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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