6/25/2012

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IV Therapy

Legal Issues

• Accountability

– The act of being professionally responsible and answerable for one’s actions, inactions, decisions, and judgments

• SC Nurse Practice Act

• Standards of Care

– Minimal acceptable level of care

• Employer’s Policy and Procedures

What is RN Accountable for?

• What IV therapy is ordered and its indication

• Desired outcome of the IV therapy

• Possible adverse or side effects that may occur

• Prepare the patient mentally & physically

• Administer, maintain, and monitor the therapy

• D/C the therapy when ordered

• Document and report

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Advantages of IV Therapy

• IV therapy provides:

– Access route for meds, fluids, anesthetics in an emergency situation

– Access route for unconscious or NPO patient

– Alternative choice for irritating or poorly absorbed meds by other routes

– Faster absorption

Disadvantages of IV Therapy

• Patient discomfort

• Fluid overload

• Allergic reaction

• Local or systemic infection

• Venous thrombosis or emboli

• Transmission of Hep B, Hep C, HIV

What is Ordered (cont)

• IVF are prepared in bags or bottles ranging in size from 50-1000mL

• Label contains the complete name of the fluid and fine print identifies the exact amount of each component

• Orders and charts contain abbreviations and numbers/symbols

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What is Ordered (cont) Common Abbreviations

• Abbreviation:

– D

– W

– S

– NS

– LR or RL

• Full Meaning:

– Dextrose

– Water

– Saline

– Normal saline

– Lactated ringers or ringer’s lactate

Isotonic Solutions

• Same amount of particles as body fluids

• Expand circulating volume but no shifts into or out of vessels/cells

• 0.9% NaCl = NS

• D5W

• LR

• D5 ¼ NS

• D2.5 NS

Hypotonic vs. Hypertonic

Hypotonic

• Less particles than intracellular

• Moves water into cells

• May deplete circulating volume

• D 2.5 W

• ½ NS

Hypertonic

• More particles than intracellular

• Moves water out of cells into circulating volume

• D10W

• 3%NS

• D 5 NS and D5 ½ NS

• D10NS

• Mannitol

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Equipment

• IV solution in container

• IV tubing

• Venous access device

• Start kit

• Electronic infusion device

• Labels

Equipment (cont)

• Solution containers

– Glass

• Require venting

– Plastic

• Do not require venting

– Label

– Extensions/ports on bottom

• One for IV tubing spike

• One for adding meds

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Equipment (cont)

• Tubing

– Primary

– Secondary

– Blood

– Lipids

– Extensions

– Parts

• See diagram

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Equipment (cont)

• Catheter

– Most frequently used

– Rigid needle on inside, flexible catheter on outside

– Hub is color coded to indicate gauge & length

– 14-24 gauge; ¼ - 12 inches

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Equipment (cont)

– Straight steel needles

• 14-27 gauge; ¼ - 3 inches long

• Rarely used today

– Winged Needles

• Used primarily for peds

Equipment (cont)

• Start Kit

– Tourniquet

– Antiseptic skin preparation

– Gauze

– Tape

– Dressing

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Equipment (cont)

• Electronic Infusion Device

– Rate in mL/h

– Volume to be Delivered

– Primary

– Secondary

– Total infused

– Infusion time

Equipment (cont)

• Labels

– IV solution

– Tubing

– Site

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Common Complications

• Hematoma

– Infiltration of blood into tissue

• Infiltration

– Catheter dislodges out of the vein and IVF infuse into surrounding tissue

• Thrombus

• Clot within or around the catheter

• Phlebitis

– Inflammation of the vein

Common Complications (cont)

• Thrombophlebitis

– Thrombus along with inflammation

• Fluid Overload

– Infusion of too much fluid for the body to handle

• Infection

• Air Emboli

• Speed Shock

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Hematoma

• Infiltration of blood into tissue

• At Risk:

– Bruise easily -anticoagulant therapy

– Long term steroid use

• S/S:

– Discoloration -Swelling/Discomfort

– Inability to advance catheter

– Resistance when attempt to flush

Hematoma (cont)

• Prevention:

– Be gentle when starting IV

– Use smallest needle

– Apply tourniquet just before sticking

• Treatment:

– Apply pressure when d/c catheter

– Elevate

– ice

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Infiltration

• Catheter dislodges and solution infuses into surrounding tissue

• S/S:

– Coolness -tautness of skin

– Dependent edema

– Slowed infusion rate -no back flow

• Prevention:

– Assess

Infiltration Treatment

• Stop infusion

• Remove IV catheter

• Apply pressure to stop bleeding

• Apply cold or your agency policy or HCP orders

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Thrombosis

• Clot within or around the catheter

• S/S:

– Slowed or stopped infusion

– Inability to flush catheter

• Prevention:

– Use pump or controller

– Avoid lower extremities or site near flexion joints

Thrombosis (cont)

• Treatment:

– NEVER flush and force clot to move

– d/c IV site and restart at new location

– Assess for circulatory impairment

– Notify MD

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Phlebitis

• Inflammation of the vein

• S/S:

– Redness -warm to touch

– Local swelling -palpable cord

– Sluggish infusion rate

• Prevention:

– Good hand washing

– Use smallest size catheter

– Change site q 72 hours; solution q 24 hours

Phlebitis Treatment

• Prevention is the best intervention

– Asepsis

– Good hand washing

– Use smallest length and gauge cannula

• If occurs:

– Stop IV infusion and d/c catheter

– Warm compresses per policy

– Culture drainage if present

– Notify HCP who may order antibiotics

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Thrombophlebitis

• Thrombus and inflammation

• S/S:

– Decreasing arterial pulses

– Mottling/cyanosis of extremity

• Prevention:

– Dilute irritating meds/solutions

– Use FA not hand veins

– Assess

Thrombophlebitis (cont)

• Treatment:

– d/c

– Comfort measures

Fluid Overload

• Signs & Symptoms

– Jugular vein distension

– Confusion

– Respiratory difficulties

– Increased respiratory rate

– Shortness of breath

– Crackles in lungs

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Fluid Overload (cont)

• Prevention is the best intervention

– Place IVF on electronic device and monitor flow rate closely

– Monitor I&O, breath sounds, respiratory rates

• If overload does occur:

– Decrease or stop IVF infusion

– Notify HCP for further orders

Infection:

• S/S:

– Redness and swelling

– Drainage

– Increased WBC’s

– Elevated temp

• Prevention:

– Assess

– Change site q 72 hours, solution q 24 hours

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Infection (cont)

• Treatment:

– d/c catheter

– Notify MD

Less Common Complications:

• Air Emboli

– Check all bags, syringes, tubing for air in them

– Do not push air through lines

• Speed Shock

– Use IV electronic infusion device

– Follow instructions carefully for IVP

Selection of a Vein

• Site selected should: – Provide the most appropriate access to the vessel

– Accommodate the prescribed therapy

– Minimize associated risks of complications

• The Nurse should consider: – Pt age & health status

– Purpose & duration of IV therapy

– Condition of the site

– Possible s/e of the IV therapy

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Steps to Venipuncture

• Check the Order

– Date & time of order

– Name of IVF and/or medication to be added

– Dosage of medication

– Volume to be infused (VTBI)

– Rate of infusion

– Duration of infusion

– Signature of provider

Selection of Veins (cont)

• Don’t use veins of lower extremities

• Don’t use veins that are irritated or sclerosed

• Don’t use areas of flexion unless joint is immobilized

• Don’t use veins in the antecubital fosssa

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Selection of Veins (cont)

• Don’t use veins on the side in an extremity

–Mastectomy

–CVA impairment

–Partially amputated

–Third degree burn

–Arm with an arteriovenous shunt or fistula

Difficulty Locating a Vein

– Stroke or gently tap extremity

– Open & closing the fist

– Apply warm washcloth or other heat on extremity

– Lower the extremity below level of the heart

Steps to Venipuncture

• Select the Appropriate Needle

– 18-20g hypertonic or isotonic solutions with additives

– 18-20g blood administration; trauma; surgery; labor

– 22g fragile veins in elderly

– 22-24g pediatric patients

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Steps to Venipuncture

• Apply Gloves

• Apply tourniquet

• Prepare the Site

– Povidine-iodine

– Alcohol

– ChloraPrep

– Tincture of Iodine

Steps to Venipuncture

• Enter the Vein

– Pull skin taunt

– Enter the skin at 15-45 degree angle

– After bevel enters vein and flashback is seen, lower the angle of the catheter and advance into the vein

– Release the tourniquet

– Remove the stylet

– Connect the catheter hub to the administration set

Steps to Venipuncture

• Stabilize catheter and apply dressing

• U, H, or Chevron methods

• Label the Site

– Date, time, size of jelco, nurse’s initials on dressing

– Date, time, nurse’s initials on tubing

– Date, time, nurse’s initials, any additives on IV bag

• Disposal of Equipment

• Regulate Flow Rate

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Steps to Venipuncture

• Document

– Date and time of insertion

– Location of IV catheter (vein used)

– Device used

• Brand name, style, gauge, length

– Name and Rate of IVF infusing

– Method of infusion

• Gravity, electronic infusion device

– Pt response

– Signature

Maintenance of IV Therapy

• Visually inspect and palpate the IV insertion site at least daily. Note any redness, edema, or drainage. Document per infiltration and /or phlebitis scale

• Keep site dressing clean, dry, and intact

• Replace dressing with each devise change or more often if wet or soiled

Maintenance of IV Therapy (cont)

• Replace peripheral catheters at least every 72-96 hours

• Replace administration set at least every 72-96 hours

• Replace IV bag every 24 hours or sooner per order

• Replace lipid containing solutions and infusion sets every 24 hours

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Maintenance of IV Therapy (cont)

• If IVF are discontinued but access device remains in place, then IV site must still be assesses as previously stated

• Jelco should be flushed with NS or heparin lock solution(10-100 units/mL) per facility policy

– For example: Every 8-12 hours or every shift

Discontinuing IV Fluids/Therapy

• Don gloves

• Obtain 2*2 inch gauze pad

• Loosen tape and apply gauze over insertion site

• Remove cannula and dressing as one unit

• Apply direct pressure to the site

• Apply band aid if needed

• Document cannula removed intact and condition of site

Special Considerations: Peds

• Selection of Vein

– Age and size of child

– Mobility and level of activity

– Cognitive ability

• Peripheral Veins

– Scalp

– Hand/forearm

– Dorsum of foot

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Special Considerations: Peds

• Equipment

– Container with no more than 500mL of IVF; 250mL if child less than 12 months

– Use volume control chamber

– Fill volume control with no more than 2 hours worth of IVF

– May use syringe pump

Special Considerations: Geriatrics

• Skin and Vein Changes

– Loss of subcutaneous fat and thinning make skin and veins fragile

– Use tourniquet loosely and for short period of time

– Select smallest access device

– Be careful with tape

• Cardiovascular Changes

– Increased risk fluid overload