IV THERAPYPART I

Catherine Luksic BSN,RN

WHAT IS IV THERAPY ?

Intravenous – into the vein

Administration of substances (fluids) directly into the vein

Parenteral route

PN SCOPE OF PRACTICE: IV THERAPY

State of Pennsylvania – requirements Satisfactory completion of Board approved IV therapy

course LPN complies w/ policies/procedures of institution Review of policies/procedures q 12 mos.

Functions of PN Perform venipuncture Administer IV fluids **As of 7/2012 – LPN

may May NOT administer: administer & maintain

Antineoplastic agents TPN, lipids Blood products Titrated medications IV push medications

PN SCOPE OF PRACTICE: RULES AND REGULATIONS

Refer to Handout

LEGAL ISSUES

Informed Consent Pt. has right to refuse treatment If pt. is incompetent or unable to give consent,

legally authorized rep. may consent Coercion of rational adult patient to place an IV

catheter constitutes assault & battery Manual of IV Therapeutics, Phillips, 2010

Nurse must comply w/ acceptable nursing standards established by facility, as well as state/federal guidelines Infusion equipment, administration of meds,

monitoring of pt., documentation, etc. If an act of malpractice causes harm, legal

action can be initiated

INDICATIONS FOR IV THERAPY

Fluid & Electrolytes Maintenance Replacement – fluid or electrolyte deficit Restoration - ongoing losses. (i.e. drains, NGT’s,

severe diarrhea, vomiting, burns)

Medications antibiotics, potassium, insulin, heparin, etc.

Nutrients TPN, PPN

Blood Products PRBC’s, FFP, Platelets

ADVANTAGES OF IV THERAPY

1. Bioavailability is immediate Drug enters circulation immediately, permits access

to site of action 2. Absorption into bloodstream is complete

and reliable 3. Large doses can be delivered at a

continuous rate 4. No “first pass” effect in the liver

DISADVANTAGES OF IV THERAPY

1. Adverse reactions may occur – can be life

threatening If medication administered too quickly Allergic reaction

2. Increased risk of complications Extravasation Vein irritation (phlebitis) Systemic infection Air embolism

THE HEART

BLOOD VESSELS

Arteries - carry blood away from heart. Branch off into smaller arteries eventually into capillaries.

OXYGENATED BLOOD

Veins - blood from capillaries flow into veins, carry blood back to the heart

UNOXYGENATED BLOOD

BLOOD VESSEL WALLS

Tunica intima - innermost layer. Continuous with the endocardium.

Tunica media - middle layer. Smooth muscle and elastic tissue.

Tunica adventicia (externa) - tough outer layer.

BLOOD VESSEL WALLS

BLOOD VESSEL WALLS

ARTERIES VS. VEINS

Middle layer (tunica media) much thicker in artery

Arteries contract & relax Due to high pressure and thicker muscle layer

Pressure much less within veins. Veins have one-way valves to direct blood

flow toward the heart. Veins store blood (70% of blood volume).

ARTERIES: VEINS:

Thick wall (tunica media)

Lacks valves Pulsates Bright red blood High pressure

Thin wall valves present

approx. every 3 in. No pulsation Dark red blood Lower pressure

*pulsation may be seen in jugular vein

VEINS

VEINS

Used for IV therapy

Peripheral (arms/hands): Cephalic (upper and lower) Basilic Median (antecubital) Metacarpal *First choice for site selection

*allows for increased mobility *less risk of phlebitis

(Burton textbook recommends forearm veins – to avoid nerve/tendon damage in hands ???)

PERIPHERAL VEINS – UPPER EXTREMITY

FACTORS TO CONSIDER

Adipose tissueEdemaColor

? Adequate tissue perfusion

Hydration ? Dehydration, volume overload, normovolemic

Tissue elasticityBruising, rashes, breaks in skin

Avoid these areas

Sensation ? Lack of, can pt. feel “pain”

VEINS

Refer to handout: Veins Practice identification of peripheral veins in

classroom Learn to properly apply tourniquet to upper

extremities

VENOSCOPE: VEIN FINDER

IV ACCESS

Peripheral - Located in peripheral veins of upper (and sometimes lower) extremities Can be placed by nursing (qualified LPN’s &

RN’s)

Central - Located in large vessels near heart (ie, subclavian, internal jugular, femoral) Can only be placed by physician or specially

trained practitioners

PERIPHERAL IV

Smaller vessels Slower blood flow Easy access Veins of hands, arms most commonly used Metacarpal, cephalic, basilic, accessory cephalic,

median, upper cephalic Needs to be changed regularly

Every 48-72 hours, according to policy2011 Infusion Nursing Standards of Practice –

rotate peripheral IV catheters based on clinical condition vs. set time frame

CENTRAL IV ACCESS

Higher risk of life-threatening complications Larger vessels More turbulent blood flow Care includes sterile dressing changes and

flushes Used if peripheral access not possible, or

for long-term use. Percutaneous, tunneled, or implanted. Includes PICC lines (peripherally

inserted central catheter)

CENTRAL IV LINES

Usually located in subclavian vein, jugular vein

Can also have access through cephalic, basilic, antecubital and axillary veinsPICC lines

PICC LINE

CENTRAL IV LINE

CENTRAL IV LINE

IV SOLUTIONS

Bottle vs. Bag

Types of Solutions

Tonicity

Electrolyte Solutions

SOLUTION CONTAINERS

Bottle - Not commonly used Meds that cannot be in plastic

Advantages: Very easy to visualize solution and to see calibrations

Disadvantages: BREAKS. Easier to contaminate. Takes more storage space.

Examples: Nitroglycerin, Albumin, Lipids Lipids are also stable in special plastic

Requires tubing w/ vent

IV BOTTLE

SOLUTION CONTAINERS

Plastic - Most common container Atmospheric pressure collapses bag , forces fluid out.

Advantages: Easy to store. Not greatly affected by temp fluctuations.

Disadvantages: Can be punctured. Some meds can adhere to plastic.

**ALWAYS inspect bag/bottle before use

TYPES OF SOLUTIONS

Colloids - Pulls fluid into intravascular space, volume expanders Albumin – treat low BP/shock, provides protein

Considered to be a blood product Dextran – to prevent venous thrombosis during OR Hespan (hetastarch)

Similar to albumin

Crystalloids - Used for hydration, most common ** Saline, Dextrose

TYPES OF SOLUTIONS

Blood and blood products Restore blood volume or components PRBC’s – acute blood loss, anemia Hg <8.0 FFP – replace coag factors, will reverse effect of

coumadin (PT/INR elevated) Platelets – thrombocytopenia, control bleeding Whole blood – rarely used, restores blood

volume

LPN cannot admin. but can monitor pt. during infusion

Beware of transfusion reaction

TYPES OF SOLUTIONS:BLOOD PRODUCTS

Physician order & consent requiredType and crossmatch required (ABO type,

Rh group)Only compatible with 0.9% NS **

Dextrose can cause hemolysisFrequent VS, monitor pt. continuously for

first 15 min.2 RN’s must check blood product before

initiating infusion

TYPES OF SOLUTIONS

Transfusion Reactions 1. Hemolytic: DANGEROUS, RBC’s attacked by immune system – cells burst

Bleeding (urine), chest pain, back pain, low BP, chills May be a delayed reaction, usually immediate

2. Febrile: N/V, fever, chills, headache, chest pain

3. Allergic Itching, SOB, wheezing, possible rash

4. Anaphylaxis: DANGEROUS Wheezing/stridor, SOB, low BP, cyanosis, anxiety

5. Circulatory Overload Low SP02, tachycardia, high BP, dyspnea

ALWAYS STOP THE TRANSFUSION IMMEDIATELY

IV NUTRITIONAL SUPPORT

TPN – Total Parenteral Nutrition: IV infusion of amino acids, vitamins, electrolytes, and minerals Usually high dextrose concentration Used when GI system cannot be used for feeding LPN can administer ** High dextrose concentration (>10%) can damage

veins, usually given via central vein

Intralipids - intravenous infusion of fat (fatty acids) essential fatty acid is linoleic acid, needed for proper

metabolism. IV lipids are “white” Lipids can be “piggybacked” with TPN

IV NUTRITIONAL SUPPORT

Increased dextrose level of TPN can lead to increased microbial growth

TPN & LIPIDS

FLUID COMPARTMENTS IN THE BODY

Intracellular : fluid inside cells of the body High concentrations of potassium(K+),

phosphate, and magnesium ions 2/3 of body water

Extracellular: fluids outside cells Includes interstitial & intravascular

compartments Contains high concentrations of sodium, chloride,

and bicarbonate ions 1/3 of body water

ELECTROLYTES

Sodium (Na+)Major extracellular cationNormal 135-145 meq/L

Calcium (Ca+) – extracellular cation Chloride (Cl-)

Major extracellular anion Bicarbonate (HCO3) – extracellular Magnesium (Mg+) – intracellular cation Potassium (K+)

Major intracellular cationNormal 3.5-5.0Hyperkalemia = serious danger !

IV SOLUTIONS

Osmosis: regulates fluid & electrolyte balance = movement of water through SPM from area of lower concentration (solutes) to higher concentration

SPM’s = tunica intima, capillary walls, and cell membranes of RBC’s

Rate of osmosis – depends on osmotic pressure within tissues/cells Draws water through SPM to more concentrated area IN or OUT of cell

IV SOLUTIONS

Tonicity = osmolarity or concentration of IV solution Amount of solute in a fluid (dextrose, sodium, etc.)

ISOTONIC: concentration same as blood No osmosis No change in solute or water in blood, no shrink or

swell Increases amount of ECF

Caution w/ fluid volume overload (CHF, renal patients) Uses: replace fluid loss, dehydration, to administer

IVPB 0.9% NS, LR, D5%W

ISOTONIC SOLUTIONS

IV SOLUTIONS HYPERTONIC: Higher concentration of

solutes Osmosis pulls water out of cells Fluid shifts from intracellular > intravascular Increased fluid volume in vascular space

CAUTION with CHF patients May raise BP May irritate the vein walls Cells shrink Can cause “cellular dehydration”, cellular death Uses: dehydration, electrolyte replacement

(severe), expand blood volume D5LR, D5 0.9% NS, D5 0.45% NS, D10%,

albumin, dextran

HYPERTONIC SOLUTIONS

IV SOLUTIONS

HYPOTONIC: Lower concentration of solutes Osmosis pushes water into cell Fluid shifts from intravascular > interstitial >

intracellular Cell is re-hydrated Cells swell, can possibly “burst” – hemolysis Uses: DKA Can cause intravascular fluid depletion – caution !

May cause hypotension Can increase ICP from quick fluid shift

Cerebral edema 0.45% NS, 0.3% NS, 0.25% NS

HYPOTONIC SOLUTIONS

IV SOLUTIONS

ISOTONIC HYPERTONIC HYPOTONIC

No osmosis; no shift

Osmosis pulls water out of cell; “raisin”

Osmosis pushes water into cell; “grape”

Uses: dehydration, fluid loss, commonly used for IVPB

Uses: dehydration, electrolyte replacement (severe)

Uses: DKA, cellular re-hydration, can replace daily NaCl requirement

Caution: fluid volume overload (cardiac, renal)

Cautions: fluid volume overload, hypertension, vein irritiation

Caution: hemolysis of cells, intravascular volume depletion, hypotension, cerebral edema

0.9% NS, LR, D5%W

D5 0.9% NS, D5 045% NS, D5 LR, D 10%, Albumin

0.45% NS, 0.3% NS, 0.25 % NS

NORMAL SALINE

0.9% NS Isotonic – osmo same as blood NaCl = sodium chloride Non-caloric Standard “flush” solution Standard hydrating solution 0.45% NS (1/2) is hypotonic

Lower osmo, less concentrated

SALINE

Saline - “NS” or “NaCl”.9% (is isotonic)

.45% is ½ (is hypotonic)

When mixed with D5 may become hypertonic - MUST WATCH FOR FLUID OVERLOAD

More fluid in intravascular space

DEXTROSE

Contains dextrose and free water Available in a variety of concentrations, 5%

most common. 5% (D5W) is isotonic. Usually in mixture with NS; D5W alone can

cause severe hyponatremia, hypokalemia, and water intoxication.Dilutes body’s normal level of electrolytesNOT 1st choice for hydration

Cannot be administered w/ blood hemolysis

DEXTROSE

Dextrose - “D”usually 5%

Also 10%, 20% (usually TPN only – hypertonic)

provides calories D5 = 170 cal/liter D10 = 340 cal/liter

cannot be used with blood, certain medsCheck compatibility

can affect blood glucose monitor DM

ELECTROLYTE SOLUTIONS

Usually isotonic solutions that contain electrolytes in concentrations similar to plasma

Lactated Ringer’s most common contains potassium, sodium, chloride,

and calcium. Lactate added as bufferRingers solution = no lactate added

short-term use (48 hours) used for fluid loss (vomiting, diarrhea)

Electrolyte replacement

ELECTROLYTE SOLUTIONS

Electrolyte solutionsRinger’s or Lactated Ringer’s (LR)provides electrolytes and hydrationshort-termmonitor ELECTROLYTESno caloriescannot use lactate if liver disease

present – cannot metabolize

ELECTROLYTE SOLUTIONS

PlasmalyteMultiple combination

Dextrose Sodium chloride Sodium acetate Sodium gluconate Potassium chloride Magnesium Chloride

IV THERAPY: ABBREVIATIONS

D5W NS = 0.9%D5 0.9% NS ½ NS = 0.45% (5% dextrose solution ¼ NS =

0.225% w/ 0.9% normal saline)

D5 0.45% NS (referred to as D5 ½ NS)

D5 0.45% NS @ 50 cc/hr D5 ½ NS @ 50 ml/hr

IV THERAPY: ABBREVIATIONS

PICC KCL (meq)POC CaGlucTLC MgSO4HLSL

TYPES OF IV INFUSIONS

Continuous – not interrupted, ordered rate

Intermittent - access for infusions that are only given at specific timesIV antibiotics

IV push - meds that are given all at once. Not given by LPN’s with exception of saline flush.

IV PUSH

Meds NOT administered by LPN’sMust be given by RNDelivery is immediate

Saline flush (non-med) – 3-10 mL given directly into IV to maintain patency.

CAN be given by LPN

IVP

INTERMITTENT INFUSIONS

Not continuous “Piggy-back” meds (IVPB) -

intermittent infusions given through continuous primary IV line. ie; IV antibiotics, IV potassiumCheck compatability between

“piggyback” and continuous IV solution Call Pharmacy re: drug-drug interactions Use on-line resources Use IV compatibility chart Incompatible drugs can cause a precipitate

CONTINUOUS IV INFUSION

Can be large volume (250 to 1000cc) of solution administered continuously correct or maintain fluid and electrolyte balance.

Can be a medication being delivered on a continuous basis to maintain a constant serum level – ie; heparin,

insulin Needs to be infused with IV pump to avoid error

Continuous IV medications cannot be titrated (regulated) by LPN’s – must be done by RN