IV THERAPYGOALS OF IV THERAPY

Maintain or replace body stores of water, electrolytes, vitamins, proteins, fats, and calories in the patient who cannot maintain adequate

oral intake.

Restore acid-base balanceRestore volume of blood

componentsProvide avenues for drug

administrationMonitor CVP

Provide nutrition while resting the GIT

Nursing Role Initiating an IV – nurses must be familiar with the procedure as well as the

equipment involved in initiating an IV to provide

effective therapy and prevent complications:

SELECTING A VEIN1. First

verify the order for IV therapy

unless it is an emergency situation.

2 .Explain the procedure to the patient.

3 .Select a vein suitable for venipuncture.

Initial considerations:- use distal branches of vein

initially -vein should not be crooked,

scarred (hardened )or inflamed.

Back of hands – metacarpal vein. Avoid digital veins, if

possible. -the advantage of this site is

that it permits arm movement.

-if later a vein problem develops at this site, another vein higher up may be used.

b. forearm- basilic or cephalic vein

c. lower extremities: -foot – venous flexus of

dorsum, dorsal venous arch, medial marginal vein

-ankle – great saphenous vein4 .Instances when central vein

are used:a. when medications and

infusions are hypertonic or highly irritating,

requiring rapid, high volume dilution to

preventsystemic reactions and local

venous damage ( eg. Chemo- therapy,

TPN )b. when peripheral blood flow

is diminished (eg. Shock ) or when

peripheral vessels are not accesible ( eg. Obese patients

)c. when CVP monitoring is

desiredd. when moderate or long

term fluid therapy is expected.

Methods of Distending a Vein1. Apply manual

compression above site where cannula is to be

inserted.2 .Have the patient

periodically clench the fist ( if arm is used ).

3 .Massage area in direction of venous

flow.4 .Apply tourniquet ( made of

soft rubber tubing ) at least 5 to 15 cm.

(2-6 inches) above planned insertion site.

5 .Lightly tap vein site; this is to be done

gently so that the vein is not injured.

6 .Allow extremity to be dependent

(below the heart level )for few minutes.

C. SELECTING NEEDLE OR CATHETER :1. use the

smallest gauge catheter suitable for type and location

of infusion.2 .if blood transfusion is to be

given, use a larger bore catheter.

3 .for very small veins and infusion rate below

50ml/ hr. a 24 gauge catheter may be

appropriate.5 .For short term infusion of 1

hour or less, a steel needle may be used.

6 .For longer term therapy, choose a flexible catheter.

D. CLEANSING THE INFUSION SITE:1. If skin is usually

soiled, cleanse infusion site thoroughly with

a good surgical soap and rinse.

2 .Cleanse IV site with effective topical

antiseptic.3 .Three alcohol swabs, used

one at time, in acircular motion from site

outward and for 1min. is appropriate

cleansing.E. Initiating The

VenipunctureI. Infusion Tubing:

1 .Drip chambers:a. micro drip system – delivers 60gtts/ml. and is used when

small volumes are being delivered

(50ml./ hr ,).this reduces the risk of clotting the IV line to

slow infusion rates.

b. Macro drip system – delivers 10 15 or 20 gtts./ ml. and is used to deliver solution

in large quantities or fast rates .

2 .Vents:a. Vented tubing's should be

used with standard glass bottles. This

permits air to enter the vacuum in the

bottle anddisplace solution as it flows

out.b. No vented tubing should be

used for IV bags and glass bottles that

have a built in air vent.

3 .FILTERSa. Filters help minimize the risk of

contamination from certain microorganisms

and particulate

matter.b. Filters should be changed every 24 to 48hrs. Because

bacteria may become trapped in the filter and release

endotoxin, a small pyrogen capable of passing thru filter .

4 .SPECIAL TUBINGSa. Most mechanical infusion pumps

and controllers require specialized tubing to fit their particular pumping chamber.

5 .TUBING CHANGEa. standard is 48 to 72hrs.

b. label new tubing's with date, time hung and your

initials.6 .DRESSING CHANGES AND

FLUSHING OF IV a. short peripheral – change dressing

every days when site changed.

If used as a lock 2ml. NSS every shift or heparin 1:10

units/ml. -The doctor prescribes the

flow rate .ADJUSTING RATE FLOWHowever, the nurse is

responsible forregulating and maintaining

the proper rate.

a. surface area of the patient- the larger the

patient, the more fluid may be required and

tolerated.b. Patient condition – a

patient in hypovolemic shock requires greater amounts of fluids, whereas the patient with heart and renal failure receives fluids judiciously.

c. Age of the patient – fluids should be administered more slowly in very young and the

elderly.

d. Tolerance to solutions – fluids containing medications

causing potential allergic reactions or intense vascular

irritation ( eg. KCL ) should be well diluted or given slowly.

e. Prescribed fluid composition – efficacy of some

drugs is based on speed of infusion ( eg. Antibiotics ).

Other solutions are given at a rate titrated to the patient’s

response to them (eg. Dopamine, Dobutrex, Tridil,

heparin)..

الانواع الحين نجي TYPES OFالمحاليل:

FLUIDS:Isotonic – a solution that exerts the same osmotic

pressure as that found in plasma.

a. Normal Saline 0.9% (NSS)

b. Lactated Ringer’s (LR)c. Blood components

-Albumin 5% -Plasma

d. 5% dextrose in water (D5W)

2 .HYPOTONIC- a solution that exerts less osmotic pressure than that of blood plasma. Administration of this fluid generally causes dilution of

plasma solute and forces water movement into cells to reestablish intracellular an extra cellular equilibrium; cells will then expand or

swell. -Dextrose 2.5% in half

strength normal saline

-Half strength normal saline, 0.45%

-Quarter strength normal saline, 0.2%

3 .HYPERTONIC – a solution that exerts a higher osmotic pressure than that of blood

plasma. Administration of this fluid increases the solute concentration of plasma,

drawing water out of the cells and into the extracellullar compartment to restore

osmotic equilibrium; cells will then shrink.

-Dextrose 5% in Normal Saline 0.9%

(D5NSS) -Dextrose 5% in Half –

strength Normal Saline (D5N2Saline0 – only

slightly hypertonic because dextrose is rapidly

metabolized & renders only temporary

osmotic pressure. -Dextrose 10% in Water

(D10W)

-Dextrose 20% in Water (D20W)

-Saline 3% and 5% -Hyperalimentation solutions

-Dextrose 5% in Lactated Ringers

-Albumin 25%USES & PRECAURIONS WITH

COMMON TYPES OF INFUSION1. D5W

a. Used to replace water (hypertonic fluid)

losses, supply some caloric intake ,

administer as carrying solution for numerous

medications, or functions as a slow “KVO ”infusion.

2 .NORMAL SALINEa. Used to replace saline (isotonic fluid) losses, administer with blood components, or treat patients

in hemodynamic shock.

b. Cautious use in patients with isotonic

volume excess ( eg. Heart Failure, Renal

Failure.)3 .Lactated Ringer’s a. Used to

replace fluid losses, replenish electrolyte losses, &

moderate metabolic acidosis .المضاعفات:

COMPLICATIONS INFILTRATION

A. Cause – dislodgement of the cannula from the vein

resulting in infusion of fluid into surrounding tissues.

B. S/S1 .swelling, blanching, and

coolness of surrounding skin and tissues.

2 .discomfort, depending on nature of solution.

3 .fluid flowing more slowly.

4 .absence of blood back flow in IV catheter

and tubing.C. PREVENTIVE MEASURES:1.

Ensure that IV and distal tubing are

secured sufficiently with tape to

prevent movement.2 .Splint arm or hands as

necessary.3 .Check IV site frequently for

complications.D. NURSING

INTERVENTIONS:1. Stop infusion immediately and

removeIV cannula or needle.

2 .Restart IV line in the other arm.

3 .If infiltration is moderate to severe, apply

warm , moist compress and elevate the limb .

4 .Document interventions and assessment.

THROMBOPHLEBITIS:A. Causes:

1 .Injury to the vein during venipuncture ,

large bore needle/ catheter use, or

prolonged use.2 .Irritation to vein due to

rapid infusionsor irritating infusion (eg.

Hypertonicglucose solutions, KCL etc.).

Smaller veins are more susceptible.

3 .Clot formation at the end of the needle or

catheter due to slow infusion rates.

4 .More often seen in synthetic catheter than

steel needles.B. Clinical Manifestations:1.

tenderness at first, then pain along

course of the vein.2 .Swelling, warmth, redness

at infusion site, the vein may appear as a

red streak above insertion site.

C. Preventive Measures:1 .Anchor needle or catheter

securely at insertion site.

2 .Change insertion site at least every 72hrs.

3 .Use large veins for irritating fluids because

of higher blood flow, which rapidly dilutes

irritant.4 .Sufficiently dilute irritating

agents beforeinfusion.

D. Nursing Interventions:1. Apply cold compress

immediately torelieve pain and inflammation.

2 .Later follow with moist, warm

compress to stimulate circulation and

promote absorption.BACTEREMIAA. Causes:

1 .Underlying phlebitis increases risk.

2 .Contaminated equipment or infused solutions.

3 .Prolonged placement of an IV device

(catheter/ needle, tubing, solution container .)

4 .Non aseptic IV insertion or dressing change.

5 .Cross contamination by patient with

other infected areas of the body.

6 .The critically ill or

immunosuppressed patient is at greatest risk for

bacteremia.B. Clinical Manifestations:1.

elevated temp., chills2 .nausea and vomiting

3 .headache, increased pulse ,4 .may progress to septic

shock with profoundhypotension.

5 .possible signs of local infection at the iv site

(eg. Redness, pain, fowl drainage.)

CIRCULATORY OVERLOADA. Cause: delivery of excessive

amounts of IV fluids (especially a risk for

elderly pts .infants, or pts. With cardiac

or renal insufficiency.

B. Clinical Manifestations:1. increased BP and pulse

2 .increased CVP, venous distention

(engorged neck veins)3 .shortness of breath

tachypnea coughing

4 .pulmonary crackles, chest pain ( h/o CAD)C. Preventive

Measures:1.know whether pt. has existing heart or

kidney condition.2 .closely monitor infusion

flow rate3 .splint arm or hand for

children and elderly

D. Nursing Interventions:1. slow infusion to KVO rate &

notify Dr .2 .monitor closely for

worsening condition3 .raise pts. head to facilitate

breathing

4 .document interventions & assessments

AIR EMBOLISMA. Causes:1 .A greater risk exists in

central venous lines, when air enters catheter during tubing

changes.2 .Air in the tubing delivered

by IV push or infused by infusion pump.

B. Clinical Manifestations:1. drop in BP, elevated heart

rate2 .cyanosis, tachypnea

3 .rise in CVP4 .changes in mentation, loss

of consciousnessC. Preventive Measures:1.

clear all air from tubing before infusion to patient

2 .change solution containers before they run dry.

3 .ensure that all connections are secure

4 .use filter unless contraindicated

5.change IV tubing during expiration

D. Nursing Interventions:1. immediately turn patient on left side and lower head of

bed; in this position, air will rise to right atrium

2 .notify Dr. immediately3 .administer O2 as needed

4 .reassure patient5 .document interventions and

assessmentsHEMORRHAGE

A. Causes:1. loose connection of tubing or injection port

2 .accidental removal of peripheral or central catheter

3 .anticoagulant therapyB. Clinical Manifestations:1.

oozing of blood from IV site or catheter

2 .hematoma

C. Preventive Measures:1. cap all central lines with PRN

adapters and connect tubing to the cap- not directly to the

line.2 .tape all catheters securely –

use transparent dressing when possible for peripheral

& CVP .3 .keep pressure on sites

where catheters have been removed- 10min. for an anti-

coagulated pt.VENOUS THROMBOSIS-the vein in which the

peripheral or central catheter lies becomes partially or fully

occluded by a thrombus.Causes:1. infusion of irritating

solutions2 .infection along catheter

may preclude this syndrome. B. Clinical Manifestations:1.

slowing of IV infusion or

inability to draw blood from the central line.

2 .swelling and pain in the area of catheter or in the

extremity proximal to the line.C. Preventive Measures:1. ensure proper dilution of

irritating substancesD. Nursing Interventions:1.

stop IV fluids immediately and notify Dr .

2 .reassure pt. and institute appropriate therapy.a. anticoagulants

b. heatc. elevation of affected

extremityd. antibiotics

PREVENTION OF ASSOCIATED INFECTION

SINTRAVENOUS THERAPYIV therapy is used only when

indicated and promptly stopped when the indication

is no longer present. Cut down are usually avoided as much as possible because of

the high risk of infectioN

3 PRINCIPLESwhich must be applied to all IV therapy from the time of cannula insertion until the

cessation ;1 .ASEPSIS – the nurse has a

dual function to detect extrinsic contamination.

2 .SAFETY – aim of therapy is safe preparation and delivery

of fluid or drug.3 .COMFORTa. The nurse must

have knowledge of anatomy

and physiology to know how to choose suitable vein & site.b. Knowledge of he type of IV needles and cannula with the

associated advantages and disadvantages, indication of

use and possible choices.

Preventive Nursing:a. Practice rigid

aseptic technique when inserting a cannula. Consider

the procedure a minor operation.

b. Thoroughly cleanse the insertion site using proper

antiseptic ( alcohol)c. Take care to anchor the catheter/ cannula firmly in order to prevent excessive

movement that might

traumatize the vein and possibly facilitate entry of microorganism at infusion

site.d. Once the skin has been

cleaned, don’t touch the site .e. The cannula site should be

kept clean and dry, change the top dressing if it becomes

soiled.f. The following should be

documented on the venipuncture dressing:

a. date and time of insertionb. gauge no. of cannula usedc. name/ initials of the nurse

who insertedg. the venipuncture site

should be inspected regularly for signs of redness, cellulitis and inflammation, as well as

to ensure proper functioning of infusion.

h. A non- touch technique should be followed when

changing IV set, and bottle and as quickly as possible.

i. IV tubings must be changed every 48- 72 hrs.

1 .label new tubing with date, time hung ,

and your initials.2 .in case blood products

change to IV fluids and vice versa, one

must change the IV set as well.

اللحين خلصنا لله الحمدمن االول الجزء

بركة على الكورسنبدا

الثاني الجزء DRUG---اللهADMINISTRATION

10R’S OF DRUG ADMINISTRATION:Right medication

Right dosageRight routeRight time

Right patientRight to privacyRight to refuseRight recordingRight approach

Right to know the action of medicine

FORMS: 1. SOLID: a) cap, pills, tablets

b) suppositories, oint, powder2 .SOLUTIONS:

a) syrupsb) elixirs

c) suspensionsMETHODS:1. ORAL ( P.O )a)

follows directionsb) ability to swallow

2 .TOPICAL:a). Rectalb). Sublingual

c). Nasald). Eyese) earsf). Skin

3 .PARENTERAL a). Intradermal ( just below skin)

-mantoux test ( TB testing ) -allergy testing

b). Intramuscular ( IM ) into muscle

c). Subcutaneous ( SQ) undremis

-small amount -non irritating volume

NURSING

RESPONSIBILITY :1.

administer only what you prepare

2 .be familiar with medicine’s -general purpose -side effects -average dose -safety precautions3 .document meds.4 .Evaluate – pats. Condition,

medicine compatiblity5 .Aseptic technique6 .No meds. Should be stored

at bedsideيجيبله منكم واحد كل من ابغى االن

نسكافية --------------كاسة الصح بالشغل حنبدا الننا

I.V. CALCULATIONIV FLOW RATE:

3 FACTORS MUST BE KNOWN:V – Amount of solution ordered

T _Duration of infusion

R _Drop Factor – number of drops per/ml macro set/micro

set/ blood infusion set.

IV CALCULATION:

1 .V = ml/hr.

T (hrs.)500 = 62.5 ml/hr - 500 = 41.6 ml/hr.

8(hrs )12(hrs)2 .V = ml/ min

T (hrs) x 60Ex. 500 = 1.04 ml/min.

8x601.04ml/min.

x 60min.

62.49ml/hr

62.49ml/hr.

x 8499.99 or 500ml

3 .V x R (drop factor ) = gtts/min.

T x 60Ex. 500 x 20 = 20.8 or

21gtts/min.

8x60

100ml/hr x 20 = 33.33ggts/min.

60

If you want to confirm if the gtts /min. is correct, this is

how you will confirm.

20gtts/ml .

33.33gtts/min.

x 60min.(1hr.)

1999.8gtts. in 100ml.

1999.8( gtts in 100ml = )99.99 or 100ml.

20gtts/ml.

MEDICATION CALCULATIONDESIRED

DOSE X Q (quantity) =ml/hr.

STOCKED DOSE--------------------------

ex. INSULIN: 6units/hr.

in 49ml NSS to

add 100units of Regular insulin

D X Q = ml/hr.

S6 units RI X 50mlNSS = 3ml/hr.

100units4units X 50ml = 2ml/hr

100units------------------

HEPARIN

1 VIAL = 25,000UNITS in 5ml1ml= 5000units

Dr’s order 750units /hr. to add 100ml of NSS via infusion

pump.

D X Q = ml/hr- 750units X 100 = 3ml/hr

S 25000units1200units/hr X 100ml =

4.8ml/hr .

25000units

AMINOPHYLLINE1 AMP.= 250mg. In 10ml.-

25mg./ml.

Dr’s order add 2amp. in 400ml of NSS x 6hrs. the giving set

is 20gtts/ml.

Question:

How much Aminophylline will be delivered after 4hrs ?

V = mgl/hr. 500mg = 83.33mg/hr

T 4 x4

333.33mg in 4hrs2 .How much Aminophylline in

each ml of IVF?

formula = added medicine = mg./ml

solution ( IVF)ex. 500mg of aminophylline =

1.25mg/ml400ml of NSS x400ml of NSS

500mg-------------------

3 .At what rate you should set the infusion?

V x drop factor = gtts /min.

Tx60min. In 1hr.

400ml x 20gtts = 22gtts/min

6hrs.x604 .How much ml/min. the pt.

will received?

V 400 = 1.11ml/min.

Tx 60 in min. 6x60 x60min. In 1hr

66.66 x 6 = 400ml NSSTRIDIL

1 ampoule = 50mg in 10ml 5mg/ml. (stock)

How to prepare the solution.

65 ml of NSS + 1ml (5mg)of TRIDIL

1 .)Dr’s order 5uq/ min.

5uq x 60(min.) X 66 = ml/hr.

5mg. (x1000uq) 1mg=1000uq.

5uq x 60 X 66 = 3.96ml or 4ml/hr.

5000

2 .)Dr’s order 12.5uq/min.

5uq x60 X66 = ml/hr.

5mg x1000uq

-----------------------

KCL1 ampoule = 20meq per

10ml - 2meq/mlDr’s order to add 40meq in

250ml of IVF.

How many ml. of KCL are you going to add in the IVF?

D X Q = ml .

S 35meq KCL X 10ml/amp.= ? ml

20meq (stock)----------------

قانون لكم حقول ROLE OFهنا

6DOPAMINEUsing Rule of 6AIM: To make a

100ml of solution with a

concentration of 1ml/hr.

(1mcgtt/min = ).1mcq/kg/min.

FORMULA : 6 x BW (kg) =

mg Dopamine/Dobutrex + NSS = 100ml.

1 vial of Dopamine = 200mg in 5ml.= 40mg/ml

Dr’s order 5uq/min in a pt. with the BW 67kg.

6 x 67 = 402 mg. of Dopamine

-------------

402mg Dopa. X10ml.(5ml/ vial)= ml.DOPAMINE

400mg (2 vial)

9.75mg of Dopamine

90.25 ml. of NSS100 ml of the prepared solution

If the Dr’s order to give 5uq of Dopamine/min. How many ml. or mcgtts are you going to set

your infusion set ?

--------------

DOBUTREXFormula same with Dopamine using rule of 6.

1ampoule = 250mg / 5ml. – 1ml.= 50mg.

70kg x 6 = mg.of Dobutrex(DobutamineHCL)

70 x 6 X 10 = ? mg of Dobutrex

500mg (2 amp.)

70 x 6 X 10 = 8.4ml.of Dobutrex to + in NSS

91.6ml. NSS100ml. Prepared solution.

If the order is 10uq.so 10ml.or 10mcggts/min.

you are going to set your infusion.

---------------------------------