IV THERAPY

C Washington RN, MSNEd

IV Therapy

Administration of fluids, electrolytes, nutrients, or medications by the venous route

Clients receiving IV therapy require constant monitoring for complications

Intravenous Therapy

Indication for IV Therapy Establish or maintain a fluid or electrolyte

balance  Administer continuous or intermittent

medication 

Administer bolus medication 

Administer fluid to keep vein open (KVO) 

Administer blood or blood components 

Indication for IV Therapy Administer intravenous anesthetics  Maintain or correct a patient's nutritional

state

Administer diagnostic reagents  Monitor hemodynamic functions

Major Types of IV Fluids Isotonic Fluids – increases extracellular

fluid volume O.9% NS-expands intravascular

volume

5% dextrose & water-lowers serum Na+

Isotonic fluids  Same osmolarity as serum- 275-295 mOsm/kg

Fluid stays within the intravascular space Fluid flows from an area of lower concentration of

molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance).

Isotonic Fluid Used for hypotensive or hypovolemic patients Risk of fluid overload, esp in patients with

CHF & HTN

Contain an approximately equal number of molecules (blue dots nest slide)

In this example, there is no fluid flow into or out of the intravascular space.

Hypotonic Fluids Lowers the osmotic pressure and causes

fluid to move into cells

O.45% NS-maintains level of plasma sodium & chloride

Hypotonic fluids < 275mOsm/kg  

Dilutes the serum, which decreases serum osmolarity

Used for dehydrated and dialysis patient on diuretic therapy

Used for diabetic ketoacidosis - high serum glucose levels draw fluid out of the cells & into the vascular & interstitial compartments

Hypotonic fluids 

Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells-cardiovascular collapse and increased intracranial pressure (ICP) in some patients

Example: D5NS.45 (5% dextrose in 1/2 normal saline).

Hypotonic fluids 

Water is pulled from the vascular compartment into the interstitial fluid compartment.

As the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells. 

Hypotonic fluids Contain a lower number of molecules

than serum Fluid shifts from the intravascular space

to the interstitial space (represented by the green arrows).

Decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it) which then causes fluid to move into the cells.

Green arrows represent fluid movement, not molecule movement

Hypertonic Fluids Increases osmotic pressure, drawing

fluid from cells

D5% in 0.45% NS-provides sodium chloride

Hypertonic fluids> 295 mOsm/kg 

Higher osmolarity than serum Stabilize blood pressure, increase urine

output, and reduce edema.  Rarely used in the prehospital setting

Dangerous in the setting of cell dehydration

Examples: 9.0% NS, blood products, and albumin

Hypertonic Solution

Pulls fluid & electrolytes from the intracellular & interstitial compartment into the intravascular compartment

Hypertonic fluids Contain a higher number of molecules

than serum Increases the interstitial space

osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.

Fluid shifts from the interstitial space to the intravascular space

Crystalloid Ideal for patients who need fluid

replacement.  Used as a replacement to support blood

pressure from blood loss

Examples: Lactated Ringer's (LR), NS (normal saline)

Crystalloids

Colloids Draw fluid from the interstitial &

intracellular compartments into the vascular compartment

Reduce edema (pulmonary or cerebral

edema) while expanding the vascular compartment.

  Examples: albumin and steroids

Initiating Intravenous Therapy

Starting an IV is an art-form which is learned with experience accumulated after performing many IVs.

Some patients are easy but many are difficult.

IV Equipment Peripheral IV & Heparin locks – establish a

venous route in those clients whose condition may change rapidly

Vascular Access Devices – allow long-term IV therapy

Steel Needles: Butterfly catheter

Deliver small quantities of medicines

Deliver fluids via the scalp veins in infants

Draw blood samples (although not routinely, since the small diameter may damage blood cells).

Small gauge needles

Over the Needle Catheters   Example: peripheral IV catheter. This is the kind of catheter you will

primarily be using.

A Word About Gauges Gauge is the diameter of catheter The smaller the diameter, the larger the

gauge A 22-gauge catheter is smaller than a

14-gauge catheter The greater the diameter, the more fluid

can be delivered

A Word About Gauges To deliver large amounts of fluid, you

should select a large vein and use a 14 or 16-gauge catheter

A Word About Gauges To administer medications, an 18 or 20-

gauge catheter in a smaller vein will do.

Veins of the Hand Digital Dorsal veins

(1) Dorsal Metacarpal

veins (2) Dorsal venous

network (3) Cephalic vein (4) Basilic vein (5)

 Veins of the Forearm Cephalic vein (1) Median Cubital vein (2) Accessory Cephalic

vein (3) Basilic vein (4) Cephalic vein (5) Median antebrachial

vein (6)

Points to Remember Try to cannulate the most distal veins first

Failed cannulation attempts of antecubital veins can cause problems in the event of a successful cannulation further down

Any drugs or fluids put through the cannula may extravasate at the failed cannula site.

Points to Remember Cepahlic veins

(1, 3, 5) are the best veins available

Large and the forearm provides a natural splint

Points to Remember Placing the cannula too far distally along the

vein, you can run into problems with the wrist joint, and are getting close to the radial nerve

The tendons that control the thumb can obscure the vein

These problems can usually be avoided by moving a little further proximally along the vein

Points to Remember Basilic vein (4) is often

overlooked Hides along the ulnar

border of the hand and forearm.

It's fairly large It can roll like a tanker in

a rough sea Can have more valves

than a submarine.

Points to Remember Dorsal veins are often quite handy Metacarpals splint cannulae well They can be quite small. If the patient is elderly, look elsewhere Lack of turgor in the skin & loss of

subcutaneous tissue make it quite difficult to cannulate these veins

Points to Remember Cannulation of the antecubital veins may

occlude the vein as the patient bends their arm Avoid areas where cannulation or venipuncture

has previously taken place

Repeated puncture of the vein wall can result and is painful

Points to Remember Locate the vein section with the straightest

appearance Choose a vein that has a firm, round

appearance or feel when palpated

Avoid areas where the vein crosses over joints

Preparation: Gather Supplies

Absorbent disposable sheet

1 alcohol prep pad 1 betadine swab Tourniquet IV catheter

IV tubing Bag of IV fluid 4 pieces of tape

Disposable gloves Gauze (several

pieces of 4x4 or 2x2)

Inspect the fluid bag:

desired fluid

fluid is clear

bag is not leaking

bag is not expired

Prepare the IVF administration set

Select mini or macro drip administration set Do not let the ends of the tubing become

contaminated. Close the flow regulator (roll the wheel away from

the end you will attach to the fluid bag). Remove the protective covering from the port of

the fluid bag and the protective covering from the spike of the administration set.

Prepare the IVF administration set

Insert the spike of the administration set into the port of the fluid bag with a quick twist.

Do this carefully. Be especially careful to

not puncture yourself!

Prepare the IVF administration set

Hold the fluid bag higher than the drip chamber of the administration set

Squeeze the drip chamber once or twice to start the flow.

Fill the drip chamber to the marker line (approximately one-third full).

If you overfill the chamber, lower the bag below the level of the drip chamber and squeeze some fluid back into the fluid bag.

Prepare the IVF administration set

Open the flow regulator & allow the fluid to flush all the air from the tubing

Let it run into a trash can or even the (now empty) wrapper the fluid bag came in.

You may need to loosen or remove the cap at the end of the tubing to get the fluid to flow although most sets now allow flow without removal.

Prepare the IVF administration set

Take care not to let the tip of the administration set become contaminated.

Turn off the flow & place the sterile cap back on the end of the administration set (if you've had to remove it).

Place this end nearby so you can reach it when you are ready to connect it to the IV catheter in the patient's vein.

Perform the venipuncture Be sure you have introduced yourself to your

patient & explained the procedure Apply a tourniquet high on the upper arm It should be tight enough to visibly indent the skin,

but not cause the patient discomfort Have the patient make a fist several times in order

to maximize venous engorgement Lower the arm to increase vein engorgement

Perform the venipuncture Select the appropriate vein If you cannot easily see a suitable vein, you can

sometimes feel them by palpating the arm using your fingers (not your thumb)

The vein will feel like an elastic tube that "gives" under pressure

Tapping on the veins, by gently "slapping" them with the pads of two or three fingers may help dilate them.

Perform the venipuncture If you still cannot find any veins, then it might be

helpful to cover the arm in a warm, moist compress to help with peripheral vasodilatation

If after a meticulous search no veins are found, then release the tourniquet from above the elbow and place it around the forearm and search in the distal forearm, wrist and hand

If still no suitable veins are found, then you will have to move to the other arm.

Be careful to stay away from arteries, which are pulsatile.

Perform the venipuncture Don disposable gloves Clean the entry site carefully with the alcohol prep pad Allow it to dry. Then use a betadine swab. Allow it to dry. Use both in a circular motion starting

with the entry site and extending outward about 2 inches.

(Using alcohol after betadine will negate the effect of the betadine) Note that some facilities may require an alcohol prep without betadine.

Perform the venipuncture

Perform the venipuncture To puncture the vein, hold the catheter

in your dominant hand With the bevel up, enter the skin at

about a 30 to 45 degree angle and in the direction of the vein

Use a quick, short, jabbing motion After entering the skin, reduce the angle

of the catheter until it is nearly parallel to the skin

Perform the venipuncture If the vein appears to "roll" (move around freely under

the skin), begin your venipuncture by apply counter tension against the skin just below the entry site using your nondominant hand.

Many people use their thumb for this. Pull the skin distally toward the wrist in the opposite direction the needle will be advancing.

Be careful not to press too hard which will compress blood flow in the vein and cause the vein to collapse

Then pierce the skin and enter the vein as above.

Perform the venipuncture Advance the catheter to enter the vein

until blood is seen in the "flash chamber" of the catheter. 

Perform the venipuncture

Perform the venipuncture

If not successful Slowly withdraw the catheter, without pulling all

the way out Carefully watch for the flashback to occur If you are still not within the vein, advance it

again in a 2nd attempt to enter the vein While withdrawing always stop before pulling all

the way out to avoid repeating the painful initial skin puncture.

If not successfulIf after several manipulations the vein is notentered release the tourniquet place gauze over the skin puncture site withdraw the catheter tape down the gauze Try again in the other arm.

Inadvertently entering an artery Bright red blood is quickly seen in the IV

tubing and the IV bag because of the high pressure that exists.

If this occurs, stop the fluid flow, remove the catheter, and put pressure on the site for at least 5 minutes.

If Successful After entering the vein, advance the plastic

catheter (which is over the needle) on into the vein while leaving the needle stationary.

The hub of the catheter should be all the way to the skin puncture site.

The plastic catheter should slide forward easily. Do not force it!!

If Successful Advance the plastic catheter

If Successful

Release the tourniquet

If Successful Apply gentle pressure over the vein just proximal to

the entry site to prevent blood flow. Remove the needle from within the plastic catheter. Dispose of the needle in an appropriate sharps

container. NEVER reinsert the needle into the plastic

catheter while it is in the patient's arm! Reinserting the needle can shear off the tip of

the plastic catheter causing an embolus.

If Successful Remove the protective cap from the end of the

administration set and connect it to the plastic catheter.

Adjust the flow rate as desired.

If Successful Tape the catheter in place using the

strips of tape and/or a clear dressing. It is advisable not to use the "chevron"

taping technique.

If Successful Label the IV site with the date, time,

and your initials. Monitor the infusion for proper flow into

the vein (in other words, watch for infiltration).

IV Therapy: Sample IV Orders 1 L 5%D/0.45 NaCl with 20 mEq KCL at

125cc/hr

1000 ml D5 ½ NS with 20 mEq KCL every eight hours

1000 ml D5 ½ NS with 20 mEq KCL to run in 8 hrs

Flow Rates: Microdrip sets

 Allow 60 drops (gtts) / mL through a small needle into the drip chamber

Good for medication administration or pediatric fluid delivery

Flow Rates: Macrodrip sets Allow 10 to 15 drops / mL into the drip

chamber Great for rapid fluid delivery Also used for routine fluid delivery and

KVO

Flow Rates How much fluid do you want your patient

to receive each hour? “Keep the Vein Open” (KVO), infusing IVF

slowly to keep the vein patent, small amount of volume infused

Faster flow rate are expressed in mLs/hr Maintenance“ amount: NS at 125 ml/hr Your patient would receive 125 mL of fluid

every hour

Flow Rates Unless you are using an electronic pump to deliver the

fluid at precise amounts, you will need to learn how to set a flow rate yourself.

This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute.

To do this, you must know what size administration set you are using (micro or macrodrip).

Plug the numbers into the following formula and you've got it! (See Drug Calculation Handout)

Calculating Flow Rate Total Volume = mL/hour infusion rateHours of Infusion

For example:

1000 mL = 125 mL/hour infusion rate 8 Hours

IV Therapy: IV Label Amount & Type of

solution Additives & their

concentrations Rate & duration of

IV therapy Expiration date

Initials of pharmacist who prepared

Pt’s name & room #

Date & time started

RN initials

IV Therapy: Documentation Type of fluid & flow rate Insertion site location (L forearm, R

hand, L antecubital) State of IV site (swelling, reddness, pain) Patient’s response to therapy IV intake on I & O flow record

Managing IV Therapy IV Therapy requires constant monitoring Peripheral IV and PICC line Assessment

pain (palpation) discoloration: redness, bruise swelling induration maceration

Managing IV Therapy Concerns may be:

Hypervolemia (increased fluid volume)

Infiltration (seepage of foreign substances)

Phlebitis

IV Therapy: Nursing Care Monitor IV site & infusion every 2 hours

Pt age, size, status, c/o discomfort, teaching

Intake & Output No IV solution hung > 24 hrs Monitor for complications

IV Therapy: Nursing Care Change IV site, dressing, tubing per

institution policy (standard q 72-96 hrs No application of antimicrobial ointment

on catheter site Prevent neddle stick injury Standard precautions

Complications of IV Therapy Phebitis

Pain, increased skin temp, erythema, along path of vein

Complications of IV Therapy Infection

IV site red, swollen, warm, tender; purulent foul smelling drainage

Complications of IV Therapy Hematoma

Discolored area/bruising around IV site, pain, swelling

Complications of IV Therapy Infiltration

Swelling, possible pitting edema, pallor, coolness pain at site, decrease flow

Complications of IV Therapy Extravasation - inadvertent

administration of a vesicant substance into the tissues can have disastrous outcome.

Complications of IV THerapy Circulatory overload Air Embolism

Complications of IV Therapy FVD

Decreased urine output, dry mucous membranes, hypotension, tachycardia

FVE Crackles, SOB, edema

Complications of IV TherapyBleeding anticoagulant

therapy bleeding disorder disconnection of IV catheter from

tubing

Cath embolism ↓BP pain along vein weak, tready, rapid

pulse cyanosis of nail

beds/circumoral unconsciousness

Complications of IV Therapy Speed shock

Lightheadedness/dizziness; chest tightness; facial flushing, irregular pulse

Allergic reaction Local versus systemic reaction

Discontinue an IV

Observe universal precautions Clamp off the flow of fluids Gently peel the tape back toward the IV

site As you get closer to the site and the

catheter, stabilize the catheter and remove the rest of the tape from the patient's skin

Discontinue an IV (cont)

Place a 4 x 4 gauze over the site Gently slide the plastic catheter out of

the patient's arm Use direct pressure for a few minutes to

control any bleeding. Place a band aide over the site.

Methods of IV Drug Therapy Intravenous fluid container

Volume-control administration set

Intermittent infusion by piggyback or partial fill

IV push or bolus

Administration of IV Medications

General principles Check site for complications (redness,

swelling, tenderness)

Check for blood return Prepare medication according to

manufacturer's specifications

Administration of IV Medications

Appropriate tubing selection varies according to institution policy

Generally, rates greater than or equal to 12 hours require micro tubing (60 gtts/ml

All others require macrotubing (10, 15, or 20 gtts/ml)

Intermittent Therapy: Saline Lock

Intermittent therapy (saline lock) Swab injection port with alcohol at each step.

S: flush with 2 ml saline. A: administer medication at prescribed rate

using a short needle with a gauge equal to or smaller than catheter (25 g, 1/2 in).

S: flush with 2 ml saline (maintain positive pressure to prevent blood back-up into catheter). Not required if drug compatible with heparin.

H: flush with 10-100 units heparin if required by facility policy.

Secondary IV Piggyback With regulator turned off, spike tubing into

IV bag with medication. Squeeze drip chamber; fill halfway with

solution. Run fluid through tubing. If using add-a-line tubing, lower main IV

bag on hanger provided, otherwise hang bag at same level as primary bag.

Secondary IV Piggyback (cont)

Swab most proximal port with alcohol for add-a-line systems, otherwise lower port is acceptable.

Attach 20 g 1-inch needle to tubing, if a needleless system is not being used. Insert needle into injection port.

Regulate rate with control and watch to count drops.

When medication absorbed, main line will start to drip again.

Turn off secondary tubing.

Secondary IV Piggyback (cont)

Return main bag to original position. Special concerns

Be sure to label tubing with date. Use new tubing every 24-72 hours

(according to institution policy).

Intravenous push medications Using an appropriately sized needle, prepare

medication as ordered Cleanse injection port with alcohol or other

appropriate cleanser Unless otherwise recommended, turn off

primary IV bag; flush with saline if indicated Insert needle and administer medication at

prescribed rate (IVP Lasix over 5 minutes)

IV Pumps and controllers

Prime tubing Do not purge when attached to client Prior to connecting IV to client, check to

determine if tubing allows gravity free-flow If it does be sure to turn off regulator Connect tubing to client and turn on

electronic regulator

IV Pumps and controllers (cont)

Confirm alarm function by keeping tubing clamped while machine is turned on

Do not turn off alarms.Follow manufacturer's directions for

deactivating alarm and starting IV flow Explain regulator and alarms to clientConfirm flow rate with hourly checks on client,

fluid, and regulator

Peripherally Inserted Central Catheter

Central Line

Quinton Catheter

Portacath

DVD Resources/Lab Practice Venipuncture Establishing an IV Infusion Electronic Infusion Pump Regulating IV Flow Rate Discontinuation of a Peripheral IV

line

Initiating IV Access Complete Virtual IV Tutorial

Practice weekly for IV insertion competency

Mr. Watson Lives in a SNF Dx: Pneumonia Receiving IV

antibiotics Peripheral IV site C/O arm hurting at IV

site, especially with IV antibiotic

What would be your best action at this time?

Mr. Watson What possible

complications may explain his discomfort?

Mr. Watson IV discontinued

Restarted in other arm

Started infusion at 50 ml/hr

Mr. Watson 1000ml infused/1 hr C/O SOB puffiness around eyes Engorged neck veins Crackles both lower

lobes BP 154/96

Mr. Watson Another nurse tells

you that the client is experiencing speed shock because the saline went in too fast

Do you agree? Explain your answer. What should you do at

this time?

A patient, being discharged, will need to receive antibiotic therapy for an additional three weeks.

The peripheral vascular access device that would be the best for this patient would be:

1. A peripheral short catheter.2. A winged steel infusion set.3. A midline catheter.4. A PICC line.

A patient receiving parenteral fluids is prescribed an intravenous medication to be infused every 6 hours.

Which of the following infusion devices should the nurse use for this medication?

1. Stop cock2. Extension set3. Elastomeric balloon4. Secondary administration set

The staff development department is planning an annual skills review day for the basics of intravenous therapy.

If the Infusion Nursing Standards of Practice are being followed, the purpose of this skills day would be to:

1. Ensure that all nurses follow Standard Precautions.

2. Preserve the patient’s right to safe quality care and protect the nurse who administers infusion therapy.

3. Ensure that the nurses are in compliance with all regulatory agencies.

4. Ensure that the nurses’ skill levels are adequate.

A patient is prescribed parenteral fluid therapy.

Which of the following should the nurse do first?

1. Wash hands.2. Gather the equipment to insert the

peripheral access device.3. Prepare the flush to use once the

peripheral access device is in place.4. Review the procedure with the patient

and obtain consent.

A patient receiving parenteral fluid therapy complains of the arm “feeling cold” and the dressing “feeling tight.”

What should the nurse do?

1. Check for a blood return in the catheter.2. Stop the infusion and remove the

catheter.3. Turn off the infusion, reposition the

catheter.4. Change the dressing and observe the

site.