introduction to iv therapy - rutgers school of...
TRANSCRIPT
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Introductionto
IVTherapy
Whatisit?Intravenous (IV) therapy is the
administration of a fluid substance (solution) directly into a vein as a
therapeutic treatment
PurposeMaintainfluidandelectrolytebalanceToadministermedicationsTransfusebloodandbloodproducts
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ArteriesVS.Veins
•Superficial,locatedclosetothesurface•Carryunoxygenatedbloodfromthebodytotheheart•Havevalvestoensureonewayflow.•Cancollapse•Donotpulsate
•Locateddeepinthetissuebymuscleandbone
•Carryoxygenatedbloodfromthehearttotherestofthebody.
•Pulsate
•Donothavevalves
Arteries VS Veins
VeinSelection
Dorsal/Meta‐carpalandforearmsveinsareidealforIVtherapyStartlowthenmoveyourwayup
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AvailabilityofVeins….Althoughveinsarefoundinthesamelocationinmostpeoplewithminorvariations,certainsituationsmightmakeitmoredifficulttofindthemsuchas:• BodyFat• Burnsandscarredskin• Edema• IVDA
Review!
MaintainingFluidandElectrolyteBalance
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DowntotheCellularLevelTheadultbodyisabout50‐60%waterBodyfluidsconsistofwateranddissolvedparticlesThesebodyfluidcompartmentsexchangecontinuouslythroughasemi‐permeablemembraneviaosmosisChangesinbodyfluidsandelectrolyteimbalanceaffectallofthebodilyprocesses
ElectrolytesOsmolarity:
• The concentration of osmotically active particles in solution, which may be quantitatively expressed in osmoles of solute per liter of solution.
• Overhydration and deyhdration
• Na+andK+
Tonicity• Isotonic
• Hypotonic
• Hypertonic
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Osmolarity > body fluid (more particles)
Osmolarity = body fluid
Osmolarity <body fluid ( less particles)
D5LR3%-5% NaClD5NaCl
0.9% NaClLRD5W
0.33%NaCl0.45%NaCl
HowdoesthisRelate?
YourbodyisalwaysworkingtomaintainequilibriumthroughthefollowingRegulatingmechanisms:
Kidneys(Adrenalglands)LungsSkinPituitaryGland
HowdoesthisRelate?
Ifanyoftheseregulatingsystemsareinterrupted,partofthetreatmentwillrequiresIVelectrolyte
therapywithdifferenttypesofsolutions.
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Review!
Administering IVMedications
BeforeAdministeringMedications…
• Patient’sAllergyHistory• Patient5Rights
• Giveceftriaxone500mgIVQ12hours,firstdosestat
• Compatibilityofmedswithothermedsand/orsolutions
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Incompatibilities
• Physical‐ Seevisiblechanges(cloudy,precipitate)
• Therapeutic‐ 2drugsaregiventooclosetotogetheritmaychangetheaffect
• Chemical‐ onedrugmaychangethechemicalcompoundoftheother.
HowtogiveIVMedication
DrugsdilutedinalargevolumeoffluidI.V.P.B.IntermittentInjection(IVPush)ContinuousviasyringeorIVpump
Review!
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TransfusionofBloodProducts
Indications
Maintain/RestorebloodvolumeToincreasetheO2carryingcapacityofbloodbysupplyingredbloodcells
ToprovidecoagulationfactorsToprovideproteinToprovidewhitebloodcellsToprovidepassiveimmuneprotectionandtreathypogammaglobulinemia
Type Components Indication Amount
WholeBlood RBCsPlasma,Plasmaproteins
Massivebleeding,Expandingvolume
Upto500mLWithin4hours
PackedRBC’s
RBCsandsmallamountofplasma
Increaseorganoxygenationwithminimalvolumeexpansion
250‐300mLWithin4hours
Platelets Plateletsinsmallamountofplasma
Thrombocytopenia,Plateletdysfunction
50‐400mL20‐60minutes
FFP Clottingfactors,plasmaproteinsandwater
Bloodloss,clottingdisorders,DICover‐anticoagulation,clottingfactordeficiencies
200‐250mL15‐30minutes20mintothawUseassoonasready
Cryoprecipitate Clottingfactors,fibrinogeninplasma
Hemophilia,VonWillebrand’sdisease
10‐20mL3‐15minutes
ColloidSolutions
Albumin5%or25%,immunoglobulins
Volumeexpanders,Congenitaloracquiredautoimmunedeficiencysyndromes
Dependsonorder
Granulocytes Granulocytesandlymphocytes
Seriousmicrobialinfectionsinapatientwithsevereneutropenia
200‐400mL1‐2hours
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TransfusionEquipment
YtubingNormalSaline(anotherwithseparatesoluset incaseofreaction)ExtraLeukocytefilterBloodwarmer
RN Role in Transfusion (cont.)NEVER keep blood product on the unit for more than 30 minutes prior to starting transfusion
• Return to the blood bank• Specially designated refrigerators may be used in specialty areas
(e.g. OR)Obtain and record baseline vital signs prior to starting
transfusions• If patient has a fever notify MD first (may mask reaction)
Assess patients understanding of the procedure• Instruct patient to notify nurse of: Chills and fever Back pain Flushing Palpitations Difficulty breathing
Proper and complete patient identification is extremely important during the entire process of transfusion therapy, from the initial acquisition of a blood sample for compatibility testing, to the actual transfusion of blood NO SHORT CUTS! Checks must be done at patient bedside.
Inspect blood for, expiration date, any discolorations, and/or frothiness
DuringTransfusion
ObservepatientfrequentlyforanyadversereactionsObservesitefrequentlyforsignsofinfiltrationAdministeratprescribedrate
(Nolongerthan4hours)MonitorVitalsignsanddocumentasperhospitalpolicyusually:
Withinonehourbeforestartingthetransfusion 15minutesafterstartingthetransfusion Every30‐60minutesWheneverpatientsconditionrequires Atcompletionoftransfusion
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Febrile,Non‐hemolyticReactionCause– sensitivitytodonorwhitecells,platelets,orplasmaproteins(antigen‐antibodyreaction
ClinicalPresentation–
ChillsandfeverHeadacheFlushingAnxiety
MusclepainChestpainDyspneaNausea&vomiting
Onset– immediateto6hourss post‐transfusionManagement–
AntipyreticsDoNOTrestart
Prevention– considerleukocytepoorbloodproducts
AnaphylacticReactionCause– infusionofplasmacontainingIgAproteinstoanIgAdeficientrecipientwhohasdevelopedIgAantibodiesfromaprevioustransfusionorpregnancy
ClinicalPresentation:
Respiratory
bronchospasm
Wheezing
Dyspnea
Tachypnea
cyanosis
Cardiovascular
Tachycardia
Hypotension
Shock
PossibleCardiacArrest
GI
Nausea
Vomiting
Cramping
Diarrhea
AcuteHemolyticReactionCause – infusionofABOincompatiblebloodproductsAntibodiesintherecipientsplasmastimulateanantibody‐antigenresponsecausingredbloodcelldestruction
ClinicalPresentation–
Chillsandhighfever
LowbackpainFlushingTachycardia
HemoglobinuriaHemoglobinemiaBleedingNausea&vomiting
Onset– Usuallyinthefirstimmediately‐15minutesbutmayoccuratanytimeManagement–
Supportive Sendbloodandurinespecimentolabforserology
TachypneaHypotensionCardiovascular
collapse
Dyspnea/chestpainRenalfailureShockCardiacarrestDeath
Prevention – meticulously verify patient Identification
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Nurse’sResponsibilityinTransfusionReactionsStopthetransfusionKVOwithN.S.(changetubing)Reportreactionto:
• AttendingMD• BloodBank
Doclericalcheckatbedsidetoverifypatient,compatibility,expirationandunit#’sMonitorV.S.andclinicalstatusofpatientFollowHospitalpolicyincluding:
• Drawbloodforchemistrypanel• DrawbloodforCBCDandreticulocytecount• Sendurinespecimen• Sendunusedbloodtolab• Fillouttransfusionreactionforms
Review!
IVInsertion,MaintenanceandComplications
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Selectingasite
TheprimarygoalofsiteselectionistochooseonethatwillbeleastvulnerabletoinfiltrationaswellasallowthepatientthemostfreedomtocontinuewithA.D.L.’sStartlowandmoveyourwayupFindaveinthatisvisibleandpalpableAvoidareasofmovement‐AvoidareasofjointflexionAvoidareasaffectedbymastectomy,CVA,orA‐Vfistula
DoNOTattemptinsertionorphlebotomyonpatientiftheyrefusedorelseitwillbe
consideredbattery!
TypesofPhlebotomyandAngiocathEquipment
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InsertionProcedureCheckforIVTherapyOrderGatherandprepareequipmentWashhandsApplycleanglovesCleansightwithalcoholorchlorehexadine swabwithslightfriction(upanddown,sidetoside)andallowtodry.Donottouchaftercleaning.Applytourniquet4‐6inchesabovesight.
• Withthemouthoftheneedlefacingupinserttheneedlewithcannulaata10‐30degreeangleuntilyouseeflash
• Advancecannulaintotheveinasneededwhileholdingneedlestill
• Stabilizethehubofthecannulagentlyasyouwithdrawneedle
• Attachedprimedextensionsetintoangiocath
• Securewithocclusivedressingandtape.
• Removetourniquet• Attachflushanddrawbackslightlytocheckforbloodreturn
• Flushwith1‐2MLofNSthenclamp.• Observeforswelling,leaking,pain
•Labelanddatesight.IVsightshouldbechangedevery72‐96hoursinordertoavoid,infiltration,phlebitis,andinfection•Checkinstitution’spoliciesforlineflushing.• AlltubingandIVfluidbagsmustbeinitialed,datedandtimedwhenopened.
CommonComplications
HematomaInfiltration– tendernessaroundthesiteExtravasationsPhlebitisThrombosisThrombophlebitis
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Phlebitis
Infiltration
Thrombophlebitis
Extravasation
WhattoDocument
ThespecificlocationoftheveinThetypeofvenousaccess,lengthandgaugeThenumberofattempts(evenifone)Date,timeandnameofthenursestartingtheIVThetypeofsolutionormedicationadministered
Thetypeofinfusion(continuous,bolus)Themethodofadministration(Pumporgravity)InfusionrateQuotesfromthepatientregardingtheprocedureFileanincidentreportforanycomplications
• 1345 – Inserted20gangiocath onthebackoftheRhand.Receivedgoodbloodreturn.Attachedsalinelockandflushedwith2mLof 0.9%NS.Observednoswelling,blanching,colorchangeorleakingatsiteduringflush.Securedwithocclusivedressing.ContinuousinfusionofD5.45%NSstartedat45mL/hr byIVpump.
• 1910– Pt havePIVonlefthand.Observedsitetobesoft,pink,dry,clean,intact,tapedwithocclusivedressingandcleartape.0.9%NSinfusingat100mL/hr.
2200‐ PatientstatedtohaveslightburningpainatPIVsightinrighthand.Observedsitetohaveswellingandblanching3inchesfrominsertionsight.RemovedPIVsightanddressedsitewith2x2gauzeandcleartape.Explainedtopatientaboutinfiltration,andtheneedforwarmcompressandelevationofrighthandfor5minutesatatime.Patientstatedreplied“ ok,ifithelps.” Appliedwarmcompresstoswellingonrighthand.Willreassessrighthandin1hour.
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Review!
CentralVenousCatheters
CentralVenousCatheters
Why?• Infusingfluidsdirectlyintothecentralvenouscirculation.Foruseoftreatmentoptionsthatarenotgenerallyaccessiblethroughstandardperipheralintravenousaccess:• Minimalornoperipheralaccess• ForsolutionswithdextroseconcentrationhigherthanDW12%
• ContinuousVesicantInfusions(chemotherapy)• Lengthofprescribedtherapyis6daysorlonger• DrugpHisbelow5orgreaterthan9• Continuoushighpressureflow(rapidtransfusion)
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Types of Catheters
• Non‐tunneledcatheters
• PICC• Tunneled• ImplantedPorts
Ensureaseptic/steriletechniqueismaintainedduringinsertionEnsurethatChestX‐RayisdonetocheckproperplacementofcathetertipbeforeuseInspectionofthecatheter,dressing,andinsertionsiteEvaluatetheintegrityofthecatheterandmonitorformicrobialinfectionChangingthedressingandendcapsflushingthelumenofthecatheteraccordingtofacility’sprotocolWatchforsignsandsymptomsofpneumothorax:cyanosis,dropinBP,HRincreased,lethargy
RoleofRN
Place patient in left Trendelenbergposition, give 02 and call MD (Rapid Response)
Review!
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ReferencesZerwekh, J., Claborn, J., Gaglione, T. Mosby’s Fluids and Electrolytes Memory Cards. Second Edition Mosby 2009
Consortium of New Jersey Nurse Educators, Adult IV Therapy Course, 5th Edition 2008
Perivascular Nurse Consultants. Peripherally Inserted Central Catheters: Monitoring and Complication Management ProgramPericascular Nurse Consultants, Inc. 2010
Smith, N. Central Venous Catheters: n. Cinahl Information Systems. 2010
Smith, N. Peripheral Intravenous Cannula: Insertion. Cinahl Information Systems. 2010
Smith, N. Blood Transfusion: Administration.. Cinahl Information Systems. 2010
Infusion Nurse Society : Parenteral Nutrition Vol. 33 No 4, July/Aug 2011.
Amjad, I., Murphy, T., Nylander-Housholder, L., Ranft, A. New approach to Management of Intravenous Infiltration in Pediatric Patients: Pathophysiology, Classification, and Treatment. Journal of Infusion Nursing. Vol. 34, No 4 , July/August 2011