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# IVF

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How to an IVThe use of time taping an IV solution is being rate. It also helps facilitate calculation of fluid intake. To time tape an IV you may make your own time tape with adhesive tape or use pre-made labels: Place a strip of adhesive tape along the fluid level marking lines. At the top of the strip - label the time the bag of fluid was started.

Time TapeIV helps ensure that an infused at the prescribed

Knowing the hourly infusion rate - mark each hour on the tape that corresponds with the level of fluid marks on the IV bag. At the bottom of the strip - mark the time at which the solution will be completely infused.

INK ALERT: Never write directly on an IV solution container with a felt tip type marker; the ink may leach into the solution. The following illustration demonstrates a bag to be initiated at 9am. The infusion rate is 100mls per hour. The liter of fluid to infuse at 100mls per hour should be complete in 10 hours, or 7pm.

1. Take the medication bag and write down everything you see on the label and on the bag of solution itself. You need it to verify your patient, the drug, the route, the timeuhhhhwhats that called? Ha just testing you! You will need all of this information and more not just to figure out drop rate but to document into your home health notes! Do NOT forget to write the lot number and expiration rate of the medication, the solution the medication is in and the saline you used to flush the line. 2. Multiply the amount of fluid in the bag to the drops per ml of the primary tubing set. What do you mean you threw it away? GUYS! Been around me too long!! It will probably be 15 drops per ml, but could be 10, 15, 30 or 60. Read the packages!! 3. Lets say you have a bag of Vancomycin with 250 ml of fluid x 15 drops per ml of the primary tubing set equals 3750 4. Divide that by the amount of time you want the medication to infuse. Is 250 too much? To me it is. So 3750 divided by 120 equals 31. 5. Your drop rate is 31 drops per minute. 6. Now for the dial a flow setting. What was that? Dial a flow doenst go higher than 200 on the roller? Whereas that would be a problem if the amount of fluid in the IV bag were 500ml, in this case you are fine because as I said, the dial a flow works on an hour principle. Half of 250 equals 125 so set the scroll for that but then what? 7. ABSOLUTELY!!! 8. Count your drops per minute. The first time try and stand there with your watch and count a full minute but patients will distract you if the things you do take what they feel is inordinately long. So count for 15 seconds and multiply by 4, thats good. Now, which roller can you use if it does NOT come ut closest to 31 drops per minute? The one on the primary set or the one on the dial a flow? Right. The one on the dial a flow. That must be why they call it a dial a FLOW! It controls the FLOW! OHHH!!!! 9. Real hard wasnt it? All of that information just to give you a three step process for calculating dops per minute without a pump. Cool OH YOU

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IV THERAPYIndicationsEstablish 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 Administer intravenous anesthetics Maintain or correct a patient's nutritional state Administer diagnostic reagents Monitor hemodynamic functions

IV Devices

Steel Needles Example: Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. They are used to deliver small quantities of medicines draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles (i.e. 23 gauge).

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

A Word About Gauges And now, a word about gauges: Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

IV FluidThere are three main types of fluids: Isotonic fluids Close to the same osmolarity as serum. They stay inside the intravascular compartment, thus expanding it. Can be helpful in hypotensive or hypovolemic patients. Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and hypertension. Isotonic fluids contain an approximately equal number of molecules (blue dots) as serum so the fluid stays within the intravascular space. Remember that fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is no fluid flow into or out of the intravascular space. Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water).

Hypotonic fluids Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells. Can be helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients. Example: D5NS.45 (5% dextrose in 1/2 normal saline).

Hypotonic fluids Contain a lower number of molecules than serum so the fluid shifts from the intravascular space to the interstitial space (represented by the green arrows). This 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. Note that the green arrows represent fluid movement, not molecule movement.

Hypertonic fluids Have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Can help stabilize blood pressure, increase urine output, and reduce edema. Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration. Examples: 9.0% NS, blood products, and albumin.

Hypertonic fluids Contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (represented by the green arrows). This 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.

There Are Two Main Groups Of FluidsCrystalloid Are isotonic and remain isotonic and are therefore, effective volume expanders for a short period of time. However, both the water and the electrolytes in the solution can freely cross the semipermeable membranes of the vessel walls (but not the cell membranes) into the interstitial space, and will achieve equilibrium in two to three hours. They are ideal for patients who need fluid replacement. When using an isotonic crystalloid for fluid replacement to support blood pressure from blood loss, remember that 3 mL of isotonic crystalloid solution are needed to replace 1 mL of patient blood. This is because approximately two thirds of the infused crystalloid solution will leave the vascular spaces by about one hour. Generally, a good rule of thumb is that initial crystalloid replacement should not exceed three liters before whole blood is instituted. Continued use of crystalloids runs the very real risk that the fluid that has leaked into the interstitial space will result in edema, primarily in the lungs (pulmonary edema). Examples: Lactated Ringer's (LR), NS (normal saline). Colloid These contain molecules (usually proteins) that are too large to pass out of the capillary membranes and therefore remain in the vascular compartment. The large protein molecules give colloid solutions a very high osmolarity. As a result, they draw fluid from the interstitial and intracellular compartments into the vascular compartment. They work well in reducing edema (as in pulmonary or cerebral edema) while expanding the vascular compartment. Colloids can produce dramatic fluid shifts and place the patient in considerable danger if they are not administered in a controlled settings. Examples: albumin and steroids

Vein Selection

Veins of the Hand 1. Digital Dorsal veins 2. Dorsal Metacarpal veins 3. Dorsal venous network 4. Cephalic vein 5. Basilic vein

Veins of the Forearm 1. Cephalic vein 2. Median Cubital vein 3. Accessory Cephalic vein 4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein

Generally speaking, it is better to try to cannulate the most distal veins first. If for example, the antecubital veins are ruined as a result of failed cannulation attempts this 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. The cepahlic vein is one of the best veins available. It tends to be large, and the forearm provides a natural splint (Weinstein, 1997). If you place 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. Also the tendons that control the thumb can obscure the vein (Hadaway, 1995). These problems can usually be avoided by moving a little further proximally along the vein. The basilic vein is often overlooked, hiding as it does along the ulnar border of the hand and forearm. On the plus side, it's often fairly large - on the minus side it can roll like a tanker in a rough sea and can have more valves than a submarine. The dorsal veins are often quite handy (excuse the pun) as the metacarpals splint cannulae well (Weinstein, 1997), but they can be quite small. If the patient is elderly, look elsewhere. The lack of turgor in the skin and loss of subcutaneous tissue make it quite difficult to cannulate these veins in the chronologically gifted (Whitson, 1996). Cannulation of the antecubital veins can also cause problems as the cannula may occlude as the patient bends their arm. Avoid, if you can, areas where cannulation or venipuncture has previously taken place. Repeated puncture of the vein wall can result and is painful (Ahrens et al., 1991) In general, 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.

If the IV treatment is for a life-threatening illness or injury, your choice may be limited to an area that remains open during hypoperfusion. Otherwise, limit IV access to the more distal areas of the extremities.

TechniqueIt is important to point out that 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. Preparation It is important to gather all the necessary supplies before you begin. You will need: Absorbent disposable sheet 1 alcohol prep pad 1 betadine swab Tourniquet IV catheter IV tubing Bag of IV fluid 4 pieces of tape (preferably paper tape or easy to remove tape which has been precut to approximately 4 inches (10cm) in length and taped conveniently to the table or stretcher. Disposable gloves Gauze (several pieces of 4x4 or 2x2) Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking, and the bag is not expired.

Prepare the IV fluid administration set

Select either a mini or macro drip administration set and uncoil the tubing. 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. 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!

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.

Open the flow regulator and 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. Take care not to let the tip of the administration set become contaminated. Turn off the flow and 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. Be sure you have introduced yourself to your patient and 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. 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. 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.

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. 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 carefully 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. Advance the catheter to enter the vein until blood is seen in the "flash chamber" of the catheter.

If not successful If you are unsuccessful in entering the vein and there is no flashback, then slowly withdraw the catheter, without pulling all the way out, and carefully watch for the flashback to occur. If you are still not within the vein, then 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 after several manipulations the

vein is not entered, then release the tourniquet, place gauze over the skin puncture site, withdraw the catheter and tape down the gauze. Try again in the other arm. Otherwise, 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!!

Release the tourniquet.

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. Remove the protective cap from the end of the administration set and connect it to the plastic catheter. Adjust the flow rate as desired.

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. 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).

Occasionally, you may inadvertently enter an artery. You'll recognize this because 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. It is sometimes helpful to draw blood after you have entered the vein and before you have connected the IV tubing and bag. You can easily withdraw blood into a 15 or 20 mL syringe and then inject it into blood vials. Be sure to fill the vials to at least three quarters full. To recall the order of the blood tubes, remember the pneumonic Red Blood Gives Life for red, blue, green, lavender top tubes. Gently rock the tubes back and forth a few times to mix the blood with the additives. There is no need to rock the red top tube, however, the blood in this tube will clot quickly because it contains no additives. It should not be shaken because this will destroy the sample. To discontinue an IV Remember to observe universal precautions. Start by clamping off the flow of fluids. Then 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. Then place a 4 x 4 gauze over the site and gently slide the plastic catheter out of the patient's arm. Use direct pressure for a few minutes to control any bleeding. Finally, place a band aide over the site.

Some of this text was modified and the pictures borrowed from an unknown nursing website. How to correctly apply a warm, moist compress Put a bath towel under hot water and wring it out. Then fold it in half (by width not length) and enclose the arm from fingertips to elbow in the towel. Now place the towel-wrapped arm into a plastic bag and seal the open end of the bag near the elbow. While the pack is working (using heat to cause venous dilation), you can be setting up your supplies and be ready to perform the venipuncture as soon as you remove the pack. It works wonders! Many professional, experienced IV Therapy nurses would not even consider performing a venipuncture on patient with limited venous access without using a pack first

The Five RightsRemember the five rights: The minimum standard of practice for medication administration is checking the five rights (right drug, right patient, right dose, right time and right route) to provide patient safety. Do I have the right drug? Do I have the right patient? Do I have the right dose? Do I have the right time? Do I have the right route? Now add to this: Do I have the right solution? Flow Rates You will often need to calculate IV flow rates. The administration sets come in two basic sizes: Microdrip sets Allow 60 drops (gtts) / mL through a small needle into the drip chamber. Good for medication administration or pediatric fluid delivery 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 Fluid may be ordered at a KVO rate. This means to Keep the Vein Open, or run in fluids very slowly, enough to keep the vein open, but not really deliver much volume. At times, you may desire a faster flow rate. This is usually expressed in mLs / hour. In other words, how much fluid do you want your patient to receive each hour? A common "maintenance" amount, for instance, would be "run it in at 125 an hour". Your patient would receive 125 mL of fluid every hour. 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! (Volume in mL) x (drip set) -----------------------------------(Time in minutes) = gtts -----min

Let's say you want your patient to receive 250 mL of normal saline (NS) over a 90 minute time period. You decide to use a macrodrip (10gtt / mL) administration set. The formula will now look like this:

(250 mL) x (10 gtts/min) -----------------------------------(90 min) Which becomes: 2500 -----------------------------------90 Then solving for gtts: = =

gtts -----1 min

gtts -----1

gtts 27.7 = -----1 Or, gtts = 28 Sometimes you will need to know how many milligrams of a medication to give a patient based on their weight. Let's say you need to give the patient some D50. You look up the medication and see that it should be given in a concentration of 0.5 mg / kg. The patient weighs 220 pounds. The first thing to do is convert the weight to kilograms. Then we can express all of this as simple ratios. We now have: 0.5 mg --------1 kg Solving for? Give us 50 mg = ? mg -----100 kg ((0.5 mg x 100) kg / 1 kg) Fortunately for you; 50 mg is exactly what is in one amp of D50.

Want to try this yourself? Let's say you want your patient to have 500 mL of NS given over a two-hour period using a microdrip administration set. Use the first formula above. Here's how it's done. First, the formula... (Volume in mL) x (drip set) -----------------------------------(Time in minutes) Plug the numbers in... = gtts -----min

(500 mL) x (60 gtts/min) -----------------------------------(120 min) Which becomes: 30000 -----------------------------------120 Which becomes: = =

gtts -----1 min

gtts -----1

gtts 250 = -----min

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