Unit 11. Objectives. Indications for IV Therapy. Intravenous Access Devices & Common IV Fluids. 3 categories. Maintenance Replacement Restoration

Transcription

1 Unit 11 Fluids, Electrolytes and Acid Base Imbalances Intravenous Access Devices & Common IV Fluids Objectives Review the purpose and types of intravenous (IV) therapy. Recall the nursing care related to IV therapy appropriate for patients across the lifespan. Outline the steps to an IV assessment for various types of patients and IV therapy. Differentiate and start to evaluate diagnostic exams used to assess appropriateness of IV therapy. Distinguish between the nursing care of the patient with TPN and peripheral IV therapy. Compare and contrast rationales behind long term antimicrobial therapy. Relate nursing care to long-term antimicrobial therapy. Indications for IV Therapy 3 categories Maintenance Replacement Restoration

2 Nursing care related to IV Therapy Prescreening Ongoing screening Care and Assessment of the IV site Hourly site assessment Monitor flow rate Monitor Intake and output Monitor vital signs Types of Access Peripheral Central External Internal

3 Types of Devices Ash-Cath (dialysis Catheter) Port-a-cath Single lumen PICC Triple Lumen Hickman Groshong Catheter Central Venous Access What is it needed for? Chemotherapy Total parenteral nutrition (TPN) Antibiotics Blood transfusions Rehydration Multiple / frequent blood tests Why is it useful? Reduces damage to small peripheral veins from toxic solutions Long-term placement of these devices allows for reduced number of venous punctures for routine (frequent) line changes

4 What are the considerations? Device type Hickman, PICC, Groshong, ASH etc. Port (this is the part that that receives the needle during injections) This can be subcutaneous (under the skin) or external Tubing (connects the port to the vein) This can be external or tunneled under the skin Insertion site Peripheral (into small arm veins) Central (into large veins, near heart) Number of lumens (tubes) Triple Lumen Placed by the physician Allows for multiple IV drips simultaneously Easy and quick access in emergency (if physician is present) Peripherally inserted central catheter (PICC) It s a non-tunneled external catheter Small flexible catheter inserted into a peripheral vein then threaded so that its tip is positioned in a central location

5 Why a PICC? Best suited for treatments lasting from several weeks to 6 months requiring frequent access to veins There is also a short version of the PICC known as a midline, the tip of this catheter does not end up in as large or central a vein as a standard PICC line PICC cont d Pros Only slightly more invasive than a standard IV Easily inserted and removed Inexpensive Complications are rare and usually minor Cons High maintenance (require daily flushing) Often migrates Limits lifestyle (showering, swimming) Best suited for treatments lasting from several weeks to 6 months PICC Line A word of caution Blood drawing shortens the service interval of PICC lines When done through a dual lumen line (a tube with 2 tubes), the large lumen should be used for sampling

6 Port-a-cath (Subcutaneous devices) Plastic or metal (titanium) housing placed under the skin and connected to the vein via a tube The port is a silicone disk that can withstand 2000 punctures It can be single or dual lumen Subcutaneous Port Pros: Least maintenance Good for long term access (> 6 months) or monthly chemotherapy Cons: Most costly device Most time consuming to implant and explant Tunneled Catheters such as Hickman and Broviac Catheter A tunneled external catheter Single or dual lumen Reasons for use: Frequent access High flow infusion and or Infusion blood products Intermediate to long-term use

7 Broviac or Hickman Catheters Insertion of Hickman A tunnel is made under the skin between the port and the vein In this diagram, the catheter goes into subclavian vein Dacron Cuff Possible complications of Central Lines Acute/related to procedure (all rare) Sepsis (systemic infection)4% Pneumothorax (air in chest) 1-2% Hemothorax (blood in chest) 1% Hematoma (blood clot) 1% Mediastinal hemorrhage 1% Air embolism 1% Arterial injury 0.5% Wound dehiscence 1%

8 Site Care Refer to the copy of the Policy it is individual for each facility Central Line dressing change kit Explain to patient Dialysis catheter sites are usually cared for by the HD nurse Document date and time of change on the dressing site with your initials and in the nurses notes Document in Patient care note: Tolerates procedure IV site observation Condition of skin (irritation, inflammation, drainage, etc) Peripheral Sites Not nearly as complex Short term use Close observation for infiltration and redness Variety of sizes Blood Component Therapy Types of blood products Whole Blood PRBC s Platelets Cryoprecipitate FFP Plasma

9 TPN Total Parenteral Nutrition Composition Methods of Administration Catheter placement Potential complications Nursing management Long Term antimicrobial Therapy Complications of antimicrobial therapy include diarrhea secondary to overgrowth with Clostridium difficile Overgrowth of resistant organisms Common solutions Indications Dextrose Sodium Chloride Dextrose and Saline Ringer s and Lactated Ringer s solution Maintains homeostasis through sparing the body proteins. Provides basic nutrition of sugars. Provides calories for energy Provides water Used as a diluent for IV medications Treats dehydration Replaces the loss of sodium and chlorides Replaces the lost extracellular fluids Used as diluent for IV medications Used to correct water overload of tissues Used to irrigate venous and arterial devices Hydrates cells Promotes diuresis Supplies calories Used as a plasma extender Replaces lost electrolytes and nutrients Replaces lost extracellular fluids Used to treat burns and dehydration Provides electrolytes

10 Common IV Fluid Use Contraindications Isotonic saline Replaces losses in conditions such as GI fluid loss and burns CHF, Pulmonary edema, renal impairment Isotonic 5% dextrose in water Hypotonic 10% dextrose in water Isotonic 5% dextrose in 0.3% NaCl Maintain fluid intake and provide daily caloric needs, acts as peripheral nutrition, does not replace electrolyte deficits Supplies calories for nutritional needs Head injuries, added insulin for persons with DM No typical contraindications, added insulin for persons with DM Hypotonic 5% dextrose in 0.9% NaCl Isotonic Ringer s solution Isotonic Lactated Ringer s solution Maintains fluid intake, is maintenance fluid of choice if no electrolytes are needed Replaces electrolytes in concentrations similar to normal plasma levels contains no calories Has similar electrolytes as in plasma, correct metabolic acidosis, replaces fluid losses from conditions such as diarrhea and burns No typical contraindications, added insulin for persons with DM Electrolyte replacement is not needed CHF, Renal impairments, liver disease, respiratory alkalosis or acidosis