LPN 8 Hour Didactic IV Education Peripheral Intravenous Therapy By Pamela Truscott, MSN, Nurse Educator, RN Peripheral Vascular System Health assessment and physical examination Adequacy of blood flow Integrity of the venous system Factors impacting circulatory functioning
Peripheral Veins Inspect for varicosities, peripheral edema and phlebitis Varicosities superficial veins that become dilated Dependent edema sign of venous insufficiency or right-sided heart failure Phlebitis inflammation of vein due to trauma, infection, immobilization, or prolonged IV catheter insertion Peripheral Replacement of Fluids and Electrolytes Peripheral IV catheter tip lies in a vein in the extremity Central Venous IV catheter tip lies in the central circulatory system e.g., vena cava close to right atrium of the heart Maintain standard precautions to minimize your risk of exposure to bloodborne pathogens
Parenteral Nutrition IV administration of highly concentrated solution containing nutrients and electrolytes May be administered, depending on osmolality, through peripheral IV or central IV Osmolality concentration or osmotic pressure of a solution Intravenous Therapy (Crystalloids) Goal of IV fluid administration correct or prevent fluid/electrolyte disturbances Allows direct access to vascular system Must have provider s order for type, amount, speed of administration Must have knowledge of correct ordered solution, reason ordered, equipment needed, procedures required to initiation infusion, regulate infusion rate and maintain system, how to identify/correct problems, and how to discontinue infusion
Types of Solutions Isotonic same effective osmolality as body fluids e.g., normal saline indicated for extracellular fluid volume replacement Hypotonic effective osmolality less than body fluids Decreasing osmolality by diluting body fluids and moving water into cells Hypertonic effective osmolality greater than body fluids Increase osmolality rapidly and pull water out of cells, causing them to shrivel Intravenous Solutions Solution Dextrose in Water Solutions Saline Solutions Comments Dextrose is another name for glucose Saline is sodium chloride in water Dextrose in Saline Solutions Balanced Electrolyte Solutions
Dextrose in Water Solutions Solution Concentration Comments Dextrose 5% in Water (D 5 W) Isotonic Isotonic when first enters vein; dextrose enters cells rapidly, leaving free water, which dilutes ECF; most of water then enters cells by osmosis Dextrose 10% in Water (D 10 W) Hypertonic Hypertonic when first enters vein, dextrose enters cells rapidly, leaving free water, which dilutes ECF; most of water then enters cells by osmosis Saline Solutions Solution Concentration Comments 0.225% sodium chloride (quarter normal saline, ¼ NS; 0.225% NaCl) Hypotonic Expands ECV (vascular and interstitial) and rehydrates cells 0.45% sodium chloride (half normal saline; ½ NS; 0.45% NaCl Hypotonic Expands ECV (vascular and interstitial) and rehydrates cells 0.9% sodium chloride (normal saline, 0.9% NaCl) Isotonic Expands ECV (vascular and interstitial); does not enter cells 3% or 5% sodium chloride (hypertonic saline; 3% or 5% NaCl Hypertonic Draws water from cells into ECF by osmosis
Dextrose in Saline Solutions Solution Concentration Comments Dextrose 5% in 0.45% NaCl sodium chloride (D 5 ½ NS; D 5 0.45% NaCl) Hypertonic Dextrose enters cells rapidly, leaving 0.45% sodium chloride Dextrose 5% in 0.9% sodium chloride (D 5 NS; D 5 0.9% NaCl) Hypertonic Dextrose enters cells rapidly, leaving 0.9% sodium chloride Balanced Electrolyte Solutions Solution Concentration Comments Lactated Ringer s (LR) Isotonic Contains Na +, K +, CL -, and lactate, which liver metabolizes to HCO 3-. Expands ECV (vascular and interstitial); does not enter cells. Dextrose 5% in Lactated Ringer s (D 5 LR) Hypertonic Dextrose enters cells rapidly, leaving Lactated Ringer s.
Equipment Sterile technique necessary fluids infuse directly into bloodstream Large gauge indicates small diameter catheter Over-the-needle catheter small plastic tube/catheter threaded over sharp stylet/needle IV catheter connects to primary line Electronic Infusion Devices (EIDs) are infusion pumps Gravity-flow IVs do not utilize EIDs and work by gravity through microdrip and macrodrip tubing Over-the-needle IV Catheter
Initiating the Intravenous Line Assess patient for a venipuncture site e.g., inner arm Venipuncture is contraindicated if site has signs of infection, infiltration, or thrombosis Avoid vascular graft/fistula sites Avoid same side as mastectomy Avoid areas of flexion Choose most distal appropriate site
Common IV Sites Regulating the Infusion Flow Rate Correct IV infusion rate ensures patient safety Electronic Infusion Devices (EIDs) also called IV pumps or Infusion Pumps, deliver accurate hourly IV infusion rate Ensure proper insertion of infusion tubing on EID or gravity-flow system before opening clamps Ensure that tubing is not kinked, knotted, occluded, or damaged
Electronic Infusion Pump IV Pump Maintaining the System Keep the system sterile and intact Change IV fluid containers, tubing and contaminated site dressings Help patient with self-care activities to prevent disruption of system Monitor for complications of IV therapy
Helping Patients to Protect Intravenous Integrity Help patient with hygiene, comfort measures, meals, and ambulation Teach nursing assistants and patients that they must not break the integrity of the IV line Arm or hand infusion patients are able to walk unless contraindicated Check to ensure IV container is at proper height on IV pole, no tension on tubing, and correct flow rate Instruct patient to report blood in tubbing, stoppage of flow, or increased discomfort Complications of Intravenous Therapy Potentially dangerous complication circulatory overload s/s often arise rapidly Frequent assessment of patients receiving IV therapy is important
Complications of Intravenous Therapy with Nursing Interventions Complication Description Assessment Findings Nursing Interventions Circulatory overload of IV solution IV solution infused too rapidly or in too great an amount Depends on type of solution ECV excess with Na+-containing isotonic fluid (crackles in dependent parts of lungs, shortness of breath, dependent edema) Hyponatremia with hypotonic fluid (confusion, seizures) Hypernatremia with Na+containing hypertonic fluid (confusion, seizures) Hyperkalemia from K+containing fluid (Cardiac dysrhythmias, muscle weakness, abdominal distention) If symptoms appear, reduce IV flow rate and notify patient s health care provider. With ECV excess raise head of bed; administer oxygen and diuretics if ordered. Monitor vital signs and laboratory reports of serum levels. Health care provider may adjust additives in IV solution or type of IV fluid, watch for and implement order. Complications of Intravenous Therapy with Nursing Interventions Complication Description Assessment Findings Nursing Interventions Infiltration or extravasation IV fluid entering subcutaneous tissue around venipuncture site; Extravasation: technical term used when a vesicant (tissue-damaging) drug (e.g., chemotherapy) enters tissues Skin around catheter site taut, blanched, cool to touch, edematous; may be painful as infiltration or extravasation increases; infusion may be slow or stop Stop infusion. Discontinue IV infusion if no vesicant drug. If vesicant drug, disconnect IV tubing and aspirate drug from catheter. Agency policy and procedures may require delivery of antidote through catheter before removal. Elevate extremity. Contact health care provider if solution contained KCl, a vasoconstrictor, or other potential vesicant. Apply warm, moist or cold compress according to procedure for type of solution infiltrated. Start new IV line in other extremity.
Complications of Intravenous Therapy with Nursing Interventions Complication Description Assessment Findings Nursing Interventions Phlebitis Inflammation of inner layer of a vein Redness, tenderness, pain, warmth along course of vein starting at access site; possible red streak and/or palpable cord along vein Stop infusion and discontinue IV line. Start new IV line in other extremity or proximal to previous insertion site if continued IV therapy is necessary. Apply warm, moist compress or contact IV therapy team or health care provider if area needs additional treatment. Complications of Intravenous Therapy with Nursing Interventions Complication Description Assessment Findings Nursing Interventions Local Infection Infection at catheter-skin entry point during infusion or after removal of IV catheter Redness, heat, swelling at catheter-skin entry point; possible purulent drainage Culture any draining (if ordered). Clean skin with alcohol; remove catheter and save for culture; apply sterile dressing. Notify health care provider. Start new IV line in other extremity. Initiate appropriate wound care if needed.
Complications of Intravenous Therapy with Nursing Interventions Complication Description Assessment Findings Nursing Interventions Bleeding at venipuncture site Oozing or slow, continuous seepage of blood from venipuncture site Fresh blood evident at venipuncture site, sometimes pooling under extremity Assess if IV system is intact. If catheter is within vein, apply pressure dressing over site or change dressing. Start new IV line in other extremity or proximal to previous insertion site if VAD is dislodged, IV is disconnected, or bleeding from site does not stop. Infiltration Occurs when IV catheter becomes dislodged or vein ruptures IV fluids inadvertently enter subcutaneous tissue surrounding venipuncture site Extravasation occurs when IV fluid contains additives that damage tissue Causes coolness, paleness, and swelling of area
Infiltration Scale Grade Clinical Criteria 0 No symptoms 1 Skin blanched, Edema <2.54 cm (1 inch) in any direction, cool to touch, with or without pain 2 Skin blanched, edema 2.54-15.2 cm (1-6 inches) in any direction, cool to touch, with or without pain 3 Skin blanched, translucent, gross edema >15.2 cm (6 inches) in any direction, cool to touch, mild-moderate pain, possible numbness 4 Skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross edema 15.2 cm (6 inches) in any direction, deep pitting tissue edema, circulatory impairment, moderate-to-severe pain, infiltration of any amount of blood product, irritant, or vesicant Infiltration
Phlebitis Inflammation of vein Typical signs of inflammation include heat, erythema, tenderness along the course of a vein Blood clots may form along the vein and, in some cases, cause emboli May cause permanent damage to vein Avoid routine replacement of peripheral IV catheters Phlebitis Scale Grade Clinical Criteria 0 No symptoms 1 Erythema at access site with or without pain 2 Pain at access site with erythema and/or edema 3 Pain at access site with erythema and/or edema; streak formation; palpable venous cord 4 Pain at access site with erythema and/or edema; streak formation; palpable venous cord >2.54cm (1 inch) in length; purulent discharge
Discontinuing Peripheral Intravenous Access Discontinue IV access after infusion of prescribed amount of fluid, infiltration, phlebitis, or local infection occurs Educate patients that moving from IV to oral fluids is a sign of progress
Protection of Skin and Veins During Intravenous Therapy Older Adults Use smallest-gauge catheter or needle Avoid the back of the hand Avoid vigorous friction while cleaning Fragile skin limit tourniquet or place over sleeve utilize blood pressure cuff Lower the insertion angle Veins roll away from needle use traction Secure IV site with a catheter stabilization device Medications and supplements increase likelihood of bruising/bleeding Intravenous Administration Administer medications IV by the following methods: As mixtures within large volumes of IV fluids By injection of a bolus or small volume of medication through an existing IV infusion line or intermittent venous access By piggyback infusion of a solution containing a prescribed medication and a small volume of IV fluid through an existing IV line Because IV medications are immediately available to bloodstream, verify rate of admission with drug reference book or pharmacist
Large-Volume Infusions Mixing medications in large volumes of fluids is the safest and easiest With continuous infusion if IV fluid is infused too rapidly the patient is at risk for medication overdose and circulatory fluid overload Current best practices include use of IV medication that come in standardized concentration and dosages; standardized procedures for ordering, preparing and administering; and ready-to-administer doses Do not add medications to IV bags that are already hanging no way to tell the exact concentration of medication only add to new IV bags Intravenous Bolus Involves introducing concentrated medication dose directly into the systemic circulation IV Bolus/push is the most dangerous method for administration Bolus may cause direct irritation to the lining of blood vessels Determine rate of administration for IV bolus/push Consider the purpose of the IV medication Consider potential adverse effects related to rate or route
Volume-Controlled Infusions Administers IV medications through small amounts (50-100mL) of compatible fluids Advantages of volume-controlled infusions include: Reduces risk of rapid-dose infusion by IV push Allows for administration of medications that are stable for a limited time Allows for control of IV fluid intake Piggyback Small (25-250 ml) IV bag/bottle connected to short tubing Connects via upper Y-port of primary infusion line or intermittent venous access Piggyback tubing is either microdrip or macrodrip system Called piggyback because it is placed higher than the primary infusion bag/bottle Primary infusion bag Piggyback infusion bag
IV Piggyback Medication with Label Following ISMP Safe-labeling Guidelines John Smith (1) Room 2631 (2) MR# 0123456 (3) Hydrocortisone (4) 100mg (6) (SOLU-CORTEF) (5) In D5W (7) IVPB (8) Total Volume 50mL (9) (10) Exp: 12/31/2020 (12) RPh Initials AMH (11) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Patient Name Location Second Identifier DOB, Medical Record # Generic Name Brand Name Patient Dose Diluent Route Total Volume Bar Code Initials as Needed Expiration Date as Needed Pharmacy Information Comments Other information as needed Somewhere Pharmacy (13) Infuse Medication over 20-30 minutes (14) Notify physician of concerns (15) Volume-Control Administration Sets are small (150 ml) containers Attach just below primary infusion bag/bottle Attached and filled similar to regular IV infusion Buretrol
Syringe Pump Syringe battery operated Allows medications to be given in very small amounts of fluid Controlled infusion times Uses standard syringes Intermittent Venous Access Commonly called saline lock Provide cost savings Effective in enhancing nursing time by eliminating constant monitoring of flow rates Provides increased mobility, safety, and comfort for the patient Before administering medications ensure patency/placement Flush with solution to keep it patent
Key Points Body fluids contain water, Na+ and other electrolytes are distributed between ECF and ICF compartments Osmolality imbalances are abnormal concentrations of body fluids, manifested at altered serum Na+ levels and decreased level of consciousness Initiation and maintenance of IV therapy require clinical decision making, skill and organized procedures to maintain sterility and patency of the system Nurses monitor vigilantly for complications of IV therapy Safety Guidelines for Nursing Skills Be vigilant during entire medication administration process Do not get distracted during medication set up Verify expiration date Identify patient correctly Clarify all unclear orders Do not use work-arounds Educate patients Follow Nurse Practice Act and employer policies/procedures
Reference Potter, P.A., Perry, A.G., Hall, A., & Stockert, P.A. (2017). Fundamentals of Nursing. St Louis, MO: Mosby Elsevier. Contact Information Nebraska Health Care Association Licensed Practical Nurse Association of Nebraska 1200 Libra Drive, Suite 100 Lincoln, NE 68512 402-435-3551 nhca@nehca.org