INTRAVENOUS THERAPY

Presented by:Bracket A

INTRAVENOUS THERAPYIt is an effective and

efficient method of supplying fluid directly into intravenous fluid compartment producing rapid effect with availability of injecting large volume of fluid more than other method of administration.

Kozier and Erb’s Fundamental of Nursing Vol.2 Page 1455

History

• 1831-Europe

History

• Russian Cholera or Blue Cholera-dusky cyanotic complexion of its victims

History

• William Brooke O’Shaughnessy, hypothesized that the primary cause of death in persons who has blue cholera was a deficiency of fluids and electrolytes

History

• Dr. Thomas Latta

LEGAL BASIS

• R.A. 7164 – The Philippine Nursing Act of 1991 Section 28 states that in administration of IV injections, special training shall be required.

IV Therapy and Legal Implications

• Board of Nursing Resolution No.8 Sc. 30 © Art. VII or administratively under Sc. 21 Art. III – states that any registered nurse without training and who administers IV injections to patients shall be held liable, either criminally, administratively or both.

LEGAL BASISIV Therapy and Legal Implications

• R.A. 9173 – The Philippine Nursing Act of 2002, Article VI Nursing (a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to . . .

Administration of written presentation for treatment, therapies, oral, topical and parenteral medications . . .

that in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice.

LEGAL BASISIV Therapy and Legal Implications

PURPOSE OF IV THERAPY

–Restore or maintain F & E–Administer meds–Provide nutrition–Transfusion

TYPE OF IV SOLUTIONSType of IV solution

Isotonic Hypotonic Hypertonic

GREEN

0.9% SODIUM CHLORIDE/

PNSS

ISOTONIC SOLUTION

PINK

D5 Lactated Ringers (D5LR)

HYPERTONIC SOLUTION

BLUE

PLAIN LACTATED

RINGERS (PLR)

ISOTONIC SOLUTION

LIGHT BLUE

D5 0.3 Sodium Chloride (D5

0.3 NaCl)

HYPOTONIC SOLUTION

YELLOW

D5 Normal Saline Solution

(D5NSS)

HYPERTONIC SOLUTION

PURPLE

Balanced Multiple Maintenace

Solution with 5% dextrose (D5IMB)

5% Dextrose, water and isotonic

solution

RED

D5 WATER(D5W)

ISOTONIC SOLUTION

ISOTONIC HYPERTONIC HYPOTONIC

O.9% NaCl D5NSS 0.33% Saline

PLR D5LR 0.45% Saline

D5W D5 in 0.45 Saline

D5 0.3 NaCl

3% NaCl

D10W

Categories of intravenous solutions according to their

purpose: Nutrient solutions. Electrolyte solutions. Volume expanders.

Nutrient solutions. It contain some form of carbohydrate and

water.

Water is supplied for fluid requirements and carbohydrate for calories and energy.

They are useful in preventing dehydration and ketosis but do not provide sufficient calories to promote wound healing, weight gain, or normal growth of children.

Common nutrient solutions are D5W and dextrose in half-strength saline.

Electrolyte solutions (Crystalloid)

fluids that consist of water and dissolved crystals, such as salts and sugar.

Used as maintenance fluids to correct body fluids and electrolyte deficit .

Commonly used solutions are: -Normal saline (0.9% sodium chloride solution).-Ringer’s solutions (which contain sodium, chloride, potassium, and

calcium. -Lactated Ringer’s solutions (which contain sodium, chloride, potassium ,calcium

and lactate) .

Volume expanders (Colloid)

• Are used to increase the blood volume following severe loss of blood (haemorrhage) or loss of plasma ( severe burns).

• Expanders present in dextran, plasma, and albumin.

VENIPUNCTURE SITES

VARIES WITH CLIENT’S:• AGE• LENGTH OF TIME OF INFUSION• TYPE OF SOLUTION• CONDITIONS OF VEINS

VENIPUNCTURE SITES

VENIPUNCTURE SITES

VENIPUNCTURE SITES

CENTRAL VENOUS CATHETERS

VENIPUNCTURE SITES

CENTRAL VENOUS CATHETERS

IV Infusion Method

IV Infusion Method

I.V. Bolus (I.V. push)

Continuous-drip

infusion

Intermittent infusion

DUTIES AND RESPONSIBILITIES

1. Interpret and carry out the physician’s prescriptions for IV therapy.

EG.D5LR to run for 8 hours

DUTIES AND RESPONSIBILITIES

2. Preparing necessary materials and observing inaccuracy

Materials• Infusion Set• IV Solution• IV pole• Adhesive tape• Clean Gloves• Tourniquet• Antiseptic swabs• IV catheter• Arm splint If required• Electronic infusion device

Infusion Set

IV SOLUTIONIV POLE

ADHESIVE TAPE

TOURNIQUET

ANTISEPTIC SWABS

IV CANNULA

SPLINT

INFUSION PUMP

ADPIE

Nursing assessment1- assess the solution:

2- Reading the label on the solution.3- Determine the compatibility of all fluid and

additives.4- observe I.V sets

No leakage

Sterile

No small particles

Clear

and

not

expired

Cracks

Holes

Missing

clamps

Expired

date

• Also, the nurse should assess the patient for :1- Any allergies and arm placement preference.2- Any planned surgeries.3- Patient’s activities of daily living.4- Type and duration of I.V therapy, amount, and rate.

Nursing diagnosis:

• Anxiety (mild, moderate, severe) related to threat regarding therapy.

• Fluid volume excess. • Fluid volume deficit. • Risk for infection. • Risk for slKnowledge deficit eep pattern

disturbance. • related to I.V therapy.

Planning

• Identify expected outcomes which focus on:• preventing complications from I.V therapy.• minimal discomfort to the patient.• restoration of normal fluid and electrolyte

balance .• patient’s ability to verbalize complications.

Implementation I. Implementation during initiation phase A) Solution preparation: the nurse should: Label the I.V container. Avoid the use of felt-tip pens or permanent

markers on plastic bag. Hang I.V bag or bottle .

University of La SaletteCollege of Nursing

Date:______________

Patients’s Name

______________________________

IVF:_________________________

Additives: ___________________

______________gtts/min

Time Started:________________

Hours to run:__________________

Prepared by:

______________________/BSN student

DUTIES AND RESPONSIBILITIES

3. Performing Peripheral vein puncture

Implementation

B) Site preparation:1- Cleanse infusion site.2- Excessive hair at selected site should be

clipped with scissor .3- Cleanse I.V site with effective topical antiseptic.4- Made Venipuncture at a 10 to 30 degree angle.

DUTIES AND RESPONSIBILITIES

4. Determine solution and medication incompatibilities.

Table 1Examples of drug compatibilitiesDrug Compatible in syringe Incompatible in syringe Comments

Benzylpenicillin 600 mg powder for reconstitution

No common drugs listed in published data Prochlorperazine, promethazine, chlorpromazine, sodium bicarbonate

Dexamethasone sodium phosphate 4 mg/1 mL Metoclopramide, ondansetron, ranitidine Glycopyrrolate, midazolam, prochlorperazine, promethazine

Diazepam 10 mg/2 mL Nil Widely incompatible - do not mix with other drug solutions

Poorly water soluble drug marketed in a complex solvent system

Frusemide 20 mg/2 mL No common drugs listed in published data Buprenorphine, chlorpromazine, droperidol, metoclopramide, midazolam, morphine sulfate, prochlorperazine, promethazine

pH of solution is 8.0-9.3. Frusemide is unstable in acidic media which may include glucose 5% solution.

Haloperidol 10 mg/2 mL Hydromorphone Benztropine, ketorolacHydrocortisone sodium succinate 100 mg powder for reconstitution

Metoclopramide Prochlorperazine, promethazine, midazolam

Lignocaine hydrochloride 2% in 5 mL Glycopyrrolate, metoclopramide Ampicillin, sodium bicarbonate solution

Metoclopramide hydrochloride 10 mg/2 mL Chlorpromazine, dexamethasone, droperidol, fentanyl, hydrocortisone sodium succinate, lignocaine, midazolam, morphine, pethidine, promethazine

Ampicillin, frusemide, sodium bicarbonate

Morphine sulfate, morphine tartrate (various strengths)

Stability of at least 15 minutes published for atropine, bupivacaine, droperidol, fentanyl, glycopyrrolate, hyoscine butylbromide, ketamine, prochlorperazine, and up to 24 hours for metoclopramide

Aminophylline, flucloxacillin, frusemide, phenytoin, promethazine, sodium bicarbonate

Is less soluble in alkaline conditions

Prochlorperazine edisylate Atropine, hydromorphone, hyoscine hydrobromide, morphine sulfate (may vary with brand), pethidine

Aminophylline, amphotericin, ampicillin, benzylpenicillin, calcium gluconate, cephalothin, dexamethasone sodium phosphate, frusemide, heparin, hydrocortisone sodium succinate, midazolam

The bulk of the published data refer to the edisylate salt which is marketed overseas. The salt marketed in Australia is mesylate which is similar, and for which extrapolation of data is considered reasonable.

Promethazine hydrochloride 50 mg/2 mL Atropine, droperidol, fentanyl, glycopyrrolate, metoclopramide, midazolam, pethidine

Aminophylline, benzylpenicillin, dexamethasone sodium phosphate, frusemide, hydrocortisone sodium succinate, morphine, phenytoin, sodium bicarbonate

Locally irritant and unsuitable for subcutaneous injection. Avoid extravasation in intravascular injection.

Tramadol hydrochloride 100 mg/2 mL No common drugs listed in published data Diazepam, midazolam This is a relatively recently marketed drug on which there is a paucity of published compatibility data

DUTIES AND RESPONSIBILITIES

5. Administer computed medications, chemotherapeutic drugs, flow rates of solutions, compatible blood/blood components and parenteral nutrition as prescribed by the physician.

Regulating flow rate:

The nurse calculate the infusion rate by using the following formula :

Fluid delivered

IV pump Gravity

Volume (ml) X Drop factor (hospital protocol) (gtts/min) = Drop RateHours to run (hr) 60 min/hr

DUTIES AND RESPONSIBILITIES

6. Assess all adverse reactions related to IV therapy and initiate appropriate nursing interventions.

7. Establish nursing care plan related to IV Therapy.

8. Adhere to established infection control practices.

9. Maintain proper care of IV equipments.

II. Implementation during maintenance phase

A) Monitoring I.V infusion therapy: the nurse should :

inspect the tubing. inspect the I.V set at routine intervals at least daily. Monitor vital signs . recount the flow rate after 5 and 15 minutes after initiation

B) Intermittent flushing of I.V lines Peripheral intermittent are usually flushed with saline (2-3

ml 0.9% NS.)

C) Replacing equipments (I.V container, I.V set, I.V dressing):

I.V container should be changed when it is empty. I.V set should be changed every 24 hours. The site should be inspected and palpated for tenderness

every shift or daily/cannula should be changed every 72hours and if needs.

I.V dressing should be changed daily and when needed

III. Implementation during phase of discontinuing an I.V infusion

The nurse never use scissors to remove the tape or dressing. Apply pressure to the site for 2 to 3 minutes using a dry,

sterile gauze pad. Inspect the catheter for intactness. The arm or hand may be flexed or extended several times.

DUTIES AND RESPONSIBILITIES

10. Document relevant data in the preparation, administration and termination of all forms of IV therapy

Recording and reporting:

• Type of fluid, amount, flow rate, and any drug added.

• Insertion site. • Size and type of I.V catheter or needle. • The use of pump. • When infusion was begun and discontinuing. • Expected time to change I.V bag or bottle,

tubing, cannula, and dressing.

• Any side effect. • Type and amount of flush solution. • Intake and output every shift, daily weight. • Temperature every 4 hours. • Blood glucose monitoring every 6 hours, and

rate of infusion.

Evaluation

• Produce therapeutic response to medication, fluid and electrolyte balance.

• Observe functioning and patency of I.V system.

• Absence of complications.

Parenteral Nutrition (PN)

• Parenteral nutrition is a form of nutritional support that supplies protein, carbohydrate, fat, electrolytes , vitamins, minerals, and fluids via the IV route to meet the metabolic functioning of the body.

Clinical indications of parenteral nutrition

• Client cannot tolerate internal nutrition as in case of paralytic ileus, intestinal obstruction, persistent vomiting.

• Client with hyper metabolic status as in case of burns and cancer.

• Client at risk of malnutrition because of recent weight loss of > 10%, NPO for > 5 days, and preoperative for severely depleted clients.

Local Complication- Hematoma

• Hematoma– S & S– Interventions– Prevention

Local Complication-Infiltration

• Infiltration– S & S– Interventions– Prevention

Local Complication-Phlebitis

Local Complication-Site Infection

Local complication-Tissue Sloughing

• Fluid overload• This occurs when fluids are given at a higher rate or in a

larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema.

• Hypothermia• The human body is at risk of accidentally induced

hypothermia when large amounts of cold fluids are infused. Rapid temperature changes in the heart may precipitate ventricular fibrillation.

• Electrolyte imbalance• Administering a too-dilute or too-concentrated solution

can disrupt the patient's balance of (sodium) (potassium) (magnesium), and other electrolytes. Hospital patients usually receive blood tests to monitor these levels.

Systemic Complications• Embolism• A blood clot or other solid mass, as well as an air bubble, can be delivered into

the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV.

• Air bubbles of less than 30 microliters are thought to dissolve into the circulation harmlessly. Small volumes do not result in readily detectable symptoms, but ongoing studies hypothesize that these "micro-bubbles" may have some adverse effects. A larger amount of air, if delivered all at once, can cause life-threatening damage to pulmonary circulation, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart.

• One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. Air bubbles can leave the blood through the lungs. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Fatality by air embolism is vanishingly rare, although this is in part because it is so difficult to diagnose.