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Introduction to IV Therapy Readings: Heitz, U., & Horne, M.M. (2005). Pocket Guide to Fluid, Electrolyte, and Acid-Base Balance (5th ed.). St. Louis: Mosby. Chapter 1. (Available on Mosby’s Nursing Consult – Books) Lavery, I, & Ingram, P. (2008). Safe practice in intravenous medicines administration. Nursing Standard. 22(46). Scales, K. (2008). Intravenous therapy: A guide to good practice. British Journal of Nursing. 17(19). IV Therapy – Mosby’s Nursing Skills Browse by Index: “I” Intravenous Therapy: Initiation Intravenous Therapy: dose and Flow Rate Calculations Intravenous Therapy: Dressing Change Intravenous Therapy:: Solution Change Intravenous Therapy: Tubing Change Intravenous Therapy: Discontinuation Browse by Index: “M” Medication Administration: Intravenous Bolus Medication Administration: Injection Preparation from Ampules and Vials Medication Administration: Adding Medication to Intravenous Fluid Containers What is IV therapy? Administration of liquid substances into the venous system. Goals of IV Therapy The goal of IV fluid administration is correction or prevention of fluid and electrolyte disturbances in patients. For example, a patient who is NPO (nothing by mouth) after surgery routinely receives IV fluid replacement to prevent fluid and electrolyte imbalances. Another reason for IV access is to administer intermittent or emergency medication. From: Potter, A.G., & Perry, P.A. (2010). Clinical nursing skills & techniques (7th ed.). St. Louis: Mosby. Osmolality • Osmolality reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis. • Osmolality measures the solute concentration per kilogram in blood and urine. • Osmotic pressure is the pulling pressure demonstrated when water moves through the semi permeable membrane of tissue cells from an area of weaker concentration to stronger concentration of solute . • The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. • There are two fluid compartments: extracellular & intracellular. Intracellular Fluid • Intracellular fluid is the fluid contained within the cells. In adults, approximately two thirds of the body's fluid is intracellular; this is approximately 27 L in the average (70-kilogram [kg]) adult male. In contrast, only half of an infant's body fluid is intracellular. Extracellular Fluid • Extracellular fluid is the fluid outside the cells. The relative size of ECF decreases with advancing age. In the newborn, approximately half the body fluid is contained within ECF. After 1 year of age, the relative volume of ECF decreases to approximately one third of the total volume. This equals approximately 15 L in the average (70-kg) adult male. ECF is further divided into the following: • 1. Interstitial fluid: Fluid surrounding the cells, equal to approximately 11 to 12 L in adults. Lymph fluid is included in the interstitial volume. Relative to body size, the volume of ISF is approximately twice as great in the newborn as in the adult. • 2. Intravascular fluid: Fluid contained within the blood vessels (i.e., the plasma volume). The relative volume of IVF is similar in adults and children. Average adult blood volume is approximately 5 to 6 L, of which about 3 L is plasma. The remaining 2 to 3 L consist of red blood cells (RBCs, or erythrocytes), which transport oxygen and act as important body buffers; white blood cells (WBCs, or leukocytes); and platelets. Functions of the blood include: ▪ Delivery of nutrients (e.g., glucose, oxygen) to the tissues ▪ Transport of waste products to the kidneys and lungs ▪ Delivery of antibodies and WBCs to sites of infection ▪ Transport of hormones to their sites of action ▪ Circulation of body heat • 3. Transcellular fluid (TCF): Fluid contained within specialized cavities of the body. Examples of TCF include cerebrospinal, pericardial, pleural, synovial, and intraocular fluids, and digestive secretions. At any given time, TCF is approximately 1 L. However, large amounts of fluid may move into and out of the transcellular space each day. For example, the gastrointestinal (GI) tract normally secretes and reabsorbs up to 3 to 6 L per day. Heitz, U., & Horne, M.M. (2005). Pocket Guide to Fluid, Electrolyte, and Acid-Base Balance (5th ed.). St. Louis: Mosby. Available on Mosby’s Nursing Consult - Books Commonly Prescribed Intravenous Fluids • Intravenous fluids are divided into two major categories: crystalloids and colloids. Crystalloid solutions contain only electrolytes and glucose, substances that are not restricted to the intravascular space. Therefore these solutions expand the entire extracellular space. Depending on their sodium content, crystalloids also may expand the ICF volume. Isotonic NaCl (0.9%) and Ringer's solution expand only the ECF, whereas hypotonic NaCl solutions and dextrose and water solutions expand all fluid compartments. Crystalloids are typically classified according to the osmolarity (tonicity) of the solution. Isotonic solutions have an osmolarity similar to plasma, hypotonic solutions have an osmolarity significantly less than plasma, and hypertonic solutions have an osmolarity significantly greater than plasma. Because of the risk of RBC hemolysis, there is a limit to how hypotonic a fluid may be and still be safely administered IV. Pure water and hypotonic saline solutions such as 0.225% NaCl require the addition of 5% dextrose to allow safe administration. For the clinician administering IV fluids, it is important to consider the “true” tonicity of the solution. Although both normal saline (0.9% NaCl) and 5% dextrose in water (D5W) are considered isotonic (osmolarity similar to plasma) before administration, D5W is in fact a hypotonic fluid once it has been administered and the dextrose has been metabolized. Advantages of crystalloids are that they are relatively inexpensive and non-allergenic. Colloid solutions contain cells, proteins, or synthetic macromolecules that do not readily cross the capillary membrane. These solutions remain within the vascular space and, depending on their concentration, may cause an osmotic shift of fluids from the interstitium into the intravascular space. Disadvantages of colloids can include increased cost, risk of allergic reactions, and clotting abnormalities. Blood is the most commonly administered colloid. From: Heitz & Horne (2005). Chapter 6. Types of IV Fluids ISOTONIC • Has similar osmolality close to ECF & don’t cause RBC’s to swell. • Stays where you put it - expands intravascular compartment only. • Isotonic fluids expand the ECF volume • One L of isotonic fluid expands the ECF by 1L therefore, but 3L is req’d to replace 1L of blood loss. • Pt’s are at risk for fluid overload as isotonic fluids expand the intravascular space. Normal Saline 0.9% Lactated Ringers Hartman’s Solution Albumin Plasmalyte Plasma D5W (Dextrose 5% in water) Types of IV Fluids HYPOTONIC • Replaces cellular fluid • Shifts fluid and electrolytes out of intravascular hydrating intracellular and interstitial. • Provides free water • Used to treat hyponatremia • Excessive infusions of hypotonic solutions can lead to intravascular fluid depletion, decreased blood pressure, cellular edema, and cell damage. 0.45% sodium chloride Types of IV Fluids HYPERTONIC • These solutions are very strong as they exert a strong pull from ICF to the ECF making cells shrink • Draws fluid into the intravascular dehydrating intracellular and interstitial • Can be corrosive to veins therefore must be given slowly and into a large vein • If given rapidly, they can cause extracellular volume excess and precipitate circulatory overload and dehydration Dextrose 5% in normal saline 0.9% Dextrose 5% in half – strength normal saline Dextrose 10% in water Dextrose 20% in water Saline -3% and 5% Dextrose 5% in Lactated Ringer`s Haemaccel 3.5% Gelofusine Albumin 25% How can we deliver IVF? 1. Continuous Infusion By peripheral access 2. Intermittent Infusion By central access 3. IV Push (IVP) Central (Venous) Catheters (lines) • Long term therapy: days, weeks, months • Specialized training required for caring for CVL Peripherally Inserted Central Catheter • Can remain in for weeks to months • Used for patients with limited peripheral access • Specialized IV training to insert them Peripheral Catheters • Most common • Training required for insertion • Nurses are trained for peripheral cannulation • Some substances CANNOT be given by the peripheral route Peripheral IV Cannulas N.B. the different colours of the cannulas correspond to the different sizes (gauges) IV (fluid)Bags • 50mL, 100mL, 250mL, 500mL, 1L sized bags Solution type Expiry date Bag intactness Clarity/colour IV Bag Time Strips To keep track of how much fluid has been infused IV Tubing (+piggyback) IV Tubing • Drip chambers can be: • A micro drip system delivers 60 drops\ml. • A macro drip system delivers 10,15,20 drops\ml. • Drops/ml is also known as gtt(s)/ml. • Drop factor can be found on the packaging of the IV tubing. • Usually looks like: 20 IVF Orders: Look at this order… The Dr has asked for 1L of 0.9% of Normal Saline to be infused over 8 hours, but did not write down the mL/hr…we have to figure that out ourselves!! Calculating mLs/hr. EASY PEASY!! Using the IVF order on the previous slide, take the amount of fluid ordered and divide it by the time the Dr has stated. Ex: 1000 (mL) ÷ 8 (hrs) = 125 mL/hour. Calculating drops/min (gtt/min) First you have to find out the drop factor on your IV tubing, remember this can be micro or macro. Let’s say the IV tubing on your ward has a 20gtt factor. Ex: 125mL/hr 20 (gtt factor) 60 (time) = 41.6 gtts/minute or 42 gtts/min !! Counting gtt/min Now if you are using a gravity system, you don’t want to stand there for ages adjusting the roller clamp and counting 42 drops in the drip chamber every minute..you could be there for AGES!! • Simply, divide 42 gtt/min by 2 to count drops for 30 seconds. (answer=21gtt/30 seconds) • Or, divide 42 gtt/min by 4 to count drops for 15 seconds. (answer=10.5 or 11gtt/15 seconds) IV Pumps What is your role in IV administration/therapy? • To prevent adverse effects of IV therapy WATCH FOR: • Signs of infiltration or sluggish flow • Signs of phlebitis, thrombophlebitis or infection. • Cellulitis or sepsis. • Air embolism, hematoma, clotting, mechanical obstruction. • Correct solution , medication, volume, and rate (I & O!!) • Dwell time of catheter. • Condition of catheter dressing and changing same. • Fluid and electrolyte balance (lab tests). • Signs of fluid overload or dehydration. • Patient satisfaction with therapy. Complications Hematoma Extravasation Infiltration Infection Extravasation Complications • Hematoma: can occur when the luer leaves the vein or when the luer is taken out and bleeding occurs into the tissues. • Infiltration: can occur when the luer leaves the vein and nonvesicant fluid continues to infuse into the tissue. • Infection: can occur when a luer or previous luer site becomes infected because it’s been insitu >72 hrs or the previous luer site has been contaminated. • Extravasation: occurs when a vesicant fluid leaks out of the vein and damages the tissues and leads to tissue necrosis. • Speed shock: can occur at anytime a medication is introduced too quickly into a vein. This is especially evident and risky when giving IV Push (IVP) medications. To prevent this, read manufacturers instructions and push medication over allocated time – NO FASTER!! YouTube: Introduction to IV Therapy (Spiking & Priming an IV line) • http://www.youtube.com/watch?v=7QpX6Np QvdU