IV Therapy

Question 1

Purpose of IV Therapy

Answer 1

• maintain fluid, electrolyte and energy demands
• prevent fluid and electrolyte imbalances
• administer blood and blood products
• administer total parenteral nutrition
• administer prescribed IV medications (i.e. antibiotics)
• to have venous access in case of emergency (KVO-keep vein open)

Question 2

Nursing Responsibilities (IV)

Answer 2

a. assess need for IV therapy
b. assess IV site
c. assess/maintain prescribed IV flow rate
d. assess patient response to IV therapy
e. prevent complications associated with IV therapy

Question 3

Signs and Symptoms of Fluid volume deficit (FVD)

Answer 3

• loss > 2.2 lbs in 24 hr
• decreased b/p
• tachycardia
• slow cap refill
• dry skin and mucous membranes
• decreased skin turgor
• thirst (late sign)
• decreased urine output
• confusion/restlessness (very late sign)

Question 4

Signs and Symptoms of Fluid volume excess (FVE)

Answer 4

• gain < 2.2lbs in 24 hr
• bound pulse
• distended neck veins
• abnormal lung sounds (crackles)
• edema

Question 5

Vascular Access Devices

Answer 5

a. Peripheral Vascular Access Devices (PVADs)
SHORT TERM USE
b. Central Vascular Access Devices (CVADs)
LONG TERM USE
1. central venous catheters
- meds that irritate veins, i.e. chemotherapy
- poor peripheral veins
- large volume of fluids
- emergency
2. Implanted infusion ports
- implanted underneath skin
3. Peripherally inserted central catheters (PICC)
- through peripheral vein and through to the vena cava

Question 6

Equipment

Answer 6

a. IV cannulas (16G, 18G, 20G, 22G, 24G)
b. tourniquet
c. gloves
d. antiseptic swabs
e. IV dressing (transparent occlusive)

Question 7

Common Peripheral IV sites

Answer 7

median cubital, cephalic (hand), great saphenous vein (foot)

• choose non-dominant hand
• most distal site possible in case vein punctures
• feet in infant and children only
• feet in adult may cause clot or venous return issues
• avoid anywhere with infection or thrombosis
• 70% alcohol or chlorhexidine to clean site

Question 8

Changing an IV dressing

Answer 8

• change as per organizational policy
• hand hygiene
• apply gloves
• be careful not to dislodge catheter when removing old dressing
• assess IV site
• clean site in circular motion

Question 9

Considerations in Older Persons

Answer 9

• use smaller gauge needle (22-24g)
• choose site that does not interfere with ADLs
• use minimal tourniquet pressure
• lower angle of insertion
• apply traction to skin below insertion site
• use protective device

Question 10

IV Fluids

Answer 10

Crystalloids

• contains solutes that mix, dissolve and cross semi-permeable membranes, smaller molecule
  a. NaCl
  b. Dextrose
  c. Lactated ringer’s

Colloids

• contain proteins or starch that do not cross semi-permeable membranes, remain in extracellular space/intravascular fluid
• increase vascular volume
  a. blood
  b. plasma proteins
  c. pentastarch

Total Parenteral Nutrition (TPN)

• nutritionally adequate solution
  a. glucose
  b. nutrients
  c. other electrolytes

Question 11

Crystalloid IV Solutions

Answer 11

Isotonic

• same osmolarity as blood
• expands fluid volume without fluid shift between compartments
  i. e. normal saline (0.9%), dextrose 5% in water (D5W), LR
  uses: increase or replace vascular volume from vomiting, diarrhea

Hypotonic

• lower osmotic pressure
• moves fluid into cells, causing them to enlarge, hydrates the cell
  i. e. 0.45% NS, 0.225% NS
  uses: cellular dehydration (risk: hypovolemia, hypotension)

Hypertonic

• higher solute concentration
• pulls fluid out of cells, causing them to shrink
  i. e. D10W, 3-5% NS, D5LR
  uses: cerebral edema, severe hyponatremia

Question 12

Body fluids

Answer 12

Intracellular fluid
- fluid within the cells
0 60% of body fluids

Extracellular fluid

• fluid outside of cells
  a. interstitial (between cells and outside vessels)
  b. intravascular (blood plasma)
  c. transcellular (cerebrospinal fluid, peritonea, synovial and GI tract)

Question 13

Common Additives

Answer 13

- potassium chloride KCl (red writing)
always runs through infusion bump, never directly inserted
used to treat vomiting, diarrhea
can result in death
- multivitamins (banana bag)

Question 14

IV Tubing

Answer 14

Macrodrip - 10 or 15 gtts/mL

Microdrop - 60 gtts/mL

• a lot more precise!
• critical care and peds

Buretrols
volume control device, reduces risk of an increased volume being infused

Question 15

Regulating IV Flow Rate

Answer 15

• manual regulation using roller clamp
• electronic infusion devices (EIDs) - infusion bumps

(Infusion volume x drop factor)/time in minutes = gtt/min

Follow rounding principle
*unless solution needs to be infused especially slowly, then round down

Question 16

Factors influencing flow rate

Answer 16

• patency of IV catheter
• patency of IV tubing
• height of solution
• restrictive IV dressing
• position of extremity
• infiltration (solution goes into surrounding tissue and not vein itself)

Question 17

IV Maintenance

Answer 17

• keep the system sterile, alcohol swab and hand hygiene
• 10ml of air or less, as little as possible
• assist patient with self-care activities
• assess IV infusion and site regularly
• change solution when there is ~50 mls remaining

Question 18

Infiltration

Answer 18

IV fluid (non-vesicant) enters subcutaneous space but not vein itself

symptoms: swelling, pallor, coolness, pain, leakage from IV site
prevention: avoid area of flexion, observe site frequently, advise pt to report any swelling or tenderness
intervention: discontinue IV, raise affected extremity to promote venous return, apply warm compress for 20 mins

Question 19

Extravasation

Answer 19

Vesicant medications/fluids enter subcutaneous space
i.e. chemotherapy, epinephrine

symptoms: burning or pain at IV site, swelling, coolness, blistering or skin sloughing, leakage from IV site
prevention: avoid small veins and area of flexion, give vesicant meds last, adhere to proper administration techniques
intervention: discontinue IV unless administering antidote, notify md, elevate extremity, apply warm or cool compress (as per manufacturer indication)

Question 20

Phlebitis

Answer 20

Inflammation of the vein, can result in blood clots and emboli

symptoms: pain, edema, redness along the vein, warmth
prevention: avoid flexion, dilute meds as per instruction, be especially careful with certain meds with chemicals added or antibiotics
intervention: discontinue IV, apply warm compress

Question 21

Infection

Answer 21

symptoms: redness and possible discharge at IV site, elevated temperature
prevention: use aseptic technique, hand hygiene before any contact with infusion system, clean injection ports before use
intervention: discontinue IV and notify MD, remove device and culture site/catheter as ordered, monitor vitals

Question 22

Bleeding/bruising

Answer 22

risk factors: patients receiving heparin, patient with bleeding disorders

interventions: apply pressure dressing at the site

Question 23

Fluid Overload

Answer 23

Occurs when fluids are given at a higher rate and in a larger volume than the body can absorb or excrete

complications: HTN, heart failure, pulmonary edema

treatment will depend on severity

• fluid management
• medication administration
• diuretics

Question 24

Air embolism

Answer 24

Presence of air in the vascular system that travels into the right ventricle and/or pulmonary circulation

symptoms: SOB, cough, neck/should pain, anxiety, light headedness, hypotension, increased HR
prevention: ensure drip chamber is 1/3-1/22 full, ensure IV connections are secure, remove air by priming tubing
intervention: occlude source of air entry, trendelenburg position, oxygen, vitals, notify MD

Question 25

Advantages of IV route

Answer 25

1. Rapid response 2. Effective absorption 3. Accurate titration 4. Can be stopped immediately in case of adverse reaction

Question 26

Disadvantages of IV route

Answer 26

1. Solution and drug incompatibilities - physical or pharmaceutical incompatibility - chemical incompatibility (foaming, crystal forming) - therapeutic incompatibility (make another more/less potent) 2. Immediate adverse rection 3. Long-term use damages intima (layer around lumen)

Question 27

Preparing IV Medications

Answer 27

a. aseptic technique b. independent, double-check of calculated, high or unusual doses and high-alert drugs c. know key information d. reconstitute powdered drugs e. dilute medication in suitable amount of compatible solution f. label IV bag g. check compatibility (IV compatibility wall chart)

Question 28

Administering IV Medications

Answer 28

a. asses patient - vital signs! b. check IV site first c. follow 10 rights and 2 checks using MAR - what you are giving, why you are giving it d. observe closely for s&s of adverse reaction

Question 29

Continuous infusions

Answer 29

Mixture within large volume of IV fluid in primary site a. pre-mixed: heparin drip, morphine drip, KCl added b. added by RN: morphine drip, multivitamins

Question 30

Direct injection (IV push or bolus)

Answer 30

Inject directly into vein without IV line or through an existing infusion line - clamp infusion tube above the injection port to ensure meds go into the body - luer-lock technology only certain RNs are able to give IV push drugs (ICU, emerg, PACU)

Question 31

Admixture: Adding Meds to IV bag

Answer 31

- use aseptic technique (clean injection port!) - inject through port using syringe - mix well - often pre-prepared - label

Question 32

Piggy back of mini bag infusions

Answer 32

Piggy-back (add a line or secondary medication set) through: a. primary IV b. device such as saline or heparin lock Principles: - ensure compatibility of secondary extension tubing - secondary bag is higher - use roller clamp on primary line to set flow rate - prime secondary bag by lowering bag, let fluid from primary bag flow into secondary tubing to let air out

Question 33

Intermittent Infusion Devices (saline or heparin locks)

Answer 33

IV catheter that is threaded into a peripheral vein, flushes with saline and then capped off for later use Minimal amount of fluid for patient Protects privacy Must be flushed after each use, prevent blood clotting

Question 34

Types of Saline Locks (Needle-less access)

Answer 34

1. Prepierced septum/blunt cannula 2. Luer-activated device 3. Valve technology - positive pressure caps used for CVAD caps redirects a small amount of fluid into the internal catheter tip to prevent blood reflux into the lumen

Question 35

Flushing

Answer 35

*Check patency first! Saline > Administration of Meds > Saline - use 10mL diameter syringes pre-filled with normal saline PVAD (saline lock) flushed with at least 3mL of NS before and after administration of medications and prior to locking Standard 3mL - 55ps BD Posiflush 3mL - 19.75o

Question 36

Turbulent Flush Technique

Answer 36

Push-pause (start-stop) flushing method - allows flushing solution to "scrub" inside of device wall - promotes removal of blood/fibrin - important for CVAD

Question 37

Positive Pressure Locking Technique

Answer 37

To prevent blood reflux from the vein into the lumen of the VAD, prevent occlusions Maintain a forward motion on the syringe plunger as the syringe is removed form the access/injection site or slide clamp as you push last 1-2ml

Question 38

Other methods

Answer 38

a. administering IV meds via buretrol - inject into buretrol b. PCA (patient controlled analgesia) - patient self dosing: monitor! - subcu, IV or epidurally

Question 39

IHI Suggestions for reducing ADEs

Answer 39

- standardized IV solutions - pre-mixed solutions - smart infusion pumps - label

Question 40

Troubleshooting (IV not working)

Answer 40

a. check site for infiltration b. check for kinks or leaks c. reposition arm d. . increase flow rate e. lower bag below arm to check for blood return f. raise IV pole g. check that clamps are open

Question 41

Adverse or Allergic Reaction

Answer 41

a. stop medication immediately b. follow guidelines for response, assessment and reporting c. notify MD d. document allergy in health care record e. let the patient know!

Question 42

Discontinuation of Peripheral IVs

Answer 42

a. close all clamps prior to discontinuation b. remove tape and site dressing, stabilize catheter while doing this c. apply light pressure and withdraw catheter, keep hub parallel to skin d. apply pressure for 2-3 minutes e. cover site with gauze or bandage f. inspect catheter tip for intactness