cell
- solution infused remains in the ECF; used to expand the ECF
Examples: `0.9% sodium chloride (N saline), lactated ringer’s solution (a balanced electrolyte solution- hospital rehydration), 5% dextrose in water (D5W is a solution containing 5% dextrose in water)
7
Q
Lactated Ringers
A
Isotonic Solution
-used to tx dehydration, the infusion rate can be as high as 500 ml/hr if the patient has N cardiac & renal fxn
8
Q
Cell in hypotonic soln
A
- has an osmolarity lower than that of serum
- shifts fluid out of the intravascular compartment, hydrating the cells and the interstitial compartments (into intracellular space)
-water moves into cells, possibly causing them to burst
~contains less solutes than the intracellular space
-hydration of cells may deplete the circulatory system (e.g. plasma vol)
Example: 2.5% dextrose in water, 0.45% NaCl
9
Q
Cell in hypertonic soln
A
-has an osmolarity higher than that of serum
-draws fluid into the intravascular compartment from the cells & the interstitial compartments
-will shift ECF from the interstitial spaces into the plasma
-water w/in a cell moves to the ECF, causing cells to shrink
-most of the therapeutic vitamin & mineral solutions administered by naturopaths are hypertonic
-most of the therapeutic vitamin & mineral solutions
Examples: 5% dextrose in 0.9% NaCl, 5% dextrose in lactated ringers, 10% dextrose, colloids (albumin 25%, dextran, plasma protein fraction)
10
Q
Isotonic Solution Osmolarity
A
250-375 mOsm/L
11
Q
Hypotonic Solution Osmolarity
A
< 250 mOsm/L
12
Q
Hypertonic Solution Osmolarity
A
> 375 mOsm/L
13
Q
Know how infusion of these different solutions affects fluid balance in different compartments: intracellular
A
fluid within cells; high in K+ and low in Na+
14
Q
Know how infusion of these different solutions affects fluid balance in different compartments:interstitial, intravascular.
A
Extracellular fluid – blood, lymph, interstitial fluid, channels of the brain and spinal cord and in muscular and other body tissues, tends to be high in Na+ and low in K+
15
Q
how to calculate osmolarity
A
Osm = [total mOsm / Total vol in mL] *1000
16
Q
Know how to calculate drip rate, infusion rate
A
-Volume of solution to be infused
-Time frame for infusion of the solution
-Drip factor of specific type of IV tubing you are using
ii
Drip rate = gtts/min= vol (mL) x drop factor (gtts/mL)
Time (min)
17
Q
Know which solutions need cautious infusion rates and why
A
- High osmolarity (> 600 mOsm/L) due to potential for irritating the vein, the infusion rate should be btn 150-200 ml/hr
- Solutions that can act on heart or vasculature: IV fluids w Ca++, Mg++ or K+ can cause cardiac irregularities if infused too rapidly, so keep infusion rate between 150-200 ml/hr. Also, Mg++ can cause hypotension due to its vasodilating effects.
- Solns w very high conc of Vit C (>50 grams) are best infused through devices that terminate in the superior vena cava (PICC lines, Groshong lines, port-a-caths)
- HTN can occur if fluid is infused too rapidly, due to incr fluid volume in the circulatory system
18
Q
Calcium: Adverse side effects, special considerations with calcium gluconate
A
- loss of appetite, nausea, vomiting, constipation, abdominal pain, dry mouth, third and frequent urination; more severe may result in confusion, delirium, coma and death
- Shell fish allergy
Adverse reactions: hypotension, bradycardia, arrhythmia, tingling sensations, syncope, cardiac arrest due to effect on nerve conditions and muscle contraction
19
Q
Magnesium: Adverse side effects of magnesium,
A
flushed w a sensation of heat often in the face, skin, trunk, followed by hypotension, cold sweating and even fainting
20
Q
Magnesium: common administration rates, researched uses
A
- DO NOT GIVE MORE THAN 4G PER ADMINISTRATION
- Common push: up to 1500 mg over 20-40 min
- Common drip: up to 3000 mg over 2 hours
21
Q
Combine Magnesium Chloride with Calcium _____
Combine Magnesium Sulfate with Calcium _____
A
Chloride
Gluconate
22
Q
uses of Magnesium
A
Pts w ST elevation and AMI, migraines, bronchial hyper-reactivity, asthma and headache, mag chloride for cardiac arrhythmia.
23
Q
How to administer Potassium
A
Never as a push, always diluted 100ml or more
Give with MTE-4
24
Q
When to use caution with potassium
A
- Renal insufficiency
- Endocrine disorders (hypoaldosteronism)
- Potassium sparing/altering medications (diuretics, ACE inhibitors, ARBS, digoxin, beta blockers, etc)
25
dose and administration of potassium
- 2-5 ml in a drip containing 200-500 ml, given over 1-3 hours.
- Administer at a rate not to exceed 10-20 mEq/hr
- Maximum dose of 100mEq in 24hours
26
What are the constituents of MTE 4 and MTE 5
MTE 4: Chromium, copper, manganese, zinc
MTE 5: Chromium, copper, manganese, zinc, selenium
27
Conditions to use caution in with Copper
caution with cholestasis, cirrhosis, Wilson’s dz of copper storage
28
Conditions to use caution in with Manganese
– caution with cholestasis (toxicity may result if biliary excretion is impaired), may cause neuropsychiatric sxs: irritability, excitement, compulsive behavior
29
Conditions to use caution in with Molybdenum
– aggravates copper deficiency; avoid in pregnancy
30
Conditions to use caution in with Selenium – caution with renal dz, decreased excretion
caution with renal dz, decreased excretion
31
Conditions to use caution in with Zinc
caution with renal dz, biliary excretion conditions, pregnancy, wilson’s dz
32
What must be decided for each patient as you are formulating his or her potential IV therapy?
a. Goals and monitoring
b. Push vs drip
c. Carrier solution
d. Which nutrients to use
e. Solution osmolarity
f. Which vein to use
g. Infusion rate
33
What are the main difference between and IV Push and an IV Drip?
IV Push/syringe
• Smaller volume of nutrients administered with a push
• Butterfly needle 21-25 gauge MC
• Need to make sure that tubing is flushed
• Volume 5-60 cc
• Typically more concentrated
• Can inject directly into IV tubing via Y-port
• Primary IV set is usually clamped off
• Practitioner intensive
```
IV Drip
• Large volume parenteral (LVP)
• Hung on an IV pole above patient’s head
• Flow is maintained by gravity
• Sterile tubing attached to LVP
• Catheter in patient’s vein
• 20-24 gauge MC
• Infusion 1-3 hrs
• Volume 100 + cc
• Typically less concentrated
• Less practitioner intensive
```
34
Over what gram amount of Vitamin C must you check for a G6PD deficiency?
Dosage > 5g
35
Compounded IV solutions fall under the USP exemption for Immediate Use if they are used within____ of starting the preparation of the solution.
one hour
36
How soon must you use uncontaminated multidose vials (Under USP Chapter 51)?
28 days
37
1. Review the different standards of care for site prep before starting an IV.
-Preparation: circular wipe from center to periphery- clean to dirty. Repeat with new swab until they are no longer discolored
If chlorhexidine allergy
- Alcohol then Povidone Iodine. Do NOT rub off Iodine
- May also use 10% H2O2
IV duration < 30-45 min
- Access device: any-butterfly or catheter OK
- Preparation: any- isopropyl ETOH only OK
IV duration > 30-45 min
- Access device: catheter only
- Preparation: isopropyl ETOH plus chloraprep
38
1. When writing a well-designed Evidence Based Medicine question, you should include 4 elements, PICO: what does this stand for?
a. Patient, problem, population
b. Intervention
c. Comparison, control
d. Outcome
39
diagnosis codes
ICD10
40
procedure codes for a medical, surgical or diagnostic service
CPT Code
41
Use of CPT code of 99212 (Most common) for
i. visit portion-updating meds, allergies, health hx, vitals
42
J codes
relate to cost of drugs that ordinarily can’t be self-administered
43
Can you give hypotonic solutions to patients with low blood pressure? Why or why not?
do not give hypotonic solutions to pts w low BP bc it will further a hypotensive state
44
Upper Limit for a peripheral IV is what osmolarity?
900
45
Solutions less than what rarely cause phlebitis
<450
46
Osmolarity choice for IV push in Small Medium and large vein
Large vein: 1200
Med vein: 950
Small vein: 400
47
Osmolarity choice for IV drip in Small Medium and large vein
Large: 1400
Medium: 700
Small: 400
48
What is the Ideal pH
7-7.5
49
What can be used to alter the pH of an IV solution?
a. Normal saline to decrease the pH
b. Sodium bicarbonate to increase the pH
i. Do not combine with other nutrients in single syringe
50
How recently must lab tests (CBC, CMP) have been completed in order to be able to administer an IV treatment?
6 months
51
On a UA, Specific gravity: normal, Low,
| High
a. Specific gravity: normal (1.005 – 1.030)
i. Low – renal dz (decr ability to concentrate urine), overhydration
ii. High – dehydration
52
On a UA, Glucose: normal/abnormal
Normal is negative
| Positive= confirm with blood glucose
53
On a UA, Protein
a. normal is negative
i. Positive
1. Renal dz, acute infx, trauma, HTN, malignancy, poisoning, toxemia
2. False positive (esp w alkaline urine)
a. May do SSA to confirm
b. Retest on different day or measure 24 hour quantitative protein
54
On a Ua, Blood
i. Positive
1. In females, check is menstruating
2. UTI, stones, renal dz, trauma, medications esp anticoagulants, malignancy
3. Confirm w microscropic exam of urine
4. True positive may cause false positive protein
5. Idiopathic hematuria is relatively common and often transient but always work it up esp in pts > 40 yo bc of risk of malignancy.
ii. False positive
1. Males – semen in urethra after ejaculation and may cause positive heme reaction on the dipstick
2. Alkaline urine with pH > 9
3. Presence of myoglobinuria
55
On a Ua ,Bilirubin
- Positive: biliary tract dz
- Cirrhosis
- Gallstones in biliary tract
- Hepatitis
- Liver dz
- Tumors of the liver or GB
- May confirm w Ictotest, esp if urine is dark in color. I.
56
Vitamin C may cause a false negative in what UA test?
Blood
57
What should you add to high dose vitamin C due to its weak chelating properties?
Calcium glutinate
58
1. Review the effects of high dose vitamin C on blood sugar.
- Hexose derivative, inducing insulin and decreasing blood glucose.
- bring snacks during infusion to prevent hypoglycemia
59
1. Review proper sharps disposal.
a. avoid recapping, bending or breaking needles
b. immediately dispose of used needles and other sharps in sharps container
c. always keep sharps container as close to your work station as possible. Never carry any used or uncapped needle across the room for disposal
60
What is the ml/kg dosage of Epinepherine given during anaphylaxis for an adult versus a child?
Adult: 0.2 – 0.5mg (1:1000 [1 mg/mL] solution) every 5 -15 min in the absence of clinical improvement
Child: 0.01 mg/kg (0.1 mL/kg of 1:1000 [1 mg/mL] solution) every 5 to 15 min
Max single dose: 0.3 mg
61
What is the Oral versus IV dosage of Diphenhydramine for an adult?
- Oral administration: 25-50 mg capsules; onset 15 min
| - IM-IV: 10-50 mg in a single dose every 2-4 hrs; do not exceed 400mg/day immediate onset
62
The antidote for magnesium overdose is which nutrient?
- Calcium gluconate
63
If you suspect a catheter embolism, what are the proper steps to take?
- Stop infusion
- Apply tourniquet above IV site
- Start a new IV in other arm
- Arrange for an xray
64
What do you do to treat an ecchymosis?
a. Apply pressure after catheter/needle removed
b. Elevate extremity above pt’s head to maximize venous return
c. Apply cold pack to site
65
What are the signs and symptoms of a thrombosis?
a. Pain at the site
b. Site warm to touch
Sluggish or no infusion rate
66
Possible causes of phlebitis include?
a. Trauma to the vein with cannula/needle – mechanical phlebitis
b. Irritation due to type of fluid infused – chemical phlebitis
c. Introduction of pathogens related to contaminated needle/site prior to insertion – bacterial phlebitis
67
If you suspect pulmonary embolism, what are the steps to take?
call 911
- keep patient sitting upright
- give O2 by mask
- maintain IV site
- transport to hospital
68
what are the signs and symptoms of a person in shock?
a. rapid respiration rate (SOB)
b. anxiety or restlessness
c. distended neck veins
d. HTN
e. Rise in central venous pressure
69
What is the difference between infiltration and extravasation?
a. Infiltration – seepage of non-vesicant IV fluid/medication into surrounding tissues
b. Extravasation - infiltration of vesicant solution into the tissues
70
if you suspect a patient is experiencing infiltration, what steps to you take to help?
a. Stop IV immediately and remove IV
b. Apply ice if infiltration was detected within 30 min, otherwise apply warm compress
c. Elevate site above heart level
71
you suspect a patient is experiencing infiltration, what steps to you take to help?
a. Stop IV immediately and remove IV
b. Apply ice if infiltration was detected within 30 min, otherwise apply warm compress
c. Elevate site above heart level
72
Review how to prevent coring of a IV bottle
o The needle should be inserted at a 45-60° angle to the plane of the stopper with the opening of the needle tip facing up (i.e., away from the stopper).
o A small amount of pressure is applied and the angle is gradually increased as the needle enters the vial.
o The needle should be at a 90° angle just as the needle bevel passes through the stopper
73
Know what information is needed on a IV bag/syringe
i. Pt initials, DOB, date and time of preparation
74
When do you use a filter needle?
calcium gluconate
75
Know how to use the roller clamp on the IV tubing.
i. Roll all the way down to close/stop
| ii. Drip rate controller by roller clamp
76
Review which steps or the nutrient draw-up procedure need alcohol to be used.
i. Always clean top of nutrient bottle/swan lock with alcohol even if new bottle
ii. Clean containers carrier solutions with alcohol
77
Isotonic Solution Indication and Cautions
-indications:
fluid loss
dehydration
hypernatremia
caution:
- pts w/ renal dz & cardiac dz
- pts w/ increased risk of fluid overload
- may cz dilution of the hgb and lower hct levels
78
Hypertonic Indication and Cautions
- replaces electrolytes
- treats hypotonic dehydration
- temporary tx of circulatory insufficiency and shock
Caution:
- irritating to vein walls
- may cause circulatory overload
- some are C/I in patients with heart failure and pulmonary edema
- give slowlyy
79
Hypotonic Solution Indication and Contraindication
indications:
- hypertonic dehydration
- water replacement
- diabetic ketoacidosis after initial sodium chloride replacement
caution:
* do not give to pts w/ low blood pressure b/c it will further a hypotensive state
- can deplete the circulatory system, can cause hemolysis
IV Therapy
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