Indications for Intravenous Therapy

Purpose of IV Therapy

• To provide maintenance and replacement of– acid-base balance or – fluid and electrolyte balance

• When rapid absorption is necessary (bypasses hepatic system)

• Access for blood sampling and blood transfusion• TPN: Total Parenteral Nutrition (nutritional therapy)

Purpose of IV Therapy

• Chemotherapy• Avenue for continuous or intermittent medications

e.g. antibiotics, vasopressors, analgesics, electrolytes, vitamins and diuretics

• To have a thorough knowledge of fluids and drugs, their effects, dosage, recommended rate, incompatibilities, contraindications, and allergic reactions, prior to administration

• To have good judgment and assessment skills prior to, during, and post administration

LPN

Nursing Responsibilities for IV Therapy

Nursing Responsibilities for IV Therapy

• To have the ability to interpret physician’s orders

• To have good documentation and communication skills

• To know your own scope of practice

Nursing Responsibilities for IV Therapy

• Choose the most appropriate vascular access device by selecting a device that– has the potential for providing access throughout

the course of therapy ,– ensures the best possible outcome, – has the least risk to the patient and the health

care provider.• Collect and document relevant patient data• Manage venous access cost-effectively

The Skin• First line of defense• Fertile ground for bacterial growth

– Warmth– Moisture– 10,000 organisms per square centimeter

• Three layers– epidermis– dermis– subcutaneous tissue

The Skin

• Resident Flora– Permanent residents– Not readily removed by handwashing– Can be inhibited with use of antimicrobial soaps

The Skin

• Transient Flora– Not normally present on the skin– Survive poorly on skin surfaces– Noncolonizing flora, vary from day to day– Present from touch contamination– Can be eradicated by good handwashing– Staphylococcus aureus

Handwashing• 50% of nosocomial infections could be eliminated by

handwashing alone– Hands are only washed 50% of the times indicated– Wearing gloves does not eliminate need to wash hands

before or after patient contact– 15-20 second hand wash vigorously with soap and running

water Don’t forget to

clean your pen!

Skin Cleansing and Disinfecting

Disinfectant Types

10% Iodophors• Iodine fixed to a carrier molecule reducing the

amount of free iodine released on the skin which reduces irritation to the skin

• Two minutes of contact before effective• Must be allowed to air dry• Residual activity, if reservoir left on the skin• Effectiveness is affected by organic material,

wash skin with soap and water if needed or alcohol swabs if available

• Ensure no allergy to iodine

70% Alcohol• Recommended agent for iodine allergy• When used alone requires 1 minute scrub• Provides immediate kill• Has no residual activity• Must be allowed to air dry• Repeated use is drying to skin

Antimicrobial Skin Prep

• 70% Ethyl Alcohol & 10% Povidone-iodine combination

• One-step prep

• 5-7 day efficacy beneath sterile transparent film dressings

2% Chlorhexidine vs Iodine options• Chlorhexidine has comparable

effectiveness and is safer, cheaper, and preferred by staff, so it is an alternative to iodine tincture.

Journal of Clinical Microbiology, May 2004, p. 2216-2217, Vol. 42, No. 5

• Applied in a scrubbing motion both horizontally and vertically

Layers of the Vein

Tunica Intima

• Characteristics– Innermost layer– Smooth elastic lining– Recognizes foreign material– Prostaglandin & heparin mast

cells. . .mediators for inflammatory process

– Stage for phlebitis

Tunica Media

• Characteristics– Middle layer– Smooth muscle & elastic tissue– Nerve fibers

• dilation/constriction• muscle tone

• Clinical indications– Affects efforts of vasodilation

Tunica Adventitia

• Characteristics– Outer layer– Fibrous connective tissue– Vein support– Vein nourishment

• Clinical indications– “Pop”– Sclerosis, scarring

Those Pesky Venous Valves

• Damage may lead to thrombus formation

• Incomplete catheter insertion can lead to leaking, variable IV rate and/or early removal

Comparison of Arteries and Veins

Differentiating Arteries and Veins

Artery• Lie deep in tissue• Thicker connective

tissue: prevents collapsing or distending with pressure

• Protected by muscles

Vein• Superficially located• Collapses under

pressure• Muscle layer may

spasm with pain• More numerous than

arteries

Differentiating Arteries and Veins

Artery• There are some

areas where the arteries are superficial

• Supply single area• Pulsate• Color bright red

Vein• Inner layer has one-

way valves• If spasms, other

veins compensate• Darker color, bluish

Associated Nerve Structures

Radial nerve1. Posterior cutaneous nerve

of forearm arises in spiral grove

2. Branches to brachoradialis and exteral radial

3. Deep branch perforates supinator to form posterior interosseous nerve which supplies extensor compartment

4. Superficial branch supplies skin on dorsum of hand and digits proximal to nail beds

Assessing Patient for IV Therapy

Patient Preparation/Education

• Psychological preparedness• Age specific• Purpose of therapy• Possible duration (peripheral/central)• Method of administration• Insertion procedure• Mobility limitations or restrictions • Long-term alternatives to peripheral IV

may be nec.

‘Informed’ Consent

• Requires – Sufficient information to make a decision– Capacity to make a decision– No coercion

• Refusal of treatment– Assault and Battery: Coercion of rational

patient into having an IV.

Special Considerations

Disease States/Conditions

• Immunosuppression– Increased risk of infection

• Dehydration– Decreased intravascular volume

• Mastectomy– May have compromised

circulation, but vascularization has likely been rebuilt. Some pts will be “No IV” “No BP” on affected limb.

Disease States/Conditions

• Heart disease/edema– Obscures veins– Irritating cardiac meds– Fluid overload– Anticoagulation therapy

• Diabetes– Peripheral neuropathy– Infection risks, slow to heal

• Cancer– Chemotherapy– Decreased cell counts

Disease States/Conditions

• Renal Dialysis– Hemodialysis grafts

• Obesity– Veins deep or pushed to surface

• Sclerotic Veins– Tendency to roll

Osmolarity of Fluid

• Osmolarity = the osmotic concentration of a solution expressed as osmoles of solute per liter of solution– Osmole = the molecular weight of a solute

• Normal osmolarity of blood/serum is about 300-310 mOsm/L.

• The tonicity of an IV fluid dictates whether the solution should be delivered via the peripheral or central venous route. Hypotonic and hypertonic solutions may be infused in small volumes and into large vessels, where dilution and distribution are rapid.

• • When solutions with extremes of tonicity are infused,

fluids shift into or out of cells, including endothelial cells of the tunica intima near the catheter tip and blood cells. The resulting changes in the cell size of the vein wall causes the inflammatory and clotting processes to occur, leading to phlebitis and thrombophlebitis.

Osmolarity of Fluid

Allergy Assessment

• Medication history• First dose considerations– Risk analysis

• Iodine allergy (note shellfish allergy)– Use alcohol or chlorhexidine

• Latex allergy• Local anesthetics

Nursing Assessment

• Consider the following– Patient condition, age, diagnosis & activity level

– Vein condition, size & location

– Associated structures

– Skin integrity

– Type & duration of therapy– Drugs that affect skin integrity

• Corticosteroids• Heparin/Coumadin• Chemotherapy• Prednisone

Veins: So many to pick from!

Antecubital Fossa

• Large veins • Tendency to “roll”• Because the veins in this area are visible and

easily accessed, the antecubtial is ideal for blood samples and bolus drugs

• Unless joint is immobilized, cannula could kink or move in and out of the vein damaging the vein. Discuss cannula, what, why, rigid?

Infants only (Up to 2 years old)

Dangers Associated with Lower Extremities

• Thrombosis• Varicosity• Immobility• Increase risk of

Pulmonary Embolism a travelling clot

By understanding the physiology of veins, the IV therapist can use vasoconstriction and vasodilation to increase the vein size, increase visibility and decrease venous spasm.

• Tourniquet (just enough to restrict venous return but not impede arterial flow)• Dependent Position, (works well for elderly with tortuous veins instead of tourniquet)• Warm moist heat compress• Blood pressure cuff (40-50 mm HG below systolic—check for pulse)• Clenching fist (muscles pump veins up)

Distending Techniques

Intravenous Supplies and Equipment

The Right Device to Start

• Greatest likelihood of surviving anticipated length of therapy

• Accommodates therapy requirements

• Is the least invasive

• Utilizes the fewest number of catheters

• Meets a benefit vs. risk assessment

Short-term Peripheral Catheters

• Most commonly inserted catheter

• Any appropriate peripheral vein

• Usual dwell time (P&P)– 48-72 hours– Heparin lock - 96 hours

• Peripheral solutions only

• “Clean” vs. sterile technique

Short-termAcute Catheters

• Tip located in the SVC or IVC

• Dwell time varies 7-14 days

• Used for all types of solutions

• X-ray required (why?)

• Sterile technique

• Inserted subclavicular region by specialty nurse or physician, with imaging assistance- ultrasound

Midline Tip

• Tip placement in proximal portion of the upper extremity– Lower extremity may be used in the neonate and

infant

• Dwell time– 2-4 weeks avg

• Peripheral solutions only• Sterile technique • No X-ray required

Peripherally Inserted Central Catheters (PICC)

• Tip located in the SVC (superior vena cava) or IVC

• Dwell time indeterminate– Consider in patients requiring therapy up to one year

• Used for all types of solutions• X-ray required• Maximum sterile barrier precautions

*

Advantages of PICCs & Midlines

• Eliminates need for multiple venipunctures• Reliable venous access• Increased hemodilution• Less traumatic to insert• Insertion at bedside• Cost & time efficient• Easily removed• Increased patient comfort and satisfaction

Advantages of PICC

• In addition…...– Can be inserted by qualified RNs

– Provides a reliable means for collecting blood samples

– Safe alternative to central access

Midline & PICC may be indicated

• Coagulopathy

• Immunosuppression

Less risk of arterial puncture / bleeding compared to multiple “pokes”

Lower infection rates

Caution

Non-Tunneled Central Venous Access

• Tip SVC (superior vena cava) or IVC

• Used for all types of solutions

• Dwell time < 1 year• X-ray required• Sterile technique

Tunneled Catheters & Implanted Ports

• Tip in SVC or IVC

• Dwell time not established

• Used for all types of solutions

• Surgical placement

• X-ray required

• Sterile technique

Port• A port is a completely

implanted device that consists of:Reservoir - a hollow titanium disk that has a rubber septum. The reservoir is implanted in a pocket just below the skin on the chest wall.Catheter - a tube that is connected to the reservoir and placed into one of the large veins of the chest.

Implanted VADs- Vasc. Assist Devices

Mediport Access

• After the port is placed, it can be used for both infusion of medication and blood draws. The port is accessed using a special needle called a Huber needle.

Umbilical Artery Catheter (UAC)

Infusing Blood & Blood Products

• Fluid viscosity– Doubling the viscosity of a fluid will

decrease flow rate by half

• Temperature of the fluid

LENGTH + GAUGE + WALL THICKNESS+ VISCOSITY = SLOW FLOW RATE

Plastic Containers

• Advantages– Flexible, collapse as fluid flows out– Not evacuated (no vacuum)– Air venting is not required decreasing risk of

airborne contamination– Easily transported– Easily stored – Easily disposed

Plastic Containers

• Disadvantage– Some medications are absorbed by

plastic, e.g. insulin or diazepam

• Inspection before using– Squeeze and visually inspect– Check lot number and expiration

date– Assess label with physician order

Lot # jkl675

Expiration date: 6/5/08

Glass Bottles

• Sterile bottle with a vacuum inside• Any additives are pulled in quickly from

vacuum• Air intake is essential for solution to flow

correctly

• Advantages:– For medications that are absorbed by plastic

Glass Bottles• Disadvantages– Difficult to store– More likely to break– Increased chance of air-borne contamination

• Inspection– Look for cracks or chips in glass bottle– Check lot number and expiration date– Assess label with physician’s order– When puncturing rubber seal, make sure vacuum is

present

How can I infuse thee?

Let me count the ways.

IV Administration Sets

1. Nonvented vs. Vented2. Piggyback3. Pump Administration Sets4. Filters

Standard Straight Gravity Flow IV

IV with Piggyback (IV PB)

Infusion sets•Injection sites for piggy back medication

•Notice airway that can be open or closed as needed

Blood Infusion Set• Large filter to catch clumps

• No injection ports

Airway

Volume Control Set Clamp

Injection port

Drug and fluid administration chamber

Drip chamber

Check valve

Drip Regulating Clamp

Drip Factor

• Some of these supplies are becoming obsolete, with pumps taking over

• Is indicated on the top of the cover

• A macrodrip delivers solution at rapid rates

• A microdrip, always 60 gtts/cc, is more controlled

IV Filters

• Remove pathogens and particles – to reduce infection – To reduce chance of infection

• To minimize phlebitis • To reduce introduction of bacteria , foreign

particles and air into the blood stream• Filter needle- when using a glass vial that must

have tip snapped off

IV Filters• Types– Inline– Others need to be added, always using aseptic

technique• Sizes– 5 to 1 micron filters; Removes particle matter

but not most fungi or bacteria– .45 micron filters: Removes bacteria not fungi– .22 micron(absolute filter): Removes all fungi

and bacteria

IV Filters: Indications

• Hyperalimentation (nutrition/TPN)• Using additives comprising of many particles

such as antibiotics • Solutions requiring reconstitution or when

administering several additives

IV Filters have Idiosyncrasies too!

• INS Standards recommend routine usage of 0.22 in-line filter but CDC states it is not necessary if the tubing is being changed every 24 hours

• Filters used with infusion pumps must be able to withstand the pressures generated by the pumps

• In-line filters must be primed when you set up the system

Needle-less Systems

Interlink System Clave System

Saf-T-prn

Infusion Methods

Continuous Infusion

• Used to maintain a constant rate of infusion

• Uses– TPN– Post and Peri operative– Hydration– Pain Control– Pump is useful in maintaining a

constant rate

IV Pumps• Controllers• Mechanical• Mini Infusers• Syringe Pumps• Computerized– Cadd Prism – Cadd Plus– Sabratek 6060 – Sabratek 3030

IV PUMP

• Clinician should have complete working knowledge:– How to turn it on– How to prime administration set (what is

priming?)– How to calculate and set rate of flow– How to correct alarms– How to program the programmable pumps

IVPB “Piggyback”• A secondary line that is

connected to the injection port of a primary IV line

• Check for incompatibility with primary IV

• Allergies• If pump is unavailable, hang

primary with extension hook to position primary IV container BELOW the piggyback container.

Intermittent Heparin Lock/Reflux Valve

• Use an administration set to infuse solution directly into a capped system

• Flush with normal saline before and after administration to reduce irritation to vein (per MD order)

• Prevent clotting by flushing with dilute heparin solution, usually 10U/cc (per MD order)

IV Push or Bolus

• Remember to use a 10 cc syringe, usually

• Give slowly over 3-5 minutes, usually

• Flush afterwards with appropriate solution

Important ! ! ! • Never assume ALL drugs are compatible

with Sterile Normal Saline, but incompatibility is very rare

• Check with your institution’s Policy and Procedure Book or your dispensing pharmacists for information, or your online aide for nurses often by subscription with your employer