+

IV THERAPYPOCKET GUIDE

+

TABLE OF CONTENTS

1. Basic Principles of IV Therapy2. Fluids and Electolytes3. IV Delivery Systems4. Peripheral IV Therapy5. Central IV Therapy6. IV Therapy and the Nursing Process7. Crystalloid Solutions8. Colloid Solutions9. Blood Component Therapy10. Parenteral Therapy11. Iv Pharmacological Therapy12. IV Therapy and Infants and Children13. IV Therapy and the Elderly14. IV Therapy within Community-Based Settings

+

Why is IV Therapy important?

IV fluids come in four different forms:• Colloids• Crystalloids• Blood and blood products• Oxygen-carrying solutions

As many as 75% of patients admitted into the hospital receive some type of IV therapy.

•Establish or maintain a fluid or electrolyte balance •Administer continuous or intermittent medication•Administer bolus medication •Administer fluid to keep vein open• Administer blood or blood components •Administer intravenous anesthetics •Maintain or correct a patient's nutritional state •Administer diagnostic reagents •Monitor hemodynamic functions

50%-70% of the average human is body fluids. Distribution of fluid in the body is:

1/3 in extracellular fluid• Interstitial fluid • Plasma • Transcellular fluid

2/3 in intracellular fluid• Red blood cells • Other cells

+

Crystalloids are water with electrolytes, which form a true solution and are able to pass through a semipermeable membrane. Crystalloids are lost rapidly from intravascular space into interstitial space (depending on the osmolality), and they remain in extracellular compartment for about 45 minutes. Therefore they require larger volumes than colloids for fluid resuscitation. Eventually water from crystalloids diffuse through intracellular fluid as well (membrane pumps and metabolism alter crystalloid distribution and osmotic forces). These may be hypertonic, isotonic or hypotonic.

Crystalloids

•ISOTONIC•Because an isotonic solution stays in the intravascular space, it expands the intravascular compartment.

HYPERTONIC•A hypertonic solution draws fluid into the intravascular compartment from the cells and the interstitial compartments.

HYPOTONIC•A hypotonic solution shifts fluid out of the intravascular compartment, hydrating the cells and the interstitial compartments

A solution type depends on whether you want to change or maintain a patients fluid status.

+

Solution Type Uses Nursing Considerations

Dextrose 5% in water (D5W)

Isotonic •Fluid loss•Dehydration•Hypernatremia

•Use cautiously in renal and cardiac patients•Can cause fluid overload•May cause hyperglycemia or osmotic diuresis

0.9% Sodium Chloride (normal saline-NaCl)

Isotonic •Shock •Hyponatremia•Blood transfusions•Resuscitation•Fluid challenges•Diabetic Ketoacidosis

•Can lead to overload•Use with caution in patients with heart failure or edema•Can cause hyponatremia, hypernatremia hyperchloremia or calorie depletion

Lactated Ringer’s

Isotonic •Dehydration•Burns•Lower GI fluid loss•Acute blood loss•Hypovolemia due to third spacing

•Contains potassium, don’t use with renal failure patients•Don’t use with liver disease, can’t metabolize lactate

0.45% Sodium Chloride (1/2 normal saline)

Hypotonic •Water replacement•Diabetic Ketoacidosis•Gastric fluid loss from NG or vomiting

•Use with caution•May cause cardiovascular collapse or increased intracranial pressure•Don’t use with liver disease, trauma, or burns

Dextrose 5% in ½ normal saline

Hypertonic •Later in Diabetic Ketoacidosistreatment

•Use only when blood sugar falls below 250 mg/dL

Dextrose 5% in normal saline

Hypertonic •Temporary treatment from shock if plasma expanders aren’t available•Addison’s crisis

•Don’t use in cardiac or renal patients

Dextrose 10 % in water

Hypertonic •Water replacement•Conditions where some nutrition with glucose is required

•Monitor blood sugar levels

Commonly Used Crystalloid IV Solutions

+

ColloidsColloid solutions are IV fluids that contain solutes in the form of large proteins or other similarly sized molecules. The proteins and molecules are so large that they cannot pass through the walls of the capillaries and onto the cells. Accordingly, colloids remain in the blood vessels for long periods of time and can significantly increase the intravascular volume (volume of blood). The proteins also have the ability to attract water from the cells into the blood vessels. However, although the movement of water from the cells into the bloodstream may be beneficial in the short term, continual movement in this direction can cause the cells to lose too much water and become dehydrated.

+

• PlasmaThis is the liquid part of the blood. It is often used to add volume to the blood system after a large loss of blood. Cryoprecipitate is a concentrated source of certain plasma proteins. It is used to treat some bleeding problems. • Red blood cells These carry oxygen from the lungs to other parts of the body and then they carry carbon dioxide back to the lungs. A low red blood cell count is called anemia. A red blood cell transfusion may be needed to treat anemia. • White blood cells These help fight infection, bacteria and other substances that enter the body. When the white blood cell count becomes too low, it is called Neutropenia. A white blood cell transfusion may be needed to treat Neutropenia. • Platelets These help blood to clot. Platelet transfusions are given when the platelet count is too low.

• Oxygen-carrying solutions are synthetic fluids that carry and deliver oxygen to the cells. These fluids, which remain experimental, show promise for the prehospital care of patients who have experienced severe blood loss or are otherwise suffering from hypovolemia. It is hoped that oxygen-carrying solutions will be similar to crystalloid solutions in cost, storage capability, and ease of administration, and be capable of carrying oxygen, which presently can only be accomplished by blood or blood products.

Oxygen-carrying Solutions

Blood Products

+

Daily Recommended Electrolyte Levels

Leavitt LeavittLeavittLeavittV LeavittLeavittLeavittLeavittLeavittLeavittLeavittLeavittLeavittLeavitt

+

Fluid ImbalancesCause Signs/Symptoms Treatment

FluidVolumeDeficit

Acute weight loss, changes in mental status, posture,hypotension, dizziness,syncope, vertigo, distention of neck vein, decreased central venous pressure, weak pulse, nausea, vomiting and anorexia,increased thirst, decreasedurine output, poor skin turgor over sternum and forehead, dry skin and mucous membrane, sunken eyes

SerumHematocrit: IncreasedHemoglobin: IncreasedProteins: IncreasedOsmolarity: NormalUrineSodium: 50 mEg/LOsmolarity: 500 mOsm/LSpecific gravity: Above 1.030

Restore fluid and electrolyte balance using isotonic sodium chloride solutions.Treat underlying cause.

FluidVolumeExcess

Weight gain; edema occurswhen 2–4 kg of fluid isretained; altered respiratoryand cardiovascular function:hypertension, tachycardia;altered LOC, skeletal muscleweakness, and increasedbowel sounds

SerumHematocrit: Normal to lowHemoglobin: Normal to lowProteins: Normal to lowOsmolarity: NormalBUN: Normal to lowUrineSodium: ReducedOsmolarity 500 mOsm/LSpecific gravity: 1.010

Reduce fluid retention bysalt and fluid restriction.Diuretics to increase fluidExcretion. Treat underlying cause.

+

Electrolyte ImbalancesSodium Cause Signs/Symptoms Treatment

Sodium DeficitHyponatremiaSerum Na135

Abnormal loss of GIsecretions (vomiting,diarrhea); lossesfrom skin;hormonal—SIADHOxytocinAdrenal insufficiency

Na115: affects CNS cellsHeadacheSensation of taste impairedAnorexiaFeeling exhausted, muscle crampsFocal weakness(hemiparesis, ataxia)

Replace sodium and fluid losses.Restore normal ECF volume.Correct any other electrolyte losses.

Sodium ExcessHypernatremiaSerum Na145

Person who cannot respond to thirstHypertonic tube feedingAdministration of sodium-containingsolutionsDrowning in seawaterHeat stroke

Marked thirstTemperatureSwollen tongueRed, dry, sticky membranesDisorientationIrritabilityHyperactivity

Infuse hypotonic saline solutionOr 5%D/WUse diuretics

Potassium Cause Signs/Symptoms Treatment

Potassium DeficitHypokalemiaSerum K3.5

Prolonged gastric lossesLaxative overusePotassium-wasting diuretic therapyDrugs such as sodium penicillin, carbenicillin, glucocorticoidsSweat losses

Neuromuscular changesFatigue, muscle weakness, diminished deep tendon reflexesAnorexia, nauseaECG changesIncreased sensitivity to digitalis

Mild: Dietary potassium supplementsPotassium replacement by IV(See guidelines for administration of potassium)

Potassium ExcessHyperkalemiaSerum K5.5

Increase in potassium intake, oral or IVDecreased urinary excretion of potassiumShift of K+ out of cells

Changes to ECGVague muscle weaknessAnxiety, nausea, cramping, diarrhea

Restrict dietary K+Administer regular insulin (10–25 U) in hypertonic dextrose to shift K+Sodium polystyrene sulfonatePeritoneal dialysis

+Positive Trousseau’s SignCarpopedal attitude of the hand when blood pressure cuff is placed on the arm and inflated above systolic pressure for 3 minutes. Positive reaction is the development of carpal spasm.

Positive Chvostek’s SignOccurs after tapping the facial nerve approximately 2 cm anterior to the earlobe.

Calcium Cause Signs/Symptoms Treatment

Calcium DeficitHypocalcemiaSerum level8.5 mg/dL

Inadequate secretion of PTH caused by primary hypoparathyroidism or surgically induced hypoparathyroidism; also results from calcium loss through diarrhea, wound exudate, acute pancreatitis, hyperphosphatemia associated with renal failure.Prolonged NG suctioning.Infusion of citrated blood.

Neuromuscular symptoms (numbness of fingers, cramps in muscles), hyperactive deep tendon reflexes, and positive Trousseau’s sign and Chvostek’s sign. Irritability, memoryimpairment, delusions, seizures (late), prolonged QT interval, and altered CV hemodynamics.Laryngospams and tetany-likecontractions.

Alleviate underlying cause.Administration of calcium gluconate (orally or IV).IV 10–20 mL of a 10% solution in5% D/W for 20 minutes.

Calcium ExcessHypercalcemiaSerum calcium10.5Symptomsoccur when12 mg/dL orhigher

Excessive release of calcium from bone. Hyperparathyroidism, multiple fractures, overuse of calcium-containing antacids.Patients with solid tumors that have metastasized or hematologic tumors. Drugs that can increase calcium levelsinclude mega-doses of vitamins A or D, diuretics, androgens, estrogens, IV lipids, lithium, and tamoxifen.

Neuromuscular symptoms such as muscle weakness, incoordination, lethargy, deep bone pain, flank pain, pathologic fractures. Constipation,anorexia, nausea, vomiting, polyuria, and renal colic.Patients taking digitalis must take calcium with extreme caution.

Administer calcitonin.Occasionally, plicamycin administered, which inhibits bone reaborption and lowersserum calcium.

-- ---

+

Magnesium Cause Signs/Symptoms Treatment

MagnesiumDeficitHypomagnesemiaSerum value1.0 mEq/L

Chronic alcoholism; malabsorption syndrome,prolonged malnutrition or starvation; prolongeddiarrhea; acutepancreatiti s, prolonged NG suctioning.Administration of magnesium-free IV solutions past 1 week.

Neuromuscular symptoms, hyperactive reflexes, coarse tremors, muscle cramps, positive Chvostek’s and Trousseau’s signs, seizures, paresthesia of feet and legs, painfully cold hands and feet, disorientation, tachycardia, and increased potential for digitalis toxicity

Administer oral magnesium salts.Administer 40 mEq (5 g) magnesium sulfate added to 1 Lof 5% D/W.Administer 1 to 2 g of 10% solution of magnesium sulfate by direct IV push at rate of 1.5 mL/min.

MagnesiumExcessHypermagnesemiaSerum value2.5 mEq/L

Renal failureHyperparathyroidism; hyperthyroidism; excessive magnesium administration duringtreatment of patients with eclampsia.

Neuromuscular symptoms such as flushing and sense of skin warmth, lethargy, sedation, hypoactive deep tendon reflexes, depressed respirations, and weak or absent cry in newborn.Hypotension, sinus bradycardia, heart block, cardiac arrest (15 mEq/L), nausea, vomiting, and seizures

Administer calcium gluconate to antagonize the action ofmagnesium.Support respiratory function. Peritoneal orhemodialysis..

Chloride Cause Signs/Symptoms Treatment

ChlorideDeficitHypochloremiaSerum Chloride95 mEq/L

GI lossesAcute infection and use of Chlorothiazide diuretics

Note: Serious acid-base Imbalances occur with chloride imbalances

Neuromuscular symptoms such as tetany and hypertonic reflexes.Depressed respirations and excessive loss of chlorides result in alkalosis Increase in HCO3 levels

Treat underlying cause (alkalosis) Administer sodium chloride solutions

+Electrolyte Composition of Body Fluids

+Electrolyte Composition of IV Fluids

+ Common IV Formulas and ConversionsInfusion Rate (mL/hr) Desired amount x drop factors of tubing

Time in minutesCalculate volume/hour Total Volume ÷ Administration time = mL (volume)/hour

Calculate drops/minute X gtt/min = Volume(mL) x drop factor of tubing(gtt)

Time in minutes (60)

Body surface area √Ht(cm) x Wt (kg) 3600

Conversions K=Kilo(meters)H=Hecto(meters)D=Deci(meters)B=Basic Unit(Meters)D=Decka(meters)C=Centi(meters)M=Milli(meters)

+

Comparing Needle and Catheter GaugesGauge Uses

16 •Adolescents and adults•Major surgery•Trauma•Whenever large amounts of fluids must be infused

18 •Older children, adolescents, and adults•Administration of blood and blood components and other viscous infusions

20 •Children, adolescents, and adults•Suitable for most I.V. infusions, including blood, blood components, and other viscous solutions

22 •Infants, toddlers, children, adolescents, and adults (especially elderly)•Suitable for most I.V. infusions

24,26 •Neonates, infants, toddlers, school-age children, adolescents, and adults (especially elderly)•Suitable for most infusions, but flow rates are slower

+

Complications of IV TherapyComplications

Causes Signs & Symptoms Nursing Interventions

Infiltration When the infusion cannula becomes dislodged from the vein and fluids are infused into the surrounding tissues

•Edema at the site of infusion•Discomfort, burning, pain at site•Feeling of tightness at site•Decreased skin temperature around site•Blanching at site•Absent backflow of blood

•Notify physician•Assess circulation•Remove the device•Elevate the limb•Document the patient’s condition and your intervention

Phlebitis Injury during venipuncture •Pain•Vein is sore, hard, cord like and warm to touch•Red line above the site•Signs of infection

•Notify physician•Application of warm compress•Continuously monitor the patients vital signs

Infection Transmission or encounter of host with potentially pathogenic organism which can be local or systemic

•Fever, chills & malaise•Contaminated IV site

•Notify the doctor•Administer medications as prescribed•Culture site and device•Monitor patient’s vital signs

Allergic Reaction

Local or generalized response to tape, cleansing agent, medication, solution or intravenous device

•Redness•Pruritis•Swelling

•Stop infusion immediately and infuse normal saline•Maintain a patent airway•Notify the doctor•Administer drugs as treated

Fluid Overload

An excess of fluid disrupting homeostasis caused by infusion at a rate greater than the patient’s system is able to accommodate

•Shortness of breath•Elevated blood pressure•Bounding pulse•Jugular vein distention•Increased respiratory rate•Edema•Crackles or rhonchi upon auscultation

•Raise the head of the bed•Slow the infusion rate•Administer oxygen as needed•Administer medications as ordered

Air Embolism

When air is introduced the vascular system, it may accumulate and cause complications such as blockages of the right side of the vascular system

•Sudden vascular collapse•Cyanosis•Hypotension•Increased venous pressures•Loss of consciousness•Respiratory distress•Weak pulse•Unequal breath sounds

•Notify the doctor•Discontinue the infusion•Place patient in Trendelenburg position on his left side to allow air to enter the right atrium and disperse through artery•Administer oxygen•Document the patient’s condition and interventions

Speed Shock

Rapid introduction of a foreign substance, usually a medication, into the circulation

•Flushed face•Headache•Tight feeling in the chest•Irregular pulse•Loss of consciousness

•Stop the infusion•Careful monitoring of IV flow rate and patient response•Begin infusion at 5% dextrose at 30 ml/hr in emergency cases•Evaluate circulatory and neurologic status•Notify the physician

+

Air Embolism Obstruction of the circulation system by air that has gained entrance to veins

Bolus A dose of a substance (such as a drug) given intravenously; specifically, a large dose given for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream

CI (Continuous Infusion)

intravenous that continuously carries fluids and or drugs directly into the body through a vein.

CVAD (Central Vascular Access Device)

a catheter inserted into a centrally located vein where the tip resides in the vena cava and permits either intermittent or continuous infusion or access to the venous system

EID (Electronic Infusion Device)

an electronic device designed to regulate the infusion rate of medication

Intermittent Infusion used when a patient requires medications only at certain times and does not require additional fluid

PICC (Peripherally Inserted Central Catheter)

typically utilized when intravenous access is required over a prolonged period of time

Piggybacking the use of connector(s) to allow another infusion set onto the same lin

Subcutaneous Infusion the administration (infusion) of medications into the tissues which lie beneath the skin

TKVO (To Keep Vein Open)

Administer fluid at rate to keep vein open at rate of minimum 30 ml/hr

TPN (Total Parental Nutrition)

Complete form of nutrition administered intravenously

Tunneled Catheter vascular access device (VAD) which tunnels subcutaneously from the insertion site and is brought out through the skin at an exit point

VAD (Vascular Access Device)

catheters, tubes or other devices inserted into the body for the purpose of obtaining access to the vascular system including veins, arteries, etc

Venipuncture surgical puncture of a vein especially for the withdrawal of blood or for intravenous medication

Vesicant highly reactive chemical agents which can cause tissue necrosis and damage.

Common Terms and Abbreviations

+9. Infusion-related complications 60 9.1 Phlebitis 60

9.2 Infiltration 60

9.3 Extravasation 61

9.4 Haematoma 61

9.5 Haemorrhage 62

9.6 Pneumothorax and haemothorax 62

9.7 Cardiac tamponade 63

9.8 Air embolism 63

9.9 Speedshock/fluid overload 64

9.10 Infusion-related bloodstream infections 64

9.11 Thrombosis 65

+ References Lenox, A. C. (1990). IV THERAPY: REDUCING THE RISK OF INFECTION. Nursing, 20(3), 60-61.

Retrieved from EBSCOhost

Southern Nevada Regional Professional Development Program. (n.d.). Effects of Solutions on a Red Blood Cell. Retrieved http://www.rpdp.net/sciencetips_v3/L8B2.htm

Gasparis, L., Murray, E., & Ursomanno, P. (1989). I.V. solutions: which one's right for your patient?. Nursing, 19(4), 62-64. Retrieved from EBSCOhost.