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NUR 1021 MARION TECHNICAL COLLEGE SPRING SEMESTER 2016 INTRAVENOUS THERAPY I. INTRODUCTION TO IV THERAPY • INDICATIONS FOR IV THERAPY • TO PROVIDE WATER, ELECTROLYTES, AND NUTRIENTS TO MEET DAILY REQUIREMENTS • TO REPLACE WATER AND CORRECT ELECTROLYTE DEFICITS • TO ADMINISTER MEDICATIONS AND BLOOD PRODUCTS WHAT DO IV SOLUTIONS CONSIST OF? • IV SOLUTIONS CONTAIN • DEXTROSE OR ELECTROLYTES MIXED IN VARIOUS PROPORTIONS WITH WATER • CAN ELECTROLYTE-FREE WATER CAN BE ADMINISTERED BY IV? • NOO! IT RAPIDLY ENTERS RED BLOOD CELLS AND CAUSES THEM TO RUPTURE IV SOLUTIONS • THERE ARE SEVERAL TYPES OF IV FLUIDS • TYPE OF FLUID USED SELECTED ACCORDING TO THE CLIENT AND THE REASON FOR ITS USE • IV SOLUTIONS ARE CLEARLY LABELED WITH THE EXACT COMPONENTS AND AMOUNT OF SOLUTION • IV SOLUTIONS ORDERS – OFTEN WRITTEN WITH ABBREVIATIONS REMEMBER THE ABBREVIATIONS! • “D” IS FOR DEXTROSE • “W” IS FOR WATER • “S” IS FOR SALINE • “NS” IS FOR NORMAL SALINE • RINGER LACTATE (LACTATED RINGER)- COMMONLY USED ELECTROLYTE SOLUTION • ABBREVIATED “RL” OR “LR” SOLUTION STRENGTH • IV’S OFTEN IDENTIFIED WITH ABBREVIATION LETTERS • THESE INDICATE THE COMPONENTS IN THE IV SOLUTION • THE NUMBERS INDICATE THE SOLUTION STRENGTH OR CONCENTRATION OF COMPONENTS IN THE IV FLUID • NUMBERS WRITTEN AS SUBSCRIPTS • FOR EXAMPLE, D5W (DEXTROSE 5% IN WATER). LET’S PRACTICE: • WHAT IS THE FULL NAME OF THE IV’S FROM THESE ABBREVIATIONS? • NS = SODIUM CHLORIDE 0.9% • D5W = DEXTROSE 5% IN WATER • RL = LACTATED RINGER SOLUTION (ELECTROLYTES) • D5 AND ½ NS (0.45%) = DEXTROSE 5% IN 0.45% SODIUM CHLORIDE COMPONENTS OF IV SOLUTIONS D5W- EACH 100 ML OF SOLUTION CONTAINS 5 G DEXTROSE D5W/0.9NS - SOLUTION CONTAINS 5 G OF DEXTROSE & 0.9 G (OR 900 MG) OF NACL PER 100 ML SOLUTION D5W/0.45NS - SOLUTION CONTAINS 5 G OF DEXTROSE & 0.45 G (OR 450 MG) OF NACL PER 100 ML SOLUTION IV SOLUTION ADDITIVES- POTASSIUM • POTASSIUM CHLORIDE (KCL) – • COMMON ADDITIVE TO IV FLUIDS • POTASSIUM CHLORIDE- MEASURED IN MILLIEQUIVALENTS (MEQ) • ORDER USUALLY WRITTEN TO INDICATE THE AMOUNT OF MILLIEQUIVALENTS PER LITER • IV SOLUTIONS ARE OFTEN AVAILABLE WITH POTASSIUM PREMIXED IN THEM SAFETY ALERT! REMEMBER THE FOLLOWING WHEN ADDING POTASSIUM TO AN IV: • IT SHOULD BE COMPATIBLE WITH THE SOLUTION AND WELL-DILUTED • MONITOR CLIENT DURING INFUSION, RAPID INFUSION OF POTASSIUM CAN CAUSE DEATH DUE TO CARDIAC DEPRESSION, ARRHYTHMIAS, AND ARREST. • CHECK IV SITE FREQUENTLY, MEDICATION IS EXTREMELY IRRITATING. • ADMINISTER IV USING AN INFUSION CONTROL DEVICE. • NEVER ADMINISTER POTASSIUM CONCENTRATE IV PUSH. • DO NOT ADD POTASSIUM TO AN IV BAG THAT IS ALREADY INFUSING • THIS WOULD CAUSE THE MEDICATION TO CONCENTRATE IN THE LOWER PORTION OF IV BAG • RESULTS IN CLIENT RECEIVING A CONCENTRATED MEDICATION SOLUTION- CAN BE HARMFUL. IV FLUID • 3 MAIN TYPES: • ISOTONIC • HYPOTONIC • PROVIDES MORE WATER THAN ELECTROLYTESDILUTING THE ECF • HYPERTONIC TYPES OF IV SOLUTIONS Isotonic Hypotonic Hypertonic 0.9% Sodium Chloride = Normal Saline 0.45% NaCl D5/LR Lactated Ringer’s (LR) 0.33% NaCl D5/0.9%NS (D5/NS) D5W D5W- Glucose rapidly metabolized = hypotonic TPN D5/0.45 %NS Solutions containing meds ISOTONIC FLUIDS • CLOSE TO THE SAME OSMOLARITY AS SERUM • ISOTONIC FLUIDS EXPAND THE ECF VOLUME • EXPAND THE INTRAVASCULAR SPACE WHAT IMPLICATIONS DOES THIS HAVE FOR A PATIENT WITH HYPERTENSION OR HEART FAILURE IF THEY RECEIVE ISOTONIC IV’S? • RISK OF FLUID OVERLOAD ISOTONIC SOLUTIONS • PROVIDES BENEFITS OF: • HYDRATION • MAINTAIN ELECTROLYTES • USED DURING AND AFTER SURGERY D5/W -HELPFUL FOR: • PROVIDES FREE WATER NECESSARY FOR RENAL EXCRETION OF SOLUTES • USED TO REPLACE WATER LOSSES AND TREAT HYPERNATREMIA • PROVIDES 170 CALORIES/L • NCLEX PRACTICE: • THE NURSE RECOGNIZES REQUIRES FLUID REPLACEMENT WITH ISOTONIC SOLUTION. ONE OF THE ISOTONIC SOLUTIONS THAT MAY BE ORDERED BY THE HEALTH CARE PROVIDER IS: • 1. 0.45% SALINE • 2. LACTATED RINGER’S • 3. 5% DEXTROSE IN NORMAL SALINE • 4. 5% DEXTROSE IN LACTATED RINGER’S HYPOTONIC FLUIDS – PURPOSE • REPLACE CELLULAR FLUID • PROVIDES FREE WATER FOR EXCRETION OF WASTES • OFTEN USE 0.45% NS – RX HYPERNATREMIA OR OTHER HYPEROSMOLAR CONDITIONS • LESS OSMOLARITY THAN SERUM • DILUTES THE SERUM EXCESSIVE USE OF HYPOTONIC SOLUTIONS • LEADS TO INTRAVASCULAR FLUID DEPLETION • DECREASED BLOOD PRESSURE • CELLULAR EDEMA 0.45% NS - HYPOTONIC • PROVIDES FREE WATER IN ADDITION TO NA+ AND CL– • USED TO REPLACE HYPOTONIC FLUID LOSSES • USED AS MAINTENANCE SOLUTION • DOES NOT REPLACE DAILY LOSSES OF OTHER ELECTROLYTES • PROVIDES NO CALORIES • A HYPOTONIC SOLUTION THAT PROVIDES NA+, CL−, & FREE WATER • USED AS A BASIC FLUID FOR MAINTENANCE NEEDS HELPFUL FOR: • CELLULAR DEHYDRATION: • FLUID SHIFTS OUT OF BLOOD VESSEL (LESS CONCENTRATED) TO THE TISSUE CELLS (MORE CONCENTRATED) • EX: DRY MUCOUS MEMBRANES • HYPERGLYCEMIC CONDITIONS: • DIABETIC KETOACIDOSIS CAN BE HARMFUL: • SUDDEN SHIFT OF FLUID FROM BLOOD VESSEL TO THE CELLS – CARDIOVASCULAR COLLAPSE • HYPOTONIC SOLUTIONS - POTENTIAL TO CAUSE CELLULAR SWELLING • MONITOR FOR CHANGES IN MENTATION →INDICATE CEREBRAL EDEMA • EXAMPLES- HYPOTONIC IV SOLUTIONS • D5NS.45 (5% DEXTROSE IN ½ NORMAL SALINE) • 5% DEXTROSE AND WATER (D5W)- PROVIDES CALORIES AND WATER • NCLEX PRACTICE: • A CLIENT EXPERIENCES A LOSS OF INTRACELLULAR FLUID. THE NURSE ANTICIPATES THAT THE INTRAVENOUS (IV) THERAPY THAT WILL BE USED TO REPLACE THIS TYPE OF LOSS IS: • 1. 0.45% NORMAL SALINE (NS) • 2. 10% DEXTROSE • 3. 5% DEXTROSE IN LACTATED RINGER’S • 4. DEXTROSE 5% IN NS HYPERTONIC (HYPER-OSMOLAR) • HIGHER OSMOLARITY THAN SERUM • PULLS FLUIDS AND ELECTROLYTES FROM THE INTRACELLULAR & INTERSTITIAL COMPARTMENTS INTO THE INTRAVASCULAR COMPARTMENT • EXAMPLES • D5/0.9NS AND D5/0.45NS • USE POSTOP WHEN SOME SODIUM IS NEEDED • D5LR HELPS TO: • ↓ EDEMA • URINE OUTPUT • STABILIZE BP • USED TO MAINTAIN FLUID INTAKE • CAN TEMPORARILY BE USED TO TREAT HYPOVOLEMIA IF PLASMA EXPANDER IS NOT AVAILABLE • SOLUTIONS WITH CONCENTRATIONS GREATER THAN 10% MUST BE ADMINISTERED THROUGH A CENTRAL LINE • ALLOWS ADEQUATE DILUTION TO PREVENT SHRINKAGE OF RBCS • A CLIENT IS PRESCRIBED 0.9% SODIUM CHLORIDE (NORMAL SALINE), WHICH IS AN ISOTONIC SOLUTION. THE NURSE RECOGNIZES THE PRIMARY GOAL OF SUCH INTRAVENOUS THERAPY IS TO: • 1. EXPAND THE VOLUME OF FLUID IN THE VASCULAR SYSTEM • 2. PULL FLUID FROM THE CELLS • 3. KEEP PROTEIN LEVELS NORMAL • 4. MOVE FLUID INTO THE CELLS • A CLIENT IS PRESCRIBED 3% SODIUM CHLORIDE, WHICH IS A HYPERTONIC SOLUTION. THE NURSE RECOGNIZES THE PRIMARY GOAL OF SUCH INTRAVENOUS THERAPY IS TO: • 1. EXPAND THE VOLUME OF FLUID IN THE VASCULAR SYSTEM • 2. PULL FLUID FROM THE CELLS • 3. KEEP PROTEIN LEVELS NORMAL • 4. MOVE FLUID INTO THE CELLS • A CLIENT IS PRESCRIBED 0.45% SODIUM CHLORIDE, WHICH IS A HYPOTONIC SOLUTION. THE NURSE RECOGNIZES THE PRIMARY GOAL OF SUCH INTRAVENOUS THERAPY IS TO: • 1. EXPAND THE VOLUME OF FLUID IN THE VASCULAR SYSTEM • 2. PULL FLUID FROM THE CELLS • 3. KEEP PROTEIN LEVELS NORMAL • 4. MOVE FLUID INTO THE CELLS IV SITES • PERIPHERAL • SUPERFICIAL VEINS OF FOREARM, HAND, AND SCALP OF CHILDREN • ARM VEINS - COMMONLY USED • RELATIVELY SAFE AND EASY TO ENTER • CHOSE SITE - DOES NOT INTERFERE WITH MOBILITY • USE MOST DISTAL SITE OF THE ARM OR HAND FIRST • THIS PERMITS SUBSEQUENT IV ACCESS SITES TO BE MOVED PROGRESSIVELY UPWARD • IS THE ANTECUBITAL FOSSA A PREFERRED IV SITE? • NO - LIMITS MOBILITY OTHER IV SITES TO BE CAUTIOUS OF: • LEG VEINS SHOULD RARELY BE USED • HIGH RISK OF THROMBOEMBOLISM • AVOID VEIN ACCESS DISTAL TO A PREVIOUS IV INFILTRATION • AVOID SCLEROSED OR THROMBOSED VEINS • AVOID AN ARM WITH AN ARTERIOVENOUS SHUNT OR FISTULA • AVOID ARM AFFECTED BY EDEMA, INFECTION OR BLOOD CLOT • AVOID ARM ON THE SIDE OF A MASTECTOMY - IMPAIRED LYMPHATIC FLOW. PICC LINE (PERIPHERALLY INSERTED CATHETER) • CAN BE INSERTED BY NURSES WHO HAVE HAD SPECIAL TRAINING • LONG CATHETER INSERTED INTO ANTECUBITAL VEIN WITH TIP POSITIONED IN SUPERIOR VENA CAVA • USE FOR IV ANTIBIOTICS FOR SEVERAL WEEKS OR TPN • LESS RISK OF COMPLICATIONS CENTRAL LINE IV THERAPY • CENTRALLY INSERTED CATHETERS SPECIAL CATHETER INSERTED INTO A LARGE VEIN IN THE NECK OR CHEST (SUBCLAVIAN OR JUGULAR) • THREADED THROUGH INTO THE RIGHT ATRIUM • TIP RESTS IN DISTAL END OF SUPERIOR VENA CAVA USE OF CVC’S (CENTRAL VENOUS CATHETERS) Medication administration •• Cancer •• Chemotherapy- infuse irritating or vesicant medications •• Infection •• Long-term administration of antibiotics Nutritional replacement •• Infusion of parenteral nutrition (PN) •• Able to infuse higher dextrose solutions through central line than peripheral line ADMINISTRATION OF IV FLUIDS • USE AN IV INFUSION SET • A DRIP CHAMBER IS CONNECTED TO THE IV BOTTLE OR BAG • FLOW RATE IS ADJUSTED TO DROPS PER MINUTE (GTT/MIN) WITH ROLLER CLAMP • INJECTION PORTS - LOCATED ON THE IV TUBING & ON MOST IV SOLUTION BAGS • ALLOW FOR INJECTION OF MEDICATIONS DIRECTLY INTO IV BAG OR IV LINE • INJECTION PORTS ALSO ALLOW FOR ATTACHMENT OF SECONDARY IV LINES FOR IVPB MEDICATIONS COMMON COMPLICATIONS OF PERIPHERAL IV THERAPY PHLEBITIS : INFLAMMATION OF A VEIN • SIGNS & SYMPTOMS OF PHLEBITIS • REDNESS, SWELLING, PAIN, AND EDEMA AT THE INSERTION SITE AND/OR ALONG THE VEIN • TREATMENT - REMOVAL OF CATHETER & APPLICATION OF WARM SOAKS INFILTRATION : VENIPUNCTURE DEVICE IS DISLODGED FROM THE VEIN • S & S: • • • • • • • LOCAL EDEMA SKIN BLANCHING SKIN COOLNESS LEAKAGE AT THE PUNCTURE SITE PAIN & FEELINGS OF TIGHTNESS BLANCHING AT THE SITE ABSENT BACKFLOW OF BLOOD • TREATMENT: • DISCONTINUE THE IV & MONITOR SITE WHICH IS IT? • REDNESS • EDEMA • SWELLING • SKIN BLANCHING • PAIN AND EDEMA AT THE INSERTION SITE AND/OR ALONG THE VEIN • SKIN COOLNESS • LEAKAGE AT THE PUNCTURE SITE • ABSENT BACKFLOW OF BLOOD • PHLEBITIS • INFILTRATION VARIETY OF WAYS FOR IMPLEMENTING IV THERAPY