Download Chapter 15 - PNIVTherapy

Intravenous Flow Rates
1
Principles
• Keep to a method you
understand
• Have some idea where your
answer should be so you can
ask yourself:
• Is my answer reasonable?
• IF IN ANY DOUBT –STOP AND
GET HELP !!!
Drug Calculations
• Http://youtu.be/2o8h-8UPAak
• http://youtu.be/Ppkpvlgzs1M
 SIX RIGHTS OF MEDICATION
 ADMINISTRATION

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
 1. Drug
 2. Dose
 3. Patient
 4. Route
 5. Time
 6. Documentation
Objectives


Calculating drops per minute (gtt/min)
when given the total volume and time over
which an IV solution or intravenous
piggyback is to be infused
Calculating milliliters per hour (mL/h)
when given the total volume and time over
which an IV solution or intravenous
piggyback is to be infused
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
5
Infusions
Common additives to infusions:
 Medications
 Electrolyte milliequivalents
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
6
Intravenous Infusion Set
Includes:
 Sealed bottle or bag
 Tubing
 Drip chamber connected by small tube or
spike
 Tubing leading from drip chamber to
needle or catheter
 Clamp to adjust flow rate
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
7
Intravenous Infusion Set
(cont’d)
FIGURE 16-1 Intravenous infusion sets. (Modified from
Clayton BD, Stock YN: Basic pharmacology for nurses,
ed 13, St Louis, 2004, Mosby.)
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
8
Intravenous Infusion Set
(cont’d)
Types of infusion sets (based on drop factor)
 Microdrip sets
 Macrodrip sets
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
9
Regulating IV Flow Rates



Regulation is the responsibility of the nurse.
Irregular rates lead to complications.
Sometimes the rate must be adjusted.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
10
Adjusting Flow Rates
FIGURE 16-3 Count drops per minute by watching the drip chamber for
1 minute and adjusting the roller clamp as needed to deliver the desired
number of drops per minute. (From Potter PA, Perry AG: Fundamentals
of nursing, ed 6, St Louis, 2005, Mosby.)
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
11
Gravity Infusion
Calculation Formula
V C  R
T
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
12
IV Administration of
Fluids
by Gravity
Example:
Hespan 650 mL is ordered to be infused over
3.5 hours. The drop factor is 20 gtt/mL. How
many drops per minute should be
administered to infuse 650 mL of Hespan
over 3.5 hours?
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
13
Infusion of IV
Piggybacks
by Gravity
FIGURE 16-4
Tandem/intravenous piggyback (IVPB)
administration setup. (From Potter PA, Perry AG:
Fundamentals of nursing, ed 5, St Louis, 2001, Mosby.)
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
14
Infusion of IV
Piggybacks
by Gravity (cont’d)
Example:
The physician orders gentamicin 50 mg in
80 mL D5W to be infused over 45 minutes.
The tubing drop factor is 60 gtt/mL. How
many drops per minute should be
administered to infuse the gentamicin over
45 minutes?
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
15
IV Pump Infusion
Formula
Total volume in milliliters
 x mL h
Total time in hours
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
16
Infusion of IV Fluids
with an IV Pump
Example:
Infuse 750 mL of lactated Ringer’s solution
(LR) over 8 hours. How many milliliters per
hour should the IV pump be programmed
to deliver?
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
17
Infusion of IV
Medications
with an IV Pump
Example:
Administer 1.5 g of vancomycin over 90
minutes. The vancomycin is dissolved in
200 mL of D5W. How many milliliters per
hour should the IV pump be programmed
to deliver?
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
18
Saline and Heparin
Locks



Reduce the number of patient
venipunctures
Allow patient greater mobility when fluid
not being infused
Can be flushed with normal saline solution
or heparin flush solution
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
19
Central Venous
Catheters
Required for patients who need:
 Frequent venipuncture
 Long-term IV infusions
 Hyperalimentation
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
20
Central Venous
Catheters (cont’d)
Required for patients who need (cont’d):
 Chemotherapy
 Intermittent blood transfusions
 Antibiotics
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
21
Patient-Controlled
Analgesia
IV narcotics can cause:
 Depressed respirations
 Hypotension
 Sedation
 Dizziness
 Nausea or vomiting
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
22
Patient-Controlled
Analgesia (cont’d)
Requirements for PCA:
 Patient must not be allergic to narcotic.
 Patient must be able to understand and
comply with instructions.
 Patient must have a desire to use PCA.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
Copyright © 2007 by Mosby, Inc.
All rights reserved.
23
IV THERAPY
PRESENTATION
PREPARING IV SOLUTION &
TUBING
What’s the first thing you always need to do?
Check the Doctor’s order.
Farmer, Edward
Dr. Jones
DOB 10-23-50 MR
54276
Height:
Weight:
ALLERGIE Codeine
5’7
150 lb
S Date Time
PRESCRIBED TREATMENT, MEDICATION AND DIET
TPN ORDERS MUST BE ORDERED ON “PARENTERAL NURTRITION ORDER FORM”
3- 15-11
0730
Start IVF – 1000ml Lactated Ringers
@ 100ml/hr
T.O.
Dr. Jones/B. Meyer, RN
Check and Inspect the IV Bag
 Expiration Date
 For cloudiness or particles – IV Fluid should be clear
 For Leakage
 Correct IV fluid
 Correct amount
And Always Do The 3 Checks of the IVF with the
Dr’s Order
Primary Tubing
•
•
•
•
•
•
Open package
Pull off paper tab and unroll the tubing
Close the roller clamp
Pull off clear tab on IV bag
Remove plastic covering the spike
DO NOT touch part of IV bag where tab was removed or
spike, IT MUST REMAIN STERILE!
• Spike the IV bag
Primary Tubing (Cont)





Hang on IV pole
Fill drip chamber ½ full
Remove end piece from tubing
Open roller clamp – Slowly!
Flush tubing with IVF
 Keep end of tubing sterile
 No large air bubbles in tubing (less than 1”)
 Be sure to prime the Y-site, also
 Close the roller clamp
 Replace end piece on tubing
Date
Time
Initials
Label IV Fluids
•
•
•
•
•
Date
Time
Initials
Patient’s name
Any additions made to IV fluid
Gather IV Equipment
 Needle/angiocath
 Start kit (tape, tourniquet, alcohol pad,
tegaderm, and label)
 Chux pad
 Clean gloves
 Goggles
 IV Pole
 Wash Hands (Don other PPE if needed
– Contact Precautions, Agitated
patient, etc)
 ID your patient – You MUST take the
Doctor’s order in with you
 Check for allergies:
 Tape
 Latex
 Betadine (if using)
•
•
•
•
Do 4th check at the bedside
Explain procedure
Provide privacy
Body Mechanics (Bed up [if standing], etc)
Equipment Inventory
Prepare Supplies
 IV pole/pump
 Angiocath needle
 Label
 Tourniquet
 Cleaning solution





(depends on facility)
IV solution & tubing
Cut Tape
Goggles
Chux
Tegaderm
Inspect Potential Sites
Place tourniquet around the upper arm
Inspect Potential Sites
Examine and Palpate Veins
Common IV Sites of the
Hand
Common IV Sites of the
Arm
What are Some Ways to
Promote Venous
Distention?
Place arm in a dependent position
Have patient open and close fist a couple of time
Warm compresses
“Flicking” the vein
Massaging blood flow proximal to distal
Using a blood pressure cuff instead of a tourniquet
But, Mrs. Meyer, I Can’t
See a Vein!
Trust Your Fingers more than Your Eyes
Other
things
to try:
•Applying Warm Compresses
•Massaging the Blood Flow Proximal to Distal
•Using a Blood Pressure Cuff instead of a
Tourniquet
•Use Two Tourniquets instead of One
Other Things to Consider
When Selecting an IV site
Is the Skin Intact?
Is your Patient Left or Right Handed?
What is the IV going to be used for?
Avoid Bony Prominances and First 2” of the Inner Side of the
Wrist
Avoid Antecubital Area, if Possible.
Use Most Distal Site First
Can not use any site above antecubital
Once You Have Selected
Your Site
Prepare For Insertion
Put on Disposable Gloves and Goggles
Place a Chux Pad under the arm
Scrub Site with Alcohol (or what facility requires):
- Allow site to dry
Apply Tourniquet 5 to 6 inches above Insertion Site:
- Secure Tightly enough to Occlude Venous Flow
- Check Presence of Distal Pulse
Perform the Venipuncture
Use your Nondominant Hand to Anchor the Vein
- Stretch Skin Dorsal to Site - Do not “Hop Scotch” your Thumb
Warn Patient of the Stick
With dominant hand: Insert the Stylet, bevel up, at a 20 to 30°
angle
- Hold by Flash Chamber, not IV hub
Watch for a “Flash Back” of Blood
Advance Stylet into Vein
Loosen Catheter from Stylet
Advance Catheter into vein
Whew! I’m in the Vein,
Now What?
“POP” the tourniquet (loosen it without letting go of the IV)
Occlude vein at cannula end Before pulling the stylet
completely out or
IT WILL LOOK LIKE A BLOODY MASSACRE!
Quickly attach the IV tubing to the IV catheter
Moving Along…………
• Slowly open the roller clamp
• Tape the hub of the catheter – Do not tape
over insertion site- Chevron- U
• Place Tegaderm over insertion site and hub of
cannula
• Tape the rest of the IV tubing – Make a “J”
Clean Up Time
Remove Gloves and goggles
Dispose all used materials
Throw Stylet in Sharps Container
Preparing IV Solution & Tubing
(Changing the IV tubing at the IV site)
•Prepare tubing as before
•Gather Equipment (Fluid ● Tape ● Prepared Tubing ●
Gloves
Chux● Goggles●Tegaderm●
2x2)
•Wash Hands
•ID patient and check allergies
•Explain yourself
•Prepare Tape
Preparing IV Solution & Tubing
(Changing the IV tubing at the IV site)
•Loosen Tape and Tegaderm
•Put Chux Pad under arm
•Don Clean Gloves
•Place 2x2 under IV site (optional)
•Stabilize the hub of the IV with thumb and index finger
•Occlude blood flow
•Gently disconnect old tubing from IV
•Insert new tubing into hub of the catheter & screw on tightly
Preparing IV Solution & Tubing
(Changing the IV tubing at the IV site)
•Open the roller clamp to establish flow of IV solution.
•Reestablish drip rate, gravity or pump
•Tape cannula in place and apply a new dressing to the site
•Document on dressing site- date, time, initials
•Clean Up
•Wash Your Hands
•Document on IV sheet – bag and tubing change
Changing IV solution
Farmer, Edward
Dr. Jones
DOB 10-23-50 MR
54276
Height:
Weight:
ALLERGIE Codeine
5’7
150 lb
S Date Time
PRESCRIBED TREATMENT, MEDICATION AND DIET
TPN ORDERS MUST BE ORDERED ON “PARENTERAL NURTRITION ORDER FORM”
3-16-11 1100
Continue IVF 5% Dextrose and Water
at 150 ml/hr
T.O.
Dr. Jones/B. MEYER, RN
Changing IV Solution
Complete 3- Check Procedure
Label IV with date, time, and type of solution
Wash Hands (Don Clean Gloves, if indicated)
ID patient with order & Check allergies
Introduce Yourself & Explain procedure
Be sure the drip chamber is at least half full.
Close the roller clamp to stop flow of fluid or stop IV pump
Remove the old IV from the pole.
Remove the old bag from tubing.
Keep spike end sterile.
Spike the new bag or bottle with tubing
Reestablish prescribed flow rate.
Check for air in tubing
Empty remaining fluid from old IV bag if needed into toilet
Hanging IV Piggyback
1. How to transcribe a New
Medication Order to MAR
2. How to Mix an IVPB using
Practi-Powder
3. How to Hang an IVPB
For All IV Piggybacks….
In Addition to Completing the
Usual 4 Checks, You must also:
Ensure that the antibiotic and the fluid mixing with are compatible
Ensure that the IVPB is compatible with the primary IVF and
any additives in the IVF
Verify how fast to run the IVPB- will find in med references
Ensure that it is an antibiotic you are hanging!!!!!!!!!
Mixing an IVPB using
Practi-Powder
Look at the Piggyback (50 ml bag of NS)
- There are 2 ports - “Set” and “Add”
SET Port: Port where IV tubing spike is placed
ADD Port: Port where medication/additives are instilled
Mixing an IVPB using
Practi-Powder
1.
Pop off the blue “add” cap from IVPB bag
2.
Attach needle to syringe – do not use blunt needle
3.
Pop-top off of demo dose powder (the medication)
4.
Withdraw fluid from IVPB (amt indicated on vial)
5.
Wipe off top of demo dose powder
6.
Instill fluid into powder
7.
Withdraw syringe- BE CAREFUL OF AIR IN
VIAL
8.
Mix vial well
9.
Wipe off top of vial
10. Reinsert syringe into vial
11. Withdraw all of the fluid from medication vial
Mixing an IVPB using
Practi-Powder
12. Wipe off “add” port on piggy back with alcohol
13. Insert needle/syringe
14. Instill medication into piggyback bag via the
“ADD” port
15. Recap needle/ Engage safety
16. Shake piggy back gently
17. Must label the IVPB: Patient’s name, date, time,
initials, drug name and dose
18. 3 Checks are completed while preparing med
Hanging an IVPB
•
•
•
•
Secondary infusion set
IV tubing label
Alcohol swab
IV connector (AKA alligator clamp)
Hanging an IVPB
ID pt, check allergies. Do 4th check at bedside.
•
Close roller clamp
•
Remove cap from “SET” Port on IVBP
•
Insert IV Tubing Spike – Do not touch spike, it’s sterile!
•
Fill drip chamber ½ full by squeezing drip chamber
•
Prime Secondary Tubing
– There are Two Ways:
1. Open roller clamp. Prime tubing & connector. (#7 on list)
2. Prime the tubing using retrograde fluid flow from the
primary IV solution (See #16, 17, & 18 on your list)
Now, we’re Primed &
Ready to Go…
Label Tubing (Date, Time, Initials)
Hang 1° IV bag lower than IVPB – Use hanger. Connect
to primary tubing using connector.
Open Roller Clamp of IVPB !!!!!
Infuse IVPB at Prescribed Rate (Look in your med book)
Assess patient’s response
Document on MAR- does not go on iv sheet
PRN adapter
YOU WILL NEED
Gloves
adapter
Normal Saline Flush
Swab
Tape
Chux
Goggles
PRN
Alcohol
PRN Adapter
•Obtain 3 ml Normal Saline into syringe. Attach blunt tip end.
•Wipe off PRN Adapter end with Alcohol
•Prime PRN Adapter with NS – Leave Syringe Attached
•Don gloves and goggles
•Stop the infusion
•Loosen the Existing Infusion Tubing
•Stabilize Site and Occlude Blood Flow
•Remove infusion
•Attach PRN Adapter and screw it securely onto the cannula hub.
•Flush IV with Normal Saline
•Re-Tape IV site and PRN Adapter
Discontinuing IV site
DISCONTINUE IV SITE
 INFORMATION GIVEN IN PREVIOUS
LAB
 WILL NOT BE TESTED ON
 MAKE SURE CANNULA INTACT AND
CHART ACCORDING TO
INSTITUTION POLICY
 HAVE WRITTEN ORDER BEFORE
REMOVE
 ID PT BEFORE REMOVAL